(Originally published as an Intelligence Memo from C.D. Howe Institute –November 6, 2019)
From: Duncan G. Sinclair, David Walker, Chris Simpson and Don Drummond
To: Canada’s health ministers
Re: Getting to a People-Centred Health System
Notwithstanding its iconic standing as one of Canada’s defining characteristics, medicare, our publicly funded health insurance program, is widely recognized to be in need of fundamental change.
It was designed primarily to ensure a younger population’s access to in-hospital and physicians’ services, divorced from ability-to-pay considerations.
But now we face a greater challenge to optimize the health and well-being of people, many of them aging, with multiple chronic conditions, some preventable. Once developed, few are curable but their ill effects can be significantly ameliorated by appropriate care. That appropriateness now involves many institutions in addition to acute-care hospitals, especially care in people’s own homes and communities.
The providers needed now to help people optimize their health are a range of different care givers working in teams; the care itself extends well beyond medical/nursing and other ‘traditional’ services to helping people also access the social determinants of health.
The system’s once narrow purpose is no longer sufficient; the disconnectedness and lack of communication among its elements is embarrassing. Begun as a component of Canada’s social safety net in a period of economic optimism now long past, the financial sustainability/affordability of health and healthcare services is also under serious question. So are the structure and future modus operandi of those services in a digital age not conceived of in medicare’s early days. It’s (over) time for a serious systemic re-think and major structural and operational change.
Start with the purpose.
Helping people to recover from the effects of their illnesses, injuries, and disabilities remains an important component of the larger, overarching goal of optimizing the health of Canadians, ensuring each individual has access to the services each needs to be as healthy and well as s/he can be throughout the whole of their lives.
So the basic purpose should be to foster wellness, the preservation of good health in addition to its restoration when threatened or lost. Achieving that requires nothing less than a culture change, a shift in focus from patients to people, helping the latter do everything they can to prevent their becoming the former. There is much that can be done to reduce people’s growing dependency on the so-called healthcare “system” were it to be genuinely person-centred and its goal primarily focused on people’s health and wellness.
Second, we must expand its reach. Hospitals and physicians provide essential services but so also do nursing and retirement homes, rehabilitation and mental health facilities, the providers of home care and other community services, including housing, income and personal security, respite, community support, and other health determinants.
How can we afford to expand access to this wider range of health-supporting services now financed primarily by users who can afford them and/or by charitable giving?
Other developed countries expand the range and effectiveness of their systems by using a greater admixture of public and private insurance and out-of-pocket spending, concentrating funding from their public purses on first-dollar coverage of those with limited private resources and incomes. With the same 70:30 split between public and private financing in Canada, we could easily do better to extend the reach of an expanded and real health/healthcare system to the whole of our population, the well off and the now largely excluded poor, to a much wider spectrum of health-supporting services.
And our so-called “system” should become a real one with all of its elements connected and smoothly and transparently co-ordinated. Fulfilling these characteristics (long overdue) of a functional system is within easy reach as the technologies of our digital age make informed communication increasingly easy among all elements of the system down to its very roots in the personal interactions between service providers and the individual people they serve.
Thorny policy issues remain to be sure, safeguarding the privacy of health records principal among them, but with good will and the beneficial result of healthier Canadians in mind, they can be resolved.
Let’s get on with the creation of genuinely people-centred health systems in every Canadian province and territory.
The views expressed here are those of the authors.