Presidential CMA Speech 2007
Aug 22, 2007
Canadian Medical Association
Dr. Brian Day
Dr. Brian Day's speech at the CMA / August 21 2007
Colleagues, honoured guests. It is my pleasure to speak to you just hours before my inauguration as president of the Canadian Medical Association.
Before I begin my remarks, I would like to thank my colleagues in British Columbia and across the country for the opportunity to serve as your President. I would also like to thank the CMA - its talented staff, its Board of Directors and all elected officers for the way they have welcomed me into the fold this past year.
Most of all I would like to pay tribute to Dr. Colin McMillan. You have been one of the great CMA presidents, and I admire and respect your intellect and strength of character. Colin, you have been a great support during my introduction to the CMA leadership. You recognized that I can be impatient and in a hurry to get things done; yet you have never been impatient with me. Our goals are very similar, and I am looking forward to working with you again this year.
Some of you know me, but for those that don't, let me tell you a bit about myself. I was born and raised in post-war Liverpool, in a very depressed bombed-out area known as Toxteth. Violence, crime, and poverty were the norm. I was fortunate to be one of only three children in my elementary school that was able to enter grammar school and go on to university, and I earned my medical degree from the University of Manchester. I came to Canada in the early 70s, and since my residency, I have spent almost 30 years on faculty at the University of British Columbia and on staff of the Vancouver General Hospital. During those years I have been heavily involved in teaching, research and academics, both in Canada and abroad.
In my professional activities, and no matter what I have tried to do - easy or challenging - I have benefited from the strong support of my wife Nina, a family physician, and my six children. They are a constant reminder of the real priorities in life.
In 1995 I helped found and became the President and CEO of the Cambie Surgery Centre in Vancouver - the first private facility of its type in Canada.
The motivation behind our group was simple. Our services were subjected to rationing.
Meanwhile, patients waited, and waited and waited. Personally, MY OR time dwindled from 22 to 5 hours a week. 10 hours less than the minimum recommended for competence by the COA. Creating our own place to work seemed the logical thing to do. You may have heard I am focused on a single issue. In a way, I suppose that is true. My focus is to ensure ALL Canadians receive timely access to necessary care, regardless of ability to pay. That can only happen when we put the patient first. Not politicians, not hospital administrators, not health professionals, not trade unions. The patients.
Putting patients first is really at the heart of my remarks today. I'd like to share some of my thoughts and beliefs about the current state of our health care system.
Growing up in Toxteth was tough, but instilled in me a great deal of compassion for the poor, the needy, and the underprivileged. I want to see a healthcare system that supports them.
The ability to pay should never be a factor for any patient needing health care in Canada. No one I know wants to adopt so called American-style health system. But, those who have studied or worked in other countries know there are systems with universal coverage and no wait lists. They do deliver better care at less cost than here in Canada.
But time is not on our side. My generation - the Baby Boomers, represent a huge bulge in the population curve, especially in Canada. We represent a looming crisis for health care. As we grow older and our health declines we will have a profound economic and social impact on our country. The over 65 population in Canada stands at its highest per cent level in history, while the under-15 population is at its lowest.
How will our health system respond to our aging population?
Do we simply increase the tax burden on our children? Do we reduce services? Or is there another way? I believe Canada must implement a long-term plan to ensure the future viability of our health system. It cannot be one that simply spans the four-year electoral cycle of governments. We must face the reality that we cannot put unlimited resources into health care.
The World Health Organization has stated: "if services are to be provided for all, not all services can be provided."
Canadians face difficult choices, but we must act. We and our patients remain frustrated by waiting periods that exceed all ethical standards. Wait guarantees were a good start, but wait time guarantees must not mean guaranteed waiting. Wait times are NOT a necessary evil.
If we eliminate them, "benchmarks" will not be needed, wait lists won't have to be studied, and queue-jumping won't be an issue since there will be no queues.
When patients with acute problems are wait listed, neglected and become chronic, they result in major costs to the suffering patient - physical, emotional and financial.
