Canada playing in wrong health league
Canadians tend to mock Americans’ ignorance of our country and the rest of the world. We do know more about their country than they know about ours. But we also tend to be unsophisticated when it comes to the rest of the world. Canadians need to become a lot more refined if we want medicare to be there for the next generation.
When we compare ourselves internationally, we start and often stop with the United States. Of course, our health system does well when compared with the U.S. But so do almost all other developed countries’ health systems. It’s like winning a high jump contest against a bunch of midgets. The bar is very low. It means a lot more when we beat the U.S. at hockey.
The U.S.-based Commonwealth Fund released their latest comparison of seven health systems on June 25. Predictably, the U.S. system rated last overall and that was the focus of the fund’s report and the U.S. and international coverage. But Canada was second last. We were last for overall quality, effective care and timeliness of access. We scored second last on efficiency.
The report compared Canada with other countries 18 times in the text. These included two favourable comparisons and 16 unfavourable ones, including indictments for long waits, the poor management of chronic conditions (like diabetes), the lack of electronic systems, poor care coordination and the failure to involve patients in decisions about their care.
Other countries, such as the U.K., scored better than Canada while spending a smaller share of their economy on health. And the U.K.’s system is actually more public than ours.
The main determinant of overall health-care system performance is the quality of primary health care. Unfortunately, Canada’s system of family doctors and a few community health centres just isn’t built to carry the load that it must if Canada is to beat anyone but the U.S. in the health-care Olympics.
The Ontario Health Quality Council has shown that this province’s primary health-care services have been getting slightly more effective. The provincial government has established a plethora of new primary health-care models for private doctors. Anecdotally, there is some innovation and many doctors report rejuvenated professional lives. But evaluations indicate that the province has spent a lot of money establishing family health teams in wealthier areas of the province and the new patients enrolled have tended to be relatively healthy.
In the meantime, hundreds of thousands of Ontarians still don’t have a primary care provider and the vast majority of current practices in this province still lack integrated health records. As the H1N1 flu problems demonstrated, we need to fully engage primary health care with its natural partner, public health. Ontarians should find it cold comfort to know that primary health care is as bad or worse in other provinces.
Primary health care was identified as a priority by Justice Emmett Hall’s national review of medicare in 1980, Dr. John Evans’ Ontario-based review in 1987, and dozens of times since. Yet change is still something feared by most providers and many patients as we cling to the mantra that we are better than the U.S.
Paul Martin’s 10-year federal-provincial-territorial health accord of 2004 was supposed to heal health care for a generation. But it turned out to be just enough to get the feds back into the health policy arena and give the old system some breathing space.
The Romanow Commission called for federal money to buy change. Unfortunately from my perspective, the calculus of federal-provincial politics ensured that the 2004 accord gave money without strings. It looks even bleaker for those of us favouring a strong federal presence at the table in 2014.
That means it’s up to the provinces to take on the heavy lifting of reform. Father of medicare Tommy Douglas always said that medicare would be implemented in two stages.
The first was public payment for the old system based on treating illness in hospitals. He said the second stage would feature a new system, designed as much as possible to keep people healthy.
He predicted that the second stage would be more difficult to attain than the first and he was right. But we need to move quickly on the second stage or we will risk losing the first. As the Commonwealth Fund study reminds us, we have a long journey ahead of us.
Dr. Michael Rachlis is a health policy analyst and an associate professor at the University of Toronto.
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