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. 






Impact of Ontario Physician Demographics

  Many knowledgeable people agree that there is a physician shortage in Ontario and Canada despite some individuals who are widely publicized as claiming that  we are just not using our physicians efficiently. 

Looking at demographics of the physician population, it is clear that there are more visits provided by  male physicians  across all age groups per year than by  younger female physicians. Nothing against female physicians, I am one after all.

The statistics provided by the OMA show that the  most productive cohort of physicians is aging and will be replaced eventually by a younger group with a greater percentage of female physicians that will see fewer patients in general. This is not only because of a greater percentage of female physicans graduating from medical school  but a reflection that the younger generation of doctors is attempting to find more balance in their lives and the tendency to work extreme numbers of hours is dropping.

The solution of luring physicians back from the US is not all that likely.  It's not a bad concept, it is just not likely to make much of a difference.

Neither is the solution of IMDs since Alberta and Ontario alone are expected to be short over 5,000 physicians combined in the coming years.

Even if these IMDs and the physicians  in the US could be incorporated into the Canadian system, how would Ontario pay for their services when only a few short years ago during the 2004  negotiations,  government led physicians to believe that there was no more money for physicians looking for a better contract.

Will physicians from the US return? Will more IMDs be allowed into the Canadian system?

If they are, how will funding for their sevices be provided?

If we build more ORs to handle the Big 5 as the Ottawa Hospital has done, how will they be funded in a time when Ontario provincial health care  is already exceeding 46% of the provincial budget?

Take a look at this piece from mdpassport (Medical Post) and see from the sampling if it seems likely the US docs will return to Canada. 


In the end, what will matter is keeping them here if we can lure them back. Stifling of physicians' professional lives through  government involvement isn't likely to help attract them  or retain them.

Long term solutions are needed. 







Chronic Disease Management

 I am not quite sure if ELB was serious in the request for this topic but it would seem to be a reasonable place for plenty of discussion given the myriad of chronic diseases that exist and seem to crop up as we age.  BC has had some interesting innovations and with its slightly older population, its governments seem to have understood the need for dealing with this. The day when some types of cancers will become chronic diseases treated over decades is coming and we really should be prepared.

It is an area that I find quite complex but what area of health care isn't?

As always, please feel free to make your insightful comments. We wander off topic sometimes, but no worries. In general, the opinions here are   enlightening and thought provoking.

 Take it away ELB or any other contributor faster off the mark!









What Vision?

 An interesting issue of Canadian Government Executive, March 2007, Volume 13, Number 3 has some insightful pieces on leadership. The editor's note includes the following quote:

"Avoiding danger is no safer in the long run than outright exposure. The fearful are caught as often as the bold."-Helen Keller

Although the publication is intended for the public service, it has relevance for physicians working within Ontario's health care system and points toward some of the pitfalls that have occurred in the transformation agenda to date.

In "Focused Renewal",  by editor-in-chief Paul Crookall, Kevin Lynch, Clerk of the Privy Council and head of the federal public service,  comments that public service renewal is a continual and dynamic process. It is not all about something that is broken, or needs fixing to reach a certain point and stay there.

No truer words could be spoken if this were in reference to  health care. It is perhaps where Ontario's health care transformation agenda falls flat. There is a belief that if those LHINs and FHTs and that IT system  can just get going, all will be well. But health care is not static and just as we "fix" one area, another leak shows up.

What we need is a system with more flexibility that can adapt to changes within health care in a reasonable time frame--a  time frame that doesn't require decades to accomplish the task.  And many of us know that a large bureaucracy is not flexible or terribly adaptable. 

Kevin Lynch is quoted as saying with respect to innovation within the public service that as long as decisions were taken "for the right reasons, with the right degree of openness, and the right focus on excellence", then "making mistakes is part of doing things".

 I agree with this premise but the reality is that in health care transformation the reasons appear to be cost control and limitation of options for patients based on funding. This just doesn't seem like the "right reason" or the "right degree of openness" or the "right focus on excellence".

Why should health care be different from the rest of the public service?

As far as I can tell, the difference lies in the vote getting and as has been mentioned here before, the "politicization" of health care is likely to be the roadblock in finding sustainability because the leadership in health care fails us in this regard.

Carol Stephenson, Dean of the Ivey School of Business, writes on leadership in the same issue of CGE. She outlines the importance of cross-enterprise leadership in the public service  in her article "Think-Act-Lead". She writes, "Leaders today must fully understand what is happening both inside and outside their organizations. That requires leaders to step outside of their comfort zones-to consult widely across the organization .....".

 I cannot say that that has been done in health care, although some would argue that it has, and would have to add that many physicians have the feeling they have been " steamrolled"...hardly helpful for recruitment and retention, two of the challenges in the public service idenitifed by Kevin Lynch.

