No Health Accord – now what?

– CARP proposes an Alternate Vision- Get to Work on Pharmacare, National Home Care and Age-Friendly Health Care

Just because the provincial premiers did not get the year long fight they were girding up for doesn’t mean that the health care system will collapse nor that it is fine as it is. The federal government dropped the so-called bombshell just before the Premiers met in January – ‘Here’s $40 billion in federal funds – take it or leave it – we’re not discussing any conditions’.

The premiers as a group called this a bad thing – leaving the rest of us scratching our heads – and came up with a hastily constructed Plan B for a couple of committees to study practice protocols and tinker with managing the supply of doctors and nurses. There must have been more but we can’t know because it’s to be studied. If this was what the Health Accord negotiations were going to be about, it’s just as well we saved months of political posturing.

First, the good news – stable, predictable funding in the billions of dollars poured straight into provincial coffers. So no need to close hospitals or fire doctors and nurses.

But here’s the bad news – the federal government’s hands-off approach means that we are relying on the provinces to set national standards of care, resolve structural inefficiencies and get health care spending under control – all without any immediate accountability. At least the feds could have demanded this much accountability for our billions of tax dollars.

The real importance of the Health Accords was not to keep the provinces happy but to keep Canadians healthy – by fundamentally redirecting the country’s health care resources to that end and not being held captive by what had been done in the past, or whose ox would have to be gored. National cooperation, with or without the feds as the uber-paymaster and shot-caller, is needed to produce the political spine to get this done.

So here’s an alternate vision.

National Pharmacare: Take the increasing non-affordability of prescription medication for example. Already there is research that too many people are not taking needed drugs or cutting back because they can’t afford them See CMAJ report . The provinces mostly cover drugs for seniors but not to the same extent. Provincial treasuries just can’t cope with the eye-popping costs of the newer drugs so the funding approval process is slowed to a near stop. Meanwhile, much needed treatments are unavailable to all but the most well heeled or well insured.

In desperation, the larger provinces have demanded price concessions from drug manufacturers and outlawed retail rebates from generic manufacturers. The prospect of financial ruin has steeled their political resolve. Imagine if all the provinces and the federal government acted in concert to demand fair drug pricing across the country and with bulk buying agreements, an independent drug review process and other systemic savings, begin the conversation about first dollar basic drug coverage for all Canadians.

Make Aging at Home a Reality: Canadians want to stay in their own homes as long as possible even if they have medical challenges but they can’t do that alone – the public system needs to reorient itself to make that hope a reality. The current Health Accords identified post-acute home care as the next essential service and put serious federal money behind it. The provinces would do us – and themselves – a great service if they’d show us where the money went and how close we are to making aging at home possible for everyone in Canada.

The recent federal caregiver tax credit is a good example of national action that offers modest support for family caregivers. But much more is needed and frankly resides in the provincial jurisdiction – stable funding and mandatory standards of home care, income support for caregivers, especially those providing heavy care, geriatric care, assisted living services at home and in affordable housing and quality end of life care. These need to be seamless, coordinated and integrated.

New dollars may be needed but redirecting existing resources makes more sense. The Virtual Ward project – assigning a care manager to follow a discharged patient home – can pay off not only in preventing costly readmissions but also help stabilize the person at home and possibly avoid having to go to a nursing home altogether. Professional staff who prefer to stay in their own silos will necessarily be displaced by those who take a more patient centred approach.

Similarly, setting up caregiver support clinics that provide training, respite care and navigation support is more a matter of sharing knowledge than new work.

A system of integrated continuing care done right, at a fraction of the cost of institutional care, can divert billions of dollars of demand from the formal healthcare system. A real opportunity for premiers shouldering intractable deficits.

Age Friendly Healthcare: Canadians are living longer healthier lives but from the doomsday predictions that the aging population is going to bankrupt the health care system, you’d think that longevity was a curse. The evidence that health care costs are actually driven by the escalating price of new treatments and greater demand from everyone is pre-empted by the stereotypical image of a grandmother languishing in a nursing home.

When the system fails its older patients and leaves them in acute beds because another government department has failed to provide enough home care or long term care beds, the finger is pointed at the “bed-blockers” not the dysfunctional system that keeps them there.

That there are erstwhile reports recommending “age friendly” hospital protocols gives some hope that things will change but also begs the question: what’s happening to people now?

Media reports of security staff haranguing a discharged patient waiting for his wife to get back to bed is illustrative not just of the security guard’s high-handed behaviour but also of the normative values of the hospital.

This kind of thing necessarily leads older patients to suspect that they are not being given the best of care or all the options. Are there assumptions being made about what level of mobility, stamina or quality of life a person of a certain age is entitled to expect? Fatigue dismissed as “just getting old” might be a sign of too much iron in the blood which is treatable but leads to potentially fatal cirrhosis of the liver if left untreated.

There are too few geriatricians – specialists who would know better and see past the stereotypes. But there are only about 200 geriatricians in all of Canada, about 25% of what is needed. So rather than leave it to the specialists, all front line health care professionals need to adopt the age-friendly/patient centred lens.

The failures of the health care system matter to everyone but especially to older Canadians who not only face more immediate health challenges but also worry that the system treats them unfairly.

Luckily, this generation of seniors will also be more demanding and willing to accept innovative solutions. Addressing the issues that resonate with them will also improve the system for everyone. The system wide changes needed to ensure integrated continuing care is a prime example. So too with electronic health records, multidisciplinary teams and a single national or regional waitlist for surgery. The growing political clout of older Canadians should help politicians face down the sacred cows blocking innovation now.

From our polling, CARP members have demonstrated a refreshing willingness to grapple with the more delicate end of life issues. That may yet help policy makers to overcome their inertia.

Consider this from the Los Angeles Times Oct 24, 2011

“What if a new medication for severely ill patients had no role in curing them but made them feel much better despite being sick? Let’s say this elixir were found to decrease the pain and nausea of cancer patients, improve the sleep and energy of heart failure patients, prolong the lives of people with kidney failure, drive down healthcare expenditures and ease the burdens of caregivers?

Those are the promises of a fledgling medical specialty called palliative care — not a new drug but a new way of treating patients who are living, often for years, with acute or chronic Illnesses that are life-threatening.

If palliative care were a pill, government regulators would very likely approve it for the U.S. market. Federal healthcare insurance programs would quickly agree to pay physicians and hospitals for treating patients with the new therapy. And patients would make it a blockbuster drug in no time flat.”

End of Life care is part of the “quality of life” care continuum and remains an unmet need in Canada.

System wide change is needed for the health care system to properly fulfil its role in ensuring the health of Canadians and providing the highest quality of health care equitably across the country regardless of income or in this case, age. That there will be no political confab is no excuse for inaction. Canadians certainly deserve more than a couple of committees.