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. 






Misguided Nobility

When Ontario Premier Dalton McGuinty and Ontario Health Minister George Smitherman proudly announce they are bringing on line more International Medical Graduates and that they are pouring more funding into the Big Five (cardiac care, cancer care, cataract care, hips and knees and diagnostics) are they really aware of what they are doing and the potential consequences?

Is their approach really noble or does it just appear to be noble and filling a short term requirement? Does their approach include long term thinking and understanding of the consequences of their actions?

In the new millennium, the public is growing more aware of its global responsibilities. If it knew the consequences of its government’s actions, what would it think?

We need to learn from the experiences in other countries to properly understand what needs to be done in our own.

Laurie Garrett, Senior Fellow for Global Health at the Council of Foreign Relations and the author of Betrayal of Trust: The Collapse of Global Public Health, writes in her essay “The Challenge for Global Health” in Foreign Affairs, Jan/Feb 2007 issue:

"The fact that the world is now short well over four million health-care workers, moreover, is all too often ignored. As the populations of the developed countries are aging and coming to require ever more medical attention, they are sucking away local health talent from developing countries. Already, one out of five practicing physicians in the United States is foreign-trained, and a study recently published in JAMA: The Journal of the American Medical Association estimated that if current trends continue, by 2020 the United States could face a shortage of up to 800,000 nurses and 200,000 doctors. Unless it and other wealthy nations radically increase salaries and domestic training programs for physicians and nurses, it is likely that within 15 years the majority of workers staffing their hospitals will have been born and trained in poor and middle-income countries. As such workers flood to the West, the developing world will grow even more desperate.”

In Ghana, as money has poured in for HIV/AIDS and malaria programs, the country has moved backward on other health markers as the country has shifted its health care workers to the better funded (foreign) projects and lost physicians to jobs in developed countries. 604 out of 871 medical offers trained in the country between1993-2002 now practice overseas.

In Zimbabwe, out of 1200 doctors trained during the 1990s, only 360 remain in the country today.

In Zambia, only 50 of the 600 doctors trained over the last 40 years remain today.

Mozambique’s health minister says that AIDS is killing the country’s health care workers faster than they can be recruited. Six thousand lab technicians have died in the pandemic and a study by the International Labour Organization estimates that 18-41% of the health-care labour force in Africa is infected with HIV.

The outcome of world health is going to depend on whether the path taken includes public and private efforts to make significant improvements in the health of billions of people or whether poor societies are pushed more deeply into trouble while their pool of health care workers is plundered by developed nations.

The funding for a few diseases like HIV, TB and malaria , called “stovepiping”, is taking the resources both financial and human away from basic public health care in Africa including prenatal care, maternal health programs, resources for common illnesses like childhood diarrhea which kill many children in Africa.

Garrett writes; “Today the top three killers in most poor countries are maternal death around childbirth and pediatric respiratory and intestinal infections leading to death from pulmonary failure or uncontrolled diarrhea. But few women’s rights group put safe pregnancy near the top of their list of priorities, and there is no dysentery lobby or celebrity attention given to coughing babies.”

Two overall points for Ontario and Canada to learn from this information:

Ontario and Canada in general have no business plundering the human health care resources from undeveloped countries. Canada needs to become self-sufficient in production of physicians and nurses which will have a big price tag but it is the moral thing to do.

Pouring money  into several chosen medical areas whether it be HIV/AIDs, TB and malaria in Africa or the Big Five in Ontario, will have consequences to those areas that remain outside this funding leaving the potential for deterioration in the less favoured areas. With a finite pool of public resources as we have in Canada, this is particularly troubling and is likely to create an imbalance not only in access but in provider distribution.

If you think that the real threat to health care in Canada is private provision, think again.


Individual Responsibility: The Key to Prevention

Okay, I promise to keep this entry short.

It is no coincidence that the US health care system is the most costly per capita of all the OECD nations and that it is also the leading nation in obesity rates. Complications of being obese involve multiple systems and are complex. Just being overweight poses risk to health and to the overall health care budget.

Canada is not far behind in its obesity rates and is one of the most expensive systems as well.

Now China is catching up. Weight related problems and obesity are expanding in China as the economy grows. The number of obese people tripled to 90 million between 1992-2006 according to WHO.

It shouldn’t come as a big surprise that as China’s economy booms, so does the population’s waist line. As Dr. Zheng, chief of surgery of Shanghai’s Changhai Hospital says “When Chinese people get money, the first thing they do is invite all their friends out to dinner.”

So what responsibility does the patient have for their health in Canada, China or the USA? How much is the state’s responsibility and how much is the patient’s? How can patients be empowered to be managers of their own health?

