Shifting Our Thinking
Interest groups and media have done a good job of letting Canadians know the health care system is in trouble but productive solutions and improvements have not emerged as quickly or easily. Everyone wants a system that is affordable, efficient and effective, so why can’t we seem to make the necessary changes to improve our health care system?
In the course of our work within Canada’s health care industry, we have come to believe that one of the biggest barriers to change is people’s inability to imagine what a different kind of public health care system might look like. We decided the launch our White Paper series by presenting a few ideas that we think may stimulate a different level of thinking toward what could help make health care in Canada more affordable, efficient and effective. There are some small suggestions and a few big ideas; hopefully, they will spark your imagination, provide a bit of a food for discussion and offer some hope for health care.
Stratavera believes that a publicly funded health care system which is affordable and meets the needs of Canadians will likely look quite different from the existing system. As Canadians, we are very proud of our health care system and have a fierce belief in the five national health system principles: public administration, comprehensiveness, universality, portability, and accessibility. In order to be successful, any change to the health care system must align with the principles that Canadians hold dear.
This series is not intended to suggest that the Stratavera thinking is the only or even the best approach to addressing Canada’s health care problems. We do believe however that an informed and engaged public is essential to creating the kind of collective action that will be necessary to support long term change and sustainability in our public health care system. It is our sincere hope that by sharing our ideas, people will begin to take part in a national conversation and define their own role in creating hope for health care.
Canada’s Current Health Care System
Canada’s current health care system was introduced in the late 1960’s. Health care in the 1960’s was structured so that people accessed the system through physicians and hospitals. The system was well designed to treat acute conditions and emergencies. The structure worked well for Canada’s population at the time. In the 1960’s Canada’s population was relatively small at around 18.5 million and quite young, with 70 percent of the population under 40.1 In the last fifty years, Canada’s population has almost doubled to around 34 million and demographics have shifted so more than 50 percent of our population is now over 40. Canada’s population size, demographics, and disease patterns have changed considerably in the past fifty years. In 1960, Canada’s total expenditures on health care as a percentage of GDP were just over 5 percent. Health care spending in 2009 was $183 billion representing almost 12 percent of total GDP. 2
The way Canadians live, work and communicate has changed dramatically in the past 50 years. The manner in which we detect, diagnose, and treat disease has also changed dramatically but the structural elements of health care, as a system, are largely the same as they were in the 1960’s. The path to detection, diagnosis and treatment still starts with a visit to your Doctor’s office. The health care structure built around physician’s offices, hospitals, and long term care institutions has grown bigger but its fundamentals are unchanged.
The health care structure that worked well in the 1960’s is too inflexible and too expensive for the needs of Canadians in the 21st Century.
Shifting Thinking: The Stratavera Approach
In the context of stimulating some new thinking, the next few pages will take three recent headlines and present several strategies directed at dealing with them in some new ways.
MD’S Warn Of ‘Catastrophic’ER Failure In Alberta 3
Canadians are concerned about wait times. Whether it is waiting for treatment in an Emergency Room, waiting for a specialist appointment, or waiting for surgery.
In response to the question of how to address Emergency Room (ER) wait times a commonly heard solution is that we need more hospitals and more hospital beds. This solution is far too simplistic. A significant percentage of the inpatient hospital beds are currently occupied by elderly patients and those with chronic diseases who would be more appropriately and less expensively cared with a different level of care outside of the acute care hospital setting.
Often these frail, elderly patients are kept in the hospital until they are just able to be sent home. The pressure to discharge these patients to make room for the next group of similar patients is intense, and too often they end up back in the ER within a few days or weeks.
Many of these patients could be seen by practitioners in the community rather than coming back to the ER for care but unless they have a family doctor, the ER is thought to be the only place to go for care. Several strategies are currently being undertaken to try to address the ER crisis. We offer some additional thoughts intended to inform a broader discussion about ER solutions.
- We need to do a much better job of informing the public about where to go to receive the appropriate level of care away from the hospital ER’s. Many good changes and systems have been put in place to reduce the strain on ER’s including Urgent Care Centers and Primary Care Networks of physicians, however, not enough people know about or understand how to best use these services.
