It was assumed that quality would not be an issue." 
 
 
 
 
 
 

Canadian Medical Association
131st Annual Meeting
Whitehorse, September 7, 1998

Check Against Delivery

Thank you for your kind introduction.

On behalf of the Prime Minister and the Government of Canada, I want to convey my best wishes to the executive and members of this great association and the profession you represent.

The origins of the CMA can be traced to the beginning of Canada itself, and over the years, your association has grown and evolved with our country. But through all the challenges and change, one thing has remained constant -- and that is the public trust and confidence that Canadians invest in their doctors. Canadians look up to you -- just as you look after them -- because we know that your sense of professionalism has always been anchored in the larger interests of the society you serve so well.

One of the roots of your enduring reputation has been the quality of this association's leadership. At this meeting, Dr. Victor Dirnfeld leaves his post as your President. I want to congratulate him on the job he has done.

We have had our differences, to be sure: but that is to be expected. In troubled times for health care, your silence would be most worrying of all. These are times for discussion and debate. And Dr. Dirnfeld has engaged on your behalf in a vigorous dialogue on the very issues we must thrash out. I can testify from personal knowledge that he does not hesitate to express his views to me directly, plainly and with force.

Dr. Dirnfeld's  leadership has reflected an unwavering commitment to the cause of quality health care in Canada, and I thank him for his work.

Our Shared Challenge:  Access to Quality Health Care

When I stood before you last year, I talked about the fundamental bargain that underpins our health care system, a bargain between the Canadian people and their governments. Canadians' support for a publicly funded single-payer system of health care in Canada is not given freely: it is given in exchange for our assurance that they will have access to the highest possible quality of care, when they need it.

I talked about our paramount responsibility to preserve that bargain, and about the pressures and the anxieties that are undermining it today.

I talked about my commitment to the values of openness, pragmatism, innovation -- and, above all, collaboration -- in addressing that challenge.

And I asked for your advice on how we, together, could be stewards of the positive changes that Canadians expect -- and deserve.

Since our meeting last year, you have responded with a great deal of worthy work. And I believe we have, over the past 12 months, forged a solid working partnership between Health Canada and the CMA:

• I have had direct meetings with your President, to address our shared agenda;
• Our officials have been in close and regular contact;
• Last December, I became the first federal Minister of Health to appear before your Executive Council, where I enjoyed a full and frank discussion of the issues;
• We have co-hosted meetings to bring others into our discussion, including an important workshop held two months ago on quality and access.

And during these past several months, you have mounted a major effort -- of which this meeting is a milestone -- to focus on a common approach to questions of access and quality care.

Along with others, you have been working hard to document issues relating to quality and access -- a welcome effort to lift the discussion above assertion and opinion to fact and analysis.

And here in Whitehorse, you are examining practical strategies to address the challenges we face.

All that work is welcome -- and very much needed -- because the situation we face today is far from re-assuring.

The sense of insecurity among the Canadian people over the current state and the future fortunes of their treasured health care system is not improving. Indeed, surveys show that it is, in fact, worsening, and that confidence has been shaken. 

The members of this profession know that only too well. You cope with its symptoms every day. 

The restructuring and reform process, while absolutely necessary, has, in some cases, missed the mark. Modernizing a $74 billion enterprise is anything but simple. It is not likely to be completed with uniform success. There have been some mistakes and many frustrations. But they make it no less important for us to continue our efforts, learn from each other and get it right.

You have made a good start in identifying the specific areas where you believe careful, selective re-investment is needed in both the acute and non-acute sectors. 

The question that remains is not whether there are problems: clearly there are.

The question is how do we solve them: and clearly, we must.

Responding to the Challenge:  Towards a More Responsible and Responsive Health Care System

And surely we can only answer that question by working together, and together we must build a more responsible and responsive health care system.

Canadians know that the Canada Health Act spells out the five key principles on which medicare is based. But most Canadians would probably be surprised to learn that the Canada Health Act does not contain one single reference to quality. It does not establish national standards for quality or access. And it does not, for that matter, include the notions of effectiveness or efficiency.

The fact is that when the Canada Health Act was enacted,  these elements were assumed. It was assumed that quality would not be an issue. That service would be to the highest standards. It was assumed that adequate resources would always be available. It was assumed that asking hard questions about efficiency and effectiveness was not necessary -- as long as the dollars flowed freely.

Of course, yesterday's easy assumptions are today's difficult issues. And saying that we want to establish and achieve high standards of quality and access is only the beginning. Like low unemployment and low inflation, it is something on which all can agree. The issue is not the goal. It is how to reach it.

