Health in Canada - How can we get beyond the private/public fruitless debate -
Some ideas developed for Prince Edward Island
Health – Seeing the System
Introduction - The Value of Looking at the System
How to have a healthy population for a sustainable cost is one of the great questions facing the western world today. Conventional wisdom suggests that as we all get older, our already expensive healthcare system will become yet more expensive. The risk is that without an effective intervention today, its future cost could crowd out other important aspects of our social system and our economy. This paper will suggest that this need not be true. The core assumption of this paper is that we can alter this trajectory because we have evidence that policy makers can have a major impact on large scale social and economic problems provided that they can see the “System”.
Twenty years ago, New York was suffering from an epidemic of crime. Ever larger police budgets, ever more resources allocated to solving individual crimes had no effect. Citizens began to lose confidence in their city and visitors were put off by a reputation of danger. New York is now one of the safest large cities in the western world. How did this happen in only 20 years?. A handful of policy makers, by seeing crime not as a endless series of individual events but as a product of an environmental system, focused on changing a few environmental signals and shifted the entire system. The system change began by simply eradicating graffiti on the subway cars and by cracking down on fare dodging on the subway. By dealing with these simple drivers, they dealt with the entire system. All categories of crime collapsed.
Our opportunity is to stop seeing the health system as a bottomless money pit where we chase each category, each disease and each service delivery shortage or problem and see the system as a whole as the New Yorkers saw theirs. Our opportunity is to identify the environmental drivers that will give us the chance to shift the whole system.
To understand this we have to step back and see the “System” itself. We have to do something that is hard to do for we have been conditioned to see only events and parts and not wholes. To help see the System, we will highlight the trends and components that make up our current Health System. By “Health System” – we do not mean the organization that works for the Province of Prince Edward Island but the complex system of interactions that affect our health as individuals and as a society.
This is a very optimistic environmental scan. While it will highlight our significant and growing problems, it will show us a way of approaching them which is appropriate for government and which history tells us has a good chance of working.
What is in this paper
This paper will deal with 6 related themes make up a view of the larger system. They include:
· Cultural and Economic Change – Population health always breaks down when the prevailing set of technology and cosmology changes. This type of event has a label, a shift in the “Techno Economic Paradigm”  When this occurs there is a substantial impact on all health outcomes. We are midway through such a shift now. In our case the shift from an Industrial to a Knowledge economy. These shifts drive a set of specific and powerful factors that adversely affect population health. We will identify these factors and examine ways of mitigating their impact.
· The Beliefs that hold us back – When the “Techno-Economic Paradigm” shifts so do the underpinning beliefs. Societies that hang on to the old beliefs too long pay an even greater health price. We will examine the most destructive of these beliefs. These beliefs cannot be challenged by an individual – say a doctor or a patient on their own. But they can be challenged by policy makers. Challenging myths will provide us with a powerful tool for change.
· The gap between new technology and the mindset for using it – Genetic engineering will soon offer us choices about life and death that may have a significant impact on the very process of human development. What are some of the issues that confront us as we search for understanding?
· The impact of our Demography – We all know that the baby boomers will hit the formal system hard. We will look at what has to be done to respond to this challenge We will look beyond the obvious for other key demographic trends that affect the system and consider policy responses.
· What is the meaning of the “Early Years” - There is little debate anymore about the impact of intervening in the early years. The question is what to do? We will evaluate the opportunity.
· The lag between new technology and doctrine – We suspect and hope that somehow new technology will help. History tells us that the winners are not those who simply use new technology. The key is to find a way of linking the new set as a system and to develop a new operating doctrine. We will look at another sector of the economy that has done this and examine the parallel with our health system today.
You will find a number of slides in the paper that are expanded in Appendix A
The Pattern of History – The reaction of populations, groups and individuals to major changes in the “Techno-Economic Paradigm”
· Loss of identity and culture
· An increase in the gap between rich and poor
· A breakdown in the health of the workplace
But first what is the nature of the transitions themselves? The transition begins with a failure of the old system. To understand the scale and impact of these transitions let’s look back briefly at the last one, the Industrial Revolution. Before there was an industrial revolution there was an agricultural revolution. The bulk of the European rural population were driven off the land. They went to cities or to the new world. Towns which had always been unhealthy places, when they had populations of 30,000, now became death traps with populations of millions. Communities that had existed for millennia were destroyed, families were broken and individuals lost their identity as they lost their place in the country and became nameless workers in the new industrial urban society.
