Remarks from the Honourable Jane Philpott, Minister of Health, to the Canadian Medical Association Annual General Meeting
August 23, 2016
Check against delivery. This speech has been translated in accordance with the Government of Canada’s official languages policy and edited for posting and distribution in accordance with its communications policy.
Good afternoon. Thank you so much for inviting me here. Thank you, Cindy, for that very nice introduction.
What a pleasure to be with you. I have been following very closely all that you've been doing here over the last number of days. I want to start by acknowledging the ancestral, traditional, and unceded lands of the Musqueam, Squamish, and Tsleil-Waututh First Nations here in Vancouver. It's a privilege to be on the territory of these First Nations.
I want to express my congratulations to all of you as you gather for the CMA's 149th annual meeting and general council. And of course I want to say a big thank you to Cindy in particular for the excellent year that she has had at the helm. One reason for the incredible success of the CMA has been the outstanding quality of leadership, and I won't start naming names, but there have been some really incredible people that have taken up this role. Cindy is among them. She has served with such distinction, and I appreciated working with you, Cindy, and your team on many interesting and challenging issues already in the first months of my time in this role.
I also welcome Dr. Granger Avery to his new role. I'm certainly looking forward to working with you in the year ahead, and I know that we have many more interesting tasks to address together.
Congratulations on the great program that the organizers have put together. I was particularly interested to see that there was a pre-conference day on indigenous health. It's something that's very important to me, and I'm so pleased to see that the CMA is playing a leadership role on that matter. And how fascinating, the focus that you took on climate change in particular. There has been too little attention to the matter of climate change paid among health professionals. Dr. Margaret Chan, who is the Director General of the World Health Organization, talks about the slow motion catastrophes in health. And the three that she highlights in particular are diabetes, antimicrobial resistance, and climate change.
I would say climate change is indeed a slow motion catastrophe and I'm delighted to see your emphasis on the topic, your determination to raise awareness on this among your membership and to draw attention to the links between health and climate change, and to encourage physicians to be champions for real action on climate change.
The focus of my remarks today will be on sustainability but not particularly on the sustainability of the planet per se but rather on the sustainability of health care. And I suspect if one were to look back over the agendas in the last 149 years of the CMA General Council, that sustainability of health care systems has been on the agenda numerous times. There are often serious concerns expressed by patients, providers, policy makers and members of the general public about how we in Canada can cope with ever expanding demands on health care systems and now particularly in light of still sluggish economic times. I know that, as doctors, you have unique insights into this exact matter. You have concrete ideas about how we could all do better: how we could do better in delivering care to Canadians, how we could achieve better value for money, and how we can adapt health systems for the future.
But actually, it turns out that those actual opportunities to act on those concrete ideas sometimes are limited. And of course that's one of the important roles that the CMA plays; to give voice and gather together those important insights that you provide. I hope you will see that it's good news that there is a physician in the role of federal Minister of Health; someone who has “in-the-trenches” experience of the kinds of things that I know you experience every day. And I can't overemphasize how important it is that government and providers partner together in ensuring that we can adapt to our ever-changing social, technological, and economic climate, so that Canadians will have the health care that they need in the generations ahead.
So as we face the question of the future of the Canadian health care systems, a good place to start, I think, is to challenge some common assumptions. Some of these may be assumptions you hold yourselves; some of them are assumptions that you'll hear in the general public. And I wanted to start our conversation today by tackling a few myths, things that I'm not sure we should allow to perpetuate in the current dialogue and that have found their way into the discourse on health. I'm going to suggest four misconceptions in particular about the future of health care in this country.
The first myth is that the aging population is going to bankrupt us. You've heard it called the grey wave, the silver tsunami, but whatever kind of catchy title we put on it, the message is the same. It's a message of doom and gloom: that our population is aging and we can't afford to pay for care; that doing so will require a massive infusion of cash on behalf of all levels of government, that publicly-funded health care is doomed.
It's true that the potential fiscal challenges associated with an aging population are well documented and that these are data that you are intimately acquainted with. For example, seven percent of all hospital beds are taken up by individuals receiving long-term care, and some 14% of acute hospital beds are recognized to be not appropriately used in Canada each day. In my home province of Ontario, it costs a minimum of $840 a day to keep a patient in hospital and the CMA data I think is higher than that, nationally upwards of $1,000 a day as a baseline. And depending upon the availability of alternatives for care, these patients may occupy those beds for months at a time.
