Michael M. Rachlis MD MSc FRCPC
Double, double: the National Health Council causes lots of trouble
(Published in the Winnipeg Free Press July 24, 2003)
Two weeks ago, the Premiers shared surf and turf on PEI, the postcard province. As usual, they agreed to disagree. First they agreed to disagree with the federal government. They concurred that the feds have too much money and too much power. Then they agreed to disagree with each other. The highest profile controversy concerned the proposed National Health Council. Alberta's Ralph Klein and Ontario's Ernie Eves said they would not cooperate with such a council. BC's Gordon Campbell and Quebec's Jean Charest were also unsupportive. Saskatchewan's Lorne Calvert said if it were up to him, the council would already be conducting business. Manitoba's Gary Doer also said he liked the idea. Adorned with sackcloth and ashes, the council's advocates haunted the meeting. Like MacBeth's witches, they portended doom for those who did not heed their prophecies.
But, is the proposed council Medicare's saviour or an unwarranted intrusion into provincial affairs? And, what can be done to safeguard Medicare if the four largest provinces refuse to cooperate with the federal government? Or, is this just a temporary tempest until heir apparent Paul Martin takes the throne and presides over a pan-Canadian lovefest?
For starters, the Council is not a new idea. The Department of Health Act of 1919 provided for a 'Dominion Council of Health' which would facilitate co-ordination with the provinces, and was to be the principal advisory agency to the Minister of National Health and Welfare. Membership was to include deputy ministers as well as external representatives from health groups, women’s organisations, labour, and agriculture.
Many Canadians still think administering health care amounts to little more than ensuring there is a doctor available to see patients. But, over the last three decades, students of health policy have realized that even the best doctors cannot achieve excellence in health care without effective organization. Embedding doctors in teams greatly improves access and quality. Centralized management of wait lists can decrease delays by 70% or more. Since 1993, seven drugs have been introduced into North America and then withdrawn from the market after contributing to over 1000 deaths. Little wonder that from Romanow to Rome, government health care commissions recommend better management and using new money to, "buy change".
Unfortunately, Canada's unique dysfunctional confederation has hamstrung attempts to implement more effective management structures. England is a unitary state with no troublesome provinces. The Department of Health sets overall policy. The Commission for Health Improvement measures the performance of regional health authorities and primary care trusts. The National Institute for Clinical Excellence assesses new drugs and other technologies. The Modernization Agency facilitates continuous quality improvement.
Canadians often think the American federal government is weaker than ours. After all, the Americans believe in 'State's Rights'.
The American federal government pays for and unilaterally sets the rules for their Medicare program, which covers the elderly and certain other groups like kidney dialysis patients. The federal government also sets most of the rules for private health insurance. The National Institute of Medicine provides expert professional advice from doctors, nurses, and scientists. The Food and Drug Administration is responsible for the assessment of drugs and medical devices.
Concerns about a system 'out of control' have been brewing within a growing Canadian political consensus that neither the provinces nor the feds can be trusted to protect Medicare. Quebec and Alberta question Ottawa's right to enforce the Act. According to Auditor General Sheila Fraser, the federal government doesn't even have the information it needs to monitor whether the provinces are adhering to the Canada Health Act. The feds are moving so slowly that some suspected infringements have been on the books for nearly twenty years. Holy molasses in January, Batman!
The large provinces also reject the Ottawa's authority to target funds to national priorities. The September 2000 federal provincial agreement targetted 7% of the spending to new medical equipment and primary health care. However, some provinces used the high-tech funds to buy lawn mowers. Initially the feds wanted five criteria for primary health-care pilot projects, but the provinces forced them to fund projects if they met only one.
