Category Archives: Aging Population

A Five-year Plan for the NHS

Several weeks ago, Simon Stevens who is head of the English National Health Service (NHS), published Five Year Forward View. The report details his plan for the NHS, and it’s well worth a read because it is remarkably relevant to the Canadian context.

He describes a context that is quite similar to ours: an aging population with multimorbidity as the major epidemiological feature. The excellent hospital sector and well-developed primary care network of general practitioners is not adequate or entirely appropriate for the population served by the NHS.

He recognizes that there must be a “radical upgrade in prevention and public health”  (NHS 9). The failure to do this in the last decade has resulted in “a sharply rising burden of avoidable illness” (NHS 3). In Canada, the weakness of public health initiatives has been marked by similar increases in obesity, diabetes and other preventable conditions.

Secondly, he sees that patients must “gain far greater control of their own care – including the option of shared budgets combining health and social care. The 1.4 million full time unpaid carers in England will get new support, and the NHS will become a better partner with voluntary organisations and local communities” (NHS 3).

This is clearly what must happen in Canada too, but there are few policymakers here who have such thoughts because of the severe limitations on the boundaries of our healthcare system. The relationship between the system and voluntary organizations is pretty sparse, and the idea of giving patients and caregivers control over any funds for their care is certainly not top of mind. It is time to include patients and family caregivers in discussions about their perceived needs and consider new ways of providing funds to meet them.

Thirdly, the document argues that:

The NHS will take decisive steps to break down the barriers in how care is provided between family doctors and hospitals, between physical and mental health, between health and social care. The future will see far more care delivered locally but with some services in specialist centres, organised to support people with multiple health conditions, not just single diseases. (NHS 3)

Importantly, he does not plan any structural changes in the NHS. Reforms will not involve changing the governance or boundaries of the many organizations that make up the NHS. It will include strengthening primary care, integrating access to a wide variety of services that will avert unnecessary hospital visits, and increasing the already abundant community services (which are notably sparse in Canada).

We recommend that policymakers take a good look at the document and consider how it might be applied in the Canadian context.

 

National Health Service. Five Year Forward Review. England: National Health Service, 2014. Web.

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Canada’s Healthcare System Today: A Need for Change

About 40 or 50 years ago, Canada’s healthcare system was pretty good. These days it is no longer addressing the needs of Canadians so well. It still provides proper care for people with acute illnesses by way of excellent surgeons, well-trained specialists, and an increasing number of family practice professionals. But by and large, it is not very good at dealing with the four main causes of mortality today – cancer, heart disease, lung disease and diabetes, and the population that is most affected by them, those 65 and over.

One of the great successes of the modern era has been the dramatic increase in life expectancy. People in the developed world lived for an average of 35 to 40 years in 1850 (Reynolds). People born in Canada today can expect to live for more than 80 years (Statistics Canada). This increase is typically common knowledge.

What is less widely known is that the increase in longevity also brought with it an increase in healthy years lived. As late as the 19th century, most people over 40 suffered from one chronic condition or another. Many of these conditions were primarily the result of the infectious disease that they survived as children or young adults. Today, chronic conditions affect most people over the age of 65. So we can describe the improvement from 1850 to now by saying that we have an added 25 years of disease-free life. Of those over 65, 89% have been diagnosed with at least one chronic condition. And in fact, 25% between 65 and 79 years old report having four or more chronic conditions (Public Health Agency of Canada).

The causes of chronic diseases today are different from those of 1850: they tend to occur as a result of lifestyle, environmental or genetic factors, rather than earlier infectious disease. Also, chronic conditions tend to be diagnosed at an earlier stage. When medicare was introduced in Canada in the 1950s and 1960s, chronic conditions often manifested in their acute phase – heart disease as heart attacks, lung disease as cancer and so on, and they were treated in acute care hospitals. Today we diagnose these conditions far earlier. We can identify early stages of the four main chronic killers and we know that early diagnosis is very effective in slowing the progress of these conditions and even reversing them.

Unfortunately our system is not well-structured to keep people with early stages of chronic disease healthy. We do not provide the health education, systematic support for changes in eating habits, and exercise and lifestyle recommendations that would avert the slow development of these chronic conditions. The result has been a tremendous boon for drug companies. Because we have inadequate support in the community for helping people to deal with pre-diabetic conditions, high cholesterol counts, increased blood pressure or reduced lung capacity, our primary care system relies almost entirely on referrals to specialists and to medication.

