EDMONTON – Crumbling infrastructure. Empty rural emergency departments. Secretive funding decisions. Political manipulation.
Albertaâ€™s hospital system is in serious trouble.
A five-month investigation by the Edmonton Journal has found disturbing details about the condition of the provinceâ€™s aging hospitals, how the facilities are evaluated, and who gets money for upgrades or new buildings.
Indeed, while the leaky conditions at Edmontonâ€™s Misericordia Hospital have been making headlines recently, the Journal has discovered the situation around the province is much more critical and certainly more far-reaching.
About one-third of Albertaâ€™s 97 hospitals are now at least 40 years old, while two-thirds are at least 30 years old â€” crucial milestones in a buildingâ€™s lifespan when there are heightened maintenance costs and increased risks of a breakdown. In fact, serious infrastructure failings are already happening at a number of facilities, and the price tag to fix it all could be more than $1 billion.
The Journal investigation is based on hundreds of pages of public reports, Alberta Health Services statistics and government documents obtained through access to information requests.
Over the past five months, the information was compiled into a database that provides, for the first time, a comprehensive and searchable analysis of the provinceâ€™s hospital system for Albertans to learn about the state of their local hospitals â€” from a facilityâ€™s current infrastructure woes and the size of its repair bill, to its occupancy and infection rates, and whether itâ€™s a priority for provincial funding.
Search the database at http://bit.ly/15MwuVI
The investigation also found that while the province spends about $1.5 million a year to rate the condition of its health facilities, the process is highly flawed and subject to manipulation behind the scenes. Moreover, there is minimal evidence the rating system plays a significant role in determining which facilities are first in line for repairs or rebuilds â€” suggesting politics are involved.
The lack of a reliable system to evaluate facilities is a concern at any time, but is particularly worrying at a time when the growing province is about to face a massive dilemma over whether to spend billions renovating and rebuilding dozens of aging hospitals or face the political consequences of closing some forever.
â€œThey are in a terrible dilemma,â€� says Donna Wilson, a University of Alberta nursing professor who ran for the Liberals in the Edmonton-Whitemud byelection, and has studied hospital trends.
â€œThis government, and governments forward in Alberta are going to have to make the tough choice: Either you rebuild these hospitals or you refocus,â€� she says.
â€œItâ€™s a delicate balance, because people are afraid they are not going to get the health care they need.â€�
So, how did we get here?
HOW DID WE GET HERE?
The use of infrastructure for political benefit has been a long-standing practice of governments everywhere.
Asphalt, steel and concrete are used as tools to buy votes in areas where the ruling party believes it will receive the most advantage. While hardly an ethical practice in any circumstance, itâ€™s particularly questionable when it comes to funding health facilities that can determine whether people live or die.
In Alberta, the last great hospital-building era was 30 years ago, when the Tory government led by Peter Lougheed constructed facilities in dozens of small towns. A single-storey, red brick structure with a sloped glass canopy was the common design used for about 20 of the builds.
While the construction initiative bought tremendous loyalty to the PCs in rural Alberta and helped fend off the upstart Western Canada Concept party, the hospitalsâ€™ inevitable deterioration three decades later is coming back to haunt the current Tories â€” the Lougheed legacy is now mired in leaky roofs, malfunctioning elevators and rotting pipes.
Alberta Infrastructure suggests about $637 million is needed to address all of the deferred maintenance in the provinceâ€™s medical facilities, though Alberta Health Services pegs that tab much higher at $1.02 billion.
The cost of reconstructing hospitals is, of course, even more massive, considering the going rate for a new rural facility is between $80 million and $210 million, while a new urban hospital can be more than $1 billion. Even if the province rebuilt only the facilities more than 40 years old, that could add up to nearly $8 billion.
Yet, at the same time the hospitals have declined in condition, many rural facilities have also declined in use. Originally designed to accommodate 20 to 30 beds, some now have less than half that total. ERs are sparesly used, operating rooms are closed and beds are empty.
Though hindsight suggests some of these hospitals shouldnâ€™t have been built, experts argue the construction made sense for the time. At that point, rural hospitals tended to offer a greater variety of services, and the province did not have the air ambulance system it has today that quickly transfers patients to major hospitals for serious issues.
But times have changed and other jurisdictions have shed themselves of smaller, low-volume hospitals. Saskatchewan stopped funding 52 rural hospitals in the 1990s, while Ontario closed and merged a number of its facilities to save costs.