We all have horror stories about patients who suffered delayed diagnosis or treatment.
Let's not forget that there are also huge financial costs to the health care system. Study after study confirms that wait lists cost a lot - estimated at many, many billions of dollars a year in Canada.
To allow acute problems to become chronic makes no sense and exacerbates the already existing crisis in chronic care.
Of course, not everyone has to wait.
In many provinces injured workers, and many other groups who are similarly exempt from the restrictions of the Canada Health Act, don't wait.
In addition, we already have significant private funding, multiple user fees, and co-payments.
Canada has a multi-tiered health care system that allows selected Canadians access to quicker and better care. The terms "medically necessary or required" are widely used, but have never been defined. As a result, patients are charged for "upgraded" implants and devices, and a host of other items prescribed by physicians. How can crutches after breaking one's leg or an ambulance for someone who has had a heart attack not be "medically necessary"? How can antibiotics prescribed to fight an infection, or painkillers to relieve pain, not be "medically necessary"?
It is a fact that almost three out of four Canadians have private insurance for these essential services in the form of extended health benefits. We tend to forget that it is the people who need it most that lack such coverage. Many who profess to oppose private insurance have it through their employers, and use it regularly. They accept for themselves what they reject for others.
Our system was built to meet the needs of the underprivileged. It is now failing both them and everyone else, because it has not adapted to the times. The greatest deficiencies are in the poorest regions of our nation, especially aboriginal communities. Our health system has been ranked 30th by the World Health Organization. If a hockey team were one of the most expensive in the league, but ranked 30th, would we not hold the owners and managers responsible? You all know the answer.
So I ask you, what do we do?
We must take action on the most pressing issues, five of which I would like to briefly highlight today. First. We must first modernize the Canada Health Act, which is based on principles developed over 40 years ago - a time when the Berlin Wall was being built.
The Act must meet the needs of the 21st Century. In the Chaoulli case, the Supreme Court of Canada ruled that existing laws violated the rights to life, liberty, and security of person.
They unanimously ruled that patients experienced "physical and psychological suffering," and the system imposed the risk of death and irreparable harm to waiting patients.
The basis of the Canada Health Act and our Medicare system is the 1961 Saskatchewan Medical Insurance Act of Tommy Douglas. Three of the eight principles that Tommy Douglas described as essential were omitted from our current Act. Those principles were "effective", "efficient", and "responsible". Let us demand that those principles be enshrined in an updated Canada Health Act. This will help ensure accountability.
I want to be very clear.
My support for universal health care is unequivocal, but I believe the Act must be revised, reformed and updated. The second action we must take is to look at hospital funding - the single biggest expense to our health system.
Our current system of block funding does not reward productivity, customer service, excellence, or efficiencies. Nor does it penalize failure to deliver on those key indicators.
There are those that dismiss these concepts of success and excellence as elitist or undesirable. They support the status quo and dismiss the plight and suffering of patients.
Their beliefs have become prejudices that do not serve the underprivileged in our society.
Hospitals must have incentives to re-open operating rooms, increase the number of beds available, hire more staff, and treat more patients.
Hospitals must view patients as individuals deserving of outstanding care, not as a drain on their predetermined budget.
Last year the Organization for Economic Co-operation and Development better known as OECD, released a report stating, "Market-orientated mechanisms reduce costs of hospital services, even when primarily government operated."
Patient-focused funding, where government resources follow the patient, must be considered as the alternative to block funding that puts the system first rather than the patient.
Third: We must emphasize that the shortage of doctors and other health professionals has reached a crisis level in Canada.
In 1970, when public insurance was first fully applied to physician services in Canada, we ranked second among developed countries in the number of physicians per capita.
We now rank 26th.
