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Health Care - Time for Transformative Change

I come to health care issues by virtue of my position as Deputy Chair of the Senate Standing Committee on Social Affairs, Science and Technology. The word health doesn’t appear in the title, but this is the committee that covers health care matters for the Senate. For example, the much acclaimed ‘Kirby Report’ was produced by this committee under the chairmanship of Senator Michael Kirby.

In March of 2012 we produced a report titled ‘Time for Transformative Change’ which was, at the request of the government, the statutory review of the 10 year plan to Strengthen Health Care, or as it is more commonly known, the Health Accord, signed in 2004, and focusing on collaboration between the federal/provincial/ territorial governments on health care reform.

We found that the Accord did provide the health care system with stable, predictable funding for a decade. It also outlined a new jurisdictional flexibility in managing health care that established joint responsibility for the development of health strategy goals and benchmarks. It also showed that a focused commitment, especially on wait times, can lead to improvements.

However, we also found that real reform of health care across the country has not occurred; despite more than a decade of government commitments and increasing investments.

We still have a system that is stuck in the past; a system for example, that is designed primarily for acute care, even though 58% of health care spending today is for chronic care. Governments haven’t progressed enough in such areas as primary care reform, home care, chronic care management, prevention, establishing electronic health records, and pharmacare coverage. And because of this we have great inefficiencies in the system that drives up costs and slows down access.

Compared to other developed countries, we have middling results or outcomes (notwithstanding the excellent work of most health practitioners), and, at the same time, one of the costliest systems in the world. Or as Jeffrey Simpson said in his book ‘Chronic Condition’, “we have a Chevrolet system at Cadillac prices”

Canadians want 21st century health care that meets their needs, not the needs of the population 30 or more years ago. 

So what needs to change?

First and foremost, we need governments working together. Collaborating to bring about health care Canadians want and deserve. The federal government shouldn’t just dump money on the table and then walk away as the Harper government is now doing. They need to be a full partner with the provinces and territories in pushing change.

To make change we need incentives. Incentives to break down the silos that block our path to progress. Incentives that better integrate health care services and advance innovative ideas to make the system more efficient and effective.

Our first recommendation was that any increases in funding be used to transform health care, to ‘buy change’. Proposals to tinker at the edges or to tweak the status quo belong to yesterday. We need to drive real, system-wide change and we need a national partnership with supporting political will to get there.

We recommended the creation of a Canadian Health Innovation Fund that would spread promising practices across the country. We can’t continue to be the land of pilot projects; we need the efforts that are working being implemented to better serve Canadians. And part of that is developing a patient centred culture, making patients’ needs and perspectives central to these reform efforts.

One of the main ways to reorganize is to make better use ‘multi-disciplinary teams’, of doctors, nurse practitioners, social workers and others that work together outside the hospital setting to support patients with their health issues. This will not only provide better care but it will reduce the need for costly emergency room visits. As will greater use of tele-health.

Also there needs to be increases in homecare, with supportive services. There are far too many people who languish in hospitals for extended periods but who would be better served elsewhere. The Canadian Wait Times Alliance estimates that one in six hospital beds are taken up by these so-called "bed blockers." Here we have called for a pan-Canadian Homecare Strategy.

Some progress is happening in parts of the country but much remains to be done. Key challenges such as current remuneration models (fee for service) for physicians, the lack of governance to manage and steer systemic reform efforts, limited joint training of health professionals, and insufficient use of electronic health records need to be overcome.

We also called for a broader view of health which sees physical and mental wellbeing as inextricably linked.  For too long, mental health has remained in the shadows. We need to bring it into the open, remove the stigma and make sure Canadians receive the help they need.

We also know there is a strong connection between being poor and having poor health. For example, a Hamilton, Ontario study found that two neighbourhoods, separated by just five kilometers, one high income and the other low income, had a 21 year difference in life expectancy.  If the low income neighbourhood were a country it would rank 165th in life expectancy, just behind Mongolia. That is shocking! How could such a difference exist in one of the richest countries in the world?

We also know that the poorest quarter of Canadians uses twice the health care services as those in the wealthiest quarter. A child born into poverty has a greater chance of dying in infancy and, if the child lives, is likely to have a lower birth weight and more disabilities. As they grow, they are more likely to l suffer from poor nutrition and poor health. As adults, they will have higher rates of chronic illness.

This situation is costing the system a lot of money. According to the Public Health Agency of Canada, one in every five dollars spent on health care in Canada is attributed to socio-economic factors such as income.

So we need to do more to alleviate poverty, and to provide adequate and affordable housing. It will not only provide better health and care for Canadians but also save money in the system.

And nowhere is that more evident than in aboriginal communities where the social determinants of health must be addressed with urgency.

We also need more done on prescription drugs. In 2006 the federal government walked away from creating a national pharmaceutical strategy that would have expanded drug coverage for Canadians. Instead prescription drug costs are as much as 50% higher per capita in Canada than in other developed countries. And prices are rising. Many Canadians had to pay out-of-pocket for medications, with some paying as high as $20,000 a year for certain drugs. While others forego filling prescriptions because they simply can’t afford them.

To fix this we recommended that governments get back to the table and negotiate a national pharmacare plan based on the principles of universal and equitable access for all. This also makes economic sense as studies show a national program under a single buyer would be less expensive than what we have now.  

These are just some of the 46 recommendation we offered the federal government. I believe our Report offered the right prescriptions for change.

So how do we pay for these reforms, you may ask?

If we make the changes outlined above, Canadians will get health care much more relevant to current day needs. Many expert witnesses testifying before the Committee said that resources currently committed to federal, provincial, and territorial health care systems were sufficient to provide Canadians with a high standard of quality care. These changes are about spending smarter to make the system for efficient and effective.

But there are other possibilities.

For example, in hospitals, we should look at ‘activity based funding’ where funding is based on how many patients a hospital treats. Almost all OECD countries have this type of funding. And studies show that this will lead to greater efficiencies where patients move through hospitals faster and wait lists decline.

Another option that shows promise is increasing specialized clinics for common surgeries. Current examples include the Shouldice Clinic that is renowned for hernia operations or the Kensington Eye Institute that does cataract surgery. Or similarly, the Southern Alberta Eye Center in Calgary.

This specialized care has been going on for years. It is all within the system, and paid for by Medicare.  It provides high-quality care that is timely, accessible and affordable.

Finally, if necessary, there is the option of instituting or broadening health care insurance premiums. 

One example, is individuals and possibly employers could be required to pay a monthly amount that is scaled to earnings, perhaps similar to the Canada Pension Plan. This could be used to cover the cost of new or expanded health services. This could bring in much needed money for strapped provincial budgets, where health care spending is almost 50% of their budgets and growing. That in turn would cut down the competition in provincial budgets that squeezes other vital programs and services, like education and public transit.

Many European countries already use insurance funding to finance parts of their system. Their citizens are okay with these schemes because they clearly see the connection between premiums and benefits.

It has also been done in Ontario. Many predicted immense public backlash when the provincial government introduced a premium in 2004. But the government has been reelected a couple of times since then.

In closing, the 2004 Accord was signed with great fanfare and genuine hope. Hope for progress in key areas. Hope for shorter wait times and better access to needed care.

In some areas, those hopes have been realized. But in many others we still have some distance to go.

Canadians deserve quality care, delivered promptly, safely, respectfully, affordably, and equitably. We need the right incentives for change. A clear path to take us forward. And the political will to act. Let this be the moment when we begin the truly transformational change our health care system desperately needs.