Remarks from the Honourable Jane Philpott, Minister of Health, to the Duncan G. Sinclair Lecture in Health Policy: "What I've Learned as a Physician and Minister of Health"

September 26, 2016
Kingston, ON

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.

Introduction

Thank you so much for inviting me today. I want to start by acknowledging that Queen's University is situated on traditional Anishinaabe and Haudenosaunee (Hoe-den-oh-'show-nee) territory.

It's an honour to speak at an event named for Dr. Duncan Sinclair, who is known to all of you, whether as the former Dean of Medicine at Queen's, Chair of the Ontario Health Services Restructuring Commission, or his many other contributions.

As you may know, Dr. Sinclair can't join us tonight due to ill health, but his son Gord has joined us in his place.

As you also may know, Dr. Sinclair is an icon of healthcare reform both in Ontario and Canada - and I suspect he has the scars to prove it.

He is a treasure of Kingston and Queen's University and I'd ask Gord to pass on my personal congratulations to his father for his admission to the Canadian Medical Hall of Fame.

I'd also like to thank Queen's for holding this annual event. Although I attended medical school at that other school down the 401 - Western - I'm well aware of the respect that exists for Queen's, this school and its graduates.

I want to speak today about healthcare in Canada - a topic that is near and dear to Dr. Sinclair.

Dr. Sinclair is fond of saying we don't have a healthcare system in Canada - but rather, at least 14 so-called systems, one for each province and territory and one for the federal government. And it fits no dictionary's definition of a "system" because the moving parts are not coordinated.

Dr. Sinclair has also pointed out that much of what we do is not about health; it is about care for illnesses and injuries. His perspective on health systems in Canada is built on years of studying our successes and failures - and his important work to help us improve those systems to the benefit of Canadians.

As I speak to you today, I have my own reflections to draw upon.

They are grounded in more than 30 years as a physician, most of which was spent here in Ontario, but also in Niger.

Now I find myself in a position - which is perhaps a health policymaker's dream job. To be federal Minister of Health is an extraordinary privilege but a daunting responsibility.

I'd like to talk about some of the things I think I've learned about healthcare in Canada, and then, about where we could go from here.

I became a doctor because I wanted to help people enjoy happy, healthy and meaningful lives.

But I quickly realized that it takes more than good medicine to achieve these goals, which is why I ran for elected office. It takes education, a good job, quality housing, a clean environment and universally accessible social services, including healthcare.

A strong middle class - the platform that our government ran on - doesn't happen by accident. It takes good public policies - robust social and economic policies but also, smart health policy, our focus for today.

The Canada Health Act is as relevant as ever

Let's start by going back to a period in this country's history when it wasn't unusual for families to go into debt to pay for medical care.

A few years ago, The Ontario Coalition of Seniors Organizations produced a book, Life Before Medicare.

It's a collection of stories from those who lived in Canada before the introduction of hospital and medical insurance, and if anyone needs a primer on why we need a strong health and healthcare systems, I would encourage you to read this book.

I'm just going to read briefly one of the stories from that book. The story happens to be based in a part of Ontario where my own parents grew up. The story is from John Hallman, about his grandfather.

"He was removed from the accident site and taken to their home in Listowel. The doctor was summoned and the dining room was eventually turned into an operating theatre. Excess fluid pressure in the skull had to be relieved. My dad's mother's assignment was the cloth/boiling needs. My dad's was "to hold the light." I recall my dad saying that the doctor said to him words to the effect, "This isn't going to be pleasant. Do you think you can do the job? Once I start I have to have the light till I'm done." The doctor then proceeded to hand-drill through the skull in an attempt to remove the excess fluid and relieve pressure.

"The operation was to be unsuccessful and his dad died some days later, not regaining consciousness from the time of the accident.

"Why wasn't he taken to a hospital? Maybe there was none very close, maybe my family couldn't afford it. Maybe the doctor felt that the remedy could be done just as effectively at home as at a hospital, at less cost. It's hard for me to believe: to be an attendant to an operation, performed in my own home on a close family member, at the age of fifteen or sixteen, and then to see it all for naught, anyhow."

This may seem like so long ago but in fact, it took place in Canada around the time of my birth - where, unless you were well off or had private insurance, you either relied on charity, or you went without.

Canada today is a country where Canadians, when they visit the doctor's office or the hospital, are treated on the basis of medical need, not the basis of ability to pay.

I will never make apologies for supporting our commitment that, if Canadians pay for health services through their tax dollars, they should not be asked to pay for them again when they access the service, in the form of a user fee.

There is resolute international consensus on this - user fees are a barrier to the accessibility of health care. They are not fair. They are bad medicine. They are bad policy.

