Dr. Merrilee Fullerton on Healthcare

We've heard rumblings from various parts of Canada regarding physicians or groups of physicians holding lotteries for access to their care due to shortages of medical providers in many parts of the country.

The National Post reports August 6th that a Northern Ontario physician, Dr. Ken Runciman, reluctantly eliminated about 100 patients in two separate draws to avoid having to provide assembly line service or extend onerous work hours.

In Newfoundland, a lottery was held last month to allow a new family practice to  "pick  its caseload from among thousands of applicants".

The National Post also reported that  "an Edmonton doctor selected names randomly earlier this year to pare 500 people from his heavy caseload".

Jill Hefley, spokeswoman for the College of Physicians and Surgeons of Ontario has said there are "all kinds of ways that doctors are trying to deal with their patient loads" and that the CPSO is not against lotteries and other random systems for cutting back.

And so while some doctors are accused of  avarice for seeing many patients using a fee-for-service funding model, I am hard pressed to understand how, with a shortage of providers of all kinds, we going to manage to service all patients requesting or requiring care.

Providing "holistic care"  as Dr. Runciman prefers, spending 15-20 minutes per patient, should be appreciated but what happens to the patients who are let go? Is it better to have the patients retained in his practice having this kind of "holistic care" and  others who are "lotteried out" of the practice with potentially  none  or is it better to have patients put through more quickly, all of them  seen and the doctor to sort out who needs more investigation or referral?

As a physician, I happen to prefer the 15-20 minutes per patient approach, simply because it is less stressful for me as a provider and because most patients are satisfied with this time. However,  if all physicians approached care in this way, I expect that the physician shortage would be even worse. Coupled with a nursing shortage and human resource shortages of many kinds, it is folly in my opinion to think that the "holistic" team approach, although much ballyhooed, is really the solution to sustainability in primary care.

The patients who can access it may be very satisfied...and the physicians who choose to practice this way may also be satisfied, but it doesn't address the looming larger issue which is the lack of access for the others and the cost of this kind of approach if physicians, particularly in team models, see fewer patients and work fewer hours and more layers of providers are required.

Recently the Health Council of Canada published its report,   "Sustainability in Public Health Care: What does it mean?" , and also suggests that it is team-based care that in part will provide sustainability for public health care:

"..providers can be organized into teams to manage care more effectively.....The next step may be to convince medical professionals of its soundness. Given medical school's more comprehensive and integrated learning curriculum, interested champions can make this happen."

Yet, in the same report, the Health Council appears to admit that choices will need to me made regarding "wants" and "needs":

"Canada's health care system does not have adequate means of separating wants and needs. Decisions must be made about choices and limits. While limits are implicitly set in some areas already (some services are not publicly funded), an explicit ethical framework may be helpful in resolving some debates. When tough choices need to be made, both decision-makers and the public must be confident that they are made fairly".

Is a lottery for access to primary care "fair"?
What does it tell us about our system's ability to provider "universal" care?
What does a lottery tell us about our system's "sustainability"?

It would appear to me that the experts have lost sight of what is  happening in the front lines of health care and while teams are fine and well, they will not be the solution to primary care sustainability and certainly not productivity issues within health care.

But some don't care  just as long as they produce more reports.

I'll post the links in the comments section.

Best to all of you,

Realist

First, I'd like to thank all of the contributors on this blog for their most informative and insightful comments. I am continually in awe of the knowledge and experience that exists 'out there' which makes me wonder why it is that we can't seem to manage to circumvent "the political stick in the spokes" of health care.

In this recent CMAJ article from July1, 2008, "Public engagement in setting priorities in health care", which I will hopefully be able to provide the link for in the comments section, it is clear to me that a significant degree of innocence  exists in some academics' minds. The University of Toronto Priority Setting in Health Care Research Group (how's that for a long acronym: UTPSHCRG!) reports on the value of public engagement, perceived barriers, ways to increase public engagement and cautions and realities.

Although the researchers do admit, " It is important that the requests for public input not be overtaken by advocacy groups. In our current system, there is already ample opportunity for disease-oriented groups to engage in political lobbying and, although their voices should be heard in public-engagement exercises, it is the "unaffiliated public" who have the least say in decision-making, with important societal implications."

Now folks, you've heard all of this before, right here on this blog on numerous occasions and I did not receive a research grant or command a salary...or even receive a golf membership for my efforts. I certainly agree with the researchers' understanding of the importance of this. The funny part, or not-so-funny part depending on how you look at this, is that they seem to think that the public can engage in priority setting without this happening.

"All deliberations made with public input need not be conducted in public. There can be great value in an appropriately constituted decision-making body meeting in private, but then publicly disclosing the results of deliberations. This is analogous to the private deliberations of juries in our legal system, which allow them the opportunity to discuss freely, question and argue to arriveat the best decision."

Yikes.

