The road to better health
Essays on the MILENNIUM
Is Canadian health care getting worse ? Or is it simply changing? In this essay, Toronto health consultant and writer Michael Deder, who served as Ontario’s deputy health minister in the early 1990s and is now chairman of the Canadian Institute for Health Information, argues that such distressing events as hospital closures are part of a needed revolution in Canada’s approach to care as the next century dawns.
On Oct. 4, 1998, the Calgary General Hospital was destroyed in 35 seconds by a series of explosions. The elimination of the vast, 108-year-old complex from the skyline was not the work of terrorists. Nor was it an act of God or a natural gas explosion. Rather, it was an organized, deliberate demolition carried out by the hospital’s owners, the Calgary Regional Health Authority. The 960-bed institution was simply no longer needed.
Although more dramatic than most of the more than 100 Canadian hospital closures, Calgary’s experience is a clear example of the radical transformation under way in health services. The shutdown of a hospital is traumatic for any community, large or small. Yet the transition from hospital beds to health services is essential. To treat illness with drugs rather than surgery, to conduct operations on a day basis, and to shorten stays for patients are all progress. The closure of more than 11,000 hospital beds in Ontario, fully 25 per cent of the total, is a victory for better care—if the rest of the health system is expanded and reformed to cope.
Nearly 30 years ago, my parents drove me to Cambridge, Mass., to begin my university studies. We crossed the American border south of Montreal in our Pontiac, bearing “Friendly Manitoba” licence plates. I soon spotted my first New Hampshire licence plate bearing the state motto, “Live free or die.” It startled me, providing early, tangible evidence of very different values in the United States. Our constitutional bedrock is “peace, order and good government,” a very Canadian foundation for a nation, while the American Declaration of Independence sought “Life, liberty and the pursuit of happiness. ” The values of Canadians are just as firmly entrenched in our approach to health care. In Canada, we have financed health care together. It is paid for from our taxes and given to those who need it. The Europeans call this the solidarity principle. We call it medicare.
Even so, calls to dismantle the fundamental principles of medicare come from powerful interests. Organizations led by the B.C. and Ontario Medical Associations advocate a return to private medicine. Our
two national newspapers campaign for the right of the wealthy to opt ¿ out, for the primacy of the individual above the community in health § care. But how long will the opted-out willingly share the tax burden? I Isn’t higher taxation still the price of a civilized society? °
Most Canadians still regard medicare as an essential part of the nao tional fabric of Canada. They are concerned for the health of their 2 friends and neighbors as well as themselves. Canadians are reluctant g to allow medical bills to claim a house or rob the life savings from a family, as happens so often in the United States. Canadians rightly doubt the virtues of the American approach, which leaves 40 million people without health insurance coverage.
Yet Canadians are alarmed and frightened by some of the rapid changes in our health-care system. Is Canada without medicare a real possibility? Unthinkable? Are we healing medicare or dismantling it?
In 1982, Tommy Douglas, the former Saskatchewan premier and founder of Canadian medicare, reflected on its progress. “When we began to plan medicare, we pointed out that it would be in two phases,” he wrote. “The first phase would be to remove the financial barrier between those giving the service and those receiving it. The second phase would be to reorganize and revamp the delivery system—and, of course, that’s the big item; it’s the big thing we haven’t done yet.” Now we are revamping and reorganizing. There are some tough problems. But concern and cautious optimism, not panic or fearmongering, are appropriate. Leadership and courage are essential.
Canadian medicare is not in a terminal crisis. It is undergoing necessary renovations and modernization. There is risk of erosion as care shifts from doctors and hospitals to a much greater reliance on drugs and home care. Medicare needs to expand to provide more
A revolution is unfolding in Canadian care
comprehensive coverage, as recommended by the Prime Minister’s National Forum on Health. Without expansion we risk a gradual return of the financial burden to individuals. We need to achieve the second victory without giving up our first—the removal of financial barriers.