The result has been that we have an overmedicated population that spends more than $900 per capita on prescription drugs (Lexchin and Gagnon). Another survey found that 76% of people over the age of 65 had taken a prescribed medication in the last two days (Ramage-Morin). We are second only to the United States in our consumption of prescription drugs.

In my next blog entry, I will describe services that are part of the National Health Service in England that have enabled the UK to keep people with chronic conditions healthier, avert institutional care for a longer time and have significantly less drug consumption.

 

Canada. Government of Canada. Statistics Canada. Life expectancy, at birth and at age 65, by sex and by province and territory. Ottawa: Statistics Canada, 2009. Web. 3 No v 2014.

Canada. Public Health Agency of Canada. The Chief Public Health Officer’s Report on the State of Health in Canada 2010. [Ottawa]: Public Health Agency of Canada, 2010. Public Health Agency of Canada. Web. 3 Nov 2014.

Lexchin, Joel and Gagnon, Marc-André. “CETA and Intellectual Property: The debate over pharmaceutical patents.” http://labs.carleton.ca/canadaeurope/wp-content/uploads/sites/9/CETD-Policy-Brief_CETA-and-pharmaceutical-patents_MG_JL.pdf. Oct 2013. 7 pages. Web. 27 Oct 2014.

Ramage-Morin, Pamela. “Medication use among Senior Canadians.” Component of Statistics Canada Catalogue no. 82-003-XPE . Health Reports 20.1 (2009). Web. 3 Nov 2014.

Reynolds, Neil. “Good news: life’s no longer short.” The Globe and Mail 19 Feb 2010. Web. 3 Nov 2014.

Policy from the patients’ perspective: needs-based funding

So far in this series on Paradigm Freeze, I’ve presented the various areas that the writers of selected for study. I’ve also focused on regionalization, as it became clear that the processes and consequences considered in the book were restricted to the boundaries of the current healthcare system and were especially focused primarily on acute care. The book appears to argue that it is hard to reform that system, but does not consider expanding or even significantly changing what the system contains.

The same appears to be true in their discussion of needs-based funding. For a long time, the funding for health care was historical: every year the budget for each health care organization was revised based on the previous year’s funding. The problem was that this funding model provided no basis for change or development, nor was it related to the changing needs of the population. The model of needs-based funding presented in Paradigm Freeze derives from an article called “The Financial Management of Acute Care in Canada” by McKillop, I., Pink, G.H., and Johnson, L.M. This article is concerned only with how hospitals are funded. Here is the main table that sets out the various types of “needs-based funding.” Note: Global funding is what we usually mean by historical funding.

Method  //  Description

1. Population-based:    Uses demographic or other characteristics of the population (such as age, gender, socio-economic status, etc.) to determine the relative propensity of different population groups to seek health services.

2. Facility-based:    Uses characteristics of the organization providing care (such as size of the organization, type of the organization, geographic isolation, occupancy rate) to estimate the cost to sustain a specified profile of cases and/or service volumes in the future.

3. Case Mix-based:    Uses a profile of cases and/or service volumes previously provided (such as a number of knee replacements, number of dialysis procedures) to estimate the cost to sustain a specified profile of cases and/or service volumes in the future.

4. Global:    Applies a factor to a previous spending figure (or to a forecasted cost) to derive a predicted spending level for an upcoming period.

5. Line-by-line:   Applies factors on an individual basis to previous cost experiences (or to forecasted costs) to derive a proposed funding level for each line item (such as housekeeping, inpatient nursing, etc.) for an upcoming period.

6. Policy-based:    Directs spending to address specific policy initiatives of the Department or Ministry of Health. These policy initiatives affect the operation of multiple organizations within the jurisdiction.

7. Project-based:    Flows funds to a single health service organization in response to evaluating a proposal from that organization for one-time funding, often for a major expenditure.

8. Minister discretion:    The Minister of Health decides on the specific dollar amounts to flow to health service organizations.

This is pretty comprehensive if we are looking only at what hospitals need. But it is not so good if you consider the health care system on a larger scale and the needs of people with non-acute long term conditions. It is especially not effective if we want to consider what such people need to stay out of hospital. During the study period of this book, we already knew that we had an aging population that could benefit from many health-related interventions apart from acute care and that it was generally a good idea to keep people out of the hospital. Therefore it seems really odd that Paradigm Freeze considers the health care system to be made up of hospitals and doctors and little else.

