A PEOPLE-CENTRED MODEL FOR HEALTH: AN OPEN LETTER TO THE MINISTERS OF HEALTH
Vol. 34, Issue 3, Oct 2004
"Too often in politics, what we cherish most we inadvertently destroy by believing that protecting something means freezing it in time, when in fact protecting it may require dramatic change. Protecting children, for instance, means encouraging them to grow and adapt to the world in which they have to live. If we are going to save Canada's health-care system, we will have to change it, and the sooner we embark on the road to change, the smoother the journey will be."
Janice McKinnon (former minister of finance in the province of Saskatchewan)
The need for change
As the September summit on health care approaches, Canadians are very concerned. Will this opportunity be squandered trying to find a short term fix for a Canadian health system that is incapable of fulfilling the expectations of an informed public? Or will this instead be the initial meeting of a group of leaders who have the courage to explore the options and implement the changes that will reform the current system, so it can fulfill the health support needs of Canadians for an indefinite period of time?
One option for the ministers of health, premiers and prime minister to consider is a people-centred health system that places the health of the individual as the non- negotiable.
People (patient)-centred is a term that is used frequently in health literature but no political or professional group has considered what a system designed around people would be like or how it would function.
This article briefly outlines several aspects of a people-centred proposal with the intention of stimulating further discussion and debate.
Introduction: toward a citizen’s perspective
Health care is one of the top priorities on Canadians’ agenda. Yet many groups who have studied the arrangements in place for health care in Canada have described them as unsustainable and/or broken. The premiers met in the summer of 2004 to discuss ways to save or fix the system. Once again, the main focus of their discussion was funding: the debates have centred on how one might find ways to inject more money into the system to provide more, better or faster services.
Increasingly, health stakeholders (politicians, health providers and citizens) are beginning to understand that the central problem is not funding. Financial gaps are only symptoms of the system’s difficulties in providing comprehensive health care in an informed society.
If we truly want an effective, efficient, accountable and sustainable health support system then we must examine the system itself, and make the necessary changes. Critically examining the existing system, and looking for ways to improve it should not be regarded as a form of civic betrayal or amount to political suicide.
If we look at the system from the citizen’s perspective two critical issues stand out: (1) Canada does not have a health-centred system, but an illness-centred system; (2) the Canada Health Act is not a health act, but an insurance or financial act, and it is not based on principles of health, but on insurance principles. As a result, citizens and care providers are not served as well as they should be. It is time to design a system around health.
The present system has strengths, and it is important to identify them. But it is equally important to recognize its weaknesses, and to develop creative solutions to deal with them.
It is time for the premiers, the prime minister and all the ministers of health to consider what a people-centred health system would look like, a health system that will support the varying health needs and values of 31 million informed Canadians.
This paper will examine a people-centred (PC) health system with respect to four topics:
The first challenge is to determine what, if anything, Canadians agree on. There are two facts that most Canadians seem to agree on with respect to “what” our health system should do:
There is also broad agreement among Canadians with respect to “how” this should be accomplished:
If the purpose of a health system is to support the health of the people, then the designers must accept that there is no such thing as a one-size-fits-all way to deal with health issues. Unless and until all people and providers are cloned and programmed in an identical manner, there must be a variety of support options available for the 31 million unique people in the country, since their needs are different and the support they want also varies.
Health needs vary and evolve
There is no agreement on what health is and, therefore, there is no universal definition of health. Health is personally defined and can change each time life’s circumstances change. When Tommy Douglas pioneered the framework for the current health system, he had two fundamental goals: first, to ensure that Canadians had access to care for preventable or treatable illness; and, second, to ensure that they did not go bankrupt trying to obtain this care. These goals focused around what can be defined as illness or emergency care.
The expectations of today’s Canadian citizens go well beyond a simple demand for care in illness and emergency. Today, prevention, holistic dimensions of health, and wellness are terms that people use when referring to their health goals. Supporting citizens in their pursuit of these health goals requires a very different approach from that required to deal only with illness.
