Redesigning hospital rooms from the patient perspective

Last Friday, an article in the New York Times described the patient rooms in the new University Medical Center of Princeton, New Jersey. The architect is Michael Graves who is in a wheelchair after suffering from meningitis some years ago. He brings a strong patient perspective to the design of the hospital’s patient rooms.

For starters, the rooms are singles; there are no double rooms. Research shows that patients sharing rooms provide doctors with less critical information (even less if the other patient has guests). Ample space is given to visitors because the presence of family and friends has been shown to hasten recovery.

Ditto the big window: Natural light and a view outdoors have been regarded as morale boosters since long before Alvar Aalto designed his famous Finnish sanitarium in the 1930s (a “medical instrument,” as he called it), bragging about curative balconies and a restorative sun deck. (Kimmelman, pars. 12 & 13)

And generally, they look more like hotel rooms than hospital rooms.

It’s less antiseptic, cluttered and clinical than your average patient room, more like what you find in a Marriott hotel, anodyne and low-key, with a modern foldout sofa under a big window; soft, soothing colors; and a flat-screen TV. (Kimmelman, par. 23)

The new rooms also include a bedside-to-bathroom handrail to make it easier for patients to go to the bathroom safely on their own.

HospitalroomBringing their perspective to the design of hospitals rooms will make a big difference to the experience that patients and families have in hospitals. The hospital in New Jersey is an excellent and concrete example of the difference it makes to consider the patient experience; patient satisfaction ratings are now in the 99th percentile – not just for the room, but for everything from the food to the care. And staff like working there as well.

In the redesigned room, patients asked for 30 percent less pain medication. According to the article, “Reduced pain has a cascade effect, hastening recovery and rehabilitation, leading to shorter stays and diminishing not just costs but also the chances for accidents and infections” (Kimmelman, par. 6).

This is an excellent example of what Patients Canada has been working towards: including the perspective of patients and their families, and thereby contributing to a better outcome for patients and a better experience for everyone involved.

Kimmelman, Michael. “In Redesigned Room, Hospital Patients May Feel Better Already.” The New York Times. The New York Times Company, 21 Aug. 2014. Web. 25 Aug. 2014.

The College of Physicians and Surgeons and transparency

Last week I was interviewed by the Toronto Star about how the College of Physicians and Surgeons of Ontario (CPSO) communicates with the public when there are complaints about doctors. At the moment, there is almost no reporting about complaints except for when they are very serious. Less serious complaints, even when they are successful, are not made public. The CPSO is trying to be more transparent about its activities and at Patients Canada, we support this. Patients should know more about their activities. And we are interested to know what steps they will take to make their rulings more transparent to patients and the general public.

When the article came out, some friends who are doctors told me that they disagreed with the view that all complaints should be made public because after all, some of them are frivolous or merely mean-spirited, but all can have a bad effect on a doctor’s reputation. And we agree. We do not think that it is necessary to make all complaints public or even to make all the workings of the CPSO entirely open to public scrutiny. However it would be a good idea to let people know if there are recurrent cases of bad behaviour or a litany of justified complaints about particular doctors without any change in behaviour. We know that the CPSO tries to help doctors learn from their mistakes and provides support for them to do this. It would be a good idea to also publicize these efforts and be more transparent about them as well.

As we see it, the change is from an ancient culture where the CPSO was a keeper of professional secrets and the public was never admitted into this inner sanctum. The mystery of medical knowledge was not open to public scrutiny at all because the power of medicine was to some extent dependent on this secrecy. That view of professionalism died many years ago to be replaced by a more responsive and open one. In the old world, doctors applied their professional authority to help patients without much regard for the patient’s perspective. Today, doctors are beginning to partner with their patients to come to shared understanding of health issues and how to deal with them. We expect that it is in this vein that the college is beginning to partner with patients to develop a greater transparency in its activities.

In Nova Scotia, this has gone further. The province is making the medical mistakes registry available online:

According to the government website, making the information public “raises the level of accountability – and demonstrates a commitment to transparency and openness. The goal is to share lessons learned and prevent the event from happening again.”

