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. 






Health Care Human Resources: Assets not Expenses

There isn’t much doubt that the demand for health care providers is increasing at a time when the effect of government cuts to nursing and medical schools is beginning to be felt nationally.

It isn’t the cuts alone that have been detrimental to the supply of health care providers but also the day to day difficulties of working in a system that cannot provide what was originally intended.

You could solve the human resources problems by churning out many more nurses, physicians and various technicians for a price. But we need to keep them providing care to Ontario’s patients and Canada’s patients by creating a system that provides improved access and availability of technologies and treatments here that are already available in other developed countries. We shouldn’t be in the business of exporting physicians like Cuba or sending our home grown physicians overseas as Interhealth Canada was intended to do.

We need to find a system that competes against itself, that rewards individuals for their hard work and dedication and that provides patients with a way of optimizing their health by engaging them rather than just preaching, providing posters or advertising lame primary care ads on TV.

In the case of nurses, Calgary Health Region has a campaign to recruit nurses from across Canada. In response, Canadian Federation of Nurses Union president Linda Silas has said that poaching nurses won’t solve anyone’s nursing shortage.

She may be right but nurses do have the right to leave and begrudging them higher pay or full time jobs isn’t the way to keep them. Physicians are also free to leave and have done so over the years to the point that Ontario still had a small net loss of physicians in 2005. This at a time when we need to be retaining the physicians we have but also attracting Canadian physicians back and retaining retirement age physicians as well.

Co-payments are one way to generate necessary funding and this can be done fairly by charging individuals who use the system a small fee, as is done in Sweden and many other OECD countries. This is certainly much less complicated than establishing private hospitals as was eventually done in Sweden.

In Sweden, like Canada, there was an underperforming health service monopoly with long wait lists, overspending and questionable quality. To improve the Swedish system, 150 private providers were licensed to compete for health service contracts and then gradual privatization of primary care in 1998. In 1999, St. Goran’s (a public hospital) was sold to Capio AB, a private company, and has shown significant improvements over its performance as a public facility.

The Stockholm government compared costs in six medical specialties and found the cost of consultation to be lower in private practice. St.Goran’s costs for lab and x-ray services fell by 50% and overall costs 30%. Doctors in the private sector have reduces expenses to 15% lower than the same procedures in the public sector.

At St. Goran’s, the average wait time for heart surgery is 2 weeks compared to 15-25 weeks in Sweden’s average public sector hospital. The average wait time for hip replacement surgery is 10 weeks compared to more than a year in the average public hospital. St.Goran’s is now treating 100,000 more patients each year than it did as a public hospital but it is using fewer resources.

But here in Canada, the unions hold strongly to the belief than privatization is equal to Americanization and that it will be bad for their union members.

In fact, when Sweden privatized delivery, nurses unions initially resisted too. But then nurse’s wages rose 40% in some cases and one head of the largest nursing union had to admit that her assessment had been wrong. Nurses also did less administration duties with privatization and could focus on real care while clerks were hired to do the paperwork.

We must get past the belief that “privatization” means Americanized health care if we want real progress in keeping our human medical resources providing much needed care where it is needed.

Start with co-payments and move to small “experiments” with private care. Allow physicians and health care providers to innovate and prosper from their advancements. Allow patients to engage in their own care and share responsibility for costs beyond taxation. These are ways to improve human resource shortfalls. Pouring millions of dollars into the system around election time isn’t.


Sacrificial Lambs

So let’s have a little look at the “best health care system in the world”:

Adolfo Flora, the retired Toronto school teacher diagnosed with liver cancer in 1999 after receiving Hep C tainted blood in 1976, loses his fight to have OHIP pay for life-saving treatment in England after doctors here essentially ruled him out as a candidate for a full liver transplant from a deceased donor.

Dr. Halloran, one of Canada’s foremost transplant surgeons says that almost 1,200 Canadians a year who need life-saving organs don’t get them because of failings in our transplant system.

Canada is the only developed country without a national transplant organization. In Canada, a handful of provincial/regional transplant agencies are doing their own thing and the Canadian Council on Donation and Transplantation has no power, no national mandate and no budget to speak of.

Dr. West, an internationally renowned pediatric cardiac surgeon and president of the Canadian Society of Transplantation says, “We all have patients who die on waiting lists…It’s not fiction or melodrama. A lot of people are dying for lack of organs.”

