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Looking for Solutions in Health Care for 2006 and Beyond

Our health care system needs to change to accommodate new demographics, new technologies and new pharmacologic advancement.

The roots of compassion and caring in health care should not change however, and it is with this in mind that the dialogue of change should be had surrounding health care.

How can we adapt to different needs that emerge as our population ages?

How can we  find sustainability in the midst of so many new advancements?

How can individuals become more empowered in serving their own health care needs?

What role does the individual have in enabling the  health care of others  beyond paying taxes?

Many questions like these need to be answered and if we are willing to look with open minds at the problems within our health care system, and beyond political posturing, then we can find new  solutions to take us further into this century. 

 

 

 

 

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Tuesday
Dec052006

Priorities, Wait Times and Patient-centric Health care: Compatible?

 The Wait Time Alliance graded the provinces' performance on wait time benchmarks and commitments earlier this month with grades from A to F.  So there  IS movement forward  in the Big Five, even if small, which is good. While government should be applauded for  acknowledging the need for  more funding and trying to improve it , we need to ask how far does $5.5 billion (earmarked for wait times) of the $41 billion (from the 2004 federal/provincial health accord) go to making a difference for the patient who requires an expensive medication for a rare disease/cancer or the patient with Alzheimers or the patient that doesn't fit these 5 favoured groups. Are the priorities outlined by the five wait time areas geared to patient centred care or not? Given the facts, it doesn't look like it.   We need another solution, a long term solution.

One in four Canadians will be older than 65 by 2031. We will be managing the health care of 9.3 million seniors in the relatively near future. At current rates, 744,000 Canadians will be afflicted by Alzheimer's or related dementia with associated costs of care, medication and infrastructure.

Canada's aging population will create a steady rise in the number of people developing cancer. In 2005, it was estimated that 149,000 Canadians would be diagnosed with cancer-thousands more than the previous year. Over the next 20 years, an estimated 3.6 million Canadians will develop cancer. The federal gov't has unveiled a national cancer plan with $260 million to improve cancer care which amounts to a few million per province.  This may be helpful for the time being but the long term picture isn't pretty.

In 1956, 39% of the population was under 2o, while 7.7% of the population was over 65.

In 2040, 20% of the population will be under 20, while 24.3% will be over 65.

According to Chief Economist Don Drummond at TD Bank, Medicare is getting hit hard by a double whammy of ageing population and expensive technology and by 2011 health care spending will be rising by 8-10% per year. Spending on health has been rising 6-7% a year, education 3-4% and all other discretionary spending has been flat or falling. 

People will need to work longer or more private sector involvement will be needed or taxes increased or use  co-payments to cover rising program obligations.  We already talk about working smarter and squeezing more out of a shrinking workforce but Canada is barely scraping out a 1% productivity growth recently....not really close to the 2.5% productivity growth needed to pay for mounting obligations.

If people are going to have to work longer and contribute substantial amounts of tax dollars to healthcare,  they should be able to get it when they need it  and it is not surprising that  the term "patient-centred" keeps cropping up.  It is  central to finding real solutions.

To have patient centric health care I believe we need three things:  adequate numbers of providers to provide the care required by the patient, adequate funding to treat and care for the patient and the funding to be attached somehow to the patient.

Personally, I don't think we have any of the above at this point and I don't think it can be achieved with the transformation agenda proposed to date. We will need more private sector involvement to provide the competition to create efficiency; we will need to openly discuss co-payments; we will need to discuss the use of co-operatives for healthcare; and we will need to consider a "last resort" insurance fund to send patients to other jurisdictions when the need arises  as the CMA has suggested.

Hope this post inspires some friendly and respectful debate by some familiar voices or new voices and I am privileged to have you all aboard. 

 


 



 

Reader Comments (73)

Accountability and responsibility.

How to achieve the right balance.

From "centrals" position, do recognize that the legislation which has been passed is a formal recognition that the past system "failed'. There was no accountability of resources spent aligned to "real" patient care. Step one started. The waste is well documented.

What is step 2?

Should each Ontario resident (properly documented) be in charge of their allocation of resources. A fee for completed service is only transferrred if the patient presents and completes care? The movement away from "global funding" is opposed by all existing institutions. Central needs answers.
December 5, 2006 | Unregistered CommentermovingForwardOntario
http://www.auditor.on.ca/en/reports_en/en06/308en06.pdf

The auditor describes a dated bureacracy with difficulties, seemingly unable to monitor or implement policy apparently due to the "system"..

"Recommendation 8
... has challenged the aging architecture of the claims payment system."

What does that mean?

--------------------------------------------

More health cards than people found in Ontario
Dec. 5, 2006. 02:04 PM
CANADIAN PRESS


The auditor general has found there are about 300,000 more Ontario Health Insurance cards than there are people in the province.

Auditor Jim McCarter says most of the extra health cards are held by people in Toronto, or those living close to the United States border.

McCarter also found there are hundreds of unlicensed doctors in Ontario still able to bill the system, even though they may have been suspended or moved away.

He also says there was at least $17 million wrongly charged to OHIP last year that the government failed to recover.

McCarter says the College of Physicians and Surgeons doesn't update its data on doctors who have died, retired, resigned, moved out of Ontario or had their license revoked.

At least 40 unlicensed doctors submitted claims last year and had them paid by OHIP.

The auditor general also found Ontario hospitals expose young children and even staff to high levels of radiation from CT and MRI scans and don't analyze the dosages absorbed by patients.
December 5, 2006 | Unregistered Commentereklimek
If private is so great why is the Health spending % GDP in US highest of all OECD countries and ours has been stable for years?
What do you think would happen to the public system human health resources issues and waiting lists if private happened?
December 5, 2006 | Unregistered Commentermohler
Wait in the OHIP line for an MRI and it takes 3+ months.

Wait in the WSIB line and it takes 3 days.

Can anyone say 'two tier'?

What a health care system it is that the pointy headed devised---300,000 more OHIP cards than there are citizens in Ontario--- more doctors billing OHIP than there are doctors in Ontario---AG stated 23000 doctors billed OHIP, does he have the foggiest idea how many doctors there are in actual active practice in Ontario?--- the AG thinks nothing of the $17 million extorted by the MRC/OPRP mafiosi from innocents driven into bankruptcy, marital breakdown and suicide as a consequence of their high handed activities that denied natural justice and the protections afforded to the citizenry of Ontario to the accused---had there been actual fraud, the police would have been called in quite rightly as was done in the recent Methadone clinic scams---the AG should have had a quiet chat with Judge Corey who, quite rightly, put an end to the unjust auditing system of the time.
December 5, 2006 | Unregistered CommenterAndris.
Well, it just goes to show that there are "inefficiencies" in the system. We knew that already and if we looked a little deeper it would be even more shocking. I still recollect asking why a patient on my staffman's service could not be moved to another room (22 years ago)....I was told by a ward clerk that it would cost about $70.00 just for the paperwork to have the patient change beds...I shudder to think what it costs now. About the same just for registering in the ER. Needless to say the patient wasn't moved.

But the inefficiencies equate with a large bureaucracy where nobody can clean wax from an ear without a dozen forms.

In a private business this would not happen because one could not stay in business with this kind of inefficiency. Yes, business, yes profit....it is a driver.

And interesting that the private businesses external to hospitals are being relied upon more and more in our society to top up the social programs that seem to be gradually slipping in their ability to deliver...food banks, hospital foundations to keep diagnostic machinery up to date and infrastructure maintained....$100 million raised for a new ICU and ER at one hospital I know.

