#physicians – justanoldcountrydoctor

“Health Care for All” Policies Will HURT Physicians and Patients

Recently, physicians leaders have been in the media promoting the right to primary care. I generally refer to this as a “Health care for All” policy, as it is reflective of one of the tenets of former Health Minister (and current Dean of Queens Medical School) Dr Jane Philpott’s new book. Dr. Tara Kiran has also promoted the same through her “Our Care” project. These proposals seek to guarantee a family physician for everyone in a certain geographic area, just like children in an area are guaranteed a school.

While these policies sound nice (for reasons I’ll go over later) – they are doomed to failure. To understand why, let’s look at just two other situations – The Barer Stoddart Report and the move toward safe injection sites and decriminalization of illicit drugs. I appreciate my three loyal readers (I actually gained one!) might be wondering what this has to do with primary care. Bear with me, it hopefully will make sense later.

The Barer-Stoddart report is infamous in Ontario medical politics. It’s the report that is widely viewed as suggesting Ontario had too many (!) doctors in 1990s and led to the reduction of the number of medical school positions. However, what is not commonly appreciated is that was the last recommendation in the report. The first recommendations were to support the current supply of physicians by adding a large number of allied health professionals and making many health systems modifications. If and only if all those recommendations were carried out, then medical school enrolments could be cut. The bureaucrats and politicians looked at that, went through the report, decided that all the other recommendations were too expensive or complicated, and just cut med school enrolment. “The report told us to.”

Similarly, when it comes to drug decriminalization, the idea is best implemented in Portugal. The top line read is “addiction rates fall 40%” after Portugal introduced this policy. BUT a deep dive shows that before decriminalizing drugs, Portugal made a number of legislative changes, ensured that the court systems were educated, ensured that addiction therapy and counselling was available for addicts, and then implemented the decriminalization policy.

In Canada, our bureaucrats looked at Portugal, and figured all the rest of the changes were too complicated. But hey, maybe just decriminalizing will be enough without the other stuff! The result is a disaster when it comes to safe injection sites and an obviously failed policy.

So let’s look at the right to primary care that Drs. Philpott/Kiran and others propose. At their heart, ideas like this are reasonable, make sense and will help improve health care for the general population (I bet you didn’t think I’d say that did you?). They speak to a fairness that just isn’t apparent in the current system. One of the reasons that people pay taxes is so that those taxes can fund health care. How is it fair then, that one taxpayer has a family doctor, and another does not? How is it fair that one quarter of Ontarians can access team based health care, but the rest cannot? And so on.

Well then, what’s the problem and why do I think “Health Care for All” type policies will hurt physicians and patients?

Because I simply don’t believe that our politicians/health care bureaucrats will be able to implement all the work necessary to support this, prior to implementing this change.

Look at the other items I mentioned. Do you really think that the bureaucrats who mucked up so badly will get it right this time? Do you really believe that those bureaucrats are going to provide the admin support, the additional allied health workers, the organizational and structural backing first, before just writing out “everyone gets a family doctor” in the funding contracts?

Not a chance. Zilch. Zero. They will look at the need to invest in teams and say “too expensive.” They will look at the need to add administrative support first and decide that’s not feasible. They will look at the need to build healthcare infrastructure and be confused as to how to do it properly. They will be aghast when they come to the part that says for teams to be successful, they must be physician led. “But I’m the aide to the executive secretary of the assistant to the assistant deputy minister’s attache for the chief regional officer of the Primary Care Branch of the Ministry! I should run the team!”

Then they will come to the part of the policy that says ensure every patient in a geographic area has a family doctor. And those bureaucrats will say “oh that’s easy to do with just some changes and regulation”. And they’ll do just that without any of structural changes needed.

I did some rough calculations for my neck of the woods. Each family doctor in my area would have to take on 200 unattached patients to make this work. The problem is we’re all working at 110% capacity right now. There’s no way we can do that.

So, once “health care for all” comes in what’s going to happen? Physicians will stop doing comprehensive family medicine, myself included. You can only ask a person to work so hard before they get frustrated and quit. Which increases the burden on the remaining physicians, which will cause more of them to quit. And so on.

What’s worse, presenting these policies now deflects from the main issue. Basically, family medicine is no longer economically feasible. Without some immediate stabilization funding, family medicine will collapse. By the time people figure out how to implement “Health Care for All” and reduce admin burden, you won’t have any family physicians left. By introducing the “right to primary care” now, the laser like focus on just what is needed to make family practice economically viable is lost and this hurts everyone, patients included.

