An 85-year-old woman is being sent home from hospital today. She had pneumonia, spending five days on oxygen. It was complicated because she already had heart failure and diabetes. Her medications were adjusted. She needs a walker. She lives alone. Her son is a two-hour drive away. She’s scared.
A version of this story plays out in hospitals across Canada every day. Our hospitals are failing to provide what patients truly need when they leave; the tools to reclaim personal responsibility.
A hospital admission works on three assumptions:
- Patients come to hospital for a perceived health need that cannot be managed elsewhere;
- Triage protocols weed out those who do not require hospital care; and
- Patients, if capable, will reclaim personal responsibility when they leave.
When a patient satisfies the first two assumptions, requiring hospital admission, a temporary dependency is created. This results in a transfer of responsibility from the patient to the hospital, for their immediate and future health. The vehicle for this shift is trust. Hospitals willingly accept this, as they house talented professionals who’ve spent their working lives preparing for these situations.
After their hospital stay, a patient ideally returns home, resuming independence. Doing so requires satisfying the third assumption. However, transferring responsibility back is not so easy. In hospital, responsibility is spread across multiple actors, all adept at their craft. Upon discharge, responsibility is placed solely on the patient and, if fortunate, their informal caregivers. The vehicle for this transfer is not trust; it is empowerment.
This is where hospitals are failing. They are right to assume that patients reclaim personal responsibility, based on the principle of autonomy. They are wrong to expect this will be done willingly or easily. The result of inadequate empowerment is a patient being woefully unprepared to manage themselves at home. More importantly, it leads to preventable human suffering.
What prevents hospitals from empowering patients? An overwhelming focus on money. In our publicly insured system, governments carry the financial risk for hospital care. To control spending, governments legislate hospitals to balance their books, working within constrained budgets. So, hospitals cut costs. Common tactics include closing beds, cutting staff, and reducing length-of-stay. Patients are sent home as soon as possible. There aren’t enough staff with enough time to help patients understand their transition home.
Lack of control over the entire spectrum of care is another challenge for hospitals. Frail elderly patients often require home care, convalescent care, or nursing home care after a hospital stay. Hospitals are at the mercy of third-party agencies, who control these resources. Staff can never be sure what a patient will be offered. Instead, they hope that a patchwork of services will materialize following the patient’s departure.
There is opportunity on both sides of the responsibility gradient. Patients must accept that hospitals cannot solve all of their health problems, and, so long as they remain capable, the onus for ongoing health maintenance will fall back to them. Funders and health professionals can help with this messaging. It should also be understood that although one can freely choose not to take responsibility, such a decision does not obligate anyone else to accept it.
On the hospital side, a critical eye should be cast on the alignment between stated values and daily reality. The search would quickly uncover routine instances where patients are not the foremost concern. Leaders must confront what is found with integrity and the desire to do better.
In a nation that prides itself on publicly funded health care, it is understood that society protects the health of its citizens by carrying the financial risk. This allows individuals to act without concern of financial ruin from health crises. This costs governments tremendously, but it is a business they ought to be in. The final opportunity is at this level. Governments are uniquely positioned to redirect the focus from balance sheets back to patients. If done, hospitals could properly afford to empower patients, resulting in healthier citizens and a more productive society.
