Cutbacks loomed during cancer crisis, N.L. inquiry told

A newly formed Newfoundland and Labrador health authority was asked to cut millions of dollars in its budget just as it was grappling with problems in breast cancer testing, a former executive says.

George Tilley, the former chief executive of Eastern Health, also testified Friday that legal advice was not the main reason the authority decided not to inform cancer patients by mail that tests used to determine their course of treatment might have been wrong.

Tilley told a judicial inquiry, which is examining what went wrong with hormone receptor tests used for breast cancer patients' treatment over an eight-year period, about how Eastern Health's first months in 2005 involved not just massive reorganization, but intense cost restraint.

"Six months into the role, I still hadn't seen a way to achieve the original targets that were set upon me," Tilley told Justice Margaret Cameron, who is presiding over the inquiry.

Tilley said he was asked to find between $8 million and $10 million in operation savings. Eastern Health was formed from the merger of six hospital, nursing home and community health boards, and also took in a cancer treatment board responsible for the entire province.

Cancer test problems clear by July 2005

In 2005, the Newfoundland and Labrador government was still intent on trimming spending. By July of that year, Eastern Health officials were aware of serious problems with tests of estrogen and progesterone receptors, with patient samples dating back to 1997 potentially at risk.

Tilley told the inquiry, though, that much of his work that year dealt with bringing together dozens of hospitals, nursing homes, clinics and offices spread across a large geographic area.

Tilley said when hospitals in the capital city came together under the former St. John's Health Care Corp., it took considerable effort for that organization to find its feet.

"Year seven or eight, the organization start[ed] to feel that it was coming together and we were talking the same language," he said.

"This one was even more complex, because we were dealing more than just hospitals. We were taking on a much larger continuum of care," Tilley said.

"Plus we had a rural element that I had not had any exposure to until that point in time."

Tilley — who had previously testified that he did not ask government for extra lab resources when the problems with the hormone receptor tests were being detected — said he had misgivings about the Newfoundland and Labrador government's expectations. At one point, he sent an e-mail to a government official warning about moving "in the wrong direction."

Legal advice not key to decision: Tilley

In other testimony, the inquiry focused, sometimes quite sharply, on why it took so long for Eastern Health to contact patients, and why patients were not told in writing about their problematic hormone-receptor tests.

The inquiry had already dealt with an October 2005 letter by St. John's insurance lawyer Daniel Boone, who advised against sending a letter at that time because of the risk of litigation. By that time, the basis of what would become a class action lawsuit had already been registered with Newfoundland Supreme Court.

Even though Tilley informed his board of trustees the following day that Eastern Health would instead be contacting patients by phone, he testified Friday that legal concerns were not paramount in this decision.

"It was a judgment call that we felt was the best way to make contact," Tilley said. "My preference from a very early stage was the inappropriateness of a letter being sent to a patient, and how that might impact a person who's opening that letter and having to deal with that disease as it is."

Tilley came in for intense questioning about the process of making that decision. When Tilley testified that the process of sending a letter would be "a significant amount of work," co-counsel Bern Coffey — who has frequently used an aggressive style of questioning with Tilley — went on the offensive.

"A letter had already been drafted," Coffey said. "So, if a form letter exists — 'Dear patient' — and if you have a mailing list, you just merge the two, don't you?" Coffey told Tilley.

"You impose the addresses on each individual letter, and then have people put it in an envelope, seal the envelope and bring it to the post office," Coffey said.

As well, Cameron herself jumped into the fray at several points to question whether Eastern Health had genuinely worked out a realistic plan for contacting patients.

"Not to prejudge this kind of thing, but from what I have seen so far, there's not a lot of indication that that was the case," Cameron told Tilley.

Patients might react differently: Cameron

Cameron also questioned whether phoning patients was necessarily the best tactic for all patients.

"It would seem to me … that some people on getting a call like that would be cool, calm and collected and say, 'What does this mean?' and ask a whole lot of questions," Cameron said.

"Other people might take a longer period of time to absorb what's going on and then [wonder] two hours later, 'Why is this happening and why didn't they know it before and what does this mean for me?' " Cameron added that some patients would likely want to call back and that "there would be a lot of personal contact."

Tilley agreed, and said patient relations officers would connect patients with the appropriate provider. However, Tilley acknowledged that the work he expected could be completed quickly ended up taking months.

The Newfoundland and Labrador government has acknowledged that the process of initial contact and informing patients of results has been time-consuming, and that some patients have fallen through the cracks.
 
Earlier this month, the government's task force on adverse health events said that 24 patients had not yet received the results of retests, and that one patient had not been contacted at all.

The inquiry has been told that Eastern Health executives and medical staff had strong differences of opinion about contacting patients, as well as about informing the public at large.

The health authority did not start phoning patients, including through their physicians, until after the issue surfaced in media reports.