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Dismantling AHS: Alberta’s acute care solutions require investment

“The patient needs to be admitted, but there’s no place to send them so they stay in emergency, in a bed of which we have limited capacity”

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A new plan to break Alberta Health Services up into four distinct agencies is expected to roll out this spring, one of Premier Danielle Smith’s top priorities in the wake of a November 2023 shakeup that included the dismissal of an AHS CEO and Smith’s firing of the AHS board.

Divvying up AHS into four “pillars” is expected to create separate agencies: primary care, acute care, continuing care, and mental health and addiction, each with its own budget and executive.

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Over the coming month, this Edmonton Journal series will look at each of the four areas to highlight what ails health care around the province — and where the solutions may lie.

Part 1: Primary care, a way forward in Alberta

Today: Acute care

Part 3: Continuing care

Part 4: Mental health and addiction

There isn’t much Dr. Louis Francescutti hasn’t seen over his more than three decades working in emergency rooms.

He works part-time in the Royal Alexandra Hospital’s ER, and describes conditions there now as “challenging at best,” with doctors over-worked, nurses burned-out, and patients, many of them homeless, left frustrated after spending hours in waiting rooms.

“They show up each and every day in our emergency department, each and every hour, asking for help because they can’t find it anywhere else,” he said.

The reasons the acute care system isn’t working as it needs to, in his view, are many and complex, but he notes a big part of why ERs across the province are being overrun is a failure to better integrate acute care with longer-term forms of care.

“There’s a lot of patients upstairs on the wards that really shouldn’t be there,” he said. “The patient needs to be admitted, but there’s no place to send them so they stay in emergency, in a bed of which we have limited capacity.”

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The problem, for Francescutti, is that those continuing care beds are already full, under-staffed, or don’t yet exist.

Without those, he said, there’s nowhere else for many patients to go, which in turn affects acute care bed availability, leading to long wait times that prompt some to give up entirely, and leaving.

“These are people that are possibly leaving with heart attacks that are developing cancer that’s undiagnosed,” Francescutti said.

It’s an example of the consequences of a system that those who work in it and know it best say is being overwhelmed.

They cited a lack of staff, funding that isn’t keeping up with a growing population base, and poor integration with other forms of care as among the causes, leading them to be skeptical that the government’s overhaul of the health care system will improve things.

Dr. Louis Francescutti
Dr. Louis Francescutti speaks to the media during a news conference at a new transition bed facility referred to as the Bridge Healing Transitional Accommodation Program, 16022 100 Ave., in Edmonton on Jan. 12, 2023.  David Bloom/Postmedia

Premier Danielle Smith has acknowledged the issues in acute care, some of which are made worse in small population areas where forced closures due to lack of staff have become common events.

Last November, her government announced plans for a massive restructure of the health care system through the fall of next year, one that reduces the role of AHS and spreads many of its prior duties across multiple new service agencies while overhauling the agency’s leadership team as well.

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The province has also turned to pharmacists and nurse practitioners to take on primary care roles, with the thought they can relieve pressure off over-burdened ERs.

“One of the things that we learned in the last year is that all roads lead to an emergency room,” Smith said in a year-end interview with Postmedia in December.

“I think that we will begin to start seeing some progress very soon. We had some early progress but not enough and that’s why we needed to get some new management in there.”

Francescutti said he has yet to see any of those promised improvements in the ER he works at.

“It’s not a very pleasant environment to work in these days.”

‘Changing the letterhead’

Dr. James Talbot, the former chief medical officer of health between 2012 and 2015, said he doubts the ongoing institutional rejigging will do much to help acute care, unless it is accompanied by a significant spend by government, and not just in health care.

“Unless they make an investment in things like primary care, public health, and safer and healthier neighbourhoods, and an investment in continuing care, and an investment in a properly trained workforce in which there are enough people with the right skills, then they’re not doing anything to fix overcrowding or weakness,” he said.