- As the baby boomers age, the number of frail elderly patients will increase and we need to find better ways of keeping them out of hospitals when they don’t require the level of care typically associated with an acute care hospital bed.
- We could utilize emerging technologies to monitor the frail and elderly and to help increase medication compliance. Many patients in ER’s are dealing with issues related to their medications.
- Build into the system a new kind of bed that offers a different level of care. Focus on the population of chronically ill patients and elderly who are too sick or frail to be at home or in extended care. This group does not usually require the level of care provided in a fully resourced hospital bed but do require more help than they can get at home or in most extended care settings. Building this mid-level care into the system would be a more cost effective way of increasing access. In some cases we may not actually need to build new facilities as some existing ones could be repurposed for these patients.
- If we were using all of the other urgent care access points, we could set a goal of using the hospital ER’s for ambulance emergencies only.
- We need to continue and perhaps grow the focus on systemic issues that drive ER visits (e.g. poverty, mental illness, addiction). In Calgary, several years ago, a study of a segment of the homeless population indicated that at least one chronic addict cost the health care system close to $1 million dollars per year for their repeated ambulance trips and visits to the hospital.4
Fewer Canadians Have Family Doctors, Stats Can Finds 5
The number of Canadians without family doctors has been steadily increasing. This trend will continue as fewer new physicians are choosing to practice family medicine and more baby boomer doctors retire or scale back their practices. Despite recent increases in the number of physicians in Canada, many Canadians are still without a family doctor because new physicians are not choosing family medicine as their specialty. In 2004, fewer than 25 percent of medical school graduates chose family medicine and in five years that number has risen to 32 percent. However, estimates are that as many as 40 percent of new physicians need to choose the specialty in order to ensure the number of family doctors required on an ongoing basis.6 Currently, Canada’s health care system is structured so that a family physician is the first point of contact between individuals and the larger health care system (specialists, surgeons, etc.). When there are not enough family physicians access to care is limited, as well, continuity and quality of care may be compromised.
The following are some changes, actions or strategies that might change the way we view this problem and promote discussion:
- We need our physicians to be working with the patients who have complex health issues, but trying to see a complex patient in only a few minutes appointment does not serve either the patient or the physician very well. In order to change this we will need to think about changing the way physicians are paid. We need a fresh approach to make sure physicians are paid to do the work they are trained for and enjoy doing, not for trying to see a patient every few minutes in order to earn a living.
- Utilizing the highly trained and specialized skills of a physician for routine procedures is not a good use of a scarce resource. The system must use the services of our most highly trained health care professionals judiciously. What would it look like for your family to have a “family nurse” for routine health care rather than a family doctor?
- The current system is built around the idea of showing up in person to a doctor’s office. The new system needs to modernize the way we pay physicians for all the work they do whether they are communicating with their patients in person, on the phone, using email or by home video link.
- We need to increase the number of health care professionals who can act as gateways into the larger health system. If some families have a family nurse and not a family doctor, others may have a health care team. These teams can include; pharmacists, physiotherapists, registered massage therapists, chiropractors, certified personal trainers, registered nutritionists, acupuncturists and many others who can look after the needs of Canadian families. Some of these individuals should be allowed to make direct referrals, for specific conditions, to specialist physicians.
- Health care needs to become a more appealing career choice and Canada’s health care professionals should be happy to go to work. They should feel useful, appreciated, positive and productive and be prepared to work their entire career in health care. We have large numbers of nursing graduates, in some places as many as 30%, leaving their profession before they are 30 years of age. 7 Dealing with this issue will require new thinking about improved working conditions and better leadership skills in health care.
- There are many emerging technologies, particularly in the area of remote patient monitoring that can have a positive impact on early intervention and medication management, we need to continue to develop plans to use them on a larger scale.
- We could grow the focus on approaches that support patients to move easily between practitioners and services. Patient navigators and case managers are examples of roles that can help patients with complex care needs stay on track.
- Let’s increase our use of portable and flexible Electronic Health Records (EHR/EMR) systems and take them out into the community.
Canadian Cardiovascular Congress Sounds Alarm On Childhood Obesity 8
For the first time in 100 years, it is possible that today’s children might not live as long as their parents. A less active lifestyle and a daily diet too high in sugar, fat, and sodium has led to a population where more than 60 percent of Canadians are overweight or obese. 9 The health effects linked to being overweight are significant and include diabetes, heart disease, and cancer.
