Dr. Merrilee Fullerton on Healthcare

The throne speeches  from Ontario, BC, and Canada, as well as the budgets that follow them, hint at the challenges ahead with deficits and debt in abundance, potentially shrinking tax base in part because of demographic factors, and a fertility rate that indicates a major problem for future Canadian workforces.

Ontario government suggests that an online University and allowing more international students to assist in funding the higher education system will bring in much needed revenue.

BC's Kevin Falcon indicates that allowing medical tourism is another way to generate much needed revenue.

The recent federal Budget 2010 will maintain federal transfers to the provinces for health...a key difference from the 1990s with Paul Martin's Liberals at the helm. Despite grappling with a huge deficit budget and infrastructure/stimulus spending, the current federal government is prepared to "pay on", at least for this year.

There is discussion in the back rooms of how to bring in a national Pharmacare program either by a CPP type program or through some other mechanism of federal funding. If you thought health care was unsustainable now, just wait for that plan!

All of these issues surrounding taxation and education and health care costs are exacerbated by Canada's low fertility rate in all provinces except for the territories which have a much higher fertility rate than the national average.

And if we look carefullly, the trade off is between "paying now" or " paying later". There simply isn't any other choice. We can raise taxes, look for other funding revenues or create a larger tax base either with more productive people in more productive companies.

Babies, or lack thereof, are very much a part of the equation. Quadrupling immigration will not be sufficient to change the "dependency ratio" or the "providing ratio" as some like to call it.

There are many reasons why Canada's birth rate is falling but interesting that the US birth rate is not despite their private insurance/employer-based health care.

Does higher taxation play a role in declining birth rate? I'm not sure but often financial reasons are given for putting off having children or having none at all. Raising children is expensive. 

In days gone by, families were expected to care for their loved ones in their senior years, for the most part. Some long term care existed but frequently, a senior family member would be cared for by at least one of his/her offspring and sometimes shared around at various times of the year. This was seen to be an obligation. There was no expectation that government or tax dollars would provide all the necessary care long term.

Now, government intervention is expected at all levels of care. We expect to pay taxes and have all of our needs cared for. This is impossible because of simple realities. There are not enough people to pay all of the taxes necessary to provide the care.

There is a VOLUME issue. Not enough tax paying base. Too many people consuming the care.

What to do?

Keep personal taxes low to encourage more families to have more children.

Keep business taxes low to encourage entrepreneurship and less reliance on government for employment.

Give more tax incentives for people to have more children.

Give more tax incentives for people to care for their own family members.

Continue to heavily subsidize post secondary education including apprenticeships.

Do NOT increase public expectations for a national pharmacare program.

Have an honest dialogue about what can be funded in the public health care system and what cannot.

Be frank about the need for more self-care and more savings for individual future health care...But NOT a CPP type plan! Please NO!

I encourage readers to check out the Comments....unlike most other blogs, this is where the real interesting conversation goes on!

Take care. Happy Reading. Enjoy some R & R!

What to choose? The fight for public funding for In Vitro Fertilization coverage or the potential wage freeze for public sector employees at various locations across Canada or the "patients as widgets" approach by some health care sector groups or the health care spending spree in Alberta?

Tough choice.

The Alberta spending spree attracts my attention mainly because it shows a province deeply challenged by a deficit that is likely to linger even though we all know the Alberta economy is one that adheres to the boom/bust/boom cycle. Difficulty is knowing exactly when the boom will hit again and if you are one of the patients left behind in the bust cycle.

With announcements out of Alberta recently that health care funding will be increased substantially in this year's budget...an increase of 17% I believe over last year's budget, it seems that the approach is destined to break the bank in the shortest possible time.

Is this a plan to give the public what they want and see what happens to all other sectors and the public's reaction to pot holes, crumbling infrastructure, and an education system that doesn't meet the needs of a modern world?

Is it a plan to bring in more services offered through  private providers but funded with public money?

Is it a move toward more private provision overall?

My answer is "yes"...and it's about time.

See the link to the Edmonton Journal article. Unless the public understands the trade-offs between monopoly public health care and everything else, we are destined to a paralysis in transformation. The more things change, the more they remain the same scenario is not an option.

I leave you with one question:

Why are nursing unions so set against private provision of care in addition to a public health care system when they are the first to be laid off when the going gets tough in public health care budgets?

Any rational thought that any of you could provide on this would be helpful but then again, some things simply defy logic.

One of our regular contributors had posted an informative post on the previous journal entry regarding accessing beds in Ontario hospitals for emergency cases using Criticall, particularly neurosurgical cases. It  indicates a true lack of access in 2010. This is not something new but it is easy to be hoodwinked by the science of studying wait times and the systems designed to deal with lack of capacity in a system that is likely to get much worse before we come to our collective senses.

Of course, tens of millions were thrown at neurosurgical cases in the past couple years in an effort to create an improvement but in my own estimation, nothing has really changed. I still wait for months...a year in some cases...for a neurosurgical consult in cases with positive MRI findings. I still have referrals rejected because the fax back reads "due to focus on cancer cases, cervical and lumbosacral cases will not be seen".

I do note that what did change after some money flowed was that neurosurgeons were suddenly quiet.

Looking ahead to an aging population and a population with increasing obesity, diabetes and cardiovascular disease, with all the inherent cerebrovascular complications such as stroke and MIs, it doesn't take a rocket scientist, or even a LHIN administrator, to figure out that things are going to get nastier.

I have copied the post almost in its entirety and hope that it provides a deeper understanding of how poorly our system is equipped to meet the needs of the future, not to mention now.

I will also have a look for Mr. Smitherman's comment.

