Dr. Merrilee Fullerton on Healthcare

I suspect what many people ask themselves when a budget comes out, whether federal or provincial, is:

"What does this mean for me?"

Most people don't ask:

"What does this mean for the province or what does this mean for the country."

I don't want to sound too altruistic or unselfish on this point because ultimately if the province and country are doing well I likely will too, but the reality is that most people are not looking too far down the economic road. They are simply looking at the very near future.  I can't blame them in some respects. We all have immediate needs to be satisfied.

But what if meeting the immediate needs makes longer term needs impossible to meet?

Looking only at the immediate future and your three foot personal  perimeter will not give you the bigger picture of what is coming.

Listening to the various  parties hammering the federal budget makes it clear that self-interest is overwhelmingly the driver of the opposition. Is it sufficient to oppose everything the government puts forward? Does that make for purposeful, thoughtful movement forward? Does that prepare Canada for what is coming? Probably not.

On the other hand, the Ont. budget isn't likely to do enough to settle the rising deficit..and good luck holding health care increases to 2.1 %. I expect more health care expenses will be hidden in some way or that the Ont. government will simply cave in as protests from various groups become more strident.

To put it another way: I think that the  Ontario Liberals will cave.

Health care has become more complicated in the past 20 years. It is about to get exponentially more complicated with point of care testing, genomics and microbiome understanding.

Ontario does not have a hope of meeting the demand for health care with a 2.1% increase. The Federal government recognizes the realities of unsustainability and larger than life expectations and is not about to keep feeding the Monster.

So what do we do?

I suggest, once again, more personal responsibility, a greater role for population health, and more options for funding mechanisms of medically necessary care.

How bad does it have to get before the public begins to understand?

I hope not much longer...but some plain, honest communication would help.

Cheers to finding the way forward (sorry mfO) and thank you for all of your "sustained" support and contributions!

Over the past year, shortages of commonly used drugs are becoming more frequent and widespread in Ontario and Canada. Recently, injectable meds are affected including shortages of emergency medications such as epinephrine.

There are multiple reasons for the shortages and plenty of advice from opposition parties suggesting that government should take over monitoring of medication supplies.

All I can say is:

With the rationing and shortages of almost every kind of care, can you imagine if government were to take over regulating the supply of medications! Just getting access to standard antibiotics would become onerous and difficult with wait times being measured and monitored.

The last thing we need is more measuring and monitoring by government. It wouldn't surprise me if provincial governments' push for cheaper generics is forcing pharmaceutical companies to look for greener pastures and switching to different product lines.

As in all things related to health care, if you squeeze one area the effect is felt somewhere else.

I'm not saying that Ontario's plan to play hard ball with Big Pharma is entirely responsible, but I can't see it helping very much.

If you want new products, new vaccines, new protection from the next nasty pandemic, you should embrace profit by pharmaceutical companies. No profit, no product.

Short and sweet today...

Imagine just for a few seconds what would happen if longevity keeps increasing while the fertility rate stagnates and as we continue to bring in more working age immigrants.

I don't need to be a statistician, demographer or seer of the future like Kevin Page or understand details of GDP growth to have common sense and some basic logic.

Let's say that in the next two decades with all the prevention, clean air, clean water, vaccinations, various screening tests, personalized medicine, organ transplantation, 9 million dollar diagnostic machines and stereotactic surgery, that Ontario succeeds in extending the life expectancy of large numbers of its citizens to 90+ years.

What do you think will happen?

Do you think that the government will succeed in controlling health care costs to under 3% per year?

Do you think that the government will succeed in population growth that is productive?

What will happen to the taxes that the working population will be required to pay as it shrinks in relative size to the dependent population?

What will happen to productivity of the remaining workers as more and more people are required to look after more and more ill and frail individuals either relatives or through health care provision even with remote monitoring?

Do you think that the relatively smaller population of working people will have more children as they pay more and more taxes to pay for more and more dependents?

Do you think that the society is still benefiting from increasing longevity?

Has the ability to prevent illness and prolong lives exceeded society's and the economy's ability to provide quality of life for older and older populations?

Has government thought out what spending on more and more medical care and entitlements will do to the standard of living for the population expected to pay for it?

Sometimes I think that as a general population, Ontarians don't grasp what is coming next. Is that because they can't figure it out themselves, don't want to know, or prefer to believe people that lie to them over and over again?

Just asking.

Many thanks for all of your contributions..I'm astounded that the last journal entry received almost 500 comments in such a short time frame.

Since Federal Finance Minister Jim Flaherty announced new funding for the provinces with no strings attached, there has been a brouhaha from the provinces and from the "do-gooder-know-it-all-morally-superior-super-sanctimoneous" types. In today's Globe and Mail, Ms. Gagnon has an excellent piece on Mr. Romanow getting things wrong...and I agree.

I have no doubt that Mr. Romanow is a great guy and that he cares deeply about Canada and Canadians and their well-being particularly when it comes to health care. The reality, however, is that the health care climate is rapidly changing.

I don't have a docudrama of a health care iceberg falling into the ocean to convince people that there is change going on like Al Gore...but I can tell you that the volume of services that is going to be required in the coming decades cannot be provided  in the context of a single payer system, not with a relatively shrinking tax payer base and growing numbers of elderly and scientific advancements. I won't go on because you've heard most of this from me already but it is important to give a different perspective from all the cheer leaders who are feeding at the trough.

It shocks me that "leadership" is so self-interested that it cannot see what is coming.

As for the whining of the provinces when they are handed a "no strings attached, huge sum of federal money" for health care I say: Get over yourselves and get a grip on reality.

I am disgusted with the short term vision and self-interest displayed by the majority of our provincial leaders..Brad Wall aside. For the most part they seem to think that Federal dollars are some sort of magic money pot whose offerings spring eternal.

