HEALTH CARE (2000 – Revised 2007) Introduction Health care has traditionally been thought of as primarily a public sector, social issue, not a subject of serious interest to the business community. The Chamber, however, does have serious concerns about healthcare issues for two primary reasons. Firstly, healthcare in BC is under intense pressures and needs to be better prepared to address pending challenges. Despite annual increases to healthcare funding in BC, waiting lists continue to be an important issue, emergency facilities overflow and practitioners deal with frustrations that cannot help but divert their attentions from their primary focus of patient care. Secondly, The Chamber believes that a healthy economy and the new investment needed to develop communities require an acceptable level of public services. That is why the seriousness of the current healthcare situation in BC is of paramount importance to The Chamber. Healthy communities lead to a healthy economy.
Regional Healthcare Issues All communities in the province of BC share the need for efficient, accessible, accountable, transparent and cost-effective healthcare. In fact the Canada Health Act specifies five principles for healthcare, including accessibility and comprehensiveness. Nevertheless, provision of services in many parts of the province does not provide reasonable access. There needs to be continued and greater recognition in government policy that non-urban areas have unique healthcare issues separate from those of urban centres.
Through the government’s approval and support for the start up of the Northern Medical Program and the Island Medical Program, recognition has been given that health programs such as these are the key to recruitment, retention and stability of healthcare throughout the province and are critical to the success of the medical education process.
There are many other initiatives that can be undertaken at the local level to provide better service to those in more remote areas. The BC Government is encouraged to continue improving and initiating the programs outlined in the Ministry of Health Service Plan for 2007. One example is “First Call” which is a program in place in Vanderhoof and MacKenzie that allows people to see a nurse for minor ailments then be referred to a doctor, if necessary. This program ensures that while patients are still able to make their own appointments with a doctor, the intervention system works only in the emergency department and allows a nurse to assess the patient’s medical condition and determine whether a doctor needs to be called in.
Healthcare services affect health status and the economy. Residents should receive appropriate and effective services and, equally important, such services are required to attract and retain investments and key personnel. Furthermore, many facilities are inadequate and outdated because of limited capital dollars.
Millions of dollars have been spent on restructuring the healthcare system; dollars alone will not resolve problems in the healthcare system. It is clear that there is still significant work to be done in maximising and identifying the benefits of regionalization.
The Healthcare system can also be improved through better use of technology to improve quality and accessibility of healthcare services. Both the internet and telephone usage have proved successful in providing tele-psychology, tele-radiology and tele-trauma services. They not only reduce costs but also provide access to services not otherwise available in the rural or remote areas. The BC government should be congratulated for prioritizing initiatives such as the ministry service plans.
Another potential area for alleviation of the regional healthcare situation comes from the realization that even in the complete absence of other healthcare facilities, there are pharmacies in virtually every community in British Columbia; it is the best example of a "closer-to-home" healthcare system that we have. Government must seek ways to take advantage of this.
In November of 2002, the federal Ministry Advisory Council on Rural Health released, “Rural Health in Rural Hands: Strategic Directions for Rural, Remote, Northern, and Aboriginal Communities”. This report gives a thorough analysis of the concerns raised above and makes a series of recommendations for addressing them. Many of those recommendations coincide with those made by The Chamber.
THE CHAMBER RECOMMENDS
That the provincial government:
1. in ongoing reviews of the regional health plans, ensure they contain strategies to advocate, and ultimately to ensure accessibility of services to all communities in BC;
2. work with the regional health authorities to allow individual communities the flexibility to incorporate “made at home” solutions to health problems;
3. continue to fully support the programming and infrastructure needs of the five regional health authorities and the provincial health services authority; in particular, the Northern and Island medical programs;
4. continue to investigate and implement the better use of communications technology to improve quality and accessibility in health services as per BC’s e-health strategy;
5. continue to investigate options to enhance the utilization of existing community pharmacies to play a greater role in making fundamental primary care available to the residents of BC (examples include the Pharmacist Line, BC Nurse Line and the Northern Health Authority EPIC Program);
6. improve primary care and chronic disease management strategies as a means to improve outcomes; and
7. work in co-operation with the federal government to set the priorities for addressing rural health issues as per the recommendations addressed in the rural health study.
