VIEWING healthcare as a policy concern due to rising costs and pressures on the system, in September 2006 British Columbia, Canada's westernmost province, launched a public consultation titled “The Conversation on Health,” inviting input on how to meet the challenges. The consultation closed on July 31, 2007.
Stated to be “the largest and most wide-ranging public discussion on health and our public health care system ever held in … our province,” the exercise revealed continuing strong support for nationally determined core principles for the provision of healthcare: universality, public administration and financing, comprehensiveness, and portability. Recognition also was apparent for the importance of sustainability and openness to innovation at all levels from governance to systems design and performance.
Our purpose is to convey an independent perspective on the process and content of this public consultation, emphasizing its primary healthcare (PHC) dimensions, which we believe are relevant to PHC development elsewhere in the Americas and globally.
Healthcare in Canada
Canadian healthcare is mostly a public sector enterprise, administered provincially using a single-payer system. Its core features are enshrined in the Canada Health Act (1984), the aim of which is “to protect, promote and restore the physical and mental well-being of residents of Canada and to facilitate reasonable access to health services without financial or other barriers” (Madore, 2003). The following 5 principles are upheld: public administration, comprehensiveness, universality, portability, and accessibility, all defined under the Act but open to interpretation. From the patient's standpoint, the system is virtually free of charges for hospital and medical care, approaching the aim of reasonable access to health services without financial or other barriers. Other elements are not fully covered, and charges generally apply for home care, long-term care, dental care, physiotherapy, and pharmaceuticals. Decisions to differentiate what is considered “medically necessary” within the framework of the Act are made at provincial level, because delivery of healthcare in Canada is a provincial responsibility. In British Columbia, the funded system of patient care is known as a medical services plan (a low-cost publicly administered medical insurance system); other provinces use similar mechanisms.
British Columbia (population 4.11 million) extends from the Pacific coast to much of Canada's Rocky Mountains (Statistics Canada, 2006). The economy is mainly resource-based: forest products, tourism, mining, energy, agriculture, and fishing being the main occupations. Manufacturing is expanding and diversifying. Although the capital is historic Victoria (population > 300 000), the city of Vancouver has a population of more than 2 million, of whom 43% have a first language other than English. This city is the main commercial hub and will host the 2010 Winter Olympics.
The population of British Columbia, a major destination for international and domestic migration, is aging demographically, with 28% now aged 45 to 64 years and 15% older than 65 years (Statistics Canada, 2006). Cancer is responsible for 21% of premature mortality and years lived in poor health, followed by cardiovascular disease (18%), injuries (12%), mental disorders (11%), neurological and sensory disorders (9%), and chronic respiratory disease (7%); all others are responsible for 22% (Hazlewood, 2006). Approximately 80% of residents have contact with primary care in any 1 year, making it the most important avenue for accessing health services. General practitioners (>4600) constitute the largest PHC workforce. More than 1.3 million people suffer from 1 or more chronic conditions, and more than 90 000 suffer from 4 or more. A recent agreement between the government and physicians focuses on system change, with new allocations for chronic disease management and encouraging general practitioners to pursue full-service practice (Ministry of Health, 2007).>
Focus groups and other meetings (78 sessions) were held with representatives of the general public, patients, and healthcare professionals throughout British Columbia. Electronic submissions were openly invited from organizations and individuals. An international symposium was held. The consultation is well recorded in a comprehensive (>1500 pages) document.
The public stream
All-day forums were held at convenient times in 16 communities over a 6-month period. Participants were registered in advance, and applicable travel costs covered. Each involved up to 100 participants, drawn randomly when registration exceeded this number. Participants set the morning agenda, identifying items to discuss in small groups. In the afternoons, they chose from a set of preset topics for facilitated group discussions. Focus groups were held in each community, up to 10 patients and their families to share experiences and insights. Since more older people attended, additional input from high school students was sought. Aboriginal community meetings were held, cohosted by 4 First Nations. Other communication avenues included a toll-free telephone line, an e-mail address, a Web site, and a mailing address; more than 12 000 submissions were received through these channels.