But this is a good thing because it engages people from the community to be actively involved in the delivery of healthcare to those in need.

In coming decades, we will need to encourage more philanthropy and more entrepreneurial spirit in the delivery of healthcare.

How to do this if every time a physician or other sees a need and tries to fill it but gets whacked?...ie Urgent Care Centre in BC

December 6, 2006 | Unregistered Commenterrealist
"What do you think would happen to the public system human health resources issues and waiting lists if private happened? " - mohler

May be you could answer this for us? Most practices already absorb an opportunity cost for providing certain OHIP services. I know mine does. Is public care responsible care?

How about marginalized cases, such as the following? Would private care be more responsible care?

=====================================

November 12, 2006
Hon. George Smitherman
Minister Health and Longterm Care
Hepburn Block
10th Flr
80 Grosvenor St
Toronto ON M7A2C4
Phone: 416-327-4300 Fax: 416-326-1571

Sir:

On September 19, 2006 your Ministry was notified of a concern regarding neurosurgical infrastructure shortcomings in Ontario. Please review the correspondence and the clinical vignette excerpted below. As presented, it is entirely consistent with tragic outcomes so far discussed and extends the scope to pediatric age groups.

Clearly this situation risks foreseeable and remediable disability for all residents of Ontario. It has now occurred to an 11 year old. The lack of capacity to care for these cases must be addressed by the individuals in a position of authority who may be able to intervene. We ask you to act on behalf of these patients.

E. Klimek MD FRCPC

145 Queenston Street, Suite 301
St. Catharines, Ontario, Canada L2R 2Z9
Telephone (905) 688-2066
Fax 688-9335

=======================================================

Vignette #3 - obtained from the Ontario Neurology email list


Just returned from ER after spending 4 hours on a Pediatric case.

11 year old girl, born in Canada.

--clinical details removed at this point ------

MRI not available in Windsor from 11 pm to 7 am.

Called London Children's hospital. No MRI tech on call tonight. Neurosurgeon on call not a spine surgeon, so suggested call Sick kids.

Called Criticall. Sick kids can take the patient , but cannot get MRI because it is down, so they suggest get MR done in am or in Detroit tonight.

We are now trying to get an MRI done in Detroit. Will probably transfer her as an inpatient for logistics of urgent MRI including consultation with a Pediatric Neurosurgeon.

Good night.

...

Follow up:

Patient was transferred to Detroit. The Radiologist and ER doc in Detroit did not agree with my diagnosis of possible Epidural abscess, so they waited till this morning and after consultation with other radiologists and Pediatric Neurosurgeon agreed that an MRI was in order. MRI was done late in the morning and patient was taken to the OR. 20 cc of pus was drained from the interhemispheric fissure. Gram stain shows mixed organisms. Patient continues to have right hemiparesis.

When we first called for an urgent MRI at Children's Hospital in Detroit, to be done in the middle of the night, they told us this could be done in "10 minutes" if the patient was an inpatient. So we had to transfer the patient and admit her in Detroit.

++++++++++++++++++++++++++++++++++++++++++++



December 6, 2006 | Unregistered Commentereklimek
Realist has raised questions that have been with us for at least 20 years. And every 10 or so they come around again. That in itself is a commentary.

Patient-centred care is what we all aspire to - or should - but our own concept of patient-centred care may not be the same as the patient's view of patient-centred care. A sensible balance is required between medical need and demand-driven utilization. I cannot help wondering what degree of pressure might be released from the system if all patients made rational choices about how they use the resource. Patients who routinely do not make rational choices (and we all have them in our practices) compromise the integrity of the system. Patients who need the resources are disadvantaged.

So I find tying the funding to the patient at this point a bit problematic, unless I am missing Realist's point. What might be one approach is to assure each tax-payer a basic flat amount in each calender year for basic health care over and above which other payment mechanisms would kick in. But that is a 'cloud in my coffee' and I have no sensible suggestions about how to implement this.

So there is a significant portion of patient behaviour that needs to be restrained. (That is one large systemic issue that seems not to be addressed for reasons one can guess.) The question would be how to go about this effectively. In the US, it is done through the HMO's and their cognate organizations where there is a nay-sayer at the gate. Recent legislation, dubbed "any provider legislation" in many of the states indicates just how unpopular an approach this is. But, where the payor has a pot of such-and-such a size, this is how one goes about that kind of control.

So we do not nay-say directly. But, if I wanted to do it indirectly, how would I do it? I would have to introduce rationalization in some form which would serve the twofold purpose of curbing those behaviours mentioned above, and containing spiraling costs that will continue to escalate. I would do it through structures built to manage funding flows that regulate the number of programs and services deliverable in any given area. (And you can guess the rest of the story.)

Now, my motives for doing this will not be all bad. It would provide an opportunity for rechanneling funds in more productive directions. But, the Law of Unintended, or semi-intended consequences, is bound to kick in, and my indirect method of necessary nay-saying is going to burn a number of consumers who should not be burned. So my method of control is not any better than the HMO's. But I will not have violated the Canada Health Act. Health care will still be conceptually universal. And nobody actually gets their hands dirty in the business of control that one can identify or appeal to.

The Canada Health Act is a sacred cow. There are advocates of reform for this act who -- and not without reason -- believe we can no longer afford ourselves (they are not wrong about this), and we read in the news on a frequent basis about federal responses to the serious challenge that two-tiered medicine is thought to pose. We already have two-tiered medicine; it is called the insurance industry and WSIB. But technically, they do not violate the CHA. Without some reasonable form of open privatization (much of which is already going on through the tendering business for service delivery), we indeed cannot afford our future.

Added to the spiralling cost burden of our aging demographic is the increasing immigrant demographic which often brings a huge burden of chronic disease. The relatively smaller potential contribution to the tax-base those who find work will make, when coupled with the diminished size of the actual number of tax-payers in the post-baby-boom generation, that is people who pay into the system, exacerbates the problem at the tax base.

This is not a reason to stop immigration. I would never suggest this. My own ancestors were immigrants fleeing the irish potato famine. They were grateful to have the new world to come to as I am sure all those who find their way to our shores are. But there is a health-care-related cost to our openness which we had better be prepared to address. And our newcomers deserve the same health care considerations as our old-comers.

The cost projections for the future are indeed daunting. Our own contribution is to try now to exercise diligence in how I and my colleagues dispense our own meagre resources. And our role will be to continue to advocate for our patients in a non-user-friendly environment as best we can to ensure they get what they need when they need it even if if means referring outside our LHIN which we are quite prepared to do and which we have to be permitted to do if the LHIN structure cannot serve our patients when they need it.

I can't spend all day at this, but a word about the provider issue. It is far from clear just what the optimal number and mix of providers should be, factoring out demand-driven utilization. We have physicians graduating all the time. But look at the stats from the academic health science centres about what disciplines are not able to fill, and about who is not going into conventional practice. And look at the Ministry approach to the Nurse Practitioner Program. Desultory or what?

Last, about the claims system. One root of this I suspect is the OHIP computer which is so old that it's held together with chewing gum and bailing wire (aside from the broader compensation-related system issues). What happens if it croaks or someone kicks the plug out?

Sybil
December 6, 2006 | Unregistered Commentersybil
" What would happen to the public system human resource issues and waiting lists if private happened?"---easy answer,the problems would be resolved.

