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Trevor Hancock: Health-care reform needed on a grand scale

When starting this column two years ago, I indicated I would not be focusing on clinical care and and lifestyle issues, as almost all health columns do, but on the “upstream” environmental, social and economic conditions that make people healthy or s

When starting this column two years ago, I indicated I would not be focusing on clinical care and and lifestyle issues, as almost all health columns do, but on the “upstream” environmental, social and economic conditions that make people healthy or sick.

In looking back on the more than 100 columns I have written since then, I have largely kept to my commitment, although about 20 per cent of my columns have been about the health-care system.

It’s not hard to see why: After all, the health-care system is a determinant of our health, although not as big as we might think. Recent estimates suggest only 10 to 20 per cent of health outcomes over a lifetime are attributable to the health-care system, meaning that 80 to 90 per cent is due to everything else. So it’s not the Ministry of Health that makes us healthy (it’s really a Ministry of Illness Care), it’s what the rest of government and of society does.

Unfortunately, the health-care system is by far the largest part of provincial government expenditure, exceeding 47 per cent in B.C. and growing. So it is crowding out our ability to invest in the social, economic and environmental policies that will actually improve the health of the population and reduce the burden of disease and the need for health care.

In two columns this week, I will address two big ideas: First, that we need health-care reform on a grand scale — in part to create the space for reform for health — but second, and even more important, we need to reform our current social and economic systems to make them more healthy.

Sadly, there has been a lack of good strategic thinking on these issues among those who manage our health-care system and those who manage our government.

There are three key strategies to reforming our health-care system. First, reduce the need for health care by reducing the burden of disease in society. Second, reduce the demand for unnecessary health care by recognizing that self-care is the largest part of the system and needs to be systematically supported. And third, manage services efficiently; use scarce resources effectively, stop duplication and waste, and do less harm to both patients and staff.

Here I focus on the first two strategies because they could potentially reduce the number of people seeking care by quite large numbers, yet are largely ignored in B.C. and across Canada. A modest increase in the number of people who are healthy and not needing care, and in the number of people who practise effective self-care, could significantly reduce demand for health care.

There are two major service areas within the system that do prevention work: public health and clinical prevention. But while B.C.’s current priorities document lists “targeted and effective primary prevention and health promotion” as the second priority, this is not pursued in practice.

For example, the proportion of their total expenditures that B.C.’s five regional health authorities allocated to population health and wellness (the prevention part of the system), already a meagre three to four per cent, declined by 4.6 per cent between 2012/13 and 2015/16. That doesn’t suggest it’s a priority.

In addition, B.C.’s clinical-prevention initiative — the preventive services provided mostly by your family doctor — is not given the priority it deserves. The Lifetime Prevention Schedule lists 15 cost-effective services that, if consistently provided, would have significant population health impacts.

Yet there is no systematic approach, no campaign to reach British Columbians and their primary-care providers, nor sufficient training and support for those providers. My auto mechanic reminds me when my car needs a checkup — why can’t my physician do the same?

Self-care is not even included in the current list of health-system priorities in B.C. While we do have HealthLink B.C., which provides access to non-emergency health information and advice, there has been little investment in systematically strengthening people’s skills and capacities for self-care. This is a strategically important task that needs to begin early in life and needs a comprehensive support system to be effective — and it is being largely ignored.

So serious health-care reform is not happening; how about reform for health? That is the topic of my next column.

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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