Canada is a health consumer's Utopia. For an observer and, indeed, consumer of the jaded and dysfunctional Irish health system, it is a refreshing place to visit.
Imagine being sent to casualty with a heart attack and then admitted to hospital within minutes for surgical treatment which could stop the heart attack in its tracks. You don't have to be the manager of Liverpool Football Club, GΘrard Houllier, to get this kind of treatment. Consider being part of an equitable system - which has no private patients.
Unlike the Republic, Canada does not keep hospital waiting lists. This is because waiting for essential treatment is not an issue for the Canadian people. If treatment is deemed medically necessary, then residents are guaranteed to receive it within an acceptable timeframe
"Accessibility, universality and public administration" are the key planks that underpin the Canadian health system. Since the 1984 Canada Health Act, these principles have driven healthcare development in a country that shares a huge land border with the US but could not be more different from it.
Privately funded healthcare is still anathema to the Canadian psyche. That so few avail of the facilities south of the border is a testament to this but also to the high quality of medical care which they receive from Medicare, the state-run health system.
In fact, healthcare in Canada is publicly funded but privately delivered, using an interlocking system of 10 provincial and three territorial health insurance plans (HIPS). All medically necessary hospital, in-patient and out-patient physician services, including GP services, are included in Medicare.
Canadian residents are given health insurance cards which they present when attending family physicians or out-patient clinics. Canadians do not pay directly for Medicare services, nor must they fill out insurance forms. There are no deductibles, co-payments or limits to coverage.
Dental services, pharmacy services and some community health professionals, such as physiotherapists, are provided for certain groups such as older people, children and those in receipt of social welfare. All other Canadians pay privately for prescription drugs, dental care, optical care and appliances such as prostheses. Most take out private insurance to cover ancillary medical costs.
Healthcare in Canada is primarily financed through taxation which was consolidated into a single annual government transfer to provincial health programmes in 1996.
Health expenditure in 2000 accounted for 9.2 per cent of the federal gross domestic product (GDP). It amounted to around one-third of all expenditure by provincial governments. In 1999, the government of Canada announced that for the five-year period to 2004 additional transfer payments had been ear-marked for health research and enhanced health promotion and protection programmes.
Having spent a week in Ontario, which has a population of almost 12 million, my opinion is that the system works remarkably effectively. Dr Bernard Goldman, chief of cardiac surgery at Toronto's Sunnybrook Hospital, says: "The system compares well with the United States. We have a rational way of rationing our resources which is far more equitable than anything you will find south of the border."
Dr David McCutcheon, CEO of the same hospital, is proud of the public service ethos of Canadian healthcare. "There are pressures linked to the reduction in taxes by provincial governments which are posing funding challenges. However it is important that we do not introduce economic factors into the doctor-patient relationship," he says.
Chronic nursing shortages are a problem for all hospitals (as in Ireland). Chief nursing officer Gail Mitchell manages 2,200 nurses on the three campuses that make up the Sunnybrook and Women's College Health Sciences Centre. She recently had 99 vacancies. The average age of nurses in the hospital is a worrying 47 years.
Canada does have a well-developed nurse practitioner grade; operating half way between a traditional nursing and medical role both in the hospital and the community, nurse practitioners practically run neo-natal and coronary care units. Many rural communities in northern Canada rely on these professionals for day-to-day healthcare.
The value of a stand-alone elective hospital (operated on the basis of planned or booked appointments and admissions) is evident from a visit to the Orthopaedic Institute, a hospital located in the heart of Toronto's financial district. With no accident and emergency patients to interrupt its tightly planned schedule for orthopaedic surgery, eight orthopaedic surgeons perform 1,200 operations in each of the institute's four operating theatres every year. Targets are set and reviewed on a quarterly basis to ensure the hospital's 77 beds are utilised to the maximum. Interestingly, in the midst of a national shortage of nurses, it has a low turnover of nursing staff. Chief executive Ann-Marie MacLeod says this probably reflects a low-stress, predictable working environment for nurses at the institute.
Telehealth - based on video links and Internet technology - is a particular feature of Canada's healthcare system. In Alberta, the country's wealthy conservative and oil-rich western province, Alberta Wellnet - a health information network - enables the secure exchange of information among health providers. Wellnet allows rural health practitioners to link directly with specialists in urban centres. Already, psychiatric consultations, emergency departments links and the reading of complex scans can take place without the need for patient transfer from remote areas. By May this year, 70 videoconferencing sites and 15 remote ultrasound workstations were operating throughout the province.
Alberta is one of the provinces leading a national debate about the future of Canadian healthcare. Driven partly by the mounting costs of a publicly funded system and partly by the influence of privately funded health in the US, a Senate committee is due to report this autumn on Options for the Healthcare System.
A nationwide opinion poll in August shows that a slim majority of Canadians believe it would help the system if people were allowed to purchase private healthcare. However, Canadians are also acutely aware that by over-reforming Medicare they could end up throwing the baby out with the bath-water.
Primary care is the least developed aspect of Medicare. Since GPs are independent contractors, paid on a fee-per-service basis, there has been no incentive for them to develop group practices or extended teamwork. This is about to change. Donna Segal, executive director of the Ontario Family Health Network, is responsible for a number of family-practice pilot schemes aimed at altering the structure of primary care.
Some practices, such as that of Dr Scott Wooder in Hamilton, are now paid on the basis of capitation (a system whereby GPs are paid according to the number of patients on their lists rather than per visit ). He is now part of a local network of 18 physicians who have developed a team approach by recruiting counsellers, nutritionists and nurse practitioners to work in their practices. A particularly successful development has been a telehealth initiative in which out-of-hours patient calls are dealt with by telephone by qualified nurses, who prioritise casualty patients according to the urgency with which they require treatment. They may then contact the doctor on call for the primary-care group to initiate a consultation with a specialist.
So what might the Republic learn from the Canadian health system? There is probably no one better placed to comment than Dr McCutcheon, former chief executive of Tallaght Hospital and now president and CEO of Sunnybrook in Toronto. "The two-tier system of healthcare in Ireland concerns me. The existence of public and private waiting lists for treatment is inequitable and would not be tolerated in Canada," he says. He also found the emphasis on sickness rather than health in the Republic - especially in primary care - very different. "There was no culture of annual check-ups - you need to focus much more on preventative health," he adds. Dr McCutcheon is especially concerned about Irish people in relatively low-paying jobs who are not eligible for medical cards and for whom even basic healthcare payment is a significant financial blow. He also thinks hospitals here could be run far more efficiently - he cites in particular the Canadian practice of completely "working-up patients" in pre-surgery clinics, making it routine to enter hospital on the day of operation, even for major procedures.
To me, the biggest advantage of Canadian healthcare is its level playing field. Whether you are a senior member of the judiciary or a recently arrived immigrant from Vietnam, the only determinant of when you will receive a coronary bypass is the medical urgency of your case.
Maev-Ann Wren's analysis of the politics and economics of the Canadian health service, with details of the States of Health series: Weekend 3Series edited by Kevin Sullivan.