This dysfunctional and punitive centrally planned health care system has driven over 9,000 Canadian trained doctors out of the country---if, as in the 29 health care systems judged to be more effective than Canada [#30] and the USA [#37], the state/provincial health care monopolies were abandoned, leaving Cuba and North Korea alone in their monopolies, Canada and in particular Ontario might again become an attractive environment to work in resulting in the retention of doctors and the repatriation of the self exiled.

The Canada Health Act is as dead as the dodo, the sacred cow is sacred only in an abstract sense and not in reality, each province having turned a blind eye to the aspects of the Act that each wished to ignore, 'universal' it is certainly not----as for expecting 'rational choices' from patients, one can expect no more rationality from them as from the central planners , the bureaucracies of the various ministries and the political class----as for 'Two tiers'...we already have eight at the last count...getting it down to two is unlikely and down to one an impossibility.
December 6, 2006 | Unregistered CommenterAndris.
It is far from clear just what the optimal number and mix of providers should be, factoring out demand-driven utilization. We have physicians graduating all the time.- Sybl

It is not manpower shortage that is wanting in all areas. It is infrastructure and organizational committment and support that is lacking. See for example

Can J Neurol Sci. 2006 May;33(2):170-4.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?itool=abstractplus&db=pubmed&cmd=Retrieve&dopt=abstractplus&list_uids=16736725

Unemployment in an underserviced specialty?:

The need for co-ordinated workforce planning in Canadian neurosurgery.

* Woodrow SI, * O'Kelly C, * Hamstra SJ, * Wallace MC.

Department of Surgery, Wilson Centre for Research in Education, Faculty of Medicine, University of Toronto, Toronto, ON.


BACKGROUND: A recent report suggested that newly trained Canadian neurosurgeons are experiencing difficulty finding employment in
Canada. Such occurrences, in combination with recent certification restrictions imposed in the US, have resulted in increasing concern
that we will shortly be seeing a surplus of graduating neurosurgeons in Canada.
December 6, 2006 | Unregistered Commentereklimek
eklimek is accurate in his assessment I believe.

Take for instance the cap that was imposed for many years and only just recently which drove able bodied physicians out of the country after reaching their cap. Some went to India to provide care to the destitute, some went to Africa to provide care at agencies sorely lacking specialty care. Some went to other countries and provided their services for a fee while others simply did other things.

Operating rooms could be running full tilt. But there is not the funds to cover the cost of the services that could be provided or the cost of unionized nurses and other employees.

Even the holiday down time in ORs help control budgets....let us not kid ourselves.

And utilization is UP and will likely stay up. We are forced to play a game where one gov't party spends and spends when in power, gets voted out because of the economic results, the other viable party gets in and is forced to clean up the mess, usually too quickly, and gets the boot eventually, only to be replaced by the other party that gets in and spends and spends again.

This is no way to run healthcare. This is not fair to patients. This is not the way to find a sustainable system. And it is no way to keep providers.

December 6, 2006 | Unregistered Commenterrealist
Boy, that recent audit was a bit hard on our venerable OHIP Claims system. But it's interesting to note that the harshest criticism came not from the auditor but from the MOHLTC itself.

You'd think they'd be defending it instead. I can tell you it's not the hardware or the software that's the major problem, it's the 'peopleware'.

Yes, it's basically unchanged since the mid-seventies, but so are physicians billing habits. The 2004 agreement (actually signed in late March 2005) was a challenge to implement, but, for the most part, went in without a hitch.

I can't imagine the next one being any more complex. (And hopefully it won't be signed a year late)

December 6, 2006 | Unregistered CommenterTragically an OHIPster
I find it interesting that some think that the ability to get a contract signed is a big success.

Let's put things in perspective:

-Largest health spending component is hospitals (about 45%)
-Fastest growing health spending component is drugs ($3.7B), double digit annual growth rates
-Total govt expenditures on Drugs has increased 322% between 1990 and 2005
-Medical services per patient almost doubles for ages 51 to 85
-physicians per 1000 in Canada is flatlining from 1990 to 2004 (some slight increases in medical school enrollment and IMGs coming but won't be enough....)
-about 48% of physicians are now over 50

So although nobody should be ripping off the system, patients, physicians, bureaucrats or other, we need to remember that the solution required is of much greater magnitude.

Of interest however in Mr.McCarter's report, is that information presented on the health ministry's highly publicized wait times website is "misleading" and should be taken "with a grain of salt" as he told reporters Dec.5.

Can't blame Ontario's Auditor General for trying to do his best. Unfortunate that attempts to mislead may delay more changes and affect more patients.

And yes Sybil, we are likely to see the merry-go-round health care politics make us all dizzy and we will ask the same questions in 10 years again because of the lack of honesty, courage and foresight.
December 6, 2006 | Unregistered Commenterrealist
How is manpower shortage related to the Waiting List strategy successes?

If recent stories are correct, soon there will be no waiting list for cataracts in the province. Like passenger pigeons, once numerous, they will all be done. Did we suddenly have more manopower? Was this a "shortage" of opthalmologists, Or was this a contrived rationing of care through inadequate funding?
December 7, 2006 | Unregistered Commentereklimek
Re. wait times and other bits...

Ontario's Auditor General (AG) has said that we should take the Ontario wait times with a grain of salt. Last week, Dr. Terrence Sullivan of Cancer Care Ontario suggested that comparing wait times for cancer related activities across Canada was analagous to comparing apples and monkeys. (Although I query whether Dr Sullivan would have made that comment had Cancer Care Ontario's data looked very good in the national comparison...but I digress). Anyone who has paid even a little bit of attention to the collection of wait time information is aware of the problems but in spite of this our politicos wax on eloquently if a single wait time appears to have come down. My sentiments are similar to Realist's with respect to Ontario's AG - thanks for trying to do a good job. In our world of 30 second sound bites however, the AG's perspective is already lost I fear. MFO has issued similar refrains in terms of the context of mis-information and simply not telling the truth. I guess I should just get over it and accept that it is the way of the world we live in. Something akin to:
"do what you want; then when the consequences are unfavourable, deny, deny, deny....and then quietly seek forgiveness. Perhaps the recent scare in London Ontario regarding surgical instruments and the possibility of the rare, but fatal brain waisting disease is evidence that some folks are bucking the trend and actually trying to be up-front...well, at least from the press reports it has appeared that London Health Sciences has been beyond reproach...maybe there is hope.
December 7, 2006 | Unregistered Commenternotadoc
Notadoc:

No reasons to be overly discouraged. Many still try to play by the "rules.

Sadly our "system" however drives many to respond to the master - there is no other way to provide care.

It's a political system - and the voices of dissent and frustration over what can be clear misuse of money - or shortages - are not to be tolerated. The response, by those whose jobs are directly dependant on the tax dollar, is to do what they are told, and speak with the correct tone. The beauty of a state run monopoly is the potential of it working for the people - the dangers arise when it works against the people so that it can "survive".

Health in Ontario is roughly where the postal system in Canada was 20 years ago, fighting change and protecting tuff for the "evil" competition of equal payment for equivalent work. Long live global funding.
December 7, 2006 | Unregistered CommentermovingForwardOntario
Global funding is a bit of a catch 22. It has the general mantra of "give us what we want and we'll do the right thing". However it is no longer reasonable to assume that is the case. The number and scope of discrepancies across the province is huge. Furthermore, our geography and political geomap tends to screw things up in an ongoing way.

