This article was originally published in Maclean's Magazine on September 25, 2000
Health Spending Increased
Dr. Phillip Malpass begins his day on Sept. 11 by attending a 7:30 a.m. meeting of Nelson, B.C., community leaders on what to do about the town's decaying, understaffed, badly equipped hospital. By that hour, three time zones away in Ottawa, Prime Minister Jean Chrétien and the provincial premiers are deep into final bargaining on terms for pumping billions more into the whole Canadian health system. Malpass has an intense interest in the outcome, but little time to follow the politicians' progress through the day's newscasts. He rushes from his morning meeting on Nelson's dream of a new hospital to another gruelling day at the old one. Six serious new cases need his attention, from heart attacks to pneumonia. Malpass doesn't finish work until 9 p.m. By then, he has heard that Ottawa and the provinces have a deal - one that gives him hope that money will flow Nelson's way. "We've got a facility here," he says, "that's crumbling around us."
Sometimes over the past few years it has seemed that the grand medicare experiment might simply crumble on its foundations. So, many Canadians greeted last week's agreement in Ottawa as a breakthrough. In all, the federal government promised $23.4 billion in new health funding over five years. But too many questions remained unanswered for beleaguered doctors like Malpass to celebrate without reservations. Just how would the provinces use the new money? How soon would new equipment and staff arrive to shorten waiting times for tests and treatment? Federal Health Minister Allan Rock will meet his provincial counterparts early next month to start working on the details to put the pact that Chrétien and the premiers signed into practice. But Rock says the bickering between the two levels of government is over. "We have overcome the jurisdictional squabbles," he told Maclean's. "We have more money and a common plan."
On the question of more money, at least, the first ministers reached a settlement. Chrétien promised that Ottawa will be handing over $21.1 billion a year to the provinces under the Canada health and social transfer by 2005-2006, up from $15.5 billion this fiscal year. As well, he earmarked $1 billion for new medical equipment, $500 million for information technology and $800 million to bring more order and efficiency to the delivery of so-called primary care - the doctors, clinics and emergency departments where patients first seek help. But the second half of Rock's claim - that the two levels of government share a common plan - may overstate the case. The system's worst symptoms remain all too evident: weeks, even months, of waiting for some tests and treatments, overcrowded hospitals and long delays to receive attention in emergency rooms, especially in flu season. When it comes to prescribing exactly where governments should reinvest, though, there is no clear consensus.
Studies have been maddeningly inconclusive. A major 1998 Health Canada report on waiting lists found them so "capriciously organized [and] poorly monitored" that it was impossible to pinpoint where the need is truly greatest. Any patient who has spent sleepless nights waiting for a magnetic resonance imaging scan, or a worried parent who has sat for hours in an emergency waiting room with a feverish kid has an idea of where new money could be spent. The danger, warns John McGurran, director of the Edmonton-based Western Canada Waiting List Project, is that governments will merely throw money at those politically damaging problems without addressing systemic failings. "It's all based on impressions and subjective data," he says. "And that's the issue. Are we just going to turn on the spending tap, or is there going to be better management?"
McGurran's project, a $2.2-million federally funded research effort launched in 1998, aims to make that better management possible. It is developing standardized forms to help doctors determine which patients get first crack at some in-demand treatments: cataract surgery, children's mental health services, hip and knee replacements, MRI scanning and general surgery. Using a concept that could be applied to many more medical services, patients would be rated on a set of questions including the severity of pain and likelihood of their condition deteriorating. The results would then determine their position on a list of patients needing the same services.
Rock believes such an approach would not only make waiting lists fairer but could also standardize practices enough to make accurate national comparisons possible. "We have to be able to compare waiting times for knee surgery in Halifax and Victoria, and know that we're not misleading people," he said. In fact, the Prime Minister and premiers agreed to begin reporting comparisons of that sort in two years. Besides speed and quality of service, they will also compare such indicators as low birth weight and changes in life expectancy.
But comprehensive, clear-cut national comparisons are a long way off. Confusion - sometimes near panic - at the provincial or health region level is more common. Last week brought alarming revelations that breast cancer patients at Toronto's Princess Margaret Hospital were waiting up to seven months for radiation therapy after surgery. On closer examination, it turned out that the long delays involved patients who, for various reasons, chose not to take an opportunity to travel elsewhere for treatment. Because Toronto's facilities cannot meet the demand, some patients opt for expenses-paid trips to Thunder Bay, Ont., or such U.S. centres as Buffalo and Cleveland for faster radiation therapy. Why can't everyone be treated in Toronto? Surprisingly, government cutbacks are not being blamed. "There's a shortage of radiation technicians throughout the industrialized world," explains Princess Margaret's vice-president, Dr. Robert Bell.
While some reforms will depend on what the new information gathering reveals, spending on new medical equipment will begin swiftly. The agreement commits Ottawa to provide $1 billion over two years for the purchase of MRI scanners, bedside lifters that help nurses move patients and other much-needed hardware. Another $500 million is dedicated to upgrading computer information systems in hospitals and clinics. But getting new machines is the easy part. A tougher challenge, most experts say, will be recruiting and training the extra doctors, nurses and technicians that the system needs to function efficiently. And it will be up to the provinces to decide how to use the pumped-up federal transfer payments to pursue sought-after professionals.
The prospect of more money for hardware and the professionals to run it sounds like a dream to Malpass. At Nelson's Kootenay Lake Regional Hospital - 46 years old and aging ungracefully - there are no high-tech scanners, just an old X-ray machine, and never enough nurses and doctors. Malpass, 51, has been in Nelson since 1978, but vows to get out if there is no firm decision to build a new hospital soon. The town of nearly 10,000 has rallied around the idea of raising funds locally, but the province would have to contribute, too. After last week's deal with Ottawa, Malpass says, "Now they've got to step up to the table and do this thing." Like many others on medicine's front lines, he sounds eager to believe that Canadian health care has turned a corner to better days.
What the Provinces Got
$21.1 billion over five years in increased general transfer payments from Ottawa for health and social programs
$1 billion over two years earmarked for medical equipment including MRIs and other diagnostic machines
$500 million to upgrade computerized information-gathering technology in hospitals and clinics
$800 million over four years for innovations in the delivery of primary care (where a patient first seeks help from doctors and other health professionals)
Maclean's September 25, 2000