Health professional stream
Healthcare professional workshops were held in the same 16 communities, participants nominated by their associations and/or unions. Additional evening sessions were held to discuss issues of importance in facilitated groups.
Health innovation stream
This stream brought together experts, practitioners, and decision makers to study the best practices, innovative solutions, and ideas put forward by participants. It included a workshop series and an international symposium on health innovation. The latter attracted almost 150 thinkers, policy makers, and practitioners, mostly from developed English-language countries, to examine the best practices; speakers came from New Zealand, Australia, the United Kingdom, the United States, and Canada. The workshops were smaller in scope and participation, focused on key solutions identified in the domains of primary care, seniors and aging, human resources, and delivery models.
Following guidelines for submission, 61 electronic submissions were posted by organizations, and an additional 13 from individuals. Both sets reflected a wide range of perspectives, including, for example, professional bodies, provider organizations, industry, alternative practitioners, and community groups.
A Web site was updated weekly with transcripts of meetings, and all electronic submissions were posted. Topics ranged widely: environments and societies, financing models, and professional concerns. These were later compiled into themes to reflect challenges, issues, and ideas. The documentation was said to represent all views presented, not only those of the health ministry or other government entities: The Government does not endorse them, nor are they considered a consensus. The detailed summary of input is now accessible online (BC Ministry of Health, 2008).
PHC DIMENSIONS OF THE CONSULTATION
Throughout the conversation, as reflected in public forums and submissions, there was broad recognition that keys to improving population health and gaining health system efficiencies lie within the scope of PHC and that prevention, demand management, and self-management are all part of effective and efficient PHC.
Among the articulate contributors to this part of the debate was the BC College of Family Physicians, which made 3 submissions; one of these submissions included the following statement:
Primary Health Care is a relatively neglected component of the health care system. Some of the most effective and lowest cost health systems are based on a “primary care” foundation, supported by a thoughtful healthy public policy framework. This would represent a significant change for BC, but offers a chance to move from a position of conservative, timid change where … inefficient, inequitable, costly private health care alternatives (are) allowed to creep in by default…. (BC College of Family Physicians, 2007)
Other participants advocated a vision where practitioners other than physicians could serve as gatekeepers, for example, nurse practitioners, chiropractors, and naturopaths. An integrated team environment was envisioned with practitioners working together to provide the best possible patient-centered care plan for each individual. This, it was argued, would reduce the load on the acute care system by providing more entry points for patients, focused first on maintaining and improving health and self-care before turning to acute care (BC Ministry of Health, 2008).
Participants warned, however, that movement to such a system of PHC would require major adjustments, beginning with a new approach to remuneration and incentives for physicians (to compensate for activities that support community-based disease prevention and health promotion) and a new societal attitude toward health and healthcare. These would require a long-term change in management process, designed and managed effectively across the government and communities, with strong leadership for it to work.
Facilities, funding models, and accountability structures were explored around PHC models. For example, community health clinics were advocated as a means to encourage a health promotion ethic incorporating new types of practitioners. Also proposed were certain PHC services not currently funded by the medical services plan, such as preventive eye and dental examinations and care.
A key issue was whether PHC should be managed by regional health authorities (there are 6 in British Columbia): Some participants argued that this would provide a more holistic perspective on community health and better service the needs and demands of the population; others argued that this would add to the bureaucratic inefficiencies best avoided.
Patient advocates and navigators and case management
Given the complexity of the system, lack of continuity of care adversely affects both patients and acute care services. Patient advocates and “navigators” were proposed as means to help patients improve continuity (BC Ministry of Health, 2008). This need is especially relevant for persons with different cultural backgrounds and language barriers and for older people who may receive care from several practitioners as well as home care services. A navigator could help them understand the care they receive and how to take better advantage of it. An advocate could push for different care or services when they feel it could improve patient outcomes and avoid unnecessary acute care interventions. Participants also suggested creating a patient ombudsman to receive and follow up on complaints within the system.