Ok.. novel crazy idea.

1. Infrastructure funding based on standards (provincially set - if you want better you can spend more) relative to building, building age, etc. Yeah I know... "impossible to achieve".. but it would move us all to a common platform for many of the common types of expenses. It also would allow us to better position the system to consider regionalization of core key functions (finance, payroll, HR, Health Records/Info Mgmt, etc.

2. A continuous moving window of funding relative to the previous 6 months worth of clinical activity. Yep that would mean that health care would actually have to meet patient's needs rather than the needs of the worker's vacation times. Ya know what? Not everyone can/will/should get summer off - unless you are a teacher, but let's not go down that path.

3. Standard clinical funding based on acuity/severity or whatever other common index we could agree on. So our budgeting cycle would reduce to 6 month forward blocks of activity. Funding flowed (in advance - did you hear that central) for planned clinical activity and activity levels. Then subject to reconciliation against actual provided service levels. This means the agencies (not just hospitals here... ccac, ltc..etc) would need to NOT spend out if they aren't delivering the services.

3. Provincial development of standardized/expected levels of service provision. Know what? Not everything can be done everywhere. Get used to it.. move on. Use ICES-centric type of data to actually decide where services will be provided based on real demographics and trends. Yep, docs would have to move.

4. Provincial development of a "no service" provision policy. Some things just won't be done.

5. Provincial subsidization and development of formally integrated (to hospitals) linkages of FHT/FHG/FHN/FHWhatever to the hospitals. EMR's, Rad repositories.

6. Get rid of duplicated administrative functions. E.g. CCACs LTCs etc have own payroll, HR, finance, IT functions. Run it all centrally within each LHIN (doesn't need to be done IN the hospitals and maybe it's best if it isn't).

7. Pull out all registration and booking functions from ALL agencies and centralize it to a LHIN/region. Dentists have been getting it right for years while the rest of the system fritters around. Patients call in, get scheduled and get a call the day or so before to remind them.

8.. ok.. tired out.. more later maybe
December 7, 2006 | Unregistered CommenterNew Peon
Hello from the pastures. New Peon. Some interesting ideas to be pursued, but not right now because we're in the middle the clinic from hell (is it a full moon?). I thought I would take a sanity moment and ask a question that would scratch an immediate patient-centred itch. Why, when not so long ago we could get them in timely fashion for the patient, is a Section 8 suddenly taking 60 days or more? We have patients who cannot afford the medications necessary for their current conditions, whose Section 8's have been outstanding for this long. I am talking about things like anti-siezure medications critical to treatment. Can someone enlighten us?

Patient-centred care?
December 7, 2006 | Unregistered CommenterHayseed Docs
For the physicians wondering why delays occur, the following chapter from the AG report will help.

http://www.auditor.on.ca/en/reports_en/en06/408en06.pdf

Of all the issues identified by the AG in his 2004 report, not one has been completed by the 2006 report.

December 7, 2006 | Unregistered CommentermovingForwardOntario
New Peon has the picture needed essentially correct in my view. They basically describe the features of a 'service contract' environment. Cash flow based on target acqisition progress (patient based or otherwise). Let's get there and see what develops. I suspect lots good.

Folks should not underestimate the current impact on health politics or distraction levels posed by the MOHLTC 'New Directions' initiative.

There is an overall'keep-the-lights on' attitude in play at 'central' as SMG level stuggles to figure out, among other things, where they all land and empire-lines are to be re-set in the detail. This is the stuff of people's lives and therefore profound whether it matters to those working at the clinic level or not. Just hope the evolution happens quickly as it currently promises to do if information I have is correct.

I do happen to agree with Dr. Fumerton's general prescription stated at the start of this string by the way. However, the devil be in the details I suspect.


Cheers.
December 7, 2006 | Unregistered Commenterhedgehog
4. Provincial development of a "no service" provision policy. Some things just won't be done. - NP

Put it in writing and absolve the health care provider from responsibility. In other words, provide the same immunity currently enjoyed by those in positions of authority to those currently liable for provision of care after an untoward or unexpected outcome.
December 7, 2006 | Unregistered Commentereklimek
What is a "no service" provision policy?
Anybody?
December 7, 2006 | Unregistered Commenterrealist
What is a "no service" provision policy?

ER closes after 9 pm.
December 7, 2006 | Unregistered Commentereklimek
I am willing to pool my ignorance here, although I expect New Peon may elaborate. "No service provision" occurs when there is no connectivity to some mandatory basic structure/system that enables the provision. So, for example, no health card produced, no service. But, there is also the version whereby, in accordance with some agreement or contract, no service of a certain kind is provided. You will recall the "Oregon Experiment of the '80's, where a panel at the state level drew up, in the context of the democratic process, an array of services that will and will not be provided within the State of Oregon. The driver was, as I remember budgetary exigency. This is a simplistic statement of the concept, perhaps. But that is how I understand it.
December 7, 2006 | Unregistered Commentersybil
About 'no service' matter:

What consequence for the doctor who works in a remote location with not much more than their 'black bag' when a patient presents with a heart attack?

The doctor deems it useful to 'deep freeze' the patient to improve outcome (apparently a useful technique in opinion of some). Problem is there is no ice supply for the task and it does not happen. The patient forgoes the putative benefits and recovery does not go very well.

Can the patient hold the physician responsible for not anticipating that a patient heart attack is at some point likely and all associated treatment needs such as plenty of ice are to be available?

Is this not all about 'reasonableness testing'? Does every citizen expect every service every time? In general, clearly they do not or polls on the subject would reveal other than what they currently do on this subject.

If this is the case, why do certain voices carry on as if wait times, expensive treatments and costly Rx pressures are any different than finding oneself without ice in a clinical situation calling for it?

Just wondering where I should construe the line to been drawn here as a non-physician.
December 7, 2006 | Unregistered Commenterhedgehog
Hedge-Hog: Let's wait until New Peon elaborates his understanding. In Oregon, if you're over 55, you can forget a hip replacement. I don't think they were looking at the primary care level services as much as procedures that would or would not be avialable, and the criteria for services/prodecures available.

I will now confine my relative ignorance to silence until we hear from New Peon. I am interested in any new spins on this.
December 7, 2006 | Unregistered Commentersybil
I recall a friend along the St Lawrence telling me 10 years ago that they knew of Ontarian's holding non-picture Ontario Health Cards who would lend it across the international border to a relative in New York State who then entered Ontario, had their surgical operation performed at"no cost", and returned to the U.S. after a brief recovery.
Presumably this is no longer possible.

However, other things are strange - a doc once got asked by a "walk-in" patient to authorize the filling of a certain drug (street saleable) prescription for him - the doc phoned the physician who had originally written the prescription and who said, "Yank the damned thing - this is over the 10th time that he's re-newed that non-renewable prescription."
First doc yanked it, cut it in half and mailed
both halves back to their originator. Don't these things get taken out of circulation by the first (and only) filling pharmacist? And does OHIP's computer not actually track and double check for illegal multiple fillings? Not a doc, but have watched & supported one for over 30 years :-)
December 7, 2006 | Unregistered CommenterMissississy
Missississyissyisssy....

The street drug issue is easily dealt with...in Alberta over 20 years ago they used triplicate prescriptions for narcotics and abused drugs...doc wrote one for patient to take to pharmacy, one was kept and I think the other went to RCMP or something...recollection is a bit foggy..but in any case, even before computers or EMRs this was simple to deal with.

