Trevor Hancock: Putting health into our health-care systems

It is a curious fact of health policy in Canada and around the world that the health-care system pays little attention to health. The focus is on illness — its diagnosis, treatment and management. We should really call it an illness-care system.

But the system is overloaded and struggling to keep up with the demand for illness care.

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Clearly, when the bathtub is overflowing, the first thing to do is to turn off the tap. That means reducing both the need and the demand for care, as well as improving the way we manage the care that is needed. In this and the next couple of columns, I will explore these issues.

I begin by looking at health-care reform — how do we change the way our health-care system works? In the next column I will look at self-care as the largest and most-neglected part of the health-care system.

In the third, I will look at what I call reform for health: How do we reform our communities and our society so as to improve health and reduce both the need and the demand for care?

I have twice mentioned both need and demand. In planning a health-care system, it is important to understand how they are different. Need is the health care you need to have because you are sick, but demand is what you say you need. Demand can be greater than need, but it can also be less.

For example, residents of a low-income community with a lot of health problems might not “demand” all the care they need because they don’t have services nearby, or they can’t afford the time away from work, or because they don’t see the need for preventive services, or because their way is to tough it out until they are really sick.

On the other hand, a high-income community might be pretty healthy and have a low need for care, but might demand a lot of care because they are the “worried well” or because they no longer have the knowledge and skills to practise appropriate self-care.

We need to reduce the need for care (turn off the tap) everywhere by improving the health of the population, especially in the least-healthy communities. And we need to reduce the unnecessary demand for care by encouraging and supporting self-care, where appropriate. But above all else, we need to reform the way our health-care system is designed and how it works.

Let’s start with a thought experiment. Imagine for a moment that our entire health-care system disappeared overnight and we had to start again. What would our new system look like? I like to think we would not start at the end of the pipe, by building a lot of hospitals.

Instead, we would turn the current system, with the hospital at its apex, on its head. First, we would put in place a system to keep people healthy, extending beyond the health-care system into the way we organize and operate our communities and our society. How do we create the conditions in which people can lead healthy lives?

Second, we would put in place a self-care support system; this will be the focus of my next column. Third, we would establish a strong, community-based public-health and primary-care system, with a range of providers, including many more nurse-practitioners and midwives. This would be the first point in this system where we would interact with a health-care provider.

This level of the system would provide the vast majority of health care, including many health-promotion and disease- and injury-prevention services. Part of its job would be to identify where real needs are not being met and meet them, and it would also co-ordinate care for its clients. The specialist care system would be accessed through primary care, as it is now, but with a greater use of Telehealth to increase access.

Next comes a strong home- and community-care system, designed to keep people in their homes and communities as much as possible. Only when all these options have failed would we actually need a hospital; it would become the place of last resort, not the apex of the system.

Obviously, we will not get from here to there easily or quickly, but it would help to have a clearer vision of where we should be going.


Dr. Trevor Hancock is a professor and senior scholar at the University of Victoria’s school of public health and social policy.

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