Care, not just Cure

Though we talk a lot about healthcare systems, we have a tendency to focus more on cure-givers than care-givers, particularly on high-priced institutional and specialist care.

It's true that we have health systems providing excellent hospital and medical care on a universal, first dollar coverage basis.  We have some of the best-trained health professionals in the world and many of our healthcare institutions are recognized leaders in research, training and specialized care.

But 50 years ago, Emmett Hall and others envisioned even better than that.  They saw a nationwide adoption of public health insurance. But they went further, recommending coverage for dental care, prescription glasses and pharmacare. Justice Hall said "The only thing more expensive than good healthcare is no healthcare."

There are reasons why we never got there. By the time the last province adopted universal insurance for medical care in 1972, Canada was on the verge of hyper-inflation, high unemployment, and slow growth. That led to belt-tightening at the federal and provincial levels.

Wrenching debates about national unity would soon follow. Further reforms of health systems were moved to the back burner.

Healthcare delivery has changed in the decades that separate us from Hall's Royal Commission on Health Services. Forty years ago, nearly 60% of Canada's health spending went to hospitals and doctors. Today, it's down to 45%.

At the same time demand for prescription drugs, long-term care, home care, and mental health needs all continue to grow.

It's no surprise. Our population is aging, people are living longer, chronic diseases are on the rise. Technological progress is shifting the focus of healthcare delivery away from institutions into the home and community.

But most public healthcare funding still goes to support hospital and physician services, while other services make due with a patchwork of limited public funding, private insurance and out-of-pocket payment.

A Health Accord for All Canadians

Most health policy experts would agree. We are way overdue for health systems reform in this country. If so, the federal government needs to be a player. There has never been a major development in the history of healthcare in Canada, where the federal government did not play a critical role.

Which brings us to discussions about a new health accord with provinces and territories.

Unfortunately, the conversation more often revolves around how much we should spend on healthcare, rather than how we should improve health and healthcare for Canadians.

I'm proud to be part of a federal government that is prepared to show leadership on health, and I believe there is a strong will to do that among provincial and territorial health ministers as well. By collaborating together, we will be able to bring about real change in health care.

To date, we have agreed on shared priorities for health. These include home care, pharmaceuticals, mental health, innovation, and better healthcare for Indigenous Canadians.

We will meet again next month in Toronto, and I have every reason to believe we will have productive conversations, contributing towards the ultimate achievement of a new Health Accord.

Priority: Home and Community-based Care

Instead of systems that, by default, keep patients in a hospital bed, imagine ones where the new normal is that wherever it's in the patient's best interest, they are effectively cared for at home.

On any given day, some 15% of hospital beds are occupied by patients, who might be better off at home or in long-term care. This has a huge financial impact. For example, in Ontario, basic homecare costs $42 a day, compared to a minimum of $840 a day in a hospital.

Even though their quality of life, and in some cases their death, would be vastly improved if they were in hospice or at home surrounded by friends and family, most Canadians continue to live their final days in hospital. That's where 6 out of 10 patients die.

This is not by design. The reality is that a hospital bed is where many patients end up, because home care supports and services are inadequate and poorly coordinated.

In Canada we spend about $10 billion annually, or about 5% of total health spending, on home and community care.

That's a lot of money, but it's probably not enough, especially since our population is aging and burdened by increasing rates of chronic disease.

Where patients are receiving care at home, imagine a design that supports their families and caregivers so that they don't burn out.

While we need to expand home care supports more broadly, improvements are especially relevant for palliative and end-of-life care.

As we respond to new legislation around medical assistance in dying, we must also improve palliative and end-of-life care options outside of acute care settings.

We have a golden opportunity to put in place robust systems of services and supports that will address these gaps.

We want to collaborate with the provinces and territories as they further develop the infrastructure necessary to support home care and integrate it seamlessly with the rest of the circle of care.

That means supporting innovative delivery platforms like tele-homecare, where providers monitor their patients' health status remotely, offering education and health coaching.

It also means supporting innovative funding models that bundle the budgets for home care and acute care services - so that the right care is provided in the most cost-effective setting.

Taken together, these actions could fill critical gaps and lead to stronger home care that is rooted in primary care and integrated with other health and social services, better supported by technology.

Priority: Improving the affordability and accessibility of pharmaceuticals

Next, we need healthcare systems where drugs are accessible, affordable and appropriately prescribed for every Canadian.

Health Canada, is responsible for reviewing new drugs to make sure they are safe and work as intended.

But the review process is indifferent to whether these new drugs are any better than what is already on the market.

The result is that many of the new drug therapies approved each year offer little benefit over what is currently available, yet come at a significant extra cost.

