Shaping Health Care for the Millennium

Our health-care system has been an important and defining feature of what it is to be Canadian. It reflects a vision of health for Canada and Canadians that was articulated over 30 years ago with the creation of Medicare, and was reaffirmed in the eighties when Parliament passed the Canada Health Act.

Rex Murphy of CBC fame describes Medicare and the principles it espouses-public funding and universal access-as this country's Magna Carta and Declaration of Independence combined.

On the cusp of the new millennium, it is appropriate to reflect with pride on our nation's past but it is also a time to reflect on and reaffirm our vision of health care for the future.

The new century will present us with many new health challenges to meet:

- A growing and aging population;

- Increased knowledge with corresponding advances in technology and research;

- Empowered health-care consumers; and

A broadening of emphasis from cure to include prevention and rehabilitation.

Public debate and input is essential to determine the direction of our health system. There must be a collective societal vision of health care-whether it is a reaffirmation of the principles of our current system or a new vision altogether-to drive the renewal of the system.

The art of balancing the needs of patients with the cost of care has proven to be very difficult. The combination of medical excellence and medical expense left us facing a dilemma entering the 1990s. While medicine's possibilities seemed limitless our purse strings were not.

It is this dilemma and its impact that has fuelled the health-care debate across Canada, and it is this dilemma that demands that we articulate our vision of health care for the new century.

The Canadian Medical Association strongly supports public sector funding for necessary medical services. And we can speak very forcefully to what we believe must be the cornerstones of a health-care system:

- Patient focus; - Quality;

- Accessibility; - Research.

The health-care system is not about hospitals or economics or doctors or nurses. It is there for one reason only. To be accessible in a timely fashion and without barriers to provide good quality care for Canadians-for patients-when and where needed. Our health-care system must be focused on patient care.

The rights of privacy and consent are essential to the trust and integrity of the patient-physician relationship. That is why the CMA developed its Health Information Privacy Code. The CMA has taken this message to the federal government to ensure that in an age characterised by the growth of electronic information, its legislation on electronic documents must recognise that health information requires stronger privacy protection than other types of information. Putting privacy first comes down to putting people first.

Experts have struggled for decades to formulate a concise, meaningful and generally applicable definition of quality health care. As quoted in recent articles in the New England Journal of Medicine the quality of health systems must be judged by their capacity to promote health, reduce disability and enhance quality of life, and not solely on their capacity to provide life-extending treatments.

Quality means meeting specific requirements:

- Safety for the patient;

- Competence and availability of the service provider;

- Acceptability of the treatment; o Accessibility to/for the patient;

- Efficiency of service delivery, and

- Appropriateness and efficiency of the treatment;

All within the current state of knowledge and resources.

The CMA believes that access to quality health care should be based on needs and reasonable expectations of patients and quality of life considerations, and should encompass the full continuum and process of care.

To quote the Toronto General Hospital: "Today's research is tomorrow's quality care."

The CMA is very supportive of the creative initiatives that are being undertaken to improve health research within the broad context of the Canadian Institutes of Health Research, and to improve health information through the expanded mandate of the Canadian Institute of Health Information.

In fact, just last week the CMA presented its views on the importance of health research to the House of Commons Standing Committee on Health.

Now it is important to say that I, and indeed the CMA, believe that Canada still provides better access to health care for more of its population, without barriers, than anywhere else in the world.

But to maintain and enhance access and quality, we must take action now. To quote Canada's Health Minister, The Honourable Allan Rock: "Canada's system of Medicare will not be able to provide Canadians with timely access to quality care in the years to come unless it is renewed substantially through innovation and collaboration. I believe that the status quo is not an answer." The CMA would agree with Minister Rock.

I would like to focus now on two of the many factors that can determine how we can renew our health-care system: funding and the health-care work force.

For Canada's health-care system to not only survive but thrive in the new millennium we must ensure that adequate, long-term funding is available to meet the health-care needs of all Canadians.

A well-educated, aging population with high expectations together with advancing knowledge and technology will put a level of demand on the health-care system that has not been seen before and will place additional pressure on health expenditures.

The CMA believes a well-funded, sustainable, quality health-care system must be at the forefront of the federal government's strategic priorities.

Just as strong economic fundamentals are generally viewed as an essential requirement for Canada's prosperous future, stable, adequate and, where required, increased resources for health and health-care funding should also be considered as an investment in the future well-being of Canadians, and by extension our economic ability to compete.

As our Prime Minister said in an address to Michigan State University in May of this year: "In Canada, we consider Medicare to be the best example of how good social policy can be good economic policy, too. While reflecting the desire of Canadians to show compassion for their fellow citizens, Medicare also serves as one of our key competitive advantages."

The federal government in its 1999 budget took an important first step. The re-investment of $11.5 billion into health care was recognition of the need to infuse funds into a failing system.

What immediate and successive steps will be taken by the government to place the funding of our health-care system on a longer-term and sustainable basis now become the critical issues.

Canadian physicians, nurses and others dedicated to health and health care are not alone in the view that there must be a full restoration of the funding. A Communique issued by the First Ministers following their 40th Annual Premiers Conference in Quebec City was clear in the interpretation of sustainability: "Funding is the key for health sustainability."

Last month the CMA and other members of HEAL, the Health Action Lobby, appeared before the House of

Commons Standing Committee on Finance as part of the pre-budget 2000 consultations.

Some key concerns raised in our brief were:

- The recommendation that the federal government move to re-invest an additional $1.5 billion for health care to facilitate continued system stabilisation as well as further development towards an expanded continuum of care.

- The need to index cash entitlements through an escalator in the Canadian Health and Social Transfer to ensure that the federal cash contribution will continue to grow to meet the future health needs of Canadians. The escalator formula recognises that health-care needs are not always synchronised with economic growth.

