COVER

Expert evaluations

'The Maclean's Health Report clearly demonstrates that medicare is facing challenges'

June 15 1998
COVER

Expert evaluations

'The Maclean's Health Report clearly demonstrates that medicare is facing challenges'

June 15 1998

Expert evaluations

'The Maclean's Health Report clearly demonstrates that medicare is facing challenges'

The people who know Canadian health care inside out are the ones who spend their lives working in the system, who help design and shape Canadian medicare, who work day-to-day delivering the care

that Canadians take such pride in—and who have experienced the feelings of helplessness when things go wrong. Maclean’s asked eight such experts

from across the country to comment on the issues raised in the first national Health Report. Some, like B. C. Health Minister Penny Priddy, are public figures. Others, like Nova Scotia rural doctor Bob Martel, are dealing with realities on the front lines of health care.

Penny Priddy VICTORIA

British Columbia minister of health. Trained as a nurse, Priddy worked for 30 years in programs for children, families and people with disabilities before entering politics.

If medicare is to continue serving Canadians, we must improve the system without abandoning the principle of universal access. I believe the best way to do that is by looking beyond our traditional view of health care to consider ways of providing patients with a greater range of choices. We have to educate ourselves about the lifestyle choices we make and how they affect our health. My experience as a breast cancer survivor has taught me to take more responsibility for my own health. Governments and health-care providers also have a responsibility to inform people about their health and health-care options.

The Maclean’s Health Report clearly demonstrates that medicare is facing challenges. The vacuum created by the federal withdrawal of funding is causing Canadians to ask what role Ottawa has in health care. Improving medicare takes more than goodwill. British Columbia is one of the only governments to increase total health-care funding for seven consecutive years. As a result, British Columbia leads every other province in per capita public spending for health care, despite federal cuts to transfer payments.

Expanding the role of nurses in health care is an important part of creating more choice and increasing access to care for patients. The success of medicare will also depend on how well we care for seniors. But in charting the future of the system, we have to keep the interests of those it will serve tomorrow in sight. Today’s children are depending upon us to nurture medicare so it is there for them when they need it. We cannot let them down.

Steven Lewis SASKATOON

CEO of Saskatchewan’s Health Services Utilization and Research Commission. Lewis has been involved with health-care planning, research and evaluation since 1974.

The Health Report tells us a lot about health care and less about health; it conceals more than it reveals. Much of this is not the fault of Maclean’s: we do not have a lot of decent information about the quality of health care in this country, nor do we specify with any precision what the $76.6 billion spent in 1997 was supposed to produce, and for whom. Unfortunately, the utilization data tell us very little, and worse, they distract us from more fundamental issues surrounding the health of Canadians. Still, I think just beginning the discussion, as Maclean’s has, may be very useful in getting the kind of information that is more truly indicative of what we’ve got, and what we don’t have.

Despite fairly significant differences in per capita expenditures and the availability of physicians and technology, by global standards health status is pretty much the same across the provinces. Adding countries like Spain and Portugal to the international table would show that nations spending about half per capita than Canada have a healthy population. In any other industry, these data would occasion a spirited debate about overspending. In health care, it’s always about scarcity—curious in light of the obvious diminishing returns from huge outlays.

Presenting interprovincial data washes out startling variations in practice within provinces and even municipalities. In Ontario, for instance, researchers at the Institute for Clinical Evaluative

Sciences have published two major volumes that show huge differences in surgical rates from one county to the next. A quality health-care system would have rigorous standards for assessing need and deciding whether, when and how to intervene.

The Health Report briefly touches on the most important cause of substandard health in Canada: inequality among classes. There is increasing evidence that our fates are significantly sealed by the time we are 3. No amount of miraculous health care can overcome the handicap born of deprivation. Despite the apparent cracks in our system (a worrisome and inefficient 31 per cent is now funded privately), we have access to a staggering array of health-care services. But huge disparities in health status persist, and Canadians should worry less about how many MRIs we have than about how many poor, unconnected, undervalued, underemployed, and irremediably ill remain among us.

Marion Suski WINNIPEG

CEO of Winnipeg Community and Long Term Care Authority. Suski, president of Victoria General Hospital before joining the authority in 1997, has also worked in hospitals in California and Minnesota.

When I was the CEO of an acute-care hospital, the mandate was clear—reduce the number of patient days without compromising care. That worked well for some, like laparoscopic surgery or obstetrical patients, but for others it didn’t. Mental-health patients, the frail elderly and those without family supports needed a bridge from the hospital to the community. Upon discharge, we lined people up at the front and back doors, wondering why community care, home care and long-term care couldn’t respond.

