The fires are put out, but the Czar is not!
In the last post, the Czar laid out plans and ideas for how to address the immediate crises plaguing Canada's cherished health care system. Now begins the hard part: reforming the beleaguered system itself. Though clearly intertwined, the system challenges can be divided into proximate problems and long-term problems. The Czar will discuss the proximate problems first: inadequate long term care (LTC) and home care; inadequate palliative and hospice care; inadequate and poorly distributed mental health care; and the closely related problems of poor worker morale, toxic labor relations, and increased bureaucritization of health care. In fact, the problem of LTC and home care is the direct cause of hospital overcrowding, so I will defer readers to my previous post once more for that discussion.
For end-of-life care, the Czar of all Health Care hereby decrees:
1. Every hospital, home care service, and cancer treatment program will submit a census of all patients identified as needing end-of-life care.
2. A body with professional and patient representation will be convened to develop enforceable national standards - not guidelines - for end-of-life care.
3. As with basic home care, all palliative care services will be made insured services under the provincial health insurance plan on a fee-for-service basis.
4. Based on the above census data, hospices will be built and funded until every Canadian wishing to die in hospice is permitted to do so.
While we'd often like to think otherwise, the human death rate is still 100%. There are an abundance of misconceptions about end-of-life medicine, first and foremost that anything short of intensive care is equivalent to no care. Nothing could be farther from the truth. In fact, patients receiving good end-of-life care, particularly in hospices, live longer than - and at a dramatically reduced cost to - those treated aggressively. Hospice and palliative care is less stressful on families, and more responsive to patient and caregiver wishes and values. More medical care is not always better medical care, and nowhere is that more evident than at end-of-life.
For the problems of excessive and sometimes nonsensical bureaucracy, labor relations, and cratering health professional morale, the Czar of all Health Care hereby decrees:
1. Provinces shall have a single level of bureaucracy for health system planning, administration, physician relations, labor negotiation, capital funding, integration, and so on.
2. Provinces shall institute binding arbitration as the final step of labor conflict resolution.
3. Provinces shall do away with all Limited Use/Special Authorization/Restricted Access programs.
4. Sick notes shall be the financial responsibility of the employer.
We've now reached the point of nonsense with health care bureaucrats. Ontario can't get enough of them, bringing in yet another layer of red tape on top of the still-useless layer it put in a decade ago. Meanwhile, Alberta and Saskatchewan are pulling the plug on regional health authorities (RHAs). Why? Because the bureaucrats in the provincial ministries can't stop themselves from micromanaging. Even where RHAs have been somewhat effective, the provinces still have control over doctor pay and pharmaceuticals, the two biggest budget items apart from hospitals. If a bureaucracy is needed - and it is - better it be one and only one.
It's now time to raise the morale of the health care workforce. The Czar feels that solving the crisis of overcrowding and funding better home- and end-of-life care will go much of the way towards alleviating unnecessary strain. Two more steps are necessary.
First, health care professionals need collective bargaining rights respected. The Czar has ideas for provincial budgetary issues he'll address in subsequent posts. Health professionals are adults, and understand that binding arbitration guarantees a process, not an outcome. Provinces are free to negotiate and propose all manner of cuts or "stewardship", but these cannot be imposed.
Finally, the Czar sees needless paperwork as a waste of health professional time, doctor, physical therapist, pharmacist, and nurse alike. Medications will henceforth either be covered on the drug formulary or they won't. Social assistance will either be given or it won't. And a person is either too sick to work or well. Putting the onus on patients and care providers to navigate the paperwork is a waste of everyone's time except the for bureaucrats hired to process it. The Czar will end it.
Finally we come to mental health. All of Canada is in dire need of mental health care, in young children, working adults, and lonely seniors. Much of what's driving the need is suicidal. The Czar can advise on some of these matters, but even the Czar cannot decree an end to domestic violence, sexual abuse, racial discrimination, or social isolation. The Czar can, however, hereby decree:
1. The federal government shall appoint a Royal Commission on mental illness and suicide in Aboriginal communities. The Commission shall make recommendations that the government of Canada is legally bound to implement.
2. Each province shall set up an arms-length body for planning and delivery of mental health services, modeled on organizations such as Cancer Care Ontario. The Atlantic provinces may consider forming a single body for the entire region, to reduce the impact of fixed administrative costs.
3. A body with professional and patient representation will be convened to develop enforceable national standards for mental health and addiction care, including maximum wait times for consultations. Those standards will not, however, include accountability for outcomes.
4. Governments shall commit the necessary resources to implementing, funding, and maintaining the aforementioned standards of care.
Mental health care needs a complete overhaul, but the Ministry bureaucracies are simply too sclerotic to develop and implement sweeping plans, and politicians can't be trusted to manage a program that affects people less likely to vote. The answer lies in arms-length bodies. For all their flaws, the better organizations (I use Cancer Care Ontario as an example, but there are others) have a solid track record of delivering targeted and focused programs with less bureaucratic constipation than Ministries.
There's one major difference in mental health, however: care providers cannot be held accountable for clinical outcomes on their patients. The sad and disturbing truth is that many suffering with mental illness do not get better despite state-of-the-art medication and recognized modes of psychotherapy. To suggest that treatment failures - and the worst possible outcome, suicide - can be blamed on care providers is insulting. Except in the rare instances of abuse on the part of the health professional, treatment failure is often as heartbreaking to the care providers as it is to the patients' families.
The Czar can sense the reader's hand-wringing at the costs of these large-scale changes to the health care system. Though the Czar reminds the reader that calming anxieties was not in the job description, the Czar is not finished.
Next time: the Czar tackles long-term system reform