No one would argue that Canada’s health system is working well.
Current budgets are unsustainable. Current models of care are out of sync with the way we live – and the care we need – now.
We need more money, but also smarter spending and investments in new models of care.
“If we don’t shift the delivery model, I don’t see us making progress.” – Stephen McNeil, Health Summit panellist
The importance of aligning funding with system change was one of the key takeaways from the first event in the Canadian Medical Association’s (CMA) Health Summit Series: Bold Choices in Health Care – an unfiltered discussion with former British Columbia Premier Christy Clark, former Nova Scotia Premier Stephen McNeil and political columnist Chantal Hébert.
CMA President Dr. Alika Lafontaine hosted the two-hour session, which attracted more than 350 participants and sparked more than 150 questions and comments.
Health Summit Series: Bold Choices in Health Care
The video features four speakers on screen all the time. Clockwise from top left is host and CMA President Dr. Alika Lafontaine, former BC Premier Christy Clark, political commentator Chantal Hébert and former Nova Scotia Premier Stephen McNeil.
Opening shot is a slide that says Health Summit Series: Bold Choices in Health Care with an image of a young physician.
Stephen: If we as Canadians don't have a broader conversation about how we're going to access primary care and how it's going to be delivered to us, there is no amount of money. It doesn't matter if if the economy takes off, there is no amount of money to run the healthcare system. That the way it is currently being run.
Next shot is a slide that lists the names of the host and the three panellists.
Alika: We often talk about funding and linked to funding is often this idea about transparency and accountability towards patients, practitioners, and sometimes towards governments when it comes to the way that money is spent for health care services. Is this the right problem to be solving?
Christy: Yes, it is a problem? Who knows who spends who spends money on health care - is it the Feds or the province? They don't agree amongst themselves. I mean, we just saw not long ago, the federal government saying to the Premiers, you know, hey, yeah, but you guys take all our money, and you just put it into jacking up wages for nurses and doctors, which is exactly what Alberta did, by the way, instead of, you know, putting more money into other areas of the health care system. And then the provinces say to the federal government, no, you guys were supposed to pay for 50% of the system. We're supposed to be executing on it. You just don't give us the money, so don't question how we spend it, because each province has different needs, as Alberta did at that time.
Chantal: I think from a patient's perspective - and I translate patients into voters - the main issue would not be transparency and accountability, but timely access. Nobody really cares who's spending money for what, or who's doing what, if, when you need care, you can actually access it.
Stephen: Transparency is not something that anyone had raised with me in my entre time in political office other than they, unless it was some other aspect of our government, it was not about the delivery of health care. Making sure that whatever money is put into the system is about the delivery model and shifting the delivery model, then we can figure out at the bargaining table, how we're going to pay the people who are in the system, and hopefully, we'll have a broader conversation about access to care, and then we can start a conversation about where are we going to get more trained professionals to be in the system.
Alika: Should we disconnect health reform from government? Any progress will be destroyed every four years when a leader tries to get re-elected?
Stephen: It would be great if you could do it but guess what, every four years, people like Christie and I end up going to look for support to be re-elected.
Christy: We will never have profound and fundamental change that we need in the Canadian health care system if we are depending on people who have a four-year time horizon for their annual, their next stockholder’s meeting where they get voted in or voted out from the board of directors, to bet on a huge change that's going to have long-term benefits that are uncertain.
Chantal: I totally agree that best practices should start at the local or regional level and filter up and then provinces to provinces. It can't be a top down someone has this great idea that everyone will have. But I am reminded that I am paid to be live in the real world. And in the real world, it is not happening that governments are going to devolve the reorganization of the healthcare system to non-political actors.
Alika: Is there a way for us to shift from a focus on cost reduction to value?
Christy: We can build different incentives in at the ground floor for people. So, for example, emergency rooms in British Columbia, we did a good experiment a while ago, where we were paying, we would top up the budget of the emergency department in a hospital if the solutions for change that the people working in that space, created and implemented, actually lowered costs, they will get to keep the money that they'd saved and use it for other things. What our experience was, that professionals in the specific areas of hospitals, for example, often know what the savings are that need to be paid. They work in a very unresponsive system, where they can make suggestions for change and they don't happen, most of the time. By giving the professionals in the space the ability to be able to make those things happen and giving them some, not personal financial incentive, but giving their department some incentive, it really brought about a lot of change. A lot of really positive change in terms of wait times, throughput, the patient experience, the whole gamut they saw improved metrics.
Stephen: Christy's idea, you know what I think deserves merit - I wish I’d known you guys were doing that - but that's an interesting concept because it allows the people in the facilities, who are running them and managing the budgets to drive the efficiencies and know how best, and not be fearful that your government is going to just claw back.
Alika: We hear frequent calls for more doctors and nurses, for changing delivery models and for collaborative care models. Collaborative care encompasses health care teams. When will the conversations led by governments become more inclusive of the number of health care professionals, other than doctors and nurses, which can be part of the solution? And I'm going to tack on one more part to this question: In your experience, what other health care workers should be involved in health care teams that we maybe aren't including when we just frame it around doctors and nurses?
Christy: Paramedics could be one. I mean, they're doing that in Ottawa, I think they've got a trial going where ambulance paramedics are helping to provide home care for people, for elderly people, in their homes. So, I would certainly include them in it. We should also think about whether or not firefighters can do some work in emergencies?
Chantal: I think pharmacists come first on the list, by far. And we've seen that over the course of the pandemic. The number of things you can do, dealing with your pharmacist, at least where I live today, compared to even a decade ago, that doesn't even compare. I can solve a lot of problems just by going to my pharmacist now, including getting all those shots that doctors don't need to be delivering anymore.
