The National Forum reports: Crisis? What crisis?
Charlotte Gray
CMAJ 1997;156:891-2
[en bref]
Charlotte Gray is a contributing editor at CMAJ.
© 1997 Charlotte Gray
In brief
The National Forum on Health's final report appears to have said what Canadians -- and the federal Liberal government -- wanted to hear about the health care system. It called for preservation of the single-payer model and the 5 principles of the Canada Health Act, and also recommended that medicare be expanded to embrace pharmaceuticals and home care. Edmonton internist Tom Noseworthy, chair of the forum's steering committee, said public anxiety about medicare is caused by the rapid pace of change, not its direction. However, the CMA's Dr. Judith Kazimirski was quick to challenge Noseworthy and his criticism of those who say a crisis exists.
En bref
Dans son rapport final, le Forum national sur la santé semble avoir dit ce que les Canadiens -- et le gouvernement libéral fédéral -- voulaient entendre au sujet du système de soins de santé. Il préconise le maintien du modèle à payeur unique et des cinq principes de la Loi canadienne sur la santé, et recommande d'étendre l'assurance maladie aux produits pharmaceutiques et aux soins à domicile. Le président du comité directeur du Forum, Tom Noseworthy, spécialiste en médecine interne d'Edmonton, a déclaré que l'inquiétude du public au sujet de l'assurance-maladie est causée par la rapidité du changement et non par son orientation. Le Dr Judith Kazimirski de l'AMC n'a toutefois pas perdu de temps pour contester le Dr Noseworthy et les critiques qu'il formule à l'endroit de ceux qui affirment qu'il y a crise.
The chair of the National Forum on Health's steering committee raised his eyebrows when he saw the number of reporters and TV cameras at the forum's Feb. 4 press conference. Dr. Tom Noseworthy seemed surprised by the media interest. After 30 months of labouring away in the shadows, the forum's staff found themselves overwhelmed by demand for their wrap-up report. But Noseworthy, a Newfoundland-born internist who chairs the Department of Public Health Sciences at the University of Alberta, wasn't fazed. He seized the chance to berate the crowd.
"Shame on you," he said, "for saying there is a crisis."
He admitted there are grounds for concern and that Canadians are worried about the deterioration of the health care system and about preserving access and quality. However, the 24 forum members think the public anxiety is due to the rapid pace of change rather than its direction. They said changes are both necessary and overdue, and have been endorsed by a string of recent provincial inquiries and commissions.
According to Noseworthy, myths and misinformation abound when medicare is being discussed. As the forum's report, Building on the Legacy, puts it: "We regret that raising fear among the public is viewed by some as a legitimate way to pursue personal, professional and corporate interests."
In the scrum after the press conference, CMA President Judith Kazimirski was quick to respond. "I can't find beds for my patients when they urgently need hospitalization," she told reporters. "I can't find home-care programs when patients are discharged quickly from hospital. I watch people waiting for hip-replacement operations. As far as people in my part of Canada are concerned, there is a crisis."
But reporters hadn't come to discuss whether or not there was a health care crisis, and they weren't particularly interested in the forum's thoughtful analysis of what works and doesn't work in health care. Instead, they wanted to see how the next federal election was shaping up. Prime Minister Jean Chrétien is expected to go to the polls during 1997, and he has already staked out the survival of medicare as one of his campaign pledges. As he accepted the National Forum's report, he professed support for its unqualified endorsement of the federal government's role in health care and commitment to its policy recommendations. "I can assure Canadians that the report will not be gathering dust on a shelf. Our government will be acting on these recommendations in the days, months and years to come."
So what does the forum recommend? First, it insists that certain key features of the current system must be preserved and protected. These include public funding for medically necessary services, the single-payer model, the 5 principles of the Canada Health Act and a strong federal/provincial/territorial partnership.
But the status quo is not enough, the forum adds. Health care can only be deinstitutionalized satisfactorily if extramural health care services, such as drugs and home care, are also publicly funded. Forum member Robert Evans, a professor of economics at the University of British Columbia, pointed out that a pharmacare program would involve a shift from private to public funding, but not a rise in total spending on drugs because Canadians -- 90% of whom are covered by drug plans -- are already spending this money.
The forum also wants reform of primary care. It does not promote any single model but it is clear that the report's authors endorse salaried providers and far greater use of nurse practitioners. They also want significant investment in children, including an integrated child-benefit program to alleviate child poverty, good day care, family-friendly working conditions and tax breaks for families with children. And they recommend an Aboriginal Health Institute to help Canada's natives find solutions to their health problems.
Lastly, the forum concluded that "a key objective for the health sector should be to move rapidly toward the development of an evidence-based health system, in which decisions are made by health care providers, administrators, policy-makers, patients and the public on the basis of appropriate, balanced and high-quality evidence." It wants Ottawa to establish quickly a National Population Health Institute, which would link into a federal-provincial health data network.
In short, the general thrust of the report is mainstream, old-style, left-leaning liberalism. Its authors see no reason to open up the Canada Health Act, redefine its principles, enlarge the private sector or further decentralize health policy. They believe wholeheartedly in a role for Ottawa and embrace the view that government provides better health care, at considerably lower cost, than a mixed public/private system could.
In an era of right-leaning, business-minded neoliberalism, can these proposals fly? Some have already been overtaken by events. Last year, the forum declared that cash-transfer payments to the provinces should not fall below $12.5 billion -- a statement that was repeated in this report. But in his 1996 budget, Finance Minister Paul Martin cut transfers to $11.1 billion for 1998-9. Kazimirski, the CMA president, pointed out that "while the forum's recommendations assume a strong framework of federal leadership and financial support, we believe that this framework has been severely eroded since the 1980s."
The forum members have 2 things going for them. First, the report does reflect public opinion. Even the most hard-headed, deficit-slashing provincial premiers hesitate these days before squeezing health care budgets yet again. Second, federal Liberals see health care as an issue with which they can rediscover their progressive roots and perhaps even recapture their reputation for integrity.
The first sign that the Chrétien government took the report seriously came in the Feb. 18 budget, with its cash commitment to a new program to alleviate child poverty and a new national health information system. But most of the forum's recommendations are much more difficult for Ottawa to act upon because they involve extensive federal-provincial collaboration -- a phenomenon Canadians haven't witnessed for several years.
Provincial health ministers were quick to react to the report. Predictably, they were sceptical. New Brunswick's Russell King, a physician, said that until Ottawa shows it is prepared to fund health care adequately, provinces may pay no heed to the federal definition of what medicare should cover. And the Pharmaceutical Manufacturers Association of Canada staked out its turf defiantly in a news release -- it said the pharmacare proposals are vague and insufficiently researched.
In the current babble on the future of health care in Canada, the National Forum has undoubtedly advanced the debate. It has published a few blunt truths about the slippery slope of privatization and underfunding. It has given clear advice on the policy directions it would like to see pursued and suggested a time frame and price tag for each. In a raft of supplemental reports on values, determinants of health and evidence-based decision-making, it explores the choices facing policy-makers. It has articulated what Canadians want and expect.
"Our report presents a blueprint for building on our health legacy," boasts Noseworthy. Whether the blueprint is used to build anything remains to be seen.
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