Funny thing is that if this were done in Ontario (plenty more population now than Alberta 20 years ago), somebody might actually have to act on the now documented abuse and more money would have to be spent...sorry, not really funny.

Just imagine the costs of tracking every person down who abused and of dealing with them... not to mention that gov't now wants to spend to regulate herbal remedies too.....(only about 10% of all herbal remedies are currently reviewed by the Natural Health Products Directorate...but this for another topic much later).

Getting back to HH:

In your scenario of the doc in some remote area with no ice and only a black bag, I can only say the patients in that location are lucky to have him/her. Thank goodness some docs are actually willing to risk working in areas with poor back up and inadequate supportive care. My hats go off to them.

Is it the docs responsibility to build a tertiary care centre and staff it and supply it with all the necessities including ice while gov't rations care to control costs?

" why do certain voices carry on as if wait times, expensive treatments and costly Rx pressures are any different than finding oneself without ice in a clinical situation calling for it?"-HH

What if the patients family said "we have ice", "we'll make ice", "we'll bring ice"...should the doctor refuse to use the ice based on the idea that he doesn't have ice for the next person because the gov't didn't supply it?

Maybe I don't understand your question HH? You can always elaborate and see if dunces like me get your point in the end.


December 7, 2006 | Unregistered Commenterrealist
Is this not all about 'reasonableness testing'? Does every citizen expect every service every time? - hh

It is about a duty of care and a failure to provide the same for one individual that is the issue. And, yes, every citizen expects every service every time.

There has not yet been an adequate defence of an untoward outcome based on infrastructure inadequacy. In every case the statement of claim (the law suit) indicates the physician knew, or ought to have known, that the facility lacked the capacity to care for this person adequately and it was his/her duty to transfer the patient to one that could.

In one case dealing with the lack of CT scanner in the hospital, the ruling by the judge indicated that it was not the role of the physician to consider the cost to the system of transferring all patients (plural), it was the issue of not transferring this patient that was before the court. The untoward outcome for this patient stemming in part from not undertaking a needed test was the essence of the suit.

If you want a cold shower read about Dr Reddoch's 6 year legal experience resulting from a patient with botulism in the Yukon.

http://www.courts.gov.bc.ca/jdb-txt/ca/02/yk/2002ykca0017.htm

http://www.cmaj.ca/cgi/content/full/168/3/330
December 7, 2006 | Unregistered Commentereklimek
Sorry if my point was not made clearly. Without belabouring the point, I will just add that I think New Peon makes a point that gov't can and should more clearly spell out policy on 'no service' resulting in better understanding and less legal debate.

In his response klimeck alludes to expectations that a physician 'knew, or ought to have known....'. Determining what was known or especially what shoudl have been known calls upon the adjudicator to make reasonable assumptions based on the facts (a reasonableness test).

I still maintain that it is a myth that 'every citizen expects every service every time'. I think those who propose this mix the meaning of 'want' with 'expect'. There is a material difference here and one politicians understand I think.

I'll leave it at that.
December 8, 2006 | Unregistered Commenterhedgehog
HH- I agree the "gov't can and should more clearly spell out policy on 'no service' resulting in better understanding and less legal debate."


"Until immunized by law from tort action for following reasonable cost-saving practice guidelines and parameters, society pays a price for intolerance of unforeseeable and unpreventable error that in fact has no causal relationship to outcome."

from my signature line - Eklimek
December 8, 2006 | Unregistered Commentereklimek
1- The reasonable test

"In order to evaluate a particular exercise of judgment fairly, the doctor's limited ability to foresee future events when determining a course of conduct must be borne in mind. Otherwise, the doctor will not be assessed according to the norms of the average doctor of reasonable ability in the same circumstances, but rather will be held accountable for mistakes that are apparent only after the fact."

Lapointe v Hôpital Le Gardeur, [1992] 1 S.C.R. 351, at 362-63:

(from the case of Dr Reddoch above.)

2- Does every citizen expect everything everytime? Maybe not, but those who file a suit do.

December 8, 2006 | Unregistered Commentereklimek
http://www.theglobeandmail.com/servlet/story/LAC.20061208.CANCER08/TPStory/Front
Clinics let cancer patients purchase treatment
Drugs not covered by medicare fetch up to $40,000
LISA PRIEST

For the first time, cancer patients across Canada will be offered what the public health-care system has been unable to deliver: intravenous drugs not covered by medicare for those who want to prolong their lives or fend off a recurrence -- for a price.

December 8, 2006 | Unregistered Commentereklimek
Former Senator Michael Kirby To Review Wait Times Reporting
McGuinty Government Responds To Auditor General Concerns

TORONTO, Dec. 7 /CNW/ - The McGuinty government is asking former Senator Michael Kirby to independently review the Ontario Auditor General's concerns on how the province measures and reports on its wait times strategy and provide advice for improvement, Health and Long-Term Care Minister George Smitherman announced today.


December 8, 2006 | Unregistered Commentereklimek
Thanks eklimek.

So will gov't let the patient and their family "buy ice"?

Of interest is "Sandy" Sehdev. If he is who I think he is then he is Sandeep Sehdev and quite a brilliant fellow who is compassionate with an entrepreneurial spirit.

I hope he can fill a niche needed and requested by patients before the CHA supporters with their blinders on say there will be no "ice" for patients unless government can provide it.

It will be interesting to see how the Cancer Foundations begin to lobby hard for their spots alongside the Cardiac Institutes across the land vying for the supreme position for gov't funding and donations.

Shouldn't patients be allowed to pay for this type of treatment and not just the biggest donor?

********************888
Clinics let cancer patients purchase treatment
Drugs not covered by medicare fetch up to $40,000
LISA PRIEST

From Thursday's Globe and Mail

For the first time, cancer patients across Canada will be offered what the public health-care system has been unable to deliver: intravenous drugs not covered by medicare for those who want to prolong their lives or fend off a recurrence -- for a price.

In what could be likened to one-stop shopping, patients can buy cancer medicine not paid for by their provincial governments, and in some cases, receive financial assistance. Medication will be administered by a nurse, under a doctor's supervision, in one of 18 infusion clinics across Canada.

Three key players are providing the service: Roche Canada, a drug company that holds the licence for five cancer products; McKesson Canada, which is administering the program; and Bayshore Infusion Clinics Inc., which provides clinical staff and medical equipment.

It's not clear how many patients would use the service. However, those requiring Avastin -- a drug proven to prolong the lives of patients with incurable colorectal cancer -- could tally in the thousands. Drugs to treat lymphoma and breast cancer would also be available.

The drugs don't come cheap: Price tags range from $22,000 to $40,000 for a course of therapy, depending on the medicine. A financial-assistance program can mean a discount as long as patients subject themselves to a means test.

The sheer number of clinics -- seven now operating, with 11 more set to open in January -- suggests there will be a large demand.

"We're offering a service to patients in need," said Janet Daglish, project manager for Bayshore.

The company is operating infusion clinics in London, Ont., Mississauga, Hamilton and Halifax, as well as two in Toronto and soon one in Brampton, just west of Toronto. Ms. Daglish said 11 more are to open in Nova Scotia, New Brunswick, Quebec, Ontario, Manitoba and British Columbia next month.