- The introduction of a health-specific portion of federal cash transferred under the CHST Canadians want and deserve to know if their tax dollars are going to fund the programmes for which they were intended.

The Auditor General's report recently noted the lack of accountability in much of the federal government's health-care spending.

Good economic policy and good health policy are compatible and interdependent. They should not be in competition. While good health contributes to our individual quality of life, a healthy population is essential to Canada's ability to be industrially competitive.

The viability of our health-care system is also dependent on the health-care work force. An adequate supply of qualified health-care professionals is essential. We do not have that today.

Every province and territory is currently facing a nursing shortage-quality full-time nursing positions are rare-and specialty health-care areas have decreased access because of a shortage of certified specialty nurses. The Canadian Nurses Association has projected that there will be a shortage of more than 50,000 registered nurses by 2010.

When it comes to physicians, it has long been recognised that there are supply and distribution problems in rural Canada. In Ontario, the Ministry of Health has designated more than 70 communities as not having sufficient doctors. The problem is no longer confined to rural and remote areas.

Many of the communities are urban centres such as Windsor and Kitchener-Waterloo. A similar picture exists in all provinces and territories.

A public opinion poll commissioned by the Canadian Medical Association in August 1999 revealed that 61 per cent of Canadians do not think that we have enough doctors practising today to meet our health-care needs.

Many factors influence physician resources:

- A 17-per-cent reduction in medical school entry class size since 1991.

Patterns of practice are changing as young physicians and female physicians, who now make up 46 per cent of physicians under 35, want a better balance between their professional and personal lives.

- An aging physician population. Today 6,000 physicians are 65 years of age or over, including 2,000 that are over 70.

The situation today has set up an unfortunate cycle of decreasing resources, increasing workloads coupled with deteriorating working conditions that push physicians and nurses towards the generous employment offers from the U.S. and other countries-or away from health care altogether.

The brain drain has resulted in a net loss of approximately 400 physicians per year during the past decade.

That's 4,000 doctors. In 1996 the equivalent of 56 per cent of Canadian nursing graduates emigrated to the United States.

The departure of each one of these physicians and nurses represents the loss of a major public investment in highly educated, skilled and dedicated practitioners. Depending on the size of the community, the departure can have a devastating effect on the service provision in the area. The loss has a direct negative influence on the quality and continuity of care.

We are currently experiencing shortages in family practitioners, and in many of the specialties such as anaesthesia, obstetrics, paediatrics and psychiatry.

Medical training is a long process. It must be recognised that from the time of entry to medical school it takes on average six years to train a general practitioner, eight to nine years to train most specialists, and 11' years to train a cardiac surgeon.

All levels of governments, physicians, and other health professionals must work together in ongoing consultation to provide a balanced and integrated health-care work force. There should be a transparent process and an absence of coercion.

The Canadian Medical Forum representing all national medical organisations met with the federal, provincial and territorial Ministers of Health in November to present its findings and recommendations on the issue of physician shortages.

In order to meet the needs of a rising population Canada needs 540 to 600 additional doctors annually. The Canadian Medical Forum recommended:

- An increase enrolment in undergraduate medical education to 2,000 by next September to meet future needs; and

- The expansion of postgraduate positions as part of short- and long-term strategies to increase physician supply.

Increasing post-graduate training positions would allow for greater flexibility in career choice, enhance opportunities for re-entry into specialty training and enhance opportunities for the appropriate assessment of qualified international medical graduates.

Additionally we must engage in a creative programme of recruitment and retention of Canadians physicians, including the repatriation of those who practice outside Canada.

If we are to avoid what appears to be a significant worsening crisis, planning for the future must begin now.

The past years have taken their toll on the health professions. Many physicians are disheartened, frustrated, angry or depressed. Physicians, indeed most health-care professionals, feel that they have not been an important part of the decision-making process.

It is important to remember that improving the quality of goods and services in any sector of the economy including the health-care sector-requires the active participation and leadership by the people who do the day-to-day work of producing those goods and services. The involvement of physicians, nurses and other healthcare professionals in the measurement and management of quality care is not simply desirable but also essential to the improvement of quality. Physicians are willing and waiting to bring their expertise, without prejudice, to decision-making tables.

And we are reaching out to our colleagues in nursing and other health professions, to business, to governments and to consumer groups. We are building alliances and constructive partnerships across the country to build a vision together for health care into the next century.

But the consumers of health care must also be actively involved in discussions. L.L. Golden, in his 1962 book about the crisis in the steel industry in the United States, reminded all of us that in the end we are mandated to do what we do "Only By Public Consent." That is why I am delivering my message here today. You are the opinion leaders; your action can make a difference. As heads of business and leaders of communities, you overcome complex challenges.

I am calling on you today to join the team. To encourage thoughtful dialogue and debate. To push for creativity and responsible accountability as we shape the healthcare system for the next century.

I can assure you that the CMA, Canada's physicians, want solutions so that the health-care system is there for you when and where you need it.

I would like to close with a definition of excellence-a driving force in my life.

Excellence is:

- The result of caring more than others think is wise; o Risking more than others dare;

- Dreaming more than others think is practical; o Expecting more than others think is possible.

Let us all-each one of us-make a commitment to excellence. That commitment, our courage, determination and perseverance will take us where we need and want to be to assure a sustainable health system and a healthy population vigorously contributing to the productivity of our nation.

None of us can do it alone, but by supporting each other we can face the challenges and opportunities ahead-and create something very special. Together we can do it.

Canadians both demand it, and deserve and expect no less.

Thank you.

The appreciation of the meeting was expressed by Catherine Steele, Vice-President and Partner, GGA Communications and Third VicePresident, The Empire Club of Canada.