Health is no longer accepted to be the absence of illness or treatment of emergencies. To develop a health support model today, it is necessary to think of health in a more comprehensive way.
Defining Health PYRAMID OF HEALTH - Copyright 2003-r.Vaughan Glover
As most people experience life without urgency or illness, a definition of health has evolved that is very different from what health leaders perceived 40 years ago.
The evolving informed age definition of health - Copyright 2003-r.Vaughan Glover
In the 1960s, the goal was to find a support system for acute disease care, for primarily definable, infectious type illness or trauma. The focus was primarily on physical health for a patient who was poorly informed and did “what the doctor said”. This is very different from the type of support required for an informed client who is seeking life-long mental, physical, spiritual and emotional well-being. This informed client is living much longer, with the result that he/she must cope with a greater incidence of incurable degenerative-type illness with a myriad of options for care.
Thus the definition of health the system is supporting has changed from being preventable and treatable illness to being a personally-defined balance of mental, physical, spiritual and emotional well-being. The lower two levels of the health pyramid are what the current system was designed to address. Peoples’ expectations suggest that we should develop a system that is more prevention-oriented and can address broader concerns than simply physical and mental ailments. As Canadians’ expectations have moved through the various levels of the pyramid, the demands on the system have evolved but the system has not.
Canadians also cherish their universal, publicly-funded system
Canadians have come to take for granted that they should have access to a universal, publicly funded level of support in the pursuit of their health goals. This may be debatable, but it is clearly something that the majority of citizens value and should be regarded as a given in the Canadian context as we explore areas of health reform.
Four principles of health and two constraints
There are four principles to be kept in mind in a people-centred support system, and these are very different from the insurance principles of the current Canada Health Act.
The first principle: individual autonomy
Everyone is different, not only genetically but also behaviorally and in the way they process information. People have different values and needs, and these vary at different ages, stages and circumstances in life. As a result each person must determine the proper balance to meet his or her needs.
The next generation health system, if it embraces all levels of health and moves beyond disease, must embrace the right of all people to personally define their own balance of well-being.
Individual autonomy sets up an interesting challenge for a one-tiered one-size-fits-all system. An informed patient-centred system must be inclusive enough to support 31 million personalized health systems that are unique to each Canadian and ultimately managed by the individual.
The second principle: people must take personal responsibility for their health
People must accept that no government can legislate health for anyone. The best government can do is to provide a support system to help individuals achieve their health goals. People must accept responsibility and ownership for their personal health. As people begin to express their individuality, there are fewer, if any, acceptable one-size-fits-all options.
“There is nothing a doctor can do that will overcome what the patient will not do,” is a saying that is a reality for health providers, and something that a people-centred health system must embrace. With the exception of some urgency care, no matter how good the diagnosis, long-term success is ultimately in the hands of the patients/clients/consumers.
The third principle: people must be informed
People never stop learning, growing and understanding themselves as human beings. An effective health system must encourage and support this. If you compare the different levels of the health pyramid with the degree of knowledge and input that the patient must provide, it varies greatly.
In emergency or life support care, the people are more passive. It is not necessary for the patient to know how to operate life support equipment or how to set a broken leg, and it is not necessary to know why or how a particular drug works. A provider can deal with the emergency and illness without having the patient play an active role. However, when the individual chooses to move beyond disease to prevention and wellness, there is an exponential increase in the need for information, knowledge and understanding. Prevention and wellness levels of health are largely dependent on the patient taking control and making informed decisions.
The fourth principle: people must be creative and make choices
As an individual moves from emergency through the different levels of the health pyramid, the options increase, and to be healthy, one must be an active participant.
The desire for choice and options is increasing with the knowledge of the people. Before this age of informed and active citizens, people readily accepted the word of the doctor and rarely asked for a second opinion. Today people regularly research their symptoms or diagnosis on the Internet, and come to an appointment prepared to discuss the options. As people embrace the principles of information and choice, the provider becomes a consultant, supporting an active participant rather than just treating a passive patient.