For the first six months of 2014, 27 serious adverse events were reported. Twenty-one of those incidents resulted in “adverse health effects leading to death or serious disability” while a patient was being cared for at a facility in Nova Scotia, including three incidents where a patient died or was injured after a fall while being cared for by a district health authority or IWK [Isaac Walton Killam Health Centre]. (CBC News)

The publication of these mistakes is not only a sign of increased accountability and transparency. It is a comfort to those who have been harmed and their families. Most often, patients and their families recognize that mistakes and bad experiences can happen, and what they want is for those errors to not be repeated. Making them public can go a long way to averting their recurrence.

“Nova Scotia Medical Mistakes Registry Goes On Line.” CBC.ca. CBC/ Radio-Canada, 14 Aug 2014. Web. 18 Aug 2014.

We liked the hospital but the food was awful

There are many little things that could change to improve our health care experience. So far we have talked about a couple of them – small changes to parking policy and improvements in visiting hours are two excellent examples of how to dramatically improve the experience of patients and family members. All our examples come from what patients tell us about their experience with health care. A growing group of patients, providers and researchers at Patients Canada think about these experiences and work together to discover the very small changes that can improve them.

Food is another example of a problematic area in hospitals. Most satisfaction surveys have found that patients complain about the food far more than they complain about doctors or nurses. And everyone knows that cost constraints have resulted in trying to find more and more efficient ways of producing food for hospitals and long-term care facilities. For many years, hospitals have been working hard to produce less expensive food while maintaining quality. Today, hospitals in Canada spend less than $8.00 per day for food per patient. The quality has been mixed. We noticed that so far hospital food policy has not usually included patients and family members, nor has much of this policy been easily accessible to patients and their families.

In the old days, food could not be brought into the hospital because the hospital provided a scientifically correct diet for patients and interfering with that would slow or even imperil the patient’s recovery. Moreover, the safety standards in hospitals were considered to be significantly more stringent than ones at home, and so a second reason to ban outside food was to avert the risk of poisoning patients.

Even today, many older patients and their families believe that these policies remain in place. Some sneak food in to give to their sick relatives. Others, who are more compliant, do not bring any food at all. One older woman watched her husband lose thirty pounds in a three-week stay in hospital because he said, “I hate hospital food and will not eat it!” However she never considered bringing in food that he did like because she (falsely) assumed that it was not allowed and she was not about to flout hospital rules. Her husband never recovered from his sudden weight loss and died within two years.

Today, most hospitals allow families to bring in food. Often they place restrictions on what can be brought in. Below is a quote from the Mayo Clinic Nutrition-wise blog (Nelson, Zeratsky). Despite the fact that it continues to mention the possibility of “deadly consequences” of not checking if it is safe to feed the patient, it is a pretty good example of current hospital policy about bringing in food.

As much as hospitals try, the food they serve may not meet expectations — especially when people don’t feel well. As a result, you may be tempted to bring a meal or special treat to a loved one in the hospital to show your concern and to help make the person feel better. In your concern, you might not ask if this is safe. It’s important to know that in some circumstances this act of kindness could have unintended and even deadly consequences.

Here are some guidelines that my department has put in place to help people navigate this thorny issue:

  • Before you bring food in, check with the nurse, doctor or dietitian. Your loved one may be at risk for infection or may need to follow a very strict diet. In some situations, even normal bacteria in foods (such as uncooked items like fruits or salads) or excess nutrients (such as those containing vitamin K, or unknown substances like gluten or allergens) can be dangerous.
  • If you get the OK to bring food in, make sure you prepare food safely. The Department of Agriculture has excellent information on their website about food safety for people who are vulnerable to infection. Throughout the steps of food preparation, it’s important to follow the mantra:
    • Clean. Wash your hands, utensils and cutting boards before and after contact with raw meat, poultry, seafood and eggs.
    • Separate. Keep raw meat, poultry and seafood away from foods that won’t be cooked.
    • Cook. Use a food thermometer — you can’t tell food is cooked safely by how it looks.
    • Chill. Refrigerate foods within 2 hours and keep the fridge at 40 F or below.
  • Bring only enough food that can be eaten at one time. Consider single-serve items, such as individual yogurts, packages of crackers and peanut butter, and wrapped cookies. That way there are no leftovers to worry about.
  • Don’t store perishable foods in the room. In addition to being unsafe, they can be unappetizing.
  • Label all food items. Put the name of your loved one on the food container and the date that the food was prepared. You don’t want your kind intention causing problems for another patient.

