Bill 114: Who broke trust?

The situation that led to Quebec's Bill 1141 is not unique, since all provinces are experiencing chronic problems in delivering emergency services. However, the obvious concern is that the ill-conceived and regrettable remedy chosen by Quebec will be duplicated elsewhere. Rather than pointing a finger, now is the time to step back and consider the numerous problems besetting emergency services in Canada and to reflect on ways to solve them.

The most significant problem is the overcrowded emergency department (ED). All parts of Canada are faced with overcrowded EDs.2 The root causes are a shortage of acute care beds and inappropriate management policies, and we must no longer accept the rhetoric that extols the virtues of policies that divert patients away from EDs.

The human resources component of emergency services has been studiously ignored:3 there has never been a comprehensive review of the needs of Canada's 850 EDs. The existence of 2 distinct training programs is an international anomaly, and neither has been proven superior to the other. Studies conducted in the early 1990s suggested that recent family practice graduates did not feel comfortable working in EDs because they lacked the needed skills.4^,5 A working group suggested that minimum prelicensure training should include 2 months of adult and 1 month of pediatric emergency medicine,6 but no jurisdiction has implemented this.

As well, there are no enforceable minimum performance standards for EDs. The federal government last published guidelines in 1988, and despite its stance on maintaining standards of access consistent with the Canada Health Act, it has all but abandoned this component. Ontario introduced guidelines for emergency units in 1989, but a 1991 survey revealed that only 50% of EDs met the minimum requirement.7 No standards currently exist in Ontario.

The Canadian Association of Emergency Physicians has developed a 6-point plan for restoring public confidence in EDs. Surely Canadians deserve an emergency service that will not let them down when they are acutely ill or injured, and surely no more Canadians should be turned away from an ED because of a demonstrable lack of system planning.