To assess the cost-effectiveness of new drugs, the federal, provincial and territorial governments have created the Canadian Agency for Drugs and Technologies in Health - or CADTH.

CADTH conducts cost-effectiveness reviews of new therapies through a mechanism known as the Common Drug Review.

This advice has been crucial to provinces and territories in deciding which drugs to cover on their public formularies.

Unfortunately, there's a gap of as much as 6 months between when Health Canada approves a drug and when the Review advises on its cost-effectiveness.

In the meantime, virtually every private drug plan in the country has listed the new drug on its formulary, providing for its reimbursement even where the cost-effectiveness data are lacking.

We must explore ways to focus our regulatory system on the review of drugs that deliver a better standard of care or better value for money.

We also need to re-examine the role of the regulatory body whose job it is to protect Canadians from excessive brand-name drug prices.

Right now, the Patented Medicine Prices Review Board is required to use as its benchmark the prices charged by some of the highest-cost, most R&D‑intensive drug manufacturing jurisdictions in the world, including the United States.

It may therefore come as no surprise that prices for brand name drugs in Canada are among the highest in the world, behind only the United States and Germany.

We also need to bring order to our fragmented market for drug coverage, which not only sees some Canadians fall through the cracks, but also imposes unnecessarily high costs on businesses.

I hope to explore with the provinces and territories ways to bring the benefits of joint price negotiation to private insurance plans.

I am pushing for agreement on a common national drug formulary for publicly funded plans, which will make it easier to leverage our buying power with pharmaceutical companies and make it harder to play one province off against another.

Priority: Investing in mental health

The founders of Medicare rightly believed that healthcare functions best when it responds to the needs of its citizens. So imagine if you will systems that make it easier for Canadians to get help when they are in mental distress or contemplating suicide, no matter where they live.

Every Canadian is impacted directly or indirectly by mental illness. The statistics are staggering.

• Depression and anxiety cost the Canadian economy almost $50B per year in lost productivity
• Suicide accounts for almost a quarter of all deaths among 15- to 24-year-olds
• Almost half of those who live with depression or anxiety have never seen a doctor about it

These aren't just numbers - they're human beings. They're your family members, friends, colleagues whose lives have been swept up in chaos, confusion and pain. Perhaps they include you.

For too long, mental illness was something to be hidden, something to be ashamed of.

Today, we talk about it somewhat more openly in our families and in our communities, and that's a good thing.

But as the full extent of the burden of mental illness in Canada becomes clear, it's become obvious that our systems are not well-equipped to heal the trauma caused by mental illness.

While responsive and supportive in some places in Canada, mental health services are non-existent and fragmented in others.

We make do with what we have. Doctors and other front line workers do their best but often don't have adequate training.

Patients with severe mental illnesses often face long waits to get access to specialists. Others who require counselling or therapy may have private insurance coverage, but most have to pay out-of-pocket, or more often, try to manage without.

The problem is most acute in rural and remote areas, including Indigenous communities, where health system resources are weak.

It is not too late to build systems where mental health services are widely available and supportive, regardless of whether you're living in downtown Kingston or northern Canada.

Priority: Renewing our relationship with Indigenous peoples

All of the challenges I have outlined are magnified many times over for Indigenous peoples in Canada.

There is a shocking gap in health outcomes between Indigenous and non-Indigenous Canadians.

If you are an Indigenous person, your life expectancy is up to a decade shorter than for other Canadians.  Your rates of diabetes are three times that of the national average. In First Nations, rates of tuberculosis are 33 times that of other Canadians. For Inuit, the rates of TB are 375 times higher than those for non-Indigenous Canadians.

These inequities are shameful, but they are not inexplicable. The lack of education, crowded housing, high unemployment and incarceration rates - all of these contribute, in some way, to poor health.

Our government has committed to invest more than $8 billion to begin the work of rebuilding Canada's relationship with Indigenous peoples.

Among other things, we will invest in better housing, clean water, and early childhood learning.

We will move ahead with a new health accord that brings Indigenous voices to the table. Instead of the status quo, where we respond to crises in Indigenous communities as they arise, I'm determined to work with Indigenous leaders and other stakeholders to build an approach to these health gaps that is proactive, effective and just.

Priority: Innovating in service delivery

So far, I have talked about specific areas of within healthcare that need attention.  But the reality is that dysfunction and inefficiency are embedded in our systems.

Fixing this requires innovation. But innovation isn't all about shiny new toys. It means adopting proven business models that can deliver better care and outcomes at lower cost.

