Canadian Medical Association Journal 1996; 155: 106-107
© 1996 Richard Cairney
But even though they agreed that health care is undergoing unprecedented change, Alberta Premier Ralph Klein, National Forum on Health member Dr. Tom Noseworthy and CMA President-Elect Judith Kazimirski offered those attending the Edmonton meeting different views on how the change should be handled and the direction it must take.
Alberta has already experienced revolutionary change. Since 1993 Klein's government has slashed health care spending by $500 million, replaced more than 200 hospital boards and handed responsibility for spending to 17 regional health authorities.
With a moratorium on further cutbacks taking effect this year, a new phase of restructuring will focus on assessing the results of budget reductions, setting priorities for care and negotiating a new CHA with Ottawa. Financially, health authorities may soon receive funding based on population rather than hospital beds, as regional boundaries ebb and flow.
"There have to be limits," said Klein, "because we can't fund everything. But if we manage our resources very, very carefully we can continue to fund the services with the greatest potential for making the most people well."
The limitations have had a personal impact. "My father is waiting for a hip replacement, and I hope he gets one soon," Klein told the audience. "But he isn't complaining."
Government's future role will be to maintain standards of health care that have been determined through a national debate. One of Klein's own goals is clear: he wants changes in federal legislation to allow doctors to work in public and private systems. The Klein government is already losing more than $400 000 a month because of federal funding penalties related to extra-billing in Alberta. The situation could get more difficult because a company called Hotel de Health is attempting to set up a private hospital in Alberta.
Whatever the outcome of the debate, physicians need to work within financial boundaries and patients will need to learn to use the system responsibly and make better lifestyle choices, Klein said.
Noseworthy's idea for "making the most people well" hinges on the development of a "national health system" instead of a national health care system. Education, preventive medicine and home care weren't addressed in the CHA but play essential roles, the Edmonton internist observed.
Instead of simply cutting health care spending and shifting costs, Noseworthy suggested a radical rethinking of the way the country is run in order to nurture a healthy nation. His ideas go far beyond traditional public-health schemes that encourage Canadians to wear seat belts and bicycle helmets and use condoms.
"All public policy needs to be reviewed within the context of its impact on the population's health," he said. "We need to undertake a range of comprehensive approaches to create living and working conditions that promote health."
The next step would be to reallocate resources to solve root causes of disease, such as poverty. "The health care delivery system can't fix that problem," he said.
Noseworthy, a member of Prime Minister Jean Chrétien's National Forum on Health, is frightened by the rapid pace of change. Referring to Galahad, the small town 150 km southeast of Edmonton where Hotel de Health has received broad public support, Noseworthy said he is worried that important decisions with national implications will be made in the wrong places by the wrong people. A vote in the small town found almost unanimous support for Hotel de Health's proposal to provide private health at a local hospital. "I'd like a little more debate [on privatization] than that," Noseworthy commented.
He also thinks trouble will arise when an environment in which health is viewed as a commodity collides with a culture in which access to comprehensive care is considered as necessary as access to food and shelter.
"Regrettably, if you're poor you [get by] with less or you do without," he said. "If you're destitute, you rely on soup kitchens and park benches. However, if you're sick and poor, do you [get by] with less, or do you do without health care? If so, what is the societal, let alone the personal, cost?
"There is a looming concern, for instance, about an increase [in the number] of homeless mentally ill. I have doubts about their ability to negotiate [in] a market-driven system. What this says to me is that market forces work fine for the haves, but perhaps not so well for the have-nots."
Noseworthy sees the current upheaval in health care as a clash between the corporate mentality and middle-class values. When patients are thought of as consumers, we lose sight of our goals, he said. "I'm left to assume that the greater the extent to which health care is viewed as a commodity, the greater the threat to vulnerable segments of the population and, potentially, the greater the cost to society in both the short and long term."
Noseworthy said the future of health care depends on our values, but Kazimirski warned the audience that these values are shifting very quickly. Dropping her prepared speech in order to respond to Klein's earlier remarks, Kazimirski commended Alberta doctors for reaching out to the public in its attempts to publicize the impact of health care cutbacks. Citing the Alberta Medical Association's Tell us where it hurts campaign, in which more than 50 000 Albertans complained to the AMA about health care cuts, she said the public expects this type of leadership from physicians.
"The public in Alberta basically said to Alberta's physicians, `Keep on speaking about the cutbacks in health care. Keep on saying they have been cut back enough and now our health care is being affected.' The bottom-line message from that is that the public expects physicians and professionals to speak with them -- not for them, but with them."
The teachers who train medical students can help mould leaders by telling students their strengths lie not only in one-on-one dealings with patients but also in their place within the community. Being involved in the community, through something as simple as offering birthing classes or talking about sports medicine at the local high school, can make a big difference, the Windsor, NS, family physician observed.
It is not impossible to alter health care delivery radically and come out with an improved system, she said, recalling the vision of medicare founder Tommy Douglas. In 1982, she said, the man who helped turned Canadians' health care values into legislation predicted the current overhaul of medicare. Douglas saw two phases to medicare: during the first phase financial barriers to health care would be removed, and in the second the health care delivery system would be fine-tuned. Kazimirski said Canada has just entered phase two, and physicians must ensure that the right changes and choices are made.
"What we are looking for is a system that is sustainable and capable of growth, renewal and continuous improvement. What we are not looking for is the 30-year fix. Medicare is not even a generation old, but it is old enough that most Canadians who use the system do not have a clear recollection of a time before universal health insurance."
Medicare, she added, is a social structure that says "I am indeed my brother's keeper. That is the value base we need to apply to how we provide service, to how we train the next generation of physicians."