Our Health Care Delusion

On Jan. 26, Maclean's is hosting "Health Care in Canada: Time to Rebuild Medicare," a town hall discussion at the Sir James Dunn Theatre, Dalhousie University, Halifax. The event, in conjunction with the Canadian Medical Association, will be broadcast live by CPAC. The conversation on health reform continues in the coming months in the magazine and at town halls in Toronto, Edmonton, Vancouver and Ottawa.

A distraught 41-year-old man from West Kelowna, B.C., arrived at the emergency department of Kelowna General Hospital on the night of Dec. 28. "He was broken mentally," his wife later told the local Daily Courier. "He wanted help." By her account, he waited 90 minutes without seeing a doctor, minor by today's emergency room standards. Kelowna RCMP put the wait at just 45 minutes. Regardless, he snapped, warning staff that he'd drive his truck into the hospital if he didn't get treatment. When threats didn't get results, he stormed out and returned at the wheel of his Chevy Blazer. As promised, he smashed through the ER's double doors, narrowly missing two elderly people (one assumes they were elderly before their wait in emergency) and came to a halt in a hospital hallway.

Police arrived to find him waiting co-operatively in his truck. The bed he was assigned that night was in the RCMP detachment cell; he faces several charges including dangerous operation of a motor vehicle. While his strategy was extreme, his cry for attention resonates with many who've had the misfortune to trade germs and waste time in one of Canada's overstressed emergency wards.

It's a Canadian conceit that ours is one of the best public health care systems in the world, a defining characteristic of nationhood; something that separates us from the Americans. In a poll by Angus Reid Public Opinion in June, 69 per cent of Canadians said they're proud of the health care system, edging out the state of Canadian democracy, multiculturalism and bilingualism.

Yet the reality, based on any number of international comparisons, shows that pride in a supposedly world-beating standard of care is often misplaced, an "illusion," as Liberal MP and medical doctor Keith Martin puts it. The sorry state of the nation's emergency wards is just one indicator of trouble today and trouble to come. ERs are just "the canary in the coal mine," says Dr. John Ross, Nova Scotia's adviser on emergency care.

Martin, a former family and emergency room doctor and an MP from Vancouver Island, has been saying as much since he entered federal politics 17 years ago as a Reform party member. He practised medicine part-time until about three years ago, experiencing the same things that first spurred him into politics: the indignity of examining patients on gurneys in hospital hallways; people enduring such agonizing waits for hip or knee replacements that they suffered heart attacks; tumours that grew to inoperable sizes as people waited months for diagnostic scans. "Those," he says, "are the casualties of our health care system, and the casualties of the inaction of modernizing the system, that people don't talk about."

Emergency wards are all too often the first point of contact with the health care system, a problem exacerbated by the fact that five million Canadians don't have a family physician, and because acute-care beds are often stuffed with elderly patients who would be better served in long-term care facilities. Often the waits are excruciating. For a man in the throes of a mental breakdown, driving to, and through, the ER of Kelowna General should have been the last, worst option. "He was at the end of his rope," his wife said. "You can't see a psychiatrist. It takes a while to get an appointment. That's why people go to the hospital."

And what they often find in maxed-out ERs is a chaotic environment and waits, of six, eight hours and more. The consequences can be deadly. In Edmonton's Royal Alexandra Hospital this September, Shayne Hay reported to the hospital's emergency ward, telling staff he was suicidal. He was placed in a room on an emergency stretcher and checked periodically, though repeated requests to see a counsellor went unanswered, his family says. Some 12 hours later he was found dead, hanging from a strap of his backpack. In Montreal, long waits in the ER at Maisonneuve-Rosemont hospital were blamed by families for contributing to the deaths of two people last year. Mariette Fournier, 86, spent four days on a stretcher in the hallway waiting for a bed in the geriatric department. She contracted pneumonia, developed a blood clot, and died on Feb. 23, a day after finally getting a bed. That same month, 75-year-old Mieczyslaw Figiel died beside the triage nursing station, with his daughter banging on the station's window as he gasped for breath. The ER was at 180 per cent capacity.