We ourselves stand on the edge of such a transition. The industrial age is ending. We intuitively feel its failure. We can anticipate an equally large adjustment. Imagine for instance an adjustment to $90 dollar a barrel oil and how that would change everything. What we did, where we lived, how we made a living would all change. We know that this has not happened yet but the effects of the sense of impending change are having an effect on our collective consciousness and our health. Our collective and individual identity is at risk.
Identity Displacement. This scale of social upheaval drives a loss of personal and collective identity which is the most powerful environmental driver for health. At a personal level, we see this when a farmer loses his farm, a man loses his wife or when men who have been traditionally employed retire. Men whose identify is in the “system” are especially vulnerable. When the societal and economic system shifts, a large section of the population loses its place in the world and has to find a new role. As our own society comes under increasing transitional pressure, we have to recognize this as a risk that will have to be managed.
What can Government do? History tells us that working to improve the overall physical, community and workplace environment has a high return. Our forefathers in the 19th century have given us a clue of how to approach the effects of this type of structural change on health.
As we enter our own transition, we too will have to look at the quality of life rather than at illness or indeed at any one of the other symptoms of structural and social failure such as the overuse of alcohol, child abuse.
The Gap between Rich and Poor – Transitional times accelerate the gap between rich and poor another key driver of poor health. The issue is not poverty per se but the perceived gap. From a population health perspective, this gap has huge budgetary and outcome implications.
Prince Edward Island, has a relatively small gap between rich and poor. It is part of the culture of the Island not to show off wealth. Very poor outcomes for Child Poverty are emerging from Ontario where Canada has the widest and fastest growing gap.
As PEI hits the transition, this issue will affect us as well. Just as some will fall, some will rise and rise. In North America, the gap is widening and the symbols of success, cars, housing etc are in the face of those that are falling. The point is not to try and stop success but to deliberately support the less fortunate. Keeping an eye on this gap and working to give those on the bottom a leg up in opportunity will be a critically important way of reducing the risk from this factor.
The Workplace Effect – We all know that Chronic Illness has replaced, for now, infectious disease as the main source of health problems. But what is not generally known is that much of our chronic illness is directly related to our increasingly unhealthy workplace.
As organizations that are themselves dependent upon and built on the assumptions of the old economy sense the threat to their power and future existence, they become frantic and frenetic. The result is that just as illness at the time of the last transition was enhanced by overcrowding and unhealthy work and living conditions which drove infectious disease, so the workplace of today is becoming a major driver of chronic illness which is a major cost driver to the system. The healthcare system, as a workplace, is directly involved in this factor itself.
There are a number of work-related factors which are driving chronic illness. The most important is the stress created by uncertainty and lack of control. This driver is highlighted in Marmot’s work on the British Civil Service. His 20 year study shows that there is a gradient that shows that the less control you have at work, the more likely you are to be ill. What the chart tells us is that the most junior people are 4 times more likely to die from Coronary Heart Disease than the Deputy level. It also tells us that even at this the most risky level, that most of the contributing factors are not smoking, weight and cholesterol but unknown factors. What are these? It is likely that they are related to the suppression of the immune system by unrelieved stress.
This trend will be made worse on two fronts.
· Firstly, as traditional organizations face the challenge of extreme change, they try harder. By trying harder, they increase the burn rate on the staff. Every traditional workplace has become much busier.
· Secondly, there is the role of women in the work force. Women always have two jobs if they work. The job “job” and the family “job”. For the working mother, there is no relief. With 70% of women in the workforce, this is a major cause of chronic illness and depression. The healthcare system itself is right in the middle of these trends. Women dominate the nursing profession and are increasingly taking a major role as Doctors. They are caught in a vice.
Many women doctors intuitively know that the two minute appointment and the 90 hour work week are part of an approach that is not sustainable. But they are caught up in a system of beliefs that they cannot challenge on their own. But beliefs can be challenged collectively and in particular by the healthcare policy makers.
