Dr. Brian Day @DrBrianDay

BC Medical Journal Volume 45, Number 2, March 2003, page 68 - 69

Editorial

A Canadian health charter

“Nothing will be a greater incentive for government than the notion that if they don’t deal with the problem, it is in fact going to cost them more money.”

—Senator Michael Kirby, Chair, Senate Commission on Health Care (on the topic of a “care guarantee”), 2002

An ethical physician’s role is to attempt to ensure quality health care that is appropriate, effective, and provided in a timely fashion. When forced to choose between loyalty to regulations and political doctrine that restricts that role or the well-being of their patients, a physician must favor the latter. This opinion has been reinforced by the courts. It is not our role to comply with overt and enforced rationing of necessary care, nor should we accede to the imposition of offensive and oppressive legislation that limits the rights of both patients and health providers. In a May 2002 CMA survey, 82% of 2000 Canadians supported a Canadian health charter that spells out the rights and responsibilities of patients, health care providers, and governments. The issues are complex, and simple questions may generate complex answers. Do Canadians have a right to health care? The Canadian Bar Association Task Force on Health Care declared unequivocally there is no such legal right under the Charter of Rights and Freedoms. Despite this, a belief in an entitlement or right to health care is held by many diverse groups and individuals.

In 1939, Dr J.H. MacDermot, a noted BC physician, stated “…our noble tradition that no sick person … shall ever suffer for need of medical care on account of poverty … should be based on our willingness to give … an act of our charity. It should not be exploited: nor should it be assumed as a God-given right. Least of all should it be a right-of-way for needy and penurious governmental and administrative bodies.” Lady Mary Warnock, a noted ethicist, has stated “…the widespread talk of ‘rights’ is empty rhetoric, encouraging the increasing tendency to believe that everything desirable may be claimed as a right ... so shifting attention away from where it properly belongs: ourselves.”

Health care as we know it is not a right, but a privilege and a benefit of living in a modern, rich, capitalist country. Our governments have misled the public into believing that medicare is like a smorgasbord where consumers can take as much as they like. If rationing is to be a defining feature of Canadian medicare, then priorities must be assigned to the areas of greatest need and choices need to be made. A charter should be based on realistic expectations and must acknowledge these limitations. Physicians should no longer continue to accept medically inappropriate waiting periods for investigation or treatment. Penalties for noncompliance, and perhaps rewards for performance, must be in place to ensure that patient care is the number one priority. Global budgets as a funding mechanism for our hospitals must be abolished. Health institutions will realize that a commitment to patient care must not only be declared in their mission statements, but also implemented for the sake of their financial statements. If hospitals divert resources and personnel away from patients, they will receive less revenue. Balance sheets will suffer and the managers responsible will be fired. I submit the following proposal:

1. Patients awaiting elective consultation with a specialist will receive a consultation within 2 weeks. Those waiting longer will receive a refund equivalent to 6 months of MSP premiums for each week of waiting beyond that period. Referral will be arranged through the (“award winning”) government web site. Alternatively, they may use that funding to arrange their own consultation with anyone, anywhere they choose.

2. Patients with acute injuries or illness (e.g., fractures, vascular, cardiac, abdominal, neurological, etc.) requiring emergency assessment in an acute care hospital shall receive investigations and treatment without delay. No such patient shall wait more than 4 hours for urgent tests or 8 hours for interventional treatment. A hospital that fails to deliver in this timeline shall be penalized through a system that (a) penalizes responsible senior management and (b) requires that the patient be transferred to an alternative institution accompanied by funding (from their existing budget) in an amount equal to five times the estimated cost of that patient’s total hospitalization period. If no alternative is available, a similar amount would be returned to the Ministry of Health from the primary institution’s existing budget.

3. Patients with subacute illnesses that are determined by the referring or admitting physician to be urgent shall receive investigation and treatment within 1 week of being referred to the institution.

4. Patients with non-emergency illnesses or injuries, who are in pain and or disabled, will receive all investigations and treatments within 1 month of referral.

5. Patients with non-urgent or chronic illnesses or injuries, who are restricted but not suffering significant pain or disability, will receive all investigations and treatments within 3 months of referral.

Failure to achieve the timelines referred to in 3, 4, and 5 will result in the patient being referred to a second facility that will receive funding at double the estimated cost of providing the services. The primary institution will be responsible for that funding. All children will be considered to be in category 2, 3, or 4.

The suggested penalties for non-compliance may appear high, but their implementation would actually save money (in the long term) through a reduction in morbidity and disability. Facilities would soon realize that resource allocation would have to be diverted from middle management to patient care. Hospitals (public and private) would compete for work and the best and most efficient would be the most financially successful. Program funding would be assigned on the basis of most urgent need. Patients would rise to the top of the pyramid and there would be no more stories of acutely ill or injured patients waiting for days on emergency room stretchers when immediate treatment is needed. “Reduced activity days” would die a deserved death. Those who wish even faster treatment than the above guidelines would be free to opt for nongovernment care. The Supreme Court of Canada recently gave prisoners the “right” to vote. Is it not time that nonjailed citizens were given reciprocity with a “right” that prisoners have; namely the freedom to bypass the public system when it fails to provide reasonable access?

—BD