The inability of the public system to cover the drugs comes as a surprise to cancer patients, who have long believed Canada's health-care system is based on the principle of equal access. But equality has never been the case when it comes to drugs, a vexing reality that often unfolds in the oncologist's office.

That is creating two types of cancer patients: those who can afford the best treatment and those who cannot -- what many would construe as two-tier care.

Sandy Sehdev, a medical oncologist who practises in Brampton, sees the infusion service as a stopgap, what he calls a "solution born out of necessity."

Consequently, he has turned the small room where his bookkeeper once worked into a makeshift infusion clinic.

He plans to open it to patients any day now, saying: "I want my patients to receive the same care that I would want to give my family."

Doctors have no financial stake in the business but are required to supervise the infusions.

In Dr. Sehdev's case, he plans to bill the public system $25 or $65 a patient, depending on the complexity of the treatment -- the standard fees for overseeing chemotherapy.

The opening of these clinics comes as governments fund some costly cancer drugs but not others, making for unequal access.

Most provincial governments prohibit hospitals from infusing unfunded intravenous drugs, though some Ontario hospitals quietly perform the service and absorb the infusion cost. ....
December 8, 2006 | Unregistered Commenterrealist
realist

I have said to you before that I have no problem per se with patients providing their own 'ice'. I have a problem with what might be the impact on access levels for the less flush.

If the demand for physician delivered 'ice' treatments explodes (only so many hours in a day and too few doctors to meet demand) how do we assure access for others without 'ice' means? Answer this simple math problem and a complex health system policy debate goes away quickly for most observers.
December 8, 2006 | Unregistered Commenterhedgehog
HH

You forget that the government solution to not having enough physicians is to provide "physician extenders".....the increases in medical school and to IMG numbers will not be enough.

There will be nurse anesthetists, NPs acting independently (as the CNO has requested some groups of nurses to be able to act independently beyond the supervision of a physician).

So you worry about how provider numbers will be affected by people being able to buy their own services or medications when the real worry is what will happen if we DON'T let people start purchasing their own care.

The reality is gov't can barely afford the current system let alone more physicians and more expensive cancer treatments for the millions of patients who are going to develop their new cases of it over the next decades, not to mention the expenses from the other big four or from Alzheimers' patients or for now treatable diseases.


According to the annual report of national health expenditures by CIHI, per capita spending on health care is expected to reach $4,548 by the end of 2006.

CIHI forecasts total health care spending to be up $148 billion this year- up $8 billion from 2005- and will represent 10.3% of Canada's GDP.

That is the highest in 31 years.

This is the tenth consecutive year where health care spending is going to outpace inflation and population growth.

And despite this, Sharon Sholzberg-Grey, president and CEO of the Canadian Healthcare Association said the report should give a boost to Canadians' confidence in the healthcare system.

HUUHHH?

Absolute denial.

There is currently a 70/30 split in Canada in public/private healthcare expenses and some people argue this is a big enough share for private provision.

But what if I want to spend on my cancer treatment along with my glasses and my dental treatments? CHA says I can't.

CHA is antiquated. It needs to be rehauled and the sooner we get on discussing how to preserve public care but allow more varied access to private care we will find a rejuvenated health care system with SUFFICIENT PROVIDERS.

December 8, 2006 | Unregistered Commenterrealist
test
December 9, 2006 | Unregistered Commentertest
A brief refresher as the plan unfolds.

Early in the 1990s, representatives from the OMA, OCFP, ONA, OHA, MOHLTC agreed that similar to the UK NHS, Ontario would move to regional services, focused around primary health teams which would be aligned to specific hospitals so that coordinated, seamless, care would be started at the Family Health Team/group/network which would be "controlled" by local hospitals boards thus creating local networks. In doing so, it would allow the MOHLTC to continue to use global funding (to achieve a controlled budget process).

It has morphed a bit and we know will have patients/clients focused in through "rostered" FHG/FHN/FHTs aligned with local hospitals, which themselves are now aligned into LHINs which "control" all resources to all medical services as dispersed down through the MOHLTC.


http://www.oha.com/Client/OHA/OHA_LP4W_LND_WebStation.nsf/page/Laboratory+Information+System+Integration+Report

We now are getting more documents becoming available for public viewing so that central can't be accused of not revealing the plan. Read the plans - the plan is good.

First glimpse of the proposed system for core lab and diagnostic services provides additional information regarding the complexity of the plan. At least the old lab and diagnostic service plan (of 9 regional sites) appears to be aligning with the 14 LHINS now.

P7 item 3.3, is interesting in that "physicians" are to be included in the LHINs control (different than the current legislation but that will be changed).

So, in summary, all patients will come through rostered FHT/FHG/FHN. Those not handled at that level will be feed through hospital specialists who are dependant on diagnostic and technical services only funded through global funding provided by the LHIN to designated hospitals and IHFs (which will fall under LHIN authority). Insufficient funding will cause needed "regional" centralization of services.

What this causes at "central" is a massive repositioning of bureaucrats trying to assure that they maintain control of budgets as the shift goes on. There are empires to carve out/protect as this goes.

The next 2 years are going to be nasty as the carve out occurs.
December 9, 2006 | Unregistered Commentermovingforwardontario
First, the UK is in a mess.

Second, the boomers have not waited for much in their lives, they are used to controlling what happens. If they want health care, and they want it in Ontario or Canada, they will find a way to get it.

Politicians ignore this but they are soon to find out.

December 9, 2006 | Unregistered Commenterrealist
Having worked in the NHS---what were the OMA/ OCFP/ ONA/ OHA and the MOHLTC drinking when they came to the conclusion that the NHS model should be their guiding light?

As a member of both the OMA and the OCFP, I can assure you that these are top down organizations, as are the others, whose ethereal views do not reflect that of the profession in general and certainly not of the grassroots in particular.

Their conclusions reminds one of the Abilene Paradox : "People in groups tend to agree to courses of action which, as individuals, they know are stupid".

Far from learning from the mistakes of others, our 'leaders' perfect the mistakes of others, resulting in 'made in Canada' mistakes of which they seem to be exceedingly proud and very protective of....the plan is the very opposite of "good".

It is alarming that the central planners have included MDs into their LHIN schemes when we had been reassured that we would not be---watch out for mass retirements, in particular from primary, comprehensive care giving FPs, if and when that comes to pass, likely in 2008.

December 9, 2006 | Unregistered CommenterAndris.
As for the planners, of course, it's top down. That's life. Now we must just deal with the plan.The MOHLTC merely responded to the physician lobby groups.

As for the boomers, they are getting what they want, they are. Free health care with no directed payment that is identifiable. As waiting/shortages are found, they lobby their MPPS and voila money is eventually found - either new resources, or shifts from ahead with weaker lobbying.

Ontario's weakness is can this all be done on a single source of public money. Most jurisdications haven't taken this position, and have some type of direct out of pocket contribution to dampered demand and bring in new resource for innovation costs. The approach in Ontario will be to build up "foundations" and charitable funds (that's why the privacy legislation gave access to patient information attained from coming into hospitals -so the hospital could solicit funds).

Continue to keep in mind over 90% of the public really can't (won't) afford out of pocket health care costs for core services. We all have become use to the "free" care. The lobby groups will be for the core health services - babies, emergency care, and chronic disease associated with age, and, of course, the big 5. That's where the money goes.
December 10, 2006 | Unregistered Commentermovingforwardontario
It's not always 'top down' for planners...in Switzerland it is very much 'bottom up', and their country is better, in so many ways, for it.