Now, as CEO of the Winnipeg Community and Long Term Care Authority, I can see why. Budgets of hospitals went down and efficiencies went up. But the funding didn’t shift appropriately to the com-

munity, which was dealing with an aging population, more people with multi-system diseases, and people surviving more acute illnesses. In Manitoba, home-care volumes and expenditures went up and programs like home palliative care, supportive housing for seniors, adult day care, companion care, and other non-bed-based options are now being developed.

Acute care is portrayed as glamorous, with shows like ER dramatizing the crises, the high technology and the speedy recoveries. In contrast, community and long-term care deal with the realities of our streets and neighborhoods, like the issues of the frail elderly, fetal alcohol syndrome, drug use, sniffers and HIV. The results are often slower and more difficult to measure, but are no less important to our overall health.

We know now that people want autonomy, they want to manage their own care, and make their own choices about their lifestyle. In a sense, we have come full circle. We are reclaiming our traditional sense of self-reliance after four decades of trusting in institutional care. By definition, that means we must have a full spectrum of choices to meet individual needs. We must move beyond just health-care teamwork to include the determinants of health, setting up neighborhood networks that involve all partners, like education, justice, housing and family services to have a real impact on the lives and families of our communities.

Michael Decter TORONTO

Health consultant and chairman of the Canadian Institute for Health Information. An economist who has worked for two decades in senior publicand private-sector positions,

Decter, was deputy minister of health in Ontario from 1991 to 1993.

Our approach to health services remains a great Canadian achievement. With 9.2 per cent of our gross national product, we provide health coverage for all Canadians.

The Americans, who spent 14.2 per cent of GNP, have more than 40 million citizens without health insurance. But we need better information in order to understand our own health and to manage our health system. This is a period of unprecedented change from an in-hospital system of care to an ambulatory care world. Patients, providers, managers and policy-makers all need better

information about the benefits and costs of various forms of care.

Canada has badly under-invested in health information. We spend roughly two per cent of the total health budget on health information. We would get better value for our total health dollar if we increased that vital investment to four per cent.

The Canadian public is extremely concerned about access to health services as well as the quality, appropriateness and speed of those services. Report cards should provide the public with information about those issues. The Maclean’s Health Report is an excellent start, but we need more consumer-level information to make intelligent decisions.

The provinces have started the tough work of reform over the past seven years, and the provincial ministers of health have borne the brunt of the criticism. It is time for the federal government to provide real support in both leadership and dollars. Federal funding for home care would be a good place to start. Medicare is what we make it. It can be as dynamic and modern as we choose. It can also be allowed to decay. Medicare will be maintained not by putting it in a museum, but by reforming it.

Gordon Lever KINGSTON, ONT.

Co-founder, Victims of Health Care Abuse. Lever became a patients’ rights activist after his wife died at age 49 last September, less than a month after being diagnosed with stomach cancer.

Our proposed motto states: “Let’s put the ‘care’ back into health care.” This, we feel, summarizes what is needed to rectify the system. The badly planned and executed changes have resulted in low morale and many health-care providers fighting for their own survival. How can one expect compassionate care in these circumstances?

Hospitals are very inefficient places, suffering from too much

bureaucracy and duplication. Why are patients entering emergency asked the same questions and have the same tests carried out (temperature, blood pressure, etc,) three, four or five times? “Super nurses” trained in screening patients could be the first point of entry. The nurse would then direct the patient to a “semi-specialist” who concentrates on several areas of medicine and therefore can keep up to date. Clinics based on this idea could be equipped with many diagnostic tools, such as ultrasound, and result in “one-stop shopping” for patients.

We also feel there are not enough specialists. Seeing a GP can usually be arranged in a matter of days, whereas with specialists it can be many months. More specialists are also needed if we are to take advantage of all the new information being generated in the field of medicine worldwide.

The Health Report makes no mention of the huge increase in expenditure in the alternative medicine fields. Every shopping mall now seems to have a health food/herbal medicine store and shelves in pharmacies are bulging

with every sort of herbal medication possible. When the amount being spent on this “private health care” is added to that spent on “public health care,” you will find a substantial increase. Overall, we feel there is enough money being spent; it is just going in the wrong areas. Very little is spent on educating people, prevention, early detection of diseases. Too much is now spent on treating patients when it is too late and therefore very costly.

Michèle Boisclair MONTREAL

Vice-president, Quebec Federation of Nurses.