At the beginning of the 1990s, Canada had approximately 900 hospitals. Each had its own governance board, building, management and clinical staff. Most had their own laboratory and kitchen. As we enter the new millennium, the rapid consolidation of stand-alone hospitals into 150 to 200 integrated health systems will be accomplished. Major investments will be under way in needed long-term care services and facilities. This is a positive step. Integrated health systems will link hospitals with treatment at home and care facilities like community clinics and nursing homes. In the new millennium, integrated health organizations will become the dominant institution of health-care delivery.
We had learned to rely too heavily on expensive hospitals for all our health-care needs. More integration will allow us to redirect money towards investments in health. And since technology allows us to treat many illnesses at home, we need to close more hospitals and put money into home care and disease prevention.
Canada also urgently needs to reorganize its primary,
non-hospital services. Fee-for-service general practitioners, often in solo practices, are anachronistic. In this information age, physicians must be part of a larger health-care team. As in other developed nations, we need primary-care organizations with a proper funding base. Nurses, pharmacists and other health-care professionals need to play a much larger role in clinics. Incentives must be recast to encourage greater health, not more frequent visits.
As we approach the new millennium, powerful forces are reshaping health and health care and accelerating the transition. Studying health-system change without understanding these underlying forces misses their dynamism and energy. Yet it is all too easy to lose sight of what is really happening, for any of us. During the past two summers, I have endeavored to teach my young daughter, Geneviève, to sail. The first time out, a gust of wind flipped us over. As we righted our capsized sailboat, Geneviève remarked sharply that I had said nothing to her about the wind. All of my lessons had been about the sailboat. Without knowledge of wind, one is an accidental sailor.
So it is for those managing health care: many have spent too much time working on the sailboat. Without knowledge of the winds of change, they are accidental health reformers. And we are accidental citizens. There are today
four strong winds blowing through global health systems, including Canadian medicare. They are, briefly, a different vision of health; a more demanding and knowledgeable public; new technology—in particular the chip and biotechnology; and the desire for greater affordability.
The first is a big, Canadian, but not-so-newidea: let’s keep people healthy rather than simply treat them when they become ill. This quiet, practical revolution in thought has been under way in health and health care since the 1974 Lalonde Report by thenHealth Minister Marc Lalonde. It cemented the realization that much of the health gain in the postwar era came not from enhanced spending on the treatment of disease but from a set of broader determinants which prevented disease. The credit for our new longevity belongs mainly to improvements in income, diet, housing, education, sanitation and other public policy and social factors.
And, for our species, it is a remarkable gain.
The World Bank informs us that in the past 40 years, average life expectancy grew more than it did in the previous 2,000 years.
Over the past 25 years, each of the industrial nations has tackled this issue in its own way.
Britain adopted “health gain” as its slogan and creating a healthier nation as its perspective.
The United States adopted “health goals.”
Canada is in some danger of having exported the theology of broader population health without really implementing it at home. Better late than never.
What are the practical implications of this revolution? Do advocates suggest a complete abandonment of the illness treatment system in favor of a redistribution of wealth? Not at all. The search for a framework for implementing broader health goals is under way in each province.
We have already seen an increased emphasis in Canada on “healthy” public policy. Compulsory seat-belt laws and harsher penalties for drinking and driving have done a great deal to save lives and reduce injuries. Some provinces and communities are introducing laws for the mandatory use of bicycle helmets and are cracking down on young people buying tobacco and confronting the problem of secondhand smoke in public places. Planes, trains and buses in Canada are now largely smoke-free. Generally, these intrusions by government are met initially with public resistance, but gradually become accepted social practices.
But we need a broader agenda. We need positive action on the issues that pose the greatest threats to life expectancy and health: unemployment, substance abuse, native poverty and social disintegration, obesity, hunger, poor eating habits, adolescent suicide, AIDS. As social issues, not illnesses, these cannot be cured by doctors in hospitals. Instead, solving them must be the focus of our approach to investing in our health as a nation. If we redirect our spending and follow it up with the right legislation, we can improve health where it is really decided.
