Okay, so I am not a doctor (yet), but I do spend my 9-5 hours working as part of Canada’s health care system, and I do have a couple of degrees in which health policy played a pretty significant role, so I’m going to take this opportunity to make one of my (thankfully) rare digressions away from the typical subject matter of this blog and talk about health care.
My master’s thesis (which was a rather shabby affair) was partially focussed on the issue of wait times for critical services. Those of you who live in civilized developed countries will be familiar with this concept already. Those of you who live in the United States will probably need a refresher. Because there exists a finite pool of resources in the world, when a large group of people want to access something that is a one-at-a-time thing, there is a good chance that some people will have to wait. In Canada, because we have a publicly-funded medical care system, we run into wait times as the inevitable consequence of more people wanting a thing than the system has the capacity to provide.
I have, incidentally, discussed why Canada’s system is not only more fair but more economically sound than the American system in a previous post that I encourage you to read.
The vagaries of comparative international health policy aside, waiting lists are something that we have been trying to devote particular attention to here in the frozen North. A new report published this week by the Wait Times Alliance suggests that certain areas of Canada have been steadily slipping in their ability to handle medical services without undue waiting, and that the national average is similarly slipping. The specific comparisons aren’t particularly interesting (unless you’re a total health policy dork like I am), but I found this particular passage very provocative:
The group called for a national strategy to deal with illnesses such as Alzheimer’s disease and to factor dementia into the management of other chronic diseases such as heart disease and diabetes. Doing so could help prevent those patients from ending up in hospitals in the first place, they said.
Sometimes I like to imagine what I’d do if I was handed absolute power over the Canadian health care system, and that paragraph got me fantasizing*.
So here’s the problem…
The health care system that Canada and the United States (and, as far as I know, every other country with a sufficiently large economy to have had a health care system of some kind since at least the mid 20th century) has is based on an extremely outdated interventionalist model. The role of medicine was primarily intended to address issues of infectious disease and acute illness (like trauma, heart attacks, other things for which quick response is needed). We have made significant progress in preventing and responding to those threats, and as a consequence the type of illnesses we do have to deal with are quite different now.
The way I describe it to people is this: if we started from scratch and built a brand new health care system, it wouldn’t look anything like the one we have now. Hospitals would be ‘special-case’ destinations, not the default. Doctors would be part of an array of allied health professions rather than the predominant one. Prevention would be considered health care rather than public health. Perhaps most importantly (to me, anyway), decisions would be guided by evidence rather than tradition. We are moving toward all of these things, but if we could start over we’d already be there.
What works better?
We need a model of health care that is better suited to our contemporary reality – cancer, arthritis, respiratory illness – conditions that must be managed over a period of years, rather than hours or days. These are conditions in which people have to have frequent and ongoing interactions with the health care system. At first this necessitates intense management by highly-trained professionals who are familiar with the intricacies of the case. However, over time many of those cases can be managed adequately by professionals who are perhaps less rigorously medically trained, but who are familiar with a person’s health care needs.
How do we do it?
The first problem is that we are dealing with a system with severe resource scarcity. This is actually a much simpler fix than people think. One of the biggest problems in hospital-managed health care is what to do with people who have mental health issues. Whether it is depression, dementia or schizophrenia, hospitals are a terribly expensive and monumentally ineffective way of treating mental illness. Hospitals are set up for things that need immediate attention, not ongoing surveillance. Prioritizing mental illness management will free up much needed hospital beds and (consequently) financial resources.
Another idea that I support wholeheartedly is the community care management model of health care delivery. Basically the idea is to put a bunch of health professionals – a doctor, a pharmacist, a nurse practitioner, a dietician, a social worker, a psychologist, a dentist, an optician – in the same collective practice. You could think of it as a mini-hospital, but perhaps it’s better to think of it as a health strip mall. Have a handful of these in each community. People go to ‘their team’ for management – the various professionals all work together to manage each person’s issues holistically (this is the only context in which that word doesn’t make me cringe). So when someone has diabetes, hir illness is seen from a variety of angles, and a comprehensive plan is put together. The afflicted person has a variety of perspectives to choose from, and can tailor a plan that suits hir. Better still – ze can talk to any member of her team rather than having to wait for hir doctor’s advice specifically.
The last component of my wish-list is something that is perhaps counter-intuitive: I want to pay doctors more money. Not only because I think their job is hard, but because I want to shift the burden of care away from MDs and toward a variety of people. I want doctors to only have to manage tough cases where pharmacists, nurse practitioners, psychologists, and whoever else has run out of ideas. All medicine (including family medicine or ‘general practice’ as it is referred to in many places) should be treated as a specialization. Doctors should see fewer patients and spend more time with them, rather than the current model which incentivizes quantity and speed.
You’ll hopefully have noticed that I avoided talking about issues of equity or drawing emotional arguments. It’s not that I don’t think those are important to a discussion of health care – it’s just that it becomes far too easy to pigeon-hole the desire for reform as an arch liberal exercise in hand-holding. There are good reasons aside from the obvious to fix health care, and we can do it without sacrificing the aspects that make public provision a better idea than private-sector care. The answers are not mysterious or beyond our capacity to put into place; we’ve just been expecting the solution to come from a very different place. We have to fix how we think about the system, and the rest will fix itself.
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*Weep with me that my daydreams are about improving bureaucracy rather than, y’know… something cool.