Having participated in these shenanigans as a premier, Roy Romanow recommended the majority of the new money be targetted. Romanow also bought the argument of the health groups about the Council. He recommended a muscular version, which would act at arm's length to government and incorporate the existing resources of the Canadian Institute of Health Information (CIHI) and the Canadian Coordinating Office for Health Technology Assessment (CCOHTA). Romanow said it should also take on additional mandates for performance measurement, the development of implementation strategies for health human resources and primary health care reform, and facilitating public input into policy discussions. If this weren't enough, Romanow also foresaw an important role for the Council in fact-finding and mediation of Canada Health Act disputes between Ottawa and the provinces.
Romanow saw himself as the artist of the compromise. Unfortunately, the provinces saw the Royal Commission as simply Ottawa's opening gambit of a new chess game. Once the premiers got through with it, the Council was on a serious reducing diet. The February 2003 dis/agreement forced the council to report through the country's health ministers. The Premiers restricted its role to monitoring and reporting on the implementation of the new agreement.
By last week, even this trimmed-down mandate was too much for some. Premier Klein said Alberta would take no part in such a council and would establish its own. Premier Eves also backed away. He's playing political football with Ottawa on SARS compensation and the Council was convenient pigskin. Last week, anonymous staffers in Chretien's office leaked rumours to a reporter that the Prime Minister would appoint the council anyways, starting with a coalition of willing provinces. One nameless official noted that Klein was receiving federal money from the agreement and, therefore, had to live up his obligations to support a council.
At this point, should Canadians take to streets to advocate for the council or relax now that it is further from the horizon? It would be useful first to list the work, which needs to be done and then identify the appropriate body to perform the tasks. For example, the federal government does not need a Federal Provincial Territorial committee to tell it how to enforce its own legislation. Like the apocryphal villages that Grigory Potemkin used to fool Catherine the Great, the Canada Health Act is a mere shell. The Act is presently difficult to enforce because most of the needed regulations were never written. Ottawa can and should write regulations and enforce the Canada Health Act.
Some potential mandates are in conflict with each other. Reporting and assessing performance requires a tough cop who enforces the rules. Facilitating quality improvement requires an entrepreneur who knows when to break the rules. Assessing technology requires a scientific obsession with the truth. Just as one would not run a Clydesdale in the Queen's Plate, one should ensure that any organization has the right structure for its proposed function. The council's advocates are very innocent indeed if they think that one organization could ever carry out so many diverse mandates.
Ottawa could engage willing provinces in establishing these new organizations. As Mr. Romanow noted this week, it took three years after the first province signed up with the 1960s Medicare legislation before all provinces joined. The six smaller provinces have little ability to take on the tasks, which are necessary to modernize their health systems. If the federal government worked with them and demonstrated the benefits of cooperation then it would be more likely that others might ultimately come on board. That's the principle of the Mid-East roadmap to peace. Get the warring parties doing something, anything together and this familiarity will likely breed more cooperation. Increasing CCOHTA's pathetic budget tenfold would be a good start.
Finally, to paraphrase that great policy analyst Yogi Berra, even when it's over, it's not over. Ottawa's growing political vacuum is postponing tricky decisions. Everyone except Mr. Chretien thinks Paul Martin is the real Prime Minister. Premier Klein and others are checking their bets, hoping for better cards when Mr. Martin starts dealing them next February. The Council's advocates might also want to reassess their holdings. Instead of pressing for rapid implementation of a flawed idea, they might more profitably spend their time sorting out potential roles and structures. They should also press Ottawa to enforce its own legislation instead of fobbing off its responsibilities to an un-elected assembly.
Like Banquo's ghost, the Health Council impolitely intrudes itself into our national feast. It is a constant reminder of Medicare's unfinished business. But while MacBeth kept Banquo from the throne, his descendants did become kings of Scotland. Even Mr. Klein cannot forever prevent Canadians from realizing Medicare's destiny.
Dr. Michael Rachlis is a Toronto-based (but Winnipeg born) health policy analyst. His third book, Prescription for Excellence: How Innovation is Saving Canada's Health Care System, will be published by HarperCollins in February 2004.