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01/28/2019 11:23 EST | Updated 01/28/2019 11:41 EST

Removing Services From Vulnerable Communities Is Bad Medicine

The communities that lose out in these situations are invariably the smaller ones.

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Earlier this month, a large group of doctors held a protest outside Scarborough Birchmount Hospital over a proposed plan to close the obstetrics and pediatrics wards. Speaking to media in the cold January air, emergency physician Dr. Lisa Salamon said, "Closing these essential services to an already vulnerable patient population is actually creating barriers for the care that they need and deserve." The ultimate plan is to move those wards to Scarborough General Hospital, the largest of the three hospitals within the Scarborough Health Network.

The proposed move follows a familiar pattern in Canadian health care that I've written about before: merge multiple hospitals together under a single managing entity, then slowly cannibalize the services of the smaller hospitals by moving wards and specialist care to the largest centre. The result is often the degradation of a vibrant general hospital with a multitude of services to an empty shell of its former self, forcing members of the local community to travel to the large, central hospital to receive care.

The communities that lose out in these situations are invariably the smaller ones. In the case of Scarborough Birchmount, it's the region of North Scarborough, a community with the lowest income and highest number of new immigrants in the entire Central East LHIN. It's well-established that poverty is a strong marker for worse health, and we often see clustering of poorer neighbourhoods outside of urban centres, as downtown living can be prohibitively expensive for lower-income families. So it goes completely against decades of evidence on poverty and health to remove services from the communities with the highest needs.

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In a previous blog, I wrote about this trend in rural communities, such as the one I work in where three of my local hospitals have seen wards closed and services moved to the largest facility inourfour hospital network. In an odd twist, Dr. Dick Zoutman, my former chief of staff at Quinte Health Care who oversaw some of these developments is now working in the same role at the Scarborough Health Network, where he defended the proposed removal of obstetrics and pediatrics by saying, "we believe that the services, while they may be located in the different locations, would still be highly accessible and will be even better quality by being able to consolidate those services."

This is a commonly made argument: that by consolidating services in the central location that has the highest volume of service delivery, care overall will be improved. Indeed with services like obstetrics, quality of care does depend on providers keeping their skills sharp and attending a minimum number of births. But what exactly is that minimum number? And how do we arrive at similar metrics for other types of care? More importantly, how do we balance that concern with data showing a direct relationship between distance travelled to access care and negative health outcomes?

Despite the spin on improving quality of care by consolidating services, the bottom line is that these are cost-cutting measures. This, too, is often spun as an efficiency and a supposed benefit of hospital mergers. But time and time again, this type of efficiency leaves smaller, more rural and poorer communities out in the cold. Can we save money by merging administrative offices and bringing multiple departments under a leaner and more centralized management? Certainly. But the removal of medical services is not an "efficiency," unless the argument that you're making is that smaller communities are over-supplied and have an excess of care. We will always save money by funding less health care. And it behooves our health care leadership to be honest about when that is happening rather than spin it as a positive development.

Canada's geography presents unique challenges for health care delivery. We are a sparse nation spread out over a vast landscape, and our northern regions, in particular, have very low population density. Delivering health care to distant communities is a fundamentally expensive enterprise, and it's hard to cut those costs without the wholesale removal of services. The higher rates of poverty in our smaller and more northern communities also means higher health care costs. This could be ameliorated to some degree if we invested more in the social services that reduce the burden of poverty, but historically we seem to have preferred letting our "free" medicare system absorb everyone's needs.

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The community of North Scarborough may not be rural or remote, but it is demographically different from the wealthier and more urban parts of the GTA. As we have seen during the "merger mania" that has infected our hospitals over the past few decades, once a service is removed, it doesn't tend to return, leaving a community permanently disenfranchised.

Do the lower income women and children of North Scarborough deserve to lose a service that their higher income neighbours in the GTA can still access?The hundreds of doctors, nurses and staff in the Scarborough Health Network who are protesting this proposed change don't think so. They know that poverty makes patients more vulnerable to bad outcomes, and that lower-income patients tend to use the health care system more. They understand the blow that taking services away from people with disproportionately higher needs can have on their overall health.

Scarborough's health care providers, community members and local leaders are joining forces with a petition to push back against the hospital administrators who believe their own spin on consolidation. Hopefully, this time around, those in the grips of merger mania will listen.

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