I genuinely have a great deal of respect for Dr. Kiran and Dr. Philpott in particular (she was the one who sacrificed her political career to warn us that our Prime Minister was an effete, vacuous ninny who for the sake of all Canadians needs to go back and teach drama classes). But as well intentioned and well thought out as “Health Care for All” may be, now is not the time to talk about it.

Economically stabilize and support family medicine first. Then let’s talk.

It’s Time to Make Health Care a Federal Responsibility

Health care is consistently viewed by Canadians as their number one priority in any federal or provincial election. It is the largest portfolio of provincial government budgets and is responsible for a substantial proportion of the federal budget. Yet despite all this expenditure, it continues to fail the citizens of Canada.

As I’ve repeatedly said in the past, our health system needs a bold and innovate transformation if it’s to provide care to Canadians in the 21^st century. In a previous blog, I had promised to come with some ideas on how to do that. I submit the first step should be to make health care a federal responsibility, and not a provincial one.

Parliament of Canada, the seat of the Federal Government

I know, I know, this will require an amendment to the Canadian Constitution, a dizzyingly complex process. But I have an idea for that as well, that I will get into later in the blog.

For now, let’s look at just some of the reasons why we should have a National Health Care system.

Canadians Already believe we have a National Health Care system

Regardless of how the division of authority is laid out, the reality is that Canadians feel that no matter where they go in this country, they will get health care paid for by their taxes. “You shouldn’t need a credit card to pay for your health care” is a mantra that is oft repeated by politicians. It’s part of the Canadian identity say other pundits. Logistics aside, politically speaking, this simply is in keeping with what Canadians already think.

The Canada Health Act puts provinces in a no-win situation.

Somewhat unbelievably, I find myself defending some politicians here (I’m just as shocked as both of my loyal readers are). The argument presented to me by political leaders with whom I have spoken in the past was that premier’s don’t want Ottawa telling them what to do, or how to spend dollars. Certainly, we saw some of that in the wrangling over the most recent health care accord where premiers pushed back on simple things like data collection.

But I feel that it’s the premiers who are in a bind here. The feds can go around saying, “hey, we are going to support the five principles of the Canada Health Act” and then……well do very little about ensuring that. The premiers are stuck because they can’t violate the act. However, they have to figure out how to manage the system with declining revenues. And of course, take the flack when the system is failing.

It’s time to make the level of government that boldly proclaims that Canadians don’t have “pay out of pocket” for health care responsible for implementing it.

The efficiency of the system will increase

I’m serious (honest). Once again, let’s look at the most recent health accord. The federal government agreed to increase spending on health but in return requested health data management. In order to do so the feds propose to have “tailored bilateral agreements” with the provinces and territories.

That’s right, instead of having one team come up with a national data standard, there now have to be 13 committees to hash out how to do it. Which means, you guessed it, 13 times the number of bureaucrats. In 13 times the number of meetings. If the feds ran health care, they could just have one committee to oversee the changes for the whole country.

The same would apply to just about every other aspect of health care. Whether determining what services are covered (there is intra provincial variation), to determining things like public health policies and so on, a unified Canada wide health system would be far more efficient.

Who knows, they might even be able to take the money saved from having 1/13^th the number of bureaucrats and invest that into hiring more health care workers………nah, they’ll probably put it into more $6000 a night hotel rooms for our effete Prime Minister.

Unified Rules/Licensure requirements across the Country

The Canadian Medical Association (CMA) is strongly advocating for pan-Canadian licensure to deal with the physician shortage (so much so they almost make it sound like a panacea). I support national licensure of course. Although I wish the CMA would focus on getting us pensions and getting the government to reverse the tax changes that so harmed physicians in 2017. That would really help their members (the ones they are supposed to be serving).

But let’s be real, national licensure ain’t gonna happen with 13 separate provincial regulatory bodies all trying to generate income to run their organizations with licensing dues.

BUT, make Health Care federal, and you only need one regulatory college that can set Canada wide standards (for all professions, not just physicians).

Similarly, programs like national pharmacare (the one then Prime Minister Paul Martin promised us by 2006) and other programs can all be implemented more easily.

So what are the next steps to take?

There are undoubtedly many other examples of what could run better with a single, Canada wide health system. The big question of course, is how do we change the constitution to allow this?

Canada is due for an election by 2025. It might happen sooner if NDP leader Jagmeet Singh tires of the foppish behaviour of our current Prime Minister and pulls his support for the “confidence and supply agreement”. I propose that whenever that election is, there be a referendum on altering the Constitution. (It would be better than having two separate votes).

