Medicare in Canada

COLONEL ROYCE:

Senator Sullivan, Reverend Sir, honoured guests, ladies and gentlemen

About three thousand years before Christ, a man named Imhotep, physician to a King Zoser of the third dynasty in Egypt, was such a successful doctor that he was regarded as a god and a number of temples were erected in his honour. On the other hand, as Sir James Frazer points out in his classic "The Golden Bough", the life of a professional medicine man was precarious indeed-possessing none of our modern scientific knowledge, he dealt with primitive savages who not only expected him to understand nature but also to influence it. And one error--such as a failure to produce rain when required-could and often did result in his disappearance from the scene in a painful manner. And yet, the mere fact that some members of these ancient civilizations appeared to possess special powers and were there fore provided with the means of livelihood in order that they might give their undivided time to the study of nature and its phenomena was a great step forward and indeed these men hedged in on all sides by superstition, ignorance, taboos and forced to pretend to know a great deal while actually maintaining their knowledge at a level barely higher than that of their tribal comrades were the predecessors of the physicians and doctors of today and indeed all our research teams and investigators. The Greek physician, Hippocrates, lived six hundred years before Christ but his oath still guides our doctors today and his Hippocratic collection contains clinical records which for their clarity have never been excelled in the thousands of years that have passed since his time. Over the centuries, knowledge has slowly improved and William Harvey, before he died in 1657, had discovered the circulation of the blood which has been described as the one factor that lies behind every important medical advance since that time. Galvani with his study of nerves, Louis Pasteur and Robert Koch with their revolutionary studies of the germ doctrine of disease and, in our own time and in our country, Banting made his brilliant discovery of insulin while his contemporary in England, the late Sir Alexander Fleming, gave us penicillin-all these men over the ages have worked to make the profession of medicine a more useful servant to mankind. Nowhere in the world are professional standards higher than those we enjoy in Canada today and in this City of Toronto, we have institutions equal, or superior in their fields, to those of any other country.

There is a bit of verse that goes something like this: "Because of that Magna Charta which was signed by the knights of old, that in England today you can do what you like as long as you do what you're told." Any Canadian who has been exposed for a reasonably lengthy period of state medicine as practised in the United Kingdom, has formed rather strong opinions on the subject, both from his conversations with doctors and from the inevitable feeling that the personal relationship has largely ceased to exist. On the other hand, a large number of people in the United Kingdom, who had not received medical care in the past, are now receiving such care. Fortunately, in our study of the subject in Canada, we are starting from a better position than the British enjoyed and we also have the opportunity of learning from the serious mistakes made on the other side of the water and which our own Government here in Ontario is obviously endeavouring to avoid. It is a matter of the greatest importance to everyone of us that the doctor-patient relationship be protected, that research and post-graduate studies and all the other time-consuming, expensive steps taken regularly by our doctors to improve their knowledge and techniques be maintained and rewarded under any system of state medicine. I am sure we shall hear much further on this in a few moments.

Our speaker today is from that province which has provided the rest of Canada with so many famous men. I refer, of course, to Nova Scotia. Graduating from Dalhousie University, he pursued his post-graduate studies at the British Postgraduate Medical School, London, Maudsley Hospital, London, and Johns Hopkins University, Baltimore.

For many years he has held important offices in medical organizations and, at present, is Professor, Psychiatry, Faculty of Medicine, Dalhousie University, Head of the Department of Psychiatry, Victoria General Hospital, Head of the Department of Psychiatry, Camp Hill Hospital, Consultant, Psychiatry, Canadian Forces, Children's and Grace Maternity Hospitals, Halifax, and a Consultant, Psychiatry of Nova Scotia Hospital, Dartmouth. He is President of the Canadian Medical Association.

A Fellow of the Royal College of Physicians of Canada and the American Psychiatric Association, he is also a Member of the Royal Commission of Insanity and Defence in Criminal Law and many other organizations.

Gentlemen--one of Canada's outstanding physicians, who has also made a great contribution to the public life of our country in the field in which he is so well qualified, Dr. R. O. Jones.

DR. JONES:

Mr. Chairman, gentlemen:

It is a pleasure and an honour to speak to this distinguished body and to attempt to give you some statement regarding the attitude of the Canadian Medical Association on what is apparently one of the hottest issues in Canada at the present moment--"medicare" by which I mean the insurance of physician services to the people of Canada.

