"Toward a Patient-Focused Health System"
Dr. Brian Day
Canadian Medical Association
Ladies and Gentlemen
It is my pleasure to be here in my own province, and to address many of those who were responsible for granting me the opportunity and privilege to serve as CMA President.
That you would trust this role to an orthopaedic surgeon - something no other group in the 141 year history of the CMA has done - has surely entrenched and cemented your hard earned reputation across Canada as "those way out whackos from the west coast".
As I have travelled across Canada these past 10 months, I have tried to fulfill the goals I set for myself last August. In addition to between 300 and 400 media interviews I have attended, and have usually spoken at, over 100 meetings. I have visited more than 20 editorial boards that have generated 39 editorials. I believe I have engaged our colleagues, the public and the media in positive and rewarding dialogue.
Across the nation, government health policies are changing and I assure you that physicians are intimately involved in driving that momentum for change. Doctors, their patients, and governments accept that the status quo in health care is not acceptable.
As Ronald Reagan once said, "status quo" is Latin for the mess we are in, and it seems that Canadians now understand Reagan's version of Latin. A recent Pollara poll revealed that 68% of Canadians believe that the Canadian health system needs major reforms, or a complete rebuild. In the past, governments have fought and lost elections on health care. The time for governments to win elections on this very issue is now.
Any political guru will tell you that with 68% support, you need not worry about any opposition, because post-election with such a majority, there won't be any. Polls still show that, come election time, health care remains the number 1 issue in the minds of voters. Though I am not one to be driven by polls (and I support the question asked by Harry S. Truman - "How far would Moses have gone if he had taken a poll in Egypt?"), yet another Angus-Reid poll released last month placed doctors - with a 94% rating - number 1 in terms of the professions the public respect and trust. We must build on and leverage that trust with governments. The public wants and expects us to lead.
Doctors must continue to be at the forefront of reform. Today I would like to discuss some examples of how the growing momentum for change is overcoming the barrier to reform in our health care system. We have a unique opportunity to step up our advocacy efforts as never before. Our goal for our health system must be nothing less than the best - nothing less than number 1. Everyone in this room recognizes that health care costs are a significant and a serious challenge for governments.
Remarkably, some still deny that sustainability is an issue. 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. We cannot ignore the demographic pressures of an aging population of baby boomer patients and doctors, new expensive drugs and medical technologies. New and effective drugs are now available that cost up to $700,000 a year to fund. So far, they are mostly for rare diseases. What will we do when effective drugs of that price become available for more common diseases?
As gene therapy, stem cell therapy, cell and organ cloning and nanotechnology enter the field of practical, effective medicine, Canadians will have to choose which services are to be covered by our publicly financed health care insurance.
"If services are to be provided for all, not all services can be provided". That's not from me; that's from the World Health Organisation.
Instead of a system that serves patients, we in Canada have forced patients - and health workers - to serve the system. 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.
At the CMA's Taming of the Queue conference 2 months ago, we sat in silence as an emergency doctor described how in 1 day in his emergency waiting room 4 patients died without even being seen by a staff member.
That same week, a BC general surgeon described how he had to cancel surgery on 6 breast cancer patients in one month. Sadly, such events are not rare in Canada.
As doctors know, our failure to provide timely access comes with a major cost, both medically and financially.
This year the CMA released research that built on the pioneering study initiated 2 years ago by the BCMA. It showed that, in addition to the human health cost and suffering, patients waiting for care in just four priority areas targeted in the 2004 First Ministers Health Accord, cost the Canadian economy 14.8 billion dollars in 2007.
We know that patients deteriorate while they wait. They sometimes develop chronic and severe irreversible damage, addiction to painkillers, and depression.
Imagine if we added those costs and looked at all, not just the 4 areas of care targeted in the Accord.
In February, a report published in Chronic Diseases in Canada, estimated the cost to the economy of mental health in Canada was a staggering $51 billion. That's a lot of money - money that could provide a huge benefits if invested into the health care system.
Canadians are paying 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 this year 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, Rumania, and Lithuania. We came in last - 30 out of 30 - in terms of value for money.
Imagine what we could achieve in the field of health promotion - one of the areas that the BCMA has championed - with the savings achieved through the elimination of extreme rationing of care.
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. By waiting and denial of access, we often convert acute into chronic illness.
Two months ago, I spoke in Washington DC, to a group of physician leaders and US politicians. Let no one be misled. The next US President, whether it be Obama or McCain, has promised to address the 47 million uninsured there.
As the 47 million gain insurance and access to physicians, recruitment efforts aimed at Canadian doctors will grow massively.
Change will demand action and leadership as shown by the BCMA when it became the first medical association in Canada to adopt, as official policy, the reduction of block funding or global budgets, in favour of patient-focused funding.
This policy has been supported by Kirby's Senate Committee, the Castonguay Task Force in Quebec, by the OECD, and by the CMA.
Building incentives to treat patients will stimulate healthy competition.
