Another health system coming apart at seams

Tue, Jan 11, 2011, 00:00

Canada’s public health system is under severe pressure from rising costs and a rapidly ageing population. Sound familiar?

IT’S TUESDAY evening in the emergency ward of the Royal Victoria Hospital in Montreal. As in other inner city hospitals, the waiting room is packed to bursting. Some patients have been waiting since that morning to see a doctor and tensions are running high.

There’s the young woman with the weak heart who has yet to go through triage, for example. She grabs a doctor who emerges from the office and tells him she’s been waiting for ages to be assessed. “I’ll probably die waiting for my number to come up,” she yells.

Just then, there’s an almighty commotion as a gory emergency case, possibly the victim of a car crash, is wheeled in.

A man with a bright yellow face, who seems to have an advanced case of jaundice, groans. It looks like his wait just got longer.

Some of the people here might have been better advised to see a family doctor – the mother whose daughter has a hacking cough or the man with the shooting pain in his leg, perhaps. But with severe shortages of doctors across the country, emergency wards have become the main recourse for millions of Canadians.

“Finding a doctor is like trying to get a ticket to a U2 show,” says surgeon Michel Dunberry, who works in Quebec, where just over a quarter of the population falls through the cracks of a health system under immense strain.

This year, an international study published by the Commonwealth Fund showed Canadians to be the biggest users of emergency services compared with 10 other countries, including the UK, the US and Australia.

The phenomenon is part of a broader crisis. Once the pride of the nation, Canada’s public health system is coming apart at the seams, torn between a desire to uphold cherished principles of universal coverage and the challenge of delivering on that promise.

Lack of expenditure does not appear to be the issue, with the country allocating roughly 50 per cent of its total spending to healthcare. Faced with challenges such as an ageing population, increasingly costly procedures, bed shortages and long waiting times, the government has actually been increasing spending by an average of 6 per cent per year.

It’s a first-world problem. Canada, after all, boasts some of the best health statistics in the world, ranking in the top 10 for life expectancy, according to the CIA World Factbook.

As family doctor Claude Cyr, a strong advocate of medicare, points out, “patients with serious illnesses such as cancer receive world-class treatment, but there are major shortages when it comes to prevention and having access to basic medical services”.

Canadians, who tend to be more socially minded than their neighbours south of the border, are generally fond of their public system, but as the cracks become more apparent, many wonder whether they would buy their way to the front of the line given the opportunity.

Increasingly, the opportunities are there. As the public health system falls into disrepair, private clinics are springing up across the country.

Surgeon Nicolas Duval is the owner of a controversial Quebec clinic specialising in orthopaedic surgery. It is the only private clinic in the country where patients can be hospitalised, attracting clients from as far away as Alberta and British Columbia.

Duval is not against publicly funded healthcare per se. “A public system offering good quality care everywhere you go would be ideal,” he says. “The problem is it costs too much.”

He decided to go it alone in 2002 out of frustration over the amount of operating room time he was allotted – one day a week, with an 18-month waiting list.

Travelling abroad to teach foreign surgeons, he realised that they all had more experience than him. “I was the one supposed to be teaching them,” he says. Now he operates five days a week, seeing as many as 500 cases a year.

According to Danielle Martin, a spokeswoman for Canadian Doctors for Medicare, clinics such as these are “breaking the law”, in particular the terms of the Canada Health Act, the legal bedrock of universal healthcare.

Duval, for his part, asserts that his practice is perfectly legal under a 2006 provincial law allowing patients to go private if they wait longer than six months for hip, knee or cataract surgery.

Huge variations between the country’s provinces, which administer their federally funded systems separately, have created a mind-boggling patchwork of exceptions to the rule. And, it doesn’t help that federal health law itself is also full of exceptions.

Visits to the doctor are free, but not prescription drugs – unless you are over 65. Homecare is provided by private companies, but not hospital care. Private clinics can offer knee surgery, but not heart surgery.

The Organisation for Economic Cooperation and Development this year called for clarification of the law, saying “there seems to be confusion about the legitimate role of the private sector in the health system”.

Experts predict a showdown between the federal government and the provinces in coming years, with the former advocating universal care as a matter of national unity and the latter keen to cut the apron strings.

Dunberry thinks that, while a certain amount of privatisation is inevitable, universal coverage will win through. “It’s a matter of principle for the federal government, that any Canadian can be treated anywhere in Canada,” he says.

With ever-increasing sums of public money being sucked into the maw of the ailing system every year, it is clear that whatever remains of universal coverage will have to undergo serious reform if it is to survive.

Colleen Flood, a professor in health law and policy at the University of Toronto, thinks that doctors’ pay, currently linked to volume, needs to be reviewed. “Nobody is taking on the issue of quality. The government is nervous about confronting physicians,” she says.

The country is also paying too much for its prescription drugs – 16-40 per cent more than other industrialised countries, absorbing about 30 per cent of total expenditure – in a bid to retain investments in the country. The provinces, which negotiate separately, are “mushy, easy payers”, says Flood.

They need to get together to wield their bargaining power.

Eventually, she says, people will have to pay more, particularly with the looming “silver tsunami” of baby boomer patients on the horizon.

Measures such as mandatory private health insurance to help bridge the gaps will be extremely unpopular. All the more reason to get the politics out of the system, she says.

“We need to devolve responsibility to arms-length agencies that are immune to the political cycle.”

WORN OUT: MEDICAL STAFF IN DISTRESS

“We call it ethical suffering. You see so many people who you’d like to follow up, but you can’t. It weighs on you, makes you feel powerless,” says medical student Rachel Gough.

Currently training to be a family doctor, she has been overwhelmed by the number of patients at the drop-in clinic where she works, many of whom have to be turned away.

Last year, she had to take time off for burnout. It’s a common phenomenon among her fellow students, she says. “But people don’t speak out. There’s so much taboo among specialists about mental health.”

Nurse Marijke Durning decided to get out of the public system after almost three decades. “It’s demoralising. You’re running from room to room putting out fires. You see a patient who needs you to sit with them to talk about their diagnosis, but there’s another patient in the next room who’s crashing because nobody is monitoring their heart rate and then the bells all start going off at once.

“I’d drive home at night, dead exhausted. But I couldn’t tell one thing I did. I’d been running for eight hours, but I couldn’t remember anything.”

CANADA AND IRELAND: THE COMPARISONS

* Both Ireland and Canada have a mix of public and private care. In Canada, all residents are automatically entitled to free healthcare, while in Ireland the level of entitlement is dependent on income.

* However, universal coverage in Canada is not as broad as in Ireland, since it does not cover categories such as long-term care, homecare and dental treatment.

* The burden on emergency services is a growing problem in Canada, where anybody can be seen free, as long as they are prepared to wait. In Ireland, those who do not qualify for a medical card must either present a doctor’s referral or pay a charge.

* In Canada, all patients below the age of 65 pay for prescription drugs. In Ireland, holders of medical cards qualify for free medicine. Those with long-term illnesses can join a drugs payment scheme that caps costs.

* The state drugs bill is a major issue in both countries, with Big Pharma stretching patent protection as far as it will go to secure higher prices. In Canada, government policy has been compromised by investment interests. This year, Ireland negotiated reductions on branded medicines worth at least €100 million a year.