Four things we can do to improve healthcare in Canada
As the federal election campaign unfolds, Canadians should be pressing the parties to take a leadership position on healthcare issues.
By JOSHUA TEPPER Mon., Aug. 17, 2015
https://www.thestar.com/opinion/2015/08/17/four-things-we-can-do-to-improve-healthcare-in-canada.html
Healthcare is the purview of the provinces in Canada, but health leadership – setting big-picture goals, helping achieve best practices across the country and providing long-term, sustainable funding models – can be the role of the federal government. As the federal election campaign unfolds, Canadians should be pressing the parties to take a leadership position on the healthcare file. Primary care, in particular, could benefit from increased national dialogue.
Evidence shows the best healthcare systems in the world are founded on a strong primary care system – practices of family doctors, nurse practitioners and others who serve as the first (and ongoing) point of contact for patients. Canada has been a world leader in many aspects of primary care for a long time and the past 10 or 15 years have seen some important changes – mostly for the better.
Not long ago, millions of Canadians said they didn’t have a family doctor. Now, in places like Ontario, as many as 94 per cent of residents report having a primary-care provider. While there is still more progress to be made on even this basic measure of access, there are several other ways we can improve primary care in Canada.
1. Timely access
It’s not enough to have a family doctor; you need to be able to see him or her promptly when you’re sick. In Canada, only 38 per cent of people report being able to see their primary care provider the same day or next day when they call. France, Australia and Britain all report 50-per-cent or higher rates, and countries such as Germany, New Zealand and Switzerland hover around 70 per cent.
Improving prompt access is critical to achieving continuity of care while reducing the number of people relying on walk-in clinics and emergency departments.
2. Doctors need to serve communities
We need to move primary care to a population-based model, which means a fundamental rethink of how primary care is organized. Perhaps the easiest analogy is public primary and secondary education. When you move to a new community, registering your children in the local public school is as easy as knowing your address and catchment area. The schools don’t have the choice of picking their students or saying they are “too full.”
Moving to a population-based model of primary care will require a new level of planning and coordination – but it’s doable. We already have examples in several rural communities in Canada, and Community Health Centres in some regions also provide a good model. Entire countries, like the United Kingdom, have already achieved this. It should be as easy to find a primary care provider as it is the local public school.
3. A commitment to equity and improving the quality of care
We need to adopt a relentless commitment to improving quality in primary care. Canadian hospitals already have a couple of decades of experience in building the skills, structures and programs to improve care – primary care can build on some of this success.
There are six widely accepted domains of quality, all of them relevant to primary care: safety, timeliness (access), efficiency, patient centeredness, effectiveness, and, importantly, equity.
In Canada, one of our great strengths is the richness of diversity represented across people and geography. It is critical that primary care, the gatekeeper and cornerstone to our health system, treat people equitably. It should not matter where you live, what language you speak, nor your age, sex, sexual identity or cultural background.
4. Integrate primary care into the rest of the health system
Canada often ranks near the bottom of a dozen Commonwealth countries in patients’ experiences of an integrated healthcare system, including the timely availability of information across provider teams. It’s about more than just getting hospital, lab and primary care computer systems connected (although this is a critical part). We need a fundamental redesign from sectors to systems while continuing to strengthen the foundational role of primary care.
Patients don’t experience their healthcare as discrete parts, so it shouldn’t function that way. The responsibility for this change is spread across all parts of the healthcare system and a wide range of healthcare providers.
While acknowledging that primary care looks different across Canada – varying payment models and structures according to your province or territory – these four goals can be a unifying vision for the next, necessary evolution in healthcare.
Joshua Tepper is an advisor with EvidenceNetwork.ca, an emergency room doctor at North York General Hospital and Associate Professor at the University of Toronto.
http://www.canadiandoctorsformedicare.ca/images/2012-01-11_Top_10_Transformation_FINAL.pdf
Top 10
Best Ideas to Transform Health Care
Improving the quality and efficiency of health care matters to all Canadians.
Finding better and less
expensive ways of providing care and preventing illness cannot be achieved by sticking to the status quo.
Our health care system requires continuous improvement. There are many ideas that have been shown
to improve quality and efficiency while preserving or improving equity. Below are the top 10 ideas
Canadian Doctors for Medicare believes would improve the quality of care, improve health outcomes, and
provide value for money in our health care system.