Feds are in debt. Provinces are in debt. Individuals are in debt. The money all comes from us-the people.

It is going to take a concerted effort for all levels of government and leadership to be more honest about the practical solutions that are needed. I know I am asking for something that won't come easily. The public does not feel the pain yet but it is coming. And where will the Premiers be? Answer: Consulting and leaving the problems they have failed to deal with to another administration. Tsk. Tsk.

I will post the link to Ms Gagnon's article as well as to the article by Adam Radwanski. They are both worth keeping at hand.

Once again, thanks for your support and excellent posts...there is hope.

Some posts ago one of you asked for a blog entry on solutions. By now, many of you know my position on honesty, personal responsibility and coming to terms with new realities, however difficult that may be.

First, let me say that it is not the easy solutions we should be looking for. We've done that for far too long. We've heard that prevention is going to lead to more sustainability and more team work is going to lead to more efficiency and now we are on the "quality" and "value for money" agenda. We've tried the efficiency route for many years as well, about twenty-five, but that seems elusive too.

The difficulty with these solutions is that they are rigid solutions and do not take into consideration the ever changing environment that our health care system survives in. We need a more flexible system. What we are currently creating is a more rigid system with ever increasing bureaucracies for ehealth, for quality, for prevention and chronic disease managment and wait time monitoring. This approach may make us feel like we are doing something substantial but it is  leading us in the wrong direction.

Don't get me wrong..I believe in prevention for individual quality of life. I believe in accountability and quality measures for patient care. Patients deserve the highest quality of care our country can afford.

Key words: "can afford"

Yes, dollars and cents. That's what it comes down to. Compassion helps but it does not pay for health care. Goodwill helps and kindness too...but they don't pay for health care.

Health care expectations are growing. The more tax dollars that are shovelled into health care, the greater the expectation of the public that it can continue this way. I'm here to say that it can't. That's the first step to finding flexible solutions that will allow our health care system to adapt to ongoing changes in science, technology, demographics, pharmaceuticals and ever changing political environments.

Health care is not static. Rather than creating ever increasing bureaucracies to measure, monitor and quantify, we need to be moving to a system that engages patients in their own care and that allows for reasonable expecations of a system based on tax dollars.

We should be allowing the evolution of care and systems that permit patient input--both perpective and monetary. A greater tolerance is needed in health care so that there is less polarization, less politicization and less impersonalization.

Below is my suggestion for a Ten Step List to Health Care Flexibility:

1. Canadian politicians of all stripes must show less posturing and more honesty. "Unlikely", you say? Economic crises have a way of bringing more honesty and more collaborative effort to the foreground. Don't be surprised that as the economic and demographic situation in Canada becomes more difficult, honesty will need to be embraced by politicians. Right now it is more about who can promise the voters the most and then not deliver. Eventually that has a way of catching up to government, and that's us...the taxpayers.

2. "Medically necessary" must be defined. The public health care system should continue to be universal with comprehensive care for medically necessary care. However, private options can also be made available. Take for example the lack of jobs for orthopedic graduates in Ontario and the OR closures to contain hospital budgets while thousands of patients wait on lists.  There is no reason why Ontario should lose the orthopedic surgeons that it trained while ORs are closed for budgetary reasons and patients wait for care. This can be done without destroying the public health care system.

3. Allow private contributions and funding arrangments. Canada already has an element of private coverage for pharmaceuticals but in an era where stereotactic surgery, PET scans, stem cell treatments, organ transplantation, personalized pharmacogenomics and nanotechnology exist, new mechanisms of funding must be found.

4. Politics and health care must be uncoupled. Public payment for medical care has a way of creating a dependency by patients on a system that cannot provide for all the wants and needs of the population yet politicians are reluctant to suggest that the current system cannot achieve universal coverage in a timely way for all of the care promised. In fact, it is the patients at the edges who may be the most vulnerable that politicians ignore in their quest to satisfy the majority. This is wrong.

5. Foster more individual responsibility through the use of mhealth..mobile health using smart phones...rather than building a black hole of ehealth. By creating more patient independence through Self-Care, less dependence on the the public system is possible to achieve.

6. Develop programs that boost Health Literacy. Without Health Literacy it will not be possible to build more Self-Care into the system.

7. Consider how the Dependency Ratio will affect our ability to fund teams and to find the human resources for these teams. Expanding the number of health providers to deliver care at a time when skilled labour shortages are just beginning is not sensible because the tax dollars available to fund multiple layers of providers may not exist in 10 years..and it takes 10 years to make change in health care. Whatever we start to change now, may not be completed for another decade at which point it will be too late to change course.

8. Address the Social Determinants of Health by improving education, providing more affordable housing and more job opportunities. No matter how much health care is delivered, without more thoroughly addressing the SDOHs, the health care system will fail more and more people.

9. Accept that achieving greater efficiencies will NOT offset the growing demand for care or the inability to fund all of the expectations. For every efficiency found, it seems there are two new more expensive developments in care provision. Instead, focus on FLEXIBILITY of the system.

10. Explore opportunities for the corporate world to become more involved in public health care infrastructure whether it is in collaborative efforts in building public hospitals through expanded private/public partnerships or through philanthropy.  As the corporate world moves toward a greater involvement in social responsibility, there is potential for many groups beyond government to be able to foster improved health care opportunities for many citizens.

Overall, many solutions are required. Our universal health care system CAN exist with a greater role from other funding mechanisms. It is time we got our collective heads around this and move forward in finding FLEXIBILITY.

As always, I am grateful for your continued support and I look forward to ongoing and necessary change in health care. Nothing stays the same forever.

Cheers to a Happy Holiday Season and Merry Christmas!

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Added by ELB:

11. Improving end-of-life care including palliative care.