On this, I believe we owe it to Canadians to be very candid. The solutions going forward won't be found by reaching back. The question is not what was our approach in the 1960's and 70's and how do we repeat it. It is how to define quality at the beginning of a new century -- and how do we secure it.

So what does "quality" mean in health care as we enter the 21st Century?

And we can no longer define quality by focussing narrowly and exclusively on one part of the system, when what matters today are not only the pieces, but how they are put together -- the whole, not simply the parts.

Similarly, as the circle of health care professionals widens,  so must the definition of quality.

Sometimes, the meaning of "quality" can be inferred from its absence. 

Clearly, we do not have quality when there is so often such a large gap between the rhetoric of a continuum of care and a reality that falls far short.

We do not have quality when so much of what used to fall within medicare coverage now falls outside.

And we will not have quality if we do not learn how to effectively manage and plan for a future where an ageing population will inevitably increase health care demands, and where the costs of technology and of drugs are almost certain to constantly rise.

Now, some believe the definition of quality is simple.

It lies in one word:  money.

Let me be clear. Money matters. Quality is not free.

And one of the responsibilities of the Government of Canada must be to make its appropriate contribution toward financing health and health services.

It is important to remember that reductions to health spending by all governments were made when there was little choice. As I emphasized last year, long before federal cuts to transfers began, there was not a single province that could continue to manage double-digit increases in health care spending when those budgets already comprised about thirty per cent of total provincial spending. 

The very first thing the Government of Canada did once it was clear our fiscal house was in order was to increase the cash floor under the Canada Health and Social Transfer from $11 billion to $12.5 billion.

Some people have said that this involved cancelling a planned cut. But that move marked the end of cuts and signalled the priority we place on Medicare.

Looking ahead, the Prime Minister and the Government have made it clear that when federal expenditures can prudently be increased, health is very much our priority.

But much as money matters, it must also be said that the complex problems that confront health care in Canada will not be solved by dollars alone. The point is not simply to spend more, but to spend more in a way that will produce a better result.

Let me make the same point in a different way. A few years ago, Canada ran the second most expensive health care system in the world. Today, we run the fifth most expensive health care system in the world. Surely, our purpose should not simply be to make our health care system rank once again among the most expensive in the world. It must be to make it rank among the best in the world.

Because, if the amount of money spent was the only test, the United States would have the healthiest population anywhere. They don't. And 40 million Americans are not covered by health insurance despite the opulence of some elements in their system.

And, with the demographic and other pressures we face, coupled with the fact that no government will ever be able to afford annual double digit increases in health spending again, I believe we must all accept the reality that while the era of cuts is over, there is no era of blank cheques at hand.

And so, if money is part of the answer -- an important part, but only part -- where does the rest of the answer lie?

Broadly speaking, I believe the fundamental challenge we face is to make the system more responsible and more responsive to Canadians -- as taxpayers, as citizens, as patients.

And I believe that meeting that challenge requires focussed action on two closely related fronts.

• First, we need to integrate health care delivery to meet the needs of people, and cure the frustration they feel in dealing with each part separately. Although great strides are being made, we are still far from providing a seamless web of efficient and effective care -- whether in terms of organizing services or providing public funding for them. We will not secure quality health care until that is done. I will return to this theme in a moment.

• Second, a quality health system is one that can be measured. Where performance can be assessed. Where all partners in the system are accountable and have a responsibility to report to those who rely on it. A quality system would enable Canadians to determine if their health dollars are being wisely spent. To judge for themselves whether care is getting better -- or worse. It is one where objective information is gathered and shared so that all health partners are held accountable for their actions -- and so that decisions are informed by facts, not by fiction. Where the public's expectations are set publicly, with public involvement, and performance is then measured against those standards, and the results are published for all to see.

Let me elaborate.

And let me deal first with the need for integration.

No one here needs to be told that health care today is delivered very differently than it was two or three decades ago.

Care is provided in a far broader range of sites -- no longer simply hospitals but also the home, the community and a variety of other facilities.

Care is furnished by many professions, each devoted to a different aspect of care, each with its own role, making teamwork and linkages more necessary than ever.

We are in a period of transition. The old hospital-centred approach is evolving, but  a new, integrated system is not yet fully in place. Physicians know all too well the distance we still have to travel.

After all, your patients rely on you to be their agents -- their entry to the system. Yet too often, the services you know they need are not there -- or, if they are, they are often difficult to access.

