Matters of Life and Death. André Picard
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Canada’s two-tiered health system: The rural–urban split
Running a health system in a country as vast and sparsely populated as Canada poses many challenges, big and small. But some of those seemingly small challenges have vast implications. Take the case of Flower’s Cove, Newfoundland. Located near the tip of the Great Northern Peninsula, the coastal community has a population of about three hundred—and maybe double that number if you include the surrounding areas. Flower’s Cove is home to the Strait of Belle Isle Health Centre, which operates twenty-four hours a day, seven days a week. It offers basic emergency services, everyday family medicine (provided largely by nurse practitioners), an ambulance service (principally for transport to larger health-care facilities), home-care nurses, dental care and medical diagnostic services, including some laboratory testing and X-rays.
On August 31, 2009, the provincial government decided to cut back the operating time of the clinic to twelve hours a day and shut down the lab. A great hue and cry followed, with protests in the streets. The health minister, Paul Oram, reversed the decision on the clinic hours so emergency services would again be available around the clock. Then he resigned, saying the non-stop pressure and scrutiny of even the most mundane decisions was taking a toll on his personal health. “There’s no end to the stress and strain,” Oram said in his words of farewell.
Flower’s Cove is, in many ways, representative of the major challenge in our medicare system: Where do we draw the lines? And who draws them? Canadians have developed an incredible sense of medicare entitlement: we want all care for all people, instantly and free of charge—after all, we pay high taxes! While this may be possible—at least theoretically—in densely populated, infrastructure-rich urban centres, distance poses a major challenge in health-care delivery in huge swaths of the country. Canada’s land mass is about 95 percent rural/remote, but less than 30 percent of its population lives in rural/remote areas.
In reality, we have a two-tiered health system, but it’s not a private–public split, it’s an urban–rural split. The health outcomes of those who live in remote settings are poor compared with urban and suburban dwellers: life expectancy is lower, child mortality is higher, injury rates are astronomical and there is far more obesity and chronic illness such as heart disease. Much of this can be explained by the fact that residents of rural communities are poorer and older (with the exception of indigenous communities, which have their own particular health challenges).
The reality, too, is these challenges predate the creation of medicare half a century ago, when the folkloric country doctor trudged miles on foot in a snowstorm to save a patient’s life. If anything, the factors that impede the availability of, and access to, good-quality care for rural residents have been exacerbated by technological advances and social change.
The question is, how do you improve the situation? Do you build a twenty-four-hour-a-day health clinic in every community, even those with a few hundred residents? A hospital in slightly larger centres? If so, how do you staff them? Modern medicine is heavily dependent on diagnostic testing. Do you build a lab in every outport? If so, how do you ensure quality and cost-efficiency? What about surgery? Should that be done in small hospitals or only in larger institutions? After all, we know that outcomes are far better in high-volume centres.
We have this jingoistic love for hospitals and health clinics—communities that don’t have one or two feel inadequate and neglected. But are patients not better served by having high-quality diagnostic tests done at a central lab and getting the results by e-mail or FedEx than being dependent on a rinky-dink facility? Should scarce health-care dollars not be invested wisely in improving transportation and family support so patients can be treated in well-equipped regional centres with a minimum of disruption instead of dotting the landscape with clinics that overreach their abilities? More important still, can we not have these discussions without their being subsumed by political rhetoric? Can we not make rational, good-for-the-system decisions without them being substituted by politically expedient ones?
The tragedy of Flower’s Cove is not whether the clinic lost a lab or some operating hours. In the grand scheme of things that doesn’t really matter. What matters is that ten thousand Flower’s Coves exist across Canada. Tough decisions need to be made—and a balance found. But decision-makers can seemingly no longer make decisions. Politicians like Paul Oram have become punching bags for those with vested interests. Health administrators and government bureaucrats whose role should be to ensure the delivery of quality care in a cost-effective manner have been emasculated. Anytime their policies make ripples, they get trashed. (And the media do a lot of aiding and abetting.) Is that any way to run a health system?
Here’s a radical health-care idea: Put the patient first
“Our current health system has been designed around the people who deliver the care. It is time to realign the values of the health system so that the patient is again made the centre of attention.” That is just one of the refreshingly frank comments found in For Patients’ Sake, a report out of Saskatchewan, one that should be mandatory reading for every politician, health administrator and health professional.
Patient-centred care and family-centred care are the buzz terms du jour. But there is a lot more talk than innovative action. Offering up convenient, timely care, making it easy to navigate the system, actually communicating with patients and treating them with respect do not seem like radical ideas, but sadly, they are far from the norm. There are too many self-interested lobby groups and too many silos, and there is always too little time to listen. Health professionals want to deliver high-quality, compassionate care (and despite the barriers, often do). But they are too beholden to systems and constrained by traditional ways of doing things to put patients and their families first.
Saskatchewan, to its credit, decided to move beyond the rhetoric. In November 2008, health minister Don McMorris announced the Patient First Review, under the leadership of long-time health administrator Tony Dagnone. The health system has had many federal and provincial reviews over the years, so the move was greeted with a lot of eye-rolling and yawns. But the strength of the Patient First Review was that it focused on two key questions:
Is the health system putting the patient first?
Is the health system achieving good value in care delivery and system administration?
The other strength was Dagnone himself, a man with a Tommy Douglas–like passion for medicare, coupled with an insider’s knowledge of the system’s strengths and weaknesses. In the half century since the foundations of medicare were forged out of Prairie populism and the pursuit of social justice, Canada has built an excellent universal, state-funded insurance program. (Or, more precisely, fifteen vaguely interlocking programs, but that is a discussion for another time.) But the underlying theme of Dagnone’s report was that, along the way, we lost sight of the people the system was designed to serve: the patients and, by extension, their family members.
What was needed to repair this fundamental flaw, he said, was not more rejigging of bureaucratic structures but a change of culture and a rethinking of priorities. “Patients ask that health-care workers and their respective leadership see beyond their declared interests so that the interest of patients takes precedence at every care interaction, every future contract negotiation and every policy debate,” Dagnone wrote. “Only in this way will we achieve a patient- and family-centred health system for Saskatchewan citizens. Similarly, government leaders and policy-makers must keep the patient front and centre when policies, programs and new models of care are designed and implemented.”
The formulation of that statement is noteworthy. “Patients ask” is used because the commissioner did extensive consultations with patients and families. Dagnone did what is so rarely done in the day-to-day operations of the health system: he asked patients what they wanted and then he actually listened to them. A vast reservoir of untapped patient knowledge exists that we need to explore to improve medicare. What the commissioner heard is that the system performs relatively well. The care is good, but not good enough.
So