Canadian Medical Association Journal 1996; 154: 233-235
As they arrived in the Fisheries Museum of the Atlantic, the meeting's location, they were greeted by a professional facilitator and handed a copy of Let's Talk, a workbook designed to elicit their views. The forum has printed 55 000 copies in English and 20 000 in French for national circulation. Judith Ritchie, professor of nursing at Dalhousie University and one of the forum's 24 members, was also in attendance.
"Many of those present were extremely well informed," says Marie Fortier, the forum's executive director. "One man turned up with a copy of the Canada Health Act and books by Michael Rachlis and Michael Decter under his arm."
Another participant was a nurse who had served on the Nova Scotia task force that investigated provincial health care. Nearly everyone was sufficiently involved in the first of the forum's "discussion groups" to return for another 7-hour session the following Saturday.
It should come as no surprise that Canadians are anxious enough about health care to surrender a Saturday to discussing it. Medicare has elbowed its way into the spotlight, forcing aside both hockey and the weather in claiming the role of defining national characteristic; with dramatic cuts to service occurring everywhere, many of us are wondering whether it can survive. The 75 discussion groups in 35 communities planned by the forum seem to be exactly what Prime Minister Jean Chrétien had in mind when he appointed an all-star cast of academics, health care providers and consumer spokespersons to the forum in October 1994. At the time, he spoke of the need to "promote a dialogue with Canadians about their health system, build on work already done, identify priorities and help Canadians develop a consensus for changes we need to make."
But is anyone going to listen? Will key decision makers hear what those 25 citizens from Lunenburg have to say? Or the citizens of Sydney, who attended similar gatherings in December? Or those in the meetings to be held across the country? How will the carefully collated workbooks and the town-hall meetings still to be organized become input into the clenched-fist negotiations between Ottawa and the provinces and territories over the Canada Health Act?
The national forum has been struggling with a credibility problem since its inception in Ottawa and the prime minister's refusal to "share the chair" with Saskatchewan Premier Roy Romanow. Since then, many provincial governments have treated it with elaborate disdain, although many have sent observers to its public events.
Dr. Ron Stewart, Nova Scotia's health minister, stood next to Diane Marleau, the federal minister, when the forum's public-consultation exercise was announced in Halifax, but there was a reason for that. The have-not Atlantic provinces are eager to stay on-side with Ottawa because they depend on federal transfer payments. However, health ministers from Alberta and Quebec, for instance, are hardly likely to stand shoulder to shoulder with their federal counterpart or welcome federal appointees to their turf.
Another Atlantic representative on the national forum, Newfoundland's Richard Cashin, explicitly confirmed the ideologic divide over health care during a conference in St. John's last October. He pointed out that Canada is trying to maintain a European-style health care system, but Western Canada appears to be strongly in favour of Americanizing the system. The national forum, he said, shares Eastern Canada's preference. That helps explain why the hearings were launched in the East, and why the launch was a relatively modest affair.
Despite these handicaps, the Lunenburg event was well received, and it gave forum members a chance to road-test their carefully crafted workbook, which is a favourite government device in the 1990s, along with ubiquitous "public consultations" on policy initiatives.
When Lloyd Axworthy, the minister of human resources, initiated his review of unemployment insurance a year ago, 100 000 workbooks were issued for the cross-Canada consultations of a parliamentary committee, and more than half were completed and returned. Similarly, the Canada Council circulated 15 000 copies of a workbook designed to focus discussion on public subsidization of the arts. Although only about 350 were completed and returned, a council spokesperson said "they were useful because they provided a framework for debate. Otherwise, it's a free-for-all."
Unfortunately, workbooks tend to oversimplify complex issues and can easily slant responses. This is certainly true of the forum's Let's Talk. For example, in comparing the amount Canada spends on health care as a proportion of its gross national product with the proportion spent by other countries, it uses 1993 data from the Organization for Economic Cooperation and Development -- 10.1% -- although those are out of date. Since then health care budgets have faced massive cuts of at least 10%, with more to come. Most experts now estimate our spending to be close to 9%, although the federal government will not release more up-to-date statistics. Spending in Alberta is said to have slipped below 5% of that province's economic output.
These developments cast doubt on the workbook's assertion that "on an international level, Canada spends proportionately more money on health care than any other country in the world except the United States." (France and the Scandinavian countries now probably spend more proportionately than Canada.) Having made this assertion, the workbook then asks whether participants think we ought to raise additional money or manage things more efficiently in order to maintain the system. If a response is based on the faulty facts presented, the answer is obvious.
The workbook is permeated by the assumption that there is enough money in the system. Its analysis, therefore, has the dated feel of the 1980s. Arguments for expanding the private sector get one sentence, while arguments against private funding are given four paragraphs. There is no discussion of whether it is possible to preserve patient choice, public administration and high productivity by, for example, contracting out services to private clinics.
A reference to the widespread overuse of drugs is the only hint that drug costs need to be contained, even though they account for the fastest growing slice of the health care pie. Various provincial governments are struggling with different options, with Ontario about to impose a copayment system. However, the workbook sticks to an "us-and-them" approach to the public-versus-private debate.
However, the workbook will give some structure to discussions. The first section is headed "How we can improve the health of Canadians" and deals with the determinants of health. The second, "How far can we maintain a fair and effective health care system?", looks at priorities for health care financing. The third deals with ways to make our health care system incorporate both Canadian values and good medicine. The book is full of graphs and pie charts that illustrate life expectancy in different countries, child poverty in Canada and government spending. In the centre is a pull-out questionnaire.
"We're a group of people interested in national issues, not a federal-government agency," insists Dr. Tom Noseworthy, who has chaired many of the National Health Forum's meetings. "There is an intense desire among us to keep the forum nonpolitical, but obviously we need a grasp of the political context."
Noseworthy, an internist who is professor and chair of public health sciences at the University of Alberta, knows that provincial collaboration is essential if the forum is to be effective. He also knows that the study groups and town-hall meetings risk being a lightning rod for grief about local services. "If we went in front of any Alberta audience and mentioned health care right now," he admits, "we'd get shot."
In Noseworthy's view, the hearings process must achieve two goals. The first is educational: "We've got to explain the seriousness of the fact that one in five kids is growing up in poverty. We've got to improve the implementation of outcome-based therapy." The second is a thorough airing of the issues and completion of some position papers, based on the discussions, which illuminate Canadians' health care priorities.
"You've got to earn some credit in order to be heard," Noseworthy acknowledges. "And you only do that when you start to deliver product that adds value to the national debate."
Forum bashing is endemic among health care providers, who see it as a smoke screen for Finance Minister Paul Martin's steady erosion of Ottawa's contribution to health care costs. Forum members are still smarting that the CMA went over the forum's head last summer in calling for a national discussion of privatization. The message from some physicians appeared to be that the forum is invisible and irrelevant.
The forum will try to meet these criticisms head on and generate a consensual approach to policy-making during a conference involving key stakeholders that will be held next spring. "Organizations like the CMA will be invited to present briefs," explains Noseworthy. "We're not in competition with these groups -- we need their input."
But as both federal and provincial governments continue the big squeeze on their budgets, can the forum's discussions groups do more than air the pain?