new improved head (www.newimprovedhead.com)

No Self-Criticism Please, We're Canadian
by John FitzGerald, publisher emeritus, NEW IMPROVED HEAD.

November 8, 2006

The Canadian health care system consumes about 40% of government spending, it is often held up as one of the chief distinctions between Canada and the United States, and Canadians can get inordinately smug about it – for example, Global TV is running a biographical sketch of Tommy Douglas these days in which they claim that the Canadian health care system is “the envy of the world.”

Well, maybe it ‘s the envy of that part of the world that doesn’t include Australia, Germany, New Zealand, the Netherlands, or the United Kingdom, because a recent survey by the Commonwealth Fund suggests that citizens of those countries have little reason to envy Canadian health care, and very good reason to laugh hysterically at the claim that they should envy it.

The Commonwealth Fund is an American foundation whose objective is to improve the accessibility, efficiency, and quality of American health care. Last week it published the results of a survey of 6,088 primary care physicians in Canada, the United States, and the five non-envious countries just mentioned (Canada furnished 578 of the physicians); the survey was conducted from February to July of this year. Yes, it is just a survey, and there are some problems with it. For example, the survey was conducted by mail in Canada, the States, and the Netherlands, while in the other countries it was conducted by phone. The response rates for the mail and phone interviews differed (the response rates in the three countries with mail surveys were all higher than the rates in the four with phone surveys). Different types of physician were sampled in different countries. As we will see, some of the items were vague. Nevertheless, the results of the survey were so striking that the report’s findings should be taken seriously as evidence that the Canadian health care system may have some very serious problems.

And perhaps the results are being taken seriously, but they aren't in Canada. A few of the results were reported by the press and then dropped. The Globe and Mail, for example, closed its online discussion board very soon after posting its article. A search of Google News found only one article in English-Canadian media published after November 3, the day the report was released (the French media seem to have produced nothing). Even Rex Murphy, always happy to go after any government program supported by anyone further to the left than Ralph Klein, contented himself in his weekly column of November 4 with some stale observations about climate change. And the Liberal leadership candidates, staunch defenders of the health care system all, didn't say anything about the report that got into the papers.

The news reports on November 2 and 3 were a little sketchy, too, so what I am going to do first is provide a summary of the more striking findings, most of which were not reported in Canada. Yup, The Man can try to keep you in the dark, but NEW IMPROVED HEAD won’t let YOU, our loyal readers, get the mushroom treatment! We know where the light switch is; if you’d like to follow along with the report itself while you read my summary, just click here to open it in another window.

The report’s findings about the use of electronic medical records were widely reported. Electronic medical records provide such amenities as access to patients’ records from outside the office, access to patients’ hospital records, alerts about prescription problems, reminders about follow-up care, and so on. Only about a quarter of the Canadian physicians reported using electronic medical records at all. They were only five percentage points behind the Americans, but the physicians in the other countries were over three times as likely as Canadian physicians to use electronic medical records (Dutch physicians were over four times as likely). Canadian physicians who did use electronic records used more rudimentary systems than physicians in the five European and Oceanic countries – that is, they used systems with fewer functions.

On the other hand, we Canadians can proudly boast that we’re not just numbers in the health care system’s computer. Instead we're misspelled names on three-part NCR forms filled out in illegible handwriting. I’m sure that most of us are aware that the only difference between the records in our GP’s office and the records in the offices of GPs back when universal health care was introduced is the substitution of NCR paper for carbon paper. Apart from that, the only difference between today’s records and the records of 1870 is the use of plastic tabs on the file folders.

Canadian performance on the survey’s measures of co-ordination of care was mixed, but one result which received coverage in the press was the length of time Canadian primary care physicians have to wait for hospital discharge reports about their patients. Fifty-eight per cent reported waiting 15 days or more; Germany, the Netherlands, and the U. K. did almost as poorly, but Australia, New Zealand, and the U. S. reported far better performance.

My own recent experience may shed some light on this problem. I was discharged from hospital earlier this year. On discharge I was given a prescription for painkillers and…my discharge report! The vehicle for delivering my discharge report to my GP was…me! It was one of those three-part NCR forms, too. I delivered it when I got up the energy, which was three weeks later or so. Now, I know these guys have heard of e-mail; the physicians at the hospital had their e-mail addresses on their cards. From what I’ve read elsewhere, and from my observation that all the physicians involved in my care,from my GP through to the surgeons were pretty swift off the mark, I suspect the reason they don’t use e-mail may simply be that regulations don’t allow them to. Apparently the rules for medical communications haven't been modified much since the 1960s. An easy problem to fix, one would think, if one could be bothered to think about it.

