The papers that follow are part of an honest, reasonable and serious attempt to build on an existing consensus at the basis of medicare, which guarantees that all Canadians can get medical attention when sick and hospital care when very sick (or injured). Without any exception, reform proposals that run counter to these principles are doomed to failure. However, it becomes harder and harder to ensure that costly and complex healthcare services can be "readily and timely" accessed without a radical shift in approaches. To say things otherwise, to keep what we cherish, we must embrace change, in the form of collaboration, measurement and evidence.
Resilience and resistance to change are two faces of the same coin. The one person who resists, if you happen to be on the side of change, would be praised as resilient if you are favourable to the status quo. Canada's health system is caught in this logical trap like a ship stuck in an ice field – hence the relevance of the frozen paradigm metaphor my colleagues and I used a few years ago to depict the odds of a successful reform (Lazar et al. 2013).
The three papers (Gogovor et al. 2019; Montague et al. 2019; Nemis-White et al. 2019) that follow are part of an honest, reasonable and serious attempt to cut through the ice. They build on an existing consensus, confirmed by a succession of inquiries, polls and consultations, respecting a core, tacit entitlement at the basis of medicare, which guarantees that all Canadians can get medical attention when sick and hospital care when very sick (or injured). Without any exception, reform proposals that run counter to these principles are doomed to failure (Forest and Denis 2012). On the contrary, as is the case with the three papers, proposals that are consistent with people's views and values have a chance of success.
In fact, the authors place Canadians' views and values at the heart of their reasoning. They use high-quality opinion data obtained through repeated polling of Canadian citizens conducted by the national firm Pollara Strategic Insights on behalf of the Health Care in Canada partnerships and surveys. Healthcare providers were also questioned through this process, albeit the small sample size for each professional category should impel us to remain cautious. Overall, unsurprisingly, the results affirm medicare's central commitment to access, universality and sound professional healthcare.
What is intriguing, however, is the expression of support for the active and collaborative management of the medicare compact. For example, although patients want to be engaged in their own care, which is to be expected, they also express a wish to see a wider range of stakeholders contributing to the stewardship of the health system. Canada missed the managed care revolution and, as a result, despite convincing real-life experiments and pilots, may possess one of the most fragmented care systems in the world. Yet everybody knows this is wrong, that integration is lacking, that information needs to circulate widely and that value in healthcare lies at the intersection of evidence and collaboration (Montague et al. 2013). To paraphrase the paper on adherence to prescribed therapies by Gogovor and colleagues (2019), this is becoming an "existential challenge."
Two specific questions raised by the papers may attract some attention. The first one, especially evident in the paper discussing a potential leadership structure for a future pharmacare program, is public openness to partnerships that comprise stakeholders of all sorts, including the private sector. Instead of immediately jumping to the conclusion that the public is naïve or manipulated, better to think of this attitude as a signal that the growing demand for information (and consequently for enlightened choice) is not satisfied by the current interactions between patients and reticent care providers.
The second question is related precisely to the attitude of providers toward a more open and collaborative health system. The results are not encouraging, at least at first glance. Physicians in particular seem to be more preoccupied by the perennial issues of access and standards of care than by the dialogue with their patients. Yet is this really a surprise? Canadians asked physicians decades ago to be the custodians of medicare, and they are following through. However, as suggested by Terry Montague and colleagues (2019) in their piece on patient-centred care, it will become harder and harder to ensure that costly and complex healthcare services can be "readily and timely" accessed without a radical shift in approaches. To say things otherwise, to keep what we cherish, we must embrace change, in the form of collaboration, measurement and evidence.
About the Author
P.G. Forest, PhD, FCAHS, is a professor and the director of the School of Public Policy and James S. and Barbara A. Palmer Chair in Public Policy at the University of Calgary.
Forest, P.G. and J.L. Denis. 2012. "Real Reform in Health Systems: An Introduction." Journal of Health Politics, Policy and Law 37(4): 575–86. doi:10.1215/03616878-1597430.
Gogovor, A., J. Nemis-White, E. Torr, N. MacPherson, L. Martin, J. Aylen et al. 2019. "Non-Adherence to Prescribed Therapies: Pharmacare's Existential Challenge." Healthcare Quarterly 22(2): 21–26. doi:10.12927/hcq.2019.25909.
Lazar, H., J.N. Lavis, P.G. Forest and J. Church. 2013. Paradigm Freeze: Why It Is So Hard to Reform Health-Care Policy in Canada. Kingston, ON: McGill-Queen's University Press.
Montague, T., J. Nemis-White, B. Cochrane, J. Meisner and T. Trasler. 2013. "Partnerships and Measurement: The Promise, Practice and Theory of a Successful Health Social Networking Strategy." Healthcare Quarterly 16(1): 31–37.
Montague, T., J. Nemis-White, J. Aylen, E. Torr, L. Martin and A. Gogovor. 2019. "Canada's Evolving Medicare: Patient-Centred Care." Healthcare Quarterly 22(2): 27–31. doi:10.12927/hcq.2019.25908.
Nemis-White, J., E. Torr, J. Aylen, A. Gogovor, L. Martin, J. Mitchell et al. 2019. "Medicare's Evolution: National Pharmacare and Shared Leadership." Healthcare Quarterly 22(2): 15–19. doi:10.12927/hcq.2019.25910.
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