ONTARIO SOCIETY (COALITION) OF SENIOR CITIZENS' ORGANIZATIONS
ROMOANOW COMMISSION PRESENTATTION
SPEAKING NOTES
Commission on the Future of Health Care in Canada
Sudbury, April 11/02
Ethel Meade & Don Wackley
Co-chairs, OCSCO
Good Morning! And thank you, Mr. Romanow, for this opportunity to present our views.
I want to start with a statement that I hope you have heard many times in the course of these hearings: OCSCO supports a completely public system. We want no room for the profit motive to drive any decisions concerning our health care
We can't help being aware that there is an active lobby recommending more private sector participation in the delivery of health care. Such proposals are based on the unquestioned assumption that the profit motive automatically makes for more efficiency. Experience does not bear out this assumption.
We have a glaring example in Toronto, where, for some time, a shortage of radiation technologists had meant dangerously long waiting lists for radiation treatments of breast and prostate cancer patients.
The first response to this problem was to finance Toronto patients to travel to northern Ontario or American border cities, where they could receive treatment promptly. This was, of course, a very expensive solution, involving travel, hotel and meal costs reimbursed to the patients.
After many months of this expensive procedure, our Health Ministry decided to let the private sector solve the problem. And at your Toronto hearings we had to listen to Ontario's Health Minister, proudly citing this as an example of how the private sector can provide care cheaper and faster.
The private sector in this case consisted of a new private company, headed by the former head of Cancer Care Ontario, who resigned his position to start the enterprise. This company is now providing the radiation treatments without dangerous delay and, as the Health Minister said, there is no cost to the patient.
But they are doing so at a higher than necessary cost to the public system. It only sounds like a saving when you compare it to the cost of sending patients away. Actually, they are being paid extra amounts to do what could readily have been done by the publicly funded hospital. They are using the hospital's own equipment to do it and have solved the shortage of technicians by offering high overtime rates to those already working in the system.
Nothing was added to the system by this new private company, except for the salary of the CEO, plus who knows how many administrative assistants and, of course, the profits for shareholders. The hospital could have offered the same premium overtime pay to technologists and used their own equipment after hours. And they could have done it with a much smaller addition to their funding than is now being paid to the new company.
Another example of using the private sector without benefit to the system is the contracting out system, which our Community Care Access Centers are forced to use. We have explained this in our written submission but will omit the explanation in order to keep within the time limits
I want to speak now about two segments of our health care system which are of special concern to seniors.
First, Primary Health Care Reform
Canadian doctors have responded, perhaps predictably, to the perverse incentive presented by our system of fee-for-service and guaranteed payment. Many have come to think of themselves as entrepreneurs, small businessmen, who have fixed expenses but, naturally, strive to increase their revenue by any means the law allows.
The advocates of increasing private sector involvement are fond of saying that health care costs are driven by insatiable patient demand. The fact is that costs are driven just as much by physicians' decisions. These decisions may represent doctors' best clinical judgement, but they can represent, consciously or unconsciously, the easiest way to maximise their income. Eliminating the fee-for-service payment method, especially for family physicians, can only enhance the sustainability of our public system.
The perverse incentive of fee-for-service is by no means the only reason that the reform of primary health care is essential to the future of our health care system. We face a steadily increasing shortage of physicians outside of large cities, and sometimes even within them, To sustain our public health system we must make the most effective use of all our health professionals.
Primary health care must be re-organised into teams of health professionals, including nurse practitioners, nurses, midwives, dieticians, podiatrists, social workers and other therapists, as well as family physicians. Many procedures performed by solo practice doctors could, for example, be performed competently by nurse practitioners. One doctor can take responsibility for many more patients if he or she is relieved of these routines.
Ontario's community health centres provide an excellent working example of primary health care thus organised. The experience of senior patients in community health centres has been very positive, because the salaried doctors who work there have time to talk with them. Senior patients, who are often managing several chronic conditions, appreciate seeing a doctor who has time to consider today's problem in the context of all their health problems.
There are many times, too, when talking with a nurse practitioner may offer just the kind of advice, reassurance and routine checks that a senior patient needs. And the importance of dieticians in supplementing the lifestyle counselling of doctors and nurse practitioners is self-evident. Moreover, now that the social determinants of health are widely recognised, the services of social workers on primary health care teams add an important dimension to patient care.
Primary health care centres can establish extended hours, home visits and on-call systems, to guarantee that medical help is available around the clock, not just during office hours. Senior patients particularly, who may find any unfamiliar symptom alarming, need after-hours access to care and advice. If it is not otherwise available, they frequently resort to hospital emergency rooms, already overburdened by bed and nursing shortages.
By making the most effective use of all our health care professionals, re-organisation of primary health care can make our whole health care system more sustainable.
To do so will, of course, involve substantial changes in attitude among both patients and health care professionals, particularly physicians. To save time, I will not elaborate on the required attitudinal changes, which we have explained in our written submission.
Federal-provincial co-operation is clearly essential to make any design for greater sustainability effective. The federal government should establish the principles for primary care reform. And it should fund whatever incentives are needed to persuade family physicians to leave fee for service behind. But such funding will need to have strings attached, unless provincial governments' attitudes are changed in the negotiating process.
Our second concern is with Home Care
We appreciate the federally funded National Evaluation of the Cost Effectiveness of Home Care and the important work they are engaged in. The recently released study by Dr. Marcus Hollander has established an important point that health care activists have been maintaining for years. He proved, from the health insurance records, that it is cost-effective to provide homemaking and personal support services for persons with age-related disabilities. Over a three-year period, those receiving such services made less visits to their doctors, made less use of Emergency Rooms and acute care hospitals and were less likely to enter facility care than those who had been cut off from such low-level home care services.
Hollander's findings take on special significance in Ontario, where inadequate and frozen budgets, combined with Ministry-directed priorities, are forcing the Community Care Access Centres to use more and more of their resources for the care of the very sick patients being discharged from our hospitals. The policy directive to take care of the sickest first, means that the availability of home care to let seniors "age in place", has to give way to the use of home care for patients discharged sicker and quicker from hospitals.
An effective balance between institutional and home care is essential to making our health care system sustainable. In the absence of national standards, with home care falling legally outside our publicly funded system, our progress towards an effective balance is greatly hindered.
The change needed is for home care to become recognised as a medically necessary service governed by the principles of the Canada Health Act.
CONCLUSION
We have discussed two of the areas where re-organisation would make the system more sustainable. A third, which is dealt with in our written submission, is Pharmacare and changes in the workings of our patenting system.
But we think that sustaining our system is not compatible with the priority given, both provincially and federally, to tax cutting. Tax cuts, especially for corporations and for the wealthy, should be abandoned. And, yes, we do think that more funding, especially from the federal government, may well be necessary.
Would we agree to tax increases if necessary to sustain our system? We say yes, as long as the tax increases do not touch our low-income citizens. Some people say they can afford to pay for care for themselves and they should be allowed to do so. On a personal note I say: "Yes, I could afford to pay for some care, though not for any catastrophic illness. But I would rather pay higher taxes so all Canadians can have care than to use my resources just to take care of myself."
Thank you.
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