Perhaps our leaders in health care should consider what  General Rick Hillier  has to say:

"Only when you have that powerful, compelling vision simply stated can you communicate with your people. Only face-to-face contact and personal communication of the vision creates the kind of trust you need to move everyone forward together. You can't lead with memos and e-mails.......Your people have to really get the what and the why of that vision. The logic has got to be sound. Both you and the vision both have to 'ring true' to them. If you and the vision don't show pragmatism and common sense, you will be seen as the emperor wearing no clothes and you will either never gain people's confidence or you will lose it quickly."

Perhaps this is why I have so much trouble trusting the leadership at the MOHLTC. The vision seems mainly about  controlling costs and staying in power. It does not seem to be about individual freedoms.

There are many things about the transformation agenda in health care that don't ring right to me. I just wish there was a health care leader or political leader who was willing to listen and be honest with the public.

General Hillier on  humility and assertiveness:

"Our leaders at every level need to help folks walk through what they have to achieve. We need to set up people for success:'Here's the mission, here's your responsibility, here's the authority to get it done. We will articulate that as clearly as possible, with input and guidance from you, and then you go off and do your job. None of us above you will tell you how to do it; that's why you are here. Let us know how it's going and what you need to succeed.'" 

I leave you with two memorable quotes from General Rick Hillier:

"Without honest and frequent feedback, I couldn't lead".

"Sometimes I'm impatient; I want to get a certain thing done, and someone will come up to me and say, 'Sir, this is  dumb as dirt.' When that happens we reassess."

 Thanks General Hillier.





Suzanne Aucoin and Many Others Like Her

The story of Suzanne Aucoin came to mind when I was wondering how many patients have had to fight the Ontario Government to provide care that many Ontarians and Canadians believe would  be provided hassle free. After all, Canada's system makes sure that people don't have to mortgage their houses and borrow from friends or go without care because they can't afford medical insurance, doesn't it?

 Have a quick look at this video clip, particularly the last several minutes of it because it shows a person devasted by her illness but wanting to keep fighting. In her cancer journey she must  battle with the government health care bureaucracy as well.   It's not exactly what we are led to believe happens here in Ontario and Canada but you never know until it happens to you. Take a walk in Suzanne's shoes.



Good with the Bad

The federal budget tabled March 19 had $1.4 billion for health care:

-$400 million for Canada Health Infoway to support development of EHR to help reduce wait times

-$612 million to support jurisdictions that have made commitments to implement patient wait time guarantees

-$300 million over 3 years in per capita funding for vaccination to prevent cervical cancer

-$22 million to CIHI to provide timely, accurate and comparable health information to support health care delivery

-$2 million for Medic Alert bracelets for children suffering from several serious diseases (my son keeps losing his…can he have one too?)

-$10 million over two years and $15 million a year thereafter to establish the Canadian Mental Health Commission

Dr. Collin MacMillan, CMA President, has said the money set aside to reduce wait times is “not enough”. He said, “We’ve got to move towards self-sufficiency in training Canadian doctors and nurses in this country to practice and serve the future and current needs of our population as we see it.”

Jack M. Mintz, Professor of Business Economics, J.L. Rotman School of Management, U of T, states that overall, the 2007 budget tax agenda has no plan to address the productivity and demographic challenges facing the Canadian economy over the long term. He predicts that federal program spending will continue to inch up as a share of GDP over the next two years, and actual spending will likely be much higher than planned.

It is a little surprising that this budget came from the Conservatives given the trend that they are the usual party to come to power after excessive spending by the NDP or Liberals and after the electorate realizes that taxes are rising because of excessive spending. Putting a “chicken in every pot” will help satisfy political needs however, but won’t do much for long term viability of our health care system.

The $612 million is for provinces that commit to a patient wait time guarantee in one of five priority areas by the end of next WEEK. Meanwhile,Tony Clement is meeting with individual provinces to negotiate separate deals with respect to funds, personnel and other resources necessary to develop a national wait- times guarantee. He did not predict how many provinces will sign up for the money from the fund. But they’ve got a week. I guess they should have seen this coming.

Does the budget address fiscal imbalance? It does for some provinces like Quebec, but for Saskatchewan which sees its equalization payment reduced from $800 million to $226 million, to zero in 2008-09, maybe not. No surprise then that Saskatchewan Health Minister Len Taylor is alleged to be resisting wait time guarantees by Tony Clement……you need money at the provincial level to reduce wait times after all and with less equalization payments Saskatchewan may have to wait on its wait times guarantees. Damned if you do, damned if you don’t.

No real long term solutions, just more spending for health care. Which brings me to the question: If the Conservatives don’t hold the line on spending, who will? How high can taxes go?

As Jack Mintz says in his op-ed March 21 titled “Mess in the Making”, “At this rate, we will need another major tax reform in a few years.”

As always, I am interested in your take on this and opposing opinions are always welcome.