a cry for federal leadership in health and health care honourable carolyn bennett, m.d., m.p....

A CRY for A CRY for Federal Leadership Federal Leadership

ininHealth Health ANDAND Health Care Health Care

Honourable Carolyn Bennett, M.D., Honourable Carolyn Bennett, M.D., M.P.M.P.

November 19, 2011November 19, 2011

►Patient as PartnerPatient as Partner►Doctor MultidisciplinaryDoctor Multidisciplinary►Hospital CommunityHospital Community►Social Determinants of HealthSocial Determinants of Health

2

Sir Michael MarmotSir Michael MarmotChair, WHO Commission on Social Determinants of Chair, WHO Commission on Social Determinants of

HealthHealth

““The worst thing for a physician is to The worst thing for a physician is to help someone get well and then send help someone get well and then send them straight back into the situation them straight back into the situation that made them sick in the first place”that made them sick in the first place”

3

Canadian Institute for Advanced Research

25% health attributable to health care system

15% biology and genetics 10% physical environment 50% social and economic environments

HEALTH VS HEALTH CARE4

Humbling realityHumbling reality

►the health of our population the health of our population cannot be the sole cannot be the sole responsibility of Ministries of responsibility of Ministries of Health and the health care Health and the health care sectorsector

►address health AND healthcareaddress health AND healthcare►unlike other `industries` unlike other `industries`

less is betterless is better5

►Health Care delivery - provincial Health Care delivery - provincial Except Federal Government is the 5Except Federal Government is the 5thth biggest biggest

provider provider ►First peoples, military, veterans, RCMP, correctionsFirst peoples, military, veterans, RCMP, corrections

►Health of Canadians – sharedHealth of Canadians – shared Health promotion, disease preventionHealth promotion, disease prevention Social determinants of healthSocial determinants of health RegulatorRegulator Health researchHealth research

6

Goal of Goal of Medicare… Medicare…

►Sharing riskSharing risk getting people the health care they need getting people the health care they need

when they need itwhen they need it

►Keeping people well not just Keeping people well not just patching them up once they get sickpatching them up once they get sick

7

Canadian Health Care SystemCanadian Health Care System

► 1947: 1947: Saskatchewan’s Saskatchewan’s The Saskatchewan Hospital Services PlanThe Saskatchewan Hospital Services Plan is is passed in the Legislature – Hospital universal free coverage.passed in the Legislature – Hospital universal free coverage.

► 1957-58: 1957-58: Hospital Insurance and Diagnostic Services Act (HIDS),Hospital Insurance and Diagnostic Services Act (HIDS), Provides a 50-50 cost sharing plan to the provinces for everything Provides a 50-50 cost sharing plan to the provinces for everything “hospital”.“hospital”.

► 1962: Saskatchewan pioneers again with 1962: Saskatchewan pioneers again with The Saskatchewan The Saskatchewan Medical Care Insurance PlanMedical Care Insurance Plan Extension of universal, publicly Extension of universal, publicly funded insurance to physician services.funded insurance to physician services.

► 1967-68: 1967-68: Medical Care Act – Medical Care Act – federal legislation providing 50-50 of federal legislation providing 50-50 of physician services costs to the provinces.physician services costs to the provinces.

► 1976-77: The 50-50 cost-shared arrangements are replaced by a 1976-77: The 50-50 cost-shared arrangements are replaced by a block fund by theblock fund by the Established Programs Financing Act (EPF Established Programs Financing Act (EPF).).

► 1984: To clarify conditions of federal contributions and keep 1984: To clarify conditions of federal contributions and keep health care free and universal, Parliament passes unanimously the health care free and universal, Parliament passes unanimously the Canada Health Act (CHA).Canada Health Act (CHA).