This set of policies and the write-up might benefit from a review by patients and their families. Critically, patients and their families should know when food can be brought to recovering patients. Otherwise there might be “deadly consequences” of starving older patients by not feeding them food that they like and are used to eating.

Nelson, J., Zeratsky, K. “Play it safe when taking food to a loved one in the hospital.” Nutrition-wise blog. Mayoclinic.org 28 March 2012. Web. 10 Aug 2014.

Parking policy discussions

At Patients Canada, we try to find very clear and concrete changes that might make the patient experience better. We develop these ideas after listening carefully to the many experiences that patients and families have when they encounter the health care system. Over these last few weeks we have been talking about parking. We pointed out that there was a very big difference between the views of providers and patients about the place of parking policy in health care. We noted some strong opposition to parking charges presented in the Canadian Medical Association Journal, which claimed that charging for parking violates the Canada Health Act because it means health care is no long free at the point of delivery. We noted that although parking is a miniscule part of the hospital budget, it is considered to be an important source of income because it is free of governmental or other restrictions, and allows for a greater flexibility in its use. Some patients do not object to high parking costs because they see them as a contribution to the good work of the hospital.

But still for many patients, parking costs are inordinately high and a significant cost associated with long waits in the emergency room or an appointment to see a specialist or visiting an inpatient. There are lots of ways to reduce the burden of parking in these cases.

Free parking

The most obvious way is the one adopted in Scotland and Wales where parking is free. In Canadian hospitals, this could easily be associated with voluntary donations for parking if people really wish to donate to the hospital. A major donor might be asked to donate to a fund that would provide free parking for all. The parking structure might be named after such a donor who would be appreciated by all those who park in her building. Various modalities can be introduced to decide who to charge for parking and who should get it as part of the hospital service. These discussions of hospital policy might by themselves be instructive and a useful basis for moving forward. In our discussions, we have come up with some ideas, for example: if an emergency room visit takes more than a designated time, free parking chits would be given to patients. These can be paid for from the emergency room budget, or the ER doctors’ joint budget or some other source relevant to ER funding.

Valet parking

In some hospitals, valet parking is offered at a slight fee to a patient with mobility issues so that they don’t have long walks to their appointments. This is an example of making the parking experience better for patients. Another similar service might include providing such valet services at the door of the Emergency Department so that accompanying family members can be right there when the sick person comes in to register.

Subsidized parking

Most hospitals and long-term stay facilities offer reduced rates for parking if there are going to be regular visits over a period of time from family members or others close to a patient. Often this practice is not well enough publicized. In the USA, specialists offer parking chits to their patients. Can this happen here? Might it relate to waiting time before the visit?

As you can see, there is no shortage of ideas about parking. We encourage you to write to us with your ideas of how parking policy can be improved.

A designated parking space for moving in to long-term care

At Patients Canada, patients and those close to them partner with health care providers and others to help improve patient and family experience.

We always begin by receiving and listening to the experiences that patients and families have. In the last several blog posts, we spoke about parking as a good example of a policy area that can have a great impact on our experience with health care. In this post, I’d like to share an example of a change that happened as a result of hearing about such experiences and then working together with Baycrest Centre for Geriatric Care to make its policies more patient-friendly.

The day of moving in to a nursing home is a particularly stressful time for a family. Ordinary house moves are considered to be among the most stressful times in anyone’s life, but the move into a long-term care facility is even more traumatic for the new residents and their spouses and children. Often the processes put in place for nursing homes admissions can add to the difficulty of this transition. At one point in time at Baycrest, the requirements for moving in a few pieces of familiar furniture to make the new room more home-like made things difficult. It was necessary to call at least three days in advance to make an appointment at the loading dock at the back of the complex. Once there, Baycrest provided no cart and no further help because of insurance concerns. It was also required that the freight elevator be used to bring the furniture to the floor.

