July 30, 2006

Health Dialogue

On July 24th the lead editorial in the Vancouver Sun chastised Finance Minister Carole Taylor for blaming the media for "shutting down" debate on the cost of health care. The editorial encouraged debate, saying: "In this space we have long argued that the issue is not whether health care is delivered by the public or private sector, but getting the most value for money while maintaining a publicly financed health-care system." The Sun editorial had it partially correct, but "the issue" is far more than maximizing value for any given cost.

Former Auditor General George Morfitt worked with the deputy ministers of his day to develop a new framework for specifying and measuring public policy. His work resulted in the requirements set forth in the Budget Transparency and Accountability Act for service plans and an overall strategic plan complete with performance measurements and follow-up annual reports. Unfortunately, it appears that government, the opposition, the public and, at the risk of offending those who buy pixels by the terabyte, the media, pay little or no attention to the plans and reports the Act requires government to produce. That has to stop if we want to have informed debate on policy rather than politics driven by the morning's headline.

The service plan for the Ministry of Health consists of statements of "Vision, Mission and Values" followed by "Goals, Objectives, Strategies and Performance Measures". If there is anything lacking in our health system, then some fault should be found with respect to one or more of the elements in that framework. It could be as simple as identifying a goal that should be added, or specifying performance measures that are missing. Alternatively, the basic vision, mission and values could be questioned.

The February 14th Speech from the Throne focused on health care and promised "real dialogue" aimed at transforming and improving our health care system. Questions posed in the Throne Speech included:

It is no wonder that public vs. private care is one of the elements of any dialogue, since the Throne Speech made a point of focusing some questions on that issue. The Campbell government has not yet taken the logical step of relating its challenging questions to the framework of its service plan for the Ministry of Health. As of late July, five months after the Throne Speech, government hasn't done anything to initiate the dialogue which Taylor falsely faulted the media for shutting down, although on July 29th Vaughn Palmer reported that government has issued a media advisory for an announcement on the start of an 18 month "conversation on health care". No one needs to wait for the government in order to begin the dialogue, and no one should accept the government unilaterally setting the agenda for any debate. Anyone can read the 2005-06 Annual Service Plan Report for the Ministry of Health and contribute to the dialogue by identifying what is wrong or what is missing, and by sharing it, whether through websites, letters to the editor, talk shows or a forum provided by the government.

Few could quarrel with the purpose, vision, mission and values specified in the Service Plan. The vision is: "A health system that supports people to stay healthy, and when they are sick provides high quality publicly funded health care services that meet their needs." In the absence of a disagreement over the top end of the Service Plan framework, it is useful to focus on goals, objectives, strategies and performance measures while keeping in mind the advice of BC's Progress Board: "What Gets Measured Gets Done"! Pragmatists may argue that the performance measurements are all that really count since they determine what gets done, and they may support many different goals, objectives and strategies.

The 2006/07 - 2008/09 Service Plan for the Ministry of Health states: "B.C.'s Provincial Health Officer tracks 91 indicators that survey the overall health of the population." Only two of those 91 indicators are included as performance measurements in the Ministry's Service Plan: smoking rates (age 15+) and physical activity levels (age 12+); the goals are to decrease the first measure and increase the second measure. The remaining 89 indicators are not readily available on the Provincial Health Officer's website although that site is given as a reference in the Service Plan. It appears that the 2006/07 - 2008/09 Service Plan refers to the 2002 Annual Report for the Public Health Officer, a must read for anyone seriously studying our health status and the performance of our health care system. Subsequent annual reports from the Public Health Office have not updated the 91 indicators, and most importantly, by not including all of the indicators in the Service Plan, goals are not set for performance of the Ministry on those indicators. Including smoking rates and physical activity levels, there are only 12 performance measurements in the Ministry of Health's Service Plan. The Ministry has yet to determine the long term targets for three of its dozen performance measurements including: percentage of clients admitted to residential care facility within 30 days of approval, proportion of patients admitted from an emergency department to an inpatient bed within 10 hours of the decision to admit, and decrease in percentage of natural deaths occurring in hospital.

If the government embraced the 2002 Annual Report of the Provincial Health Office, and set goals or "targets" for all of its 91 indicators, then the public could be assured that progress is expected on a broad front by decreasing bad indicators and increasing good ones including: potential years of life lost, incidence of depression and anxiety, teen pregnancy rates, exposure to second hand smoke and life expectancy at birth. Annually reporting on as many indicators as possible, and setting targets for those indicators, will increase government's accountability and improve the health system. Of course that presumes that the purpose of the dialogue is to improve health outcomes rather than to engage in ideologically driven restructuring and cost containment.

Cost containment is essential. The budget for the Ministry of Health increased from $8.7 billion in 2000-01 to $12.8 billion in 2006-07, a 47% increase in just six years. Everyone, regardless of interest or political stripe, must agree that an annual compounded rate of 6.6% is not sustainable; however, the conversation must be about improving health outcomes within our ability to pay, not simply about reducing or shifting costs. One of the best ways of getting better outcomes without increasing costs is to stop doing things that aren't effective. That can include reducing errors (the literature shows you have a shockingly high chance of being made worse as a result of exposure to the health system), eliminating duplication of effort (as has been done with improved orthopedic centres) and eliminating what doesn't work (as is the case for many pharmaceuticals). It does not include shifting costs from public health insurance to sick citizens. To her credit, Dr. Penny Ballem was driving the Ministry in the direction of better evidence based delivery. During the course of the conversation on health care, the Premier must convince the public that Ballem's focus has not been lost. The government needs to manage health dollars better while being more accountable for the health system's performance; sharing more information with the public will help on both fronts.