If you regularly peruse the pages of Healthy Debate, you’re in the bubble; one could call you an ‘insider’. If you’ve heard of the Canadian Institute of Health Information or Health Quality Ontario, or if you scan the news for columns by André Picard, Kelly Grant or Tom Blackwell, then you are an insider. Do you ever tune into White Coat Black Art, did you watch the clip of Dr. Danielle Martin testifying at a US senate committee, or have you read Timothy Caufield’s The Cure for Everything? Insider.
When it comes to reforming health care, most insiders can speak passionately and at length to the inadequacies of our system. We’ll quote the experts, reference reports and all nod in agreement. Most Canadians do not participate in these discussions. The reasons for their lack of involvement and, more symptomatically, their inattention to health care during Canadian elections has been described elsewhere. Chief among those reasons is the belief that our system is the best in the world, particularly when in juxtaposition to US health care.
On their current track, provinces will spend more than 50% of total available revenues on health care by 2028, so how could we not have a system that performs exceptionally well? Unfortunately, it is well known among insiders that high price does not necessarily translate into high quality care, as clearly demonstrated by the recent Commonwealth Fund report showing Canada ranked in the bottom third of all five evaluated dimensions of health system performance (quality, access, efficiency, equity and healthy lives) compared to 10 industrialized countries.
We, the writers and readers of Healthy Debate, should strive to bring these conversations to the people outside the bubble.
Outsiders are numerous and, perhaps surprisingly, often include front-line health care providers. Those who are excellent at providing care and advocating for patients are often too busy to worry about the direction and structure of the system and how these are intrinsically linked to the care they provide. Anecdotally, but objectively, Canadian medical education curriculum pays minimal attention to health policy or reform, and we have no doubt that other clinical training programs are no different. So, if many of those within the system, who are to be the players of any major reform, are neither aware nor interested in the discussions, how can we expect the general public to be?
What can we do? There is an obvious but complicated need to substantially update clinical training curriculum to make the clinical workforce more aware and ensure reform is organic. More straightforward, let us insiders lose the jargon and focus on concisely and clearly defining tangible ground level issues that truly matter to Canadians. We need to reinforce the concept that even though Canadians culturally identify with our universal care, it does not mean our system is beyond reproach. We, collectively as insiders and outsiders, are voters and should be able to express to our leaders our demand for better value for dollar.
How about the fact that Canada spent in excess of $211 billion on health care in 2013 but does not yet have a province that can boast a fully integrated electronic medical record system?
This is but one example from a long list that deserves attention from all Canadians: A universal pharmacare program or even guaranteed catastrophic drug coverage; inclusion of mental health therapy by psychologists and counsellors in provincial medicare programs; better integration across sectors; a committed emphasis on access to primary care; a national health human resource management strategy; quantifiable commitments to tackling the social determinants of health.
Our bubble is teeming with knowledge and opinions on these topics, but the walls are hard to penetrate. It’s preventing these discussions from reaching the average Canadian’s dinner table conversations.
The newly elected Ontario Minister of Health made a few remarks recently to the effect that Ontario has the best health care in the world, even though there is absolutely no evidence demonstrating this, so it’s no surprise that many point fingers at a lack of political leadership in health care reform.
However, democratically elected leaders in Canada are only accountable to us. We want our elected representatives to accept that there are many problems that plague our system and hear the many, sometimes diabolically different, solutions. First, though, we need all Canadians to start interacting with the bubble; we need health care discussion and debate to ebb and flow, floating among policy, research and, public space.
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Coming from a family of 7 living siblings + partners and children and grandchildren I find us constantly discussing, debating healthcare policy, research and practice. And we are “insiders” because we all know somebody, somewhere. Most of us do. Actually we don’t talk about the weather, we talk about healthcare. The scenario is the same with friends, co-workers and the PTA. I think healthcare has displaced the weather. Think about your first interaction in the morning with anyone at work, play or in the running room: “how are you” leads inevitably to a quick reflection on care and its impact on life. Just this week a relative in need of care at home was discovered in recent email traffic and the local CCAC was put in touch stet. By a family member. Patient associations are popular. Dr. Mike Evans is everywhere enabling two-way conversations (did you see the latest Readers Digest). I’m betting that White Coat/Black Art is on many “my favourites” lists and generates continued discussions. Newspapers and other media are full of news and opinions dealing with healthcare. Consumers can and do respond. And their network (our network) into the system is our local hospital, care provider, politician, church, school principal and neighbours. Yes our system has issues and lots of them. So do cities, farms, natural resources, roads, power grids, polluted rivers etc, etc. its a long list. I’m guessing that research will tell you that after “the weather,” healthcare ranks high on our topics of conversation. “Health care is at once the biggest item in the Ontario government’s budget, the issue of most concern to Ontarians, the source of the most intense and emotional public policy debate, and the centre of the most complex delivery system of any set of programs financed by the provincial government”.(http://goo.gl/Kwbzmn)
Claiming the chief reason for inattention to the broader issues of healthcare by Canadians during elections is because, as the “average” citizen tells it, we have the best system of healthcare, is a rationalizing cop out.