The result of this rather myopic view is that the study considers only provincial policies. It does not discuss the policy struggle between the health promotion community and population health researchers at the federal level. There is little doubt that this battle has important consequences for needs-based funding for health care in the broader healthcare system.

Health promoters were the offspring of the Lalonde Report, perhaps the most widely known policy document to emerge from Canada. In the 1970s and 1980s, they were a dominant force in Health Canada that instituted programs like ParticipACTION to encourage personal fitness, pressed successfully for anti-smoking campaigns, lobbied for and instituted seat belt legislation, reinstituted the Canada Food Guide which had been dormant since 1961, and initiated community development programs. Their loss of influence and funding meant that these and similar efforts slowed down and often stopped completely. ParticipACTION, for example, was disbanded in 2001 and only re-emerged in 2007 in response to the growing concern about inactivity and obesity.

Population health researchers derived their view from inequalities in health research in the UK. They argued that health promotion was an ineffective way of improving the health of the population – that it was important to consider the underlying causes of “why some people were healthy and others not” – that is to say, the underlying social and economic forces. The efforts of health promotion were considered to be ineffective in dealing with such disparities and some even argued that because they were largely focused on a middle class population, they actually increased inequalities in health. The population health group made up of health economists, demographers and health services researchers gained ascendency. Their mantra of reducing inequalities in health kept the focus on determinants of health over which individuals and communities had little or no control. Over the next decade it emerged that their control over the research agenda had very little influence on reducing inequalities in health through policy development. In fact, during their period of influence, inequalities have actually increased. Little wonder that current policy thinkers who emerged from that period should think that health policy has little impact on the system.

McKillop, Ian, Lina M. Johnson, and George H. Pink. The Financial Management of Acute Care in Canada: A Review of Funding, Performance Monitoring and Reporting Practices. Ottawa, Ont: Canadian Institute for Health Information, 2001. Print.

Technology helps patients assume a more comprehensive role in medical care

Over the last six months, there has been an extraordinary change in the role of patients in health care and we can hardly keep up. As little as six months ago, the question was, “How can we help patients gain a voice in health care?” We knew that patients should have a voice and that some organizations were beginning to introduce policies and committees to welcome that voice, but what has happened since has far exceeded our expectations.

In the New York Times on April 25, 2014, there was an article that described several devices that empower patients and families to be more involved in their primary care. There are now attachments and apps for smartphones that teach parents how to examine their children for earaches and determine by themselves, or with the online aid of their doctor, whether a visit to the doctor’s office is necessary. techWe already know that the cameras on some phones have become so sharp and clear that photographs of skin conditions can now be diagnosed by dermatologists online without any fancier technology. Now with the otoscope attachment and app, one can create photographs and even videos of the inner ear to check for inflammation. An otoscope is the tool that doctors use to examine the inside of your ear. The picture to the left is of the Cellscope Oto that is attached to an iPhone. Its app will allow almost anyone to examine the inner ear.

This visual otoscope is beginning to be used by doctors to help parents (and medical students) learn which conditions require medical intervention and which do not.

tech1The AliveCor is another recent device/app that allows your smartphone to monitor your heart and interpret the electrocardiogram (ECG). It can also send the ECG to your doctor. It used to be available only by prescription, but can now be purchased online for $199.

As these devices and others like them become more sophisticated and better able to interpret results, they will have a profound effect on the practice of medicine. There is already a website where your photograph can be assessed by a dermatologist for a fee. In the future there will be apps that will be able to crunch the data and do that assessment themselves.

The New York Times notes that this is a continuation of the trend for patients and their families to participate more actively in their own care. Apps are no longer merely ways of communicating with the doctor who has the necessary knowledge and skills to make the diagnosis and prescribe the treatment. Now these tools will enable patients and their families to diagnose the condition and decide by themselves if a trip to the doctor is necessary.