8

Public Health/Population Public Health/Population HealthHealth

► Tommy Douglas – 2Tommy Douglas – 2ndnd goal of medicare goal of medicare► ‘‘tyranny of the acute’tyranny of the acute’► Lalonde Report 1974Lalonde Report 1974► Ottawa Charter 1986Ottawa Charter 1986► SARS 2003 – Naylor ReportSARS 2003 – Naylor Report► Public Health Agency, Network, Chief Public Public Health Agency, Network, Chief Public

Health OfficerHealth Officer► Health Goals for Canada 2005Health Goals for Canada 2005► WHO Commission for SDOH 2005-2008WHO Commission for SDOH 2005-2008► H1N1 / listeriosis - gapsH1N1 / listeriosis - gaps

9

Medicare: who pays ? Medicare: who pays ? ► Canadian government spending as a Canadian government spending as a

share of GDP has fallen sharply since the share of GDP has fallen sharply since the mid-1990smid-1990s

► Health expenditures are not responsible Health expenditures are not responsible for provincial budget problemsfor provincial budget problems

► Cuts to other departments have changed Cuts to other departments have changed the % provincial budgets spent on health.the % provincial budgets spent on health.

► Taxes have been cut by 5.3% of GDP Taxes have been cut by 5.3% of GDP since 2000, the equivalent of $85 Billion since 2000, the equivalent of $85 Billion in lost government revenuein lost government revenue 10

Notes * Data for 2007. † Data for 2006. Source Organisation for Economic Co-operation and Development, OECD Health Data 2010 (June edition) (Paris, France: OECD, 2010).

Most data 2008

11

Sustainability =Sustainability =Prevention + QualityPrevention + Quality

►PREVENTIONPREVENTION Decrease the demand sideDecrease the demand side

►QUALITYQUALITY Increase the cost effectiveness on the Increase the cost effectiveness on the

supply sidesupply side

12

““Many attribute the quality problems Many attribute the quality problems to a lack of money. Evidence and to a lack of money. Evidence and analysis have convincingly refuted analysis have convincingly refuted this claim. In health care, this claim. In health care, good good quality often costs considerably less quality often costs considerably less than poor qualitythan poor quality.”.”

Fyke Report 2001 Fyke Report 2001 (Saskatchewan)(Saskatchewan)

Focus on QUALITY saves $$ and lives

Sustainability =Sustainability =

Prevention +Prevention + QualityQuality

►Quality accountabilityQuality accountability Federal Gov’t must lead by example Federal Gov’t must lead by example

►Aboriginal, military, vets, RCMPAboriginal, military, vets, RCMP►? Health Council Canada hold Fed Govt ? Health Council Canada hold Fed Govt

accountable for their resultsaccountable for their results

Quality Councils in 6 provinces Quality Councils in 6 provinces ►Insist on 13 ? Insist on 13 ?

14

Sustainability =Sustainability =PreventionPrevention + Quality + Quality

► Our cherished health care system will Our cherished health care system will only be sustainable if we redouble our only be sustainable if we redouble our efforts to efforts to keep Canadians well keep Canadians well as was as was articulated in the original commitment to articulated in the original commitment to medicare.medicare.

► For Canadians to be as healthy as they For Canadians to be as healthy as they can be, and in order to close the can be, and in order to close the unacceptable gap in health status for our unacceptable gap in health status for our most vulnerable Canadians we must work most vulnerable Canadians we must work across across all government departments, all all government departments, all jurisdictions and in all sectorsjurisdictions and in all sectors. .

15

The Tyranny of the AcuteThe Tyranny of the Acute

As long as citizens think of the As long as citizens think of the sicknesssickness care system whenever they care system whenever they hear the word hear the word ‘health’‘health’ we are not we are not going to be able to reorient health going to be able to reorient health systems.systems.

16

Teachable MomentsTeachable Moments

Kasheshewan Reserve . . . Dr. HillKasheshewan Reserve . . . Dr. Hill Hurricane Katrina Hurricane Katrina

The 2003 heat wave in France/SARSThe 2003 heat wave in France/SARS

The 1995 Chicago heat waveThe 1995 Chicago heat wave►Heat Wave: A Social Autopsy of Disaster in Heat Wave: A Social Autopsy of Disaster in

Chicago Chicago by Eric Klinenberg by Eric Klinenberg 17

Lessons learned from SARSLessons learned from SARS

► Jurisdictional squabbleJurisdictional squabble

Germs don’t respect bordersGerms don’t respect borders

Naylor report..Naylor report..►CollaborationCollaboration►CooperationCooperation►CommunicationCommunication►Clarity of who does, what, whenClarity of who does, what, when

18

Fleeing the Medical Model,Fleeing the Medical Model,Embracing the Medicine WheelEmbracing the Medicine Wheel

19

Blame Hippocrates?Blame Hippocrates?