The problems in ERs across the country are symptomatic of a wider malaise. Numerous international comparisons suggest our iconic universal health system is not the world leader of the national imagination. "Canadians are selling themselves short," says a report card produced last June by the Wait Time Alliance, comprised of 14 national medical associations. "Unfortunately, Canada is one of the few developed countries with universal health care systems where patients face long waits for necessary care," says the report, aptly titled "No Time for Complacency."

More and more voices are calling for health care to be put on the agenda. Former Tory prime minister Brian Mulroney and former Liberal senator Michael Kirby alluded recently to the challenge of a badly needed "national adult conversation" on health reform. "Unfortunately, intelligent debate about what should be done has basically ground to a halt by incendiary claims that any attempt to update the system amounts to treason - a repudiation of sacred Canadian values." The Canadian Medical Association (CMA), representing 74,000 doctors, has undertaken a massive review and public consultation, including a series of televised town hall meetings across Canada. The first, in conjunction with Maclean's and CPAC, is set for Halifax on Jan. 26. "I think it's time for all Canadians to get involved in this discussion," says CMA president Dr. Jeff Turnbull, who sees many of the fault lines - maxed-out emergency wards, cancelled surgeries, strained budgets, frustrated patients and stressed staff - at the Ottawa Hospital where he is chief of staff.

The evidence of a looming crisis comes not from comparing Canadian to American health care - a unique and expensive beast - but by taking a world view, as assessed by the Paris-based Organisation for Economic Co-operation and Development (OECD), the U.S.-based Commonwealth Fund, the Health Council of Canada and other groups. "We believe our own rhetoric around 'we're the best in the world.' What these [international] surveys and our own work are telling us is: no," says John Abbott, CEO of the Health Council, an independent national agency mandated to monitor and encourage health reform. "If you look at cost, we're maybe in the middle of the pack. If you're looking at overall quality indicators, quality of life, longevity, on these factors we can learn from others. When you look at how we can access the system in a reasonable and timely way, we rate quite low," he says.

Neither Canada nor the U.S. come close to being the gold standard for health care. Canada placed second last in a comparison last June of seven countries by the Commonwealth Fund, a U.S. charity that promotes health policy reform. The U.S. ranked last, scoring dismally on access, efficiency, equity and quality care, despite per-capita health spending of US$7,290. That's vastly more than the spending in top-ranked countries: the Netherlands, the U.K. and Australia. (Germany ranked fourth, New Zealand fifth.) Canada, sixth in results, was the second most expensive at US$3,895 per capita.

Canadians scored well on leading "long, healthy productive lives," but it was mid-pack or worse on every other measure. The report, based on national statistics, and patient and doctor surveys, shows Canada scored poorly on chronic care and use of electronic records. Canadian patients reported the second highest rate of perceived medical errors. Canada was dead last on two key measures: quality care, defined as "effective, safe, coordinated and patient-centred," and timeliness of care. While cost prohibits millions of uninsured Americans from accessing needed health care, wait times, not finances, are the impediment in the U.K. and Canada, the report says. "There is a frequent misperception that such trade-offs are inevitable; but patients in the Netherlands and Germany have quick access to specialty services and face little out-of-pocket costs," the report notes. Poor access to primary care contributes to Canada's overuse of emergency wards, it adds: "Of sicker respondents, those in Canada and the U.S. were most likely to visit the emergency department for a condition that could have been treated by a regular doctor had one been available." Canadians and Americans use the ER at rates three to four times that of Germany and the Netherlands.

Canada scored no better in a Commonwealth study in November of 11 wealthy countries, released with the Canadian Health Council. The lack of a publicly funded drug program, unlike most countries surveyed, raised affordability issues. One in 10 Canadians reported not filling a prescription or skipping a dose because of cost. The study also focused on Canadians' overreliance on emergency departments. Canadians have the greatest difficulty accessing care on weekends and holidays. "As a result, Canadians are the biggest users of emergency departments, compared with the other 10 countries," the report said.

