How can we improve Canada’s health system? Blaming the professionals who deliver care defies logic.
You may be very surprised to learn that one prominent journalist says the biggest obstacles to health care reform are the people who deliver it – or more specifically, their unions and associations.
Globe and Mail public health reporter Andre Picard comes back to so-called “vested interests” over and over again in a monograph (The Path To Health Care Reform: Policy and Politics) published last fall by the business-sponsored Conference Board of Canada.
Picard says of health care reform: “those who stand to lose the most are principally health professionals – specifically, the organizations that represent them, from unions to professional organizations.”
As such, so his theory goes, “they have a lot of power right now, and they’re not going to give up without a fight.”
Why would health professionals lose from health reform? Picard never says, although makes vague references to the poaching of professionals that is supposedly driving labour costs up. Really?
Yet Picard scoffs at the idea of labour shortages – “there is a constant barrage of claims of ‘shortages,’ – of doctors, of nurses, of pharmacists – but it’s a mug’s game,” he writes. “The number of health care workers is higher than it has ever been, both in absolute numbers and per capita.”
The author never substantiates this claim nor takes into consideration the fact that an aging population logically requires a greater intensity of care. For some professions, such as medical laboratory technologists, the numbers are actually in decline.
If Picard’s claims are true, where is the leverage that is driving up labour costs? In fact, where are the big wage settlements that Picard is talking about?
This attack on labour is even though four of his five “key” reform areas to be addressed have all been strongly supported by labour – equitable drug insurance, social determinants of health, a focus on primary care as well as safe and timely care (we might add in quality too). For most, this is motherhood and apple pie.
The fifth, we would argue, has been half carried out – we’ve seen the cuts to the hospitals but no corresponding scaled investments in community care. We continually draw the parallel to cuts to psychiatric hospitals that never resulted in a comparable investment in the community mental health – a point Picard himself recognizes in the book.
When Ontario has fewer beds per capita than any other developed country except for Chile and Mexico, we have a legitimate point that hospitals have already made available room for investing in community care. The problem is, the government never followed through, and the result has been incredible stress on Ontario’s hospitals and the people who have to use them. If you look at the shift in funding, most of it went to increased drug costs, not home care. Now Ontario is cutting hospitals further through a freeze on base funding. If Ontario is to look more like the Netherlands – Picard’s preferred model of efficient care – then we would actually have to re-open some of our beds.
Yet when we push back against further cuts to public hospitals, we’re portrayed as supporting the status quo. This is complete nonsense.
If you are looking for an actual “path” in this book, you needn’t bother. Picard himself said at the launch that there are no new ideas here. He’s right, there aren’t. Instead it’s the usual grab bag of vague exhortations (home care, coordination, preventative care, social determinants) with very few specifics about how we get from here to there, aside from everybody getting together, compromising (on what?) and singing Kumbaya. Okay, maybe he left out the Kumbaya.
When the province introduced and later updated the Public Sector Labour Relations Transition Act, it was intended to facilitate transfer of health professionals and support staff between providers as health care reform took place. That was the compromise. While PSLRTA applications are common, health care workers are still losing their jobs (and moving to other provinces) because in reality we are getting more cuts than reform as governments shift to austerity. It has little to do with poaching and everything to do with the lack of available permanent full-time jobs here.
Ontario hospitals have already shrunk dramatically in proportion to overall health spending. In 1975 provinces spent an average of 44.7 per cent of health care spending on hospitals. This year in Ontario hospital spending is 34.9 per cent of the health budget – or just over a third. We have lost 20,000 beds since the 1990s. Yet where is the health reform that such cuts were supposed to afford?
Picard also contradicts himself on the issue of privatization. He says the “fear of ‘privatization’ is one of the greatest impediments to reform,” yet later says the ‘default’ position is that “health services should be publicly funded and publicly delivered (or more accurately, privately delivered by non-profits.)” He says privatization should be a “last resort” only if it’s faster and cheaper and after the public option has been exhausted.
No doubt his pay masters at the Conference Board would be happy to hear his pronouncement that the public-private debate is a “false dichotomy,” “an exchange of dogma” and “circular, tiresome, and paralyzing.” If that wasn’t enough, he says the exchange over privatization prevents us from having a real debate (about what?).
This comes from the same journalist who ripped into Health Canada for its lack of public consultation over licensing of a for-profit series of paid plasma collection sites. Last March Picard asked if we had learned anything from the tainted blood scandal: “One of the many things that contributed to that public-health disaster was the use of blood from for-profit blood brokers – who purchased the products in places like Haiti, skid row in Los Angeles, Arkansas prisons and Russian funeral homes, at the outset of the AIDS pandemic, no less.”
Clearly this is not always such a circular, tiresome and paralyzing debate.
Picard was one of the few journalists to understand the Ontario Auditor General’s review of the public-private partnership agreement for the William Osler Health Centre and the heavy cost of this privatization to public coffers. In 2009 Picard bluntly translated the auditor’s review into “the taxpayers got screwed.” We should point out that his patron — the Conference Board of Canada — continues to be big proponents of such privatized arrangements for public infrastructure, including hospitals. It gains no mention in the book.
Picard appears to have swallowed the Conference Board’s line that any opposition to policy described as “health reform” is an obstacle to a more sustainable quality health system. What this really amounts to is one of those ‘you’re with us or against is’ ultimatums. The reality is many of these ideas are not about reform, but simply about beating down worker’s wages. For a guy who cares about social determinants of health, maybe Picard should give this a rethink. The recent labour unrest around Ontario’s personal support workers (most of whom earn barely more than poverty level wages) would suggest this low wage strategy may be backfiring. Ontario Health Minister Deb Matthews has promised to address the issue.
Health professionals, unions and professional associations are not the only villains in Picard’s book. He does correctly note that the Federal government has abdicated its role in public health care despite its own constitutional responsibilities and the fact that it is the fifth largest direct health care provider in the country. He also notes that Medicare began with the provinces equally shouldering the costs with the federal government, an agreement the federal government has since reneged upon.
Even as he’s carving out a limited role for for-profit health care providers, he says we need to avoid “cream skimming” where all the profitable procedures are given to the private sector and all the complex expensive care is left to the public. Is there any other kind of privatization?
Picard does argue for two-tier health care provided it does not take anything away from the public sector (like access to physicians). “It does not cause the gnashing of teeth in Europe and elsewhere than it does here,” he writes.
His sponsors may be less pleased about Picard’s take on the issue of sustainability. Picard bluntly states that the sustainability warnings have been around since Otto von Bismark created the first universal health system in 1883. “This cynicism is unhelpful, counter-productive, and dated,” he writes.
On the other hand Picard continually writes that the answer is not more, but defining what is essential. That may be easier said than done.
Picard estimates that the percentage of taxes you pay for health care over a lifetime will amount to seven per cent. Most of us would not balk at that. So why is he writing about the issue as if we were on our last dime?
Having been a regular face on progressive conference panels for the Canadian Health Coalition and others, Picard will likely surprise many with this book. It reads like someone desperately trying to please his sponsors while trying to hang on to his original values. For all the polite commentary about the book by the Conference Board, this is likely to please nobody. Picard would probably like that, seeing himself as an independent (even while under the sponsorship of a bank – CIBC funds the Conference Board scholar in resident program). The problem with trying to sit on a fence like this is that sooner or later you are likely to rip your trousers.