ST. JOHN’S, Newfoundland — If a consensus was discernible at the Canadian Medical Association’s (CMA) general council annual meeting here last month, it was that how health care is delivered should focus on what is best for patients, not on politics.

Nevertheless, discussion on the recommendations for improving Canada’s substantially publicly funded health system, embodied in the report of a blue ribbon advisory panel presented to the body representing Canadian physicians, provoked vigorous debate on means as well as desired outcomes.

CMA’s governing body commissioned the report on the eve of the beginning of discussions between the federal, provincial and territorial governments to hammer our a new accord on how the federal government will renew its financial support for the health system. The current agreement expires in 2014.

The six-member advisory panel charged with its developing the new accord has vast experience in all facets of health care, ranging from hospital administration to finance.
The panel made 10 major recommendations that it believed would improve the way in which health care is delivered to Canadians.

The panel’s priority was to address the issues emerging from what it described as “the current system’s focus on funding physician and hospital services at the expense of other supports more appropriate to the current needs of Canadians, such as long-term care, home care and pharmaceuticals.”

Dr. Jeff Turnbull, outgoing president of CMA, who is currently chief of staff at Ottawa Hospital, in his valedictory address to the delegates made no bones about what he saw as the current state of Canada’s health care system.

“We have seen a slow and steady decline in what we would now agree is a deeply troubled health care system,” he said. “To be clear, this pillar of Canadian society is eroding. We are losing something of great value. It’s slipping away slowly, ­incrementally.”

There is no doubt as to where Canadians stand on their health care system. In poll after poll they have affirmed their devotion to a publicly funded system that provides universal access.

No politician at any level of government would dare to suggest changes to that basic proposition.

Yet, at the same time, respondents express frustration at the shortage of family physicians willing to enroll new patients, long wait times for some noncritical surgical procedures, crowded hospital emergency rooms, and the difficulty patients experience in navigating among medical specialties and facilities.

The panel’s recommendations to CMA and its members included the following points:

• Be open to discussing a range of ways of funding services along the entire continuum of care.
• Help develop innovative payment systems in which funding follows the patient (rather than having a focus on treatment providers).
• Recognize the value of provider competition.
• Advocate for greater accountability of the system toward people who need care and their families.
• Work toward containing the costs and improving the health outcomes related to prescription drugs.
• Advocate for a rethinking of Canada’s national electronic health information strategy toward a focus on patients and their mainly local interactions with the health care system, away from the current national, top-down approach.

Not surprisingly, the recommendation that aroused the most vigorous discussion was that dealing with possible new ways of funding services. Specific proposals discussed included user fees. Predictably, the delegates were divided on that subject. Even the concept that patients who utilize a hospital emergency room for a condition that could equally well be treated at a walk-in clinic should be charged a nominal fee proved controversial.

Dr. Turnbull commented to reporters after the debate that it is not clear whether charging user fees would “fit within the context of equity and social justice,” but he added, “I think no stone should be unturned. We should look at everything.”

The concept of encouraging competition among health care providers also came in for close scrutiny from the delegates.

One delegate suggested this idea “favored competition over cooperation, pitting providers against each other in an already fragmented system.”

Panelists argued that competition and cooperation are not necessarily mutually exclusive.
Panel member Don Drummond, now an academic but formerly a senior Finance Canada official and then chief economist for TD Bank, argued that every hospital and physician do not have to do the same thing; there can be specialization. “If private providers don’t offer services at a lower cost and higher quality, then we’ll do it in the public domain,” he suggested.

“Most Canadians don’t care if they receive service from a public or a privately run clinic as long as they can pull out their provincial health card and it’s paid for publicly, and that’s what we’re saying,” he told reporters after the meeting. “We are talking about no exchange of dollars between the patient and the providers of care.”

Canada’s pharmacists can certainly endorse the panel’s observations on pharmaceutical prescriptions.

“Over-prescription can have negative health outcomes and compromise patient safety,” the panel wrote in its report. “Conversely, under-use and lack of compliance, often linked to financial hardship, are also detrimental. The association could assume leadership in pursuing the optimal use of ­medications.”

The panel did not specifically recommend the adoption of a universal pharmacare element within the publicly funded system, though its observations on “the optimal use of medications” may be used in support of such a development.

Provincial governments have been moving at different speeds and with widely varying degrees of progress in the development of their parts of a national health information strategy.

The costs per resident they have incurred have also differed widely and have not shown strong correlation with the progress made in each province.

Critics of the effort to date will likely endorse the recommendation that physicians should become more involved in the process and accelerate their own use of electronic ­records.

The CMA meeting was addressed by Leona Aglukkaq, the federal Minister of Health. She told the delegates her government planned to negotiate between now and 2014 a single health accord with all the provinces and territories.

Some commentators had suggested that to accommodate the different visions expressed by provincial and territorial legislators the federal government might allow them to introduce local rules within a broadly defined, umbrella agreement.

Aglukkaq firmly squelched that notion. She said the federal government’s position is nonnegotiable. She did clarify, however, that negotiations would not begin before December of this year, by which time the Senate committee is expected to have published a report reviewing the 2004 accord on which it has been working.

Aglukkaq also said that the federal government expects to place a high priority on accountability in the new agreement. “We want to be able to ensure that the dollars we invest in health care will go where they’re most needed,” she said. “We want accountability and we want results.”