the Patient First Review, under the leadership of long-time health administrator Tony Dagnone. The health system has had many federal and provincial reviews over the years, so the move was greeted with a lot of eye-rolling and yawns. But the strength of the Patient First Review was that it focused on two key questions:
Is the health system putting the patient first?
Is the health system achieving good value in care delivery and system administration?
The other strength was Dagnone himself, a man with a Tommy Douglas–like passion for medicare, coupled with an insider’s knowledge of the system’s strengths and weaknesses. In the half century since the foundations of medicare were forged out of Prairie populism and the pursuit of social justice, Canada has built an excellent universal, state-funded insurance program. (Or, more precisely, fifteen vaguely interlocking programs, but that is a discussion for another time.) But the underlying theme of Dagnone’s report was that, along the way, we lost sight of the people the system was designed to serve: the patients and, by extension, their family members.
What was needed to repair this fundamental flaw, he said, was not more rejigging of bureaucratic structures but a change of culture and a rethinking of priorities. “Patients ask that health-care workers and their respective leadership see beyond their declared interests so that the interest of patients takes precedence at every care interaction, every future contract negotiation and every policy debate,” Dagnone wrote. “Only in this way will we achieve a patient- and family-centred health system for Saskatchewan citizens. Similarly, government leaders and policy-makers must keep the patient front and centre when policies, programs and new models of care are designed and implemented.”
The formulation of that statement is noteworthy. “Patients ask” is used because the commissioner did extensive consultations with patients and families. Dagnone did what is so rarely done in the day-to-day operations of the health system: he asked patients what they wanted and then he actually listened to them. A vast reservoir of untapped patient knowledge exists that we need to explore to improve medicare. What the commissioner heard is that the system performs relatively well. The care is good, but not good enough.
So where does medicare fall down on the job? In a few areas:
Convenience and timeliness. There is too much waiting, and it’s not easy to get in the right door for care, so people end up in emergency rooms by default.
Lack of co-ordination. Patients do not move seamlessly through the system; there are often big cracks to fall through at transfer points.
Lack of equitable care. Patients want reasonable access to care but feel they are discriminated against based on where they live, their age, their ethnicity and other factors.
Lack of communication and information. When someone is sick or injured, they are frightened. They crave basic information, but everyone is too busy.
Lack of electronic health records. Patients hate repeating their medical histories over and over, and tests are oft-repeated because of lack of modern records.
Lack of respect. All too often, patients feel they are treated as a bother to health professionals. Patients are not cost centres, they are the raison d’être of the system.
Dagnone does not use the term, but reading his report one is left with the sense that the primary frustration with medicare is the total lack of customer service. That does not seem like an insurmountable barrier. In fact, Dagnone concludes that there is no need to dismantle and reinvent the health system but rather the need for a collective will and vision to implement fixes and change the culture of caring. “‘Patient First’ must become more than a mantra. For the sake of patients it must become a movement that is embraced by all who have a stake in creating healthier communities.”
Montreal’s super-hospital saga was a historic farce
It took twenty-two years in the early seventeenth century to build the Taj Mahal, the awe-inspiring white marble mausoleum in Agra, India. It took longer than that for Quebec to build a utilitarian hospital in Montreal in the twenty-first century.
The Taj Mahal is a glowing symbol of eternal love. The “Taj Hôpital” is a shameful symbol of political dithering. In a December 2010 instalment of the absurdist tale, then-Quebec Treasury Board president Michelle Courchesne announced that construction of the Centre hospitalier de l’Université de Montréal (CHUM) would begin the following spring and be completed by 2019. The tentative price: $2.1 billion. Well, she actually announced that there would eventually be another announcement because bids had yet to be tendered. Not to mention there were no final blueprints. And so it went.
The idea of building a Montreal “super-hospital”—merging archaic institutions scattered around the city into one state-of-the-art facility—was first floated in 1991. It was an eminently wise plan, particularly in a city where most health-care facilities were built decades and in some cases centuries ago. But in the health field there is no idea, however sensible, that cannot be bogged down by bureaucracy and perverted by politics. The Quebec super-hospital saga is a case in point. (In the interest of brevity, let’s leave out names and political affiliations: suffice it to say that six premiers and ten ministers of health have been involved in the file to date, and the Liberals and Péquistes have handled it in equally bumbling style.)
In 1995, Quebec’s health minister announced a merger of the three “French” hospitals—Hôtel-Dieu, Notre-Dame and Saint-Luc—to create CHUM. A similar process happened with the “English” hospitals—Montreal General, Royal Victoria, Montreal Chest Institute, Montreal Neurological Hospital and Lachine Hospital—and that was called the McGill University Health Centre (MUHC). In 1999, it was finally decided that CHUM and MUHC should be more than virtual institutions. They would become bricks-and-mortar “super-hospitals.”
Then the real jockeying began. Where would the facilities be built? What would happen with the existing hospital properties? How many beds would each super-hospital have? And so on. Forests were felled and tens of millions of dollars spent to produce studies, including a 2003 commission of inquiry headed by former prime minister Brian Mulroney and former Quebec premier Daniel Johnson.
Back then, CHUM was going to cost $860 million, and the super-hospitals were going to be built and operating by 2007. But a shovel in the ground by this date would prove to be a pipe dream. One of the most politically vicious battles was about the future site of CHUM. It came down to 1000 St-Denis St. (in the heart of downtown) or 6000 St-Denis St. (in tony Outremont). There is enough intrigue in those choices to fill a book—and, in fact, a book has been written. The travails of MUHC, by contrast, were minor. All they had to deal with was contaminated land and angry neighbours near the planned construction site in Notre-Dame-de-Grâce. And, oh yes, the costly foot-dragging of indecisive political leaders and a kickback scandal.
Plans to have the new facilities built as private–public partnerships (PPPs)—an approach in which private enterprise would build the hospitals, then lease them back to government over a thirty-year period—added to the controversy and cost and, in the end, private enterprise would play a token financing role so the government could save face. By 2016, the 772-bed CHUM’s projected total cost was $2.1 billion, along with a $470 million CHUM research centre. Not to mention the $500 million upgrade of Sainte-Justine, the “French” pediatric hospital. MUHC cost about $2.4 billion, including a new five-hundred-bed facility, a new Montreal Children’s Hospital and extensive renovations to the 332-bed Montreal General Hospital. That’s $5.5 billion and counting—though one economist calculated that when the final tally is in, the total will reach $8.6 billion.