1) Primary and Community Health Care Reform
The best health care systems are built on a foundation of high-quality primary care. With our aging
population, integrating primary care with home- and community-based care makes sense. Shifting nonacute
resources from hospitals to the community supports a stronger focus on keeping patients well and
supported in the community.i
Greater integration of community-based primary health care is needed to support a continuum of service
provision, including first contact physician care, health promotion and prevention, and the management of
chronic disease. An integrated primary health care sector would also better support a system of “shared
care” – that is, a system of primary care that is networked, patient-centred, and based on interprofessional
teams and rapid access to specialists and non-physician providers.
Primary health care reform was a key feature of the 2003/04 First Ministers’ Accord on Health Care
Renewal.ii The agreement identified primary care reform as a priority, in order to ensure equitable access
to the interrelated factors that affect health, including health promotion, illness prevention, health
maintenance, home support, long-term care, community-based rehabilitation and pre-hospital emergency
medical services. Since then, the Health Council of Canada has reported some progress on primary care
reform, but changes have been somewhat limited to the implementation of inter-professional teams and
disease-oriented collaborative practices.
Expanding access to primary care in community-based settings and supporting a smooth continuum of
care between the community and institutions are key steps in improving medicare. And there is mounting
evidence that it may also contribute to better health outcomes. Patient care delivered within a primary
care setting has been found to be more efficient and effective, while countries with “primary care-oriented
systems” have fewer disparities in health across the population.iii
2) Implement an Electronic Health Record
There is a near consensus among health care providers that electronic health records (EHRs) will
improve the practice of medicine, support a more integrated health system and allow different parts of the
health care system to communicate more effectively with one another. Electronic prescribing will enable
prescribers to better utilize their time, while a prescription drug database can be used by doctors and
pharmacists to improve prescribing practices and help to prevent dangerous drug interactions. The use of
EHRs can also better support the use of evidence-based guideline by physicians and other providers in
the health system.
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Yet, in 2009, of an estimated 322 million visits made by Canadians to doctors, 94% resulted in a paper
record. Canada is far behind all other industrialized countries except the United States in transferring to
EHRs. Almost 80% of health records in Australia are electronic, while in the Netherlands the figure is
98%. Canada has a long way to go to catch up, but achieving an almost universally applied EHR is a
reality in other jurisdictions and is a realistic goal for Canada.
3) Widely Implement Successful Wait Times Initiatives
Despite alarming assertions in some quarters, Canada’s public health care system has introduced highly
effective measures to dramatically reduce wait lists for specific surgical procedures.
A B.C. study published in 2004 concluded that two key changes contributed significantly to better
managing wait lists.iv The first was a transition among doctors from a fragmented array of solo practices
to collaborative relationships with other physicians and health care workers in teams, particularly those
who work in primary care. In such an environment other providers – such as advanced practice nurses –
are better able to work to their full scope of practice.
The second change was the transfer of wait list management from individual doctors to regional or local
health authorities. This enabled a common wait list to be developed while protecting the right of patients
to choose their own surgeon. In some provinces, notably British Columbia, physician wait times are
published on the government website to enable patients to choose a surgeon with a shorter wait time if
they desire.
Other steps that have been used successfully in Canada and elsewhere include queuing strategies to
improve current organizational processes – a process used in other sectors as well. Pre-surgical
programs that prepare patients for surgery can also reduce wait times, as well as reduce the stress
patients may experience prior to an operation.
Prompt access to care could also be enhanced by the creation of a “wait-time champion,” someone who
will point to workable and sustainable ideas being implemented in different parts of the country. For
example, Dr. Cy Frank, an orthopedic surgeon and executive director of Alberta’s Bone and Joint Health
Institute, led a team that reduced wait times for hip and/or knee surgery from 82 weeks to 11, using
innovative approaches to organizing care.v
Applying similar approaches on a provincial or national scope
should produce similar benefits for populations as a whole.
4) Move Toward a National Pharmacare Program
Since 1964, when the Royal Commission on Health Services recommended that prescription drugs be
part of medicare, the creation of a national pharmacare program has been part of Canada’s national
dialogue. Since then, the idea – and the evidence to support such a proposal – has grown.