But Alberta has resisted, and the result is we have one of the largest numbers of hospitals in the country at a time when the trend is to try to reduce traffic at hospitals in favour of primary care and home care.
â€œAlberta has been criticized for a long time for having too many hospitals,â€� Wilson says. â€œIf you compare us to Europe, we have an astoundingly large number. There really wouldnâ€™t be any in rural areas and even a city the size of Red Deer wouldnâ€™t necessarily have a hospital.
â€œThe reason we have 100 is because it used to be in the old days you could do a lot of health care in rural hospitals. Now you need a lot of big, expensive machines. You canâ€™t afford to have 100 full-service hospitals.â€�
Stephen Duckett, the former president and CEO of Alberta Health Services, says he was similarly struck by the provinceâ€™s long hospital list when he was recruited to the province from Australia in 2009.
In a lecture at the University of Alberta earlier this fall, Duckett criticized the provinceâ€™s fixation on expensive facilities and a stagnant political culture ruled by a â€œrural gerrymander.â€�
Former Alberta Health Services CEO Dr. Stephen Duckett says when he was hired in 2009, he was surprised to find out how many hospitals there are in Alberta. He argues the province canâ€™t afford to keep them all open.
Provincial health leaders admit the government is struggling to rebalance an equation that currently shows Alberta as about the highest per-capita spender in Canada on health care but getting only average results in terms of wait times, infection rates and hospital readmissions.
The health ministryâ€™s operational budget climbed to $18.4 billion this year â€” comprising a full 45 per cent of the provincial budget â€” though Albertaâ€™s total spending on health from all sources has been pegged at around $28 billion. Itâ€™s a figure expected to rise in the coming years as Albertaâ€™s population grows and the baby boomers need more health care.
A recent analysis published by the Canadian Institute for Health Information found the hefty spending is largely tied to hospital costs. Alberta is projected to spend $2,386 per capita on hospitals this year, the second highest rate in the country and well above the national average of $1,743.
â€œThe province loves hospitals. You might think that hospitals is the only form of health care,â€� Duckett told the U of A crowd.
POLITICS VERSUS PRAGMATISM
Duckett, Wilson and others believe part of the solution might be to close some of the lowest volume hospitals and replace them with a more robust primary care service. But itâ€™s a move that seems politically impossible for a PC regime that has seen much of its support in rural areas shift to the Wildrose party. Duckett says the â€œpoliticians became extremely anxiousâ€� any time he or his AHS colleagues talked about the idea of closures.
â€œAny time you close a hospital in a town, you are going to get blowback,â€� Mount Royal University political scientist Duane Bratt says.
â€œAnd even though the Wildrose plays a fiscal conservative card, they are also a rural-based party who are going to rally around the local hospital,â€� Bratt says. â€œSo while the need may be there, and it may make perfect sense economically and a from a efficiency point of view, the political challenges are great.â€�
Premier Jim Prentice and Health Minister Stephen Mandel appear to have already made up their mind not to take the Tories into that minefield â€” at least not for a while.
â€œThese (hospitals) are lifelines within communities and we need to respect that and understand their needs,â€� Mandel says. â€œA lot of revenue is generated from these communities and itâ€™s important they have that mainstay to continue to operate because they are such an important driver for the province.â€�
AN INEFFECTIVE RATING SYSTEM
All of these issues scream for the need to have an effective system of rating health facilities to give the government and public good information on what the funding priorities should be.
However, the Journal found the provinceâ€™s current mechanism is failing.
The system is managed by Alberta Infrastructure, which is responsible for planning and constructing health facilities, and providing funding for major maintenance projects. Alberta Health Services, which owns and operates most of the hospitals for the province, provides input to the rating system, co-ordinates the maintenance work and offers recommendations on the buildings most in need of refurbishment or replacement.
According to the government, much of the data used to inform the rating system comes from physical evaluations by private-sector consultants.
The consultantsâ€™ reports, which are posted online, are the only window Albertans have to gauge the condition of health facilities. Yet they are of minimal value because they are being done only once every five to seven years, are not posted in a timely way, are frequently manipulated, and are sometimes secretly rejected outright by the government and AHS.
â€œThe purpose of these metrics is to offer taxpayers a measure of how well publicly owned assets are being managed by their elected representatives,â€� says Regan Boychuk, former research manager at the Parkland Institute and lead author of a study published last year on past manipulations of Albertaâ€™s rating system. â€œBy juking the stats, the government is evading accountability for many years of negligent management that has dramatically diminished public assets.â€�
Evidence also suggests that facility ratings are not a major influence on provincial funding decisions, indicating the system is either failing to provide an effective measure of need, or else is being ignored in favour of other factors.
