Clichés are bad for our health
So I turn to the Canadian Medical Association's new report "Health Care Transformation in Canada." I savour one of those taglines that hollers vacuity: "Change that works. Care that lasts." And I plunge into a clarion call for transformative inaction.
I am entirely unsurprised, because basically these reports must do two things. First, demand fundamental change because anyone with half a brain can see that Canada's health system is unsustainable, including many CMA members. Second, avoid any genuinely radical ideas for fear of demagogic politicians and CMA members passionately committed to the status quo.
Thus the Executive Summary sets the boldly equivocal tone: "This document is predicated on the belief of the CMA that new demands for adaptation must be addressed starting now, and in a manner consistent with the spirit and principles that have guided Medicare from the beginning." And as you'd expect from a report written by a committee with all eyes looking nervously over every shoulder real and imagined, it doesn't just endorse the
existing five pillars of the Canada Health Act (all together now: Universality, Accessibility, Comprehensiveness, Portability and Public Administration) but adds two: "Patient-centred" and "Sustainability."
I won't quibble that grammatically it should be "Patient-centredness," lest it spoil the mood of sensitive. But I will say that if wishes were horses beggars would ride and central planning might work.
You can read the entire report at www.cma.ca/cma-paper-hct. But the basic idea is that if only we had better management, better technology and a better attitude, things that don't now work would and we could even expand health care.
In fact what we need is better incentives. And by that I do NOT mean better targets. The CMA report gives cautious pseudo-endorsement to this notion, in recommendation #2 in their "Framework for Transition." But the fact that incentives matter does not mean any set of incentives will do.
When you get into the details, the report talks about targets for wait times and "activity-based funding" -- which is to say, "a reimbursement mechanism that pays hospitals for each patient treated on the basis of the complexity of their case."
Now why, I ask you, should hospitals be rewarded more for treating more complex cases? Surely some illnesses require intensive but simple treatment.
I'm not just picking nits here. My point is that providing incentives to meet targets will increase the rate of people meeting targets. But no one has ever found a way to match targets to patient satisfaction and if we're not talking about that we're not talking to any purpose.
Consider this trivial example from a recent Citizen story: With Ottawa Hospital emergency waits getting longer, the provincial government just earmarked another $40 million "for an incentive fund to reward those hospitals that see a noticeable drop in how long their patients spend in the ER." Great. Now they'll wait somewhere else. And a much scarier story from Britain, from last Thursday's Daily Telegraph: "Four babies died at an NHS heart unit where managers were trying to raise the number of patients being treated in order to avoid closure, according to a damning report."
Targets are not just ineffective. They're unsafe. A genuinely bold report on Canadian health care would start "There are two kinds of superficially attractive health care targets, those that sacrifice quality to quantity and those that do the reverse." Later it would discuss a third kind, which sacrifices both to the needs of the minister of finance. (Another Telegraph story, from two weeks ago: "NHS bosses have drawn up secret plans for sweeping cuts to services ... Some of the most common operations -- including hip replacements and cataract surgery -- will be rationed as part of attempts to save billions of pounds, despite government promises that front-line services would be protected.")
Thrashing desperately, the new British government just announced new quality standards that will eventually cover 150 clinical areas. Hospitals that don't meet them will lose their right to carry out some procedures and yet, calling them "evidence-based," Health Secretary Andrew Lansley denied they were targets: "These are standards, not diktats. It is not politicians establishing these," said the politician establishing them.
These are standards, not diktats. What a vibrant new cliché. Great PR. Utterly useless for health care, mind you.