"Toward a Patient-Focused Health System"
Dr. Brian Day
Canadian Medical Association
Thank you for the introduction, and I am very pleased to be here today and to report on some of my activities, and those of the CMA, since my visit to Saskatoon last November.
I must say that the tales about rural Afghanistan that we heard yesterday from Dr. Rasuli, put our problems in perspective. We are fortunate to live in a country like Canada. My brother in law, a former surgeon in the Canadian Army, served twice in Afghanistan, and he echoes the messages we heard yesterday. Canada is in Afghanistan as part of a humanitarian mission, and we must be there for as long as it takes.
My own travels to third world countries have formed a part of my own reality check on our health system and on life itself.
It is a tribute to the vibrancy of the SMA that there were so many outstanding candidates for nomination as CMA President Elect, and I want to congratulate Dr. Anne Doig on her nomination. I look forward to working with her and supporting her as she assumes a leadership role at the CMA. Anne: you will be a great CMA President.
As I have traveled across Canada to speak with our colleagues these past eight months, I have noticed a growing momentum for change in the health care system.
Today I would like to discuss the inevitability of reform and describe a vision for the future.
I believe Saskatchewan can be the leader in health reform in Canada. Politics has been part of the problem, but must now become a part of the solution.
Canada's economy is booming. As your Health Minister stated yesterday, Saskatchewan is at the forefront of that boom. Our national debt is falling, unemployment and inflation are low and our dollar is high.
Despite this, a million or more Canadians suffer on wait lists, and some even die, as a direct result of deficiencies in our system.
An Angus-Reid poll released this month placed doctors - with a 94% rating - number 1 in terms of professions the public respect and trust. We must build on that trust and, as Dr. Joe Pfeifer said yesterday, we need to take on the leadership role that the public expects of us. We have been forceful and effective in promoting reforms, but we keep up the pressure and force the pace.
A Pollara poll released just last December revealed that 68% of Canadians believe our health system needs a major overhaul or a complete rebuild. Canadians are demanding change. At election time, health care is the number 1 priority for voters. Politicians take note - 68% would translate into a pretty big majority.
In the past, governments have fought and lost elections on health care. Now is the time that governments can fight and win on this very issue. Health care costs are a significant and serious challenge for all governments and citizens.
Remarkably, some still deny that costs are rising. The facts are plain. There has been a 400% rise in health costs between 1984 and 2005, with just a 25% rise in population (2005 dollars). That is unsustainable inflation.
Demographic pressures of an aging population of baby boomer patients and doctors, and some of the new, effective, but expensive, drugs and medical technologies, will add tremendously to costs.
New drugs - mostly for rare diseases - are now available that cost up to $700,000 a year. What will we do when similarly priced, effective drugs, become available for common diseases? Who will cover the costs as nanotechnology, gene and stem cell therapy, and cell and organ cloning become practical tools in medicine?
For just one example in my specialty, knee replacement, the numbers being done are projected to rise by 670 % within 18 years.
Chronic disease is rising and already responsible for over 70% of health costs. We have the highest percentage of over 65 year olds in Canadian history, and 70 percent of them suffer from two or more chronic diseases
Growing demands will mean that Canadians will soon have to choose which services are to be covered by our publicly financed health care insurance.
As the World Health Organization has stated, "If services are to be provided for all, not all services can be provided".
This is a long overdue discussion in Canada.
Instead of building a system that works for patients, we have patients that are forced to work the system as they languish on waiting lists.
At the CMA's Taming of the Queue conference last month, we sat in silence as an emergency doctor told the story of 4 patients dying in his emergency department waiting room in one day.
We heard of the general surgeon who had to cancel surgery on 6 breast cancer patients in one month. Those in charge should be relieved that there aren't protests in the street. Canadians are too nice.
Our failure to provide timely access comes with major costs, both medically and financially.
In January, the CMA released new research showing that, in addition to the human health cost and suffering, patients waiting for care in just four areas cost the Canadian economy 14.8 billion dollars in 2007. The cost in Saskatchewan alone was $358m.
These estimates don't include the growing, and significant costs of waiting to see the GP or specialist.
