He also thinks it would be a good idea to have family doctors fall under the purview of the Local Health Integration Networks so that family doctors would be given the infrastructure to meet regularly and discuss how to address patients who don't have family doctors.

His premise included the concept that  existing physicians could somehow arrange to divide the existing orphan patient population. He is reported to have said:

"..if we each take however many, we solve the problem."

Although this physicians' ideas are noble in intent, it is important to realize that government is not the only way to be organized and that there are existing structures already that allow for communication and organization amongst physicians. These include existing groups of doctors working in real life clinics as well as virtual groups of doctors who may practice separately but who communicate regularly and who must organized themselves to provide care for their patients without being told by government bureaucrats how or when to do their jobs.

Trouble is that some physicians are not particularly interested in being involved in meetings outside their day to day duties. Whether this is apathy or self-preservation is up for discussion. But the idea that we need more administration comes at a strange time when productivity of physicians in new models is being questioned. The argument goes that other countries are doing better than Canada in organized primary care but the reality is that to be brought up to OECD standards for physicians per capita, we would need 26,000 more physicians in Canada today. Hate to tell you this but it ain't going to happen anytime soon.

However, as we move to new models of primary care, often driven by policy and not evidence, it becomes increasingly clear that the government agenda is to budget and control.The likelihood of adding more administrative funds instead of patient care funding is not very realistic when we seem to have a black hole for health care dollars that don't necessarily get to patient care.

We are already lacking the physician resources and even nursing numbers to cover the coming needs. Losing more doctors to administrative work hardly seems reasonable to me let alone spending more on administration when the loads of paper work (real or virtual) threaten to crush us mentally and even take a physical toll.

What does this have to do with the OECD lowering forecasts for the Canadian economy, you ask?

Well, if the outlook for growth for Canada's economy is as dire as predicted by the OECD..less than one per cent and less than half of that of the US economy.....the 0.8% growth just isn't going to allow for much more health care spending, at least I hope not on more "administration".

While some doctors like the one mentioned seem to believe that more administration is the answer, others like the new CMA president, Dr. Robert Ouellet, don't agree. His comments in the Toronto Star September 3 indicate that he believes   movement away from spending on increasing administration is needed and that the role of private care alongside a universal system is quite complementary. Bravo.

At least someone can look past the mountains of administration and see the patient. There is hope.

Please feel free to comment as always and even to continue the previous comments from the other journal entry. I don't want to cut anybody off!

I've been following along on the comments from various papers including the Toronto Star and Globe and Mail and I'm not surprised to see the usual indignation from doctors and others along the lines of the "proof is in the proof".

Now don't get me wrong, I fully support the concept of harm reduction if it really can help those addicted. The problem I see is with the tunnel vision approach that improving HIV spread should somehow be the raison d'etre of the Insite program. Some will argue that the availability of the safe injection site makes accessing detox that much more likely. Fine. Offer the Onsite detox program as well but why the wait and why the inadequate resources for treatment programs?

If you really wanted to control the spread of disease and destruction from drug addiction, wouldn't you want to have an accessible and adequately funded treatment program? Such is not the case with access to treatment programs lagging seriously while "harm reduction" strategies are funded instead. 

It seems to me that "harm" defined as the transmission of HIV is a bit lopsided since harm related to drug addiction comes in many forms. More treatment programs and addiction services are needed while the debate over "harm" goes on.

Above and beyond the whole safe injection site debate is the strange optic of doctors being indignant over Mr. Clement's questioning of their actions in supporting drug use. Since when were doctors' decisions and opinions 100% pure and always accurate? Is it not reasonable to question our actions from time and time and revisit how we provide care, how we manage care and what is funded?

Why is it that we doctors take offense at the questioning of a fairly controversial program? Haven't we seen time and time again in the history of medicine that the care we provide requires revision and reassessment from time to time?