Good housing policies have helped eliminate the stress and violence—and many communicable diseases—that plague overcrowded slums. And you need only look at how those problems affect the homeless to see that a good roof over your head and a safe, caring community make a great difference in your mental and physical health.
Income remains a major factor in health status. Medicare tore down the financial barrier between health care and citizens, but we’ve come to believe it has levelled the playing field in terms of health between rich and poor. I wish that were true. The truth is, the poor account for
The chip is transforming the system
a disproportionate number of our sick. Wealthier people generally eat better, smoke less, live in safer communities, exercise more and are simply less likely to fall prey to the stress and despair of poverty.
As vast investments in new drugs and technologies have yielded diminishing returns, and as disease categories such as cancer have remained stubbornly resistant to cure, attention has turned sharply to prevention. The linkage of many causal factors, particularly smoking and diet to various forms of cancer has armed health advocates with an enormous lever to move to a new approach. The idea of measuring health by the life expectancy of a population—particularly its disability-free years—has gained great momentum in the world community. No one is suggesting abandoning treatment of illness and curing of disease, but there is a much greater focus on the health of a population, the patterns of disease and the search for root causes that may be altered. This very Canadian idea is a now a global wind.
The second powerful force is the change in public expectations. Without giving up access or the other cherished principles of the Canada Health Act, Canadians want better and faster care—improved quality, speed, affordability and appropriateness. The centuries-long era of domination by doctors, based largely on control of medical knowledge, is giving way to the empowered consumer. We are the most educated generations in history. We are the first consumers who can reach out through the Internet, into a CD-ROM, into a book or through the television to obtain health information. We can understand what is confronting our bodies. We can find out our risk factors. We demand to know the latest science and medicine in real time—mybody.com.
We are confronted in every other walk of life by a rapid increase in the pace of activity. We no longer have the patience for a lineup in our bank branches—the automated bank machine has proliferated. My 15-year-old son, Riel, expects the pizza to come in 30 minutes or it’s free. When two staples in his scalp, to close a bicycle accident wound, take 3'A hours in an emergency room, he says the service sucks. The standards and expectations for speed developed in fast food, fast TV and banking are coming to health care.
In it is also an increased demand for quality. The pizza cannot be fast but cold. Quality is part of the speed expectation, not a substitute. Badly done surgery is not excused by being rapid.
As a student, I toured the great old Framingham, Mass., car plant of General Motors. At the end of the assembly line, massive autoworkers hammered doors of Cadillacs with huge rubber mallets. Only after serious pounding did the doors fit. When I asked our tour guide what they were doing, she said, “quality control.” Quality was an add-on, the big rubber mallet after the fact. Witness the success of the Japanese and German car industries that caused the shift to
Essays on the IVI ILLEIM INI I LIM
Quality as Job 1 at Ford. Quality was engineered into the product during the manufacturing process, not an add-on.
Quality control in medicine? Too often, it has been after-the-fact: the coroner’s inquest, the lawsuit from a grieving parent. It is only in the past few years that this same consumer pressure for quality and speed has come to health-care delivery. Quality has become Job 1 in medicare. Consumers will settle for no less.
As we moved through the 1980s into the 1990s, we had the rise of the outcomes movement. This is based on the fundamental proposition that it would be better to evaluate the success of medical and health interventions based on what happens in the end rather than in the beginning. This movement has fundamentally challenged the old methods of informal evaluation. If new drugs must be subject to double-blind randomized trials, say the outcomes advocates, why not look at the outcomes of all medical/health interventions? Does the surgery really work? Does the hospital stay extend life and alleviate pain? Does that new herb really cure cancer?
Public report cards detailing quality, speed and outcomes of health service are rapidly being developed. The federal and provincial governments will support the idea of quarterly public report cards for regional health authorities and integrated delivery systems. These report cards will chart the health of the local community and could be used to reward those organizations that improve their performance. They will be provided because the public demands them.
