REPORT ON MENTAL HEALTH By Michael Kirby (Article)

Two years ago, at the outset of the Committee’s work, the Committee endorsed two major public policy objectives for Canada’s heath care system:

To ensure that every Canadian has timely access to medically necessary health services regardless of his or her ability to pay for those services, and

To ensure that no Canadian suffers undue financial hardship as a result of having to pay health care bills.

Implicit in these two objectives, particularly the first, is the requirement that the medically necessary services provided under Medicare be of high quality. Clearly, providing access to services of inferior quality would defeat the purpose of Canada’s health care system.

In addition, the Committee recognized that the value of fairness is also an important component of Canadians’ views of the health care system. This value of fairness underlies the patient-oriented principles of a universal, comprehensive, portable and accessible system that the Committee – and Canadians – strongly support.

But, to Canadians, fairness also means equity of access to the system – wealthy Canadians should not be able to buy their way to the front of waiting lists in Canada. Repeated public opinion polling data have shown that having to wait months for diagnostic or hospital treatment is the greatest concern and complaint that Canadians have about the health care system.  The solution to this problem is not, as some have suggested, to allow wealthy Canadians to pay for services in a private health care institution.  Such a solution would violate the principle of equity of access.  The solution is the care guarantee as recommended in this report.

Based on evidence presented at Committee hearings over the past two years as well as on public opinion polling data, the Committee is also aware that Canadians believe that the current system is inefficient. Moreover, Canadians are not prepared to invest additional money into the system until these inefficiencies are eliminated. The Committee realizes that changing this public perception of an inefficient system will not be easy. It will require the introduction of incentives to encourage all the components of the system to function more efficiently. It will also require that the system function in a much more transparent and accountable fashion, including in the ways in which public money is spent.

In formulating its recommendations, the Committee also took account of two additional factors. First, the Committee believes that if the second public policy objective given above – the no undue financial hardship objective – is to be met, steps must be taken now to begin to close the major gaps in the health care safety net. While the Committee believes that Canadians who are genuinely in need of help, and cannot afford to pay for it, should receive the assistance they need from public funds, this does not mean that what is needed are new first-dollar coverage programs in areas such as pharmacare or home care. In the Committee’s view prudence requires that any expansion of the current system to begin to close the gaps in it must be done in small, manageable steps.

Text Box: Anyone proposing a plan to reform and renew the health care system has an obligation to say how their plan of reform will be paid for.  The only way Canadians can develop an informed opinion on the merits of a proposed plan of reform is if they can clearly understand the benefits that will result from the plan, and what it will cost them to have the plan implemented.

The second factor that is reflected in the Committee’s recommendations is the belief that anyone proposing a plan to reform and renew the health care system has an obligation to say how their plan of reform will be paid for. Moreover, the payment method must be described in terms that are meaningful to individual Canadians. The only way Canadians can develop an informed opinion on the merits of a proposed plan of reform is if they can clearly understand the benefits that will result from the plan, and what it will cost them to have the plan implemented.

 

Text Box: Not to give a revenue-raising plan would also mean that the Committee had failed to meet the test of transparency and accountability, which it has insisted throughout its recommendations must apply to the health care system as a whole.

It is for this reason that the Committee has taken the extremely unusual (some have even described it as unique) step of both costing our recommendations and putting forward a recommended option for raising the new federal revenue required to implement fully our recommendations. To fail to do this would, in our view, perpetuate the myth that health care is a “free” good. This would play directly into the hands of those who oppose reform. Not to give a revenue-raising plan would also mean that the Committee had failed to meet the test of transparency and accountability, which it has insisted throughout its recommendations must apply to the health care system as a whole.

 

The Committee understands that the implementation of its set of recommendations will require considerable behavioral change on the part of all participants in the health care system. For example:

The change to service-based funding will alter the way in which hospitals are managed. It will make hospital management, and the health care professionals working in a hospital, much more conscious of which procedures they do efficiently and which they do inefficiently. It will also mean that hospitals in large urban areas will face competition from other hospitals and specialist clinics.

The changes involved in primary health care reform will require family physicians to accept changes to the way they are remunerated (by replacing straight fee-for-service by a remuneration model that is primarily capitation with an added component of fee-for-service). It will also require that modifications be made to the scope of practice rules for all health care professionals in order to ensure that such rules are not barriers to health care professionals being able to use their skills to the fullest extent for which they have been trained.

The changes involved in primary health care reform will also require that patients agree to stay with their choice of family physician for a year, unless they move to a different community. The recommendation to set up a system of electronic health records will require that patients agree to give the necessary approval to enable an efficient use of patient electronic health records. (As explained in Chapter 10, the Committee believes that a system of electronic health records can be built, and the resulting information system operated, in a manner that is entirely consistent with the spirit as well as the letter of privacy laws.)