In Ontario, there has been quite a lot of leading edge communications technology to allow doctors to examine patients at a distance. Because of the huge size of the province there are enormous remote areas where there is no easy access to specialists (and other health practitioners). The use of high definition television and tools like the remote otoscope, have allowed doctors to examine and treat patients at a distance for a wide variety of conditions – everything from eye examinations to cancer treatment follow-ups have been done through the Ontario Telemedicine Network (OTN). In fact it has been a leader in medical care among countries with large remote populations. Some of its technology is already beginning to become cheaper and more widely available through smartphones.

At a meeting on April 21, 2014, with a representative of OTN, Patients Canada explored ways to use their technology to increase services not only for remote communities but for populations that find it difficult to travel in rural and even urban communities. Many housebound patients and their families have difficulty receiving services. This new technology can become a way of getting more services, improving continuity of care, and creating stronger partnerships between patients, family members and practitioners. At Patients Canada we have recognized that far more care in the community is needed not only for housebound patients, but for others who have some difficulty accessing the health system. It may be that these new technologies can help to change that by improving communications and enabling patients and families to take on more of the diagnostic role themselves.

Patients and the compression of morbidity

It seems to me that living longer isn’t all it’s cracked up to be. Roger Angell, writer with The New Yorker, has provided us with a wonderful, lively and very funny description of what it is like to grow old in this day of healthcare wonders.

His hand is deformed and he says, “if I pointed that hand at you like a pistol and fired at your nose, the bullet would nail you in the left knee. Arthritis” (Angell, par. 1). He goes on to describe his other infirmities including his stents, his artificial hip, the plastic cover for the hole in his heart, and macular degeneration. He concludes, “I’m ninety-three and I’m feeling great. Well, pretty great, unless I’ve forgotten to take a couple of Tylenol in the past four or five hours” (Angell, par. 3).

If we go back to the 16th century, people lived an average of 40 years, but some of them did live to a ripe old age. There were 80 and even 90 year olds as far back as that. Thomas Hobbes (1588-1679), the famous author of the Leviathan,  died at 91.  But he, like most people of his era, began to suffer from chronic disease far earlier – his palsy began in his early 60s and he could no longer write when he was 67.

Thomas Hobbes

Hobbes was an exception: in the 17th century, most people over 40 had one chronic disease or other – many of them as a result of being exposed to an infectious disease earlier in life. Robert Boyle (1627-1691), for example, survived a prolonged fever as a child and again as a young man, and following his second bout of fever was no longer able to speak with a normal voice or write, so that much of his opus was dictated to his various secretaries over his long life. John Locke (1632-1704) was forced to take long rests in the country because of his chronic asthma which flared up in the city. Barely 10% of the population survived past 40 and the vast majority of those who did suffered from one chronic condition or other. People who engaged in manual work, like farmers and sailors, rarely could continue to work after they turned 40, if they survived that long. And what we can tell from this great distance is that they all had serious chronic conditions if they were not killed by infectious diseases.

We might say that the great advance in our time is that today most people over 65 have at least one chronic condition. That extra 25 years may be more indicative of how we are doing than the absolute numbers.

All this is to introduce the topic of compression of morbidity.

In the 1980s, a stated goal of medicine was to keep people far healthier longer and to compress the period of morbidity before death. The idea was that modern medicine would allow people to retain good health and relatively full capacity before a brief illness and death.

Roger AngellRoger Angell’s story gives us a flavor of today’s reality. Since the 1980s just the opposite has happened: there has been a prolongation of morbidity. Standard indicators identify morbidity far earlier and begin treatment with powerful medications and surgical procedures that result in far higher numbers of people like Roger Angell, who live with diabetes, treatable cancer, hypertension, stents, titanium hips and other marvels for very long periods of time.

We have then to reconsider how we think about our objectives and how we provide healthcare to such a population. And to rethink what our objectives are.

Angell, Roger. “Life in the Nineties.The New Yorker 17 Feb 2014: Web.

Third class patients cost Ontario as much as $28.4 billion

In my last blog entry, I tried to describe the three classes of patients in the current healthcare system by referring to the Alberta’s Health Services Preferential Access Inquiry. The third class users were:

  • Rural populations;
  • Individuals without family doctors, particularly individuals with complex medical issues;
  • Individuals with addictions and/or mental health issues;
  • The poor;
  • The elderly;
  • Individuals whose first language is not English;
  • Those with hearing or vision loss or mobility issues; and
  • First Nations communities

The Inquiry acknowledged that these groups were given inferior access to the system, but that looking into this was not part of their mandate. (The list may not be complete, but I will add to it if anyone thinks that there are other groups who have inferior access.)

