Day One: Part V
Fixing health care in Canada doesn’t require building more hospitals, or investing in sophisticated new technology, or expensive breakthrough drugs. The most important thing, according to some Western University experts, is to make sure every Canadian has easy and regular access to a primary health-care provider. And we could make it happen tomorrow with the resources we’re already using today.
“There is extremely strong evidence, hard medical evidence, that this relationship, that connection over time with a trusted health-care provider, produces better health outcomes and saves money,” says Dr. Danielle Martin, MD’03, DSc’22, chair of the department of family and community medicine at the University of Toronto and a practicing family doctor at Women’s College Hospital in Toronto.
A founder of Canadian Doctors for Medicare, Martin is a well-known advocate of Canada’s universal health-care system. She’s also a reformer and has joined with others who say Canada needs to concentrate on fixing our primary care model—the routine, day-to- day care offered to a patient by a family doctor or other health-care provider.
The problems in Canadian health care are well known. One in five Canadian adults don’t have a regular family doctor. More than one-third of patients who needed a joint replacement had to wait more than six months for surgery. Hospital emergency rooms are overrun, to the point some doctors have written open letters warning of imminent collapse.
And yet Canada doesn’t skimp on health care spending. At an average of $8,563 per person per year, Canada spends more than most other wealthy countries.
Our real problem, say Martin and others, is in how we organize—or fail to organize—health care. They believe we need to reshape our system around primary care.
“Primary care is the foundation for the rest of the health-care system,” says Maria Mathews, a professor in the department of family medicine at the Schulich School of Medicine & Dentistry.
“The primary care provider is supposed to know the patient well, is supposed to understand their individual circumstances and take a really patient-centred approach. Primary care is like the quarterback in the health-care system.”
With adequate primary care, a lot of the stress on the rest of the system is reduced. People don’t crowd emergency rooms looking for treatment a family doctor could give them—and they stay healthier longer.
“When people’s preventive care and the management of their chronic diseases are deferred and delayed, they end up in the hospital with more acute issues, and it’s more expensive,” Martin says.
But fewer doctors are deciding to practice family medicine than ever. “We would like 50 per cent of Canadian medical school graduates to go into family medicine. Only 30 per cent do, with the rest becoming specialists,” says Mathews, who holds a Canada Research Chair in Primary Health Care and Health Equity.
She adds that fewer of them are attracted by the old lone practitioner model, in which an individual doctor hung out a shingle and practiced solo. Many working under that system have felt increasingly burned out by the lack of support, the demands of an aging patient population and ballooning time requirements for paperwork and electronic medical records.
An increasing number of advocates are calling for a different model for family medicine—a team-based approach that makes it easier for doctors to work in groups with other doctors, as well as with nurses and nurse practitioners, pharmacists, and even educators and social workers.
The idea is that doctors will get more support from colleagues, and the teams can provide more care, more efficiently. A nurse practitioner on the team might see patients for routine vaccinations and medical tests, for instance, and refer them to the doctor only for something that requires an MD’s skills.
The health-care system quarterback: Primary care providers are supposed to know the patient well, understand their individual circumstances and take a patient-centred approach
The team-based approach could help get every Canadian a primary care spot within 30 minutes of their home. That’s a goal set by the Taking Back Health Care project, a group of reformers to which Martin belongs.
The group says Canadians should expect access to primary care the same way we expect access to primary education for our children.
“If you move into a neighbourhood, anywhere in this country, your kid has a right to go to the local public school,” Martin says. “You don’t have to go and beg the principal to let them in, you don’t have to ask around if anybody knows of a Grade 3 teacher who’s taking students.”
Lauren Cipriano, BSc’03, HBA’05, is also in favour of integrated primary care teams. She is an associate professor in management science at the Ivey Business School, and Canada Research Chair in Healthcare Analytics, Management, and Policy.
Cipriano thinks integrated teams would help Canadian medicine return to the ideal of delivering compassionate care centered on the individual patient.
“As we’ve emphasized technology and expensive drugs, that’s something that’s been lost. When we think that technologies will treat patients, we’ve missed an opportunity for patient-centred care,” she says.
Cipriano says the government should spend less money on expensive drugs and technologies that don’t give as much value for the money as basic care.
“Our system is often attracted to the new, and sometimes new technologies are really revolutionizing health care and the health of patients. But some are just marketed well to physicians and to patients,” she says.
There are many other reforms that should be made, she says. A public drug plan would make sure people can afford the medications they need. Canadians currently pay the third highest drug prices in the world. Cipriano says more aggressive price negotiations by the pan-Canadian Pharmaceutical Alliance would ensure resources are available for other types of health care including surgeries and mental health support for which there are long waits.
But the emphasis should be on reforming how primary care is delivered, Martin says.
The changes don’t require lots of new spending or big technological breakthroughs—only commitment and strong leadership from government and medical leaders.
“If we declare a national goal and then we take all of the existing resources in our systems and we put them in service of that goal, I think we can do it.”