Paul Dobrovolskis had just come back from vacation to his job in the emergency room when an official at the Greater Niagara General Hospital called with an ultimatum: Either go along with a new work schedule or leave.
"That was the final straw," Dr. Dobrovolskis recalls.
He decided he would go - but not quietly. In a letter of resignation circulated widely in the community, he declared that, because of constant cuts to its budget, the hospital where he had spent 14 years was "dying a slow death."
Similarly fed up, three of his colleagues followed suit, leaving just two-full-time doctors on the emergency ward's staff.
Their exodus highlights the depth of the discord within the Niagara Health System, a sprawling network of seven hospitals serving 434,000 people in a dozen communities. Doctors have passed a vote of non-confidence in its leadership, residents have protested in front of the Ontario Legislature and four municipal councils have called on the province to intervene.
But the conflict is more than just a tempest in a local teapot. It is classic example of the negative fallout from the fact that hospitals across Canada are on the front line in the battle to maintain the nation's health-care system.
Under pressure, hospitals are cutting services and redefining - critics say undermining - their traditional role as providers of one-stop care.
"What's getting lost amid the emotion is the reality …," counters Niagara Health's chief executive officer, Debbie Sevenpifer. "Medicine is more high tech, our population here in Niagara is older and sicker, and we have a national shortage of doctors and nurses."
She is referring to three leading reasons for the rapid increase in spending that saw health care account for $183.1-billion in overall spending last year. That amounts to $5,452 for every Canadian, and roughly 12 per cent of the gross domestic product - an all-time high and almost twice the 7 per cent seen in the 1970s.
This week, Statistics Canada announced yet another rise in life expectancy: Babies born from 2005 to 2007 will live an average of 80.7 years, up from 78.4 a decade earlier. That is very good news, except that governments, which picked up $129-billion of last year's tab, spend five times as much on caring for seniors as for the population as a whole,.
"We have a demographic tsunami headed our way as baby boomers get into the age where they'll be requiring more health care," says Deb Matthews, the Health Minister in Ontario, where health consumes 42 cents of every dollar in program spending.
Yet governments at all levels seem determined to avoid a public debate on how to sustain a system many Canadians appear to take for granted.
In a report this month, Parliamentary Budget Officer Kevin Page warns that, to cope with the changing demographics, the country must cut spending or raise taxes. The federal government will table its budget next Thursday and, despite pressure from such think tanks as the C.D. Howe Institute, says it has no plans to cut health spending. According to Mr. Page, it hasn't even begun to address the demands of its aging population.
Why? Perhaps because, as Friday's Ipsos Reid poll for the Canadian Medical Association shows, Canadians want Ottawa to attack the deficit - but only 16 per cent support cutting health to do so.
In contrast to the silence here, the debate rages in the United States, where President Barack Obama clashed with congressional Republicans this week during a live televised summit on how to fix their troubled system.
But the need to address health care becomes "more desperate by the minute," says Duncan Sinclair, professor emeritus and dean of medicine at Queen's University who led a restructuring of Ontario's system in the 1990s.
"The only comfort in all of this is, yes, we have to deal with it, but not as urgently as the United States," he says. "That's pretty cold comfort."
About 20 cents of every dollar the provinces spend on health comes from Ottawa, and federal Finance Minister Jim Flaherty has said the transfer payments won't be touched in next week's budget. They are slated to receive annual increases of 6 per cent until the fiscal year that starts on April 1, 2013.
After that, however, things may very well change in the battle with the deficit.
If the federal government reduces its payments, the provinces will be hard pressed to pick up the slack. Except for Saskatchewan, they are heading into budget season deep in deficit, and unwilling or unable to keep pace with rising costs, leaving many hospitals awash in red ink.
The situation is destined to get worse, but for now provincial governments appear content to address their problems in an ad-hoc fashion.
This month, Alberta provided $759-million in one-time funding to erase the deficit of its health-care agency. Facing public pressure, it also retreated on plans to close acute-care and rehabilitation beds at an Edmonton hospital.
In British Columbia, the Fraser Health Authority is trying to cut $160-million from budgets for its 12 hospitals by April. It will close a six-bed psychiatry unit for adolescents in Abbotsford this year and 10 beds at an addiction-treatment facility in Chilliwack, but has dropped controversial plans to reduce emergency-room hours in Mission.
Even in Ontario, hardest hit by the economic downturn and especially keen to contain costs, the government has quietly topped up funding for several cash-strapped hospitals. Just last week, Niagara Health received another $14-million, all but erasing its deficit.
With a shortfall expected to reach $24.7-billion this year, Ontario has launched the biggest restructuring of hospitals since the mid-1990s cuts of Premier Mike Harris.
As a result, health-care insiders say, hospitals are making major decisions even though there have been no policy statements on what type of system works best, how far patients should be required to travel and what services medicare should cover.
The 10-year strategic plan the province was supposed to unveil early in 2007 remains unfinished, and the Health Minister acknowledges that "we really do need to have a more thoughtful conversation about ... what we need to do to make sure that the health-care system that we value so much is there for the next generation," Ms. Matthews says.