Let me say at the outset that I believe that all parties in this debate honestly wish to see Canadians provided with a high-quality medical care. One of the difficulties in obtaining this goal is the emotional heat and the suspicions which somehow seem to be stirred up by this medicare issue. Critics of medicare suggest that physicians are concerned about and oppose a physicians service insurance plan because of the fancied loss of what is regarded as our privileged position, especially having to do with the incomes of doctors. On the other hand-doctors in general, I think, suspect that at least some of the people most interested in introducing a medicare scheme in this country, have motivations which are not entirely the provision of high-quality medical care; that is, we have a considerable suspicion that the political advantages of introducing such a plan may not be entirely irrelevant. It would be best if we could set aside the mutual suspicion and make a united effort to give the highest quality of medical care to our fellow citizens. From the doctor's angle, as far as I know, no one has proposed a plan which threatens doctors' incomes. The Saskatchewan experience certainly would not support such suspicion. Indeed, there is a considerable attraction to the medical profession in the knowledge that they will be reasonably rewarded for every service they render -a situation which does not pertain at the moment. Despite this glimmering pot of gold at the end of the medicare rainbow, a great many doctors in Canada are concerned about the introduction of a universal plan for the insurance of their services because they honestly feel that the quality of care which they can give the Canadian public may be seriously threatened.

Medicine's concern in quality care is not of recent origin. My distinguished predecessor, a fellow Nova Scotian and the first President of the Canadian Medical Association, Sir Charles Tupper, in his inaugural address in 1867 had this to say, "It is not my province now to speak, but to listen; but I cannot refrain from saying that I trust our deliberations will show to the world that our leading objects are to protect the health and lives of the people of this Dominion." I believe that this statement of Sir Charles Tupper has characterized the Canadian Medical Association from this inaugural meeting, and that the activities of the Association testify to its concern for high-quality medical care. During this past year some 33 committees of the Association have worked on such topics as the improvement of medical education, highway safety, alcoholism, emergency medical services, and countless other matters all dedicated to improving the health of the citizens of Canada. Canadian doctors have voluntarily given many, many hours to this kind of activity, and have given this time I believe because of their professional ideals and ethics.

Let me not give the idea that medicine is satisfied with the status quo. Certainly, my profession needs, and recognizes the need, for many changes. We are sometimes called a conservative profession. The changes that have occurred in medicine in my own professional life time contradict this charge. As an interne, I had not heard of sulfanilamide or penicillin; in my own specialty the anti-psychotic drugs or electro-convulsive therapy had not been introduced. Indeed, almost everything I learned in medicine is now completely outdated. This kind of achievement does not result from a "stand-pat-resist-the-new-attitude," but we have learned in medicine that it is most important to introduce change slowly, to do nothing which is going to weaken the patient in the process, and to make sure that, in our efforts to do better, we do not do harm. This has been one of the primary principles of medicine, since the days of Hippocrates--first, do no harm. We would urge on government and on the public that in this important matter of medical insurance, we pay attention to this basic precept and not be pushed into new patterns of practice which may well do harm.

The Canadian Medical Association has given very considerable study to this problem for years. We have had committees on economics, committees on professional practice, committees on medical education, all composed of sincere and honest men, anxious to produce a more efficient way of providing our services to the Canadian public. Indeed, as a result of our deliberations, we requested the Prime Minister of Canada of that day, The Rt. Hon. John Diefenbaker, to set up a Royal Commission on Health Services to make a very thorough study of the health needs of Canada and Canadians. This Commission, under Chief Justice Hall, conducted such a study and there is very much in this study that one finds oneself in agreement with. Other very sincere reformers, both inside and outside the profession, have studied and brought forward other solutions.

All groups who have studied the medical problems of Canada have reached many similar conclusions--there are huge areas of agreement. Some of the most important of these are:

1. The need for markedly increased personnel of all kinds; that is, of course, doctors, nurses, physiotherapists, occupational therapists, and so on. To meet this need, we need vastly stepped up recruitment and one of the principles that must be borne in mind is, that any scheme for medical services must do more than gain grudging acceptance by my generation of doctors, but must be of such a sort that it will attract the best young people of this country to the health professions. This seems to me to be one of the greatest dangers in the introduction of new plans and, in all honesty, one already hears of young people who are turning away from medicine because of the present unrest. If we recruit people, we are going to have to train them and this means a marked extension of medical school facilities, not only in terms of bricks and mortar, but in terms of personnel. Personnel is already in exceedingly short supply. In the pre-clinical years; that is, the first two years of medicine, the Association of Canadian Medical Colleges tells us that at the moment there are some 130 unfilled positions in our present medical schools. One of the reasons why we cannot fill these positions is because of a lack of research funds and facilities. Good teachers will not settle in Canada, unless they have an opportunity to further their researches. This matter has been studied by many bodies, most recently in the Wood-Gundy Report, and all have come up with staggering figures about our needs for increased medical research. Let me emphasize that this is not to have large breakthroughs in medical knowledge, though that would be very nice and such things have occurred in Canada in the past, but because unless we do have adequate research facilities of our own, we cannot properly teach modern medicine and we will not attract or hold our qualified teachers.
2. All groups agree that we need a vast extension of facilities, hospitals, laboratories, and so on. We welcome the 500 million dollars Health Resources Fund for this purpose, but are disturbed that it is only for capital expenditure and does nothing to help the personnel problem outlined above.
3. All groups are exceedingly concerned by the very poor conditions in the mental health services in this country, e.g., almost 50% of the hospital beds of Canada. These hospital beds are generally being supported at a cost of $8 to $9 a day, as opposed to $28 to $29 a day in a general hospital-this in a field of medicine which is supposed to require a more expensive kind of care than others and, incidentally, almost entirely government administered for the last 100 years. Here is a real sore spot in the body-medical of Canada and we have urged that steps be taken to correct this. Up to date our urgings nave fallen on pretty deaf ears.
4. All groups agree, including the medical profession, that there are a group of Canadian citizens who are unable to pay for medical care because of their financial difficulties. We believe government has a real responsibility and urge them to provide total or partial help to Canadians who need it-we do not believe government should assume either the financial responsibility or the consequent power, resulting from complete and monopolistic control of the health resources of this country.