Inferior access to health care has serious consequences. In fact access to health care is taken to be one of the more critical social determinants of health. If people cannot see a family doctor, then they can more often than not gain access to health care through the emergency department. The groups listed above have poorer health than the rest of us; lower life expectancy, higher unemployment, and increased levels of institutionalization.

This week the Health Council of Canada released a report that looks at how the different provinces fare using measures developed by the Commonwealth Foundation in the US. Provinces are compared to each other, and Canada as a whole is compared to ten other developed countries including Australia, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States. The report gives us numbers about access as well as the health status of Canadians. According to the report, Canadians who have access to primary care doctors have their serious health problems managed well, but we rank last in our ability to get same day access to those doctors; second last in getting an answer to a question we ask them; third last in finding after hours care outside an emergency department.

In terms of our health status, 57% 0f Canadians have at least one chronic disease (the third highest among the eleven countries surveyed) and 31% have two or more. Arthritis, asthma and other lung diseases, cancer, mental health problems such as depression or anxiety, diabetes, heart disease, high blood pressure and high cholesterol levels are the chronic diseases they consider. We are among the highest users of drugs – 36% of us take two or more prescription drugs a day.

This information is best put together with the financial situation in Ontario: the top 5% of healthcare users consumed 58% of the healthcare $48.9 billion budget. By my calculation, these high users consume $28.4 billion. Let me repeat that – 28.4 BILLION DOLLARS! And the high users are almost entirely the third class patients we have described above. If ordinary Canadians have a high incidence of chronic conditions and also have some trouble getting same day visits and quick responses from their doctors, it is so much worse for the population with poorer access.

So here is something to think about. Ontario is spending a considerable amount of money. It seems pretty clear that if we better served third class patients before they are hospitalized, we might be able to avert at least a portion of that $28.4 billion.

Three Theories of Health and the Mortality Shift

The Mortality Shift that began in the 1850s and continues to this day in the industrialized world is marked by a constant increase in life expectancy at birth. For many centuries, life expectancy was about 35 years, while today it is between 77 and 85 years and rising in almost all industrialized countries. The table below is an example drawn from available data that shows the changes in life expectancy in the United States, Canada and the United Kingdom over the last 90 or so years despite depression and war.

The explanation for this change is still being debated.  I will review three of the main positions.

  • Increased life expectancy is primarily due to medical science
  • The increase is due to advances in public health
  • The increase is due to a complex interaction of many factors, primarily non-health

Each of these explanations has had a strong successive influence on health policy over the last century. In all of them life expectancy at birth has stood as a surrogate for the health of a population. The three views state that the changes are due to medical science, to public health and to a broad range of determinants of health. Let me briefly describe each of them.

Scientific Medicine Results in a Healthier Population

A strong argument was made for the impact of medical science on population health.  Many histories of medicine have claimed that the major scientific advances in medicine in the 19th century resulted in the dramatic reduction of surgical mortality through the introduction of ether in the 1850s, and the promotion of sterile operating environments by Joseph Lister in the 1860s. These innovations also helped to reduce infant and maternal mortality through more scientific childbirth with fewer infections, for both mothers and infants. The discovery of the causes of infectious diseases by Robert Koch and Louis Pasteur led to the development of vaccines that saved the lives and increased the longevity of large numbers of children. Finally, the introduction of penicillin and its widespread use during World War II confirmed the incredible contribution of medicine to a healthier and longer lived population.

The successes of scientific medicine in the late 19th century was probably the greatest influence in the development of our current healthcare systems which are built around hospitals, medical schools and research facilities.

Better Public Health is the Main Basis for a Healthier Population

The Miasma Theory of Illness was the theoretical frame for the Sanitarian movement led by Edwin Chadwick. It was falsely believed that foul smelling air and dirty water contained pollutants that caused diseases like cholera, typhoid fever, and even the Plague. Chadwick devoted a good part of his life to improving sanitary conditions in England, and in 1848 he succeeded in getting the first public health act passed in England. This was followed by the construction of new sewer systems for London and other cities in the late 1850s, and the passage of a much stronger public health act in 1875. Many current public activities like the development of policies related to food inspection and labelling, anti-smoking legislation and so on are in that tradition.