20

Affirm Hygeia

HYGEIA: Goddess of Health

21

Oath of Hygeia, an oath of health care providers

I swear by Hygieia, the goddess of health making her my witness that I will fulfill according to my ability and judgment this oath and covenant: I affirm that the ultimate goal of all health providers is to promote health, prevent disease and injury whenever possible.

22

Social Determinants of HealthSocial Determinants of Health

vs vs

Choose HealthChoose Health(modifiable risks)(modifiable risks)

23

2005

CAUSES

CAUSES of theCAUSES24

Health Goals for CanadaHealth Goals for Canada20052005

As a nation, we aspire to a Canada in which every As a nation, we aspire to a Canada in which every

person is as healthy as they can be – person is as healthy as they can be – physically, physically, mentally, mentally, emotionally and emotionally and spiritually.spiritually.

25

Health CARE System ORHealth CARE System OR a real system for HEALTH a real system for HEALTH

►Patchwork quilt of non- Patchwork quilt of non- systemssystems

►Focus on sickness…and the Focus on sickness…and the repair shopsrepair shops

26

FantasyFantasy

27

Public Health 101 Public Health 101

28

1.Do you think we should have 1.Do you think we should have a:a:

A) strong fence at the top of the cliffA) strong fence at the top of the cliff

B) state of the art fleet of B) state of the art fleet of ambulances & paramedics waiting ambulances & paramedics waiting at the bottom ? at the bottom ?

29

2. Would you prefer:2. Would you prefer:

A) Clean airA) Clean air

B) Enough puffers and B) Enough puffers and respirators respirators

for all for all

30

3. Would you prefer that wait-times 3. Would you prefer that wait-times were reduced by:were reduced by:

A) a falls program to reduce A) a falls program to reduce preventable hip fracturespreventable hip fractures

B) private orthopaedic B) private orthopaedic hospitals and more surgeonshospitals and more surgeons

31

4.Governments should boast 4.Governments should boast about:about:

A) how much they spent on the A) how much they spent on the sickness care system sickness care system

B) the health of their citizens, B) the health of their citizens, leaving no-one behindleaving no-one behind

32

The Grey Tsunami ?The Grey Tsunami ?

R.O.M.P.R.O.M.P.

CollingwoodCollingwood

April 24, 2008April 24, 2008

Dr. Carolyn Bennett M.P.Dr. Carolyn Bennett M.P.

The Grey The Grey Tsunami ?Tsunami ?

ACTIVE AGING

34

35

U.S.A:U.S.A:► Health care =Health care =a market commoditya market commodity

► Medicare and Medicare and MedicaidMedicaid

CANADA:CANADA:► Health care = Health care =

a universal common a universal common good good for all citizens of all for all citizens of all ages, all conditionsages, all conditions

► All universities are All universities are public and heavily public and heavily subsidized by both subsidized by both levels of governmentlevels of government

Monique Bégin

36

OECD 2007 dataOECD 2007 data

► Physicians per capita:Physicians per capita:► Nurses: Nurses: ► Acute care beds:Acute care beds:► MRIs:MRIs:► Life expectancy at birth:Life expectancy at birth:► Infant mortality rate:Infant mortality rate:► Obesity in adults:Obesity in adults:

► 2.4/10002.4/1000 2.2/1000 2.2/1000► 10.6/100010.6/1000 9/1000 9/1000 ► 2.7/1000 2.7/1000 2.7/1000 2.7/1000► 19.5/1 million 19.5/1 million 6.7/1 million6.7/1 million► 78.1 years 80.7 years78.1 years 80.7 years► 6.7/1000 live births 5/10006.7/1000 live births 5/1000► 34.3%34.3% 15%15%

Monique Bégin

37

The Citizen and the The Citizen and the ConstitutionConstitution

► The U.S.A.The U.S.A.

LifeLife

LibertyLiberty

The pursuit of The pursuit of HappinessHappiness

► CanadaCanada

PeacePeace

OrderOrder

Good Good governmentgovernment

Moniqe BéginMonique Bégin

38

Who pays for health care? Who pays for health care? (2007)(2007)

►

Total HealthExpenditure 2.4 Trillion $160 Billion

Per capita $7,290. $3,895.

