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?

Tuesday, November 14, 2006

More Questions and Answers on Healthcare

I did warn you that these entries dissecting our “would be” Alberta premiers positions on health care would be boring! Nevertheless the pursuit of the truth has no bounds, so we will continue. Another question put to our conservative leadership candidates had to do with the health professions legislation and expanded scope of practice, including the ability of pharmacists to prescribe. Good question, especially since I have recently heard that this is, in fact, already a “fait et complete” against the wishes of the Alberta Medical Association. Generally, there seemed to be an agreement among the candidates that everyone should practice “to the full extent of their training and capability”, whatever that means. Isn’t this the very essence of the discussions and the concerns of the AMA------that pharmacists are not trained to diagnose and this opens the door to that activity? Mr. Hancock included “and take responsibility”, Mr. Dinning assured the questioner that this would only happen after all concerned parties had their concerns addressed over time (doesn’t sound like that is happening), and Mr. McPherson emphasized the collaboration that needed to exist between the family physician and pharmacist.
So here is the medical reality. Many of the family physicians I have talked to are not prepared to “supervise” and take responsibility for pharmacists prescribing for their patients. In a court of law, the person who is most adequately trained in a “collaborative” relationship bears the major responsibility for outcomes, and pharmacists are not trained in diagnostics. Further, collaboration takes time, and family doctors do not get paid on a time basis like lawyers and other workers. We are already spending 20 to 30 percent of our time doing things for which we have no ability to charge (including “collaborating”). With the advent of other “advisers” in health care over the past few years and the many people involved in prescribing (various specialist) and people recommending medications (herbal remedies, over the counter medications, etc), it is already a mine field trying to monitor patients’ pharmaceutical intake. That is not to say that working with pharmacists and other health care workers isn’t essential, but overlapping responsibilities is potentially confusing and ultimately, the responsibility for untoward events will fall on the family doctor. Pharmacists should be allowed to have lea-way in repeating medications for conditions that have already been diagnosed and need ongoing management; they are essential in assisting physicians where drug interactions are a possibility, but diagnosing, at this point in time, will further alienate family physicians.
The question of electronic health records was supported by all the candidates but I must say that only Mr. Norris seemed to have significant reservations regarding cost, confidentiality, etc. There is no question that the electronic health record will have a huge positive impact on “tracking” people at risk, outcomes, etc, and possibly decreasing certain investigations and costs for the system, but there is an increase cost to the practitioner. At present some of these costs are offset by an “initiation” program, however, this program will not be continued indefinitely, but the added cost to running a practitioner’s “electronic” office will. My own personal physician has had his office computerized for many years, and our discussions invariably involve him looking at the computer screen 95% of the time. What happened to “looking the patient in the eye”, or “relating” to the patient? It’s kind of a “cold” environment, if you ask me. Is it any wonder that people feel that “holistic” doctors “care” more?
The last question asked by the Calgary medical Association was “What do you see as the biggest problem in healthcare in Alberta today, and as premier, how would you deal with it?”. Being such an important question I will consider each candidates answers separately.
1) Mr. McPherson.
a) Waiting lists b) Manpower shortages c) Lack of planning to ensure sustainability. His suggested solutions: Using personnel more effectively, and creating a “culture of health”. My response: Good luck on the culture of health “thing”. Furthermore, I recently had occasion to be in a recovery room at one of Calgary’s hospitals. My Lord, it was like an intensive care unit of ten years ago but with a lot more patients. The nurses should have been on roller skates. They all looked like they were in shock from their stress levels. Might I suggest that the caregivers within the system are already stretched to their limit? You may want to start rewarding the people in the system, like paying the nurses in that recovery room $100,000.oo a year or more.
2) Mr. Oberg
From the Vital Signs publication: “Without a doubt, the biggest challenge we face today in healthcare is the need to slow the rate of growth in the overall healthcare budget to within a reasonable range of population growth and inflation”. Not included in his response is the part “and how would you deal with it? Now I know that he has stated that he would allow doctors to work in the private system 25% of the time in an attempt to better utilize physicians and shorten wait times. Would the government pay the physicians for their work in the private system? If so, wouldn’t the cost go up, based on the increase of work alone? If the government contracted the work out, the cost would be borne by the taxpayer anyway. It would seem that a private insurance system would be required to actually decrease the cost to the average tax payer. To my recollection, Ted Morton is the only candidate that actually has stated this as his position.
3) Mr. Hancock
This premier hopeful correctly (in my view) again raises the problem of sustainability. Unfortunately he believes this can be done though healthier lifestyles (ideologically correct, but have been failing over the past forty years). He does offer some suggestions: a) offering tax incentives for healthy lifestyle choices (unfortunately the greatest demand is disproportionately by those in a “no or low” income tax bracket), b) Instituting a province wide ban on smoking in public places (will help in 20 years but may actually cost the government loss of tobacco tax revenue in the short term--------if it does anything at all to decrease consumption). c) Increasing taxes on tobacco and alcohol (add junk food to the list please), and d) Implement measures that are known to reduce avoidable trauma (protect us from ourselves). Well, at least Mr. Hancock attempted to answer the question.
Mr. Dinning
He seemed to say that although the focus was on “cost” he didn’t think that was the problem. He said “health” was the problem, and then got into the “prevention thing” and made no suggestions as what to implement, from a government perspective, for the people to have better “health”.
Mr. Norris
In the Vital signs publication he states that he believes that accessibility of health services remains at the forefront of challenges. He seems to think that increasing the efficiency of the system by addressing “bottlenecks” is the answer. His second point was to expand priorities rather than the entire system. From where I sit, it appears to me there are expansion needs in all aspects of the system. Is he referring to the possibility of actually defining what should be covered under the Canada Health Act and expanding those items, and de-listing other services? Seems like an obtuse way of proposing this. He does mention units that would accommodate patients that presently are “bed blockers” in acute care facilities (I presume he is talking about transitional care units, rehab units, palliative care units, etc. but we have been doing that for at least ten years now). I agree. We could be doing more of that, providing these units are adequately staffed and equipped (which at present, they are not), but it does have the potential of putting the patient in the appropriate environment and allows cost sharing on the part of the patient and the facilities (from the public’s perspective it means they have to pay out of pocket money; is that what the public wants?).
This concludes some excellent questions put forward by the Calgary and Region Physicians association, to the prospective conservative leaders of Alberta. Your job is to judge them on the healthcare issues by their answers. From my perspective, I see nothing new, and certainly no “vision”. Over the next day or two I will comment on what I could find on their respective web sites. So, if you are an insomniac or have a strong inclination for suffering, tune in for more on “Where I stand on Health Care” by Alberta’s “Conservative Leaders to Be”.

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