Last month, provincial Liberal leadership candidate Moira Stilwell rolled out a comprehensive healthcare reform that include a promise to "look at how the private health care system might be able to help the public system." According to the Georgia Straight's Yolande Cole, that suggestion shocked public healthcare advocate Colleen Fuller. But what does fellow leadership competitor George Abbott think about it, now that his candidacy is being endorsed by Dr. Stilwell? "I am comfortable with everything that Moira has said in this campaign. I think she's been very thoughtful in the positions she's put forward," stated Mr. Abbott during a news conference announcing that endorsement.
"There already is private involvement in the healthcare system in British Columbia," he continued. "I think, like Moira, we're looking for a thoughtful balance in this. And, furthermore, I think one of the things we share is a strong belief that we need to develop a more fulsome primary care system in this province that can help to improve healthcare without adding huge expense to the system."
The following is a complete copy of the speech announcing Dr. Stilwell's healthcare reform package.
HEALTH CARE REFORM IN BRITISH COLUMBIA
January 25, 2011
Speech by Dr. Moira Stilwell, Prince George, B.C. - January 25, 2011
As a physician who is married to a physician and also raising one, health care dominates the dinner table conversation at our house.
It was during one of these conversations that I decided to run for office in the first place - and that decision was related to health care. I had been volunteering with the Canadian Breast Cancer Foundation, and had some great success in working with government to change some policy related to screening mammography. The changes lead to faster diagnosis of breast cancer, which meant both cost savings to the system and better outcomes for patients.
When I was approached to run as an MLA, I thought of this one small policy change. I could go on helping maybe ten people a day as a working physician, but maybe - by bringing my experience to government - I could help thousands or maybe hundreds of thousands.
I keep looking for those ideas - those ways we can make small but significant changes that lead to improvements. Some of the ideas I am going to introduce today are small. Others are a bit bigger.
But all are aimed at the same challenge: how do we improve our health care system?
We simply can't go on without making changes. We all know this - we know the statistics about rising demands and increasing costs.
You'll notice some themes running through my remarks - the same type of challenge arising again and again. One of these is about the need for there to be more system in our health care system, and another is about the need to diagnose problems early, so we can take action earlier. I'll come back to these ideas again, because I think they are part of critical solutions.
There are four specific areas that I have chosen to focus on. They aren't the only areas where dialogue and ideas are needed, but they are areas where I see both tremendous need and opportunity.
1. We need to improving health care in rural and northern BC.
When I was younger, I spent a number of formative summers travelling with my uncle, who was a radiologist serving north eastern BC and north western Alberta. I learned first hand that practicing in northern and rural areas takes special skills, and special people.
I have a number of ideas about training and retaining those special people. Northern health needs professionals from the north, trained in the north, who want to stay in the north. There isn't a magic bullet, but we do need to understand what makes a doctor choose where to practice. It isn't to have their student loans paid back - it is the quality of mentoring. We have to remember that a medical degree is only a learner's permit. It is the opportunity to learn from seasoned professionals that attracts young doctors. How do we encourage this? Three ways.
We need to find ways to help the UNBC medical school take its next steps. We are not the only jurisdiction trying to address the challenges of rural and remote health care, and the UNBC facility has the potential to thrive, and generate not only the professionals we need, but also leading edge practices in telehealth and rural medicine.
We have to capture the knowledge that already exists amongst northern medical professionals, and make sure that this knowledge is passed on before they retire. We need to create incentives for northern professionals to mentor and train their replacements, and we need to ensure we aren't creating artificial barriers to this type of teaching.
Lastly, we need to ensure that those Canadians who are studying medicine abroad are able to do their residencies here. We need to bring our kids home. There are literally a hundred British Columbians who want to return to the communities they grew up in to do their residencies, but because they chose to study medicine in a different country, we won't let them. We need to change this policy immediately, because it isn't helping any one.
2. We need to provide better and more comprehensive services to our sickest patients, so we can bring costs under control.
We need to bring the costs of our system under control, or - quite simply - the costs are going to control us. One of the great things about our public system is the data we have available. We know that it is a small percentage of patients who are costing our system the most money, because - in essence - our system is failing them. Our system is great at trauma, and we world leaders in HIV/AIDS treatment, as well as cancer care and control. But our system isn't handling chronic diseases well at all.