Working with people who are actively researching health and seeking options may be frustrating for the provider who is not comfortable with being challenged on his/her diagnosis, but it is an important step in people’s transition from being diseased victims to self-actualizing individuals seeking wellness. The next generation health system must embrace this reality.
These four principles (people are individual agents who must take responsibility for their health and be well-informed in order to make sensible choices) help to bring to light two characteristics of a good support system: (i) it must allow people to define for themselves the quality of care they want, and (ii) such a system must allow people the possibility of making such choices even when they are in difficult circumstances.
The definition of quality varies more as a person moves up the levels of health. For example, there could be a high level of agreement on quality for emergency life support because it is a very physical and technical level of care. Quality can be determined by something as obvious as whether the patient lives or dies. Beyond life support, the quality of care is determined more by intangible services such as the care, skill, judgment, empathy and communication skills of the provider. As people move from urgency to life-long care, quality stops being measured by what providers do “to” you and starts to be determined by what is done “with” you.
The need for everyone to pool their resources and provide support for all people is as real today as it was for Tommy Douglas in the 60s. The challenge is to create a way to provide support and not to let financial barriers infringe on the capacity for all people to move beyond disease to the other levels of health. But, as an individual moves up the pyramid of health, there is a decrease in the significance of financial support. Life support and major surgery are probably the most expensive of all kinds of care. In prevention, behavioral change is essential. The material costs of successful prevention are minimal, but the investment of time and energy by both the citizen and the provider to achieve behavioral change is much greater than in disease or illness care.
The critical pieces for an informed people-centred health care approach
The challenges for the ministers of health are (a) to design a working model, (b) to develop a way to manage it, and (c) to create the funding mechanism that can support it.
The informed people-centred model
The graph below summarizes a model that emerges from our assumptions and embodies the basic principles mentioned above.
The informed people-centered model
It is not possible to discuss the details of this model in a short article but there are four key points for the readers to consider:
The informed people-centred management system
This transition to a patient-centred system also will involve changes in how the system is managed. If the purpose of the system is to support the health of the people, then the present management system must be reversed. The individual is at the top of the heap, and the care providers, support groups, etc., act in a support role. Every level of management would be affected if the system were committed to supporting the individual.
The doctor-centred management system
The doctor-centred management system
In a people-centred management model this would be inverted to:
The evolving people-centred management system
The evolving people-centred management system
Inverting the management system can have a tremendous impact on issues such as medical doctor shortages, and the costs of care.
In their 1989 book, Second Opinion (Toronto: Collins, page 55), Michael Rachlis and Carol Kushner, state: “According to estimates, 80 percent of all people that go to see physicians have nothing wrong with them that wouldn’t clear up with a vacation, a salary raise or relief of everyday stress. Only 10 percent require drugs or surgery to get well, and the remainder have an illness for which there is no cure. This 80 percent success rate helps to perpetuate the myth that physicians, both modern and ancient, have special healing power.”
In the same vein, another study completed in 1999 by Ontario’s Health Services Restructuring Commission 1 found that 69 percent of the billings of general and family physicians for 1996/7 were for services fees that were within the licensed scope of practice of nurse practitioners, nurses and other (lower cost) health-care professionals.
The exact numbers may be debated but everyone agrees that someone other than the doctor could manage a high percentage of primary care physician visits.
A management model that encourages the whole “health-care support team” to work together would do much to eliminate the so-called “doctor shortage” and increase dramatically the effectiveness of doctors in fulfilling their truly essential roles.
By expanding the role of properly selected and trained members of the team, the ability to effectively support greater numbers of people in a caring and timely fashion would be enhanced. The quality time available to providers, including nurses and nurse practitioners, to invest with the patient would be increased, and overall there would be an enhanced level of care. A high percentage of their time is currently invested in doing things that support staff could and should be doing.