This procedure had evolved over some years as a result of multiple efforts at cost control and risk reduction. It had not been developed with any intention of making life harder for people moving in. It responded to a whole series of problem cases, such as equipment breakdowns and demanding families. Baycrest, like most institutions, has had many cost containment exercises and the lack of help might have emerged from one of them. The requirement to move furniture without any help from the institution was further complicated by the lawyers’ instruction not to give out the names of short-term light moving companies that were familiar with the facility. No doubt, this was to avert any liability should something go wrong.

Here was a process that was obviously unfriendly to new residents and their families. When it was brought to the attention of senior staff, they agreed that this was “low hanging fruit” and could be an “early win” for the process of improving resident and family experience.

A series of meetings over several months resulted in changed policies that were not significantly more costly nor more risky and vastly improved the experience of new residents and their families. They decided that families would be given the names of light moving companies if they need help moving furniture into the resident’s room. If they wanted to do it themselves, a designated parking spot had been created at the front door for families who were helping a new resident move in. And residents and families were able to call in advance to get the help of a porter.

We can suggest that this policy or one like it can improve a somewhat traumatic experience by recognizing the need to help new residents and their families to easily move their clothing and small pieces of furniture into their new home.

The more general lesson is that changes in small policy areas like these can make a big difference to people and their experience within the health care system. If you have experiences to share or would like to help design them get in touch with us at www.patientscanada.ca.

Rethinking visiting hours

We can see that parking policy should be developed in partnership with patients. Hospital visiting hours are a similar issue. We can trace some of the changes in patient-oriented policy as hospitals become more patient-friendly by looking at policies about visiting hours.

In the early days of the modern hospital, visiting was discouraged. In the comprehensive manual from 1913, The Modern Hospital, the authors are very clear:

We may begin with the flat argument that it would be best for all sick people if all visiting could be prohibited and it is a recognizable situation in nearly every hospital that has visiting days that the temperatures are higher at night on the visiting days than at other times, all else being equal, and this is due to the excitement caused by visitors, not alone one’s own visitors but those who come to see other people…

In considering the visiting question, therefore, we have two or three fundamental ideas in the foreground; one of them is that we ought to restrict visiting as much as possible and we ought in any event to limit visits to the one patient whom visitors come to see. And visits should be as short as possible and whenever it can be done each patient should be restricted to one or two or at least a minimum number of visitors. (Hornsby, Schmidt 490)

In the old days, visiting hours varied by class of patient. Charity (free) patients had severely restricted visiting hours, often limited to a few hours every week. For example, visiting hours for the Children’s Department are listed:

Large (free) wards, 2 to 4 pm Wednesday and Sunday

Small (private ) wards: 1 to 8 pm daily

Private rooms: without other limitations than the order of attending physicians. (Hornsby, Schmidt 340)

Times have changed. Today there is a recognition that patients can benefit from visits, and typically visiting hours have been much extended. Nonetheless there are usually restrictions imposed that vary widely from unit to unit. Restrictions can make things difficult especially if one is trying to stay to support an elderly relative or stay close to a very sick friend.

A recent article in the New York Times describes the view of the Institute for Patient and Family Centred Care (IFPCC) which is to lift all restrictions on visiting hours. They point out that, increasingly, families and those close to patients can play a crucial role in their care. Beverley Johnson, the President of the IFPCC says, “People should go to a hospital with a family member or trusted friend to be an advocate, to ensure continuity, to answer questions and prevent errors.” The article in the New York Times goes on to explain that,

Because she was with her centenarian mother in a Florida hospital, for example, she could explain to a doctor who had never met either of them that that no, her mother did not have a pacemaker, and perhaps he had confused her with a different patient. (Span para 8)

The IFPCC argues that if hospitals do want to partner with patients and their families, it will be important to begin to lift restrictions on visiting hours as a matter of policy. As Johnson says, “You can’t partner with families if you’re locking them out of the hospital, especially when patients are most vulnerable” (Span para 4). We agree that policies about visiting hours should be reviewed with this in mind.

