Saturday, February 18, 2012

Rethinking Health Care

Health care and education (K-PhD) costs are equal to 65% of the expenditure by the Government of Ontario. Unless something changes, health care costs are anticipated to rise by 3% each year while education will grow at between 1.5% and 2% - all below inflation. Costs aside, Don Drummond in his major report on the future of Ontario observes that the outcomes derived from health care spending do not match expectations and that such spending for such outcomes means that the health system is unsustainable in its current form.

His point is simple. Ontario, like most jurisdictions, does not have a health care system. It has health care “bits and pieces” which operate in parallel, sometimes at cross-purposes and are poorly connected. Time, money, skills and energy are wasted by patients, staff and administrators in a system which is no longer fit for purpose. “We could do better”.

The issue is only partly about costs – it is more about design and systems thinking. The challenge is to create a system that reduces the need for medical care by focusing on the public and personal determinants of health and well-being: healthy lifestyles, healthy communities and good quality water, air and environment. The challenge is to rethink health care: throwing more money at the current system will only make matters worse, not better.

The same debate is taking place in England and Wales. The British parliament is debating The Health & Social Care bill which, if enacted “as is”, is intended to:

(a) integrate front line health care into primary health care clusters managed on a regional basis;

(b) reduce complexity and administrative burdens within and on the system by focusing more resources on patient care than on reporting patient care;

(c) enable local GP’s to commission services from the “system” on behalf of and with the involvement of their patients – the GP becomes the broker of all health services, rather like a travel agent – pushing decisions to the front of the system (the GP) rather than to the back (the hospital);

(d) create a stronger public and private market for the services which GP’s buy – still free at the point of care to the patient (unless they chose to pay);

(e) the work of the system will be overseen by five separate bodies, looking at different aspects of systems performance;

The politics surrounding this Bill are a mess. Its one of the worst examples of reform and change seen in a long time and has very few supporters, even within Government.

They key problem, it seems, is that it does not begin with an evidence based analysis of the system as is nor does it articulate a clear vision of what might be – we simply have ideologically driven reform, badly handled with little engagement and consultation with those who will be most affected. Failure is predicted.

But we do need to rethink health care to put more emphasis on prevention, public health and personal responsibility. We do need to design an integrated system of care driven by patient need, not structure. We do need to train our professionals to work closely together and respect and fully use the skills of, say, nurse practitioners, pharmacists, rehabilitation therapists and those who work in eldercare.

We also need to find alternative strategies to reduce the incidence of self-induced illness – obesity and its related consequences, smoking related cancers, addictions and other life-style choices. We need to rethink health care.

In doing so, we should not look to the UK current reforms as a prescription for a healthy care system.

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