AHS funding recommendations are similarly paid little heed. Of the 38 projects the health authority has listed as its most urgent priorities in the last five years, only a third have received government approval. Last year, just one of 10 recommended projects â€” a $9.7-million upgrade to the Red Deer hospitalâ€™s obstetrics area â€” was granted funding.
THE EFFECT ON COMMUNITIES
All of this has created a sense of frustration for communities that have been waiting to see their aging hospital rebuilt or expanded, and are wondering whether politics is playing a role.
â€œWeâ€™ve been lobbying for a new hospital for 10 years now,â€� says Myron Zajic, chairman of the Wainwright and District Community Health Foundation. â€œItâ€™s a challenge every day for our staff and administration with an aging building and limited space, because maybe the electrical is down one day and the roof is leaking the next and there is no hot water in the showers.â€�
The town of 6,500 people in eastern Alberta has been listed among AHSâ€™s most urgent priorities several times, but funding has instead gone to projects lower down the priority list â€” or not on the list at all.
Elsewhere in the province, at least two municipalities are trying some unusual tactics to get a new hospital rather than wait until their number is called by the government.
In Beaverlodge, a community of 2,500 people west of Grande Prairie, the was hospital built in 1956, making it the second oldest in Alberta. The already deteriorated facility was further degraded last year when a broken sprinkler head caused a flood that damaged the operating room and maternity areas.
Though a new Beaverlodge hospital ranks as No. 14 on AHSâ€™s list, the uncertainty of when that ranking might turn into funding has prompted the town to pursue its own course. A site for the new facility has already been picked and serviced with utility lines, developers have been contacted to gauge their interest, and residents have been fundraising to come up with as much of the needed cash as possible.
The idea of doing the project as a public-private partnership, in which industry and town could pay for the build, has even been proposed to the government.
â€œWe know the challenges with infrastructure, but we also knew this was a critical need and we couldnâ€™t wait any longer,â€� Mayor Leona Hanson says. â€œSo we said, â€˜Letâ€™s step back and see how we can do this differently.â€™â€�
The same is true in Bassano in southern Alberta, where the Newell Foundation is proposing to fund and build a new integrated health centre for the town of 1,200 people. The plan calls for the foundation to operate the seniorsâ€™ accommodations, while leasing the hospital space to AHS.
â€œItâ€™s tough to get a small community hospital high enough on the priority list to get funding,â€� says foundation chairman Barry Morishita. â€œThis is a unique way of dealing with the issue. Communities have a duty to provide solutions rather than just going to the government with their hands out.â€�
HOW MANY HOSPITALS DOES ALBERTA HAVE?
Alberta has been said to have the highest number of hospitals in Canada, per capita, but confirming this is trickier than one might assume.
Thatâ€™s because there appears to be no single, accepted definition of a hospital. Different provinces and health regions use the term in distinct ways, so facilities with one set of medical services end up being called the same thing as facilities with different services.
The Canadian Institute for Health Information does not provide standardized data on hospital numbers across the country.
As an example, CIHI lists a total of 64 hospitals in Manitoba, which would give that province a much higher per-capita rate than Alberta (with 97 hospitals) since it has less than one-third the population. But it is unclear how many of those facilities are truly full-service hospitals, and how many cater to only specific types of patients (psychiatric, rehab services, etc.).
For the purposes of this project, the Journal focused on Alberta hospitals that have in-patients beds and 24-hour emergency wards. As such, the new Strathcona County hospital was not included because it does not have any beds to admit patients.
It can be said with confidence that apart from the Maritime provinces, Alberta has the most number of hospitals for its geographic area â€” an average of one hospital for each 6,600 square kilometres.
AGING HOSPITALS, BY THE NUMBERS
6 Hospitals built pre-1960
17 Hospitals built in the 1960s
13 Hospitals built in the 1970s
47 Hospitals built in the 1980s
6 Hospitals built in the 1990s
8 Hospitals built in 2000 or later
3 New hospitals being
constructed to replace old structures â€” Edson (1969), High Prairie (1962) and Grande Prairie (1981)
Albertaâ€™s hospitals together have just over 8,000 acute care beds. About 62 per cent of those are in facilities at least 30 years old, while about 38 per cent are in facilities at least 40 years old.
On average, the oldest facilities are in AHSâ€™s south zone
(the average year built is 1975), followed by central (1978),
north (1980), Edmonton zone (1983) and Calgary zone (1986).