Canada pays more for prescription drugs than any country within the Organization for Economic
Cooperation and Development (OECD) except the United States. We pay 30% more than the OECD
average. Despite this, we have one of the lowest rates of public drug coverage, and about 8% of
Canadians are unable to fill a doctor’s prescription because of cost.vi This has resulted in one of the most
inequitable systems within the OECD in regard to access to medicines. A universal national pharmacare
program would bring Canada in line with most high-income countries around the world.
A national pharmacare program would also allow Canadians to effectively manage costs in a variety of
ways. For example, a single national formulary of essential drugs based on independent, evidence-based
drug evaluation could reduce costs by 8%. Additional savings from competitive bulk purchasing could also
reduce expenditures substantially. One study estimated that a combination of strategies could reduce our
prescription drug costs by as much as $10.7 billion per year, or an estimated 43% of Canada’s $25.1
billion drug bill.
5) Place Greater Emphasis on Health Promotion and Illness Prevention
Evidence is mounting that the social determinants of health are as important – if not more important –
than the health care system. Poverty, for example, is probably the greatest cardiovascular risk factor of
all. Similarly, physical inactivity has been linked to many chronic conditions and cancers.viii The promotion
of exercise and healthy eating, along with progressive policies that reduce poverty, may prevent illness,
reduce its severity, and generally enhance the quality of life.
Vaccination programs are also an important aspect of public health policy in Canada, and their
increasingly uneven application causes concern. Widespread application of effective vaccines should be
the norm in Canada, but recent high-cost vaccination programs, and direct-to-consumer advertising have
affected public confidence and cost more than is perhaps necessary. Vaccination programs should be
based on solid evidence and transparent arrangements with manufacturers, and should be delivered in
the most broadly accessible ways.
6) Focus on Quality Care Based on Sound Evidence
The development and implementation of evidence-based guidelines can help improve the quality of
medical care. Since the introduction of the term “evidence-based medicine” in the early 1990s, the
principle of a “hierarchy of evidence” has been increasingly central to good medicine. In 2001, the US
Institute of Medicine formally embraced evidence-based medicine, describing it as a key feature of
patient-centred, high-quality medical care. In 2008 the IOM further called for “a stronger focus on
evidence to ensure … the right care for the right patient at the right time.”ix
Access to evidence has improved with the development of the internet and the introduction of the Medline
database and other search engines. But Canada lacks a coherent strategy to put evidence into practice.
A national body tasked with continuously reviewing the evidence and issuing guidance to health care
providers, similar to the National Institute for Health and Clinical Excellence in the United Kingdom, would
likely improve the quality of Canadian health care and save money. For example, such an organization
could issue recommendations regarding when expensive diagnostic tests such as MRI scans and
echocardiography are truly needed, thus reducing unnecessary spending.
7) Use Health Resources According to Best Practices
Victoria-based researcher Alan Cassels has written extensively about the misuse of technology within the
health system. A 2009 paper he co-authored on screening technology (PET and CT Scans) found that
while a growing number of medical imaging companies in Canada were promoting health screening
services to patients, very little was known about the benefits and harms that associated with the use of
this expensive technology, especially among asymptomatic people. “Screening tests being promoted to
Canadian consumers are often marketed under the pretence that such screening can ‘save your life’,” the
paper found, “despite the fact that neither the scientific literature nor professional or regulatory bodies
condone such practices.” The use of medical imaging equipment in Canada is growing at a rate of
between 5% and 10% amidst controversies within the medical profession about the appropriateness of
screening asymptomatic patients.x
In a similar vein, the Health Council of Canada cautioned Canadians in a 2010 report about the
inappropriate prescribing of drugs and over-use of diagnostic imaging which not only can harm patients,
but also adds unnecessary costs to the health care system.xi According to the Canadian Association of
Radiologists, as many as 30% of CT scans and other imaging procedures are inappropriate or contribute
no useful information.xii The use of health technology standards and tools to support clinical decisionmaking
need to be made more commonplace, the report said, with “providers and payers held
accountable for their decisions in the interest of good medicine and cost effectiveness.”
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In health care, more is not necessarily better and, in fact, can result in greater harm than good.
Resources within the health care system should be used appropriately and when required to ensure that
patients are not exposed to unnecessary risk and that health practitioners are using the best tools to
achieve the best outcomes.
8) Increase Access to Affordable Dental Health Care
In 2009, Health Canada estimated that 62% of Canadians were covered by private dental insurance,
while another 6% received public dental care.xiii This leaves many Canadians without access to
affordable dental care.
