Throughout the 80's & 90's at both national and provincial levels, Canada and its Provinces/Territories have repeatedly reviewed and studied their respective health care systems. The last commission was conducted in 2002 by The Honourable Roy Romanow, former Premier of Saskatchewan. Public input has been invited and included in the analyses and recommendations of these former reviews.
This month's e-Rounds is focused on the public consultation used in British Columbia, which concluded in July 2007. The purpose of the paper was to review the process and content of the consultation on BC's Medical Services Plan, with particular emphasis on primary health care. In any given year, 80% of residents have contact with primary care, making this a critical component of necessary health care services.
The consultation process included 78 focus groups and other meetings involving patients, providers, and the public. There were also electronic submissions and an international symposium, resulting in a final document of over 1500 pages. The consultation occurred in three streams (public, health professionals, and health innovation) over a 6-month period in 16 communities throughout BC, with each forum involving up to 100 participants drawn randomly from the registrants. Supplementing this, there were focus groups of up to 10 participants, with additional input gathered from aboriginal communities (n=4) and school students. In each of the 16 communities, there were additional workshops for health care professionals nominated by their associations and unions. The workshops focused on key solutions to issues in primary care, seniors, health human resources, and delivery models. Including all of the above, plus a website, mail input, and toll-free telephone line, there were over 12,000 submissions to the consultative process.
There was broad recognition that primary health care was central to improving prevention, demand management, and self-management and was the foundation of the system. There was advocacy for integrated teams providing patient-centred care plans, albeit with recognition that this would require changes to remuneration and incentives for physicians and a new Ôsocietal attitude' towards health and health care. The question of whether primary health care should be managed by regional health authorities was not answered conclusively, with respondents being both for and against.
One idea with support was the use of patient advocates and navigators, particularly for those with cultural and language barriers and elderly patients receiving care from multiple providers. This was coupled with advocacy for a patient ombudsman, more integrated care management and improved hospital discharge planning. In addition, there was a strong voice for self-care and reduced reliance on providers, recognizing problems with information asymmetry between patients and providers, and patient challenges around accessibility, financial barriers, and lack of incentives.
In examining overall system performance, there was an emergent perspective that Canada had considerable room for improvement and should study those countries purported to be doing better, with a view to greater innovation and evaluation of new opportunities. Not surprisingly, social health determinants and health equity were discussed, and BC was noted to have substantial and continuing inequity, both geographically and by sub-population groups. Equity seems to be better addressed for insured medical and hospital care than for services outside of these spheres, where ability to pay has apparent and deleterious effects. In terms of system-wide issues, strong voices advocated for the addition of a 'sixth principle': sustainability. Primary health care, with due attention to illness and injury prevention, demand management and self-management, was seen as strengthening sustainability.
There is no analytic work that links the findings from the submissions to the outputs of the process. As with any consultation, there is always the question as to which voices were heard and the weight and importance given to any points made. The concept of deliberative polling has been widely used in health system reform and renewal, yet how an issue or proposition is framed has substantial impact on what comes out of the process. The more the conversation is scripted with leading questions, the greater the risk of promoting and prompting certain ideas and directions, albeit no scripting may result in a directionless free-for-all and no measurable consensus. Of course, a sampling methodology for participants was not used in the process, lacking which one risks hearing only from those with strong views or vested interests.
The same adverse consequences from cost-sharing approaches have been previously shown in different settings and manners. Notwithstanding limitations, this study is well done and the findings are worrisome if cost-sharing is erroneously being promoted as a cost saving measure. It is readily apparent that even small increases in copayments deter some patients from seeking timely medical attention and, in the long run, some patients experience poorer health at higher overall system costs. This is precisely opposite to what cost-sharing approaches attempt to achieve. This new evidence adds to the body of literature that argues against patient cost-sharing at the point of service as a mechanism for controlling health care system costs.
There was no support for private for-profit delivery or financing of health care for medically necessary services and there was recognition that improved system performance would require improved leadership, decision-making, and management at all levels. The authors suggested an increase in the scope of Medicare to include pharmaceuticals and dentistry and called for improvements in health technology assessment, health promotion and disease prevention, and palliative care.
Any health reform and renewal process would be remiss in not including public consultation, whether it is a case of really doing something of value or simply being seen to be doing something. In the end, the cost of the process was $10 million. Only the future will reveal if this was money well spent.
A Conversation on Health Care in Canada: Revisiting Universality and the Centrality of Primary Health Care, Franklin White and Debra Nanan. J Ambul Care Management 32(2): 141-149, 2.