Large enterprises, whether public or private, cannot thrive without innovation. Healthcare is no exception.  People like Dr. Sinclair know this all too well. He was the founding chair and acting CEO of Canada Health Infoway, which works to implement digital innovations to support the health of Canadians.

It's time to reclaim the political will, time and resources to develop and implement bold reforms in the funding and organization of front line delivery.

It's not easy, but other countries are doing it.

Americans have kick-started the development of a whole new suite of models to change the way health services are funded and delivered - accountable care organizations, medical homes, and bundled payment.

This is not about privatizing Canadian healthcare. It's not about how care is paid for - it's about putting in place more efficient and effective models of care delivery.

It's about reorganizing healthcare in ways that are more efficient and put the patient first, while maintaining our single-payer public model.

Indeed, some of the boldest reforms in the United States are taking place within US Medicare and Medicaid, programs that are public.

If we want to modernize healthcare systems and improve performance, we need to strengthen the underlying infrastructure, including digital health.

Despite billions of dollars invested federally and provincially in e-health over the past 15 years, huge gaps remain.

We've adopted a dizzying array of information systems across the health sector, but they rarely communicate with one another.

It's shocking that in the age of Facebook and e-commerce, we're still using fax machines in doctors' offices and most Canadians still can't go online for their health records.

We need to focus our efforts on building digital systems that are focused on patients and seamlessly integrated across care delivery.

This means that future federal investment has to prioritize the connection of patients, service providers and institutions. It means making sure patients can access their health data electronically, book appointments and consult their physician without visiting an office.

Our slow progress on e-health also means we haven't developed the kind of data systems needed for public health surveillance, nor to measure improvement, make course corrections and close gaps.

In healthcare, technology raises costs. New tests and diagnostic tools are adopted into practice, often without a robust assessment of their cost-effectiveness.

And when productivity improves, our systems for remunerating health providers don't keep pace. This is not a sustainable way to manage technology in healthcare. We need to reward providers for doing what's best for patients.

The good news is that healthcare innovation is an area where there is a strong consensus for action, and where federal investment can help drive the adoption of better business models and accelerate change.

Targeted federal investment in pan-Canadian organizations have already paid dividends in spreading innovation, supporting digital health, reporting on performance, and evaluating health technologies.

We must seize the opportunity presented by a new health accord and a commitment to new funding to build on this strong foundation.

Getting results

No discussion of healthcare in Canada would be complete without covering one final topic: the money.

Some insist that the problem facing Canadian medicare is a lack of money, and they decry the fact that the future growth rate of the CHT will be brought more in line with the growth rate of the economy.

However, the facts simply don't support the notion that what our health systems need most is even more cash.

Canada is one of the world's highest spenders on healthcare and yet we are not achieving the kind of results that Canadians need and deserve. The health accords of the past, for all their good intentions, did not tackle the fundamental structural problems facing Canadian healthcare.  We took the status quo and we inflated it.

As I said to the Canadian Medical Association recently, I am convinced that we have an obligation as the Government of Canada to do more than simply open up the federal wallet.

Canadian healthcare has never been solely the responsibility of only one level of government.

Every province, on its own, has been advancing important reforms over the past decade.  I commend their resolve and creativity in adapting their healthcare systems to the new realities of an aging population.

But, the Government of Canada also has interests at stake in the debate over the future of healthcare. Unique among the jurisdictions in this country, we have a solemn duty to ensure that our investment in healthcare contributes to the equitable treatment of all Canadians.

There is a national interest in ensuring that comparable services are available across Canada, that universal health insurance coverage is portable and comprehensive, and that we can safely share information that is in the public's best interest.

If we don't have a say in how new funds are to be spent, signing up to increased spending would amount to assuming an open-ended liability.

Our Government comes to the table ready to invest new federal money in ways that will advance the transformation in healthcare.

We must ensure that new money doesn't simply inflate health systems, but helps to put healthcare on the road to long-term stability.

Our commitment to new funding is iron clad. But I will seek agreement on how we can best use new dollars to achieve real results.

Conclusion

Canadians are proud of our health care systems, but we've taken them for granted and not recognized the gradual erosion and fragmentation.

We need to reclaim the vision that the founders of Medicare intended for our healthcare in this country.

We have a unique opportunity to bring real change to healthcare and this is an opportunity that we must not miss.

If Canada is to sustain the cherished, publicly funded and universally accessible healthcare systems we have long relied upon, we need to adapt to new ideas and renew our approach to health policy.

This can be an opportunity to shape the future of publicly funded healthcare in Canada, in order to make it more responsive to the needs and expectations of Canadians.

The role of the federal government is essential in this discussion, so that we can return Canada to once again being a world leader in supporting the health of its people.

Thank you again for inviting me today.