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.
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.
We 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.