The idea that anybody, including doctors, would be embarrassed by  a reasonable question as asked by Mr. Clement is beyond me. But I'm not embarrassed by their embarrassment since I realize that it is all political posturing. To think that a CMA ethics committee member would get up and chastise Mr. Clement for making a quasi political speech on Insite ethics is rather ridiculous since CMA General Council itself with media present is one way of mixing medicine with politics. To think that the CMA is somehow purely medical and not political in nature is truly blind... Otherwise, close the doors to the media.

I wonder who the real puritans are.

In Newfoundland, a lottery was held last month to allow a new family practice to  "pick  its caseload from among thousands of applicants".

In this recent CMAJ article from July1, 2008, "Public engagement in setting priorities in health care", which I will hopefully be able to provide the link for in the comments section, it is clear to me that a significant degree of innocence  exists in some academics' minds. The University of Toronto Priority Setting in Health Care Research Group (how's that for a long acronym: UTPSHCRG!) reports on the value of public engagement, perceived barriers, ways to increase public engagement and cautions and realities.

Although the researchers do admit, " It is important that the requests for public input not be overtaken by advocacy groups. In our current system, there is already ample opportunity for disease-oriented groups to engage in political lobbying and, although their voices should be heard in public-engagement exercises, it is the "unaffiliated public" who have the least say in decision-making, with important societal implications."

Now folks, you've heard all of this before, right here on this blog on numerous occasions and I did not receive a research grant or command a salary...or even receive a golf membership for my efforts. I certainly agree with the researchers' understanding of the importance of this. The funny part, or not-so-funny part depending on how you look at this, is that they seem to think that the public can engage in priority setting without this happening.

"All deliberations made with public input need not be conducted in public. There can be great value in an appropriately constituted decision-making body meeting in private, but then publicly disclosing the results of deliberations. This is analogous to the private deliberations of juries in our legal system, which allow them the opportunity to discuss freely, question and argue to arriveat the best decision."

Yikes.

It would seem that this research group is entirely missing the point  that the person caught up in a legal problem has the opportunity to pay for their own lawyer should they wish to.They are not required to accept  a court appointed lawyer. Sure, ultimately the lawyer will plead their case to the jury if there is one, but to think that public priorities can somehow be set behind closed doors without some political intervention is a very innocent perspective. This will improve trust and "confidence in the health care system"?

The idea that the Canadian public can determine the priorities for all of us without taking into consideration the unique needs of individuals which may or may not be met in a publicly driven system is tantamount to ignoring the needs of minorities.

I'm not against public involvement in health care priority setting, but I've been around long enough to know that politics will always be part of publicly funded priorities---make no mistake about this .

However, I think it is also time to discuss the damage that top down control is creating on members of the public service including nurses and doctors as shown in a recent study from the Association of Professional Executives of the Public Service, APEX.

In an article June 16, 2008 from the Ottawa Citizen, "Public sector ' a toxic place to work' ", a national inquiry into the management and working conditions of the public sector is called for.

Bill Wilkerson, chairman of the Global Business and Economic Roundtable on Addiction and Mental Health is reported to have said that absenteeism, disability and claims and distress among Canada's nurses, doctors, teachers, police, military and bureaucrats have reached a crisis proportion and it is time for a major study into what is "sabotaging taxpayers' investment" into these critical services.

What is it that is creating such high levels of distress?

What is wrong with the culture of the public workplace?

Disability claims in Canada are climbing and currently 30-40% of claims are for depression. Cost to the economy: 51 billion (4% of GDP).

The APEX study showed that 64% of executives think of leaving their organization at least every month. More than half want to leave because of lack of recognition.

It is the first study to show the toll of technology and how the reliance on technology has become "counter productive".  About 75% of the nearly 2,100 surveyed say technology increases their workload; 66% said it adds to their stress and 49% said it decreases their productivity.

"People are drowning in technology and risk averseness and the lack of clear lines of accountability" says Wilkerson and "senior bureaucrats could feel "policitized"-torn between being neutral, non-partisan professionals being drawn into the political arena".

