In my previous essay for Healthy Debate, I compared the health-care systems of four different countries, based on personal experience. I concluded that France had the superior system due to its lean nature, comprehensive coverage and highly responsive speed.
My observations have led me to believe that while our system is superior to the U.K, and the U.S., it is currently struggling and increased privatization is entering Ontario quickly, shifting the rules around. In this essay, I want to offer some recommendations for how our system can meet its challenges. In doing so, I’m drawing on those international experiences, and my time serving on the Quinte Health Board of Directors. I must emphasize that these are my personal views and do not represent those of any institution, group or organization.
Fundamentally, our biggest health-care issues boil down to a shortage of people. Doctors, nurses, technicians, etc., are all in short supply. With more money flowing into health care and more university spots opening up for future nurses and doctors, help is on the way, but it will take years to fill the vacancies. So, it’s time to face the music and adapt to how we use the resources we have.
But should we be cracking the whip and get our clinicians to work harder and longer hours? Absolutely not! The stresses of the overloads, and perhaps some despair, are burning out many care professionals. So too is frustration at the current environment.
The conclusion I and others draw is that the administrative burdens the system subjects our care staff to must be relieved to allow for more clinical time.
Let’s start with our family physicians. The administrative demands placed on them are immense. I’ve heard varying estimates but imagine doing one hour of paperwork for every hour of patient time! That is a challenge that must be aggressively and immediately tackled. Doctors should have the tools and infrastructure to chart as they see patients. Everything from prescriptions to billing should be complete by the time the patient leaves the examination room. I see no logical reason why this could not be done.
Likewise, our hospitals spend significant dollars on measuring and reporting. Many of these indicator measurements are important, such as wait times for services or tracking infection rates. However, many others seemed to be created with little to no impact on care, either due to their lack of utility or the unwillingness to invest to resolve any issues. Measurements consume resources. This practice needs a wholesale revisit.
Hospital funding, too, needs to be simplified or fixed. Time and time again I saw the senior hospital leadership and board tied up on hospital funding issues and their consequences. Time spent on those problems came at the expense of, for example, deeper dives into future capacity planning or exploring clinical pathways for treatment.
We must overcome the mindset embedded in the system that once a hospital is put in place and funded, it is on its own. Good ideas that may require some funding until they can be proven or until they are paid back rarely get off the ground. Fewer still get past the trial stage regardless of the results. For example, the New Humber River Hospital opened in Toronto in 2015. That hospital was built with a tremendous amount of automation that addressed both efficiency and quality of care. Have these systems been widely deployed anywhere else? Not to my knowledge.
So, isn’t privatization the answer here? Businesses running a system will always do better, won’t they? There is some privatization of care already, for example blood testing labs, imaging clinics, specialized clinics for eyes, and some surgeries, etc. Even most physicians, by law, must set up their own corporations and then bill OHIP for their services. The private sector does have some advantages. Businesses could bring a tighter focus on costs and can generally be more fleet of foot in providing services and adapting when the environment changes. They also may not be constrained by collective labour agreements that are in place in the public sector.
Why is the ministry now willing to pay for the backlog if it’s performed outside the public system?
But let’s be clear – a business’s number one raison d’etre is to make a profit. In our capitalist system, that drive for profit will always come before any other consideration. Service standards and quality are costs that will be managed in that context. And let’s not overlook a fundamental difference between publicly offered services and those provided by a private (business) clinic. That difference is profit.
Hospitals strive to keep costs down to meet budget constraints. In Ontario, a reimbursement schedule for various procedures has been in place for years (Quality Based Procedures). If the hospital spends too much on knee replacements, for example, it must recover the money elsewhere or run a deficit. (Deficits attract a lot of attention and are career limiting, to say the least!) If the hospital can do it for less, the difference goes toward its funding, ultimately reducing the burden on the taxpayer.
Private clinics will be different. For the immediate future, the clinic will be reimbursed at the same rate as a hospital. However, for business owners, the difference between the OHIP fee schedule and the actual cost is retained as a profit. Who has funded that profit? We have, through our taxes.
In either public or private, the procedures will be the same. Both will use a surgeon, nurses, recovery room staff, anesthetist, cleaners, schedulers, etc. So, the costs should be similar. What’s left, though, is the effect of volumes on productivity. Steer all your knee replacements to one provider and the high-volume one will continuously improve and get more efficient. Hospitals use that efficiency to avoid budget deficits. Business owners, on the other hand, pocket those efficiencies as profits.
Lastly – and I’m going to take heat for this one – I have yet to see the strong leadership needed to set the strategy in place to make our system more sustainable. The news is full of advocacy organizations calling on all levels of government to fix our system. How can anyone realistically expect bureaucrats across 10 provinces, two territories and the feds to collaborate on any kind of timeline let alone the one we need right now? Madness!
So, where might this leadership exist. I would look to where there is the greatest number of clinicians. OMA, CMA, large hospital networks are you listening? Solving our health-care problems needs system-wide, visionary clinical leadership.
I will be candid. This essay has been difficult to write. In Ontario, health care is a rapidly moving target. As family physicians are leaving their practices, de-rostered friends and family are reporting that virtual walk-in clinics are popping up and are expensive. One of our daughters is now paying $60/month for primary health care for her and her family. Another friend reports paying $50/visit. Need something checked out with a blood test … $50. Prescriptions needing renewed . . . another $50. And then there’s Bill 60 going through at Queen’s Park that is a profound change to the way health care is delivered and the way it is overseen. One thrust is it greases the rails for more private clinics to do surgical and diagnostic procedures. This “private” portion of care will be overseen by a new function at arm’s length from the Ministry of Health. (The legislation is quite difficult to read but there are many analyses on the web, mostly from law firms, that make it much more understandable). The aim is to have specialized clinics tackle the backlog of hip replacements and cataracts, etc. Will they? I don’t know. These procedures have been volume-restricted by the Ministry of Health. Why is the ministry now willing to pay for the backlog if it’s performed outside the public system?
In closing, I must reflect on the full picture. In my family of four, three of us, including me, would not be alive today if it hadn’t been for our health-care system. It’s been there when we needed it and it did the job. Results have been similar for friends and colleagues who have faced life-threatening conditions. It’s urgent that we need to make sure that it stays that way for ALL.