In BC, we have seen initial success with new emergency funding models based on performance in 4 hospitals. These successes have occurred despite increased visits, and despite increased acuity. The recent BC provincial budget has added further resources to fund similar pilot studies on innovations in health care delivery. Doctors must support the principles of accountability and sustainability.
The Canada Health Act must not be a barrier to improvement and progress. As I have stated before, it is based on principles developed over 45 years ago, and it must be adapted to meet the realities of modern medicine. It must not be used as a mechanism to maintain the status quo.
Society has a legal, moral, and economic duty to deliver timely care to all in need.
In 1934, the Canadian Medical Association (CMA) produced guidelines for a national health program funded and administered by the state. That was 8 years before the release of Sir William Beveridge's plan for a National Health Service (NHS) in Britain (which later formed the basis for Canada's Medicare system).
While Canadian governments maintain a system that leaves their citizens without proper access to care, in the past 4 years the English have introduced innovations and reforms that have achieved spectacular improvements in access.
At the end of 2003 there were almost one million patients on hospital waiting lists in England. By the end of 2007, that number had plummeted and almost 90% of patients were receiving treatment in less than 3 months.
As you are aware, they accomplished this by moving to a patient focused system of care and funding,
They took an aggressive approach to setting targets, introducing an 18-week target from first encounter with a family physician to the completion of specialist treatments
They introduced and achieved 98% compliance with a 4-hour maximum target for the treatment of emergency room patients. This is now being reduced to a 2-hour maximum. Failure to meet targets results in the CEO of the hospital being replaced.
Canada's aging baby boomers are informed, active, and impatient. They will not suffer as they languish and wait for necessary care, nor should they. Despite having founded Canada's first private centre of its type in 1996, and despite my philosophical support of a role for the private sector, let me say that we cannot look to private hospitals for an early solution to Canada's problems. Canada has no significant infrastructure of private hospitals.
But evidence shows that successful partnerships with the private sector have helped shorten wait lists in a number of provinces.
The private-public rhetoric on health care is a relic of tedious and tiresome propaganda and is undeserving of debate. We need a reality check.
In fact, the private sector props up our health system now. Philanthropic efforts fund many, many, capital projects in health care in Canada. Not to mention the private contributions made by the 80,000 charities that 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. In France, where over a 1000 private hospitals perform over 60% of all surgeries, data shows show that private sector treatment is 30-40% cheaper for case adjusted cases, and has lower case adjusted mortality rates.
Our patients are counting on us to keep health care at the top of the political agenda.
The CMA's current "More Doctors, More Care" campaign is designed to spur our politicians into taking action. We want a patient-focused system that is accountable, effective, efficient and sustainable.
The CMA has served notice and politicians now understand that we will not allow health care to be taken off the political agenda. In an Ipsos-Reid poll released just last week, 89% said that the doctor shortage ranked second only to the economy as an election issue.
Our health system can't exist without enough doctors. We currently rank 24th in the world in the number of doctors per population. In 1970, we were 4th.
Fifteen hundred young Canadians are going to medical school in foreign countries. Almost all are "A" students, young Canadians, who have been forced 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 and create new medical schools.
Here in BC, medical school enrolment has increased significantly, and the school here in Prince George is a great achievement, but even more capacity is needed.
As we look to the future, and a truly patient-focused health care system, the issue of electronic data collection and information processing is an issue that the CMA and the BCMA both understand fully.
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 cannot continue to spend only a third of the OECD average on IT in our hospitals. Canada's poor record in avoidable adverse effects and hospital deaths is partly due to the absence of available information in a timely manner.
A patient focused system requires that we measure outcomes, and demands that data on hospital performance and quality be made available to them, even posted on the web - as it is in many countries.
A few months ago, the CMA launched the first-ever made in Canada patient controlled personal health record that allows communication with their physician through the mydoctor.ca portal.
The massive burden of chronic disease in Canada, will be helped greatly by this initiative. It attests to the vision of our organization that major US software giants are embracing similar initiatives.
I want to finish by thanking you for the opportunity to serve on your behalf as CMA President and to thank CMA Board members Drs. Brad Fritz, Michael Golbey and Graham White and all of the other committed colleagues from BC who serve, or have served, on the CMA Board, Councils or Committees.
I believe that the CMA governance review project that was just passed unanimously by the CMA Board, and will be considered at GC in August, will enable the CMA to fulfill its mandate much more efficiently.
That mandate requires that we press for change and improvement.
We cannot continue to dismiss multiple international studies that show Canada's health system is performing badly.
Our system remains in a time warp. It is spinning in a vicious circle, whereby rationing of services leads to limited access, reductions in workforce, limited investment in technology, long wait lists that negatively impact the economy, resulting in funding pressures that force rationing - so completing the "vicious circle". Patient focused care and funding can break that circle.
Our goal must be to build the best health care system in the world: one that is efficient, effective, accountable and patient focused. Universal care and excellent access can coexist.
We are at a pivotal moment in Canadian medical history. It is up to us to seize this moment, and to lead the necessary change.