The last paragraph provides the most clarity:

"Part of the problem in the public sector is the ambiguity around who is in charge. Departments have to manage with a slew of "one-size-fits-all policies" and answer central agencies from Treasury Board to Privy Council Office. As a result, departments don't feel like they are employers in their own right," says Mr. Wilkerson. "

This certainly applies to productivity issues in the medical world. When top down approaches constrain  highly trained and responsible  professionals and create an inability for them to  function to their full capacity we have reached a significant tipping point.

Mr. Wilkerson and senator Michael Kirby plan to convene a workplace summit this fall into the productivity and health of the public sector, "especially the hardest hit health care sector".

Let us hope that the solution is not more rules and regulations and stifling of innovation, entrepreneurship and independent decision-making....but I'm not holding my breath.

1. Media latches on to a story about patients who are receiving care that seems suboptimal.

2. Money gets poured on the fire to squelch the flames sometimes immediately,  sometimes later.

3. A report is promised but it usually doesn't materialize. If it does, it is usually late and without any announcement.

4. The public is distracted by the dollar signs flying about and figures all will be well. 

5. Usually someone within the health care system is blamed. This can be the hospital CEO, the physicians, the cleaning staff or other.

6. In most cases, a government appointed overseer is brought in to sort things out and say more money is needed---something most people involved probably already knew but it still looks good. The fact that we are spending millions of dollars so that we can say we need to spend millions of dollars more seems to be lost on many.

7. Political optics are good for the short term and on we go........never addressing the real issue, which is the lumbering health care behemoth with an insatiable thirst for cash.

Long term plan? Ahh, the LHINs perhaps--  mind you they are still wet behind the ears and show no signs of being able to deliver on a very tall order while simultaneoulsy  sparing the politicians the difficult task of telling the public that all health care cannot be  "free".

Smitherman Admits Liberals Have No Plan for Health Care

The Liberals 10-year strategic report on health care is a year overdue.

(Queen’s Park – June 11, 2008) Yesterday the members of the Standing Committee on Estimates learned that the McGuinty Liberals had yet to develop and publish a 10-year strategic plan for health care; a commitment it made under the Local Health System Integration Act, 2006. According to a 2007 Ministry press release, the McGuinty Liberals promised this report would “set out a vision, priorities and strategic directions for our health care system over the next 10 years.”

“The McGuinty government has broken its own promise to produce a plan to address the gaps in Ontario’s health system,” said Witmer. “Whether it’s improving access to care, modernizing health infrastructure, shortening wait times or promoting good health, Ontario requires a long term vision. A vision the McGuinty Liberals have failed to produce.”

When confronted by PC Health Critic, Elizabeth Witmer, Smitherman said “It’s true to say, and I have to take responsibility that we haven’t hit our marks on this.” The Minister went on to suggest that the report would be published sometime in 2008, however Ministry officials refused to specify a specific date this would happen. As well, during the committee proceedings Smitherman suggested the report was held back due to the 2007 election. “I think that the difficulty that we were into, to be direct with you, was that the window last year got too close to the election,” said Smitherman.

On several occasions since 2006, George Smitherman promised to release his report in the spring of 2007. In a June 2006 letter sent to all the Chairs and CEOs of Ontario’s LHINs, Smitherman wrote, “Our government is in the process of developing a 10-Year Health System Strategic Plan to be made public next spring.” In December of that year, Smitherman told members in the Legislature that “we will develop the 10-year plan over the coming months, with an expected release date in spring of 2007.”

“The election last fall would have been the appropriate time for Ontarians to have their say,” stated Witmer. “It’s disappointing the Minister was not confident enough to bring his report forward at that time.”

Currently, the McGuinty Liberals spend 46 cents of every program dollar on health. Even without a plan, spending on health care is projected to rise to $42.4 billion next year.

“The government’s failure to deliver on their promise has left health care providers operating without a clear sense of direction. Ontarians deserve better. They deserve to know how this government intends to meet the challenges of risings costs, an aging population, overcrowded emergency departments and a shortage of health care professionals. How much longer must we wait for this government to take action and develop a long overdue plan?”