It is estimated that about 1,200 people a year are risking death in Canada because the transplant system is second rate.

Justice Archie Campbell, heading up the SARS Commission, has indicated Ontario’s public health system was lacking too.

And in the media today, a report on Mr. George Smitherman, Ontario Minister of Health and Deputy Premier who is quoted as saying: “I’m 42 years old and I think I have the best political job in Canada. I’m managing the largest budget in the country and it’s a thrill a day. That doesn’t mean some days aren’t more thrilling than I would prefer. But I’m a happy camper.”

Now I realize Mr. Smitherman has headed major change in Ontario, encouraging movement toward de-centralized health care, good or bad depending on how you look at it, and that he isn’t responsible for all of Canada’s and all of Ontario’s health care problems but it would be somewhat reassuring to hear him say that his job is a difficult one and that he is persevering against all odds and some days he wonders if he can keep going.

But to read that he states he is a “happy camper” and that what he does is a “thrill a day” should have all of us terribly concerned.

The patients on transplant lists and patients like Adolfo Flora may find it disconcerting to read how happy Mr. Smitherman is in his portfolio and about his “thrill a day” job.

I would make a hunch that they are far more interested in getting well if they can and would appreciate somebody in their court who would give them options for care close to home and close to their support systems.

Mr. Smitherman should just hope he doesn’t need an organ transplant. But then of course, he might fare better than Mr. Flora because as Doris Grinspun, head of the Registered Nurses Association of Ontario, has said:

“He has enormous amount of influence on the premier and on his colleagues in caucus and that makes a big difference when it comes to getting his voice heard.”

Pity those individuals who don’t fare so well getting their voices heard or who are told there are no options in Ontario or Canada for them because the line between the government’s responsibility for providing services to all and disbursing scarce resources has been drawn.

The court’s ruling on Mr. Flora’s case shows that there is no obligation for the government to step in and save the life of an individual.

So why oh why then, does government limit the ability for patients to save their own lives in Ontario?

Patients who do not fit the Big Five and who do not fit the flavour of the health care day should not be made sacrificial lambs.

They have constitutional rights and I hope Mr. Flora takes his case all the way to the Supreme Court. As a matter of life and death he must and as a matter of basic moral principle. But I can’t blame him if he is just too exhausted to do so. Perhaps after almost 8 years of battling, he might not find it a “thrill a day”.

The Wellness Lifestyle Industry: Engaging patients in their own healthcare.

Canadian innovation expert Jim Carroll says that the one-job career is disappearing.

“The next generation of workers will be far different than any which has gone before. They will be far more entrepreneurial because many already think self-employment is more secure than a corporate job.”

Physicians have traditionally considered themselves “self-employed” but with the encroachment of government involvement in their day to day practices and the frustration of dealing with a system that the provincial SARS Commission indicates was on the edge of a complete breakdown, I expect we will see the coming of a different kind of “team approach” from what government had intended.

Medical knowledge is doubling every eight years but the public seems very interested in paying for unproven supplements and  alternative therapies of dubious benefit. The medical and pharmaceutical establishment gets criticism on a variety of fronts while people embrace unproven, unscientific claims that give them hope and a “feeling of wellness”.

This “feeling of wellness” obviously has value to many patients (afterall, the placebo effect is real). Whether it actually improves their lives is uncertain but they are willing to pay for it and in Canada we can expect to see many physicians embrace happier and more appreciated careers as “team players”….but not likely in Family Health Teams under the government scheme.

The “wellness lifestyle” industry is a whole new market and will allow physicians to participate in providing health care to citizens outside of government parameters. It is coming and I hope government begins to understand that professional and personal freedoms have a place in Ontario, in Canada, and in health care if public provision of care is to be maintained.

If publicly funded care is to be accessible to patients then government needs to acknowledge the necessary role physicians and medical providers fill and stop considering them as expenses to the system. Failure to do this will undoubtedly drive more physicians (and nurses) to areas of work where they feel more appreciated and valued leaving a gaping hole in the knowledge and skill intensive area of health care.

This gaping hole will arrive without ever uttering the word “private health care”. It will arrive because of failure to comprehend the importance of professional freedoms; failure to value the importance of co-payments and user fees; and failure to value scientifically proven medical care compared to unproven, unregulated “wellness” treatments.