Nor the costs, short and long term, of the deterioration that occurs while waiting.
Just imagine the costs if all of these were included, in all - not just 4 - areas of clinical care.
Patients deteriorate while they wait. Many develop chronic and severe irreversible damage, addiction to painkillers, and depression. This creates more chronic illness. Chronic illness that can be prevented.
A report published this March, in Chronic Diseases in Canada, estimated the economic cost of mental health in Canada to be a staggering $51 billion. Equal to a third of Canada's total health budget.
We waste vast sums of money by limiting access and keeping people waiting. We pay to prevent patients getting better. The prevention of patients getting better is not what doctors mean when we talk about preventative medicine.
A study released last month by the European-based Health Consumer Powerhouse, comparing Canada's health system to 29 European countries, ranked us 23rd overall - alongside countries such as Slovenia, Romania, and Lithuania. We came in last - 30th out of 30 - in value for money.
Many countries have universal care, no wait lists, and cost the same or less to run as ours does. Wait lists can and must be eliminated in Canada. The momentum to do just that depends on the empowerment of patients and a shift to patient focused care.
The CMA believes we need what some have called a "Copernican revolution" in health care.
Just as Copernicus, and later Galileo, proved that the Earth wasn't the centre of the universe, so must we develop a model where the system revolves around the patient, not the other way around.
Patients have been the "Pluto" of the solar system - hardly even considered a planet. We must reposition them at the centre of our health-care system.
This change needs action and leadership.
We must eliminate block funding or global budgets of institutions, in favour of patient-focused funding, where funds follow the patient. Block funding blocks access. This idea has received broad support by the Castonguay Task Force in Quebec. And by Senator Kirby. And by the CMA. And by the OECD.
Earlier I mentioned the recent Taming of the Queue conference in Ottawa. Carole Heatly, CEO of Kingston Hospital Trust in London, England, described the transformation there over the last 4 years. She remarked that Canada reminded her of England 5 or 6 years ago. The introduction of patient focused funding in 2003 -4, has led to the elimination of wait lists and the empowerment of patients.
A consumer approach has led to efficiencies and improvements through the introduction of competition within the public system. Incidentally, specialists' wages have risen over 20% and GP's 35%. A patient is now a value to an institution, and so are their doctors and nurses.
Building incentives to treat patients returns them to their rightful place at the centre of the health care system.
The Organisation for Economic Co-operation and Development has stated unequivocally that patient focused funding will increase productivity and reduce wait lists, even in primarily government operated systems - especially in rural hospitals.
Because of our efforts, we are already seeing results.
In BC, we have seen success with new performance based funding models. An 8 month pilot project in 4 BC hospitals revealed a dramatic improvement in ER waits, despite an increased volume of admissions and increased acuity.
As a result, just weeks ago, BC announced major funding for the introduction of patient focused funding.
Quebec, Alberta, Nova Scotia, and New Brunswick are planning major new reforms. Make no mistake. Doctors have greatly influenced those initiatives.
Governments have a legal, moral, and economic duty to deliver timely care. The aging baby boomers are informed, active, and impatient. They will not want to wait, nor should they.
Our system isn't working the way it should, and it's time for change.
Union-funded groups, such as the Canadian Health Coalition - housed and funded by the Canadian Labour Congress - continue to advocate for the status quo. But let us be clear. They are a special interest group fighting, on behalf of their members, to maintain control. That is understandable, but misguided. The CMA also lobbies for a special interest group - called patients.
The private-public rhetoric must be relegated to its true and deserving place in Canadian health policy. It is a relic of tedious and tiresome propaganda and falsehood that is undeserving of debate.
The private sector props up our health system now. Philanthropic efforts fund many, many, capital projects in health care. Private contributions made through the 80,000 charities are, for the most part, not even accounted for when we calculate health costs in Canada.
Canadians know that a vibrant economy and a successful business culture are absolutely necessary if we are to fund health care and other social services.
When I gave a speech at the Empire Club in Toronto several months ago, the Registered Nurses' Association of Ontario held a press conference to denounce what I had said - 2 hours before I actually spoke! In so doing, they denounced private insurance.