An aging population combined with an increase in chronic diseases - congestive heart failure, diabetes, obesity - is exacerbating the problem and the costs to our system. A poorly managed chronic disease is like setting off a chain of dominoes. It usually ends up with the patient having a number of chronic diseases, spending a lot of time in emergency rooms, and then in acute care beds, and then eventually in long term care beds. All of these services are amongst the most expensive ones we provide. So when a patient with a badly-managed chronic condition ends up in an acute care bed, I'd suggest we consider that as a significant failure. It is a failure for the patient, and it is a failure for the system.
I have a radical idea about how to bring our costs under control - something that is going to sound counter intuitive. I think we need to identify those patients who are costing our system the most, and we need to spend more money on them up front, so hospital costs are less.
Shocking, isn't it? But there are a number of pilot projects around the world - from Denmark and the UK to the US - where people are having success doing just that. By spending more on the people who are using the system the most, they have reduced overall costs, and improved the health of patients.
What I'm suggesting is that we change our approach to helping patients with chronic diseases, and - in fact - we start changing how we approach primary care altogether.
There are a few simple reasons we handle chronic disease poorly. The first is that our primary care system relies solely on doctors. We need to integrate other practitioners into primary care. Patients with chronic diseases need assistance that goes beyond medicine. They need help with fitness, diet, complying with treatment, accessing services and many other things.
We need to increase the role of other medical professionals in primary care, to improve outcomes and to reduce the burden on general practitioners and family doctors.
We now have nurse practitioners in BC, and we need to use these uniquely-trained professionals more.
We need to explore the role of psychologists in primary care. There are a number of studies showing that the timely use of psychologists can reduce primary, specialty and emergency medical care costs for a wide range of disorders.
There is also a need to create a new type of role in the health care system. Whether we call it a health navigator or a health advisor, the concept is simple. There are lots of little things that keep people from being successful in managing their own health. From knowing how and where to access services, to ensuring prescriptions are filled or renewed on time, we need to consider that for those patients who have multiple chronic conditions, some of the basic things we take for granted become challenges to cope with. These health advisors don't need medical or nursing degrees, just specific training and a great attitude.
Next, our system pays for services and procedures, not for outcomes. We need to look at changing that, particularly when we're dealing with conditions that require more than medical intervention.
I know I've just suggested a list of changes that would radically change how we approach primary care. I know that there are many vested interests in the health care system that don't tend to react positively to change. I also know that there are elements of what I am suggesting that are being considered and piloted already.
So we need to expand these pilot projects, collect the data, and measure the outcomes - both in terms of human health and cost. When we find things that work, we need to expand them. There will be initial extra costs, but I don't know how we can afford not to try to make changes.
3. We need to re-double our efforts on mental health
There is still too much stigma attached to mental illness. At the same time, we don't talk enough about what good mental health looks like, and how to achieve and maintain it. Yet, we know that depression is a cardiac risk factor, and that mood disorders can significantly affect the course of many other medical illnesses, including diabetes, chronic pain, Alzheimer's and cancer. Studies also show that health care costs increase dramatically when stress and depression are left untreated. Further, there is some evidence that jails have become our modern mental health institutions. This - to say the least - isn't helpful.
There are a number of actions we can take:
• We need to increase the availability of care for those with mental illness. Again, just as with chronic disease management, it will cost more at first but we will see the savings in other parts of the system in the long run. Accessing appropriate care - whether it is a psychiatric bed or assistance in the community - is vital to patients and their families. Our community mental health teams work very well, but we need more of them. We have had great success with the rapid access clinics for physical health problems. We need to pilot these for mental health challenges.
• We need to start diagnosing and treating mental illness earlier. Often, we don't catch it until the symptoms are having a severe and negative effect on the patient's daily life - failed relationships, interactions with the police, failed careers, hospitalization. We can do better. For example, truculent and oppositional pre-teens and teenagers should be screened for mental illness. Early detection means a better outcomes for the patient. And - again - this means the patient will be needing fewer of our very expensive high end services, and has a better opportunity of living a productive life. We do have some programs that are working in this area, but as with most successful pilots, they are over-subscribed. An example is the EPI program - Early Psychosis Intervention.
• We need to make mental health care teams available to the public school system. We need to work with educators and education leaders to ensure that mental health teams are available to them, to assist with early diagnosis and treatment. This will lead to better educational outcomes and better health outcomes. You don't need to go farther than the downtown core of a major BC city to see teenagers whose mental health issues have gone untreated - where educational failure leads to failure at home, and is followed by a series of unfortunate behaviour - from prostitution to drugs.
