Less than two years ago you honoured me with an appointment as Deputy Minister of Health. Although we have spoken several times since, this is the first occasion on which I have felt an issue to be of such importance that I am setting my views out in writing. Oddly, my note is not prompted by the impasse in negotiations with the Medical Association or by the recent labour disputes in the hospital sector. Nor is it prompted by the media obsession with labelling every health story, a health crisis. The problems we face in implementing the health reform program are well known to you. Rather, I read something sensible and wanted to pass it along.

This afternoon as I clawed my way through the weekend pile of material, a task familiar to you, I came upon a first-rate piece of work by three of Canada's most insightful analysts (Leatt, Pink and Guerriere) on the health policy scene. Don't be alarmed, Pink is his name not his political persuasion! These are not simply academics tendering advice from the safety of the university. These are also thinkers and doers willing to manage and plan real health services. Of importance is their review of the experience of other jurisdictions and the lessons to be drawn. The article is attached and is worth a read but that is not the point of this note, merely the spark.

The other spark for this memorandum was a careful reading of the rather gloomy polling results examining public confidence in our health system and the government's management of same. Our most recent opinion surveys show two clear trends. First, the public are fearful that healthcare services are eroding and will not be there when they or their loved ones require them. Second, the public is fed up with studies, task forces and committees. They want action - solutions, not studies - is how the pollster summarized her findings. The newly announced, three-year Senate Committee is exactly the opposite of what the patient ordered!

A health system needs to be credible with the public to survive. Absent their trust, the door is open for rapid and destabilizing change.

This winter, overcrowded emergency rooms became the lightening rod for all those fearful about our healthcare system. Our nurses blamed the backlog on nursing shortages caused by cutbacks. Our public health doctors recommended flu shots for the elderly. Our hospital managers and their boards demanded more dollars from the provincial governments. Health reformers advocated greater investment in home and community care. As well, voices were raised in favour of the mysteriously labelled primary care reform. Absent bold action, these same issues will return next winter.

For most of the past century our healthcare delivery system has been evaluated on the basis of inputs.We measured the number of physicians, the number of dollars spent, and the number of hospital beds. Just about any input we could count was measured in terms of growth, and these inputs were seen as a bigger and better health system. Skepticism began to set in as it became apparent that diminishing returns accompanied much of the healthcare spending. As we moved through the 1980s into the 1990s we had the rise of the outcomes movement. This is based on the fundamental proposition that it would be better to evaluate the success of medical and health interventions, even those of health policy, on the basis of outcomes rather than inputs. This movement has fundamentally challenged the old methods of informal evaluation. The paper appended is in the new world of examining evidence.

Of particular note in the paper are six strategies for moving ahead. These are stated as follows:

• Focus on the individual
  
• Start with primary healthcare
  
• Share information and exploit technology
  
• Create virtual networks at local levels
  
• Develop practical needs-based funding models
  
• Implement mechanisms to monitor and evaluate

These themes could be summarized boldly as "It's The Patient - Stupid!" This is a refreshing place to start as most health policy begins either with providers or financing. By starting with the patient we have some chance of improving service to the patient, a laudable goal. But how to get from here to there? And how will we know when we are there? The authors also ask and answer that question. How will we know when we have a genuine health system? Their nine tests can be summarized below along with the implication of each for health system change:

When patients:

1. Don't repeat medical histories for each provider. This requires "wiring" the health system so that medical histories are available to all relevant providers on a health information network, a.k.a. the Internet.
   
2. Don't repeat tests for each provider. Ditto - wire the system.
   
3. Are not the key information source for providers. Ditto.
   
4. Do not have to wait at one level of care because of incapacity at another level of care. More capacity in both long-term care and home care would be needed to meet this test.
   
5. Have 24-hour access to a primary-care provider. This requires reorganization of doctors in family practice - easy to say and tough to do.
   
6. Have easy-to-understand information about quality of care and outcomes to allow informed choices about providers and treatment options. Much more consumer/patient information is needed to meet this test.
   
7. Are offered one-call shopping for appointments of various types. A call service linked to a health information system is required.
   
8. Have a wide choice of primary-care providers at the time they are needed. The reorganization of primary-care providers beyond the doctors is essential to this test.
   
9. Have chronic diseases managed on a proactive not a reactive basis including testing, home care, self-care support and education. Improvements to home care and patient information are needed here.

It is well accepted among policy thinkers that Canada urgently needs to reorganize its primary-care system. Fee-for-service general practitioners, often in solo practices, are anachronistic. In this information age, physicians must be part of a larger healthcare team. As in other developed nations, we need primary-care organizations with enrolled patients, multidisciplinary staff and a proper funding base. Nurses need to play a much larger role in primary care. Incentives must be recast to encourage greater health not more frequent visits.

It is time for bold action to restore confidence. You have the credibility to bring leadership to the task of genuine health reform. Bold actions could transform our provincial healthcare system from its current beleaguered state into a modern health system equal to the expectations of the residents (taxpayers and voters) of this province.

What is to be done? I recommend that your government consider an urgent and bold action plan with the following seven practical steps:

1. NURSE CALL LINES. Make them rapidly available to the whole provincial population to provide health information without a visit to the emergency room or the doctor's office. There are a range of vendors capable of providing this service rapidly and competently. A 1-800-health number would be tangible proof of action.
   
2. MORE AND BETTER FUNDED HOME CARE. This is needed on a 24-hour a day, 7-day a week basis. A greater emphasis on support and education for patients with specific chronic diseases is a genuine need within home care. You could challenge the Federal Health Minister to match our province's already significant spending on home care or, in fact, to match the entire cost of this package of measures. The likely and predictable response is that we utilize the funds already provided, which are inadequate to funding the current system.
   
3. 24/7 PRIMARY CARE. Doctors, nurses and others should always be available in urgent care clinics. This will require a major breakthrough with the Medical Association, but it can be achieved. The appeal to the public will be greater access, closer to home.
   
4. PUBLIC REPORT CARDS. Health data to enable consumer report cards are rapidly being developed. These must detail access, quality, speed and outcomes of health services. They should be used to reward those health organizations that improve their performance. They must also chart the health of the local community. Report cards will eventually be provided because the public is demanding them. Better to lead than follow.
   
5. CONSUMER-CENTRED INFORMATION. Link the excellent web sites of disease specific groups such as the Arthritis Society and others in a series of community portals on the Internet. For example, a health portal for our capital city would be a consumer site linked to all providers, hospitals, clinics, home care and these disease specific sites. Similar sites would be developed across the province.
   
6. WIRE THE SYSTEM. Commit investment to wiring the health system over the Internet. This could be accomplished in three to five years. It will cost hundreds of millions of dollars. It will save, over the next decade, a multiple of its costs. Our pharmacies are already linked together but need to be linked to the rest of the system. Next, all physicians, hospitals and laboratories should be linked together to allow all providers and patients access to electronic medical records, to allow instant reporting of lab test results and instant transmission of prescriptions.
   
7. MORE AND BETTER FUNDED LONG-TERM CARE. This is the only permanent fix for the bottleneck at the acute-care hospital. Patients needing long-term care are still inappropriately stuck in needed acute-care beds.

There is complete consistency between the above list and the health reform agenda of your government. The article by Leatt, Pink and Guerriere is an elegant statement of our urgent need to inform and support patients and their families. An integrated, modern healthcare system is not possible in the absence of an informed and enabled consumer. Confidence will not be restored without bold action.

Your loyal and faithful Deputy Minister of Health

Michael B. Decter

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