In actuality the core of the matter, and what makes the ins and outs appear thick and distant from one another, is the fact the system is predatorily complex and over-rough with abstract notions of health and well being that people have lost sight of what a system of healthcare is supposed to look like, let alone where to begin to sit and examine it.
Heck, I have been a part of the healthcare system in one form or another for most of fifty years. I have a Twitter account dedicated solely to dealing with healthcare info. I follow more blogs than a reasonable bookmarks bar should be required to handle. I have spaces on my shelves for every perspective of healthcare, from its origins to visions of its future to those still on route from Amazon. I have been active in the union, take part in community initiatives, and contribute whenever possible to an evidence based approach and a team facilitated perspective. Basically, and much to the annoyance of some of my friends, I sleep, dream and breathe healthcare. However, making claims that discussions about healthcare need be the topic for open thought over the dinner table is foolishness.
Yes, the suggestion of having such a discussion may make for warm imagery. In reality, however, given the complexity of the system, which after all of my experience I cannot fully visualize, and the breadth and width of evidence that weighs in on any decision, combined with the realization that those decisions can then affect the lives of generations, it is absurd to purpose it is an around the table chat topic.
We can even take it one step further from the author’s own words. Before I do, let us be clear, I won’t claim to know what people should be doing in their own homes. However, when I sit down to the table for dinner, the last item on my agenda (if it is even respectful to say people should have an agenda for a family meal) would be the concerns as they have been raised in the article.
More directly, when I sit down to dinner, and I suspect this would be the case in most families, the least attractive idea for a topic would be to “chat” about how everything we thought was the best basically is not. How as a result of our blindness, we need a complete multifaceted reform to an embedded and astounding piece of social infrastructure. How because of our neglect, the system we think supports us, is in fact way better somewhere else and may be so far gone it is corrupted beyond repair. Yes, I write sarcastically, but not bitterly: nothing inspires people to want to run for a home cooked meal and conversation at the end of a long and task riddled day of work like thinking what they need to talk about is all they didn’t do and all the extra effort they need to put forth.
Does this mean all is lost? Does this mean little work can be done? No. However, it does mean real creative courageous reform and not simply an adjustment of appearances need to take place. It means it is time to change the binary. It is time to burst the bubble.
How do we do it? As repetitive as it may appear it comes down to being accountable and responsible. It comes down to whether we would be courageous enough to up the grade and change the boundaries between the inside and outside.
In brief, healthcare of the individual is based on such a complex system that it makes such theories as those of Intersectionality look like an game of X’s and O’s. Moreover, the historical and growing body of evidence needed to apply to maintain the infrastructure outweighs the capability of any one group to a rightful and ethically grounded claim to be the gatekeepers any longer. In other words, the universality and portability of healthcare is for us all as it is maintained by us all. All of us are accountable.
I propose, as radical as it sounds, that we institute accountability. We need to create a means by which citizens are required in law to uphold participation in their own wellness. Once they are gathered, they would hear evidence and, upon weighing the evidence in an educational and informed setting, contribute to the design and implementation of the health and care of themselves and others.
To conclude, this level of radicalism may seem uncivilized to the average person. However as is commonly argued and historically accurate, what at the onset seems unreasonable to do may be the reason we need to it. Furthermore, I guarantee the topics of some discussions around the dinner table, during election time or not, will never be quite the same.
Interesting that, as a patient who has been successfully managing rheumatoid arthritis for over thirty years I would consider myself an “outsider” even though I interface with our healthcare system in some way almost every month. Patients need to be ‘insiders” if we are ever to improve our outcomes
As a long-time activist for more accessible healthcare services in Ontario, I congratulate you on your honest assessment of one of the main barriers to real improvement in our system: lack of honest and effective communication between “insiders” and the rest of us. Healthcare should be the ultimate leveller — those of you who work in the system are also users of it. You are highly-trained professionals; each one of you is also resident in, and part of, a particular community, one that desperately needs your voice to to be raised to politicians to demand changes to a system choked with bureaucracy, and which appears to be increasingly ineffective and unaccountable. Politicians and healthcare mandarins can ignore protests from the general public as long as they are able to dismiss us as uninformed. You can help so much by sharing your concerns and your ideas with the rest of us. Let’s break down those silos.
I’m just about to begin teaching ProComp to a new class of physician assistant students at McMaster. This is the course that’s about everything other than medicine – understanding the Canada Health Act, issues around consent and social determinants of health. It’s challenging to engage the students in these topics when they’re working so hard on anatomy, physiology and pharmacology. But I agree with the authors that HCP must be engaged on these issues if we expect the public to be engaged too.