What's Wrong with Healthcare?

Thinking inside and outside of the healthcare box. After 41 years of family practice, what's happened to Canada's healthcare system?

Monday, February 06, 2006

To Summarize

Today I would like to simply summarize the key points that have been put forward over the last few days as a basis for “thinking outside the box”. I will start with the more central fundamental issues.
1) The federal government must take ownership and accountability for the Canada Health Act; after all it is a Federal Parliament Act.
2) There must be an agreement by all levels of government as to what is encompassed by the term “medically necessary” in the Canada Health Act. Without this inclusiveness and exclusiveness, costs cannot be projected or contained. Furthermore, other services that are deemed not to be medically necessary( but possibly have health impacts), can be dealt with through insurance or savings accounts.
3) This agreement could be arrived at by looking at services presently covered by the various provincial governments and dividing them into basic coverage and optional coverage. Basic coverage must be included in “free” coverage provided by all provincial governments; optional coverage could be covered by a provincial government premium system and/or private insurance. Premium subsidies would be provided by provincial governments for low income groups and the chronically ill.
4) A federal body comprised of provincial and federal government health care representatives would review, on a regular basis, those services that should be deemed basic and those that should be deemed optional.
5) Number (4) will be determined by population needs, (not wants), and the government’s ability to meet that need based on federal and provincial GDP and/or transfer payments. Any federal transfer payments must be designated medical, educational, etc so that there is transparency and accountability in federal funding.
6) All Canadians must register provincially for access to the basic health care package as is now the case. The registration would be a more formal process with some basic screening in certain age groups ( blood pressure, BMI, other risk stratification), would occur every five years, would provide information on appropriate resources and referrals, and would have a reminder system in place on an annual basis. Technology makes most of this a pretty simple process. As an example, in Alberta we have moved in that direction with pap. smears.
7) Doors must be opened to private providers. Doctors and other health providers must be allowed to work inside and outside of the publicly funded system. Many highly qualified health providers are working at a fraction of their capacity yet we have long waiting lists. If we can move a surgeon from 10 hours of operating time a week to 20 hours of operating time a week our waiting lists will shrink. Health care workers (nurses, doctors, technicians, etc) will come to Canada because of more options in the work place. If contracting out basic procedures is cost effective, it must be done.
8) Mechanisms for monitoring quality care and assurance must be in place before #7 is allowed.
9) Community teams of providers should be established. Team members should work together on a regular basis. We don’t see professional sports teams working different days with different people on an ongoing basis. There must be a system of authority and accountability of each team within itself and to a representative at a higher regional level.
10) Recognition must be given to general medicine as being most cost effective. Exceptions to the rule is the Calgary Wound Home Care Program and Palliative Home Care Program, but the care of the aging must remain community based, general medicine and general nursing serviced, and specialist referral supported.
11) We must have education programs and organization strategies for the “well” baby boomers and others within our society to encourage them and other volunteers in assisting in the care of the upcoming “unwell” in the wave of baby boomers and chronically ill.
12) Strategies must be adopted to make “people” services more attractive and respected in an age of technology. More visibility of the “good” done, exposure at the school level, more options to involvement, and generally more “perks”, need to be built in to show societal appreciation.
13) Programs must be continued where volume dictates the program to be cost effective and community responsive.
14) Other systems must be set up to help the community care givers deal with the extremely ill and extremely complex patient. A program that sees patients once a month leaves the community to manage this patient for extremely long periods of time. Consultants should be more available until the entire “special team” can consult.
15) Communities and their care givers cannot continue to absorb the discharges from acute care and other institutions into their midst without more tools and resources at their disposal. If we are to use lesser trained personnel (pharmacy assistance, nurse practitioners, physician extenders, etc) we must give them more time to do their duties or more errors will occur (actually true of all of us).
16) Better meaningful communication must exist between various levels of health providers. As an example, the Tom Baker Cancer Clinic has had problems in this regard for many years. Although they faithfully report to the community caregiver each time the patient is seen, the community physician is rarely involved in the ongoing care and decision making. The quick and efficient relaying of results and investigations to the community care giver almost never takes place (all that is needed is “copy to community physician” on the requisition when the investigation is booked), so if the patient comes to us between their visits to the cancer clinic, we do not know what has all occurred and what the results, to date, are. If we aren’t made to feel part of the team, we will exclude ourselves from the team.
17) The development of community transitional care units is imperative. Many patients do not need a full facility hospital to deal with their needs. However, the ability to deal with their needs must be put in place before transfers occur. Without this ability, it is difficult to attract physicians and care givers to the facility and one must question the care the patients will receive. Why can’t x-ray and laboratory space be located in a transitional care facility instead of a shopping center? Isn’t it just as easy for the public to go to this “center” for their tests as to a shopping center? Certainly having these resources on site would enhance transitional patient’s care!
18) A National Drug Plan needs to be initiated, not to cover the exceptionally expensive drugs that are rarely prescribed (that's what insurance is for),but to cover those medications that serve the greatest health needs of the majority of the people (blood pressure and cholesterol medications,immunizations,diabetic medication and supplies, etc.).
The above have been some suggestions on how I think we can make the Canadian Health Care System more responsive to the needs of the Canadian people and more effective overall. Will it be cost effective? I think so (better bang for the buck). Will it be more costly? ----probably. But at least it will be clear as to who bears what responsibility at the government level and there will be more accountability and incentive at the personal level. Comments are welcome.

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