Marika Warren and Kirstin Borgerson discuss a key obstacle to improving the Canadian health care system.
In late June, André Picard gave a presentation entitled “Inequality: Bad for our Health, Bad for Business” at the North End Community Health Centre’s first annual Advocacy Breakfast. As the public health reporter for the Globe and Mail, Picard is particularly skilled at bringing research data and patient narratives together. Some of the arguments he advanced are familiar, such as the economic argument for universal health care (we all benefit from having a healthy workforce). Others are less familiar and deserve more attention than they’ve received; we trace one such argument from his presentation and add our reflections on it below.
Picard identified a tendency for Canadians to feel relieved (and, frequently, morally superior) for having avoided the inequitable and inefficient American health care system, without acknowledging that our system lags behind many other health systems in the industrialized world on measures of quality, access, efficiency, healthy lives, and equity. What this persistent comparison does is entrench a complacency about the status quo in health care and encourage a tendency to think that the way to improve our system is to pump more money or health providers into it. But we don’t (merely) need more of the same in Canadian health care; we need thoughtful and strategic changes aimed at improving equity, access, and quality of care along with concrete recognition that most determinants of health have very little to do with health care (for example, the North End Community Health Centre is currently targeting child literacy in its activities). That’s not to deny that resources matter; rather it is to point out that additional resources distributed according to current patterns won’t fully address these shortcomings.
That said, Canadians are tentative about embracing new ideas. As Picard put it, “we love our pilot projects.” So our problem is often not one of knowledge per se. Picard gave several examples of pilot projects that have been successful in improving health but which have been shelved upon completion instead of being implemented on a large scale. One such example was aimed at reducing the number of repeat visits by frequent users of emergency departments. The project, which involved assigning dedicated staff to frequent users, significantly reduced the number of visits made to the emergency department and saved more than a million dollars in a single year. Yet once the pilot project was completed, things reverted to the way they were before. So the problem is a lack of political will in moving from pilot project to policy, not a problem of insufficient evidence.
Health research is certainly valuable, but given the tendency described above to shelve the results of pilot projects, an important question for funding bodies and research ethics boards to ask is whether research bridges the gap to implementation. Evidence abounds regarding how to reduce the burdens inequality imposes, so the ethical challenge is around how we close the gap between how we know people should be treated (particularly by health systems and policies) and how they are treated.
In his closing remarks the Executive Director of the North End Community Health Centre emphasized the importance of listening to community members, and acting on their advice even when the evidence isn’t in yet. In fact, the North End Community Health Centre was held up as being particularly good at responding to community needs. Given its successes (and those of similarly structured health centres), it isn’t clear why the community health centre model hasn’t been implemented more extensively across Canada. Instead of being used as a model for primary health care delivery, community health centres are treated as specialized healthcare for marginalized populations. This is a clear case of knowing what works without acting on that knowledge.
The key message we took from Picard’s talk was, in essence, “less talk, more action, and we’ll all be better off.” Any proposed solution to our health care problems must coincide with the political will to act on what we know about how to provide the best possible care to Canadians. To sum up, the challenge to politicians, policy-makers, and researchers is, in the immortal (and catchy) words of pop artist Sara Bareilles, “Honestly… I wanna see you be brave.”