Each age of man is defined by a set of beliefs about what is real and important. Health has always been part of this belief system. We laugh today at the idea of purges and bleeding. We snigger at the idea of “Humours”. We cannot believe that doctors would resist anesthesia, and reject germ theory. History will look back at us as wonder how we too could believe the unbelievable. What are the most powerful beliefs that we hold dear today which impede making genuine progress to having a healthier society? Here are five:
· The belief in the triumph of scientific medicine. There is no doubt that modern drugs have helped health and will help health, But we have put them on a pedestal that was once reserved for “Bleeding”. Access to drugs and scientific medicine is seen not only as a right but as a critical determinant of health. The entire debate about Canada’s health care system is about resources and access. Yet the statistics showing health outcomes in the UK since the advent of the National Health system show that the outcomes for those at the lower strata, the group targeted for improvement by the idea of “Free Access”, have in fact got worse.
Drugs are a key element in this set of beliefs. The costs of drugs is rising faster than any other single element of the system. This is because there is a powerful collective belief in the drug for the problem. We do not want to know about the more effective health solutions derived from living a healthier lifestyle. So we look for a pill to reduce weight or a pill to reduce our depression. Cholesterol reducing medication and testing for cholesterol has become not only a major industry but a major factor in the conventional mindset for those that are concerned about heart disease. This is in spite of the evidence that it is only a minor factor. This belief in the magic of drugs leads many to believe that antibiotics will cure a cold and that being denied them is a failure of the doctor. So patients harass doctors until they prescribe. The result of this belief in the magic of drugs is a major cost driver and a real effectiveness risk. The risk is that over-prescribing increases the iatrogenic effect on multiple drug users, especially among the elderly, and that we have a real risk that our inventory of weapons against infectious disease is being weakened. Hospitals in the mid 19th century were death traps from infection – there is a risk that this could occur again if we do not attack the myth of the antibiotic. The CAW and Ford have begun a program of education for their workers to dispel this magical belief. The reason – the CAW and Ford pay for the drugs in their plan and it is out of control. The key point is that the doctor alone cannot push back – the formal healthcare system has to do this.
· The belief that we are just a germ away from serious illness – Collectively, we seem to believe that there are huge infectious risks all around us. We must use antibacterial soaps and we must go to the doctor, the moment we have something wrong especially if it involves our children. This fear is driving an ever higher utilization rate in the system. Triage at the emergency room is not the answer – working on these fears is.
· The belief in the direct linkage between cause and effect – Our educational system, how we organize for work and how we educate and categorize doctors and scientists is still based at the beginning of the 21st century on the belief system of the 17th century – the Newtonian concept of the universe being a machine made up of separate parts. This drives a belief in over simple and direct linkages between cause and effect. I eat fat, I will have heart disease etc. A challenging cultural by-product is also the belief in the rights of the individual over the community and the separation of the individual from responsibility for their lifestyle. Conversely this belief in the individual also means that we miss the impact of the environment on the actions of the individual. We look to the individual when we worry about smoking or teen pregnancy and miss the fact that these issues are driven by environmental issues. The slides below highlight the research that shows that smoking and teen pregnancy are connected to much broader forces than simply a matter of individual choice.
There is a policy response to the refusal of the individual to take responsibility for their own actions. Pricing works in the insurance industry for poor risks. There is also a policy responsibility to see through the individual at the environmental drivers that affect their behaviour. It will be possible to influence key environmental conditions that drive some types of behaviour such as smoking.
· Death – A Natural Event or a Medical Failure? – Our current view of death is the single most challenging block to progress. In 1900 there was not much a doctor could do when confronted with terminal illness or with a new-born who could not survive on its own. Today the two most significant drivers of health care costs are what we do in the final stages of terminal illness or old age and what we do when modern science enables us to stabilize children who will be dependent on massive support and intervention for the rest of their lives. Half our lifetime costs to the health system are spent in the last few months of life. We as family members demand that our loved ones be rescued and our doctors feel that it is not up to them to decide otherwise. Those of us who are parents demand that our children should live no matter what. We so fear death that we have ceased to remember that it is part of life. Our fear of death and the hope that we have for modern science to conquer it is so great that a new approach to healthcare will not be possible with out some form of resolution to this belief
The point is not to debate the ethics of this dilemma but to point out that progress has been made in a related field.
