A Renewed Partnership for Health Care Sustainability in Canada Speaking Notes for The Honourable Pierre Pettigrew, Minister of Health, Minister of Intergovernmental Affairs and Minister responsible for Official Languages to the Health Policy Summit 2004 Moving Healthcare Forward in Canada Toronto, Ontario April 20, 2004 Check against delivery Introduction Thank you very much David for that kind introduction and good morning to all of you. I want to thank the conference organizers for giving me the opportunity of delivering an address at this year's Health Policy Summit. I feel truly honoured to be here today to share and exchange ideas and information with you. The agenda for this Summit is as timely as it is ambitious and exciting, and provides an opportunity to obtain new insights and a broader appreciation of both the challenges confronting Canada's health care system, and the absolute imperative for policy-makers, for health professionals and for Canadians to work together to secure its future. Just four short days ago, in Toronto , the Prime Minister reminded everyone that Medicare is more than just another government program. He referred to it as «a statement of our values as a nation» and committed to sitting down with his provincial and territorial counterparts this summer «not just for lunch or dinner or even a weekend, but for as long as it takes for us to agree on a long term plan for a health care system that is properly funded, clearly sustainable and significantly reformed.» The Prime Minister also spoke about the urgency to reassure Canadians that their concerns over wait times are being taken seriously, and that real commitments for progress in this area are an absolute must. Achieving this bold agenda will require a new, more collaborative relationship between the federal and provincial governments. Indeed, what is required is a true partnership, encompassing all the mutual respect and support that successful relationships typically embody. In my remarks today, I want to expand on a number of the themes the Prime Minister articulated in his speech. I also want to outline the Government of Canada's preliminary thinking on the elements of a reform agenda which are necessary for this new partnership to succeed. Our overall objective is to ensure the improved health care system provides quality care in the most appropriate setting, is sustainable for the next generation, and includes mechanisms to allow progress and performance to be measured and reported to Canadians. But before doing so, allow me to briefly elaborate on the reasons why the Prime Minister has chosen to make progress on wait times the central construct for a health reform agenda. Why Wait Times Matter Timely access is the lens through which Canadians evaluate the whole system. Canadians need to have confidence that the high quality system they want will be there for them when they need it. This is the very underpinning of our health care system, the fundamental «bargain» that exists between Canadians and their governments. We know that the support of Canadians for our public, single-tier system of health care is not given freely; it is given in exchange for a commitment from their governments. We should be clear that when individual Canadians encounter the system, they do express a high degree of satisfaction with the care they receive. They also retain confidence in health care providers, and have a profound attachment to the version of health care that Canada provides. But, for some time now, confidence in the «bargain» -- and perhaps most particularly, the future of it -- has been eroding. Nowadays, Canadians worry about being able to book an appointment with their family doctor – and, in fact, too many even have trouble finding one. Some Canadians also worry about waiting for hours in a crowded emergency room or waiting for months to see a specialist or have a critical test. While most Canadians understand that urgent care such as heart surgery is dealt with quickly, they worry about wait times of a year or more for other services, such as hip and knee replacements or diagnostic tests. Some of these fears have grown out of misinformation and exaggerated anecdotes that have become urban legends about the health system. But, we have to acknowledge that some of these fears are legitimate concerns that arise out of real encounters with the health care system . If Canadians come to believe their governments are failing to uphold their part of the bargain they will begin to look elsewhere for «new solutions». And, most of the so-called «new solutions» aren't really so new at all. They are a step backward, to a time when those able to pay their way to the front of the line got the best care, and those who couldn't, did without. The bottom line is that, if we believe in a single payer, publicly-funded health care system, we have to make sure it continues to deliver results. While we know that reform is an essential part of the health care discussion, the real issue we care about as people is timely access to the services we need. Addressing the Wait List Challenge While there are no quick fixes or «magic bullets», there has been plenty of analysis of the issue and it is important to note that many provinces have already made progress in addressing wait times. Constructive advice emerged as recently as last month from a wait times colloquium sponsored by the Canadian Medical Association, the Association of Canadian Academic Healthcare Organizations, the Canadian Institutes of Health Research, and the Canadian Institute for Health Information (CIHI). Their findings will help governments and healthcare institutions as they contemplate further appropriate improvements. We now know that addressing the waitlist challenge on a long-term basis will require a deliberate, comprehensive and multi-faceted response: It will require governments and managers of health institutions to work together to address mismatches in the demand, supply and distribution of health human resources and of service delivery capacity. It will require further progress in delivering care in the most appropriate setting, whether