The language of health care has had dramatic change – we now commonly use terms like patient centred care, quality outcomes, accountability, and so on in our description of a current or desired state for health care systems and the delivery of care.
One discussion I do not hear frequently enough is a discussion of values in health care. I’m not talking about values of individual patients or values of practitioners or values of funders, but a discussion of the values of the health care system itself. The values that determine how we conduct ourselves as a system, how we make difficult decisions, and how we approach the increasing number of dilemmas our system faces.
Our system doesn’t really have clear values. The Canada Health Act lays out five conditions for federal funding of health care (public administration, comprehensiveness, universality, portability and accessibility), but these aren’t values, they’re legal conditions for the transfer of dollars. They don’t provide us with very much guidance when it comes to making hard decisions about something like appropriate allocation of resources or transfer of care from one environment to another.
I’m also not talking about value for money, nor the need to work within fixed funding envelopes or adhere to budgets; these are not values, they are constraints within which our values must operate. Instead, values help us determine whether we want a hospital-based health care system. Of course we already have a large, expensive, hospital based system and those practices, as much as the hospitals themselves, are solid, difficult to repurpose or change, and have been created at great expense. Clear shared values can help us with the enormously difficult task of changing course, if that’s what we decide needs to happen.
I think we need a thoughtful discussion of values, where we clearly articulate shared values that we can rely on to inform decision making, can assist us to cut through the morass of conflict when encounter difficult of troubling decisions, and can use to backstop our decisions when we have made them.
In an era where the practice of medicine is more complicated than ever and we are having to do more with less (despite ever more expensive tests and treatments), we need values to guide the health care system. This discussion won’t be an easy one. It transcends individual preferences, political demands, provider wants – all of them.
My worry is that if we do not start defining the values of the health care system, that the courts will make the decisions. We have seen the courts intervene in a number of circumstances and those decisions, independent of the reasons for their original filing, and independent of the benefit to the patient, may or may not be helpful or healthy for the health care system.