Unfinished health-care revolution

TheStar.com – comment – Unfinished health-care revolution
May 26, 2008. Carol Goar

Twelve years ago, the Ontario Hospital Association set up a health policy think-tank called The Change Foundation. It gave the new organization a generous endowment and set it free to tackle the big questions that no one – not politicians, not bureaucrats, not hospital administrators, not doctors or nurses or drug makers – wanted to touch.

Last week, the foundation invited the country’s top health-care thinkers to Toronto to grapple with a simple but sensitive question: Has the multi-billion-dollar decentralization of medicare worked?

Every province in the country has divided its health-care system into regional units over the last 35 years. Quebec was first, Ontario last.

Patients were promised better care. Communities were promised the chance to set their own priorities. Taxpayers were promised a seamless system in which all the players worked together.

Were these promises kept? Did some jurisdictions do better than others? Can Ontario, whose local Health Integration Networks are still in the formative stages, learn from provinces with more experience?

It was a closed-door symposium. The 40 participants were encouraged to speak freely on the understanding that they would be guaranteed anonymity. But the two leadoff speakers – Ken Fyke, who led Saskatchewan’s Commission on Medicare in 2000, and Steven Lewis, research director of The Change Foundation – agreed that their remarks could be reported.

They had plenty to say – little of it complimentary.

Fyke’s basic contention was that regionalization was a good idea, badly implemented.

“I know of no province that has totally succeeded,” he said. “Too many governments have made the structure an end in itself. Until health is the core business, regionalization will fail.”

He pointed to four recurring mistakes:

* Political leaders told the public they were decentralizing health care to bring decision-making closer to home. But, in most cases, they were trying to insulate themselves from the fallout of closing hospital beds, firing highly paid administrators and reining in spending.
* No one wanted to take on the medical profession, so doctors remained outside the system, operating their private practices on a fee-for-service basis.
* Major chunks of the health-care system – mental health and chronic care – were overlooked, leaving patients without access to a full range of services.
* No clear lines of accountability were set. Governments and regional health boards blamed each other whenever an unpopular decision was made. Patients couldn’t figure out who was in charge. Taxpayers didn’t know where their money was going.

“All too often, it (regionalization) has been a structure without a mission,” Fyke concluded.

Lewis offered an even harsher indictment. He thinks the provinces blew a historic opportunity.

They had a chance to transform Canada’s fragmented illness treatment system into an intelligently designed network of health services. Instead, they created another level of administration to shore up the old system.

“It’s certainly not the ambitious model we hoped it would be.”

Most policy-makers knew, when they embarked on regionalization, that more high-tech equipment, more drugs and more doctors wouldn’t make people healthier. But they took the path of least resistance, Lewis said.

It wasn’t entirely a case of political cowardice. Just as regionalization got rolling, the economy stumbled. “In a sense, it was born under a bad sign.”

With limited resources, governments focused on hot-button issues: doctor shortages, surgical wait times, emergency-room backups. They mandated regional health boards to do likewise.

For the next 15 years, those priorities prevailed. Ontario, which decentralized its health-care system in the friendlier economic climate of 2006, could have carved out a bolder path but didn’t.

No one at the 1 1/2-day meeting wanted to turn back the clock. But none of the participants could say with assurance that regionalization has improved health, enhanced teamwork or strengthened medicare.

The good news is that the people in the system have a vision of patient-centred health care.

The bad news is that their political bosses either don’t share it or don’t have the courage to follow their convictions.

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