The Maclean’s Health Report confirms that the recent transformations of the health-care system were primarily designed to respond to the financial imperatives, first, of the federal government, then, of the provincial governments. The drastic cut in Ottawa’s portion of health-care spending in the provinces (-22.4 per cent for Quebec over nine years) is worth highlighting. On the other hand, the report does not break down the spending on health care within each province. This breakdown would enable us to measure real spending trends compared with the national average. We know that in Quebec, health-care spending is lower than the Canadian average. Moreover, Quebec does not rank very well on important health determinants— incomes, education, smoldng and suicide. The federation believes there is little political will to take positive action on health determinants. Combined with budget cuts at both levels of government, this contributes to the deterioration of the health status of the population.

The absence of data on per capita investment in home care glosses over an important weakness in the transformation of the Canadian health-care system. Home care should be a government responsibility, but governments are slow in developing it.

The federation believes that personnel is a key element of any health-care system. Yet there is a steadily growing exodus of nurses to the United States. In Quebec, it exceeds that of doctors. Looking at the profile of personnel, Quebec is distinguished from other provinces by the fact that it has the highest ratio of doctors to population and one of the lowest ratios of nurses in Canada. Combined with the use of drugs and the development of technological facilities, this allows us to conclude that the Quebec government has opted for a health-care system oriented more towards “cure” than towards “care.” Yet the shift towards ambulatory care relies more on care.

Dr. Bob Martel

PORT WILLIAMS, N.S.

Chairman of the Atlantic regional committee of the Society of Rural Physicians of Canada.

The Canada Health Act guarantees all Canadians access to universal health care. Unfortunately, there is little evidence to support that is happening in rural Canada. Geography has traditionally been the greatest barrier to access, but more recently the economic agenda of provincial and federal governments has conspired to further compromise Canadians who choose to live in rural Canada. Regionalization, downsizing and rationalization of health services have been used as broad terms to explain the approach central health planners are using to restructure health care. Unfortunately, the planners have been focused on indicators like hospital admissions, length of stays and more crude yardsticks, such as infant mortality.

The problem with this approach is the focus. A community is healthy when it is working together to support its residents, in times of prosperity and of economic downturn. In closing community hospitals, health planners have failed to identify these institutions as more than a grouping of hospital beds. But those facilities function as a critical link in the greater support system of a rural community. Often serving as the centre of communication, the programs are interwoven into the social fabric where ladies’ auxiliary social functions are as important as emergency services. The other critical factor not identified is the tremendous economic impact these health-care jobs had on the community’s economic base.

Rural infrastructure expenditure reduction has threatened the ability of communities to provide the support required to keep its citizens comfortable with living in a rural area. Young professionals can no longer be guaranteed a quality of life conducive to professional and personal fulfilment.

Politicians who will eventually have to account to their constituents for the decisions being made are charged with the task of

sensitizing their advisers to rural issues. Forty per cent of Canadians are now saying that they need more attention or their way of life will be assimilated into the urban paradigm. Rural areas are beginning to understand that they have been left out of the planning equation.

Dr. Doug Sinclair HALIFAX

Chief of emergency medicine,

Queen Elizabeth II Health Sciences Centre.

I support the concept of a periodic national report card to inform Canadians on the status of health care. The system is undergoing massive, unprecedented change, and I see the frustration and confusion of both patients and staff every day. The emergency department has become the barometer of the reformed system. It is a safety net as the pace of change of different parts of the system proceeds at different rates. When overcrowding in emergency becomes significant, it is a warning that the system has become dysfunctional.

Certainly, the fiscal agendas of the federal and provincial governments have driven the health-reform agenda. But what we forget is that the health-care system was in desperate need of reform, and it took fiscal belt tightening to finally kick-start many of the programs that we now support as part of the reformed system. Some of the obvious examples include the trends to outpatient surgery and the expansion of home-care programs. We must start to harness the power of the health-care providers and their local communities to truly drive the healthreform agenda, without battles over professional turf.

All stakeholders in the health-care system have become increasingly frustrated with the lack of data to measure the effect of change on health outcomes. Because the material presented in Maclean’s is administrative data taken from large provincial data bases, it is not useful to many healthcare providers on the front lines. But it is a start. The true challenge now will be for communities and health-care providers to agree on a set of indicators to monitor the success of the health-care system. Some examples could be the rate of successful use of clot-busting drugs in heart attacks, the number of people successfully managed in a home-care setting and thus diverted from hospital, or the success of immunization programs.

As an unusually optimistic health-care provider, I am excited by the pace of change. I feel we have an enormous opportunity to make improvements, but the path will remain confused—and somewhat dangerous—for a while yet. □