But in that problem lies one of the keys to the solution. I talked about alternatives – alternative approaches to care. Care at home in my province of Ontario costs $55 a day for the delivery of home care, a small percentage of the cost of a hospital bed. But despite this cost efficiency, home care represents about five percent of provincial health budgets. But even more important than economic reasons, we know that care in the home and community is not only cost effective, it's also the option that is so much better and so much preferred by patients and their families. I know you've been hammering out this message over and over again: most seniors prefer to receive care when they are surrounded by the people they love, ideally in the comforts of their home and not in a hospital.
The need for more access to home care, including palliative care, was a message that we heard emphatically and repeatedly during our parliamentary debate on Bill C-14. I want to note that several provinces have made remarkable progress in this area, but there is so much more to be done to improve access to home care. That's why I'm very pleased about the fact that our government has made a firm commitment to addressing this need, by making sure that we invest $3 billion in home care over the next four years. In the coming months, we are going to have robust conversations amongst ourselves, with experts including yourselves, and with my colleagues, the ministers of health in the provinces and territories, about how that money should be invested to make sure that it reaches Canadian families and to make sure that care delivery systems are actually transformed in systematic ways.
So let's move on to the second myth -- and it might seem dishonourable for a Minister of the Crown to even say this -- it's a myth that Canada has the best health care system in the world. This is something that we've heard over and over again; I think I started hearing it when I started practising medicine 30 years or more ago. And delegations from around the world, I remember, would visit our country, and they would want to know what was Canada's magic formula for providing such high-quality care to so many people.
But flash forward to the reality of today. We spend more per capita on health care than many other countries. What's worse is that, while we do this, we get poorer outcomes for our patients. You all know the reports of the Commonwealth Fund, including the one that ranked us second from the last in a study that compared Canada to places like Australia, the UK, France, and Germany. The OECD also ranks us poorly on a number of specific areas that will be critical to our future health as a nation.
This should never be interpreted as a reflection on the quality of care that is delivered. And I want to emphasize that. Canadians, I know, get excellent care – hospital care, medical care. Our institutions in this country are world renowned, for research, for training, and for the provision of specialty care. But the reason to consider this is that we need to think about how that care is provided. Not what the quality of care is, but how it's delivered, and the extent to which systems incorporate all the available options and all of the things that we know.
If we look to our international counterparts who are doing better than we are, we see that the best care is coordinated and comprehensive. We see how financial incentives are aligned with what's best for patients. Here's how one patient viewed the context that doctors are working in in Canada. And this is what the patient said:
“I have a very good doctor, and we're good friends. We both laugh when we look at the system. He sends me off to see somebody and to get some tests at the other end of town. I go over there and then I come back, and they send the reports to him later, and he looks at them and then sends me off somewhere else for some more tests, and then they come back. And then he says that I'd better see a specialist. And before I finish, I've spent within a month six days going to see six different people, another six days going to have six different types of tests, all of which could have been done on one day in one clinic.”
That patient's name was Tommy Douglas. And he said that in a speech decades ago. And what I'm afraid of is that his words ring just as true today, and that scenario could be just as easily described today. It makes you think of what Einstein said about the definition of insanity: doing the same thing over and over again and expecting different results.
This leads me to myth number three, the myth that we're stuck in the system we have. This is small thinking and we need to think big if this is going to change. We need to think big, as others have in the past, as we once did as a nation. Universal hospital insurance and medical insurance were both once thought to be a pipe dream, as unaffordable to taxpayers as they were unpalatable to health practitioners, like you. And we know how that story ended. Other nations, as I've said, provide us with inspiration and with lessons from which to learn about how to expand our understanding of what's possible.
I've been looking at the National Health Service in Britain, which now ranks at the top of most international health care surveys. For those who spent time in that system, perhaps in the seventies or the eighties, it would have been unfathomable to see how it looks today. So too, Australia has been a poor performer in the past and now outranks most comparable countries on health systems. These nations, Australia and Great Britain, spend less than Canada does on health care, both per capita and as a percent of GDP, and yet they outperform us in terms of what they provide to patients. And these are not stories about the infusion of cash; these are stories about countries deciding to do things differently.