In hospitals, you see patients remaining in high-cost acute care beds, beyond the point where that is necessary, simply because there are no long-term care spaces available.

Too often, you see people frustrated trying to arrange physiotherapy, community services for the elderly, rehabilitation,  palliative care. They simply cannot integrate the system for  themselves -- a system that, after all,  should be designed to serve them.

Too often, Canadian families frantically search for care facilities for elderly loved ones -- and can't find them when they need them.

Too often, hospital emergency rooms are doing work that could be better done elsewhere.

Too often, coverage does not follow care.

And too often where there should be bridges, there are barriers, where there should be linkages, there are lapses.

None of that is responsive: It is not quality care.

It is less like a system and more like a sieve.

Michael Decter summed it up well:  "We've had a system for financing health care. But we've never had a system for delivering health care".

The fact is, although we talk about the health 'system', I think it is questionable that we have even had a ‘real' system at all. We've had more of a series of separate service delivery outlets, acting in independence, and that sometimes seem not even to communicate with each other. 

We have not done nearly well enough in organizing them as interlocking parts of a whole. 

We need to look closely not only at individual services -- but at how they fit in with others. To look to the long term -- at the same time as we try to make the right short-term choices. To face up to the reality that if we are to provide quality care for Canadians, that must mean care that is both effective and cost effective. 

What I believe we must strive for is a people-centered system in the truest sense, one that ensures the right care by the right provider at the right time in the right place -- at reasonable cost.

I couldn't put it better than your own Association did in the draft guidelines for access to quality care discussed at your July workshop:

And I quote, "Access to quality health care should be based on patient needs …, … encompass the full continuum and processes of care …; … reflect clinically effective care …; … be based on clinical appropriateness …; … reflect efficient and optimal use of resources …; .. (and) be continually measured, monitored and evaluated …"

The $150 million Health Transition Fund is now being invested in a wide range of projects -- designed together with our provincial partners -- to test new ways of implementing precisely that kind of approach. 

It is doing so in four areas -- all of which are part of the continuum of modern health care:  primary care reform; a better integration of health services; homecare; and, last, pharmacare. We often call these pilot projects -- but in fact they are widespread test runs with real implications for both the scope and the pace of health care reform.

These projects are testing on the ground, throughout the country, strategies for bringing teams of health care providers together in one place, working towards one purpose:  more effective and efficient, compassionate and responsive care for those who need it.

They are testing new ways of paying for services, a key principle of which must be fairness for all health care providers. They are exploring new approaches whose focus is the patient and their care, rather than the site or specific providers -- the integration that modern medicine now makes possible, and limited resources now make necessary.

Of course, the provinces, all in the midst of transition, are themselves very much confronting these same issues and challenges. And here, there are several points I want to emphasize.

First, while there is no doubt that the process of restructuring health care has been, and remains, difficult for many -- patients and providers alike -- and while there is also no doubt that sometimes mistakes have been made and that remedial measures are required, it is equally clear that the transition towards integration must continue to evolve. We are working towards a new, real system. But we're not there yet. True integration must be the goal, where we focus on the needs of people.

Let me give you a case in point. The pace of hospital restructuring has not been matched by sufficient investment in home and community care. 

For example, our research shows that 80 per cent of home care is delivered by an informal caregiver in the home in Canada, and much of this burden falls upon women. Today, one in five Canadian women between the ages of 30 and 55 is looking after someone in the home who is either chronically ill or disabled. They spend an average of about 28 hours a week in that work. About half of those women also work outside the home, and many of them have children. The combined burden of those responsibilities is increasingly taking a toll on the health of those women.

Stress is often at unbearable levels. Despite exhaustion, career sacrifices and financial hardships, studies tell us that many caregivers experience guilt about not doing more.

This situation is unfair to everyone, and it is only going to get worse. I am not suggesting for a moment that the State can or should move in and take over family responsibilities, or replace community kindness. Canadians are always going to be willing to care for friends and for family. But there must be a reliable foundation of professional support. Home and community care has to be integrated, as one of many elements on the continuum of care available to Canadians.

Second, on a related point, as and when we reinvest new resources, I believe the money must be used as an impetus to encourage positive reform.

And thirdly, the discussion over money is almost always conducted in terms of the ‘care and cure' part of the equation -- the supply side. But as we plan now for the medium and long term, I believe it is important that we also focus on the demand side -- on keeping people healthy rather than patching them up when they get sick. That means we need to focus on health promotion, on health protection, on population health and the determinants of health, including the health and well-being of our children. The point is so obvious you would think we would do better at paying attention to it.

