“No cap on babies” read the placard of a demonstrator marching outside Ottawa's Queensway–Carleton Hospital last fall. The marchers, who included 4 of the hospital's 7 obstetricians, were outraged by the 201-bed community hospital's attempt to cap the number of deliveries in its birthing centre. The hospital said it had no choice but to set limits if it was to avoid a deficit, but when it comes to motherhood issues — and there are none bigger than this one — that was a hard message to sell. By the time the matter was settled, “brown envelopes” had been sent to local papers and relations between physicians and the hospital board had suffered. And in the end, the board never did get its message out to the public.
So how did things turn so bad so quickly? It probably started with a letter reminding the hospital's 215 physicians that the renewal of privileges depended on their agreement to practise within “fiscally prudent” parameters.
Dr. Douglas Cochen accused the hospital board of trying to “blackmail physicians, telling them they have to choose which patients to look after.”
No matter that June Lemmex, the board chair, had always insisted that “we have not and will not turn mums-to-be away.” No matter that the hospital was deeply in the red and that budgetary chaos at the Ottawa Hospital had recently resulted in the suspension of that hospital's board. And no matter that the Queensway–Carleton's chief of staff had been pressing the obstetrics department to estimate how many deliveries it expected to handle in 2001/02. Dr. Paul Legault, its chief, would not provide a figure. The obstetricians insisted that because the birthing centre had been built to accommodate 2700 births annually, that figure should be used. However, births are nowhere near this level and the board felt that the hospital had neither the staff nor the money to handle that number.
The situation deteriorated throughout the fall, and in late November confidential hospital documents began appearing in the Ottawa Citizen, sparking the public demonstration. “Once those pregnant mums began demonstrating, the board had lost the media battle,” admits Dr. Ron Vexler, the chief of medical staff. “No hope of dialogue with the obstetricians was left.”
This debacle raises important national questions about whether hospital boards filled with volunteers and focused solely on their own institutions should decide where services are provided and funded. “All the hospitals need to work together to decide how to allocate resources,” says Lemmex. “We've got to stop the turfing. But at present, we don't have those mechanisms.”
How did this situation get so nasty? The story begins with the wrenching changes demanded by the province's restructuring commission in 1997. The shake-up included closure of the Grace Hospital, which had handled 1600 deliveries annually; that obstetrics department was then absorbed by the Queensway– Carleton, a full-service community hospital. “There was a culture clash,” explains Lemmex. “I think the obstetricians had difficulty understanding that there are other services here, such as surgery, which are of equal importance.”
The hospital was also facing acute fiscal pressure. Opened in 1976 to serve a local population of 125 000, it now served 400 000 area residents. Emergency room visits had doubled to 60 000 a year, and by early 2001 the hospital was heading for a deficit of $14.5 million on its identified revenue of $60.1 million. Since the problems were caused by patient volume and not poor management, the province allotted an extra $12.5 million, but the board still had to bridge the remaining budget shortfall. The obstetricians remained adamant that they could not forecast the number of deliveries. “We had 7 eager obstetricians, and obstetrical programs in community hospitals elsewhere in the Ottawa Valley were collapsing,” explains Vexler. “The board felt we must control growth of the programs. But the obstetricians refused to engage in dialogue.”
He responded with a letter indicating that renewal of privileges would depend on a written statement agreeing to whatever number of deliveries “is determined to be sustainable by the Board according to our financial situation.”
This implicit threat lit the fuse. Internist Charles Shaver collected ethical opinions from 3 separate sources, and all suggested that the obstetricians faced “a serious ethical dilemma” because their duty to their patients' best interests conflicted with the hospital's fiscal policies. Vexler withdrew the letter in December, and he and Lemmex now concede that it was a mistake to have sent it. However, they say there are few levers available to boards struggling to stay within budget if physicians will not consider the fiscal health of the whole institution.
“Physicians should not have to make decisions about allocation of resources,” responds Shaver, who suggests that the ministry must provide adequate funding at whatever level physicians and their patients deem necessary. And if the dollars simply aren't there? “Well, they'll just have to raise taxes, I guess. Or maybe introduce a mixed public-private system for certain tests and procedures.”
In the meantime, the furore has simmered down, with the Queensway–Carleton projecting 2460 deliveries for 2001/02. But morale has suffered, and issues of trust and confidentiality within the once tight-knit medical staff worry Vexler, whose 7-year term ends in March. “Where will the brown-envelope routine stop? Will it spread from confidential discussions on policy to confidential patient care records?”
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