With its announcement of what will ultimately be a $200 per adult person health tax and plans to introduce user fees, the Quebec budget brought the financing of our health-care system roaring back onto the public agenda. Canada’s universal health-care system needs new ideas to face a confident future, on that we agree. But experience in the U.K. and elsewhere suggests there are better alternatives for reforming – and maintaining – universal health care than those announced this week.
We shouldn’t assume that more funding is the answer. Canada already spends more than most OECD countries on health care and while Quebec isn’t the highest, it’s still above most others. A flat rate of tax hits the poorest hardest, and low-income people already pay a higher cost in their shorter and less healthy lives. User fees will cut demand, but adversely affect people on low incomes and lead people to wait till their condition is acute and more expensive to treat.
Nor is there evidence that our health-care system is particularly efficient or effective. Without better accountability – not only upward to government but downward to public and patients – people may not be as willing to pay more as Quebec Finance Minister Raymond Bachand believes.
Courage is needed to make radical changes in the design of the health-care system. My shortlist would include a few things we should ”just do” and a few we should avoid. Let’s examine closely the cost and effectiveness of our health services. Rather than adding more funding, we should look at the way we allocate our funding.
Current funding arrangements reward activity, but offer little reward for innovation or efficiency. Quebec’s most recent health-care reorganization signaled a move to a population-based approach to health – ensuring that services meet the most important needs of the population served rather than reacting to deal with demands for existing services. It’s time for funding to be allocated on that basis, weighted to reflect variable needs so that services can become proactive and targeted to people who need them most. Many countries have introduced systems where money “follows the patient.”
In the U.K., overall system performance has improved with the introduction of standard financial tariffs for common treatments and increasingly, whole “episodes of care.” In this system, a fixed fee is set and hospitals receive that amount for the patients they serve; thereby creating incentives for them to bring costs in line with or better than best practice. We also need to shift from the most expensive tertiary hospital care, toward primary health care and prevention. Montreal can be proud of progress establishing Groupe de Médicines Familiales (GMF) and Clinique Réseau (CR), but too few Quebecers have a regular primary health provider. More in-home medical and personal care services would reduce demand on expensive acute care while meeting older people’s preference to remain at home. Studies consistently show that more than half the people arriving at Emergency would be better served in primary care or minor-injury clinics. In the U.K., to divert inappropriate demand from the ER, dedicated centres for diagnostics, minor injuries and front-line treatments were set up away from the hospital.
Third, the system needs more transparency, so patients as well as administrators and clinicians are clear about what is working (and what isn’t). With its Patient Choice program, the British National Health Service has introduced patient-friendly health information, from the overall quality of service (judged by an independent regulator), mortality rates, other patients’ views, waiting times, infection rates, food quality and even parking facilities. With better information about the differences in access and outcomes across their universal system, patients can chose care that works. When funding follows their decisions, serving people well begins to make more sense financially as well as clinically. When the cost of specific health services is known, it’s possible to introduce an element of competition through the quasi-market reforms that have proved successful in the U.K. All funded from tax revenues, the provision of health care could be diversified across a wider array of institutions, spurring greater choice and best practices to harness further improvement. Within a transparent framework of standards and accountability, health services and hospitals need more incentives and flexibility to manage. People – communities and professionals – are the most valuable resource in the system. They need to be motivated and supported to spawn innovation and generate creative solutions to intractable problems. Finally, another major top-down restructuring of the health-care system should be avoided. It’s not about structure and great plans, but the attitudes and activities shaped by the way the system works. The health tax and proposed user fee won’t necessarily address the changes needed to drive the health-care system toward sustainability. Some of the political courage shown this week should focus on the patient, with population- and patient-based funding, accountability and transparency about what’s working at what cost.
Wendy Thomson is Director of the School of Social Work at McGill and served as an advisor to former British Prime Minister Tony Blair.