in a primary care clinic rather than an emergency room, or at home with the right support to recover from surgery. Appropriate home and community care can relieve pressure on the acute system, improve services to Canadians and produce a more sustainable health care system. It will require national strategies for investing in the upstream of health promotion and protection in order to relieve pressure on the downstream of health care delivery. This «public health» component is a key aspect of the federal role and our commitment to greater action on that front was reflected in the recent budget. In particular, we have a profound duty to improve the health status of aboriginal people. That is one of the reasons why the Prime Minister hosted a Summit on Aboriginal issues yesterday. It was a very frank political discussion, especially in the roundtable on Health, which I led. Simply put, we know we must do more to achieve better outcomes for aboriginal men women and children. Addressing the wait list challenge on a long-term basis will also require support for strengthening health administration, support for innovations that improve the productivity of our health system and of our health providers, and support for new mechanisms to share and adopt best-practices. Indeed, Canadians do not just want better access to a 1960's health care system; they want access to a dynamic, state of the art patient-oriented system that quickly integrates the latest and best medical technologies and treatment options. It will require greater accountability and transparency throughout the health care system. Canadians have a right to know what acceptable wait times are for different types of services and procedures, what level of care they should expect, whether their local providers are doing better or worse than the norm, and why. As participants at the recent Wait Times Colloquium stressed, information is key to progress. T he sooner we begin a national effort to collect more information, the sooner we will be in a position to spend and allocate in areas of greatest need. And, to make all of this possible, new money and a new partnership between the federal and provincial governments will be needed. For our part, as Prime Minister Martin said last week: the Government of Canada is ready to participate. Developing the Plan I want to dispel the idea that the Government of Canada is in a position of superior knowledge of what health care needs, or that we can or should dictate to provinces and territories what steps they should take to reform their services. For one thing, there is already a broad and deep consensus -- although not unanimous -- on many of the key directions the system should take. Romanow, Kirby, Clair, Fyke, Mazankowski all provided rich analysis on necessary reform. We are learning from them all, as well as from many clinical and administrative leaders and policy experts across the country. In addition, provinces and territories are already making reforms in how care is delivered: primary health care models are being developed and expanded across the country, assisted by the primary health care transition fund and funding provided in the last Accord; enrollment in professional training is increasing, especially in nursing; jurisdictions have initiatives underway to manage and reduce wait times, such as Ontario 's Cardiac Care Network, and the Western Canada Wait List project; and, together with the federal government, a Common Drug Review process is in place to improve our use of drugs in health care. In the weeks and months ahead, we need to take the knowledge we have, the objectives we share, and the resources at our disposal, and convert them into visible progress. While there may be plenty to discuss regarding which means to employ, there is no debate at all about what the end should be: our shared goal is to implement changes that will make a real difference to Canadians not just of this generation but for generations to come. We must restore Canadians' confidence in the future of their health care system in order to ensure its sustainability! Laying the Groundwork for a Successful Partnership Of course, key to success in this national initiative will be forging a successful partnership with the provinces and territories. In reflecting on the results of the September 2000 and the February 2003 Health Accords, most observers would conclude that the investment of some $55 billion of new federal money into the health care system is a notable achievement. In January, shortly after I was appointed Minister of Health, I crossed the country to meet all my provincial and territorial counterparts. From these conversations with my health colleagues, it was clear to me that all governments agree on two things, at least: 1) we've still got work to do; and 2) to succeed, we must improve the intergovernmental process and the climate for discussions. I know that my provincial and territorial counterparts are as mindful as I am of the fact that what Canadians expect from their political leaders is results, not rhetoric; collaboration, not finger-pointing; and, accountability, not excuses. So, what will be required? The First Requirement will be Mutual Respect Under our constitution, primary responsibility for the delivery of health care services in Canada rests with the provinces and territories. It is they who must cope with the day-to-day pressures of providing quality health care services to their citizens. At the same time, the Government of Canada does play an important role in health care and, through its spending power, provides health care transfers to provinces that administer public insurance plans that meet the Canada Health Act criteria. Canadians also clearly expect the federal government to exercise «national interest oversight» to ensure that the health care system continues to reflect both the letter and the spirit of the Canada Health Act. If we are seen to be doing this, we will succeed in maintaining the confidence of Canadians in the system. Whether Saskatchewan 's bold experiment of providing universal, publicly-insured health care services to its citizens would