Medical Device Daily Contributing Writer

A yearly Canadian healthcare survey reveals that residents continue to be pessimistic about the nation's publicly funded healthcare system, though not as pessimistic as in prior years.

Some 47% of Canadians surveyed say their confidence in the system is falling, which is down from 58% two years ago. Still, a mere 6% in this year's survey said they are optimistic about the system's ability to deliver good healthcare.

Canadian physicians seem nearly as pessimistic as their patients, with 41% saying their faith in the healthcare system is declining. Dr. Albert Schumacher, a family physician and president of the Canadian Medical Association (Ottawa, Ontario), attributes the low confidence in Canada's healthcare system to, among other things, government's failure to reduce the amount of time that patients must wait for treatment.

“To define what is a safe and reasonable wait time for a total hip or knee replacement or to wait for cancer surgery. The government isn't helping with that right now, but it's something that's absolutely crucial to do.“

Universal healthcare in Canada is delivered under the umbrella of the Canada Health Act, which requires that all medically necessary procedures be paid for from the public purse. But as the population ages and the strain on public finances becomes increasingly acute, the ability of the system to meet patient needs has been strained. Nearly three years ago a report commissioned by the federal government recommended a massive injection of funds into the system, improved access to healthcare in rural areas and improved wait times for diagnostic services.

The federal government responded to Roy Romanow's Report on the Future of Health Care in Canada with a promise of C$17.3 billion in increased federal support for health over three years, rising to C$34.8 billion over five years. It also fulfilled another recommendation: establishment of a national health council to create consensus among the 10 provincial provinces over uniform standards for health care delivery, a debate complicated by the fact that each province has its own health budget and decides how that money is allocated.

Romanow himself surmised that the Canadian Health Council might eventually be used to settle disputes over federal funding and federal healthcare standards. For the moment, politicians and the medical community are waiting for a report from the health council itself, expected at the end of January. The big question on everyone's minds will be how well the Health Council thinks governments have done coming to grips with the healthcare crisis in Canada and how it views its own contribution.

“When we issue our first report,“ health consultant Steven Lewis told Medical Device Daily, “when we start producing more analyses, have a more prominent face in the media, then I think people will get an accurate fix on whether we were worth establishing and whether we're going to make a contribution.“

Lewis is among those who have been highly critical of physicians' positions on Canadian healthcare, charging that primary care reform in Canada “is deeply mired in obsolete patterns of practice“ and that doctors have been largely resistant to making the necessary changes. Lewis argues, for example, that a “turf war“ has emerged in Canada, where doctors are reluctant to devolve more routine medical procedures to other less-costly healthcare providers, such as nurse practitioners.

“No one wants to give up exclusive domain over certain areas of practice, and sometimes it's a legitimate concern over quality. More often than not, it's just 'If we give up some of our turf, we lose some of our power and some of our earning power.'“

Lewis argues for a more comprehensive method of organizing and delivering primary care services, i.e., physicians working in larger healthcare centers with a full range of integrated medical disciplines. The vast majority of Canadian physicians, he says, still confine themselves to the fee-for-service compensation model and running a single office on their own. Lewis maintains larger, more collaborative practices are far more beneficial, especially for the patient.

“Some people have pretty complicated needs, i.e., they have physical needs, they have mental health needs, they have socio-economic circumstances that are affecting their health. So it's very difficult in a solo practice to have all of those needs addressed well, because physicians can only cover so much ground.“

The comprehensive healthcare center approach also is more efficient, says Lewis. In addition to allowing nurse practitioners to take on tasks previously handled by physicians, the skills of other healthcare professionals could be more adequately used, something that's not happening now, he says, “because the physicians are the gatekeepers and the division of labor is still pretty antiquated.“

Schumacher takes issue with Lewis's assertion that Canadian doctors are lukewarm in their support for primary healthcare reform. Lewis, he says, is one of many “so-called experts“ with an opinion on healthcare, but “hasn't practiced healthcare at the front lines.“ The “big obstacle“ to healthcare reform, he says, is not physicians' unwillingness to change, but a lack of money.

“I cannot get funding to bring a nurse or nurse practitioner in to work with me. I can't get funding from the provincial government to bring in an electronic medical record. I can't get access to dieticians' services, physiotherapy services that I need.“

Uncertainty around funding is the principal reason Canadian doctors are reluctant to contemplate practicing in larger, more team-oriented settings, says Schumacher. No one, he argues, is going to sign a lease on a large facility until the First Ministers accord signed in 2003, committing large amounts of federal money for healthcare, is ratified by an act of the Canadian parliament.

“(Doctors) are not willing to make substantive investments with their own money in some kind of group practice and actually go and hire massive numbers of other healthcare professionals that they're going to be obligated to when there's no sustainability of funding,“ he said.

The head of the CMA and Lewis are united on one thing and that is their hope that a Canadian Health Council will prove effective in overseeing changes to the way healthcare in Canada is both evaluated and delivered. “I don't think that anyone has any reason to say the Health Council of Canada is going to be a ringing success or a failure,“ says Lewis. But for the council to be effective, says Schumacher, it must “actively report on and document where progress is being made, where the deficiencies are and the things that need to be done next.“

He added: “Right now, for example, we have no standard comparator of province to province as far as the length of wait times and the number of machines, such as ultrasound machines, that are available . . . and those are the things we need.“

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