However, governments are less inclined to engage the public in a discussion about health care when they lack the resources to meet its expectations, says John Church of the University of Alberta's School of Public Health.
The gap between "what the public wants and what governments feel they're in a position to give" is widening, he says.
Bureaucrats insist that changes they are making are all about improving the care the public receives as medicine becomes more sophisticated and highly specialized. But that's a tough sell when cutting costs is the real goal, says James Ducharme, chief medical officer of AIM Health Group Inc., which helps hospitals find temporary doctors for their emergency departments.
"What you're doing," he says, "is choosing what health care you offer by budget cuts rather than having a global vision of how to spend money."
Cuts can backfire
Niagara Health's experience shows how trying to save by streamlining services can have unexpected consequences, leading to a disgruntled work force and, in some cases, even greater expense.
Its current difficulties were triggered by plans in late 2008 to save $28-million by converting hospital emergency rooms in Fort Erie and Port Colborne into around-the-clock urgent-care centres - essentially walk-in clinics. As well, it is closing beds for patients with chronic illnesses and consolidating services for mothers and children at one site.
But the Niagara strife is rooted in the 1990s, when the Harris government's Health Services Restructuring Commission oversaw the biggest shutdown of hospitals in Canadian history. It closed or merged 35 facilities, with Niagara's amalgamation the biggest of all: seven hospitals under one administrative roof.
But the communities affected weren't pleased, says Ms. Sevenpifer, Niagara Health's CEO. "It was essentially a shotgun marriage. That sort of laid the groundwork for some of the difficulties we faced."
She insists that many of the changes now being made truly are designed to improve the quality of care - an argument that fails to impress the parents of Reilly Anzovino, a Fort Erie teenager who died after being involved in car accident on Boxing Day. They have joined calls for a public inquest to determine whether their daughter might still be alive had the local emergency room still been operating and made a longer trip to the hospital in Welland unnecessary.
Even as a budget exercise, opponents say, converting the emergency rooms has failed. Niagara Health will save more than $1-million, but area municipalities and the province will spend an additional $3.1-million on ambulance service.
As well, documents obtained by The Globe and Mail show that keeping the emergency department at Niagara General staffed has required bringing in doctors from temp agencies - something usually done only as a stop-gap measure.
In this case, the part-timers are taking one-third of all shifts. They earn the same wages as staff doctors and are paid through medicare. But hospitals who use AIM Health, a private company formerly known as Med-Emerg, must pay a service fee and pick up any travel costs.
AIM has contracts with 29 hospitals in Ontario, often bringing in doctors from other provinces, and its services do not come cheap. According to an agreement with Niagara Health dated April 1, 2008 (well before the doctors resigned), it charges $500 for providing someone on less than 24 hours' notice as well as $30 an hour when it bills more than 150 hours in a month.
Ms. Sevenpifer calls the hiring of temporary staff "a normal cost of doing business," but she says AIM fills only a "few shifts." Most of the fill-in doctors, she says, are supplied by HealthForceOntario, a publicly financed agency whose overhead, travel costs and even incentive fees for remote assignments are covered by the province. According to its website, however, the agency's doctors are "an interim measure of last resort."
The resignations of Dr. Dobrovolskis and his colleagues came after Niagara Health announced that it was releasing a consultant's report saying the medical staff faced a risk of "burnout" because they were seeing too many patients. "It would be impossible," it states, "for the physician to deliver appropriate care, given the time constraints."
Niagara Health had commissioned the report from Hay Group Health Care Consulting because it anticipated that patient traffic in Niagara Falls would increase after the emergency rooms in Fort Erie and Port Colborne closed. But the doctors, who were putting in four long days followed by six days off, liked the status quo and fought Hay's findings.
A critique written by Kevin Speight, one of the doctors who resigned, says the report contains "glaring flaws in logic," adding that doctors were seeing an average of 4.75 patients an hour, which falls within the acceptable range of 1.8 to 5 patients an hour.
The doctors also sought input from the Ontario Medical Association's emergency medicine section, whose investigator, Myron Haluk, reported that they had run a stable, fully staffed operation for years. They acknowledged that changes were needed to deal with the influx of new patients, but insisted that a shortage of beds was the real issue. Patients waiting to be admitted were taking up space in emergency and forcing others to wait for treatment.
As well, the doctors bridled at the news that they would no longer be allowed to arrange their own hours - that duty was to be handled by Niagara Health, which has centralized its scheduling and now moves staff from one hospital to another.
Officials say the system is designed to be collegial, but that is not how it felt to Dr. Dobrovolskis when he was asked to fall into line last summer.
Tensions escalated after he led the OMA's Dr. Haluk on a tour of the ward. In a letter dated Sept. 28, Niagara Health's interim chief of staff, Joanna Hope, criticized him for disrupting the department.
"It is with great sadness," she concluded, "that I find myself obliged to write this letter and to accept your resignation from the medical staff."
But by then Dr. Dobrovolskis was already gone. His last shift had ended nine days earlier.