Hornsby J, Schmidt R. The Modern Hospital. Philadelphia, Pennsylvania: W. B. Saunders Company; 1913.

Span, Paula. “A Move to Extend Visiting Hours at Hospitals.” The New York Times. Web. 11 July 2014.

Parking policy from the patient and family perspective

Last week we started to identify some policies that are meant to improve patient experience in health care. Parking costs are a good example of a policy area that is of concern to patients, but one that they are usually excluded from. It’s also a policy area that rarely enters the minds of providers as a factor in patient-centred care.

Parking policy is not central to the range of hospital concerns, but in my experience, discussions about parking take up quite a lot of administrative time – both in terms of privilege (who gets to park where) and cost (how much do we charge employees, patients, doctors, etc.) This is so even though hospital parking does not provide much more than 0.25% of hospital income. As patients begin to participate in health care, this is a pretty straightforward area to redesign with patient input.

We are not alone in this. An editorial from the Canadian Medical Association Journal in January 2012 brought the perspective of some doctors to the issue:

A patient who seeks care in a Canadian hospital has to pay for parking. Parking fees amount to a user fee in disguise and flout the health policy objective of the Canada Health Act… Parking fees are a barrier to health care and add avoidable stress to patients who have enough to deal with. They can and sometimes do interfere with a clinical consultation, reducing the quality of the interaction and therefore of care. Almost every hospital doctor in Canada would be able to narrate anecdotes of patients being preoccupied with parking fees. Such distraction interferes with the clinical consultation. For example, some patients (who have often waited several weeks to see a doctor) try to end a consultation abruptly when they realize that they will have to pay for an additional hour for parking. This is parking-centred health care, which is not compatible with patient-centred health care (Kale).

The editorial goes on to expand the argument about the impact of high parking costs on the doctor-patient interaction. It argues against the resistance of hospital administrators:

Hospital administrators and politicians will argue that they will lose a valuable source of essential revenue if parking fees are abolished and will look to ministers to make good such losses. Though hospitals rake in several million dollars from parking fees, the net revenue from parking is likely to be around 1% of the total revenue. For example, for The Ottawa Hospital, for the fiscal year 2011/12, the net parking revenue is projected at $10.8 million while the total revenue is about $1.16 billion, excluding revenue from parking. That is a small sum to pay to get rid of parking-centred health care (Kale).

A comprehensive study at by the Centre for Health Economics at York University in England concludes:

Donabedian (1973) defined accessibility to health care as “those characteristics of the resource that facilitate or obstruct use by potential clients.” Travel, parking and time costs, both monetary and non-monetary, are one such characteristic. Microeconomic theory predicts that the price of access will affect the level of demand (utilisation by patients or visits from friends or relatives) if access is price-elastic (or cost-elastic). The empirical studies reviewed here provide some support for view that access levels by visitors are sensitive to cost, but the review found no evidence on the relationship between monetary access costs and uptake of hospital services by patients…

The majority of patients attending for outpatient appointments use cars to access the hospital. In England, parking charges vary geographically and the parking experience can sometimes be an additional source of financial pressure, worry and stress (Mason 11).

The report recommends that hospitals be encouraged “to do all they can to make the parking experience a good one” (Mason 11). At Patients Canada, we agree and suggest that a critical component of this effort is to partner with patients to co-design improved parking policies from the patient and family perspective. Patients and families have had both good and bad experiences with parking that can help inform parking policy. Some clear examples concern costs: the cost of frequent use by family members of long stay patients, the high cost of lengthy emergency room visits, costs that deter visits by friends to inpatients, and so on. Another concern is way-finding: the difficulty of getting from the visitors’ parking lot to the part of the hospital to be visited and at times, the great distances involved. Yet others are about the lack of easily accessed information about hospital parking policy: patients and families are often unaware of existing policies that might make the experience of parking easier and less costly.

On Saturday, the New York Times reported that hospitals are extending visiting hours and in some cases, removing restrictions on visiting altogether (Span). This is a significant change that is being advocated by the Institute for Patient and Family Centred Care. It will allow friends and family members more access to patients who can benefit from their company. The impact of this change in visiting policy on parking will make it even more critical to review parking policy. The experience of patients and those close to them can make important contributions to the development of patient-centred policies throughout health care. We will continue our discussion in upcoming blog entries.