By the 1950’s we had developed a collective belief that childbirth was a medical event. By the 1980’s with so many boomers having babies, we began to recognize as a society that while in some cases heavy medical intervention was useful and necessary, that most of us could see that having a baby was part of life. The power of the boomer as an influence on society may work again. Death will be a stranger no longer to this generation. Most of our parents will die in the next 15 years. We too will start to die off in ever larger numbers from 2020. We might see death again as our destiny rather than as a failure of the system. Without making this shift in our belief system we will not solve the dilemma of science and ethics. Without solving this we will not escape the economic breakdown of our healthcare system. Can we rely on the Boomers to do this work in shifting this belief? Probably not. There is a role then for policy makers to dimension this belief and develop a plan to deal with it. Who can help?
· The belief that the conventional system no longer works – Alternative medicine and healing practices are booming. An ever-growing segment of the population has lost confidence in all the beliefs mentioned above and is enthusiastically embracing a series of alternatives. They are seeing that it is their own lives and beliefs that drive their health. They are taking action in all aspects of their lives. The opportunity is to build on this pioneer segment.
The gap between new technology and our ability to use it
Genetic engineering will provide us with a set of ethical dilemmas which appear to be outside of our experience. We can see its precursor in parts of Asia where having a daughter is not seen as a benefit. Ultrasound is routinely used to screen out girls before birth. What will happen to populations that are skewed to males? What will be the dilemmas placed on us when we use genetics to screen for all sorts of issues prior to birth? We may accept screening for serious defects but what about for gender, or even hair colour? In the pre-industrial age, children were an economic benefit. Now they are an economic drain on a family. As a result, we have children later and less of them. We will tend, as the Chinese family who is only allowed one child, to seek the perfect child.
The new technology and the higher investment in a child make for an interesting dilemma.
It is helpful to look at the demography problem visually. There has never been a time in human history when there will be such a skew in population to the elderly as we will experience
Does old = ill? If the boomers hit the health system as their parents have done we will be in big trouble. The only way forward is to take a systems approach. We know that simply being old does not mean that you are automatically ill or a user of the health system. We know that elderly people who are living independently, who are physically active, who have meaningful work to do and who have a healthy network of relationships are usually healthy. In the 1980’s the majority of men retired from banks at 65 and died with in five years. Why did they die so soon? They had lost their identity. Golf was not enough. The clue is here. We have a perception of retirement as a short holiday before death or illness. If that is our perception then it will be our reality. We all need meaning and an identity to be healthy.
A community, a province or a country that sees this need for meaning as a priority for the middle aged and the elderly will find the policy solutions that will avoid the risk of the Boomers taking the health system and society down in intergenerational warfare.
Is the formal health system immune? – Years of cuts and retrenchment have meant that we over-rely on boomers to staff the front line. Who is behind them? Not many new younger people. The situation is not too bad for major centres but for most places outside of the very large cities, staffing in behind the retiring boomer health professional is becoming a crisis. PEI will not succeed in a bidding war. Without a core of professionals, the citizen will lose confidence and will have to consider leaving if they can or not coming to PEI if from away. The population strategy of PEI depends on attracting the new economy entrepreneur. He won’t come if he has no confidence in our healthcare system as it is today. We will need to again think of what are the systems issues that will deal with this shortage of professionals. In parts of Australia, it is recognized that pay is not the main determinant of relocating doctors in rural areas. What is emerging is that when a doctor leaves a major urban centre, he also is banished from his community of practice. He is isolated from education, as a gatekeeper to the new and to research. He is in effect an outcast with low or no status in a profession that is obsessed with status. Near Melbourne, they have been experimenting with setting in motion systems to keep the rural doctors formally attached to the teaching hospitals, giving them formal position at the school, and as gatekeepers and linking them to research. By offering doctors a full professional life, they create status and deal with the staffing and retention issues. We too will have to think of similar environmental issues related to improving our cadre of doctors, nurses and technicians and/or we will have to find new ways of using technology to do the job.
Doctor Exhaustion – Problem or Opportunity? – PEI’s doctors are exhausted. PEI’s health care professionals are exhausted. They have tried to hang onto their old role but cannot and have a life. They are open to change in a way that they would not have been 5 years ago. If a new way of working can be found that maintains their standard of living and their self esteem – they may be ready to accept it. This would not have been possible 5 years ago.
The Feminization of Medicine – 25 years ago most doctors were men. They could lead a crazy life because they had a wife at home looking after every other aspect of their lives. Now that more Doctors are women, who is looking after them? Answer – no one! New young doctors just will not put up with 90- hour weeks and being on call all the time. The wave will support a more “Normal” working life and open again new avenues to use technology.
