Medical Silos

I remember working in Northern Ontario, on a reserve, on an island. Most people lived on the coast but the physicians were based on the island. Medevacs had to first land in the bigger Provincial airport on the coast, then be transferred to the Federal hospital by helicopter. It was a historical arrangement, but it made little sense—we lost time, resources, and sometimes patients.

This experience is not unique. We do not have a single health care system—we have many systems under the guise of one. Different Canadians, at different parts of their lives are served by separate, siloed systems, dictated by our unique Provincial-Federal divide.

I am not only talking about moving between provinces. Many of my patients in Ottawa actually come from Western Quebec for care. I offer my services knowing of the shortages next door, despite the logistical constraints. It’s an acceptable arrangement, as the constraints are—we do not want to remove the moral imperative of individual Provinces to look after their own citizens.

Rather, I am talking about the divides between the Provincial systems and the Federal ones, for inmates, soldiers, First Nation populations and refugees.

Let us follow a refugee through their journey to Canada. Let us say they are fleeing Syria (or South Sudan, or DRC…). It is not a seamless journey: first, there will be an immigration medical exam in the source country to screen for urgent conditions. That is a Federal responsibility and most of the information is not (cannot, under current legislative limitations) be transmitted forward to the Provinces. Then, the refugee is given Interim Federal Health Coverage for their first year in Canada. The package is generous, notably for mental health concerns, but these tend to present after the first year after arrival, once the acute stressors of migration have stabilised and the long-term realities of integration set in. But this is precisely when IFHP is replaced by the various Provincial plans, with much lesser coverage of mental health counseling.

Just as the most dangerous time for a hospitalised patient is during times of handover between treating physicians (1), so are these transitions perilous for refugees. The flow of information is lacking. There is little coordination. And the same could be said of patients transferring between different silos within the “system”: between a First Nations reserve and a provincial municipality, transitioning to or from the penitentiary system, or to or from the Department of National Defense.

I am not naïve. I have worked in most of the silos. I know that funding streams for all the separate parts flows separately. But I think we need to have a better sense of the whole. How else do we compare needs and vulnerabilities? How else do we plan and prioritize?

Recent attempts at highlighting mental health needs and securing provincial commitments by the Minister of Health are laudable (2). Similar attempts are under way to better coordinate care on Reserves. It is the first time in recent memory that the Federal Department is setting a tone and setting priorities. But much more has to be done, by all of us, to simplify and unite the system into a coherent whole.

1. Ladouceur R. Are attending physician rotations costing hospitalized patients their lives? Can Fam Physician [Internet]. 2017 [cited 2017 Apr 27];63(4). Available from: http://www.cfp.ca/content/63/4/264

2. Sibbald B, Eggertson L. Budget promises more mental health and veterans’ care. CMAJ [Internet]. 2017 Apr 10 [cited 2017 Apr 28];189(14):E549–50. Available from: http://www.ncbi.nlm.nih.gov/pubmed/28396338

Photo Credit: Couvrette/Ottawa