Instead of Family Health Teams with government supplied nurses and nurse practitioners, expect to see physicians and allied providers organizing themselves into groups to provide fitness training, nutritional advice, behavioural therapy, alternative medicine, spa treatments, cosmetic treatments and even spirituality training. I expect traditional medicine to be found in there somewhere too but only if government doesn’t create too many disincentives to linkage.

If you think this is far-fetched then think again. Canada has always allowed “executive” care where fees are paid by third parties for physical exams and diagnostic care. Medysis is only one name but the industry is burgeoning.

The Cleveland Clinic, one of the world’s leading private providers of traditional medicine is launching an “executive health” product in Canada (Toronto) according to The Economist, which will combine “diagnosis, treatment and, above all, prevention”. Check it out at It has plans to produce food and a range of other products for “healthy living” while partnering with Canyon Ranch (“America’s first total vacation/fitness resort”) through Canyon Ranch Living.

Also check out Sir Richard Branson’s “Virgin Life Care” where people earn credits called “Health Miles” which they can spend at a variety of businesses. In my opinion, this could be the beginning of tangible incentives and a way to engage the public in their own care and helping to control costs. It could work in Canada and I expect it is only a matter of time.  

Other new concepts to note: Revolution Health and Miraval-Life In Balance.

Now, don’t get me wrong. It is not that I expect the “wellness” industry to supplant the need for real, scientifically based medical care. I hope it won’t and it shouldn’t.  It is just that there are many people  embracing the concept of "prevention" and "wellness". It gives them hope and it is an opportunity for traditional medical providers to engage, educate and empower patients while sustaining their practices so that they may provide traditional, scientifically proven medical care.

I anticipate many physicians will embrace these opportunities  while patients feel the need to pay for “prevention” and “wellness” under the same roof. The public has already shown its willingness to consume “wellness” whether it is true wellness or not. There is no reason why real scientifically based medical care cannot be suitably joined with this need of many patients….unless  government wants to eliminate any care that is not scientifically proven, which it doesn’t seem interested in doing based on the burgeoning health food store industry and abundant alternative therapies proliferating all across Canada.

This concept opens a real can of “wellness” worms .

Is this  "team approach"  the one that government is so keen on lately and over which the medical profession has been criticized for not being open to change?

Is this "team approach" any different from introducing ancillary care givers in Family Health Teams?

Will government claim that only the "teams" it creates are acceptable and legal?

Will government try to prevent patients from paying for "prevention" and the "feeling of wellness" that they so desire? If so, will they prevent patients from paying  if a medical provider is there to supervise, while allowing payments for unproven, unscientific, and possibly deleterious forms of care with no medical supervision?

 Times are definitely changing.

Please feel free to comment, debate and discuss.


Maintaining the Pace and Hitting the Wall

I recognize the need to give hope and maintain optimism but I also believe in looking ahead. The ability to anticipate is important when it comes to health care but often we are left analyzing data.

One of the knocks against the way SARS was handled in Toronto was aimed at the delay that resulted from a prolonged debate about key issues such as the need for, and effectiveness of, the N95 respirator mask which was supposed to protect health care workers.  Time was spent discussing what size of droplet would be the most infectious instead of arranging for the most protective masks and equipment for front line pandemic fighters in case things got ugly. Labour boards will now be involved early in any kind of process like SARS to protect workers and hence the public.

Lesson learned: If something seems dangerous, it probably is and action is required.

So it is with interest that I see CIHIs report from January 10, 2007: Trends in Acute Inpatient Hospitalization and Day Surgery Visits in Canada, 1995-1996 to 2005-2006.

Highlights in summary:

-Canadian acute care hospitals handled 13.4% fewer hospitalizations in 2005-2006 since 1995-1996. (Of note however, is that the downward trend began to reverse in 2003-2004 with a modest annual increase of 0.6%,0.4%,0.2% over the last three years. Ontario has shown an increase in the number of hospitalizations since 2002-2003.)

-Day surgeries were up 30.6%.

-The absolute number of hospitalizations has started to rise in the last three years but the age-standardized hospitalization rate continued to decrease over the 10 years.

-The number of days spent in acute care hospitals also decreased by 13.1%.