% GDP 16.2 10.1

% publicly 45% 70% paid Srs, dis, poor, vets tax, no ext-billing

% privately 55% 30% paid employer/pers insur $ drugs,dent.vis.home

Uninsured/ 47+M universal coverage forUnderinsured 25M doctors and hospitals

U.S. Canada

"Achieving Health Reform's Ultimate "Achieving Health Reform's Ultimate Goal: Goal: How Successful Health How Successful Health Systems Keep Costs Low and Systems Keep Costs Low and

Quality HighQuality High“ “ U.S. Senate Committee on Aging U.S. Senate Committee on Aging Sept 30, 2009Sept 30, 2009

1. INSURANCE COMPANIES: 1. INSURANCE COMPANIES: ► 30% of your costs – almost a third – go to 30% of your costs – almost a third – go to

insurance companies. insurance companies. ► Your patients and taxpayers have to Your patients and taxpayers have to

support massive organizations.support massive organizations.► These insurers set premiums, design These insurers set premiums, design

packages, assess risk, review claims and packages, assess risk, review claims and decide who to reimburse for how much.decide who to reimburse for how much.

► But they don’t deliver health care. But they don’t deliver health care. 39

U.S. Senate Committee on Aging U.S. Senate Committee on Aging Sept 30, 2009Sept 30, 2009

►

2. ADMINISTRATION:

Our single payer system is simpler, allowing us to run the administration of our offices and hospitals with much fewer staff – about 4%.

We don’t have to deal with multiple payers, or chase bad debts.

We don’t have to charge higher fees to compensate for unpaid for procedures

40


3. PHARMACEUTICAL PRICE CONTROLS:

Although drug costs are rising in Canada as here, we’re able to exercise more control over the cost of drugs as a result of our Patented Medicine Prices Review Board.

41


4. MALPRACTICE INSURANCE: 4. MALPRACTICE INSURANCE:

► The not-for-profit Canadian Medical The not-for-profit Canadian Medical Protective Association covers medical Protective Association covers medical malpractice for all Canadian physicians malpractice for all Canadian physicians with comparatively low premiums. with comparatively low premiums.

► Doctors’ remuneration does not have to Doctors’ remuneration does not have to reflect those extra costs and our justice reflect those extra costs and our justice system has successfully kept the awards system has successfully kept the awards in a reasonable range.in a reasonable range.

42


5. EVIDENCE-BASED CARE: 5. EVIDENCE-BASED CARE:

► From vaginal births after C-sections to, From vaginal births after C-sections to, lumpectomy, to x-rays for sprained ankles, lumpectomy, to x-rays for sprained ankles, applying evidence to determine the applying evidence to determine the appropriateness of tests and procedures appropriateness of tests and procedures translates into fewer unnecessary tests and translates into fewer unnecessary tests and procedures and less defensive medicine. procedures and less defensive medicine.

► We are committed to moving from the error of We are committed to moving from the error of pure cost-containment approach of the early 90s pure cost-containment approach of the early 90s into true evidence-based cost effective care.into true evidence-based cost effective care.

43


6. PREVENTION: 6. PREVENTION:

► Diseases are cheaper to treat if they’re Diseases are cheaper to treat if they’re caught early, and since all Canadians are caught early, and since all Canadians are insured, they’re more likely to have pap insured, they’re more likely to have pap smears, mammograms and other early smears, mammograms and other early detection visits and tests, than US detection visits and tests, than US patients who are not covered. patients who are not covered.

44


7. FAMILY MEDICINE:7. FAMILY MEDICINE: ► A long-standing speciality in Canada, A long-standing speciality in Canada, ► family doctors are trained to help patients family doctors are trained to help patients

navigate their care; navigate their care; ► we interpret the difference between what we interpret the difference between what

patients think they `want`, and what they patients think they `want`, and what they actually `need` . actually `need` .

► A point of first contact, a trusted coach to A point of first contact, a trusted coach to explain the evidence and the choices.explain the evidence and the choices.