Here is the post from eklimek:

"I am grateful the discussion is in the press about the shortcoming and unsustainability in providing service.

As some of you probably know there is a telephone communication system called Criticall in Ontario. It is used when an emergency requires treatment not locally available.

In years gone by, when there was surge capacity, it was very helpful in connecting the sending and receiving clinicians and assisted in finding emergent care somewhere in the province. Now with no excess capacity pretty well anywhere clinicians begin to view it as becoming just one more hoop.

Here is how it works. Since Criticall does not know the actual provincial bed availability for the needs of the patient (e.g neurosurgery) , it literally telephonically hopscotchs across the province sequentially ringing up on call neurosurgical services.

Reflect for a second on this. Say you are on call as at the potential receiving end. You also know there is no ICU /NICU or surgical capacity on site because you just took the last bed with the last case. Nevertheless you get called. You are obliged to respond, listen to the story, may choose to give telephonic advice for which shared liability is engendered and still must refuse to accept the case because you lack the capacity to treat the problem. All this, let's say, at 3 or 4 in the morninng.

Meanwhile, on the sending end, typically after 3 or 4 refusals for "no beds" over a similar number of hours of repetition and telephone tag with serial oncall services, the conversation turns to out-of-province care. Of course the alternative is to start over from the beginning, just to see if the bed situation has changed in the last 6 hours.

The new wrinkle is interposition of a medical director near the outset of the process if the patient is to leave the home LHIN. Who knew we really needed another noncare provider in this process?"

Thanks for putting it so plainly, eklimek. As health care in Canada sinks, the band leaders play on....except of course when they are trying to enter the life-rafts destined for the US.

I've moved forward to this journal entry only because I did not want to lose the post in the mounds of other information here. This blog has become voluminous much like some of the patient charts I see that need a volume I, II and III.

Please feel free to go back and visit the previous journal entry. I'll be checking for comments over the next few days. I've left some info there on wait times in Alberta and on the new iPad. Interesting developments..

But while I was fishing for information on how Alberta is planning its strategy for health care (and I do like to check in on Alberta because I've found Albertans to be very pragmatic in their approach to many things), I came across this video which I'll link to in the comments section.

It is nice to put some faces to names that we hear so frequently but also to understand that the term efficiency in health care has little or no meaning because it cannot be reliably measured. Accountability is what we really need to be considering to forge new health care options and I'm glad to see some politicians somewhere in Canada have figured this out.

Without going on further, have a look and listen to this video that describes the new Alberta Health Services Quality and Patient Safety Dashboard ...sounds flashy and you may think it is the same old, same old, just repackaged but I get a sense that we are finally moving on from the ill-defined efficiency quest and instead to a more distinct measurement...

And if I hear any more about seemlessly providing the continuum of health care services while working together to achieve a more efficient health care system....well...I'll have to excuse my gag reflex......

I still remember back in 1984 or so when I was a clinical clerk/medical student at one of the country's major hospitals. The staffman was upset because a large number of beds in his alotment were filled with patients waiting for placement. That means they had been treated at the hospital for some reason, their treatment was finished and they needed to be sent home...or sent somewhere....to a relative's home, to a nursing home, to a retirement home or to a chronic care institution, a hospice or somewhere more appropriate than an acute care hospital.

I still remember the calls of an elderly patient with dementia who used to call out to me as I walked past. By virtue of my female gender she would call out "Nurse! Nurse! Nurse!" and although times have changed , in those days most nurses were women. The first few times, I stopped to see what the commotion was all about thinking that there was something wrong and hoping that I could be of assistance. The nurses across at their station later told me that she did that all day long to whomever walked by and despite all of us feeling somewhat guilty about the limited time we had to tend to her, we had come to the realization that she called out as part of her routine and that after assessing there was no immediate need, we would go about our business as necessary.

This may sound cold and uncaring but the reality was that she needed to be somewhere more homelike and have the stability and structure that daily routines could have provided her. Clearly, there were no relatives capable of taking her home or she would have been discharged long ago. But sending a patient with dementia and incontinence home or even to a nursing home is not really in the cards as most social workers will tell you. They need more care than can be delivered at the usual settings.

I still remember her and many like her. In those days, patient were often restrained for their own safety but thankfully progress has been made on that front.

The reality staring us in the face is that this scenario is playing out in hospitals all over the country to an even greater degree than 26 years ago. The issues associated with alternate level care patients are still not adequately addressed. Yes, 26 years have passed and by all accounts the issues are more widespread than ever before despite ongoing efforts to address them.

Now, Aging at Home Strategies are proposed to assist seniors in staying in their homes. There appears to be little understanding of the fact that there is usually an acute event that brings an elderly person to hospital leading to that person languishing in a hospital bed once their acute care is provided.

The acute event occurs whether the patient has assistance in their home or not. Acute events are often a fall or a cardiac event or an infection that comes on quickly or is resistant to treatment  for some reason (often related to diabetes or the fact that the patient has some degree of dementia). Aging at home strategies will not stop these acute events from occuring. They occur because of the frailty of the elderly person and are associated with aging.

More family physicians and more community care will not stop any of this from happening despite what Health Minister Deb Matthews proclaims.

It seems I am not alone in my thinking. Please see the link to a letter to the editor in the Ottawa Citizen this morning. The writer gives a very good overview of the problems we are facing in local long term care. The same problems repeat over and over across the province and the country.

Minister Matthews is practicing wishful thinking....and that doesn't provide health care as far as I know.

Enjoy any sunshine you can get over the next few winter months here in the land of ice and snow and generate some Vitamin D!

Have a Happy Day...