The politicians and their bureaucrats can pass all the laws they want, produce all the plans that they want...the citizenry of Switzerland from the Federal level to the Canton to the smaller structures, have referendums every second week turning down 80% of the 'brilliant' plans/laws.

How wonderful---to have a country where the citizenry turn down 80% of the laws emanating from Bern...can one imagine turning down 80% of the laws emanating from Ottawa/Queen's Park? Each time they want to give themselves pay raises and perks the citizenry would vote on the matter.

As for 'physician lobby groups'...how many represent their own narrow views as opposed to the profession as a whole?

How many of these 'lobby groups' approach the profession and ask their permission or consult them to lobby on any particular issue---PCR is certainly a top down scheme generated by 'those who know best' and those who 'know what's good for us', it certainly didn't arise from the grassroots----certainly the OCFP lobbies away without ever having asked its own grassroots and is partially responsible for the decline and the, seemingly, inevitable demise of family medicine even as they proclaim that they're trying to save it.

Having sat on panels listening to lobby groups one can't help noting that the same people come forwards over and over again, sometimes wearing one hat and sometimes another, but always singing the same tune.

The general public will certainly get the health care system that they voted for , are willing to pay for and truly deserve...2008-9 will get really ugly with expensive, unproductive, paper pushing ersatz health care providers ineffectively handling the demanding baby boomer surge.

Sweden's FPs work is composed 80%+ with bureaucratic paper work---I don't think that those who have been used to seeing real live/sick patients all their professional lives will stick around for the paper work...carried out 'efficiently' of course with IT which they are, of course, expected to pay for themselves.
December 10, 2006 | Unregistered CommenterAndris.
So many physicians have made the switch to FHGs/FHTs/FHNs and to service the "big 5" by using well positioned funds to solve the service issues of the hospital based physicians, that no expectation of mass migration is likely to occur.

Once settled after residency, it is will documented that ordinary physicians rarely move their services. The "top fliers" always can shift, but enough resource is in place in the major teaching hospitals to maintain a good mix.

Thus by 2008-2009, most medical services will be budgetable and allocated through the LHINs by central.

By 2010-11, positions for physicians may be only availble following LHIN approval - since they will control the budget - if it's tight and the position would draw from the LHIN budget, no position.
December 10, 2006 | Unregistered Commentermovingforwardontario
....the doctors of that era will simply stay where the powers that be wishes them to stay ?...'it is well documented' that they will look to their own interests and go where their interests lie---9,000 Canadian doctor are self exiled as of today, their ranks will grow...2009-11 should be great time for MD recruiters....the brilliant central planners that gave you this present mess can 'expect' what they want...they don't 'expect mass migration'?...Mass migration will be exactly what they'll get!

Murphy rules!
December 11, 2006 | Unregistered CommenterAndris.
DrL:

Sadly, the issue is budgeting. Despite all claims to the contrary, the government system will have to draw the physician pool of resources into the LHINs in order to get the budgets under "control".

For a while, it will be "presented" with assurances that the "OHIP won't be touched, but it is already in a 'backward" fashion being driven by the government agenda - the "big 5" strategy drives utilization in prefered areas, and drives utilization away from "non preferred areas".

But if you place the IHFs and hospitals under the LHINs control, place all your diagnostic, surgerical, and technical services support in the IHFs and hospitals - those physicians will be lobbying agggressively that they need expansion of the LHIN budgets into those areas. Unless the overall budget from the MOHLTC is expanding, that means those in the LHIN will want to maximize their access - thus no need for new MDs - no hospital privileges will be granted through the LHINs.

For LHINs and MD placement, look for physician age distribution, those with younger distributions are less likely to need staff.

Many new MDs are settling into FHG/FHT/FHNs and their adjusted, lower, workloads - payments for achieved goals, etc. The MOHLTC isn't trying to drive physicians away, just live with the new reality. Most are getting it, and adjusting. The world isn't collapsing, just shifting its axis.

Physicians are just like firemen, police, school teachers. Unfortunately, they don't have the economic leverage, collectively, because they don't have, within the province of Ontario , a pooled pension plan which reinvests within the province.

Remember this is all about being able to budget.
December 11, 2006 | Unregistered Commentermovingforwardontario
Ahhh, the wonders of bureaucratic decisions. Anybody really want to follow the UK's lead...cuz it's all preventable ya know, with a little dancing (political dancing too!):

Taken from todays U.K. Daily Telegraph.

"Not available on the NHS"

While some patients are denied life-enhancing drugs by the NHS, others may be prescribed dancing lessons. Victoria Lambert tries to make sense of the health service's spending priorities

In times of crisis, it is a comfort to know you can depend on the NHS. It's there to help when we need operations or vital drugs, when our loved ones get cancer or require kidney dialysis... or perhaps when they have an unsightly tattoo that needs removing.


A merry dance: a £2.5 million scheme that included tango dancing could have bought a million doses of Aricept
We can even rely on the health service to teach our children how to go for a walk in the countryside – or our senior citizens how to wear a pair of slippers.

Despite being in the throes of the biggest budget crisis in its history – a £1.3 billion deficit that has forced hospital closures, sent doctors abroad to work, and which now threatens 29 Accident and Emergency units – it seems there is still money in the system to be spent on projects that most of us find at best baffling, and at worst cynical.

Last week saw the unveiling of an initiative by health minister Caroline Flint that promises free trampolining and tango lessons for the unfit. The programme is part of the Government's attempt to tackle obesity, which costs the NHS £7 billion a year. But did we really need £2.5 million to be spent on a pilot programme that included lessons for children in how to take walks and visit supermarkets, street-dance classes for teenagers, and boxing for the over-50s?

MP Ann Widdecombe, former shadow health secretary, has described the plans as "bonkers". "The NHS is denying some people life-prolonging drugs that ward off the horror of Alzheimer's. How can it give free dancing lessons?"

Aside from the dancing lessons, there are many local acts of madness that cause outrage. NHS South-West managers have spent nearly £400,000 on sculpture for their mental health units and then lavished a further £100,000 on research into whether anybody liked it. Andrew Murrison, MP for Westbury and Tory health spokesman who is involved in the fight to save an in-patient mental unit from closure, calls it "outrageous".

In Scotland, NHS-funded cosmetic surgery is on the increase. Procedures ranging from breast enlargements to liposuction, nose jobs and even buttock lifts cost about £4.5 million in 2005 – there was a 66 per cent rise in the number of cases from 2004.

The Department of Health goes to great lengths, without much success, to justify such applications of the NHS budget. Five years ago, the department produced a glossy magazine (£2.95 each) to help to communicate its policies and progress to staff. Circulation was impressively high at more than 61,000 copies. Sadly, only 22 of those magazines were actually paid for. The rest were distributed free at a cost of £900,000.

Bolstered perhaps by that success, the following year, Birmingham Health Authority spent £40,000 producing a book of short stories and poetry to boost staff morale. Justifying the decision, the authority's director of performance and strategy said: "The NHS is there, of course, to make people better, but we have some responsibilities to the staff as well."

In 2003, it was revealed that the NHS Health Innovations Fund in Bradford had spent nearly £500,000 making a soap opera to promote health awareness in the Asian community – but had not bothered to check if any of the TV networks were interested in broadcasting it. The 13-part series was finally shown in 2004 on the Community Channel.