The public sector could and should be playing a larger role. Canada has one of the lowest levels of public
funding for dental care in the industrialized world, falling behind even the United States. In 2009 only 5%
of dental care costs came out of the public purse, a figure that compares with 75% in Japan and Norway.
That has an impact on patients but also on our universal health care system because poor oral health is
linked to a variety of chronic diseases. The link between periodontal disease and an increased risk of
coronary heart disease, for example, has been known for many years.xiv The outright loss of teeth, on the
other hand, has been linked to malnutrition. These chronic ailments are routinely much more expensive to
treat and manage than tooth decay.
Several provinces are exploring the idea of increased public funding for dental care, especially for
targeted populations such as school-age children. But all Canadians need adequate dental care.
9) Optimal Use of Health Human Resources
Effective health human resource (HHR) planning is needed to ensure that patients are getting the right
service, at the right time and in the right place. Approximately 800,000 people work in Canada’s health
care system, and between 60% and 80% of every health care dollar goes to human resources.xv A broad
range of complex issues, from equitable access and wait times to health outcomes and patient safety,
depend on a number of factors, including an adequate supply of health care personnel. An appropriate
allocation of human resources is essential to achieve desired health outcomes, greater efficiencies and
improved recruitment and retention.
Despite the significance of HR planning, Canadian and international studies show HHR planning is often
“poorly conceptualized, intermittent, varying in quality, profession-specific in nature and without adequate
vision or data upon which to base sound decisions.” xvi xvii Although federal, provincial and territorial
governments adopted a framework for pan-Canadian HHR planning in 2005, progress towards a
coordinated approach that crosses jurisdictions and professions has not yet materialized. Canadian
Policy Research Networks found a genuine desire to move beyond the more traditional “supply-demand”
models based on past utilization patterns towards “models firmly rooted in the health needs of populations
served.” But there are equally genuine challenges to effective HHR planning, including the fact that many
of the services provided by health professionals are offered in increasingly fragmented ways, including
private clinics. “How and whether those services are accessed by Canadians,” the CPRN paper said,
“poses real HHR planning challenges.”xviii
New studies suggest that an effective HHR strategy should match HHR inputs (time, effort, skills and
knowledge) to improved individual and population health outcomes. Much of our focus to date, however,
has been on outputs (productivity) rather than outcomes.xix Canada needs to further explore the
relationship between HHR planning and proneeds on the other hand.
Governments, health professionals and institutions should pursue a more coordinated, comprehensive,
pro-active and cross-jurisdictional effort to develop a pan-Canadian collaboration on health human
resources planning. Such a plan should also include education and training of the workforce, increased
training of generalists, “shared care” arrangements, recruitment and retention strategies for health
professionals, and a rational distribution of providers across jurisdictions. A broadened scope of practice
among physicians and greater utilization of team-based care that enables nurses to assume broader
clinical tasks is needed.
Proactive HHR planning across a coordinated system of health services would benefit patients and
taxpayers considerably.
10) Appreciating the Role of Relationships
Study after study points medical professionals toward a greater appreciation of the role of relationships in
health care. Whether it is the impact of cross-cultural and inter-racial relationships on doctor-patient
interaction xx or the benefit of peer reinforcement in the management of chronic disease,xxi, xxii studies of
patient experience and outcomes show that stronger relationships between health care workers and
patients yield better outcomes for patients. As Dr. Mike Evans says, stories trump evidence, but
relationships trump stories.
A 2010 review of the Canadian and international literature found that patients treated by interdisciplinary
health care teams enjoy better health outcomes, shorter wait times, and a greater degree of patient
empowerment, as well as higher rates of patient satisfaction and greater cost savings to the health care
system.xxiii Other studies have concluded that patients who obtain primary care in community health
centres are healthier than those from similar socio-economic backgrounds whose care is delivered in
other settings.xxiv
While it may strike many as obvious that a profession that relies on accurate disclosures, confidence in
professionals and post-treatment compliance by patients would be heavily dependent on the quality of
relationships between providers and patients. But it has not been a focal point in much of the planning
around enhancing health care. The promotion of more fragmented, competitive, commercial relationships
has been a common refrain, with little emphasis on the benefits of collaboration, stronger relationships
and cooperation. Health care reform needs to focus on the relationships between patients and their health
care providers, and also on relationships between providers.
