COVER

A Healthy Debate

The forum explores visions for the future

BARRY CAME December 2 1996
COVER

A Healthy Debate

The forum explores visions for the future

BARRY CAME December 2 1996

A Healthy Debate

COVER

The forum explores visions for the future

BARRY CAME

They came in search of solutions, 19 “ordinary”

Canadians deeply concerned about the country’s increasingly strained capacity to care for its sick. There was a high-school teacher’s aide from Nova Scotia and an unemployed single mother from British Columbia, a middle-aged Calgary corporate businesswoman and a young Toronto banker, an actress, an engineer, a dairy farmer and a dozen diverse others. For an entire gruelling day, they sat under the hot lights in a television studio near Toronto’s waterfront, invited by Maclean’s and the CBC’s The National to collectively explore the revolution that is transforming health care in Canada. They traded views with four

“experts”—a family physician, a hospital administrator, a nurse and a consumer advocate—about shrinking health budgets and disappearing hospital beds. And when it was all over, few seemed to disagree with Dr. Michael Wyman’s “guarded” prognosis about the future of the health-care system in this country. “The situation is not yet grave,” said the Toronto physician, “but we have to find a better way.”

Like all of those who took part in the daylong Maclean’s/The National endeavor, Wyman offered no clear directions to that new path. But the forum’s participants did deal with a few of the signposts that are beginning to appear. They talked at length about the

spreading use of home, rather than hospital, care. They debated the pros and cons of the attempt to divert patients away from traditional doctors towards what the health industry refers to as nurse practitioners, specially trained nurses who, it is claimed, can relieve doctors of as much as 70 per cent of the routine chores they normally perform. Most of all, however, they gave voice to the anxiety many Canadians are experiencing about the future; whether, in fact, what we are witnessing at the moment is the rescue of the country’s cherished health-care system or, rather, its inevitable decline.

Opinion at the Maclean’s/The National forum was decidedly mixed. What follows is a sampling of those views.

The Optimists

“I’m going to say that our health-care system is in its adolescence,” argued Melville Flynn, a 70-year-old retired teacher from Fergus, Ont. “And I’m going to suggest that we’re going through this stage of tremendous turmoil, getting the various partners to sort of settle in and see where we’re going collectively. But sometime within the next decade-and-a-half, it will emerge as something very significant and very substantially Canadian. But I think we’ve got this adolescent restlessness and we’ve got to drop some of our ideas, get some practicality, get some more dreams and go on from there. We’re growing up. I think it’s going to get better.”

Toronto businessman Mike Tang, 58, was equally hopeful. “I think with new technology, new information systems, everything will be much more efficient,” he said. “The doctor probably will not have you wait in his clinic for so long and ask you this question, that question. Maybe a home computer will keep all the information and the doctor will just glance at it and decide if you should come in or not. I think it’s going to be better. There will be no more waste, nobody will abuse the system. When that happens, we’re going to have the best system in the world.”

Mary McIntosh, a 49-year-old dairy farmer from Perth County, Ont., said she thought the situation was bound to improve because local people “in our communities are going to become more involved in the decision-making. We’re going to look at what the Red Cross is doing, what our health units are doing. I think because we’ve hit the financial wall that we are going to look at that and want all of the people participating to work together. And we are going to demand that as consumers—we want it to be there. I come from a small rural area and I think that we have to become involved in our communities to make those wants known.”

The Pessimists

Annette Smith is 28, a married mother of two children and a cashier in a grocery store in Oshawa, Ont. She worried about “hitting middle age in the next 10 years. As you get older, it doesn’t matter if you’re a vegetarian and work out twice a day, stuff starts not to work. And it seems to me that in the current fiscal situation, we’re going to run out of money to be able to take care of everybody’s stuff that isn’t working. Over the next 10 years, I think we’re looking at trouble.”

Sharon MacLeod, 49, a teacher’s aide in Middle Musquodobit, N.S., voiced similar concerns. “My biggest fear is that we’re going to slide right down and become just like we were before medicare, become like the United States where you have to pay for everything.

‘We haven't put the pieces in place as we shift from one system to another'

Hence, the rich get richer and the poor get poorer and we’re not going to get the health care that we need.”

Alan Färber, a 45-year-old chartered accountant in the Toronto suburb of North York, expressed concern about the lack of “forwardlooking leadership” on the whole issue of health-care reform. He called for “people with very clear vision and ability to develop consensus, an ability to implement changes because lots of us can see lots of areas for change that would make a difference. My sense is that Canada came very, very close to hitting a financial wall. Governments collectively had to do something very dramatic. So the cuts started. It’s a long political process. Great leadership is needed just to run through what is a very stormy period right now. So short term, I think we’re declining and we’re still going down. If we find that leadership, perhaps we can pull out of a trough. But that’s a big ‘if.’ ”

The Experts

Scott Rowand, chief executive officer of Hamilton Health Sciences Corp., a merged organization of hospitals in the Ontario city, agreed with the argument about Canadian health care running into a financial wall. “When we hit the wall,” he said, “then we had to deal with it. We dealt with it and now we’re picking up the pieces. One of our problems is, on the one hand, we recognize that we have pretty serious problems in terms of financing public services. I mean, we’re now spending more in Ontario on debt interest than we are running the province’s 220 hospitals. On the other hand, we want to try and balance quality and access, and maintaining access is a real challenge. Unless we find ways to use our resources properly, it’s difficult. We are making changes very rapidly, driven exclusively by financial considerations, and we haven’t put the pieces in place as we shift from one system to the other.”