-30-

For further information contact:

Elizabeth Witmer, MPP

(416) 325-1306

The first paragraph of the media release:

"Despite the nationwide commitment to build real and lasting change and the infusion of billions of dollars brought about by the 2003 Accord on Health Care Renewal, progress falls short of what could, and should, have been achieved by this time, says the Health Council of Canada's latest report to Canadians, Rekindling Reform: Health Care Renewal in Canada, 2003-2008."

Jeanne Besner, Chair of the Health Council of Canada says, "As we reflect on the speed and direction of health care renewal, we find the glass is at best half full."

This is a curious statement amidst the cheerleading that goes on in health care transformation these days. With so much political need for short term wins it is rare to hear such honesty. Many of us working within the system understand the predicament but unfortunately much of the public is led to believe that the current transformation is going to solve most of our problems...and there are even some, both public and political, who still deny there are problems.

We can't fix the problems if they cannot be identified or spoken about.

Change has occurred in some areas as identified by the report:

1. Major purchases of medical equipment and information technology have boosted the number of services delivered.

2. Some jurisdictions have improved the way waiting lists are managed and provide wait time information.

3. Most Canadians have better access to health information and advice through telephone help lines.

4. Some Canadians have better access to publicly insured prescription drugs and to primary helath care teams. 

In other respects progress so far is not cause for celebration:

1. Catastrophic drug coverage and safe prescribing lags.

2. Home care is inadequate.

3. Aboriginal health has not improved significantly.

4. Primary Interprofessional team access is uneven, not comprehensive or available when patients need it.

5. Electronic health records and IT are not on track to meet the goal of having 50% of Canadians with and EHR by 2010.

According to Dr. Besner, "Governments promised to eliminate inequities and ensure all Canadians have equal access to the same services, such as primary health care, home care and prescription drugs, regardless of where they live in the country. Governments must renew their commitment to nationwide change."

I can say that the "nationwide change" that Dr. Besner refers to must be bigger than the transformation we have seen in Ontario.  The inequities in Ontario, as far as I can tell, are growing more significant with the transformation strategies. We have have-not patients on more levels than we've ever had before to my knowledge. We have more hospitals with varying degrees of support and we have a growing need in many areas that are unlikely to met with more government money or government spear-headed change.

If we are to address the growing numbers of patients with diabetes, cancer, and other chronic diseases as well as acute events such as pandemics, bacterial outbreaks of various kinds and more social needs than in the past, government will not be able to manage alone.

We know this already with private foundations and philanthropy that continues to grow across Canada to support our public institutions.

If we are to truly transform and create renewal of our health care system, its institutions, and its providers while simultaneously introducing and managing new industries such as genomics, patients will need to understand the urgency of the situation and understand their own leadership potential. Gone are the days when a few elite leaders existed to organize the masses. Patients must be seen to be leaders themselves and empowered with the ability to manage their own health care.

This will not be achieved in a top down approach driven by government need to micromanage and control. In my opinion sustainable renewal can only be achieved through the acts of  individuals in many, many capacities from volunteer work, to mentoring, to community patient leaders. 

The process must be driven by patients and to achieve this the politics must be  uncoupled, at least in part, from the provision and transformation process.  I'm not certain our politicians have the stomach for this and so politicians and our governments will continue to promise what they cannot deliver. Perhaps the courts will need to do this job.

At least the Health Council of Canada is able to admit that the government is not delivering...a step forward and for me another drop in the glass. 

It seems these days that Ontario's provincial health minister is busy cleaning up dirty "health spills" with great zeal but most often once the issue hits the media--health policy setting by the seat of one's pants, or should that be "diaper"....

In any case, with the reporting of these three infectious diseases...errr.."patient safety indicators", what will be done? More handwashing squads to supervise  medical and nursing staff to ensure proper handwashing techniques are adhered to? More prompted reminders from blackberries or cellphones? More squeegee hand sanitizers in the corridors?

