Although it is true that in another series of polls 59% of Canadian generalist physicians reported that things have "gotten worse" relative to their ability to provide quality care, 56% of US generalist physicians made the same assessment about their system.² Perhaps the most revealing comparisons relate to physicians' concerns for the future. Canadian physicians were more concerned that "patients will wait longer than they should for medical treatment" than American physicians (74% v. 43%) On the other hand, American physicians were more concerned that "patients will not be able to afford the care they need" (54% of American physicians v. 32% of Canadian physicians). And since so many Americans feel that their system puts profits ahead of people, it is clear that many patients in the United States do not even trust their physicians to do what is in their best interests — a situation that erodes the core of the physician–patient relationship.

Ralph Hawkins is right that death rates have been declining steadily for decades in the United States, the United Kingdom, Western Europe and Australia. Hawkins fails to mention that acute care capacity has also been declining dramatically in all of these jurisdictions, just as it did in British Columbia. For example, between 1985 and 1995, days of care in US short-stay hospitals declined by 38%.³ Declines in the United Kingdom, Western Europe and Australia have been similarly steep. The same pattern — decrease in acute care beds and improvement in health — has occurred across Canada, including British Columbia.⁴ For example, mortality rates fell 7.4% in Manitoba between 1987 and 1996; over the same period, hospital days per capita decreased by 23%. Changes in Ontario were even more dramatic: mortality rates fell 10.7% over a period when hospital use was essentially cut in half.

Following Hawkins' logic, should we conclude that the "obvious answer" is that a decline in acute care capacity has a demonstrably beneficial effect on population health? Obviously not. Hawkins' letter criticizing the piece by Sheps and colleagues [Research]⁵ is precisely the type of untempered claim on the part of the stakeholders that leads to the disconnect between the headlines and the facts [Commentary].⁶ Rather than assumptions that the Canadian health care system can't get it right, that more medical care must be better and that any decrease in medical spending represents a threat to life and limb, we need collaboration between medical professionals and health care researchers to better understand how well or poorly the system is working, and more importantly, the actual role of medical care in making and keeping people healthy.