Allan Rock says the time has come to refocus the system on the promotion of good health
A new direction: ‘The wellness agenda’
Allan Rock says the time has come to refocus the system on the promotion of good health
When he became health minister in June, 1997, Allan Rock confronted a system reeling from the funding cutbacks and painful restructuring programs of the mid1990s. With funding restored and the disruptions almost a thing of the past, he says he is turning some of his focus away from treating the ill to promoting health. Rock, a fit-looking 52-year-old who runs five kilometres or more daily, picked at a seafood salad lunch as he talked last week in his Centre Block office with Macleans Assistant Managing Editor Robert Marshall and Ottawa Editor Bruce Wallace.
Maclean's: The Maclean's Health Report shows some alarming ‘hot spots' for lethal diseases in Canada. Is it too much to expect a co-ordinated health-care system to eliminate such huge regional differences in mortality rates? Rock First of all, we have to find out more about why those disparities exist and why sometimes there are clusters of illnesses or disorders. We don’t fully understand why, whether they’re environmental or social or genetic. But there are correlations between health overall and social and economic factors and I think those correlations cannot be ignored. Are you educated? Do you have a fulfilling job? Do you have economic security? Correlate that with outcomes in terms of heart disease, cancers and other health problems. That’s got to be part of it. We could also say the smokng rates are higher in this part of the country and therefore the cancer rate is higher, or we might say that the quality of the air affects outcomes, but I think it’s an area that requires a lot more work. Macleans: The $80 billion we are now spending each year on health care makes our system among the most expensive, per capita, in the world. How can we transfer some ofthat spending from treatment to a cheaper, more effective approach: prevention1 Rock For the first couple of years I was minister, my main preoccupation was on the medicare system, on health care
itself. But I’ve started talking about wellness in recent months. This summer when I spoke to the Canadian Medical Association, sort of an annual command performance for a health minister, I drew attention to the wellness agenda for the first time and said I’d be focusing on it more and more. And I’ve done the same in policy work in the department. After all, I’m the minister of health, not the minister of illness. But by putting together a wellness agenda and encouraging prevention of illness and promotion of health, I’m not talking about taking money from health care and diverting it to health promotion, because God knows, the money that’s in health care is needed there. But I do think one of the answers to the long-term sustainability of the healthcare system is to reduce the demand on it and thereby control costs by encouraging healthier lifestyles and a healthy population.
Maclean’s: But surely that requires some spending.
Rock Well, some of it is not spending. Does it involve government spending to get people to be more active or to be more careful about their diets? I think getting to better health involves responsibility at a number of levels—personal responsibility, making decisions about our own lifestyle and habit, community responsibility, provincial and federal responsibilities. Some of it’s money, some
of it’s not. And maybe it is new spending, but what I want to stress is I’m not suggesting taking money from where it’s needed in health care and diverting it into promotion.
Macleans: In February of last year, you told Maclean’s you hoped a standard approach to home and community care would be in place across the country within 18 months. Here we are 20 months later. What has become ofthat home-care initiative?
Rock It’s very much alive. In September of last year, the provincial ministers agreed that home and continuing care was one of our key priorities. In the meantime, we’ve had the social union, a framework agreement that talks about governments collaborating on these national objectives. And last month in Charlottetown, the health ministers agreed to intensify our work on this, so it’s very much alive. We have to have agreement between the federal and provincial governments. That’s worked out frankly by hard work and that’s what we’re engaged in.
Macleans: Where do you fall in the current debate about whether Canada needs more doctors or should make better use of its existing resources?
Rock: Its important to talk about caregivers generally, not just doctors, because were short of nurses and other health-care providers as well. The ministers agreed in Charlottetown that part of the answer has to be to look at interdisciplinary teams to deliver primary care, different methods of paying health-care providers than fee-forservice, and trying to accelerate changes in delivering primary care that will itself have an impact on how many doctors, how many nurses you need. Were talking about developing a common approach by early in the new year, and it may be that in the last analysis we decide, the provinces decide, to increase enrolment in medical schools. Its up to them, not me.
Macleans: How do we stop so many of our best-trainedpeople from leaving the country?
Rock: One of the things that has been
front and centre in my portfolio and will continue to be is investment in research. I’m going to table legislation within a month or so that will create the Canadian Institutes of Health Research. We’re doubling the amount of money were spending on health research over the next two years. The institutes will co-ordinate research, not just biomedical, which the Medical Research Council funds now, but across the spectrum—biomedical, clinical, research into health services and also determinants of health, which goes back to your point about wellness—what makes some people well and others not. We are going to transform the way health research is conducted in Canada and, I believe, make it a more attractive place for all health-care providers to work. Maclean’s: With the provinces charged with administering the health-care system, what kind of levers does Ottawa have to maintain national standards'1
Rock: One answer is the Health Transition Fund, the $ 150 million we set aside 2 V2 years ago. We identified four key areas: primary-care reform, integration of services, home care and pharmacare. We didn’t spend a single nickel until a province identified a demonstration project or a new way of doing things that it wanted to fund with this money, and then we injected the money. It may be a community health centre in British Columbia, an integrated practice using electronic communications in Nova Scotia, a home-care project in Saskatchewan, but the lessons from each of those we’ve shared with the rest of the country. That’s one way we could have some influence, but there are others. And, of course, we have the power to withhold money if there’s a breach of the Canada Health Act’s guarantee of universal and accessible health care, but we’re not speaking in those terms and that has not been necessary in recent years. Ministers from across the country say they want federal leadership on issues like maintaining our health-care system by making it more integrated. And I think the leverage we have is a common political will to make sure we keep one of the
greatest assets this country has ever known, which is our health-care system. Maclean’s: Given the financial pressures and the proximity of the American system, how can you think it's not inevitable that the universal healthcare system will break down in favour of a two-tier approach?
Rock: Because I think the case for maintaining the one-tier system and fixing its problems is stronger. I don’t deny for a moment the problems. We’ve all had the experience, I had it last summer, of sitting in the emergency room for four or five hours worrying about whether the service is going to be there. Some people say we could take the pressure off by letting those of us who can afford it have access to care we can purchase. Well, that’s a false argument. I’ve spoken to ministers from countries where there are the two systems, and I’m almost always cautioned against it. They say, you will lose your best and brightest, not to another country but to a private system. And those of us who may not be able to afford a private system won’t have access to some of the leading practitioners, whether they’re doctors or nurses. You know England has a private parallel health-care system and yet the waiting lists in the public system are still extremely serious, if anything worse than Canadas. They also point out that because ifs for profit, a private parallel system will focus on the high volume, simple, repetitive sort of procedure where they can make a profit. But as soon as there’s a complication, you know where that case goes—right back into the public system and you end up with the public subsidizing the private.
Maclean’s: Still, to some it would seem more fair to open up the system so the patient has a variety of options.
Rock: Well, I think what is fair is universal access to quality care without cost for medically necessary service, that’s what I think is fair. I think there’s real danger in talking about health care as a commodity on the open market the way you would the sale of clothes or a car. The free-market analogy is very imperfect when applied to health care. It’s a different dynamic. C3
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