The meaning of the early years
We now know much of our life is governed by what happens to us in the first 6 years of life.
The answer? In all the other places. Especially in the last 3 months of life. How do we make this shift in resource allocation?
We need to change the story. This is where the death issue is so critically important. How do we convince each other that the best use of our public money is on our young parents and their young children? Is the answer money or is it environmental?
Technology & Doctrine
The new technology that we need to transform the healthcare delivery system is here today. The issue is to avoid the mistakes of implementing it in the wrong way. The wrong way is to see each aspect of the technology as separate and to introduce it using the operational doctrine and context of the current system This for instance is the challenge facing universities. The Universities that are getting online education wrong are those that are putting their existing way of teaching online. There is always a lag between the new technology and its effective implementation.
It is not enough to know that we can use the information handling capability to build deep personal files. It is not enough to see the value of telehealth. It is not enough to see the value of using distance education to train not only new professionals but ourselves as users. It is not enough to see the value of distance surgery and diagnosis. It is a waste of time to speculate on how a bit of technology may help.
The challenge is to out it all together so that we can see an alternative delivery system that in time will overtake the old face to face system of delivery.
Is there a successful model that we can replicate? There is. Everything we need to dramatically reduce the cost and increase the effectiveness and popularity of changing the delivery interface has been done by a very conservative institution – the banking system.
15 years ago if you wanted to do anything with your money, you had to turn up in person during set banker’s hours and wait to see someone. Banking was a face to face system focused on the most expensive person in the system, the manager and using the most expensive channel for the user, turning up in person. (sound familiar?) Over the last 15 years a complete alternative system of service delivery has been built which handles the bulk of our banking needs at a much lower cost and a much higher service level.
How did they do this? They first of all set up an alternative delivery network – Interac which they operated outside of the existing formal system. They did not try and change the whole system at once. They built the alternative like the bridge while letting the ferries run.
Secondly they unbundled everything that they had done in one place and saw that there were three distinct categories which in turn drove three different channels.
· Routine and simple transactions such as payments. This was dealt with by the ABM network which in turn connects to the Visa International network. Routine transactions are by definition simple transactions where the issue is to link a known person to a simple factor related to themselves. Do I have cash or credit sufficient to pay for this transaction. If I do, the transaction is completed. You can do this type of transaction all over the world 24 hours a day 7 days a week. How is the risk handled? By using statistical probability based on the laws of large numbers. You rarely have to wait for more than a minute for an authorization. How often has the system got your transaction wrong? We can define the health equivalent for this.
· Products and services. Most of these can be reduced to “knowns”. They can be complex but they have consistent features which can be systemized. Mutual funds, mortgages, discount brokerage etc fit into this category. How are they done – by call centres. The key is great back up of client information and decision support. You can imagine how call centres and video could be applied in this way to healthcare delivery
· Customer support. As these features grew so did customer support. You can manage your own account online. You can take courses online about tax management. Portfolio management etc.. Much of what was the mystery of the bank’s internal process and special knowledge is made available to you the customer. The system empowers you to be the informed consumer. We can also plan to build the self-knowledge of the healthcare consumer.
· Complex issues – Now the manager ( Doctor, Nurse Practitioner) is freed from all the routine, she can come and see you when you have a complex problem that can only be solved face to face - House calls again?
We have a choice. We can try and improve our formal healthcare system and the health of our Island by continuing to work on the parts or we can work on the system.
We have all talked a great deal about the Determinants of Health. This paper is largely a reminder of the value of planning to deal with them as the upstream and cost effective way of improving population health.
What stands in our way are the powerful beliefs in the critical importance of the healthcare system as it is. More beds, more drugs, more hospitals, more capital equipment and so on. The banks did not announce twenty years ago that they were going to shrink their traditional delivery system. They set out to build an alternative system in parallel. This new system was so attractive that the consumer made the switch themselves.
This is a robust and sound model to use when considering the future of the healthcare system.
 The Tipping Point by Malcolm Gladwell is a remarkable book that shows how small interventions on a system level can produce large scale effects.
 . “A Structuralist View of Technical Change and Economic Growth” by Roger Lipsey and Cliff Bekar, the Canadian Institute for Advanced Research March 1995
 The Great Wave – Price Revolutions and the Rhythm of History by David Hackett Fischer
 PEI Dept of Treasury