Once the pieces are in place, however, Rowand said he could foresee the outlines of the health-care system of the future. “I think

we’re going to see a lot more integration with home-care systems, with longer-term care, much more extensive use of information technology, physician consultations using two-way interactive video. I think the system will be a lot better linked together. The sys-

tem will be smaller. I think the hospital of the future is going to be a large intensive-care unit and large ambulatory centre with very little in between. And that means that most care will occur out of hospitals, but the systems and the processes will be put in place to assure that there’s good care.”

Wendy Armstrong, a former nurse from Edmonton, a past president of the Alberta Consumers’ Association and a sitting member of Alberta Clinical Practice Guidelines Program, did not share Rowand’s sunny view of the future. “I can see a whole generation of people, who had expectations of being able to retire and go down to Phoenix or Florida, finding themselves very strained caring for elderly parents or sick spouses—actually not having the money to travel because it’s all gone in medical expenses. We Canadians must insist that any hospital care moved to another site, whether it’s the home, a hospice or a private clinic, must be covered by the Canada Health Act. The intention of the people that developed hospital insurance was that that was where you went for expensive medical care and you stayed there until you were covered. Now, we have the option of providing it at lower cost in the community. If the intention is a hospital without walls, let the funding follow.”

In an earlier exchange, Armstrong cited the financial pressures exerted on families when public funding for health care is inadequate. “The alternative is not that you’re going to do without, because when push comes to crunch, if you need money to pay for the expensive pain medication for a loved one who is dying, you will sell your truck, you will take out a second mortgage. You will do what is necessary.” That is already a fear in Alberta, she said, and the lack of coverage has created a situation where “the private insurance companies are moving in big time, offering wraparound policies, home-care policies, long-term-care policies. Private insurance is one of the most expensive ways there is to fund health care.”

In terms of funding, Wendy Goodine offered what she clearly viewed as at least part of the answer to diminishing health budgets. She is a nurse practitioner, a breed of health professional trained to provide some of the services traditionally performed exclusively by physicians. Practitioners are common in the United States and are growing increasingly important in Canada. Alberta has enacted legislation allowing nurse practitioners. Ontario and Newfoundland are poised to follow suit. There is no mystery about the reasons why. “We have been proven to cost less,” Goodine told the

A ‘trialogue’ is needed among governments, health-care providers and the public

Maclean’s/The National forum. “Studies have show that we order fewer tests, we prescribe fewer medications, we keep people out of hospitals because mostly what we do is we teach people about their health and wellness. Most of the time, people go to a doctor, it’s for a common illness, it’s for annual checkups, it’s for the type of counselling that nurse practitioners can do. We can do 50 to 80 per cent of that kind of care. For example, I see a well baby and give an immunization. My physician partner can see a child with pneumonia and our community pediatrician can see a child who has uncontrolled asthma. Each one is being used effectively for the skills that they have.” Not surprisingly, Goodine believes in a rosy future for Canada’s health-care system if more space is created to accommodate her profession. “I’m very optimistic, provided we put the processes in place” that permit local “communities being able to decide what are the services they need most.” And what will be the role of the traditional doctor in the future? “I can’t imagine that this system or the future system will be able to function without family physicians as the primary care entry point,” said physician Wyman, adding a note of warning at the same time. “The baby boomers will become 65 in 15 years time. We have a growing population, an aging population. Unless S we start to make changes, we’re going to be in ever-deepening trouble. Information technology is critical. We need to be able to communicate better. But we need as we go along to make sure that we don’t forget about the illness care that is going to be there, regardless of how much emphasis we put on health care. So promote health care, promote wellness, but you can’t take it away from illness because we will all get sick. Fife has a 100-per-cent mortality rate. And we can’t forget that.”

According to Wyman, no reform of the health-care system is possible without what he termed a “trialogue” among cash-strapped governments, health-care providers and the public at large. “It’s OK for governments to cut budgets, but they have to have plans in place for the care that’s not being provided. The providers have to be involved in providing information to governments as to how best provide services, but it doesn’t mean anything if both of those are talking and don’t involve the consumers of health care as part of the debate—to determine how much they’re prepared to cut, how much they need, how much they want to have within the healthcare system.”

hike several others who participated in the Maclean’s/The National forum, the Toronto physician, a past president of the Ontario Medical Association, also stressed the need for leadership. “What we’re going to need, all the money in the world isn’t going to solve until we have some leadership,” said Wyman.” It’s like that great philosopher Pogo. We have seen the enemy and the enemy is us. All of us.” □