45

Health in CubaHealth in Cuba2009

Death

s in

ch

ild

ren

< 5

years

old

/10

00

bir

ths

(log

)H

ealt

h,

10

100

200

50

40

20

8

5

4

300300

30

60

6

3

80

Income, Gross National Income per capita, purchasing power in US dollar (log)

1 0001 000 10 00010 000 20 00020 000500500 2 0002 000 5 5 000000

50 00050 000

Somalia

Madagascar

richrichpoorpoor

Albania

Algeria

Angola

Antigua & Barbuda

Argentina

Armenia

Australia

Austria

Bahrain

Bangladesh

Barbados

Belgium

Benin

Botswana

Bulgaria

Burkina Faso

Cambodia

Cameroon

Canada

Cape Verde

CAR

Chad

Chile

Comoros

Costa Rica

Côte d'Ivoire

Croatia

Cyprus

Czech Rep

Denmark

Djibouti

Dominica

Ecuador

El Salvador

Equatorial Guinea

Eritrea

Estonia

Ethiopia

Fiji

Finland

Gabon

Gambia

Georgia

Greece

Guatemala

Guinea

Guinea-B

Guyana

Haiti

Honduras

Hungary

Iceland

Iran

IrelandIsrael

Italy

Jamaica

Jordan

Kazakhstan

Kenya

Republic of Korea

Kuwait

Kyrgyz Rep

Laos

Latvia

Lebanon

Lesotho

Lithuania

Macedonia

Malaysia

Mali

Malta

Mauritania

Mauritius

Moldova

Mongolia

Mozambique

Namibia

Nepal

Netherlands

New Zealand

Nicaragua

Niger

Norway

Oman

Paraguay

Poland

Portugal

Rwanda

Saudi Arabia

Senegal

Sierra Leone

Singapore

Slovakia

Slovenia

Solomon Islands

South Africa

Sri Lanka

St. Kitts & Nevis

St. Lucia

Sudan

Swaziland

Sweden

Switzerland

Syria

Tajikistan

Tanzania

Thailand

Togo

Tonga

Trinidad & Tobago

Tunisia

Turkey

Turkmenistan

Uganda

Ukraine

United Arab Emirates

Uruguay

Uzbekistan

Vanuatu

VenezuelaVietnam

Zambia

Zimbabwe

Panama

USAUK

Japan

France

Germany

India

China

Brazil

Russia

IndonesiaPhilippines Peru

Egypt

Azerbaijan

Pakistan

PapuaNG

Nigeria

Ghana

Cuba 2004

Iraq

Sub-Saharan Africa

Arab states

Europe

AmericasAsia & Pacific

Continents:

Population

10010

1 000

1

in millions

GrenadaColombia

Romania

Morocco

Samoa

Belarus

Cape Verde

Mexico

Bolivia

World Development Chart 2004Make sense of development by viewing UN statistics

with free software from www.gapminder.org

Afghanistan

Bosnia

West Bank & Gaza

Year 2002 data for 174 countries & territories with > 250 000 inhabitants. Source: WDI 2004, UNCDB 2004 & estimates in italic© [email protected], Karolinska Instintutet. Free to copy

Luxemburg

Burundi

Belize

Taiwan

Congo, Rep.Yemen

MalawiDRC

Dominican Rep

healt

hy

sic

k

47

Infant mortalityInfant mortality

20 x 1000 new born

American Region

4,7 x1000 newborn

Cuba

48

Pride in their resultsPride in their results

►Family doctors annual reportFamily doctors annual report Smokers,obese,sedentary,lipids,BPSmokers,obese,sedentary,lipids,BP

►Statisicians, Epidemiologists, Statisicians, Epidemiologists, PsychologistsPsychologists

►Accountability to Govt and LegislatureAccountability to Govt and Legislature Weekly meeting with Minister Weekly meeting with Minister

49

Integration of Health Integration of Health Professional Education & Professional Education &

CommunityCommunity

►health professional must be a professor health professional must be a professor and give tutorials to the students.and give tutorials to the students.

►`Polyclinics` - Teaching University`Polyclinics` - Teaching University► ► `̀We don`t train basketball players on a We don`t train basketball players on a

soccer pitch and vice versasoccer pitch and vice versa `̀50

Actividades con la comunidadActividades con la comunidad

► Círculos de abuelos.Círculos de abuelos.► Círculos de Círculos de

gestantes (clases de gestantes (clases de psicoprofilaxis).psicoprofilaxis).