Canadian wait times - "widely regarded as the Achilles heel of the system" - are just one of many concerns raised in recent OECD studies. Making patients wait is really a means of rationing health care - a blunt, ineffective way of dealing with a looming health-driven fiscal crisis faced by Canada and other countries, say OECD economists. "In the absence of adaptations," an analysis said in September, "costs are expected to mount relentlessly in coming decades because of population aging, technological progress and relative price developments, putting a potentially unsustainable burden on public budgets."

Canada has the sixth highest rate of health expenditures as a share of the economy among 32 OECD countries. Nor is health care as "free" as some Canadians think. When public spending is combined with the 30 per cent spent privately on health (for such things as drugs, vision care, dental, long-term and home care), Canadians personally, and as taxpayers, face the fifth highest per-capita costs among the 32. For all that, Canada has fewer doctors, fewer hospital beds and fewer high-tech diagnostics (CT scanners and MRI units) than the OECD average. Canadian life expectancy, at 80.7 years, is more than a year higher than the OECD average, but the Japanese, Swiss, Italians and Australians outlive us. Our infant mortality rate, while better than the U.S., is slightly worse than the OECD average. All told, as a foundation for Canadian values, it needs work.

Bumping against the Canadian health care system can be a bruising experience for patients. Last year, the Regina-based Frontier Centre, a conservative think tank, joined forces with the Belgium-based Health Consumer Powerhouse for its third annual comparison of the "consumer friendliness" of Canadian health care against that in 33 European countries. The survey tracks cost, medical outcomes, wait times, access to new technologies and drugs, among other measures. Canada ranked 25th among the 34 countries, just ahead of Slovakia, just behind Portugal.

"Canadians are paying for a world-class health care system but for a variety of reasons they are not getting one," the Frontier report said. Waits for such diagnostic tests as MRIs can last months; "in comparison the typical wait time in top European countries is less than a week." Drug costs are higher in Canada than subsidized plans in most European countries, and approval times for new drugs lag considerably. It takes an average 314 days for approved medicines to be entered into provincial subsidy programs, an improvement from a more than 500-day wait of six years earlier, but still far behind the standard of 150 days or less in Ireland and Germany.

The Frontier Centre, a champion of free markets, puts most of the credit for the success of the Netherlands and Germany, which finished second, on their competing system of private health insurers. (In Germany, competing insurers offer a standard benefit package, and higher-income earners can opt out of the mandatory plan to purchase private coverage. The Netherlands requires the purchase of a mandatory comprehensive health insurance package provided by a mix of nonprofit and for-profit insurers.) Still, it notes Canadian universal medicare produces impressive survival rates for heart attacks and various cancers. "In Canada you may wait a very long time to see your doctor, but once you do," it notes, "[the] quality of care you receive will generally be quite good."

The coming years present both challenge and opportunity for Canadian health care. The next opportunity for profound change comes in 2014 with the expiration of a 10-year health accord among the federal government, provinces and territories. That deal, which then-prime minister Paul Martin optimistically said would fix health care for a generation, provided $41 billion in additional federal funding, and contained a commitment that provinces cut wait lists and account better for spending. But a health care system that cost $192 billion last year has only slightly shifted course, though there are improvements in wait times in areas like cataract and bypass surgery, and cancer treatment.

If politicians, especially the federal Conservative government, seem reluctant to engage, it's perhaps understandable. U.S. President Barack Obama's health care reform bill was passed last year at enormous political cost, and with a bruising national debate that refuses to die. British Prime Minister David Cameron is drawing fire for announcing this week plans to add greater private sector involvement in the National Health Service, one of the world's best performing systems. Prime Minister Stephen Harper has cautiously avoided revealing details of federal plans for a renewed accord. In his previous role as vice-president of the National Citizens Coalition, he was no fan of the blueprint for Canada's public health care system, declaring in 1997: "It's past time the feds scrapped the Canada Health Act."