There is, increasingly, in our country a tendency to speak about the federal role in health as simply being a matter of health transfers. This year, as you know, the Canada Health Transfer has reached a historic high of over $36 billion. But I am firmly convinced that we have an obligation as a federal government to do more than simply open up the federal wallet. Throughout the history of our health care system, major reform has been an inclusive partnership between patients and providers, between provinces, territories, and the Government of Canada, and the future should be no different.
I believe that an engaged federal government has a role to facilitate the changes that can assist Canada in moving from the middle of the pack to be out in front. But to do that, we can't miss a rare opportunity that is before us in the coming months. We look forward in the next six months to the negotiation -- which has already begun -- but hopefully to the completion of that negotiation of a new long-term agreement on health between the federal government, the provinces and the territories. You have an engaged federal government. You have a Minister of Health at the federal level who is determined to be an engaged partner on health. This is an opportunity that we must not miss. How can we leverage those Health Accord discussions to trigger the system transformation that we all recognize to be necessary?
Before I talk about some of the potential solutions, I want to go to the fourth myth, and that is that money is the only answer. It was 2004 that there were the last major discussions between the federal government, the provinces and the territories, on health care funding. Those discussions resulted in $41 billion in additional funding to health care, investments that were vitally needed. Provinces and territories also stepped up and increased their own spending at that time. And the funding led to some improvements—it shortened wait times in certain areas—but I think most experts would agree that it did not buy change.
And so, as we embark on new investments through the Health Accord, we should use this opportunity to trigger innovative transformation in care delivery. So many aspects of our daily lives have undergone dramatic makeovers in the last 20 years. Think about how we access information, how we write letters, how we bank. If we want to modernize health care and improve performance, we need to remodel the system's underlying infrastructure. I don't need to tell you that we have a dizzying network of health information systems, and most of them don't talk to each other. In the age of Facebook and e-commerce, we still use fax machines in most doctors' offices, and most Canadians can't go on line to get any of their health information. But if you're a patient of Kaiser Permanente, for example, in the United States, more often than not your health care journey begins on an app on your phone.
In Canada, we need to have digital systems that are easily accessible by patients and providers, that facilitate seamless care and which help patients to be active partners in managing their care. Last month I was very pleased to announce, with the Government of Nova Scotia and Canada Health Infoway, the roll-out of a province-wide system where patients will be able to access their test results and other important information through a patient portal that they can use on their phones. Work like this is being supported by the Government of Canada's ongoing investment in Infoway, including an investment of $50 million from Budget 2016.
We could probably talk about other myths and misconceptions, but let me move on to solutions, and I believe there are many. I want to mention what I believe to be some of the not-so-secret ingredients that should be included when we think about how our health systems can be sustainable. Each of these would merit a full-length discussion, so I'm just going to touch on them briefly. But here are the things that I think are the essential ingredients.
First, we have to prioritize the social determinants of health. We will never have sustainable health systems until we put social determinants of health on the top of our list for urgent action. This is a whole study in itself, and so I'm not going to elaborate on the matter except to mention two factors that are important to me.
The first is that the biggest barrier to sustainability of publicly funded health systems is social inequity. You know it, you see it every day. Addressing inequity, though, is much more than the job of Health Ministers and health practitioners. Addressing social inequity is the work of the whole of government. In fact, it's the work of the whole of society. That is why our government believes that, in growing the economy, in creating jobs, in strengthening the middle class, in helping those who are working hard to join the middle class, we will reduce social inequity and we will improve health.
The second factor is that the most perverse example of inequity in Canada is that which exists between indigenous and non-indigenous Canadians. It is far past time for us to do something about this. It is far past time for us to have a renewed relationship with indigenous peoples that is based on rights, respect, cooperation, and partnership. There is much to do, and we all have a responsibility to respond. I'm delighted to hear that the CMA is recognizing that. So many medical education institutions are recognizing that. Our government has started to do our part by making historic investments in Budget 2016: $8.4 billion to improve the socioeconomic conditions of indigenous peoples and their communities. And every one of those dollars will be an upstream driver of the health of indigenous communities.