Kale, Rajendra. “Parking-centred health care.” Canadian Medical Association Journal 184. 1 (2012): 11.

Mason, Anne. “Hospital Car Parking: The Impact of Access Costs.” Centre for Health Economics, York University CHE Research Paper 59 (2010).

Span, Paula. “A Move to Extend Visiting Hours at Hospitals.” The New York Times. Web. 11 July 2014.

Patient developed health care system

Several weeks ago I wrote that according to the World Health Organization’s definition, we do not have universal healthcare coverage in Canada. I also said that as far as I could tell, we are the only country in the industrialized world that does not have universal coverage. The example that I used was that we do not have coverage for prescription drugs administered outside the hospital. But there is lots more that we don’t have and also some things that we do have that show how limited our system really is.

The reason for this limitation is largely historical. The Canadian publicly-funded health care system began with hospital insurance in Saskatchewan in 1947. We can be proud of that first step – we had hospital coverage a year before the NHS was created in England. However we were left behind once the far more comprehensive NHS was established in 1948. It covered hospitals, drugs, primary care, eye care (with the now famous NHS spectacles), dentistry, and a lot of diverse health care in the community. We never caught up.

Our limited system developed from hospital coverage in Saskatchewan and then for all of Canada in 1961. It was only in 1972 that all provinces provided coverage for doctors. That is where we seem to have stopped – we still do not have national coverage for all those other things covered by the NHS.

A little over ten years ago, I was asked by the researchers for the Romanow Commission to write a description of what a well-functioning health care system in Canada would look like. Brenda Zimmermann and I toiled for months on our paper which was well-received and is still widely referred to. It has since occurred to me that it would be a good idea to develop the specifics of what a well-functioning Canadian health care system would look like from the patient’s point of view. What would the policies of our system look like if patients were to lead us toward a system with universal coverage?

In our paper, Brenda and I used the now widely quoted basic requirement for a well-functioning health care system that: “It should be there for you when you need it.” What we meant was that healthcare should be a support for us in our anxiety and pain when we, or those close to us, are not feeling well. Its policies should encourage caring and generous support for us. We have a way to go to provide such a system at the moment, although lots of things can easily make it better. An excellent example of this, although seemingly innocuous, is parking.

PARKING

At an Open Meeting held by Patients Canada, we tried a new way of gathering peoples’ thoughts about health care services. We collected short phrases about three emergency rooms (ERs): the current state of the ER, the ideal ER and the ER from Hell. We also asked what might characterize each of them. The discussion was lively and everyone had brilliant ideas about what might constitute the emergency room in heaven and not surprisingly, some said that the current emergency room is the ER from hell.

Most everyone enjoyed the exercise and found it gave them a chance to work with others and provided lots to think about. Waiting times were not the only issue. Some more lateral-thinking participants pointed out that in heaven there would be no emergency room at all. If you needed hospitalization, you would go straight in. If you did not, you would be cared for by a community agency. Parking costs loomed high in many of the discussions. In fact, when we created the word clouds from the patients’ lists, the word “Parking” was among the most prominent. For patients, parking costs at emergency departments are an indication of the lack of generosity and compassion displayed by many hospitals. What patients need is reassurance that the institutions who offer care do so with a generosity of spirit that is evident in all their policies.

Below are some of the parking costs at major hospitals in Toronto, as well as the price for on-street metered parking near Toronto General Hospital for 30 minutes and one hour slots. There is no all-day street parking nearby. If you want to visit someone at the Hospital for Sick Children or one of the downtown hospitals and park in their facility, a one hour visit can cost $12.00 and if you go a few minutes over an hour, it will be $18.00.

ParkingWe repeated the exercise with providers at the Central West LHIN with a similarly enthusiastic response. This time there were about 100 participants. We collected their ideas and had volunteers help us to input the material to create another word cloud. Here, “parking” did not appear at all. The most prominent word was “doctor.” The skill and dedication of ER doctors and nurses is certainly critical to the quality of emergency medicine. Providers need the money offered by parking and do not recognize the impact it has on patients and their families.