The CMA's consultation, including a dedicated website already filling with thousands of comments, is an attempt to engage the public - their patients - in writing a prescription; one that will spur governments to update and expand the Canada Health Act. The CMA's Turnbull wants to move beyond doctrinaire positions on private versus public health care delivery. "I think we're going to have a mélange, a mix, as we currently do, but we've got to have something that delivers service to Canadians when we need it. I'm afraid unless we do something we won't be able to do that."

The OECD offered its prescription in September, some of which would violate the existing Canada Health Act. It says Canadians should pay small fees or deductibles for using health services, as most other OECD countries require, to limit overuse of the system. It also wants competition from the private sector and performance benchmarks for doctors and hospitals. Conversely, it recommends expanding medicare as most OECD countries have, to publicly pay an array of health and drug costs beyond doctor and hospital visits, a position also backed by the CMA. While this could add costs, the report notes, "government may need to devise a statutory (or decent minimum) care package determined by the public's willingness to pay the necessary taxes."

Until a consensus on national standards emerges, if such a thing is possible, provinces are charting their own course, sometimes with rocky results. In Alberta, MLA and emergency doctor Raj Sherman was suspended in November from the government caucus for criticizing the Conservative health policy, and the backlogged state of emergency wards. As the controversy flared, Stephen Duckett was fired as CEO from Alberta Health Services, the super-board of 90,000 health care workers the government instituted two years ago in hopes of getting a grip on spiralling costs and poor outcomes.

Duckett delivered a defiant farewell speech last month, but one tinged with regret. ER wait times have only grown worse, he said. At the start of the last decade 60 per cent of patients were admitted within eight hours. Now that happens just 25 per cent of the time. "Neither level [is] acceptable, of course." He warned of "a chronic disease tsunami" that requires fresh thinking. Care needs to happen first outside of hospitals, at home, or via telephone consults, and in community settings. "This requires a transformation of the Alberta mindset, which still seems to be to equate health care progress with more acute beds."

Nova Scotia is also attempting reform, spurred by the state of its emergency departments. Ross, a veteran emergency care physician, issued a series of recommendations in October to correct a litany of problems uncovered in a year-long investigation. Patients, waiting up to six weeks for appointments with family doctors, end up in emergency. So, too, do chronic care patients, those with mental health issues, and far too many with minor complaints. Emergency wards are clogged with everything but emergencies. Almost 90 per cent of ER visits can be better handled at less cost in clinics, Ross found. Just 1.1 per cent of ER cases are severe, and 0.1 per cent threaten life or limb, he found. The problem feeds on itself, consuming hospital budgets and resources. As a result, cash-strapped hospitals closed ERs across the province for the equivalent of 795 days last year.

By year end, Health Minister Maureen MacDonald accepted all 26 of Ross's recommendations, setting standards for emergency care, and diverting patients to more appropriate services. There is a need to flip priorities and put the patient first, Ross concluded. "We have allowed the system to see the patient more as a burden than its very reason for being. To some, patients are 'cost drivers' and to others they border on being nuisances who get in the way of a smoothly functioning bureaucracy."

A recommitment to patient-centred care, as obvious as that sounds, is also the goal of the CMA. One of Turnbull's roles as chief of staff at Ottawa Hospital is fielding public complaints. They are easy enough to come by in a hospital that has not run below 100 per cent capacity for about a year; where this day there are 38 admitted patients with no beds; where the daily morning discussion is not if surgeries will be cancelled today, but how many.

It's long past the time for that national adult conversation, not just about the health of a system but about the needs of the people. History shows a national consensus can be achieved, though it was a torturous journey. After years of acrimonious debate, and incalculable human cost, the blueprint was finally drafted in 1964 when Justice Emmett Hall tabled his Royal Commission report recommending medicare for all of Canada. Fifty years later, 2014 represents a chance once again to make that vision truly world-class.

Maclean's January 31, 2011