We have 17 medical schools, yet face a critical shortage of doctors. Every year, the equivalent of two full medical schools of graduates have left Canada. Fifty per cent of all newly trained orthopaedic surgeons and neurosurgeons leave within five years of graduation. Why? - - - - Because we can't offer these talented and highly trained young doctors the resources they need to work. Because doctors graduate with average debts of $160,000, and are forced to factor in their debt as they make career choices. Because doctors, and the services they recommend for patients, are considered a drain on the budget. We must address these issues.
Fourth. I especially want to address the issue of technology. I have been a long time believer in its vast potential.
As long ago as 1979, I sponsored a paper on electronic medical records by Dr. Myles Clough.
Twenty-two years ago I had the privilege of being involved in developing the world's first surgical robot, and that same year was one of two participants in the first-ever live two-way telemedicine session from North America to Mainland China.
These examples were ahead of their time, and not cost effective, but what was impractical then is a reality now.
Knowledge and data and information-processing are fundamental to sound decision-making and delivering safe, efficient care.
We are in the Information Age, and medicine needs to catch up. Technology will further change our practices in ways we have still not dreamt of.
Sadly, our access to new and valuable technologies is at a point where we rank near the bottom of developed countries. This must change.
My fifth and final action is the possible role of private health care in our public system.
I realize it will surprise some of you that I raise this topic.
Let's be clear: Canadians should have the right to private medical insurance when timely access is not available in the public system.
The CMA didn't decide that, I didn't decide that, the Highest Court in the land decided that.
Contracting out public health services to the private sector to reduce wait lists is not a new idea and does not spell the end of universality.
Most of the care of injured workers in BC has been contracted out in this way.
Injured workers do not wait for consultations or investigations or procedures, including surgery. Most importantly they don't suffer the physical and psychological distress of waiting, they pay nothing and the Workers' Compensation Board of BC has saved hundreds of millions of dollars in wage benefits and health costs.
Friends, Dr. McMillan deserves congratulation for his advocacy in promoting "a new vision for Medicare", as outlined in our Medicare Plus document.
Let us remember what our president said; "Sticking our heads in the sand will not secure the future of Canada's health system."
That is not the CMA's style. It is certainly not my style.
Canada must learn from countries outside North America. Countries that have universal care, no wait lists, and health care budgets that are the same or less than ours.
The private versus public debate is largely irrelevant and counterproductive.
It is not about private or public, it is about patient care.
What is important is putting patients first. Patients must receive the care they need when they need it.
That, my colleagues is the bottom line. Conclusion
In closing, new ideas and concepts invariably face opposition and skepticism. I experienced this in helping to introduce arthroscopic treatment for sports injuries over 25 years ago.
Medicine is changing at warp speed.
I ask those of you from my era to think back to your days in training. How many of you perform the same procedures you learned then? Order the same tests, or prescribe the same drugs?
The changes we have seen will be eclipsed by those we are about to experience.
But just as we need to consider and adapt to new diagnostics, new treatments, and other new technologies, so too must we be open to new ideas in funding and delivery.
Our system must be redesigned based on rationality, not rationing. Wait listed patients are an unfunded liability on the books of governments.
It is simplistic to equate the introduction of market principles with privatization or "Americanization". Market-orientated mechanisms reduce costs even in publicly funded, government operated services; so says the OECD.
Let's be clear.
Doctors must reject our government assigned role as a gatekeeper without a key to the gate. The Canada Health Act must be updated for this century.
Never in the history of Canadian medicine have our patients needed us to show our leadership more than now.
The system must work for patients, not the other way around.
We must continue to hold governments accountable. We can only do that if we are united as a profession.
We need more doctors doing what they love to do above all else - caring for their patients.
The CMA and doctors across Canada are ready and able to lead the reforms necessary to renew Canada's health system.
My job, as your representative over the next year, will be to work with CMA directors, staff, and most importantly with you the members, to ensure governments act and implement the reforms we need.
We have had three days of deliberation. While we may differ on the way to get there, we all agree on the destination: providing better patient care.
Today, let us leave this General Council as a determined and united association with a common goal. To take the lead in revitalizing our medical system for the benefit of all Canadians.