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“We don’t need another distraction about changing the letterhead.”

He agrees that the current issues in acute care are part of a number of bigger problems.

“The changes that need to be done are not necessarily in acute care itself, because they can be located upstream or downstream,” he said.

“You have to make investments in continuing care and in home care. And then if you do that, you can decrease waiting lists and you can decrease overcrowding.”

James Talbot
Dr. James Talbot, co-chair of the Edmonton Zone Medical Staff Association strategic COVID committee. Postmedia file

And while he said pharmacists and nurse practitioners have roles to play in the health care system, he states those alone won’t fix the system.

“That you’re suddenly going to be able to turn out enough nurse practitioners to deal with years of neglect and solve the problem is just wishful thinking,” Talbot said.

‘We haven’t kept pace’

Dr. Mike Howlett sees the issues Francescutti describe play out on the other end of the country, and concurs with Talbot that increasing roles for pharmacists and nurse practitioners won’t do much to help the pressure on ERs, calling those changes “a quick fix.”

“The big problem in the department is not people with minor illnesses coming in. Every problem is people with major illness,” said Howlett, an emergency medicine physician in Ontario as well as the president of the Canadian Association of Emergency Physicians (CAEP).

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“It doesn’t matter how many walk-in clinics you have. Somebody who’s really sick is not treated at a walk-in clinic.”

He said he feared the situation in ERs across the country will continue to worsen as resources become exhausted amid Canada’s, and Alberta’s, continually growing populations.

“We haven’t kept pace with the infrastructure in health care to be able to cover all of the care needs for those people,” he said. “We simply don’t have the capacity necessary.”

Data from the Canadian Institute for Health Information (CIHI) shows Canadians, including Albertans, are waiting longer than in previous years to see a ER physician and spending longer at the ER when they are admitted.

Alberta is under the national average of both of those metrics, though it is just under the average wait time of five hours, although the data also shows wait times nationally and provincially have both grown since 2021.

Across the province, the CIHI data shows wait times were longest in the Edmonton Zone (which is bigger than the city itself) at just over six hours, with the shortest wait times being recorded in the Central Zone.

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Time spent in the ER was below the national average across all of Alberta’s five health zones, including the province as a whole, the CIHI data states, though time spent in Edmonton Zone ERs greatly exceeded those of other regions.

Statistics Canada estimates Canada’s population is now at just under 41 million, having grown from 37.8 million four years earlier.

Alberta has similarly seen a population boom, with its headcount growing from 4.3 million in 2019 to now nearing 5 million, and forecast by Smith to reach 10 million in 2050.

Both population bases are expected to continue growing, something that Howlett said needs to be accounted for with more health care funding.

“It plays a very large factor,” he said of population increase, adding the demographics of those coming are key as well. “There are growing numbers of the elderly, especially those who are frail.”

Dr. Jon Meddings, a gastroenterologist and past dean of the Cumming School of Medicine at the University of Calgary, said increasing the number of doctors is one way to address the continued strain on ERs.

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“We need to double the number of students in medical schools in the country,” he said, but warned that was a solution that would take some time to develop, with up to six years needed for a doctor to go from medical school to working in the field.

Jon Meddings
Dr. Jon Meddings is former dean of the Cumming School of Medicine at the University of Calgary. Photo by Donna Kennedy-Glans.

He said a way to speed that up would be to do a better job of retaining Canadian medical students, estimating about 6,000 of whom seek training outside of the country.

“Our citizens shouldn’t have to pay to send their kid to Australia to learn to be a doctor,” he said.

Once here, those students could work through postgraduate training, and create a crop of new doctors on an accelerated time frame.

“There is no shortage of Canadians who have gotten a medical degree elsewhere that we could bring back.”

For Franscescutti, those potential solutions and others have been presented to the current government, as well as several before it, but the questions of funding, cross-care integration, and developing a sustainable acute care system have still yet to be realized.

“We know what we need to do,” he said. “We’ve just never done it.”

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