Human Resource Planning
The need for a highly qualified workforce within the health industry is fundamental to the effective delivery of care services. Instances have occurred, and seem to be growing in frequency, where a shortage of skilled health workers, be they doctors, nurses, pharmacists or technicians, has had a direct affect on the availability of health services. Furthermore, continuity is an important facet of healthcare and the significant turnover of physicians and the increasing reliance on locums seriously impairs that continuity. Although this is a problem for the province as a whole, human resource issues are once again of particular concern in non-urban areas where the challenges that have led to this situation are exacerbated.
In 1997, the Royal College of Physicians and Surgeons of Canada, in consultation with federal and provincial governments, restricted the licensure of foreign specialists to favour Canadian and American-trained specialists. This is discrimination and does not ensure competency or availability. Many non-urban communities need specialists but are unable to recruit them. Restrictions on visas issued to physicians and spouses are counter-productive to encouraging long-term residency by the physicians in the community.
In addition, in some communities it is difficult for physicians to cope effectively with the volume of patients requiring services. The extreme “on call” requirements are another significant factor in physicians leaving communities. Additional physician capacity in these communities, consistent with the community's Medical Manpower Plan, would result in an enhanced level of care provided. The increased utilization of locums to provide staged relief from workload issues should also be considered.
One way to reduce the workload of physicians is to examine alternative modes of delivery. Part of the physicians’ problems is due to the fact that much of their capacity is taken up seeing to non-critical or “lower-level” health services that could be easily shunted off to other health professions such as nursing and pharmacy. Things like immunizations and prescription refills, for instance, need not occupy a physician's time.
The severe shortage of nurses and pharmacists are other areas where the lack of skilled healthcare workers have attracted significant public and media attention. This shortage, in part, due to a lack of training spaces for nurses in BC and, in part, due to funding challenges is leading to “burn-out” and reduced service. Currently there are also at least 150 vacancies for pharmacists in BC, primarily in rural areas.
There are many examples of where such shortages exist. While much attention has been focused on nurses and physicians, other important professions and support workers are equally short in supply.
Community colleges and universities are now looking at courses that will offer training and encourage work experiences in rural areas. This is particularly critical in the healthcare industry.
As an example, Selkirk College has identified one area in healthcare that has a verified, but largely unrecognized, need throughout rural British Columbia. This need is for combined laboratory x-ray technicians, specifically in small health centres and clinics.
The need for an integrated overall health human resource strategic plan has been identified for many years. That need has never been more acute than what exists today. The ability to meet the care needs of British Columbians is at significant risk if such a strategic plan is not formulated, approved and implemented.
Although the Ministry of Health has committed to work with the Health Employers’ Association of BC (HEABC) and other healthcare providers to develop health human resource strategic plans, the need for a comprehensive plan for equitable geographic distribution of health professions in a wide range of disciplines continues to be an issue of immediate importance.
THE CHAMBER RECOMMENDS
That the provincial government:
1. work with associations, professional bodies, colleges and universities to develop, implement, continually update and publicly report on progress on a comprehensive human resource strategic plan for the health industry in this province that, in particular, includes a recognition of the need to recruit from outside BC and train within BC additional physicians in specialty disciplines;
2. ensure that a key component of a comprehensive human resource strategic plan addresses the rural health issue of skilled workforce training in rural communities;
3. work with the federal government and professional associations to amend immigration and licensing policies to support its physician supply measures initiative and to facilitate the retention of physicians in rural areas;
4. act with the federal government and the Royal College of Physicians and Surgeons to implement a competency model for licensure of specialists rather than one based on the origins of the specialist;
5. expand enrollment at the University of BC’s faculty of pharmacy; and
6. continue to take steps to address the shortage of nurses and other health service providers including but not limited to expansion of educational seats in all universities and colleges as outlined in the most recent Ministry of Health Service Plan.