Perhaps the most profound of the winds driving change in the health delivery systems worldwide is new science and technology. Twin scientific revolutions are evident: biotechnology and digital. The science of our genetic engineering, the very core of our existence, is rapidly being unlocked. The ubiquitous silicon chip, which has transformed our ability to obtain, store and manage information, is coming to bear on health-care delivery in a myriad of ways.
Dr. Francis Collins, director of the National Human Genome Research Institute in Bethesda, Md., has commented on the progress of understanding DNA the fabric of life: “This is more important then putting a man on the moon or splitting the atom. Biomedical research will be divided into what we did before we had the human genome and what we did after.” New diagnostics and treatments will swiftly follow—as, eventually, will cures. The new millennium will witness wave upon wave of health innovation—remarkable drugs, gene therapies, new vaccines. They will stretch our imagination as well as challenge our ethical foundations and values.
Fascinating as these technologies are, the most formidable engine of change in health care may be the chip. It is transforming how we think
For most of this century our health-care delivery system has been evaluated on the basis of inputs. We measured the number of physicians, number of dollars spent, number
of hospital beds. Just about anything we could count was measured, and success was seen as building a bigger, better health system. Skepticism began to set in as it became apparent that diminishing returns accompanied much health-care spending.
about health and illness. Information, stored in vast databases, is manipulated to reveal patterns of health and illness, and to chart the outcomes from health-care interventions. To measure is to manage. So long as measurement lagged, health care remained fragmented and unaccountable. Hiere is not a single consumer device such as the personal computer to symbolize the transformation. Nevertheless, the silicon chip is embedded in everything from sophisticated diagnostic imaging machines, to electronic patient records, to handheld lab-testing monitors for the bedside, to sophisticated telecommunications devices that
allow massive labor saving. All of these innovations are chip-dependent technologies, fundamentally changing how health-care delivery is organized.
A caution from poet T. S. Eliot in ‘The Rock,” penned before the computing age: “Where is the wisdom we have lost in knowledge? Where is the knowledge we have lost in information?” Science, technology and information are complementary to wisdom, not a substitute for it.
Finally, the fourth wind: a hurricane. The ongoing fiscal crisis has led to a massive efficiency drive in health services. Health-care cost containment has been a central issue in each of the industrialized nations for more than a decade. In Canada, our case of living beyond our means was particularly severe. All nations reduced the growth of health spending in the 1990s and lived with the restructuring set off by this necessity.
New technologies, new drugs and gene therapies will produce formidable financial challenges in health service in the new millennium. Is it appropriate to pay for Viagra? For those with what degree of illness or impairment? For those who want to enhance their lifestyle? For everyone? What about Prozac and its imitators? For the depressed, where it has wrought
miracles for some? For all those seeking to be a little happier? The challenges of reconciling what is technologically possible with what we should allow and pay for together will be extraordinary. Innovation will grind away at our determination to have affordable health care. Gradually, we will allow the share of our economy devoted to health to rise. We will demand value for each new dollar as we part with it.
These four forces are bringing about a phenomenal transformation in health-care delivery as we know it. They offer the potential of great constructive change, as well as the certainty of significant disruption. Amid this reformation some things will not alter. There will continue to be loud political debate about health and health care. No election campaign will be contested without health-care issues. But all of this is very Canadian and very healthy. Silence about health care during our elections and in legislative bodies would be far more troubling.
We, the 30 million, are struggling to be Canadian amid the challenges from our 5.8 billion fellow humans—rich and poor. Many nations across our planet look to Canada for leadership in health care. Sir Frederick Banting, co-discoverer of insulin, commented, “You must begin with an ideal and end with an ideal.” I believe our values will be sustained amid the challenges of old traditions and new technologies. We will continue to care for our neighbors as we enter the new millennium. We will take the advice we have given to others and improve the health of Canadians. Medicare will be renewed, not demolished. □