Over two decades of countless studies, reports, and commissions tackling how we preserve, develop or transform our system of healthcare has not resulted in much change. Canadians consistently underline the fact that health is the top public policy issue. Researchers continue to crank out options in areas ranging from models of delivery to broad socio-economic underpinnings. Stakeholders put forward endless arguments for either stability or change. Public leaders, including most recently the provincial and territorial premiers faced with demographic and fiscal pressures, regularly come together to try and navigate a way forward. Through all of this, we still have not found a solution.
Against this backdrop, Jeffery Simpson's new book, Chronic Condition: Why Canada's Health-Care System Needs to be Dragged into the 21st Century is a refreshing, important and constructive contribution to the challenge of tackling our healthcare conundrum. Part story, part history, and part white paper, Simpson does a superb job of showing how we got ourselves into the situation we are in now and, most importantly, provides some directions of how we can get ourselves out of it.
Playing the role of doctor to the Canadian healthcare system, Simpson proceeds in a sensitive and focused manner to address the case. He talks to the patient, through the eyes of Dr. Jeffrey Turnbull, chief of staff at the Ottawa Hospital and past president at the Canadian Medical Association. He delves into the patient's history, particularly its genetics. He scopes out the various interconnected maladies affecting the patient, including some environmental context, drawing a line of how these issues ultimately affect the patient's health. Finally, he determines a broad course of treatment, and writes some prescriptions the patient needs to get healthy.
Ironically, perhaps the most striking absence in Simpson's book is the perspective of patients, which we see only through the eyes of the doctor and the system. A patient-centred approach and the need to have the resources follow patients, rather than institutions, is a major theme in healthcare discussions that should have more central presence in his argument. This absence parallels a challenge we currently face in policy-making: how to effectively engage citizens on issues that matter to them and in whose solutions they have a significant role to play themselves.
Regardless, Simpson provides readers – from experts in health policy to those in civil society who genuinely want to better understand the system – an accessible, cogent and comprehensive analysis of the main issues bedeviling Canadian healthcare, as well as some significant solutions and recommendations.
Most effectively, he disabuses us of basic fallacies about the Canadian healthcare system. While it is true, for example, that we are in many ways better off than our American neighbours, Canadian healthcare has declined sharply relative to most other developed countries as well as against our own standards. Despite increased investments at all levels, we are simply not getting the results we should.
Moreover, while we like to believe that Canada's system is fully public, the reality is that 30% of our annual $200 billion in expenditures come from private sources.
What we have in Canada, Simpson argues, is a system that is 'deep, narrow and expensive' as opposed to our comparators internationally with systems 'somewhat shallower, wider and cheaper.' He underlines that these realities need to more front and centre in our policy discussions if we are to find real solutions.
Arguments will certainly be generated about some of the remedies he raises. Should all doctors be salaried? Should all professional salaries be capped? Should we more aggressively pursue new practice areas, such as nurse practitioners, and better cluster medical professionals? Should we better integrate our various healthcare institutions or de-hospitalize our care through increased community access?
How can we better invite and incent innovation in patient care and in every institution, especially our largest hospitals? Should we more intelligently introduce private, fee-based delivery in our largely public systems? How do we get lower costs of drugs, while seeking better medications for a diversified and aging population? Why do we accept a national formulary on acceptable and needed drugs that is applied so drastically different across Canada? Should we have a personal, pre-payment plan for healthcare fashioned on the Canada Pension Plan as we prepare for our aged years when our healthcare needs will be the greatest?
Simpson does not answer all these questions definitively, but he does lay out in one place some of the best integrated considerations of the most significant factors all policymakers need to address. His conclusion is that while the patient is not at death's door, it is in failing health and needs immediate, regular and comprehensive attention.
Simpson points us to where and how we can look to fix, or at least substantially improve, the national treasure that is our healthcare system. Leaders and policymakers at all levels in Canada should join him in this pursuit.
Paul Ledwell is Executive VP of Canada's Public Policy Forum where, among other things, he leads the Forum's work on health policy.