Although I support the KISS principle, I must admit that I think the increasing emergence of C. difficile, MRSA and VRE have more to do with much deeper rooted issues than just hand washing practices and if the overcrowding and understaffing in hospitals is not addressed can we truly hope to make inroads in curtailing the growing number of nasty germs poised to humble medical science?

Even   a new U.S. study reports that other factors come in to play in the rise of C. difficile cases including a larger number of patients who are older and sicker. Dr. Marya Zilberberg, a University of Massachusetts researcher and lead author of the study examining C.  difficile in the US indicates that the number of people hospitalized with the dangerous superbug is growing by more than 10,000 cases a year. In Canada, it is blamed for 260 deaths at seven Ontario hospitals recently and for 2,000 deaths in Quebec since 2002. The virulent strain of C. difficile was rarely seen before 2000.

"The nature of the infection is changing. It's more servere," said Dr. L. Clifford McDonald, an expert at the U.S. CDC, as reported  in the Associated Press.

Many of the people  how died had other health problems and the study did not try to determine if C. difficile was the main cause of death.

If the nature of the infection is changing and other factors played a role in these deaths then reporting the number of cases will only be just a tiny beginning into the understanding of the dynamics of C. difficile. As we know, statistics can be skewed and less than helpful unless taken in context.

Once the reports are in, how will the hospitals be evaluated and what measures will be taken if any to correct the problem? It would seem that tertiary care centres would be more likely to have higher rates of resistant germs such as C. difficile because they treat the sickest of the sick and manage to keep patients supported who might otherwise die.  This does not mean that their sanitary measures are less stringent or that the health care workers are careless non-handwashers. There are many other complexities to be understood.

If we are to gather this information then ultimately something must be done with it. It will be interesting to see what transpires if anything or if this issue is just supplanted by something bigger and  more urgent. But it is the ethical thing to do and certainly being open and honest about infections harboured in our hospitals and other institutions is a beginning.

Let's hope that China can keep the lid on its own infectious diseases this summer and that all the athletes and visitors from around the world attending the Olympics manage to wash their hands before returning home. 

Have a clean day! 

I read that Alberta is moving ahead in transforming health care by dismantling its nine regional health authorities and in their place is creating a regional superboard-the Alberta Health Services Board (AHSB). Voluntary Community Health Councils will be appointed by the AHSB to give  input on local health issues.

Can Ontario be far behind?

The Ontario government has denied that its Local Health Integration Networks are the same as Alberta's Regional Health Authorities but the concept certainly looks eerily similar. Bringing local health issues to the table is no simple matter and it may be that the unwieldy governance structures did not add to the "seamlessness" of care. 

But I have to wonder about the whole LHIN transformation which, like so many other transformations, doesn't change much at all....except perhaps to create some severance packages  for District Health Council personnel.

If LHINs were to be the Houdinis of Ontario health care, it seems the future may be well seen in Alberta. 

Alberta's Minister of Health and Wellness, Ron Liepert, is reported to have said: "Moving to one provincial governance board will ensure a more streamlined system for patients and health professionals across the province."

So no more local divisions to represent local needs but instead, a "streamlined system" with one governance board. I'm surprised the word "seamless" wasn't used as well.  Same jargon, different bag of tricks.

 Liberal Health Critic, Dave Taylor, said this week in the Alberta legislature that "no evaluation has been done of the impact of 15 years of restructuring on the health system in Alberta. In that time, the system has been completely restructured three separate times".

Sounds like a good make work project and an attempt to show the public something is being done...even if there is no proof, even if there is no "evidence-based" knowledge of the benefits of such transformation.

Yet, in health care transformation in Ontario we are moving to performance indicators and accountability agreements much lower down the health system hierarchy while there appears to be little or no evidence of improved or more efficient or effective delivery.

What is in store for Ontario? I can't say for sure, but I'm highly sceptical that LHINs are going to solve any real problems and its likely that in a few years they will be dissolved too...to make way for another round of "seamless" streamlining....so much so that we'll wind up exactly where we started.

I give the LHINs ten years...max. They've already had one.