We would point out that at the present moment in Canada there are several plans for the insurance of physicians services, which have different features about them, e.g., the Saskatchewan plan and the Alberta plan. Neither the government nor ourselves, nor indeed anybody else have final answers to the complex problem of quality health services. One only has to look at the current unrest in Belgium and in Great Britain to support this view. In Canada we have a magnificent opportunity to observe plans with different features in action, and it is our contention that we should look carefully at these various plans before adopting an over-all plan which may very well be so rigid that it will take generations to change.

The viewpoint of Canadian medicine then is that we should get on with the immediate tasks I have listed above, and at the same time, we should continually study plans currently in operation so that we may eventually come up with a plan tailor-made for Canadians.

Until mid-summer of this year, we had some reason to believe that government authority agreed with us and we were somewhat complacent about the future of health care in Canada. This complacency was rudely jolted by the Prime Minister's announcement of July 19, listing his famous four points, and aiming at a universal medical care plan, compulsory, covering all the citizens of Canada, covering all the physicians of Canada, administered by a government agency to be initiated on July 1, 1967. The ardent proponents of this plan state that nothing is to change, but the way in which doctors will be paid. Apart from this, everything will remain the same. We must confess to some doubts. It is our belief that when any single agency controls all the funds to be devoted to a particular area, especially when those funds are limited, and the events of the last few weeks (including the recent budget of Ontario) would suggest that despite the more ardent followers of Keynesian economics, there is some limitation on the amount of funds that can be spent and when the agency which controls the funds, is a government agency, subject to competing pressures for other government expenditures such as highway, education, and so on, plus political pressures which we have learned not to despise, that this economic situation will of necessity create control over the users of the funds, both doctors and patients. Experience has shown that this type of over-all scheme inevitably produces a bureaucracy and this type of bureaucracy produces a demoralization of both doctors and patient, which makes for serious dangers to the public weal. Time does not permit discussion of many concerns. Suffice it to say that we feel that the very least that must be provided for in such an over-all scheme is the right of both doctor and patient to operate outside of an unsatisfactory plan with no loss of benefits to the patient and no penalty to the doctor. The provision of this so-called "opting out" right 1 believe to be an essential in any plant desiring the co-operation of Canadian doctors. Only in this way can we preserve our patients' right to receive and our right to provide the kind of medical care dictated by the patients' need and the doctor's conscience-rather than by the Deputy Minister or worse-by the Treasury Officer.

The present situation regarding the Health Resources Fund illustrates the ever-present possibility of such control. This Fund was set up to provide-in the Prime Minister's words--"Capital grants--for--research establishments, teaching hospitals, and medical schools." We welcomed this recognition of the need for federal aid in a most important area. We collaborated in the original planning, designed to set up the machinery to administer this fund. It seemed logical that the informed bodies in the training and research fields, for example, the Association of Canadian Medical Colleges, should at least be well-represented on the final administering body. We confidently sat back to await such action. On February 1, 1966 a 2-day meeting of Federal and Provincial Ministers of Health concluded. A communique emerging from this Conference reported as follows: "In considering the composition of the Advisory Committee, the Ministers decided that a body of this kind should consist of representatives of the Federal and Provincial Ministers of Health. The Advisory Committee would be empowered to call upon professional bodies for advice on technical matters."

The position of an on-call advisor to an Advisory Committee scarcely re-assures the informed professionals of this country that they will have much of a voice in planning for facilities which are of vital importance to them.

