As noted in last week’s column, some of the fundamental principles of our health-care system — universal access to a comprehensive range of services in a system that is publicly administered — are threatened by the court challenge being mounted by Dr. Brian Day. But there is no smoke without fire.
Back in the 1990s, I organized study tours for Swedish health-care managers interested in learning from Canada’s health-care system. In introducing them to the system, I would point out that we do not have a national health-care system, as they do in Sweden, the U.K. or many other places.
Instead, we have 10 provincial, partially private non-systems; partially private in that about 30 per cent of all health care spending is privately funded, including through private insurance. This includes almost all dental care, much of the cost of medications, aids to daily living such as splints or crutches, services from a wide variety of non-physician practitioners, and a range of home and community care services.
And I say “non-system” because the health-care system was cobbled together in a series of incremental changes over the past 70 years, with no overall guiding framework in mind. But even a “non-system” is, in fact, a system — just not a well-designed and well-performing system. Indeed, a key principle espoused by the U.S.-based Institute for Health Improvement is that every system is perfectly designed to achieve the outcomes it gets.
Sadly, our current system is perfectly designed to under-emphasize public health and prevention, largely ignore self-care (which is the largest single component of health care), create fragmented, ineffective and inefficient primary care, over-emphasize hospital care and underfund community-based and home care, over-diagnose and over-treat, create long waiting lists and generate unacceptable levels of adverse events.
So Day and his supporters have a point; it’s just that their remedy will make things worse, not better. Except for those who can afford private care and insurance, the treatment will be worse than the disease.
But no matter the outcome of Day’s challenge, Canada’s provincial and federal governments need to stop tinkering and instead start to plan and create a proper system.
For example, look at two recent articles on primary care in the Times Colonist. On Aug. 28, Ruth Lavergne from Simon Fraser University and Kimberlyn McGrail from the University of British Columbia reported on their research looking at incentive payments for physicians to provide ongoing care for patients with two or more chronic diseases. They found the payments “failed to achieve the stated goal of improving primary health care for patients.”
Then on Sept. 1, Dr. Robert Brown, a family physician in North Saanich, wrote of his frustration with the primary-care system. He described it as operating “in a foundational and structural vacuum” and “disorganized and not meeting anyone’s needs.” As a result, he wrote, “my time is spent doing things that others could do.”
He reckoned that with the proper organization and support, “I would be able to adequately organize and care for twice as many patients as I currently have.”
Both of these articles identified similar problems and suggested similar remedies. McGrail and Lavergne noted that “other provinces changed the structure and organization of primary care,” while in other countries “incentive payments … were tied to performance.” Brown called for the creation of “medical homes” (community health centres), with patients tied to the centre and providers committed to providing quality care.
Both suggested a clear plan and the creation of multi-professional primary-care teams, including nurse practitioners (the focus of next week’s column).
These examples are emblematic of the wider problem outlined above. The system is not designed or operated as a system, and the result is poor performance, frustrated practitioners and poorly served patients.
Some of those approaches might not be popular with some parts of the medical profession, and with some segments of the community, but such challenges have to be met and dealt with. The provincial government might have to take on organized medicine, and will certainly need to inform and engage the public.
But business as usual is not an option; we need new and innovative approaches to make the system work properly.
Dr. Trevor Hancock is a professor and senior scholar at the University of Victoria’s school of public health and social policy.