The next generation health system must address this reality and empower and reward the team that can share this load; thereby more effectively coaching and supporting the health of the individual. There is a need for managers of health teams, and if the doctors are unable, incapable or unwilling to manage such teams, then there is a need to delegate this role to others.
Increasing the responsibility of people for their own health, and freeing highly-trained and specialized personnel from tasks that other professionals can perform very well, may well put into question the need to increase enrolment in medical and nursing schools.
The people-centred funding mechanism
The current system is in financial difficulty because of the standardization imposed on the system. Instead of imposing rigid rules that mean everyone must be treated in exactly the same way, one might allow the system to be tailor-made to the needs and preferences of the citizens.
There are a variety of funding mechanisms that may well do the job. The central point is to search for mechanisms that would be built on the principles of health, instead of allowing the debate to fall prey to conflicting ideologies: private versus public, profit versus not for profit, etc.
Using the principles of health as non-negotiable guideposts means that forms of funding that were considered unacceptable in the existing model should be re-evaluated.
For example, health accounts in a paternalistic system have never made sense, but they may be a logical alternative in a system that intends first and foremost to “inform, engage and empower” the individual to accept responsibility and be involved in the decision-making process. Providing each citizen with a “health account” for a portion of basic health services can have many positive effects over a model where the individual has no idea what the costs of care are.
Because so much personal, professional, business, political and financial investment is dependent on maintaining the status quo, change can be difficult, even painful. Building a system around principles of health means change. If we want a system that is efficient, effective, accountable, sustainable and supports the health of the people in the way that they feel is important, then putting the individual back in the centre of the funding process and managing finances (even a small portion) is one very effective way to begin this process. It may not be the only alternative but it may be a very good one, if it is part of a complete package that fulfills the criteria outlined in this proposal.
The details of how and by whom people are rewarded in a health system can be the topic of another article or book.
The purpose of this article is to encourage the health leaders to approach the upcoming meetings with open minds to bold new ways of approaching the problems that won’t just save or fix the existing system for another 10 years but will begin a process where the system can thrive indefinitely. Funding is a critical issue, and the existing mechanisms are unsustainable. It is time to address the issues, not the symptoms of the issues.
Adopting this approach requires introducing some concrete action steps that could kick-start the process. The best ideas are of no use if they cannot be implemented.
For the people:
For the ministers of health:
This article is published as the provincial and federal health leaders meet to discuss their way of “saving” and “fixing” the health-care system. Much of the discussion will again be about money to “deal” with waiting lists, lack of options, and the increasing frustration of health-care providers and citizens. The idea of promoting additional federal spending for a drug plan addresses one of the symptoms of the current system’s problems; it does not deal with the central issues:
Canada has the fundamentals in place to create a health system that can help people to take charge of their health (a personally-defined balance of mental, physical spiritual and emotional well being). The real question is do Canadians want to accept the challenge of becoming a world leader in the design of an informed and empowered people-centred health system that supports an information-age definition of health?
Dr. Vaughan Glover is a dentist in private practice in Arnprior, Ontario. He is a life-long student of all aspects of health care. In 2003, he won the top prize in a competition to identify the best new ideas for health-care reform. This competition attracted over 100 entries from health-care specialists from all over America. Dr. Glover would welcome the opportunity to discuss the details of a people-centred health-care system. He can be reached by e-mail at email@example.com. His book, Journey to Wellness, is scheduled to be published over the next few months.
1 Health Services Restructuring Commission: Primary Health Care Strategy. Advice and Recommendations to the Honourable Elizabeth Witmer, minister of health, November 1999, and proposed inter-professional primary health care groups (PCGs) costing models. A technical costing report prepared by Milliman & Robertson, Inc., (Actuaries and Consultants) for the Health Services Restructuring Commission's primary health care strategy, December 1999.
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