Well, I could be wrong. On to results that didn’t make the papers. When asked how well prepared they were to care for patients with multiple conditions, Canadian doctors again brought up the rear. Most of the countries did pretty poorly, but none as poorly as Canada.

Nor did Canada distinguish itself in access to primary care. For example, it finished last in providing early morning office hours, third in providing evening hours, and fourth in providing weekend hours. It finished fourth in cost of prescriptions, third in the cost of other care, sixth in waiting times for diagnostic tests, and second last in waiting times for elective surgery or hospital care (for these last four comparisons I have ranked countries by the percentage of physicians reporting frequent problems in these areas). Of course, standards of difficulty may differ from one country to another. Nevertheless, these results are scarcely encouraging for Canadians, especially given the differences on more easily interpreted questions.

Finally, the survey looked at quality improvement (QI) initiatives:

  • participation in collaborative QI initiatives – Canada finished last
  • participation in QI training – last
  • receiving data about patients’ clinical outcomes – last
  • surveying patients’ satisfaction – last
  • setting targets for clinical performance – second last (nosing out the Aussies by a single percentage point)
  • performance of clinical audits – last
  • processes for following up adverse events – second last
And of course Canadian physicians didn’t report a lot of financial incentives for improving quality, but that’s probably just yer Canadian culture – Canadians are so tight they’ve demonized doing things for money, especially their money.

So…the reasonable conclusion from these results is that there is a good probability that Canadian health care sucks like an Electrolux. In the context, as we say, of that conclusion, the following figures from the report take on an added piquancy. They are the per capita cost of primary care, in U. S. dollars, in each country:

  • New Zealand: $1,886
  • United Kingdom: $2,231
  • Australia: $2,876
  • Netherlands: $2,976
  • Germany: $2,996
  • Canada: $3,003
  • United States: $5,635
Well, Canada did a lot better than the States, but less better than the other five countries did. Furthermore, probably the most influential school of thought about how to fix the Canadian health care system argues that it should be more like the American system. A reasonable conclusion from the report, though, is that American health care is godawful too, so the major current of reform thought in Canada is that we should strive to be more like a country whose health care system delivers about 45% less bang per buck.

And yet the report has vanished like Stephen Harper’s pledge not to tax income trusts. Granted, the decision to tax income trusts could have been expected to steal some of the spotlight from the Commonwealth Fund report, but fewer Canadians hold shares in income trusts than have health to maintain.

My original intent was to have one or more of the experts on this site “explain,” as only they can, why this report has been ignored:

As persuasive as some of these explanations were, though, I remained shocked by how easily this report has been whisked out of the limelight by, as Bronwyn puts it, powerful corporate interests. Surely somewhere some Canadians were as disturbed as I was by the report. I know, the survey is not definitive research, but at the very least it suggests that definitive research is needed.

In the end I came up with my own proposal for an explanation. The problem is that when most Canadians think, their heads hurt. Over my lifetime the pain of thinking seems to have steadily debased Canadian public discourse. "Debate" of public issues has degenerated into flagwaving for one band or good guys or another and demonization of one band of bad guys or another. It's so hard to think how to solve specific problems in health care, like those discussed in the Commonwealth Fund report, and so much easier just to take a moral approach to the general problem, much as the Romanow report did.

As another article here shows, the Romanow report was essentially a sermon, excoriating Canadians for daring to have different opinions about health care, calling them to cast aside their unhealthy ways and live, and then passing the collection plate for even more tax money to throw at the Canadian health care system. More recently Mr. Romanow has called on politicians to stop debating possible changes to the health care system and just fix it in some unspecified way (no kidding – that's a fair summary of an article he wrote in the Globe recently). Mr. Romanow and his fellow Canadians seem to be firm believers in Dr. Phil's dictum that you can accomplish anything as long as you want it hard enough. Except, apparently, think.

Oh, well. As we've said elsewhere on this site, we get the leaders we deserve. Since the leaders we elect decide what kind of health care we get, we get the health care we deserve, too. And we pay through the nose for it – hey! No wonder we don't want to talk about it!

No Self-Criticism Please, We're Canadian © John FitzGerald, 2006

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