eventually have swept across Canada without federal leadership is a subject for historians to debate. But, the fact is that federal support was essential to making Medicare a reality, and that over the years, federal support has allowed the system to expand beyond its original boundaries. But with Medicare now an entrenched feature of the public policy landscape, it is time for a new form of federal leadership - a more collaborative form of leadership -- to ensure the health care system remains relevant, effective and sustainable. I believe that in addition to diligently enforcing the Canada Health Act, the federal role must focus on three complementary objectives: refining or developing policy instruments, arrangements and mechanisms that support innovation, improve system quality and facilitate knowledge-transfer; improving accountability to Canadians; and working with the provinces and territories to establish common population health and disease reduction goals, strategies and performance measures. In short, the federal government has an interest in the sustainability and transparency of health care, and in improving the health of Canadians. Recent initiatives like the Canadian Patient Safety Institute, Canada Health Infoway Inc., the Canadian Institute for Health Information and the Health Council of Canada point to the ability of governments to work well together when they choose to. More to the point, each of these inter-governmental bodies will have a role to play in any national effort to improve access and quality. Just as the provinces should acknowledge the federal government's responsibility to ensure equitable access to quality health care services for all Canadians, so must the federal government be respectful of the provincial role in delivering health care services to Canadians. We must avoid top-down approaches and encourage partnerships. The fact that the Prime Minister has agreed to meet regularly with the Premiers and has agreed to consult regularly with them to establish a mutually agreeable agenda, bodes well for the future. But goodwill alone is not enough, and that takes me to the second key component of a new partnership: predictable, adequate and stable funding . In his April 16 speech, the Prime Minister emphasized the need for a 10-year plan to strengthen the public health care system and ensure its sustainability and, in so doing, stated: «We're finished with the year-to-year scramble for short-term solutions. What the provinces need now is a long-term agreement that guarantees predictable, reliable funding.» We will meet that commitment, and we will put an end to this corrosive and debilitating debate over money! Canadians will know exactly what the federal government's contribution to health care should be, and whether or not it is keeping its part of the deal. But, Canadians expect us to be more than just a system bankroller or a silent partner: we are prepared to take the next step forward to become a full system partner, to share in the risk of maintaining and enhancing the system over time and in shaping its future. In his Toronto speech, the Prime Minister also noted that any health care reform plan must include measures to support the evolution of home and community care services and the development of a national pharmaceuticals strategy. These are the new frontiers of the health care system, and pharmaceuticals is the fastest growing area of provincial health spending. The Government of Canada is already supporting efforts in these and other areas, but we are prepared to engage in discussion with the provinces on how we can do more. The third prerequisite for a new partnership is to modernize the system's foundations. The Canada Health Act has been and remains for Canadians a symbol of national solidarity and of shared values. Its five principles are as relevant today as they were two decades ago when the Act was unanimously supported by all political parties. But in recent years, differences of opinion as to how to interpret the Act's provisions, and inconsistent enforcement of its requirements, has resulted in growing confusion and uncertainty as to what the Act does and does not allow. While I am not suggesting that the Act be re-opened, I do believe we have a responsibility to clarify its practical meaning in today's terms. When we first started debating Medicare many decades ago, «medically necessary» health care could be summarized in two words: hospitals and doctors. That's where, and by whom, virtually all care was provided. If you needed primary care, you went to the doctor. And if you needed anything else, you went to the hospital. And so, public funding was designed accordingly. But, then the delivery of services began to change. New surgical techniques have been developed that shorten hospital stays and allow recovery at home or occur on an out-patient basis. New drug therapies were developed that accelerate recovery or allow surgery to be avoided entirely. And, technology has made many procedures possible that have not been publicly funded. Today, hospital and physician services account for less that half the total cost of the system. Now, while all of the changes I've enumerated suggest real progress, they also underscore real challenges. For example, I believe we must be clear as to what terms like «medically necessary services delivered by physicians» means in an era where drug therapies are an alternative to costly surgical interventions, where patients are discharged from hospitals more quickly to recover at home, and where nurse practitioners and other health professionals who are not doctors are delivering a growing range of health services. And, with growing interest among the provinces to experiment with new forms of health care delivery, we need to ensure that the «rules-of-the-game» for doing so are clearly defined, and that these experiments are closely monitored through a public interest lens. We know the public administration principle of the CHA already provides flexibility on private delivery, but we may need more work to ensure our respective approaches continue to honour the purpose of the Act. To safeguard