Advocates for increased public health have argued that these and other public health measures were more responsible for a healthier longer lived population than medical interventions. This view was one of the bases for the Lalonde Report which led to great changes in public policy and population behaviour in the 1970’s and later. Today, many argue with some justification that anti-smoking legislation has had a greater impact on the reduction of cancer and heart disease than the billions of dollars spent on medical research.

The Social Determinants of Health Argument

More recently scholars of the Mortality Shift have argued that the most cogent explanation for the great increase in life expectancy was that the period that began in 1850 was one where general prosperity led to increased earnings and better living conditions for large numbers of people in the developed world. Although medical care and public health measures did contribute to a healthier population, both were less critical than improved housing, better working conditions increased education and similar factors that resulted in people living longer.

Advocates for the social determinants of health view argue that there is good evidence that tuberculosis was decreasing as a result of less crowded housing well before medical intervention began, and that the reduction of mother and infant mortality was on the decline because of better maternal nutrition. Holders of this view also believe that healthier populations have greater income equality. In many countries income disparity was reduced during the period of increasing life expectancy. However, income inequality has been increasing for the last 40 years without any reduction in life expectancy. Many who hold this view are beginning to think that life expectancy at birth may not be such a good surrogate for the health of a population.

My next blog will focus on how our health care system came to be.

How normal aging has changed

Here is the bad news.  As we age our bodies change: our skin becomes less elastic, our hair thins, we lose as much as two inches in height by the time we are 80, we lose muscle mass, and some of the mineral content in our bones. Our senses become less acute: most of us need glasses by the time we are in our 40s, and it becomes more difficult to hear the high-frequency sounds of human speech. We sleep less long and not as deeply. Our metabolism slows and we need less food. Our brains become smaller with less blood flowing through them; some memory loss is normal. Our organs also change: most of them become less efficient and more vulnerable to extremes of activity or diet.  Male sexual response times slow and women stop ovulating. The pace of aging varies not only because of differences in one’s genetic makeup but also because of income, social status, education and many other determinants of health. Heart problems, arthritis, lung disease, chronic digestive issues and their associated problems are much more common as we age. Dealing with such conditions is a significant part of the normal aging process.

There are many ways in which the health status of humans has changed over the centuries. For example, we know that for many centuries life expectancy at birth was between 30 and 35. There was a very high rate of infant and child mortality. Many deaths were due to infectious diseases – typhoid fever, cholera, small pox among others. In fact, if you lived to the age of 20 your chances of surviving to 60 were pretty good.

The critical point for me is that in previous eras almost everyone over the age of 40 had one or more chronic diseases.  For example, while doing some work on seventeenth century philosophy and science, I found that many of the famous philosophers and scientists of the time, such as John Locke, Robert Boyle and Thomas Hobbes, all suffered from chronic diseases from quite early on.  Many of these conditions were the consequence of infectious diseases that they had survived as children or teenagers. By the time they were 40, they and their peers were considered to have entered old age. Still death was not usually a result of chronic conditions – at all ages the greatest risk of dying was from the big killers, like cholera, tuberculosis, and other infectious diseases.

A great shift in mortality began in the industrialized world in the middle of the nineteenth century.  Longevity was increasing and many of the diseases of aging were starting later in life. Today, we hear that “60 is the new 40.” And it is. This rapid increase in life expectancy is continuing, as is the delay in the onset of age related morbidity. One can describe the changes of the last several centuries in terms of this delay of the onset of the diseases associated with aging.  If in the 1600s almost everyone over 40 had one or more chronic diseases, now almost everyone over 65 is affected.  If old age began at 40 in the 1600s, we can say that it now begins at 65.

Some of the main features of the mortality shift are the reduction of maternal and infant mortality, and the elimination of many communicable diseases. Infant mortality in the developed world has dropped by almost a hundredfold from more than 10% to almost 0.1% over the last 150 years.  Maternal mortality which was about 500 for every 100,000 births is now about 12. Deaths from diseases like small pox, cholera, typhoid fever tuberculosis and other communicable diseases have virtually disappeared in Canada and other developed countries. The recent WHO atlas of morbidity tells us that in Canada 89% of deaths are due to non-communicable chronic diseases. Competing explanations of the Mortality Shift have greatly impacted health policy, some of which I will review in the next blog.

How should a healthcare system respond to an aging population?