If we work more at keeping Canadians healthy, we will need to work less at treating the sick.

Let me turn now to what I believe must be the second element of a responsible and responsive health care system -- openness and transparency -- how all partners in the health system become more accountable and help bring about measurement of the system's performance. 

This country spends $74 billion a year on health care. But it is remarkable how little we know about the outcomes we get for this enormous sum. 

None of us have accounted very well for our stewardship of the system. I believe this must change.

There is a profound lack of information -- objective information -- based upon which Canadians can themselves judge the health of their health care system, and on which providers and managers can make rational decisions.

How can they manage what they do not measure?  How can they make evidence based decisions without the evidence? 

Let me quote from a letter sent to me by the former members of the National Forum on Health after reconvening recently to discuss Canada's health system:  "We continue to be seriously under-served by an inadequate capacity to measure performance ... If we cannot or do not measure system performance, Canadians will remain unable to reliably evaluate the state of our health care system".

We will never restore confidence in Canadian health care unless we have broader and better access to the facts.

Canadians do not want to simply be told things will be fine. They want to see it for themselves.

And when they ask for information, they deserve more than ritual rhetoric: they should get a real report card.

This is a matter both of citizens' rights, and of the responsibility of all those involved in health care. I believe Canadians have a right to know that their health dollars are being spent wisely. A right to know if the system is getting better or worse. A right to know if the services they need are there, whether the gaps are being closed. And they have a right -- one they are increasingly insisting on -- to become part of the process. Not bystanders, but informed participants in the decisions that will determine their health and well-being.

Beyond rights, this is also a matter of responsible decision making. 

It is a question of Ministers -- including me -- having our feet held to the fire -- not through governments being held accountable to each other, but through governments being held accountable to Canadians. 

It is a question of people who deliver and manage health care -- from physicians to hospital administrators to regional health authorities -- knowing what's working and what's not -- of being able, on an informed basis, to allocate resources and adjust services based facts.
In short, this is a matter of better management -- of being able to constantly calibrate, regularly review and correct shortcomings as they arise, rather than coasting, assuming that the future can or should look like a carbon copy of the past.

The bottom line is, we need to move beyond anecdote and advocacy disguised as analysis. The background document prepared for this meeting makes the point well. "To move beyond polemics, data-driven decision-making is needed to guide major health care reform …  The data-driven … process is only as good as the quality of the data:  health care policy development needs to become more evidence based."

A report card on a wide range of questions is needed. On resources -- dollars spent, human resources deployed, services in place along the full continuum of care. On the management of those resources -- the use, for example, of clinical practice guidelines, of quality assurance and performance monitoring, of evidence. And on results -- re-admissions, utilization rates, average lengths of stay, and health outcomes.

You know, in many ways the work is already well-started. In every province of Canada, in scores of hospitals, in leading universities, the public and the private sectors have invested in the creation of infrastructure to accumulate and analyse health-related information. But too often these separate systems stand in isolation. They speak to the issues but not to each other. They reflect part of the story but so many subjects remain unrecorded.

And the result?  A patchwork of unconnected projects, each with its uses but with a value that would increase a hundred-fold if they formed part of a coherent whole. And even when data is captured, it's sometimes unavailable to those with the capacity to analyse and understand it. And so we too often find ourselves drowning in information, while thirsting for knowledge.

The federal government can play an important role in making sense out of this information overload by helping to make the right connections, by working to build a consensus about national standards, filling gaps where it is important to have national networks and helping to solve some of the critical issues of privacy and security in a way that reflects common Canadian values.

I also believe we, at the federal level, have an obligation to report to Canadians on how we are doing on the programs that we deliver directly ourselves -- whether that is on the  regulation of health products, or surveillance of diseases, or services for First Nations.

The bottom line?  Canadians expect and deserve high standards of quality care. We need to establish those standards -- for the whole country -- and then measure performance against them and report the results.

All of us, including the public, must be involved in that process. The CMA will be a major participant. We want your advice. We need your help.

Before concluding, let me address one specific issue where the need for objective information is more evident than any other -- and that is waiting lists.

Waiting lists frustrate dedicated physicians who want to get the best treatment for their patients as quickly as possible. And for anyone on a waiting list -- or who knows someone who is, -- they can be a source of real anxiety and, sometimes, real pain.