The second essential ingredient to a sustainable health system is that we have to uphold the Canada Health Act. I want you to know that our government is firmly committed to upholding the Canada Health Act. Its principles that include accessibility and universality are essential to the provision of care if our goal is to have a fair and just society. And we've made clear commitments to the growth, prosperity and well-being of the middle class in our government, but I say – and I say this around the cabinet table – we will not grow a strong, healthy middle class unless we maintain a strong, publicly funded health infrastructure. It is the Canada Health Act that undergirds that infrastructure.
The third essential ingredient is to strengthen comprehensive primary care. So you'll accuse me of bias, when a family doctor gets on the soap box, but I believe that that bias is well supported by evidence. For decades, in fact, we have had solid evidence that health systems that are rooted in primary care deliver the best health outcome at the lowest costs, and they do it in a way that is both equitable and accessible. Canada has never sufficiently grounded its health care system in primary care. Some provinces are moving in this direction, and, to the extent that they do so, I am convinced that they will be rewarded with better results and more manageable costs. And yet, across the country, pieces are missing from primary care, and to make it comprehensive, it needs to include things like home care and mental health care. You don't have to be a health economist to know that investments in home care and mental health care will provide good value for the dollars spent.
I want to note a couple of other things when we're talking about care, and these are based on my own personal experiences. One is that I don't believe that you can properly provide comprehensive primary care, including both home care and mental health care, without a firm commitment to inter-professional teams. And I hope that the CMA will endorse that. We need to work inter-professionally and we need to work in settings where all providers work to scope and where they collaborate in real time.
And the second point on primary care that I want to emphasize is that none of these improvements will be successful without the meaningful engagement of health practitioners, including doctors. I have seen, as you probably have, too many good ideas that have been put forward by policy makers and which fell flat. They fell flat because providers were not consulted at the beginning, and providers didn't even know about them until the announcements were rolled out. That approach never works.
So let me bring you to the final ingredient, and that ingredient is that we have to find a way to build seamless systems with the patient at the centre. No customer-oriented business succeeds unless it prioritizes the perspective of the people that it's intended to serve. So, if we're puzzled about what it should look like, I'm convinced that the fastest way to figure out what the health care system and Canada's future look like is to understand what patients want and what they need.
When we consider the patient's perspective, one of the most glaring irritants that you live every day is fragmentation. Fragmentation leads to waste, to frustration, and to dangerous delays in care. Remember the reference that I made to a patient named Tommy earlier. Integration is complex, but it's not rocket science. We know what it should look like. We need an approach where patients are seamlessly connected, both personally and electronically in real time, to their primary care provider, to their hospital as needed, to home care providers, to the pharmacy and to the lab.
You can imagine it as well as I can. What is it going to take for us to get there? I think we need three simple steps: pragmatism, persistence and partnership.
First, pragmatism. Like most doctors, I'm a pragmatist. As Health Minister, I need to produce measurable results. I often say to people who come visit me that I have no room on my bookshelves for strategic plans that are not eminently deliverable. The changes that we need to make oblige us all to be courageous and practical.
Secondly, we have to be persistent. That seamless system that you can imagine and which every patient dreams of is going to require change. And every health system in the world that faces that, tries to change, faces remarkable resistance. But the solutions are not mysterious. We know what needs to be done. It's going to take dogged determination to improve our systems so that we can meet health needs fairly and effectively.
Finally, partnership. I've spent quite a bit of time studying and experiencing change in health systems, and one element that is consistent in any effective change is the absolute necessity of partnership. I've told you, and I'm committed to this, that our government will be a good partner in helping to build better health care systems. And remember that there has never been a major development in the history of health care in Canada where the federal government was not there, was not being a collaborative player. But governments – provincial, federal, territorial – cannot enable health system improvements alone. We need everyone on board. That includes providers, it includes patients, it includes administrators and activists, educators and inventors, researchers, regulators – I could go on and on.
And so I want to end on a note of optimism. I hope that, like me, you believe that better is always possible—something I've heard a Prime Minister say—and that you are here because of your commitment to improving the lives of Canadians. And if so, our goals are the same.
The importance of that task is incalculable, and it's not easy, but I am convinced that, if you and I persevere, if we take those thoughtful, practical steps forward with the needs of Canadians at the forefront, and if we work in a collaborative and inclusive way, we can build health systems that are sustainable, and we can achieve our ultimate objective, and that is health for all.
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