To return to the argument that all that is involved in present planning is a change in who pays the doctor. There are many practical objections to any complete third-party-payment arrangement--not the least matters of professional confidence and the control of over-utilization by both patients and doctors. More philosophically perhaps, one must wonder if such changes can be made without deleterious results to the profession concerned. In what follows I quote freely from a most informative book, dealing with our present problems, Medicine in Transition, by Dr. Iago Galdston, of New York City. Doctor Galdston quotes from the Right Honourable J. Enoch Powell, Minister of Health in the recent Conservative Government in Britain. Discussing the National Health Service, Mr. Powell remarks that the doctor finds himself, "in the situation of all who are confronted by that unique employer, the State, whose ability to pay, but not his will to pay, is for practical purposes unlimited." The Minister then argues that this situation is not peculiar to the medical profession and does not involve their status as a profession. He then proceeds to cast doubt on his own argument when he discusses the limitations on the physician's freedom to prescribe and asks, "If he cannot decide that, what is he to decide?" in the national health service, the physician is free to decide without regards to his patient's means, but not without regards to the government's restrictions. "This paradox," the Minister notes, "is enshrined in the famous words: Without prejudice to the doctor's right to prescribe whatever he thinks necessary in any individual case, a doctor may be called upon to justify the cost of his prescribing." Doctor Galdston comments, "The doctor in respect to prescribing for his patient is both free and not free, and yet is said to be uneffected in his professional status!" The Minister continues by stating that this paradox, manifest in numerous ways, is a derivative of "the relationship in which the doctor and the politician are placed by the needs of the health service," and describes this relationship as follows, "A contract for the performance of services not by one to the other, but by one to a third party and that third party, the patient, is someone with whom the contract is intended to leave the professional and personal relationship of the doctor unimpaired and uneffected. This," the Minister asserts, "is the heart of the difficulty." Doctor Galdston comments, "It is indeed for the intention to leave the relationship unimpaired, is under the circumstances, as impossible as it is laudable. It is impossible within the politician's framework which inevitably and invariably involves bureaucratic administration. In such administration, the paymaster becomes the most stark of owners and this kind of ownership is control. In Britain the National Health Service is virtually sole purchaser of the services of doctors and dentists."

Galdston concludes his remarks on the National Health Service, "What stands forth in terms of its effect on the profession is bureaucratization with all its attendant evils, principal among them the conversion of medical practice into the pursuit of a vocation rather than that of a profession .... In effect whether medicine is practised as a vocation or as a profession cannot but prove of great consequence to the recipient of medical care. It must effect the moral and intellectual fibre of the medical corps, it cannot but deleteriously effect medical education and the advancement of medical science. Only those ignorant or unmindful of historical experience, can doubt that these must be the inevitable sequelae of the bureaucratization of the profession and of the practice of medicine."

Let me add another telling voice to this debate. For many years the late Henry Sigerist, the Professor of the History of Medicine at Johns Hopkins University, a man who surveyed the Saskatchewan situation and was most influential in shaping the thinking of Mr. T. C. Douglas and who was an outstanding medical spokesman advocating the nationalization of medical service. Sigerist retired to his native Europe and in 1956 published Landmarks in the History of Hygiene. In this book he wrote, "Now that I am back in Europe, I am no longer in favour of Health insurance and I think that better solutions should be found. Health insurance in many a European country has become rigid and is in the hands of groups that have a vested interest in it. The machinery is frequently very clumsy and we generally find a tendency to perpetuate under an insurance scheme an outgrown type of medical service."

To conclude, Canadian doctors recognize and support the need for government aid in making possible high-quality medical services for a proportion of our population. They believe that this can best be provided by the provision of a voluntary plan, available to all Canadians with government subsidy to the individual according to his needs. In setting up such a plan they believe that the ancient but vital medical doctrine, "Do not harm"--Primum Non Nocere--should be respected.

Attention should be directed to first things first--personnel, training, and our mental health services. The introduction of a plan or plans should be constantly accompanied by research into their effectiveness and, especially, their effect on the quality of medical care. Mechanisms should be built in for the correction of faults which are bound to appear in any plan actually in operation. The freezing of patterns of medical care which will inevitably result from massive government intervention with centralized bureaucratic administration and with rigidly conceived rules, may well produce lowering of the quality of medical care exceedingly difficult to reverse in the future. Our ultimate goal is to retain that which is sound, precious, and essential in and to medicine and to the profession, and give up that which is harmful and outgrown or merely habit and not essential. To conclude in Dr. Galdston's words, "This adaptation must be attained by reasoned study, by consultative statesmanship, mindful of changing conditions but mindful also that whatever is grievously injurious and disruptive to the medical profession must prove evil to the people as a whole." To such a reasoned study and collaborative effort to improve medical services in this country with built-in self-corrective safeguards, the Canadian medical profession will gladly pledge itself.

Thanks of this meeting were expressed by Dr. H. V. Cranfield.