Stephen: We started a seniors medication review and the Government of Nova Scotia pays for it, where a senior can go in to see a pharmacist that goes through the list of medications they may or may not - that they're on - and look at any interaction with them. That's what they were trained to do. So, we make sure we get their full scope of practice. And I'm also a big believer that social workers need to be part of this conversation, helping with the determinants of health and some of the socio-economic circumstances people find themselves into. What are the supports that we can put around families earlier, before it ends up being a health issue that we're dealing with?
Alika: This is an excellent discussion, but these sessions are frustrating as we want to move to actionables. What can those of us on this webinar do? Where can we start to create change?
Chantal: For individual members who are listening to this, you have some leeway to create some of those changes at your own level, despite the bureaucracy or in sync with the bureaucracy, and ‘thinking out of the box’ is not something that is forbidden by any act of a province or the federal government for one. But two, I'm guessing, finding support across the medical health care practitioners field to call or to bring the governments to realize how bad the situation - and I know that's already happening - is the thing you really can do best for your patients.
Christy: Fundamentally the problem is that Canadians are wedded to the idea that if we don't have exactly the same system we have today, which we all admit is far from perfect, we are going to have the American system, and that is just not true. Talking about that publicly, I think, could make a real difference in opening opportunities for politicians to make some change.
Stephen: You have a powerful, you are a powerful voice in the most important part, and that's in the patient's ear. You are the most powerful voice. No one believes politician. So, we could come up the greatest idea of transformation, but unless your organization is saying, unless other organizations are on the same page, it will be very difficult for government to implement that change. So, my call to action would be strengthen your relationship with your sister organizations, and I would do it provincially and take them into Premiers’ offices, ministers of health, and lay out a consistent plan that's well thought out about what does the new delivery model look like?
Alika: Thank you for the very stimulating discussion. Once again, thank you Christy Clark, thank you Chantal Hébert, thank you Stephen McNeil for a wonderful conversation. So, we’ll switch gears now to another part of our webinar which is a bit of reflection and I’ll just invite Dr. Katharine Smart, CMA past president, and Toni Leamon, CMA’s Patient Voice chair just to join me here in the webinar. Of the interesting perspectives, is there anything that stands out to you?
Toni: So, the first would be accountability. In this conversation, we heard accountability discussed at the federal and provincial level, but ultimately, accountability needs to be at all levels. We all share the responsibility of accountability for health care and health care spending. When we empower patients and essential unpaid caregivers to be part of the decision-making process, as authentic partners, interventions can be better streamlined and tailored to individual needs.
Katharine: Where is there accountability in our system? There’s very little. We do not look at a lot of outcomes in our system nor are they incentivized nor are we necessarily accountable for them. So, if we’re not designing a system that has radical accountability and is outcomes driven and we’re incentivizing people to get those outcomes for patients, I don’t see how we really get significant change. And the other piece I appreciated was some of what Christy brought up around this idea of budgeting. I do think some of what inhibits innovation is the sort of status quo of how things are done. We all know if you don’t spend your money in the budget cycle, you don’t get it back the next year. If you save money, often it’s taken away. So, there’s some of those fundamental bureaucratic changes that we could make now that would really motivate frontline people to say – ok, I’m going to get rewarded for this, there’s something in it for me, I’ve got these ideas and if I can make good changes for my patients, I’m going to have more access to more resources to do more of that. There were many things, but those were the things that really resonated with me. But most importantly, I think, the importance of having the right conversation, and I think it’s really about these issues much more than it’s about dollars right now.
All three panellists expressed frustration with the lack of progress in health reform over more than two decades, despite dozens of studies, reports and commissions from various levels of government.
They agreed that our outdated Medicare system needs an urgent overhaul – an overhaul that can only be achieved through collaboration and innovation, and by engaging the people who work in health care and the people it’s meant to serve.
“Changing the health care system in Canada is seismic. It will require some collaboration between the federal and provincial governments.” – Christy Clark, Health Summit panellist
The panellists debated other ways to advance the transformation of care, including:
Giving providers and patients the ability to shape health outcomes
Health professionals and patients know the system best. They must play a greater role in deciding how health care dollars are spent. Christy Clark highlighted a program at a BC hospital that incentivized emergency department staff to create and implement changes that would lower costs. In return, their department could keep and reinvest the savings.
Calling for political courage
The relentlessness of a four-year election cycle makes it tough to move the dial on health care. All three panellists talked about politicians (including themselves) who’ve regretted not making bolder choices.
They agree there needs to be more public support for leaders driving mature conversations about our future. Panellists highlighted examples of practices to avoid and those worth adopting, including some effective models from European countries.
Innovating from the ground up
Health care professionals need the funding and the freedom to ‘think outside the box’ when solving challenges within their respective communities. That knowledge can then be shared with broader health networks. Innovation spreads.
“Best practices should start at the local or regional level and filter up from province to province. They can’t be top down.” – Chantal Hébert, Health Summit panellist
Breaking down barriers between professions
All health care professionals need to be considered when designing future care delivery models. Collaborating across the sector – physicians with pharmacists, paramedics with nurse practitioners – can help create a more sustainable health system and relieve many workforce pressures.
“Collaborative care encompasses health care teams. When will the conversations had by governments be more inclusive of all health care professions – not just doctors and nurses – that could be part of the solution?” – Health Summit participant
There was also acknowledgement that honest discussions are needed around the issue of private and public health care delivery. The inappropriate use of some health care was highlighted, along with the reality that an aging population will require care in hospital but also in their communities.
CMA Past President Dr. Katharine Smart, and Toni Leamon, from CMA Patient Voice, wrapped up the evening by calling for a shift from a system focused on disease to one that promotes better health.
How we deliver care to patients — the heart of an effective and efficient health system – will be the focus of the next session of Bold Choices in Health Care. Join us on December 8, 2022.