Canadians would go to the polls, vote for the candidate of their choice, and then have a question to answer as to whether they support amending the constitution. Make it binding on the provincial governments. If there is Canada wide support for this, then the provinces would have no choice but to agree to the amendment (and as pointed out earlier, it would be better for them politically anyway).

Canadians have long viewed their ability to access health care without paying out of pocket as a quintessential Canadian quality. Having the provinces run health care may have made sense in the days of paper and telegraphs, when integration was nigh on impossible anyway. But in the 21st century, when integration is paramount to running a health care system, it makes no sense.

It’s time for the federal government to take over health care, so that the system can be run in the best interests of all Canadians.

Physician Autonomy Essential for Good Patient Care

Several years ago, one of my colleagues was having a disagreement with an external health care agency. She’s a very bright young family physician, and is extremely passionate about one part of comprehensive family medicine care. She really felt the external agency was failing in providing a reasonable level of service for one group of marginalized patients. In particular, she felt the agency’s process for accepting referrals was deeply flawed.

After months of advocacy by her, the agency finally reviewed their intake process. They then pronounced that everything was ok, because 90% of the referrals were processed accordingly.

In response, my tenacious colleague sent an email to all the family docs in the area, asking them for feedback on the referral process. She the proceeded to blast said agency for the 90% processing rate. “If a server at McDonald’s got the order wrong 10% of the time, would he still have a job?” was the line in her email that really got everyone’s attention. As a result, my colleagues sent feedback, the external agency’s response was proven inadequate, and changes were made. In her own way, my colleague was following the wisdom of Ruth Bader Ginsburg:

It also shows, in one neat example why physician autonomy is so important to patient care. Because without that autonomy, and independence, we can’t speak out. We can’t advocate for our patients even if it makes bureaucrats uncomfortable. We can’t expose those situations where patient care has been compromised.

This is, of course, exactly what those who want to take autonomy away from us want. For the most part this includes two types of people. First are health care bureaucrats, who feel that because they control the purse strings, everything should be done their way, and no pesky front line physicians should dare question their judgement or expose their flaws. The second group consists of a small number of physicians, who, while well intentioned, feel that physicians autonomy impedes whatever fancy new health program they want to implement.

Suppose you are an employee in the IT department of a corporation. You make a statement like say, “If our legal department worked at McDonald’s they would get fired because they get orders wrong 10% of the time.” What happens then? Human Resources gets involved, you get called out for making derogatory comments, the CEO might even get involved, you get disciplined and basically told to shut up. Even (especially?) if you are right in the first place.

This is exactly what those who oppose physician autonomy want.

The anti-autonomy crowd feels that physicians resist change. Therefore, the thinking goes, physicians will use their autonomy and independence to impede whatever new program/model/team is being promoted. Hence, autonomy must be curtailed so physicians can do what they are told, and accept whatever the powers that be tell them is good for them.

However, this couldn’t be further from the truth. The vast majority of physicians are open to new ways of doing things. If they truly believe a new process will help their patients, and help their lives, they will adapt. This is why we use new medications, new treatment protocols and yes, newer models of health care delivery than we used in the past. Medicine would not have changed so much in the past 25 years, if it wasn’t for the willingness of physicians to explore newer and different methods of delivering health care.

But as my friend’s example shows (and there are many like hers), what is essential to the provision of good patient care, is for physicians to retain their ability to speak out. My friend saw an area where a health care agency was failing a group of patients. Because she didn’t have to fear retribution in the form of being hauled up in front of Human Resources, she was able to effectively advocate for patients (who in this case happened to be too frail to advocate for themselves). Eventually, due to her persistence, the agency recognized their errors and fixed their flawed process.

In much the same way as we explore transforming the health system again (in Ontario these are to be done with the Ontario Health Teams or OHTs), it is fundamentally important to ensure that physician autonomy is protected in these models. This will allow physicians to speak up if the implementation plans are not going the way they should, or if programs promoted by the leaders are not really going to help patients. While painful for those in charge to hear criticisms, it results in better outcomes in the long run because the new programs will be better, stronger and more effective.

Let’s hope that as the new OHTs are developed (full disclosure, I support the concept) the message of the essential nature of physician autonomy is not lost. Physician autonomy has allowed us to be the best possible advocates for patient care in the past. If we can no longer, as Ginsburg urged, fight for the things we care about, it will be the patients who suffer.