In pushing for a more integrated approach, “case management” was explored as a process in which all practitioners would be able to appreciate all aspects of patient care so as to work more effectively together for the benefit of patients. Similarly, improved hospital-discharge planning could result in better service coordination after patients are released, thus avoiding unwarranted readmission and secondary health ailments. This vision was well expressed at a workshop on seniors and aging as
…a broad base of services, in an integrated and coordinated system of care, managed or facilitated through good quality case management so that there is a champion for each person that comes into the system of care … What this allows … is … much more seamless care for individuals … (BC Ministry of Health, 2008).
While ambulatory care may be defined as medical care of persons who are able to walk in and out of a clinic and provided by healthcare professionals, it is notable that self-care was a frequent conversation topic (Last, 2007; BC Ministry of Health, 2008). Numerous participants advocated a need to reduce reliance on professionals, which (for many) was linked to the perceived escalating costs of the healthcare system. In examining the barriers to self-management and self-care, participants suggested that although lack of knowledge is the primary barrier, it is important to consider accessibility and financial barriers as well.
The system's lack of incentives for self-education or self-discipline was troublesome for many who argue that patients receive little education or encouragement to care for themselves. Ideas for improving this situation included more school health education and government-sponsored information packages. Promoting the Internet and the media as public information tools, translation of materials into minority languages, and extending education to rural communities through mobile facilities were among suggestions to increase the accessibility of self-care resources. However, note was also taken of effective resources already in place that need to be more widely publicized, such as the ActNowBC Web site, the BC Health Guide (a 450-page handbook available free of charge to residents, also available online), and NurseLine that provides 24-hour toll-free health information and advice and overnight pharmacy information (ActNowBC Web site, 2008; BC NurseLine, 2008; Ministry of Health, 2005).
Chronic disease management
Because of the critical role of patients in managing their own health and the importance to this of ambulatory care options, it is relevant to examine briefly how the management of chronic diseases (CDs) was viewed (BC Ministry of Health, 2008). There emerged general agreement that British Columbia lacks sufficient CD education; that the public is not sufficiently informed to detect chronic illness early; and that gaps in information, services, and programs exist across a wide spectrum of conditions. Views were expressed that CD management facilities should provide more comprehensive care, that youth with chronic illnesses need better transition services to adult care, that many individuals in need of complex care do not have access to follow-up services in the community, and that an increase in CD prevalence creates longer waiting lists and overcrowding in emergency departments. Suggestions for improved CD management focused on integrating services and providing greater access. Some participants requested more coverage of treatment services and equipment (eg, blood pressure monitors, medical supplies, hearing aids, residential care, prescription drugs), arguing that these steps would increase community support for those with chronic diseases and assist prevention efforts.>
We now focus on dimensions of the conversation of potential international interest: public policy, performance, sustainability, health promotion and prevention, and PHC.
Public policy dimensions
Health is viewed as a public sector goal and responsibility throughout Canada (Madore, 2003). While the societal ethic of access to health as a human right lies at its foundation, the health system is not considered to exist in a vacuum: It is also seen in relation to costs and benefits for both individuals and society as a whole. The political commitment therefore does not mean any service at any cost; the very exercise of the conversation illustrates recognition of the importance of public consultation, so as to reflect the evolving consensus as to what to include or exclude and to manage health resources effectively and efficiently at all levels, from self to the system as a whole (BC Ministry of Health, 2008).
The overwhelming majority of inputs reveal that BC's health system enjoys wide public support. Its most valued features are enshrined in the Canada Health Act, as outlined in the Background section. However, while the Act resonates politically, not all of its founding principles are equally honored in their application. Nor are they equal in terms of need, supporting evidence, or affordability. Choices have always been made. Thus, even though “comprehensiveness” is one of the stated principles, in practice, this particular attribute has never been a reality as it refers under the Act to services deemed “medically necessary” in the context of 4 decades earlier when universal healthcare was first proposed in Canada. Elements still not adequately recognized include home care, long-term care, dental care, physiotherapy, and prescription drugs. A relevant question therefore is as follows: Will universality be applied in future to services not fully financed today?