Parking seems like an odd thing to begin with, but it is useful to show that patients bring a different perspective to policies than providers. It seems that in Canada everyone might want to think about what comprehensive coverage means. In England, there is now a fierce debate as to whether hospitals have the right to charge patients for parking. Comprehensive health care coverage should, according to many advocates, include the cost of parking. Charging for parking, they say, institutes a user fee for health care services.

In Canada, there are other problems with parking. When your relative is in an acute hospital, rehabilitation facility or a long-term care institution for any period of time, the costs of parking add up. What is on offer by many such institutions is a recognition of the extreme costs of daily parking by offering reductions to long-term users. Given the amount of care provided by such family caregivers, the institutions might reduce costs to the level of staff or even give a free pass (like they do to some volunteers), if relatives could guarantee that they are there providing free care and support every day.

The argument made for charging for parking is that it is a significant source of income for the hospitals. However the money might not be worth the impression it makes on us: it demonstrates a lack of generosity and compassion. From the patient point of view these are critical components of care.

A Canada day celebration of Canadian health policy

For the last few weeks I have been writing about health policy in Canada from the patient’s perspective and Paradigm Freeze, a new and interesting book that has a narrow view of the Canadian health care system and hence a somewhat limited view of what constitutes health policy. The selection of policy topics it studies leaves out the most significant policy document in the history of Canada, and one which has had a continuing impact on how Canadians perceive health and healthcare. It is, of course, the Lalonde Report.

The week of Canada Day seems to be a good time to speak about the Lalonde report, A New Perspective on the Health of Canadians. That we no longer think of health as a product of medical science, but rather as a consequence of a complex array of determinants, is in no small measure due to the Lalonde report. Its publication marked a rather rapid paradigm shift around the world concerning the nature of health and health policy. Soon after the report was issued an international movement began to think about health policy in terms of health promotion and overall health status. This resulted in international declarations like the Ottawa Charter for Health Promotion in 1986.

The Lalonde report is named for the then Minister of Health and Welfare, Marc Lalonde, but it was actually written under the leadership of Hubert (Bert) Laframboise, an Assistant Deputy Minister in the Federal Department of Health and Welfare, where he created a “free-wheeling think tank” with which to inform government policy discussions.

The ideas of Thomas McKeown about health and health policy formed the core of this new approach. In the UK the National Health Service (NHS) had been created with the belief that a universally funded health care system would improve the health of the population and eventually reduce the demand for health care. This hope was never realized, and perhaps it never could have met that goal. In this context McKeown’s central idea was that one had to go beyond standard medical services to improve the health of the population. Indeed McKeown’s arguments were a polemic against the view that medical care was a major contributor to improving the health of a population. He argued that the medicine of the day had mistakenly reduced the concept of health to a mechanistic explanation of the state of the human organism.

The approach to biology and medicine established during the seventeenth century was an engineering one based on a physical model.  Nature was conceived in mechanistic terms, which led in biology to the idea that a living organism could be regarded as a machine which might be taken apart and reassembled if its structure and function were fully understood. In medicine the same concept led further to the belief that an understanding of disease processes and of the body’s response to them would make it possible to intervene therapeutically, mainly by physical (surgical), chemical, or electrical methods.

For McKeown,  “the major contributions to improvement in health in England and Wales were from limitations of family size (a behavioural change), increase in food supplies and a healthier physical environment (environmental influences), and specific preventive and therapeutic measures.”

The Lalonde report identifies four major influences on health and speaks of them as constituting the “health field”. The table below describes the four quadrants of the health field.Lalonde report table

Here are some examples of policies that have increased Canadians participation in their own health

There is no question that the Lalonde report marked a paradigm shift in Canadians’ sense of responsibility for their health, however I am offering only a few examples of major change and looking at only one of the quadrants. (For a more complete account please look at Towards A New Perspective on Health Policy)

Exercise

At the time of the Lalonde report moderate exercise meant going to the gym three times a month. After its publication and the introduction of policies and programs that encouraged fitness training, like ParticipACTION, moderate exercise means going to the gym at least three times a week.