Have a great long weekend and enjoy the outdoors wherever you are! 

A recent article in the Ottawa Citizen on May 5 by Lynne Cohen, an Ottawa-based lawyer and journalist, was titled, "We Need More Workaholic Doctors, Not Fewer". 

As her story goes, she had a "workaholic cardiologist father" (her term not mine) who died back in 1990. She links "dedication" with the "health care crisis" suggesting that it is lack of dedication and fewer hours worked by physicians that is causing problems for publically funded health care.  In her opinion, doctors seeking work/life balance are the crux of the problem.

Although she is way off the mark and perhaps demonstrating the bitterness that may occur in children (even grown up children) with absentee fathers, I don't believe her view is unique. 

But really, doctors are people too--with children, other lives beyond medicine and much to contribute to society besides treating the sick and preventing disease, although I'll agree that the last two items are fairly significant.

If we look back to the caps in Ontario, the claw-backs, the Medical Review Committee (MRC), the medical schoool cut-backs, we can see that it was certainly government's intention to have doctors working less. In an environment when productivity is seen as an economic burden to the system, do you really think that doctors would feel encouraged to be workaholics?

And even if they did, it is frequent that the resources their patients need are not available including diagnostics, cancer treatments, mental health support  and on an on.

Some people including politicians and various colleges including the Ontario College of Family Physicians where the CEO is nurse Jan Kasperski) would like us to believe that capitated teams with other providers are the panacea to all that ails primary care from insufficient numbers of family physicians, to improved patient outcomes, to improved cost-effectiveness and productivity. But some proof is emerging that this is not the case.

A study assessing how family health teams are doing is being conducted by University of Ottawa professor Dr. William Hogg. Reported in the Ottawa Citizen, April 29 by Randall Denley, "Family Health teams need a checkup", Dr. Hogg is reported to have said that instead of increasing doctor capacity, doctors in FHTs are seeing patients just as they always have. Any increased efficiency is eaten up by the meetings that these multi-disciplinary practices require.

While doctors and patients like the teams, "this approach costs more, substantially more. "

Randall Denley indicates that the government will soon begin a five-year study of the pluses and minuses of family health teams. He writes, " The fact that they cost more without increasing productivity seems like a big negative."

I am concerned that by the time this study is  completed, a new Ontario Premier will be in charge, the study will be forgotten and in the meantime fee-for-service...probably the most productive system around...will have died off.

Who cares you ask? If doctors are gravitating to teams (now remember that docs have always worked in teams, virtual or not) and to the higher pay in these new and ?improved teams. What happens after they turn out to be gobbling up oodles of cash? Six hundred million on 150 health teams is a fairly significant amount...just to get them going. What happens after that? What happens to all the orphaned patients as FFS doctors close up shop, unable to find replacements and cast adrift up to a couple thousand patients each?

Independent nurse-led clinics are not likely to be able to do the job with nurse practitioners seeing 7-12 patients a day (several times lower than what a typical family doctor would see in a day) at $86,000 to $100,000 no overhead plus benefits,  referrals to specialists will increase swamping the sinking specialist boats too.

And as much as some groups have a "hate" on for walk-in-clinics and urgent care clinics, they do keep orphaned patients out of the ER quite well. Even if all the walk-in clinic docs switched to comprehensive family care, there are not likely to be sufficient numbers of them to absorb all the orphaned patients.

So it is clear to me that fee-for-service must be preserved because of its value in terms of productivity. The idea that salaried physicians working with less efficient nurse practitioners will be able to carry the health care load is misguided. But nobody asked me. I guess we'll just bumble along to the next provincial election with a tanking economy and the next Health Minister will take over along with his "eager to please the voters" Premier. Wonder who it will be and if they will care. Maybe Hugh McLeod will take the provincial lead....he was at the OMA gala as an invited guest/chief MOHLTC negotiator for the government after all,  during  OMA/MOHLTC negotiations no less.....nahhhhhh, he knows better.

I'll post some of the significant links in the comments section.

Enjoy.