They had no response to my observation that their website advertised multiple levels of private health insurance for themselves and their members! In fact, 70% of Canadians have private insurance that covers many medically necessary services. Tommy Douglas would not be happy to observe that 30% of Canadians receive a lower tier of health care than the rest.
I want to acknowledge and thank Saskatchewan physicians for their support of our initiatives, and I especially want to thank Drs. Beverley Karras, Joel Yelland and Stan Oleksinski who have played pivotal roles at the CMA Board.
I would also like to thank all of the other committed colleagues from Saskatchewan who serve on our CMA councils and committees and last, but certainly not least, acknowledge Past CMA President Dr. Peter Barrett.
This year, the CMA's launched the "More Doctors, More Care" campaign to press politicians into action. We want a patient-focused system that is accountable, effective, efficient and sustainable.
We cannot achieve that without enough doctors. We are 26,000 doctors short of the average in developed countries, and we now lag behind at 24th in the world in the number of doctors per population. In 1970, we were 4th. Canada's doctors are also getting older, and the trouble with our younger doctors is that most are in their 50"s and 60's.
Fifteen hundred young Canadians are going to medical school in foreign countries. These are "A" students, Canadians, who had to leave the country for their medical training.
In the short term, we need to encourage them to return (most don't), but in the long term, we need to expand capacity here in Canada. If need be, governments should develop partnerships with the private sector to help fund and develop new medical schools. Groups in BC, Ontario, and Quebec are actively exploring such options. Last week, I spoke in Washington DC, to a group of physician leaders and US politicians. Let no one be misled. The next US President will have to address the 47 million uninsured there. As the 47 million become insured, and gain access to physicians, recruitment efforts aimed at Canadian doctors will grow massively.
As we look to the future, the role of technology must not be ignored. However, in a recent survey of doctors' use of electronic medical records in 8 developed countries, Canada came in last. I am pleased to hear that the SMA is showing leadership in this area.
Investing in physician office automation will improve the flow of information, and will lead to improved productivity, improved research data, and better care of patients.
We should be ashamed that we only spend a third of the OECD average on IT in our hospitals.
Canada's poor record in avoidable adverse effects is, in part, due to the absence of available information in a timely manner. We must document, measure and analyze all data relating to hospital, physician, and patient services, including outcomes and performance measurements.
Also, government held data on hospital performance and quality must be made available to us and our patients - as it is in many countries. Patients are entitled to access such data, which is available but currently being withheld.
The first-ever made in Canada personal health record, which operates through the CMA's mydoctor.ca portal, is a giant leap forward in the use of technology. The massive burden of chronic disease in Canada will be helped greatly by this initiative, which is being watched by software giants such as Google and Microsoft.
I believe there is a growing momentum to overhaul our health care system so that we can deliver efficient, effective, universally accessible health care that is second to none.
Looking forward, failure is not an option. We will succeed. I know that Saskatchewan's doctors will help us achieve that success, and the leadership shown by Dr. Pfeifer will continue under Dr. Fink.
Governments must recognize that inappropriate wait lists can be eliminated in Canada. This must be considered an investment, not a cost. Other countries have achieved this, and are reaping the benefits.
Canada must become self-sufficient in terms of educating and training enough health professionals. Governments should stop paying to keep patients waiting.
That Canada's system was ranked bottom when compared with 29 European countries in value for money should be a wake-up call to governments.
We cannot continue to ignore and dismiss studies, such as those of the WHO, the OECD, the Commonwealth Fund, and the European Consumer Index, that show Canada is performing poorly. They can't all be wrong.
We can say, with some certainty, that we are not performing nearly as well as we should.
In conclusion, as patient advocates, we must stress to governments that inertia, and resistance to change, will not be tolerated.
Saskatchewan, the province where Medicare was born, is ideally positioned to lead in health care reform.
Last fall, our Governor General described Canada as the greatest country in the world.
Our goal must be to build a truly patient focused health system. We want more than a good health system. We want to be number 1 - only the best should be good enough. Thank you.