Nutrition

In 1974, Canadians ate red meat and few green vegetables. The Canada Food Guide had been dormant since 1961. A new Food Guide emerged in 1977 soon after the Lalonde report. It recommended less red meat and more fruits and green vegetables. Since then Canadians have significantly changed their eating habits for the better.

The Canadian Organic Growers organization was founded in 1975 immediately after the Lalonde report was published. At the time organic foods were sold in the back part of a very few health food stores, but now regulated organic food is now sold in every major supermarket in Canada.

Smoking

At the time of the Lalonde report 46.7% of adults in Canada smoked cigarettes. That number in 2013 was 19.3% proving that policies to reduce smoking have had a strong impact on smoking reduction. According to The Emperor of All Maladies: A Biography of Cancer, smoking reduction campaigns have had a far greater impact on cancer reduction than all the billions of dollars spent on cancer research.

These three sets of policies have had a major contribution to the changing mortality and morbidity rates in Canada. We no longer die in our 60s of heart attacks, of lung cancer and strokes. We live longer and are prone to longer chronic conditions. This is largely due to the paradigm shift that happened after the publication of the Lalonde report, something that I think is worth celebrating on Canada Day.

 

Health policy from the patient perspective: does Canada have universal health care coverage?

The last topic covered in Paradigm Freeze is prescription drug plans. The multiplicity of provincial plans in Canada ranges from complete to very little coverage to serve as a safety net. Here it isn’t necessary to follow the book to make a point from the patient perspective.

In recent years, the World Health Organization (WHO) has made a strong effort to encourage developing countries to provide universal health care coverage to their populations.

Universal coverage (UC), or universal health coverage (UHC), is defined as ensuring that all people can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship.

This definition of UC embodies three related objectives:

  • equity in access to health services – those who need the services should get them, not only those who can pay for them;
  • that the quality of health services is good enough to improve the health of those receiving services; and
  • financial-risk protection – ensuring that the cost of using care does not put people at risk of financial hardship.

Universal coverage brings the hope of better health and protection from poverty for hundreds of millions of people – especially those in the most vulnerable situations (WHO).

It is clear from the definition and supporting documents that universal coverage includes not only hospitals and doctors, but also a wide range of health-related services that add to the cost of healthcare: prevention, therapeutic services, costs of access and so on. Prescription drugs are clearly a significant part of universal health coverage.

The Canada Health Act does not provide for universal coverage – out of pocket expenditures on health care has been increasing over the years. One of the consequences of this is that the cost to Canadians has grown significantly over the last few decades. The figure below shows that the burden of this falls mainly on the poorest part of the population who spend close to 6% of their after-tax income on healthcare (Government of Canada). This is largely on prescription drugs.

Figure 1In an investigation by CTV, it was found that the cost of drugs for cancer care is being passed on to patients when they can take these very expensive drugs at home (CTV). Having to provide for these expenses can impoverish patients and their families. This defies one of the main principles of the WHO’s definition of universal coverage. The story of one of our members is not atypical: the surprise at the pharmacy counter that comes when discovering the cost of cancer drugs outside the hospital; the slow realization that those costs will eat up the family’s life savings; the desperate search for other sources of funding; the disappointment with drug coverage by private insurance plans; and the threat of impoverishment because of the lack of proper drug coverage under medicare.

Which other major developed countries do not include prescription drug coverage in their publicly funded health plans? None. Now that the United States has the Affordable Care Act, Canada is alone among major developed countries in not having universal health care coverage.

WHO: What Is Universal Coverage?” WHO. Accessed June 12, 2014. http://www.who.int/health_financing/universal_coverage_definition/en/

Government of Canada, Statistics Canada. “Trends in out-of-Pocket Health Care Expenditures in Canada, by Household Income, 1997 to 2009,” April 2, 2014. http://www.statcan.gc.ca/pub/82-003-x/2014004/article/11924-eng.htm.

“CTV Investigates: The Cost of Cancer Care.” Kitchener. Accessed June 12, 2014. http://kitchener.ctvnews.ca/ctv-investigates-the-cost-of-cancer-care-1.1862427