This trend must be reversed. A comprehensive strategy to improve the health of overweight Canadians will need to engage the entire community and could include the following practices.
- Approach the current weight epidemic a bit like we approached reducing the number of smokers. Half of Canadians used to smoke, now fewer than 20 percent of Canadians smoke. 10 A combination of information, support programs, drug treatment, taxes and legislated changes to marketing and packaging have been tremendously effective in reducing the incidences of smoking.
- Create community based practices of care – we need nurses, nutritionists and other key professionals working in community centers, schools and homes.
- Repurpose underutilized public buildings, including schools into community health centers and provide health and nutrition care expertise that everyone in that community could visit on a regular basis.
- Offer trainers and/or fitness classes focused on high risk populations and offer everyone financial and tax incentives to stay healthy.
- Significantly increase taxes on high sugar, high fat food with limited nutritional value. This could mean promoting or penalizing the manufacturing and/or consumption of food choices.
In this Hope for Health Care brief we presented just a few ideas to address some of the more alarming headline issues facing our health care system. These ideas have been presented in a very condensed manner and in the next few months our White Papers will provide more detail about the choices we have mentioned in this paper.
For those who still think we can make our current system work, if only we try harder, the next two White Papers will explore two specific problems: rapidly increasing health care spending and the shortage of health human resources. The ideas contained in the subsequent solution oriented papers will make more sense within the context of these two problems. The balance of our White Papers will provide a much more complete and detailed overview of the Stratavera Approach. The remaining papers in the series will explore many different ideas including: Technology Enabled Care, Moving Health Care and Wellness into the Community, Nursing Led Community Care, Personal Accountability for Wellness, and End of Life Care.
We hope this brief introduction to the Stratavera Approach has sparked some fresh thinking and helped you develop your own hope for health care.
5 Things Every Canadian Can Do To Improve Our Health Care System
- Become aware of the alternatives to the emergency room, find out where there are Urgent Care Centers or where there may be networks of Primary Care Physicians able to deal with your health care emergencies outside of the ER.
- Talk with your family about shifting from thinking about using your family doctor as the key access point for health care to having a family nurse or a team. Is this something you can get comfortable with?
- Look at who you have on your family’s health care team. Do have all the right people to ensure you are living and eating healthy?
- Look around your community for underutilized publicly owned facilities that might be put to good use as part of a community based health care service.
- Let your Alderman/Councilor, MLA and MP know that you are ready for some fresh thinking about Canada’s public Health Care System.
- Population Information Retrieved September 23, 2010 http://www40.statcan.gc.ca/…
- Organization for Economic Development, Health Care Reform Controlling Spending and Increasing Efficiency, 1995. Retrieved November 17, 2010 http://www.oecd.org/dataoecd/… and Canadian Institute for Health Information, Retrieved November 17, 2010 http://secure.cihi.ca/…
- Calgary Herald, 2010. MD’s warn of catastrophic ER failure in Alberta, Retrieved November 3, 2010 http://www.calgaryherald.com/health/…
- Calgary Homeless Foundation, 2008, Retrieved November 17, 2010 http://www.calgaryhomeless.com/…
- CTV, 2009. Fewer Canadians Have Doctors, Stats Can Finds, CTV, Retrieved November 3, 2010 http://www.ctv.ca/CTVNews/…
- Tobin, A., The Canadian Press, November 26, 2009 Retrieved December 7, 2010 from http://www.citytv.com/toronto/…
- CBC News, August, 2008. Retrieved November 17, 2010 http://www.cbc.ca/canada/calgary/…
- Calgary Herald, October, 2010. Canadian cardiovascular congress sounds alarm on childhood obesity, Retrieved November 3, 2010 http://www.calgaryherald.com/health/…
- Tjepkema, M. Measured Obesity: Adult obesity in Canada: Measured height and weight(2008) http://www.statcan.gc.ca/…
- Physicians for a smoke free Canada, August 2009. Retrieved November 17, 2010 http://www.smokefree.ca/…
White Paper One - Shifting Our Thinking