Provincial/territorial governments will need to change a significant aspect of their approach to the health care system by agreeing to a health care guarantee, thus accepting responsibility for the consequences of their past decisions to cut budgets and ration the supply of health care services.

Provincial/territorial governments will also have to move away from their current command-and-control approach to health care by giving regional health authorities sufficient autonomy and by allowing the system of incentives, with its associated behavioral change, to generate the desired results.

The federal government will have to agree to the creation of an arms-length fund, overseen by a Health Care Commissioner and a National Health Care Council who will advise the government on how money in the fund should be spent. This advice should be made public, and there should also be an annual public accounting of how funds earmarked for health care are actually spent. This is an essential step in restoring public confidence in the system.

The federal government will also have to accept that it has a major leadership role to play in financially sustaining the infrastructure that is essential to a successful national health care system. Included in this infrastructure are the nation’s 16 Academic Health Sciences Centres, the national supply of human resources in the health care sector, technology, information systems and research.

The federal government will also have to accept that it has a major role to play in financing, and marketing, programs of health promotion and chronic disease prevention.

Finally, it is important to stress how critical the objectives of greater accountability and transparency are to the Committee’s views on the kinds of reform that are needed in the health care system, and the critical role that improved information, at all levels of the system, must play in implementing these objectives.  This increased information is needed for the following reasons:

first, to make more transparent the processes by which resource allocation decisions are made – principally with regard to money, but also including human resources;

second, to enhance the accountability of the people, institutions and governments that decide what types of services will be covered by public health care insurance and how much of any particular service will be provided;

third, and perhaps most important, to change the public debate from a debate about dollars to a debate about services and service levels. 

Canadians have a right to debate the question of whether they are willing to pay more for improved levels of service, and they have a right to understand the linkages between funding levels and service levels.  Changing the nature of the public debate about health care will mark a significant step towards gaining public support for restructuring and renewing the publicly funded hospital and doctor system.

Text Box: There is no perfect solution.  Everyone involved will have to be prepared to compromise in order to make reform work for the benefit of all Canadians. Insisting on perfection, or attempting to obtain everything one wants, will doom reform to failure.

The Committee fully recognizes that its set of recommendations will be subject to close critical scrutiny.  This is entirely understandable in such a value-laden public policy issue as health care. In fact, it is likely that each reader of this report will support his or her own unique subset of recommendations.

 

We ask readers, however, to keep in mind that no major reform of any large system, particularly one as complex as the health care system, is ever perfect.  There is no perfect solution.  Everyone involved will have to be prepared to compromise in order to make reform work for the benefit of all Canadians. Insisting on perfection, or attempting to obtain everything one wants, will doom reform to failure. 

Similarly, reform will fail if people insist on addressing all health care problems before beginning to make progress on some of them, particularly on the hospital and doctor system.  These tendencies, along with a focus on self-interest by those employed in the system, explain why reform has failed in the past.

Recognizing these dangers, we have worked hard to develop a set of recommendations we believe to be pragmatic, middle-of-the-road in ideological terms, workable and that will lead to substantial improvements in the hospital and doctor sectors of the health care system.  We believe that a steady pace of reform is the way to make the restructuring and renewal of Canada’s health care system possible.

We trust that those involved in all aspects of the country’s health care system, and indeed all Canadians, will consider the recommendations with the same pragmatic approach as the Committee, and that everyone will be prepared to make some compromises in order to meet our common goal: having a fiscally sustainable health care system of which Canadians can be truly proud.

Text Box: We trust that those involved in all aspects of the country’s health care system, and indeed all Canadians, will consider the recommendations with the same pragmatic approach as the Committee, and that everyone will be prepared to make some compromises in order to meet our common goal: having a fiscally sustainable health care system of which Canadians can be truly proud.

 

[1] See Volume One, Chapter Two, pp. 31-44.

[2] Volume One, p. 41.

[3] Volume Five, pp. 23-25.

[4] Volume Four, p. 16.

[5] Volume One, pp. 98-99.

[6] Canadian Healthcare Association, Brief to the Committee, May 2002, pp. 3-4.

[7] Volume Five, pp. 30-32.

[8] Volume One, pp. 35-36.

[9] The Government of Quebec has not always been signatory to these agreements.

[10] At present, portability does not always apply to Quebec residents as many providers in other provinces will not treat Quebec residents if they do not pay the medical fees upfront. In many cases, this is not possible and Quebec residents have been transferred in ambulance for long distances in difficult circumstances back to Quebec.

[11] Volume Five, pp. 23-25.

[12] Paul Darby, Brief to the Committee, 3 June 2002, p. 2.


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