of Brazil; the mental-health system of Australia; the health promotion philosophy of the Nordic countries; the patient and community empowerment in parts of Africa; the research and development infrastructure of the United States; the innovation, flair and speed of India; the information, communications and technology of Singapore; the choice offered to patients in France; the funding model of Switzerland; and the care for the aged of Japan.
In his book, Britnell elaborates on each of these examples of excellence; in addition, he provides a great précis of the strengths and weaknesses of health systems in twenty-five countries. The chapter on Canada is appropriately damning, noting that this country’s outmoded health system has long been ripe for revolution, but the “revolution has not happened.” Why? Because this country has a penchant for doing high-level, in-depth reviews of the health system’s problems, but puts all its effort into producing recommendations and none into implementing them. “Canada stands at a crossroads,” Britnell writes, “and needs to find the political will and managerial and clinical skills to establish a progressive coalition of the willing.”
The book’s strength is that it does not offer up simplistic solutions. Rather, it stresses that there is no single best approach because all health systems are the products of their societies, norms and cultures. One of the best parts of the book—and quite relevant to Canada—is the analysis of funding models. “The debate about universal health care is frequently confused with the ability to pay,” Britnell writes. He notes that the high co-payments in the highly praised health systems of Asia would simply not be tolerated in the West.
But ultimately, what matters is finding not a perfect approach but one that works: “This is the fundamental point. There is no such thing as free health care; it is only a matter of who pays for it. Politics is the imperfect art of deciding ‘who gets what, how and when.’” The book stresses that the challenges are the same everywhere: providing high-quality care to all at an affordable price, finding the workforce to deliver that care, and empowering patients. To do so effectively, we need vision and we need systems. Above all, we need the political will to learn from others and put in place a system that works.
Taking patient-centred care from rhetoric to reality
Patient-centred care is a term that gets bandied about a lot these days. But what does it really mean? How does our health system need to change to make it truly patient-centred? What reforms and innovations are required on a systems level? How do front-line care providers need to change to make care truly patient-centred? And how do patients need to behave differently? These are all questions that need to be answered if we’re going to move from feel-good rhetoric to doing-some-good reality.
The US Health and Medicine Division of the National Academies of Sciences, Engineering, and Medicine defines patient-centred care as “care that is respectful and responsive to individual patient preferences, needs and values.” That’s nice and inspiring and all-encompassing. It means everything and nothing. There’s a well-worn expression: “I don’t know anything about art, but I know what I like.” Patient-centred care is a bit like that; you know when you experience it—and especially when you don’t—but you can’t necessarily articulate the characteristics.
In many ways, the concept is more easily expressed in aphorisms than with a formal definition. “The needs of the patient come first” is the tagline of the Mayo Clinic; “Every patient is the only patient” was carved above the front entrance of the Harvard Community Health Plan Hospital. “Nothing about me without me” is the rallying cry of many patient activists. Another description of patient-centred care is a more esoteric one: “Giving a patient a better day.” When all is said and done, that’s what health care is all about: making patients feel a bit better. But like many aspirational goals in health care, these things tend to be a lot easier to say than to do, a lot easier to promise than to deliver. Maybe a better way to understand what patient-centred care means is to articulate what it is and isn’t.
So what do patients dislike about being in the health system—aside from being sick, of course? A number of things: the helplessness, the feeling of anonymity, the discontinuity of care, the rote and repetition, being talked about and talked to rather than talked with, the waiting, and the loneliness. Judith John, a long-time health-care executive who was diagnosed with an inoperable brain tumour sixteen years ago, has, along the way, become an eloquent and inspiring patient advocate. She says that in a system that has become obsessed with data, with measuring and metrics, we often lose sight of the importance of relationships, conversation and, ultimately, the person. “When you’re a patient, there’s only one metric that matters,” she says. “Treat me like a person. Not a chart, not a number, but a person.”
The failure to do so, which generates so much angst and fear, stems from a fragmented system and from poor communication. We have a sprawling, elaborate, expensive health system with buildings and equipment and all manner of health professionals, but we haven’t quite figured out where the patient fits in. There is a broad range of views on this—a spectrum that ranges from radical consumerism, a belief that the patient is God (or, if you prefer, the customer is always right), through to classic professionalism (or, more accurately, paternalism), which holds that medical professionals have to use their knowledge to give patients what is best for them and, in many cases, to protect them from themselves.
Let’s not forget the etymology of the word patient. It means “to suffer,” or more precisely, to be silent in your suffering. Perhaps we need a new word. At the very least, we could use a new definition. Patient-centredness has come to mean “empowerment.” But it does not—or should not—mean giving patients everything they want, when they want it. Health care is not an all-you-can-eat Chinese buffet. But it’s not a military exercise either, where patients must unquestioningly follow orders. In between those two extremes is the sweet spot: partnership, sharing of information, exchange of opinions, mutual respect. These are all the characteristics you want to see in a patient–provider relationship—and in the system–patient relationship, for that matter.
While these ideals sound great on paper, they are not easy to achieve, especially in the high-octane daily grind that is modern medicine. A whole academic literature exists on shared decision-making and its complexity. Health-care providers need to act in the best interests of patients. But patients often have a view of what is best for them that differs radically from the guidelines and medical teachings. Shared decision-making is about more than agreeing to disagree: it’s a lot dirtier and messier than that. It’s about finding a compromise that respects medical responsibility and patient autonomy. It’s a delicate dance that we’re going to have to master if we truly want quality, patient-centred, appropriate care.
Lack of dental-care insurance is a gaping hole in medicare
Canada’s medicare system has many quirks, but one of the more glaring anomalies is that the mouth does not seem to be considered a part of the body. In our predominantly publicly funded and publicly delivered health system, almost all dental care is funded privately, through employer-based insurance or out-of-pocket. The result is that many Canadians—about one in four—are unable to access dental care. The most vulnerable are the hardest hit. “The system is really not working, and it’s only going to get worse unless we act,” said Dr. Paul Allison, dean of the faculty of dentistry at McGill University in Montreal.
Annual spending on dental care in Canada tops $13 billion, but only about $800 million of that total is publicly funded. First Nations and Inuit have state-funded dental insurance, at least in theory, but they often have trouble accessing care because they live in remote communities and dentists visit infrequently. Dental care is free for children under ten in Quebec and for those under fourteen in Nova Scotia. All provinces and territories also pay for in-hospital dental