• We need to talk about dementia, and soon! Right now, it is hard to find adequate housing and care for demented adults - seniors who wander, or are violent. I'd like to suggest that this problem is not going to fix itself, and is definitely going to escalate as the baby boom ages. I think we need to invest now, because this problem is going to be upon us - and causing stress and costs to other parts of our social safety network - before we know it.
• We all need to check our attitudes towards mental illness and those who suffer from it - from how we talk about it to how we react to those who share their stories. Cultural change takes time.
• We need to ensure we are regulating professionals in this area appropriately. There are a number of changes that are needed - changes that are being requested by mental health professionals themselves. We need to begin to regulate clinical counsellors, and we need to bolster the regulations governing psychology, so that regulators can better protect the public, and the public can make more informed choices.
4. We must talk about private health care, what exists now, and what is best for our public system
I know that even mentioning the word "private" in the same sentence as "health care" is a guarantee that my presentation here this morning will cause an immediate increase in blood pressure and pulse rates across the country.
Before people have more adverse reactions to my statement, let me lay out a few premises for you:
First, private health care exists in BC. It has increased considerably in the past 20 years. There are two primary types: there are services that patients seek out and pay for, and then there are the services government pays for.
Next, there is a legal decision in Quebec that suggests private care in some way is here to stay. It is not irrelevant to us here in BC.
Lastly - and most compelling to me - the type of private care we have right isn't helping the public system.
There are no shortage of stories of people getting off the plane at YVR after having private care in another country, and taking a taxi to VGH for follow-up care. I know of many instances where patients being treated privately have had complications, and have ended up in the public system to have those complications taken care of.
Would that patient have had the same complications if they had treatment in the public system? What we have right now is a private health care system that has the public system as its safety net. I think that is a pretty compelling reason to start a real dialogue about what kind of private care our public health care system can afford.
We need to have a dialogue about both types of private care - where the patient pays, and where the government pays.
For example, what is the answer to the question - will the public system pay for my follow-up care if I have chosen to have a private operation? Because we are so scared to even mention private care, we don't have a discussion - we pretend private care doesn't exist. My personal preference would be to say that if you choose private care for your procedure, you'll need to stick with private care for any follow-up. But that's just my opinion. My point is that we need to free ourselves to have this discussion.
Another discussion we seem to be avoiding is about the ways the private system might be able to help the public system. Are there ways the capacity in the private system can be used to help relieve waitlists for routine procedures? For example, hip and knee replacements might be able to be done more efficiently in the private system. If so, we should be looking at contracting these services. It isn't a scary idea because our system already works this way on one level, as most medical doctors operate as small businesses. But if we do this, then we need to ensure we do it wisely. We need to benchmark success and complication rates, for example. If a contractor is within the norms for complications, then the public system will pay for any services related to complications. If a contractor is operating outside of the norms, then the private provided needs to pay for the services related to complications.
Is everyone still doing ok? I've been using the word private in conjunction with health care for over a few minutes, so I thought I should check in with everyone. No one is feeling faint? Everyone's blood is still going round and round in their bodies, and the air is still going in and out of their lungs?
Good. I am told those things are important.
As a physician running for the leadership of the BC Liberals, I hope I will be able to help thousands of people a day needing better healthcare instead of twenty a day.
We need to bring better health care to rural and northern BC.
We need to provide better and more comprehensive services to the sickest patients, so we can start to bring costs under control.
We need to re-double our efforts in the area of mental health by removing the stigma and making sure people get the care they deserve.
Finally, we need to accept that private healthcare has been with us for more than two decades, and that we need to have a dialogue about what kind of private health care is best for our health care system.
There are a two overall points I want to leave you with today. The first is that we have to be brave enough to look at the areas where we aren't doing very well, and figure out how we can do better. It isn't always a pleasant exercise, but it is essential if we are to grow and improve. I don't know of anyone who gets better simply by congratulating themselves on their successes... And if there is one area where we really need to get better, it is our health care system.
Lastly, there is this: As a doctor, I know that early detection of disease radically increases the chances of survival, by allowing us to intervene and treat. It is why I fought so hard to improve mammography screening. We need to bring this same rigour to public policy. Early detection of those things that aren't working allows us to intervene and make changes. It also allows us to find those things that are working and amplify them. We need to see the tremendous opportunity we have to improve our health care system, and then we need to be brave enough to try.
Thank you for being here today, thank you for your attention and concern as we explore the future of healthcare in BC. I welcome your support for my campaign and this cause that is so important to all British Columbians.