Yet what objective, systematic, reliable and comparable information do we have about waiting lists?  And what confidence, as a result, can Canadians have in what they are being told about them.

In some cases, waiting lists are constructed on sound principles. For example, the Ontario Cardiac Care Network uses agreed upon criteria for managing access to cardiac surgery. But, for the most part, the length of the list and how quickly it moves depends on local practices:  deciding the time from which to measure the waiting, deciding the criteria for adding patients to a list, and determining how patients are managed once they are on the list varies greatly from place to place.

So how can we draw general conclusion from specific examples?  And where do we begin in solving a problem that is so hard to define?

To help answer those and other key questions, my Department commissioned a three-part, three-team project involving some of the leading experts in Canada. Their report is now complete and was made available last week. Let me quote from their findings:

"Waiting lists cannot be used to improve the allocation of resources until the data are collected in a standardized and comprehensive manner…  Standardized methods for measuring and reporting waiting times must be developed…  There is a clear national role in the development and application of standards and consistent criteria."

Canadians deserve to know the true dimensions of the problem. They deserve an approach where fairness is assured -- where those who require treatment the most are the ones who receive it first. And they deserve to know that every step is being taken to systematically match needs with services. 

Your association has recognized this. Last year, when I asked for your assistance and your advice, one of the ways you responded was as a member of a consortium that submitted a proposal to develop the kinds of information and strategies we need to address this issue.

Today, under the Health Transition Fund, I am announcing $2.2 million in federal funding for the project that you and others proposed:  a project on waiting lists that will involve major research organizations, regional health authorities, medical associations and the Ministries of Health of Canada's four western provinces.

This project could have a profound and positive impact on waiting lists in this country. These would include, for the first time:  reliable, comparable, standard waiting lists for a variety of procedures; objective data so that Canadians can know if the waiting list situation is improving or worsening; a fair and valid means of priorizing needs; and a whole new set of tools to help decision makers better direct resources to close identified gaps.

We believe this project has the potential to provide Canadians with one of the best systems for dealing with waiting lists anywhere in the world. 

Let me make two things clear:  First, this is not just another study to find out whether we have a problem with waiting lists in Canada. It is a project that will produce valid tools for managing this problem. Second, this work is not going to take forever. I expect an interim report by next June and a final report nine months after that.

I want to thank this Association for your leadership on this issue. In discussions directly with me, you have emphasized the need for action -- and the involvement in this project of the CMA itself and three of its provincial branches is concrete testimony to your commitment.

In recent weeks, newspapers have been filled once again with the issue of Canada's future. As you know, last month the Supreme Court of Canada released its judgment answering certain questions we had referred about legal aspects of the national unity issue.

Reading that eloquent judgment reminds us of our proud history and our unique achievements. It should also inspire us to redouble our efforts to ensure that we preserve and pass on to our children a united and prosperous country.

And if we are looking for a unifying feature of Canadian life, if we seek a tangible expression of our shared values, we do not have very far to go.

Canadian medicare is a national asset that lies at the heart of our nation's sense of self.

It reflects a commitment by Canadians to each other that transcends regional interests, that crosses provincial borders and that brings out the very best within us. 

Because medicare is about the promise we have made to each other as Canadians:  that in times of need, we will look after each other, without regard for wealth or privilege.

We can look at the challenges facing medicare as a crisis that cannot be resolved. Or we can look at it -- as Canadians expect us to -- as an obligation upon which we must act, an obligation we have not simply to each other, but to the generations that will follow. 

I believe that despite the complexities and the tough choices, we will succeed. And if we see this as a truly national goal -- and set it -- I believe we can achieve it in a matter of the next few years.

And so, in medicare, as in nationhood, let us put aside the quarrels that drive us apart and devote our hearts and minds to the shared goals that draw us together. Let us do in our time what those who put medicare in place did in theirs -- focus on the future, working from a clear vision, to find the will and the ways to succeed.

And in medicare, as in nationhood, success will require working together. The need for collaboration has never been more evident. The dangers of division have never been more stark.

Canadians do not want us to fight over health care:  they expect us to fight for health care. They want to see us behaving as partners, because they know that no single actor has a monopoly on wisdom.

For generations, Canada's doctors have nurtured one of the greatest partnerships of all -- that between you and your patients. And you have set an example for us all -- by letting politics end at your patient's bedside.

Let us follow that example -- your example -- by reaffirming today our commitment to work in common cause, to secure the future of a health care system that will provide access to quality care in the new century that lies before us.

Thank you very much.