We all agree that the population of Canada (and of other industrial countries) is getting older. People are living longer and the birth rate is dropping. As a result, the average age of the population is rising. We have long recognized that our society must make adjustments for this change and we have introduced some effective economic and social policies to avert the impoverishment of our older population; however, our healthcare system has responded less well to this demographic change: despite the fact that they have become the heaviest users of the system, the system has, if anything, become less friendly to them and their caregivers.

There is a great disparity between the different responses to an older population. The social and economic responses have been relatively strong and the healthcare response has been disappointing. What are some of the indications of this disparity, and why is the disparity so great?

It is economically easier for people to live after retirement because we have been encouraged to save for old age through both mandatory and voluntary pension contributions; we have increased the age of retirement and, in some cases, have eliminated mandatory retirement altogether for people who want to continue to work. We also have more developmental support, and educational and leisure services for older people. These economic and social adjustments have occurred over a long period of time with both positive and negative outcomes that affect not only older people but the rest of the population as well. For example, the disappearance of mandatory retirement and increased longevity has made it more difficult for young people to enter certain parts of the works force; the increased wealth of the elderly has created the first generation of relatively independent older people who do not have to depend on their offspring to support them economically in their old age. This is evident in some of the statistics on the economic status of older people:

1. The fastest growing segment of the population are the over 85s

2. People over 65 have the lowest debt load of any segment of the adult population

3. In recent years the largest increase in debt has also been of the over 65s as they are increasing their expenditures

It is at first somewhat puzzling how poorly the healthcare system has accommodated to an older population. We know that older people have very different health need, particularly less dramatic intervention and more support. However, many of the conditions associated with aging have been characterized as diseases, even though a large number of them are in fact a natural consequence of getting older, rather than the result of a particular pathology. As a result, healthcare services appear to remain quite narrowly focused on hospital and specialist care, and in some cases people must have an acute episode before any serious consideration is given to their care. Families faced with aging parents have great difficulty in finding services that suit their needs beyond the most basic medical and nursing care; suitable supports for aging in one’s home still require great effort and remain hard to come by.

A great proportion of Canada’s healthcare dollars are spent on a relatively small part of the population – elderly people who are kept in acute hospital for long periods of time because of inadequate long term care. Once discharged this group of patients are often at high risk of returning to hospital frequently in a kind of revolving door syndrome. In Canada it has been determined that 5% of the population uses something like 20% of the funding for healthcare, and this group of elderly people are a large part of that population. In the United States there is a similar problem of mostly older people who return to hospital within 30 days of discharge, which means a great deal of energy is being focused on this population. The objective is to improve their transitions of care to keep them out of hospital once they are treated, and so far there has been no great and clear success in these efforts.

At Patients Canada we think that this problem has deep roots and we are exploring it slowly. We think that much of the problem is related to the kind of healthcare system we have created, to its focus, the kinds of strengths it has and how resources are allocated to it. I’ll continue to review these issues in the coming weeks and I encourage anyone interested to add their feedback or comments.

Health Care in Canada, 2011

January 2, 2012 – Today I received Health Care in Canada, 2011: A Focus on Seniors and Aging from the Canadian Institute for Health Information (CIHI). The report considers the health status of Canadians and recognizes the growing need to provide more ongoing support for people with chronic conditions. It declares that 48% of people aged 45-64 and 76% of people over 65 reported at least one chronic condition. “With increasing age the likelihood of having at least one chronic condition also increased” (19).

Access to health care was more closely correlated to the number of chronic conditions that people have than to age. And self-reported poor health status was similarly correlated with the number of chronic conditions. In 2009, 74% of seniors with only one chronic condition reported good self-perceived health, compared with only 27% of those with four or more” (19).

The report concludes that “Preventing, delaying or reducing the severity of chronic conditions may not only enhance quality of life as people age, but likely also help ease demand on limited health care resources” (20).

A health care system focused on acute episodes is not the right kind of system to care for a population that is suffering from long-term chronic conditions. For one thing, it is clear that patients must participate in their care far more than they do in such a system. We believe that they must become active participants not only in their actual care, but also in redesigning services to deal more effectively with chronic conditions, and in governing a system that responds more appropriately to the actual morbidity of the population.

There is a related report on Health Care Cost Drivers that supplements its annual report and can also be downloaded from the site as well.