Prevention One of the most effective ways to reduce costs within the healthcare system is through prevention. Provision of an acute-care hospital bed is one of the most expensive aspects of the healthcare system. Government should focus efforts on keeping the population healthy and ensuring the most appropriate point of access to the health system.
The most basic method of prevention is through education. It is also recognized that responsibility for one's own health is the best way of addressing the utilization of health services, especially in the areas of sexual practices, nutrition, exercise, accident prevention, road safety, and habitual use of alcohol, drugs and tobacco. The provincial government should integrate programs of public education which demonstrate to the individual the benefits that accrue as the result of good health habits.
A key method of prevention is through appropriate screening of high-risk population for a variety of diseases where early intervention can reduce costs. For example, one of the reasons BC has some of the best outcomes for cancer treatment is screening and early treatment. BC should continue to try to improve access to screening tools to improve the early detection of other chronic diseases.
Through chronic disease management programs, prevent complications, emergency room visits and hospitalizations through national and international guideline approved care and treatment.
Socio-economic issues, such as poverty, also affect the health of people. It has been found that there is a direct relationship between poverty and morbidity (ill health). Good housing has a direct influence on healthcare and there is a need for properly planned housing for the aged, handicapped and disabled. This, combined with other outreach programs, would have the effect of keeping this group of citizens in their own housing as long as possible.
All these factors have a direct influence on health and, if action were taken, there would be fewer demands for expensive hospital and medical services.
THE CHAMBER RECOMMENDS
That the provincial government:
1. in concert with health authorities, community healthcare providers and individual school boards, continue to work with parent and/or social groups to expand significantly its wellness education programs, on sexual practices, nutrition, exercise, accident prevention, and habitual use of alcohol, drugs and tobacco – ACT NOW is a great example;
2. ensure that there is accessible, province-wide screening particularly for high-risk populations; and
3. ensure province-wide immunization implementation plans for children and the elderly as per the 2007 MoH Service Plan; and
4. improve the community-based healthcare initiatives for people below the poverty level in the province by, for instance, encouraging the development of adequate and affordable housing facilities and programs for the poor.
The Ageing Population
There is little doubt that one of the key cost drivers for the future of our health system will be the ageing of our population. The ageing of the war and post-war babies over the next four decades will result in an increase in spending on the 65-plus age group from its current 54% of total provincial spending to 68% by 2040. In 1998, provincial health spending on this age group totalled $4.3 billion; by 2021, under the assumption of constant age specific health per capita spending and in constant dollars, spending on the 65-plus age group will be $8.0 billion – the same currently spent on all age groups in the province. That is approximately 70% of the total health budget today and it will increase from that point.
There is little doubt that the key to paying for these increasing costs is stronger economic growth. Nevertheless, it is also incumbent upon the healthcare system to find better and more cost effective ways to treat our aged.
One of the keys will be long-term care for as our population ages there will be an increase in the number of patients who require it. Unfortunately, many long-term care patients occupy beds in acute-care hospitals when they might not need it. Improve chronic care beds and better integrated care and discharge planning. This creates an apparent need for more acute-care beds as well as increasing the cost of caring for these long-term patients. The increased use of daycare and home care should not only reduce the need for acute care and long-term hospital beds and, hence, reduce their inherent costs, but would provide a better environment for these long-term patients.
Finally, it is also important to note that 80% of the cost of healthcare costs occurs within the last six months of an individual’s life.