It would seem that this research group is entirely missing the point  that the person caught up in a legal problem has the opportunity to pay for their own lawyer should they wish to.They are not required to accept  a court appointed lawyer. Sure, ultimately the lawyer will plead their case to the jury if there is one, but to think that public priorities can somehow be set behind closed doors without some political intervention is a very innocent perspective. This will improve trust and "confidence in the health care system"?

The idea that the Canadian public can determine the priorities for all of us without taking into consideration the unique needs of individuals which may or may not be met in a publicly driven system is tantamount to ignoring the needs of minorities.

I'm not against public involvement in health care priority setting, but I've been around long enough to know that politics will always be part of publicly funded priorities---make no mistake about this .

 

 

 

 

The conversation on the previous journal entry including C. difficile outbreaks in hospitals across Ontario is worth continuing so please feel free to post comments that may be relevant.

However, I think it is also time to discuss the damage that top down control is creating on members of the public service including nurses and doctors as shown in a recent study from the Association of Professional Executives of the Public Service, APEX.

In an article June 16, 2008 from the Ottawa Citizen, "Public sector ' a toxic place to work' ", a national inquiry into the management and working conditions of the public sector is called for.

Bill Wilkerson, chairman of the Global Business and Economic Roundtable on Addiction and Mental Health is reported to have said that absenteeism, disability and claims and distress among Canada's nurses, doctors, teachers, police, military and bureaucrats have reached a crisis proportion and it is time for a major study into what is "sabotaging taxpayers' investment" into these critical services.

What is it that is creating such high levels of distress?

What is wrong with the culture of the public workplace?

Disability claims in Canada are climbing and currently 30-40% of claims are for depression. Cost to the economy: 51 billion (4% of GDP).

The APEX study showed that 64% of executives think of leaving their organization at least every month. More than half want to leave because of lack of recognition.

It is the first study to show the toll of technology and how the reliance on technology has become "counter productive".  About 75% of the nearly 2,100 surveyed say technology increases their workload; 66% said it adds to their stress and 49% said it decreases their productivity.

"People are drowning in technology and risk averseness and the lack of clear lines of accountability" says Wilkerson and "senior bureaucrats could feel "policitized"-torn between being neutral, non-partisan professionals being drawn into the political arena".

The last paragraph provides the most clarity:

"Part of the problem in the public sector is the ambiguity around who is in charge. Departments have to manage with a slew of "one-size-fits-all policies" and answer central agencies from Treasury Board to Privy Council Office. As a result, departments don't feel like they are employers in their own right," says Mr. Wilkerson. "

This certainly applies to productivity issues in the medical world. When top down approaches constrain  highly trained and responsible  professionals and create an inability for them to  function to their full capacity we have reached a significant tipping point.

Mr. Wilkerson and senator Michael Kirby plan to convene a workplace summit this fall into the productivity and health of the public sector, "especially the hardest hit health care sector".

Let us hope that the solution is not more rules and regulations and stifling of innovation, entrepreneurship and independent decision-making....but I'm not holding my breath.

 

 

 

 

 

 I've printed this news release in its entirety because I think it confirms what many of us have been thinking for some time. There is no plan. There is simply a reactionary process by which patients' concerns get media attention then a whack of money. One of the posters here outlined a nice little sequence of events that leads to this outpouring of financial compassion..usually goes like this:

1. Media latches on to a story about patients who are receiving care that seems suboptimal.

2. Money gets poured on the fire to squelch the flames sometimes immediately,  sometimes later.

3. A report is promised but it usually doesn't materialize. If it does, it is usually late and without any announcement.

4. The public is distracted by the dollar signs flying about and figures all will be well. 

5. Usually someone within the health care system is blamed. This can be the hospital CEO, the physicians, the cleaning staff or other.

6. In most cases, a government appointed overseer is brought in to sort things out and say more money is needed---something most people involved probably already knew but it still looks good. The fact that we are spending millions of dollars so that we can say we need to spend millions of dollars more seems to be lost on many.

7. Political optics are good for the short term and on we go........never addressing the real issue, which is the lumbering health care behemoth with an insatiable thirst for cash.

Long term plan? Ahh, the LHINs perhaps--  mind you they are still wet behind the ears and show no signs of being able to deliver on a very tall order while simultaneoulsy  sparing the politicians the difficult task of telling the public that all health care cannot be  "free".

 

Smitherman Admits Liberals Have No Plan for Health Care

The Liberals 10-year strategic report on health care is a year overdue.

(Queen’s Park – June 11, 2008) Yesterday the members of the Standing Committee on Estimates learned that the McGuinty Liberals had yet to develop and publish a 10-year strategic plan for health care; a commitment it made under the Local Health System Integration Act, 2006. According to a 2007 Ministry press release, the McGuinty Liberals promised this report would “set out a vision, priorities and strategic directions for our health care system over the next 10 years.”

“The McGuinty government has broken its own promise to produce a plan to address the gaps in Ontario’s health system,” said Witmer. “Whether it’s improving access to care, modernizing health infrastructure, shortening wait times or promoting good health, Ontario requires a long term vision. A vision the McGuinty Liberals have failed to produce.”