-Increasingly surgeries are being performed in a day surgery setting ( increase of 30.6%) compared to inpatient hospital setting (down by 16.5%) .

-Total number of surgical events has increased by 17.3%.

This information may look good on the surface but it raises several concerns:

If hospitalizations are decreasing in general, one would expect that this would impact healthcare in a positive way. But health care costs are still rising across Canada including in Ontario.

Efficiency is apparent in the ability of hospitals to provide 17.3% more surgeries and to provide 30.6% more day surgeries. All well but we need to ask if this pace of efficiency can be maintained. The fact that hospitalizations have started to increase modestly over the past three years is a sign that it can't, especially when we face continued aging of the population.

The age- standardized hospitalization rate is declining but is this a fair way to consider the status of the system? Age-standardized rates are adjusted for population aging and account for population growth (via rate calculations). Fact is, our population IS aging and growing so adjusting to take into consideration the age and growth of population could give false optimism. The actual numbers of surgeries performed and hospitalizations are what will generate costs to the system whether they are age adjusted or not.

With the growing number of day surgeries and the growing number of aged citizens, one can wonder where these patients are recuperating and what the rate of complications is. Accordingto Caroline Heick, CIHIs director of health services information, patients are being cared for in other settings such as the community, home care or long term care facilities. Many of these costs are hidden and outcomes unreported.

So just like the auditor general in Ontario has suggested wait time reports need to be taken with a grain of salt, we need to understand what the decreases in hospitalization rate and increases in day surgery rates mean. At some point, the decrease in hospitalizations and decrease in length of stay will negatively impact patients and outcomes just as early discharges did for mothers and babies when they were discharged too quickly from maternity wards in the not so distant past. At what point will this happen? Who is measuring the outcomes? Who is measuring the costs being borne outside the hospitals?

The SARS lesson should have taught us to value the ability to anticipate even though analyses are helpful and make decisions more comfortable. We cannot always act based on fact, sometimes we need to act using common sense.

This CIHI report gives statistics that could give a false sense regarding health care delivery. They do not tell the whole story. Our monopoly system may hit the wall , but I am still hoping for vision and foresight. Is that too much to ask?


What's It Going to Take?

Working over the holidays it became clear to me that patients will have to get much more vocal about their lack of access to medical care before things will improve.

I watched the line-up stretch out the door and down the hallway at 9am yesterday when I arrived for my shift at an urgent care medical clinic.

Patients knew to come early and the line wasn't much better by the time I left at  3pm, with no lunch, no breaks and insufficient staff. But it is the best we can do considering physicians are hard to come by.

 Needless to say, I saw many patients who can't find a family physician and the Family Health Teams in the area  supposedly taking new patients with their new nurse practitioners don't seem to be, or more simply:   they aren't making a dent in the gradual demise of the family physicians in the area.

The brouhaha over the emergence of nurse practitioners seems to be mute and neither positive or negative. They just don't seem to be making a difference.

 Nor do all the new facilities we have here in Ottawa.  $800 million of facility expansion is supposed to be good for our area but tell that to the patients who were wearily sitting around the foyer and waiting room of the office building I worked in yesterday. It sure didn't seem to be helping them much.

But the media is starting to get it and an editorial in the Ottawa Citizen questioned the benefit of the large infusion of money into the infrastructure without the manpower to actually service the patients. It is a kind of "build it and they will come" mentality. However, this concept doesn't work well if gov't is rationing services at the provider supply end of things.

I suppose there are individuals who like to leave themselves legacies, a building perhaps, a cardiac institution, a palliative care facility etc. and this is all well. But leaving a legacy by providing more manpower is tough because it is a committment that goes beyond just building the facility. If one trains more physicians in a monopoly system, only the gov't can pay for their services. So there is impetus to control provider numbers. 

The Ottawa Citizen editorial goes on to say: "Politicians like new labs and hospital wings--ministers and MPPs get to clip ribbons at grand openings while people applaud. Nobody cuts a ribbon when CHEO hires a nurse or a general practitioner opens a family practice in Barrhaven.

As always, the underlying problem is that the government rations care--the health ministry, not Ontario's sick and injured, decides when the care is good enough."

 Until we have more honest editorials  like this and until we can get both our political and medical leaders to stop the  "positive" spinning, we won't get any closer to long term solutions.

What's it going to take?