THE CHAMBER RECOMMENDS
That the provincial government:
1. provide further funding for research and services for the study of gerontology in order to address the problems (and opportunities) arising due to the increasing numbers of elderly citizens;
2. encourage the University of BC medical faculty to place more emphasis and funding on teaching and research of geriatrics and to provide post-graduate work in that speciality area;
3. continue to support chronic disease management programs to ensure appropriate care and keep people from needing to use emergency services;
4. initiate additional policies to enable the aged to remain in their homes as long as possible through, for example, the use of senior citizens’ centres and outreach programs;
5. develop more home care and adult day care programs and facilities such as will result in a decrease in use of residential and hospital beds;
6. optimize the utilization of acute-care hospital facilities, extending further encouragement and support to non-government and voluntary agencies involved with adult day services and home care programs;
7. work with municipal governments to continue and expand the provision of congregate-life facilities, providing low-rental housing accommodation with access to medical and nursing monitoring, dietary and housekeeping services and social, recreational and spiritual opportunities;
8. encourage further development and construction of day hospitals and short-stay assessment units as a method of reducing admissions to expensive hospital beds and services;
9. expedite construction of multi-level care facilities and encourage greater use of facilities operated by the private sector, and that the provincial government encourage the private sector, rather than just government or non-profit societies, to bid on the construction and operation of multilevel care facilities;
10. ensure that all multilevel care facilities and community agencies be accredited to ensure that quality standards are being met. An inspection process is not sufficient because it addresses minimum, rather than optimum, standards;
11. continue to promote greater co-ordination and communication between governments and institutions on research, studies and services being offered across Canada; and
12. work with healthcare and community counsellors to investigate ways to educate British Columbians with regard to end-of-life decisions that focus on less intervention wishes expressed in advance by the critically ill.
Health Costs The five principles of medicare in Canada as enshrined in the Canada Health Act are: comprehensiveness; universality; portability; accessibility and public administration. The Chamber believes the provincial government should include sustainability, accountability and transparency.
The Chamber is concerned with the effectiveness and, in some cases, the appropriateness of health expenditures. Given the current importance of maintaining fiscally responsible government and the ongoing concern surrounding our healthcare system, it is an appropriate time to analyze where and how health dollars could be more effectively expended and/or reduced. Encourage the MoH to see the cost effective benefits within the system across departments within the ministry. That increased expenditures in one part of the ministry may have significant benefits in other parts of the ministry and these efficiencies should be encouraged and rewarded to eliminate silo budgeting. The Chamber believes that a foundation of this analysis must be an objective assessment of the services removed from the Medical Service Plan (MSP) such as, physiotherapy, chiropractic, massage therapy, optometry coverage to determine whether it is cost effective to have these remain uninsured. It must also be recognized that when health services are de-insured, private health plans typically are forced to extend coverage for those services. As a significant number of British Columbians have employer-paid health benefits, the increased premium costs devolve to employers. Off loading of costs as a policy of government cannot be seen as the panacea to meeting the escalating demand for health resources.
The Chamber also believes a significant number of emergency hospital visits could be reduced if there were more economical alternatives available. Such alternatives might include 24-hour ambulatory care centres. This also ties into the whole issue of prevention. Our healthcare system must strive to provide the most appropriate care by the most appropriate practitioner at the most appropriate time and at the most effective cost.
It is recognized that health is a labour intensive industry in that around 75–80% of health expenditures are wage and wage-related costs; therefore, any discussion about health expenditures must be cognizant of this area. Recent agreements continue the trend of adding costs to the system.
Because there is little support in BC for an additional tax burden, The Chamber believes that all health expenditures must be analyzed to ensure value for money is being received for each dollar expended.
THE CHAMBER RECOMMENDS
That the provincial government:
1. either directly, or through delegated authority, ensure the appropriateness and effectiveness of healthcare expenditures;
2. commit to any further increases in labour costs being tied directly to corresponding increases in productivity within the health industry;
3. conduct a cost-benefit analysis to determine the true cost of de-insured services and, where a clear benefit is found, return services to insured status; and
4. need to treat the health system as a whole so that expenditures that benefit other parts of the system can be credited for savings in other parts of the ministry – cross-silo accounting.