the essence of the Act in these rapidly evolving circumstances, we need sound and effective regulatory frameworks. I am committed to working in partnership with provinces and territories to develop such frameworks. Canadians will not want us to permit the basis of our publicly funded, single payer health care system to be compromised by stealth, default or neglect. And finally, in that context, I believe we need to review existing CHA dispute avoidance mechanisms to make them more transparent and inclusive and to ensure enforcement is more consistent and evidence-driven. While the Canada Health Act is federal legislation, we must not undertake this renewal effort alone. We must work together with the provincial and territorial governments, and with Canadians themselves, to ensure the CHA continues to serve as a beacon for our health care system. The fourth step in creating a productive and successful partnership in health is to make accountability the centerpiece of any renewal effort. Health care in this country is now a $120 billion enterprise, comprising roughly 10% of our economy. But, we have really just begun to account for how effectively that money is spent. Too often, Canadians are asked to blindly accept assertion as fact, to simply trust governments and providers to do the job. To improve the way in which we organize, deliver and manage the health system we need to undertake research, assess innovation and apply evidence to the policy-making process. Over the past few years, the Government of Canada has made a series of commitments in this area totalling over a billion dollars (through such initiatives as the CIHR, CIHI and Research Chairs) and we continue to regard research as an essential element in determining how best to meet the health needs of Canadians in a timely fashion. We will not restore confidence in the system unless we give Canadians broader and better access to the facts. Canadians no longer accept being told things will get better; they want to see proof that they are. They have a right to know, for example, what's happening with health care budgets; what the number of hospital beds, doctors and nurses are; whether the gaps are being closed and home and community care services strengthened; and whether treatment outcomes are improving. Better information will allow Canadians to discuss national objectives for quality care. It will let them answer questions like: how many MRI machines do we need? What should be the standard for the number and distribution of various specialists? What are the unique requirements for health professionals in rural and remote areas? Let me suggest how the goal of greater accountability to citizens can be applied to the practical problem of wait times: we have more information from health care institutions than ever before; we should use that information to identify the procedures where wait times give us the greatest concern; in partnership with clinical experts, and learning from our own and international experience, we should publicly set goals for appropriate wait times; and governments should regularly publish data on performance in reaching those targets. Canadians need this information, not to make governments accountable to each other; but so that all governments and all providers are held accountable to citizens. My own experience in working with the provinces on the National Child Benefit Program provides a good illustration of what cooperation can achieve. Just as there is a consensus in Canada as to the intrinsic value of publicly funded health care, so too is there a consensus when it comes to the welfare of our children. To accomplish our goal of assisting low income families to make the transition from welfare to work, we created the «Ministerial Council for Social Policy Renewal ». Together, the federal government and the provinces were able to define common objectives within this field of shared jurisdiction. Together, we were able to decide on an appropriate formula for delivering what is now $10 billion in federal contributions to the program. Together, we were able to agree on how they would report annually to their respective citizens on the results of their efforts. This program has been very successful both from a policy and intergovernmental perspective. I see no reason why with continued good faith and with good sense, we cannot do the same in health care. Before I conclude, I should note that, aside from provinces and territories, there are other key partners in the health care system whose advice and active contribution will be required to ensure we succeed in ensuring the long-term viability of the health care system. Without the commitment of health care professionals, beginning with doctors and nurses we will not succeed. There is also an important role to be played by Teaching Hospitals and Regional Health Authorities. These entities help to facilitate the convergence of improved access to (specialty) care and train the full range of health care professionals. They also undertake most of the health research in the country. Conclusion Forty years ago, Malcolm Taylor, a member of the Emmett Hall Royal Commission speculated that, as far as health care reform was concerned, there are only two times when change is possible. He said: «One is when there is a budget feast; then change can be bought. The other is when there is a budget famine, when change becomes inevitable.» While we are not graced with a budget feast today, neither are we in a famine. And so with due respect to Mr. Taylor, I would like to suggest a third time when change is possible -- and that is, when forward-looking people decide that managing change is a far better alternative than being overwhelmed by it. I believe Canada 's First Ministers have both the commitment and the creativity to effectively manage the changes confronting our public health care system. I believe they understand that Canadians expect them to work together. I am confident that they can solve the wait time challenge and restore public confidence in the system's future. And I have confidence that they can and will make the right choices. Thank you.
