A JIT health care system. (Comments).

Just-In-Time systems are found in many manufacturing industries. JIT assures that enough supplies are available in the manufacturing process at the time they are needed. Day and night tracks transport supplies where needed, creating savings on the costs of inventory and spoilage. A good but not perfect system since traffic problems and inclement weather sometimes cause production delays.

The recent SARS crisis in Toronto indicates that Canada's health care system is being run on a just-in-time basis and that it works badly when something unusual occurs.

SARS is a new infection that was brought to Toronto from Hung Kong by one person (the "index" case). Because of the problems in identifying the infection early, the disease spread. To be cautious, thousands of "probable" or "suspected" cases were quarantined for 10 days over two months and most of these cases were health care workers (including doctors, nurses and emergency service workers) and their families. Though relatively few developed serious illness, the precautions were deemed necessary.

SARS in Toronto was a largely hospital centred infection. As the Center for Disease Control in Atlanta advised: visit Toronto but don't go to a hospital. To control the infection several hospitals were closed completely, and others had to curtail all but the most urgent procedures. Quarantine removed large numbers of nurses and emergency service workers from the system. With police and security at the entrances, access to hospitals by families and friends was extremely limited, leaving many patients alone, without the healing support that such contact brings, or the ability of families and friends to monitor their care.

The SARS crisis brought home the serious inadequacies of the health care system that we have created with our "reforms" over the past seven years. Staff has been cut to the barest minimum and to exacerbate the stresses and strains, half the nurses were put on a part-time and on-call basis ("on-call" is the health care version of just-in-time).

Many part-time and on-call nurses worked in more than one hospital in order to earn a full time living. When SARS arrived, this had to be cut back out of fear that the part-timers would spread the infection from one institution to another. Effectively, fewer staff were available. Waiting lists for treatment were delayed long before SARS came on the scene, and the additional delays caused by the SARS infection have made those waiting lists even longer.

While health care in Ontario and Canada is very much a just-in-time system, it is not timely for patients. It seems to work, if at all, for the provincial health politicians and their advisors. The pattern in Ontario is that the Premier or the Minister of Health announces a new reform--be it a program or funding arrangement. This is followed by a budget announcement of the same thing, which is then followed by an allocation announcement that shows up in the provincial books as if funds have already been spent. After that, there are further announcements when the money is actually spent, a few years later. Just-in-time means just before the next election. All of this is very confusing because one dollar spent sounds like four. Ordinary people ask: if so much money is being spent on health care, why are there so many problems? A forensic accountant is needed to answer this question.

The chickens have come home to roost with the SARS epidemic. The health care system had been reigned in so tightly by seven years of so-called reform that the impact on the morale of people who make the system work has been a negative one. A bad situation became worse.

The health care "reforms" of the past seven years have chased tens of thousands of nurses and other health care workers out of the field. Now, provincial governments are trying to recruit them back, as well as looking to recruit additional staff from overseas. But Canada was not alone in its foolishness. Many other countries instituted the same "reforms" and now they are all competing with each other for health care workers. Almost every developed country is recruiting trained health care workers from the same pool of underdeveloped countries, a situation fraught with bad management and questionable ethics for all countries concerned.

A review of the management of the SARS crisis is now underway. We ask that this not be limited to a technical analysis of medical matters alone, but that it deal with the preparedness of our health system to handle such crises in the future.

--L.K.