That same year, trusts all over the country introduced £75,000 schemes to teach senior citizens the right way to wear slippers, and hence to avoid falls. Grannies were even encouraged to bring their slippers along for inspection.

The traditional response from NHS trusts when confronted about initiatives such as dancing, art and videos is to explain that the money is not taken from the bit of their budget that is actually spent on healthcare. Oddly, the ring-fencing of money for what is best described as the more hare-brained end of healthcare finance seems commonplace, whereas none exists for medical procedures that can be cancelled whenever Patricia Hewitt, the Health Secretary, knocks on the trust's door.

If trusts were to stop spending money on poets and boxing gloves, what would that money buy for patients? Well, the £2.5 million tango and trampoline scheme would pay for one million doses of the Alzheimer's drug Aricept, which costs £2.50 a day and is currently denied to early and moderate sufferers of the disease. And for £500,000, you could either buy 17 works of art and commission a survey on whether anyone likes them – or you could pay for 125 hip operations at about £4,000 each.

The plastic surgery bill for Scotland – £4.5 million – would buy three new MRI scanners and vitally speed up waiting lists and treatment times.

The £900,000 behind that glossy NHS magazine could have been spent on prostate cancer sufferers, allowing 90 of them to have up to 10 courses of the drug Taxotere, currently approved by the National Institute for Health and Clinical Excellence (Nice) but often denied by individual trusts on the grounds of expense.

A budget for poetry to boost staff morale translates to two new nurses, while £500,000 of educational soap opera could have been spent on 25 heart operations. And £75,000 worth of "slipper" education could have bought 5,000 flu jabs.

So who – apart from the bureaucrats – is in favour of schemes, dreams and dancing lessons over surgical procedures and drugs? Katherine Murphy, of the Patients' Association, says the charity receives many calls from people concerned that NHS money is not being spent wisely.

"You have to ask whether art projects, for example, are a good use of public money when we know that infection control teams are having to raise their own funds despite the epidemic of superbugs in our hospitals," she says. "The priorities are wrong. We should be focusing on issues such as patient care or pain relief for the elderly – areas that will make a difference to patients and their lives."

Dr Charlie Chan, a consultant surgeon at Cheltenham General Hospital, says the public sould decide where the money is spent. "Decisions made by trusts are arbitrary and there is no standardisation in this country. But maybe it is up to the medical profession to engage the public in a moral argument. What are their priorities? We're all only prepared to spend so much in taxation, so perhaps we [the public] should be prepared to make tough choices."

The Department of Health insists that budget decisions are subject to intense scrutiny. "We don't throw money about – everything we do is backed with research and academic work. We believe that public health initiatives – such as the one that recommends dancing – are vital to the health of the country in the future. It is a case of spend £2.5 million now and save billions in 40 years' time. How can it be a bad idea to invest in people's futures?"

A spokeswoman added that NHS finances were "incredibly complicated". "It's not a case of Patricia Hewitt having one big pot of money and just doling it out."

Not all NHS schemes inspire so much heated debate and every so often an initiative results in a leaflet drop to GPs' surgeries and hospital clinics that restores your faith in the Department of Health.

In April, NHS Tayside produced a four-page guide catchily entitled Good Defecation Dynamics. "Potty Training for Grown-ups" might have been a more precise title. It contained the vital advice that one should sit up straight and keep the mouth open – and "don't forget to breathe".
December 11, 2006 | Unregistered Commenterrealist
"Physicians are just like firemen, police, school teachers."

Not really mfO. Because if they were, they would have pensions and benefits and reasonably strong unions plus much fewer years of training.

Train a fireman in a few years. Train a teacher in a couple years at teacher's college. Train a policeman reasonably quickly too.

And unlike firemen or teachers or policemen, there is a global shortage of physicians which cannot be fixed with a couple years of training.

If gov't thinks that bringing physicians into LHINs to control the budget is the answer then they are in for a rude awakening.

Some physicians are buying into the FHG, FHN, FHT programs but many are doing so because they feel they are following the money. When the money flow is strangled, they will go elsewhere or choose other career opportunities.

As for some of the older docs, they are basically signing on to squeeze as much out as they can for their retirement...and they will retire.

40% of physicians are over 50 years of age.

As for the younger docs, they have been protected in "academialand" and won't know reality until they are hit square in the face with it...that usually happens about age 35-40 for many physicians I know. Then the light comes on and they begin looking for greener pastures and other business opportunities.

I just get the feeling that gov't is heading down a disastrous path...seem to recollect a misguided plan to cut medical school enrollment by 10%...that was supposed to save the system wasn't it!?

The LHINs are going to control costs...tell me another fairy tale.
December 11, 2006 | Unregistered Commenterrealist
Realist:

It's just money. The Government will control the health budget because the public wants free access, and it gets what it wants, waiting times and all, because it assures access for the majority. the polls continue to confirm that the public "Love" free health care, even with its warts.

Will LHINs control budgets - Yes. Will it be an adaequate budget - doubt it, but it will suffice for most. A few will be hurt; most will get what they need.

Will MDs flee for greener pastures - a few, but overall most are happy now, good income, work levels set in FHG/FHT/FHN at reasonable levels. Responsiblities being reduced for a better life style. If they don't move out of Ontario right after residency, they just don't move, central knows this. Hmmm - Ontario versus North Dakota - which would you want?

Pensions/benefits/etc. More MDs are electing for the "packages". The young are taking "pay" assurance schemes.

The angry are the older FFS MDs, some whom are stuck, in a no win situation. Fees not shoting up, costs are going up, and no clear sign that anyone, including their union, cares.

It is a political system - move to the money, or move out. But don't expect a "collapse", it ain't going to happen - the Government has unlimited access to more money to buy its way out of anything.

Ontario's only risk is it "denial" of a private "pop off" valve for those cases needing "non MOHLTC" money ( a small number but politically sensitive). It will come, note the proposal that cancer care CAN buy services using public facilities.

This ain't rocket science or brain surgery. Balancing the budget, versus the "threats" from health care providers, is just that - a balance. So far, the balance is working, MDs in Ontario by and large are staying, new and expanding training is occurring in many areas (including NPs and expanded care nurses), and the crises are being met without "busting" the budget.

Realist - move to the money and be happy.
December 11, 2006 | Unregistered Commentermovingforwardontario
Far from trying to maneuvering doctors around like widgets under the impression that they'll stay where the central planners want them....the central planners' emphasis should be on retention, retention, retention.

Productivity in this new world of FH whatever is already dropping, the productive self sacrificing geezers of the past are being rapidly replaced by a new generation of 'life style' doctors, 60% of whom will be female who have the temerity to get pregnant and try to raise families---taking 3 of them to replace one geezer---as to less responsibility...the fear is that future FPs will have to function in teams where decisions will be made collectively but with the medico-legal onus resting on the shoulders of the poor FP sap.

Tango classes?

Perhaps the future is not so dark as we thought.
December 11, 2006 | Unregistered CommenterAndris.
"the productive self sacrificing geezers of the past are being rapidly replaced by a new generation of 'life style' doctors, 60% of whom will be female who have the temerity to get pregnant and try to raise families---taking 3 of them to replace one geezer"

In the end, it will rebalance. The "geezers" have had their time.

NPs and expanded nurses specilists, and the "new" FPs and specialists will figure it out.

Move on.
December 11, 2006 | Unregistered Commentermovingforwardontario

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