► Círculo de lactantes.Círculo de lactantes.► Círculo de Círculo de

adolescentes.adolescentes.► Círculos de interés Círculos de interés

de escolaresde escolares

51

DispensarizacionDispensarizacion

►`the constant assessment of `the constant assessment of population and risk`population and risk`

►``We don`t expect people to get sick ``We don`t expect people to get sick and come to us``and come to us``

52

Cry for Federal LeadershipCry for Federal Leadership

►Romanow, Kirby, Fyke, Castonguay, Romanow, Kirby, Fyke, Castonguay, Mazinkowski…..Mazinkowski…..

►2004 Accord 2004 Accord bought peace with the provinces did not bought peace with the provinces did not

buy change – health reformbuy change – health reform Post-SARS –emphasis on public healthPost-SARS –emphasis on public health

►2011 -CMA call for National Standards2011 -CMA call for National Standards53

Federal – Provincial Federal – Provincial

PREVENTIONPREVENTION►Public Health NetworkPublic Health Network

PHAC + Chief Public Health Officer for PHAC + Chief Public Health Officer for CanadaCanada

13 Juridictions 13 Juridictions

QUALITYQUALITY►Health Council CanadaHealth Council Canada

was overseeing 2004 Accord was overseeing 2004 Accord 6 provinces have Quality Councils6 provinces have Quality Councils

54

The Goal: The Goal: evidence-basedevidence-based

► Most appropriate careMost appropriate care

►In the most appropriate placeIn the most appropriate place

►By the most appropriate person – By the most appropriate person –

paid and unpaidpaid and unpaid

55

ResearchResearch

► Evidence-informed practiceEvidence-informed practice► Practice-informed evidencePractice-informed evidence

► Courage to fund what worksCourage to fund what works► Courage to stop funding what doesn`tCourage to stop funding what doesn`t

► Complex adaptive systems…Complex adaptive systems…

56

Sir Michael MarmotSir Michael Marmot

““Evidence is not enough. There has to Evidence is not enough. There has to be the desire, be the desire, the political will for the political will for changechange. Given that will - a big given . Given that will - a big given but I am an optimist - the evidence of but I am an optimist - the evidence of what works will be a great help.”what works will be a great help.”

57

Research

Practice Policy

Research

Practice Policy

KT

Research

Practice Policy

KT

Political will

Research

Practice Policy

KT

Political will

Appliedresearch

Research

Practice Policy

ENGAGED CITIZENS

KT

Political will

Appliedresearch

Empowered PatientsEmpowered PatientsEffective AdvocatesEffective AdvocatesEngaged Citizens Engaged Citizens

► Use the system wiselyUse the system wisely

Keeping our families wellKeeping our families well Clinical guidelinesClinical guidelines Self Care ManualsSelf Care Manuals

► Fight for more HEALTH so we`ll need less health Fight for more HEALTH so we`ll need less health carecare

► Democracy between electionsDemocracy between elections

63

““We are not tinkers, who patch and We are not tinkers, who patch and

mend what is broken. We must be mend what is broken. We must be watchmen, guardians of the life and watchmen, guardians of the life and health of our generation, so that health of our generation, so that stronger and more able generations stronger and more able generations may come after.”may come after.”

Dr. Elizabeth BlackwellDr. Elizabeth Blackwellfirst woman physician North first woman physician North

AmericaAmerica

64

Dr. John Hastings Dr. John Hastings M.O.H. Toronto…M.O.H. Toronto…

on the occasion of his Presidency of the APHA on the occasion of his Presidency of the APHA,,19181918

► Every nation that permits people to remain under Every nation that permits people to remain under the fetters of preventable disease and permits the fetters of preventable disease and permits social conditions to exist that make it impossible social conditions to exist that make it impossible for them to be properly fed, clothed and housed for them to be properly fed, clothed and housed so as to maintain a high degree of resistance and so as to maintain a high degree of resistance and physical fitness; and, who endorses a wage that physical fitness; and, who endorses a wage that does not afford sufficient revenue for the home, does not afford sufficient revenue for the home, a revenue that will make possible the a revenue that will make possible the development of a sound mind and body, is development of a sound mind and body, is trampling on a primary principle of democracy. trampling on a primary principle of democracy.

65

““The care of the public health is the The care of the public health is the first duty of a statesman." first duty of a statesman."

Benjamin DisraeliBenjamin Disraeli

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a cry for federal leadership in health and health care honourable carolyn bennett, m.d., m.p....

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