When confronted by PC Health Critic, Elizabeth Witmer, Smitherman said “It’s true to say, and I have to take responsibility that we haven’t hit our marks on this.” The Minister went on to suggest that the report would be published sometime in 2008, however Ministry officials refused to specify a specific date this would happen. As well, during the committee proceedings Smitherman suggested the report was held back due to the 2007 election. “I think that the difficulty that we were into, to be direct with you, was that the window last year got too close to the election,” said Smitherman.

On several occasions since 2006, George Smitherman promised to release his report in the spring of 2007. In a June 2006 letter sent to all the Chairs and CEOs of Ontario’s LHINs, Smitherman wrote, “Our government is in the process of developing a 10-Year Health System Strategic Plan to be made public next spring.” In December of that year, Smitherman told members in the Legislature that “we will develop the 10-year plan over the coming months, with an expected release date in spring of 2007.”

“The election last fall would have been the appropriate time for Ontarians to have their say,” stated Witmer. “It’s disappointing the Minister was not confident enough to bring his report forward at that time.”

Currently, the McGuinty Liberals spend 46 cents of every program dollar on health. Even without a plan, spending on health care is projected to rise to $42.4 billion next year.

“The government’s failure to deliver on their promise has left health care providers operating without a clear sense of direction. Ontarians deserve better. They deserve to know how this government intends to meet the challenges of risings costs, an aging population, overcrowded emergency departments and a shortage of health care professionals. How much longer must we wait for this government to take action and develop a long overdue plan?”

-30-

For further information contact:

Elizabeth Witmer, MPP

(416) 325-1306

I would think that the report from Canada's Health Council released today has no hidden surprises for most of the readers of this blog.

The first paragraph of the media release:

"Despite the nationwide commitment to build real and lasting change and the infusion of billions of dollars brought about by the 2003 Accord on Health Care Renewal, progress falls short of what could, and should, have been achieved by this time, says the Health Council of Canada's latest report to Canadians, Rekindling Reform: Health Care Renewal in Canada, 2003-2008."

Jeanne Besner, Chair of the Health Council of Canada says, "As we reflect on the speed and direction of health care renewal, we find the glass is at best half full."

This is a curious statement amidst the cheerleading that goes on in health care transformation these days. With so much political need for short term wins it is rare to hear such honesty. Many of us working within the system understand the predicament but unfortunately much of the public is led to believe that the current transformation is going to solve most of our problems...and there are even some, both public and political, who still deny there are problems.

We can't fix the problems if they cannot be identified or spoken about.

Change has occurred in some areas as identified by the report:

1. Major purchases of medical equipment and information technology have boosted the number of services delivered.

2. Some jurisdictions have improved the way waiting lists are managed and provide wait time information.

3. Most Canadians have better access to health information and advice through telephone help lines.

4. Some Canadians have better access to publicly insured prescription drugs and to primary helath care teams. 

In other respects progress so far is not cause for celebration:

1. Catastrophic drug coverage and safe prescribing lags.

2. Home care is inadequate.

3. Aboriginal health has not improved significantly.

4. Primary Interprofessional team access is uneven, not comprehensive or available when patients need it.

5. Electronic health records and IT are not on track to meet the goal of having 50% of Canadians with and EHR by 2010.

According to Dr. Besner, "Governments promised to eliminate inequities and ensure all Canadians have equal access to the same services, such as primary health care, home care and prescription drugs, regardless of where they live in the country. Governments must renew their commitment to nationwide change."

I can say that the "nationwide change" that Dr. Besner refers to must be bigger than the transformation we have seen in Ontario.  The inequities in Ontario, as far as I can tell, are growing more significant with the transformation strategies. We have have-not patients on more levels than we've ever had before to my knowledge. We have more hospitals with varying degrees of support and we have a growing need in many areas that are unlikely to met with more government money or government spear-headed change.

If we are to address the growing numbers of patients with diabetes, cancer, and other chronic diseases as well as acute events such as pandemics, bacterial outbreaks of various kinds and more social needs than in the past, government will not be able to manage alone.

We know this already with private foundations and philanthropy that continues to grow across Canada to support our public institutions.

If we are to truly transform and create renewal of our health care system, its institutions, and its providers while simultaneously introducing and managing new industries such as genomics, patients will need to understand the urgency of the situation and understand their own leadership potential. Gone are the days when a few elite leaders existed to organize the masses. Patients must be seen to be leaders themselves and empowered with the ability to manage their own health care.

This will not be achieved in a top down approach driven by government need to micromanage and control. In my opinion sustainable renewal can only be achieved through the acts of  individuals in many, many capacities from volunteer work, to mentoring, to community patient leaders. 

The process must be driven by patients and to achieve this the politics must be  uncoupled, at least in part, from the provision and transformation process.  I'm not certain our politicians have the stomach for this and so politicians and our governments will continue to promise what they cannot deliver. Perhaps the courts will need to do this job.

At least the Health Council of Canada is able to admit that the government is not delivering...a step forward and for me another drop in the glass.