I doubt very much that EMR’s and infoways and sharing of medical information on line between medical providers will create self-discipline and self-esteem and routine for patients which are all so crucial to maintaining their weight, their fitness and their health.

Far more likely is that improved education and personal support will lead to improved health along with an expectation from government and society that as a functional individual you are responsible for your own health and a portion of the cost associated with your health care.

 Please feel free to contribute ideas and solutions as well as comments.



ER Wait Times, Nurses, Physicians, Beds and Denial

Andre Picard from the Globe and Mail writes in today’s paper:

“Ontario Health Minister George Smitherman said the answer to relieving the strain on hospital emergency rooms is to create a health-care system with more resources in the community. He said he would like to see more care delivered to the elderly in their homes so they can remain independent longer.”

Almost ten years ago, I wrote in the Ottawa Citizen that while a nursing shortage loomed and physician supply was manipulated and decreased, and acute care beds were cut from hospitals, funding for home care and long term care was not forthcoming.

I wrote that building new health infrastructure would not be much good without the health care providers necessary to keep it running and without the funding for long term care and home care, the system would not function.

Let me repeat: I said this TEN years ago. No study. No money spent. No electronic tracking. No consultants…just common sense. But common sense seems to be in short supply and sometimes decision makers hear what they want to hear.

Some consultants told government that we just needed to use human resources more  efficiently. But ten years later, don’t you think we would be getting closer to solving the efficiency issues in the ER and elsewhere, rather than seeing the problems get worse?

Now we begin to measure ER wait times and lo and behold we find that patients in Ottawa and area are not being treated within recommended times according to a new report from CIHI. Ottawa is not unique.

Only about half of patients in ERs across Ontario are seen within the recommended times.

Dr. Louise McNaughton-Filion, chairwoman of the Champlain Emergency Services Network says that “It’s good to see the numbers coming out.” But she says that the report is not detailed enough to be really useful to hospitals trying to improve care.

Apparently she believes that an electronic system is needed in each ER department capable of tracking patients in real time and recording when they came in, when they saw a nurse, when they were assessed by a doctor and what treatment they received.

“We don’t have that,” she says.

Oh , we need more reports and an electronic tracking system to know how squeezed things are? Ten years ago it was clear if you looked around any busy ER department that the lines were longer than they had been before, waiting rooms were too small, people were in hallways already receiving treatment because of lack of examining rooms and lack of beds, physicians and nurses were overworked, and patients who needed long term care beds were taking up acute care beds for a variety of reasons.

Many nurses couldn’t get full time positions ten years ago and some that I knew left for Texas and elsewhere south of the border or took up selling real estate. Now the health care budget is eating up more of the provincial budget and various groups say our system is unsustainable which they back with convincing evidence. In this environment how will more nurses  be found to hire and how will the cash be found to pay them?

The Ontario Liberal government said it would hire more nurses years ago. Where are they? The new Liberal program to start in February, “The New Graduate Promise” is supposed to guarantee full time employment for a few months (between 3-6 months I believe) and then the hospital is supposed to make these positions into full-time permanent positions. What happened to the previous promises of 8,000 more nurses…Will this be another promise that cannot be fulfilled? How will hospitals find the cash for these new positions when they can barely manage to fund what they have currently?

In Ottawa, one of the problems in the ER has been with paramedics being held up there, unable to off load their patients because of lack of health care personnel to take over from them and lack of beds,  and ER back log in general, hence longer ambulance off loading time.

The Ottawa Hospital has started a pilot program in which two nurses will be brought on line to take over from the paramedics so that hopefully ambulance response time can be improved. No electronic tracking system required…just angry voters willing to voice their concerns after horrendous delays in ambulance response times in Ottawa over the holidays.

A colleague in one of the busiest ERs in the country, not in Ottawa, tells me that they might be able to do the same if they could actually find more nurses to hire. This individual expresses exasperation at watching 15-20 paramedics on occasion filling in time playing cards or chatting while patients remain strapped to gurneys, some waiting in pain for their turn at access while the ambulances are prevented from getting back on the road.

It is not the paramedics who are at fault here. They are required to stay with their patients until appropriate and safe hand off can take place. It is a system failure. It is a system failure at the level of health care resource management dating back decades and during which almost all major political parties played a hand. It is system failure from a funding perspective. It is a system failure in lack of acute care bed availability and long term care beds and home care. It is a system failure in lack of understanding by decision makers that short changing one area will affect another area.

We need more funding for home care and long term care-agreed. But the problem is much greater than that. And it is certainly deeper than an electronic tracking system can provide the solution for. It is ludicrous to think that treating patients like widgets with a bar code attached, tracked by electronic systems that their health care would be any better.


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”.