Performance of the Canadian healthcare system
Globally, the question arises as to whether the underlying principles of Canada's universal system have actually delivered desirable health outcomes for its population. In partial response to this critical question, a systematic review of 38 studies recently confirmed that Canada's system leads to health outcomes that are favorable overall when compared with the US private for-profit system, at less than 50% of the cost (Guyatt et al., 2007). However, perhaps more relevant is WHO's landmark study, in 2000, of health systems performance in almost 200 countries, ranking the United Kingdom at 18th place, Canada at 31st, and the United States (most expensive healthcare in the world) at 37th. Most European countries performed better than Canada, while Australia's performance (similar sociodemographics) at 32nd place was virtually tied with Canada (The World Health Report, 2000). Several other countries scored better, for example, Singapore and Japan. In our view, Canada should study those systems that appear to be doing better and (while staying consistent with its core principles) be more prepared to innovate and evaluate new approaches.
Internationally, social determinants have a strong influence on the indicators of health and equity, which vary enormously both between and within countries (World Health Organization, 2008). In the BC provincial context, however, where the evidence for internal disparity is now well developed (Hertzman & Irwin, 2007) acting on this evidence should be the priority. The motivation should stem naturally from the social contract embodied within the aim of the Canada Health Act (Madore, 2003). When one looks at Canada's population health internally, it is obvious that there is still substantial inequity, both regionally (eg, northern regions, inner-city areas) and by population group (eg, First Nations). In this regard, however, the system does appear to be delivering improvements in equity. A new study (James et al., 2007) reveals that over a 25-year period, differences between the richest and the poorest quintiles in expected years of life lost amenable to medical care decreased 60% in men and 78% in women. Reductions in rates of death amenable to medical care made the largest contribution to narrowing the socioeconomic gaps. Continuing disparities in mortality due to causes amenable to public health suggest that public health measures have an unrealized role in further reducing these disparities.
To the extent that the system delivers on equity, it approaches this only for fully insured medical and hospital-based services, but where coverage is not universal, ability to pay is critical. This reflects how society views health as a public good, what it considers essential, the extent of equity it seeks, and the resources it is prepared to allocate. While the performance overall is positive, commitment and sustainability remain functions of values and political will.
Sustainability and cost considerations
For the purpose of the conversation, the BC Ministry proposed a sixth principle: sustainability (BC Ministry of Health, 2008). This was controversial, seen by some to threaten the founding principles, especially with regard to the potential for privatization (portrayed as a hidden agenda) (Smith, 2007), while others supported the need to formally recognize sustainability, most notably the BC Medical Association, closely reflecting the position of the Canadian Medical Association (“BC Physicians,” 2007). However, neither the BC Medical Association nor Canadian Medical Association positions resonate among all physicians, witnessed by the emergence of Canadian Doctors for Medicare, a nationwide organization that defends the system's public sector character (Canadian Doctors for Medicare, 2008). The Canadian Centre for Policy Alternatives is also active in the debate, arguing that government projections for rising healthcare costs are based on faulty assumptions, noting that demographic change is only a small cost driver and that inflation and population growth are the more dominant forces along with increasing technology costs. The Canadian Centre for Policy Alternatives observes that the cost of dying is high (a third to a half of a person's healthcare expenses in the final year of life) and that increases in prescription drug prices and a shift toward expensive drugs largely explain the growth in drug expenditures that are not accompanied by improved healthcare outcomes. They advocate that “cost efficiencies could be gained through a national pharmacare program,” that greater use of palliative care and “advanced health directives” would reduce the costs of dying, and that more thorough health technology assessment would ensure benefits more in line with costs (Lee, 2006). While international comparisons of health sector efficiency are problematic because of varying methods and assumptions, Canada ranked 5th of 24 OECD (Organization for Economic Cooperation and Development) countries in a 4-year pooled analysis while the United States ranked 13th (Raty & Luoma, 2005). While both countries are considered “technically efficient,” both incur relatively high expenditure on health systems (Liu et al., 2006). Clearly, there is a lot of room for improvement.
Health promotion and preventive medicine
To the extent that health systems fail, especially with regard to addressing priority needs with equity (universality, accessibility, and affordability), this most often results from failing to deliver for groups lacking power or recognition (White & Nanan, 2008). However, when engaged in public debate about healthcare, as a society Canada tends to focus on high-cost items that preoccupy institutional administrators, often overlooking the fundamentals that preserve health: healthy environments and workplaces, primary prevention (eg, nutrition education, immunization, antenatal care, physical activity, and smoking prevention), and social policies (affecting literacy, employment, crime, housing quality, and community well-being). These are the “upstream factors.” Society also has become so preoccupied with acute care issues, which are crisis-prone and often glamorized, forgetting not only the upstream factors but even downstream ones (eg, long-term care, home care) whose availability determines the speed with which acute care patients may move on to more appropriate levels of care.
It is, therefore, timely to reexamine what services should be core or essential, to reconsider what is indeed “medically necessary” with emphasis on the more vulnerable (eg, dental care for children and the elderly) provisions for new parents (eg, maternity leave and child care), and to expand drug-benefit eligibility criteria.
In addition, there is a need throughout Canada to strengthen the response to the surging chronic disease burden. The international literature indicates that much of this burden is preventable by acting on modifiable behaviors (eg, smoking, fitness, and weight control) and that about half of those who do develop these conditions can be prevented from progressing through more rigorous attention to secondary prevention (eg, blood pressure screening and glucose monitoring for persons with diabetes).
The conversation revealed broad recognition that keys to improving population health and gaining health system efficiencies lie within the scope of PHC and that prevention, demand management, and self-management are all part of this. Already convinced of the need to strengthen PHC, the Ministry of Health launched a new PHC charter even before the conversation had concluded (BC Ministry of Health, 2007), declaring 7 priorities: improved access to PHC, increased access to primary maternity care, increased chronic disease prevention, enhanced management of chronic diseases, improved coordination and management of comorbidities, improved care for the frail elderly, and enhanced end-of-life care.
A broader vision still for PHC emerged from the conversation: emphasizing population health and focused on integrating the services of practitioners to improve continuity of care, including health promotion and disease prevention, all supported by new facilities and funding (BC Ministry of Health, 2008). In this vision, patient “navigators” and advocates would support case management and discharge planning with the aim of keeping people healthy and helping them manage their own care. In examining the issues surrounding self-care generally and chronic disease management in particular, there was wide recognition that people must be enabled to take more responsibility for their health. This is a central principle of the Ottawa Charter on Health Promotion (1986) (World Health Organization, 1986); many participants also recognized that investments in PHC that work toward this vision would yield long-term cost savings.
While ideas about PHC ranged from pragmatic to idealistic and positions ranged from maintaining the status quo to visionary, as in all health services planning, the transformational challenge is not how to come up with “good ideas” (which are plentiful, but often inseparable from their vested interests), but “the management of change”: How to move from the way things are to the way things ought to be, so as to evolve a more sustainable healthcare system with steadily improving outcomes (White, 1998). In this regard, an evidence-based approach seems critical and it is this message that is most readily translatable to other countries, regardless of the design of their health system.
The conversation revealed broad support for the view of health as a public good, more than sufficient to uphold the principle of public administration, and to curtail any drift toward private for-profit entities as an alternative for “medically necessary” services. Clearly, government must ensure a health system that is in compliance with the Canada Health Act. The challenge in achieving better performance necessarily must lie in improving leadership, priority setting, decision making, and management at all levels. While many believe that the present system is doing well, the budget is aligned with the status quo (ie, it supports established programs and approaches) and mainly a legacy from the early 1970s (when most provinces launched their version of universal “medicare”). However, whether this is the only formulation British Columbia is capable of and whether it is optimal remain open for debate. In our view, the time has come to expand the scope to include currently underfinanced subsectors, for example, pharmacare and dentistry and to do a much better job at technology assessment, health promotion, disease prevention, and palliative care. While there is overwhelming support that the health system must remain strong and sustainable, especially with regard to its universality, several lines of input also reveal a need for it to be more open to innovation, recognizing that the current model falls short of what many people and their organizations believe is implied and feasible under the Act. The conversation also revealed broad recognition that keys to improving population health and gaining health system efficiencies lie within the scope of PHC and that prevention, demand management, and self-management are all part of this. Whether the exercise has been worth the cost to the taxpayer (estimated $10 million) will be measured by whether future decisions and actions take guidance from it.