[Editor's note: This is the fifth and last in a series on health care reform issues in European countries Premier Campbell has visited.] Canadian public health care is in crisis! Really? Compared to what? One of the fundamental assumptions of Premier Gordon Campbell's recent tour of Europe is that Canadian public health care is in crisis, a theory so widespread and often repeated these days that it stands as common sense. One classic formulation of the crisis theory is to be found in Paying More, Getting Less: Measuring the Sustainability of Provincial Public Health Expenditures in Canada, by Brett J. Skinner, published by the Fraser Institute last fall. Skinner argues that health care costs are out of control, and will, before the middle of this century, spiral upward to consume all provincial revenues. The Canadian health care status quo is unsustainable, he argues, in terms reminiscent of the most recent throne speech delivered for the Campbell government. The solutions, says Skinner, include requiring patients to make co-payments for publicly insured health services, "allowing people the option of paying privately (via private insurance or out-of-pocket) for all types of medical services, including hospitals and physician services," and allowing for-profit health providers to compete for delivery of publicly-insured care. Skinner's other publications include a study for the Atlantic Institute for Market Studies in 2002 titled "The Benefits of Allowing Business Back into Canadian Health Care." Upon the Premier's return from his fact finding tour, The Tyee repeatedly requested an interview to learn what European measures most impressed him. If Canada's system is in crisis, which countries did he think dealt with similar emergencies effectively? And what might he say to those European experts we've found who argue that privatization, rather than solving any crisis, is adding news stresses and fractures to their health systems? The premier has so far refused to speak with The Tyee. What collapse? Not everyone agrees that the Canadian system is in imminent collapse, or that market mechanisms represent the best way to stave off disaster. The Canadian Federation of Nurses Unions recently published "Can We Afford to Sustain Medicare? A Strong Role for the Federal Government," which argues that the so-called crisis in public health care in Canada is overstated in accounts like those of the Fraser Institute or BC's premier. Public spending on health care, the author points out, has fallen as a percentage of gross domestic product, from 7.4 percent in 1992 to 6.7 percent in 2002. Even projecting out to 2040, when aging baby boomers will represent a major draw on health care resources, the federal department of finance, the paper says, has estimated that public expenditure on health care will still represent less than 10 percent of GDP. The last decade's cuts to non-health components of provincial budgets combine with provincial and federal tax cuts that have foregone nearly $250 billion in tax revenue between 1997/98 and 2004/05 to create the appearance of crisis where one doesn't really exist, argues the union document, and solutions to what real problems exist, like skyrocketing prescription drug costs, aging infrastructure and impending shortages of health care professionals, can be effectively addressed by the federal government wisely investing some of the enormous revenue surpluses it has generated back into health care for all Canadians. 'Passing the buck' Armine Yalnizyan is the author of "Can We Afford to Sustain Medicare?" Yalnizyan is an economics consultant and research associate at the Canadian Centre for Policy Alternatives, and the first recipient of the Atkinson Foundation Award for Economic Justice. She told The Tyee that over the past decade the federal government has downloaded costs onto provincial governments "passing the buck without passing the bucks." "There have been cascading effects associated with the single-minded effort to balance the books," she said. "We've seen widespread 'passive-aggressive privatization' in so many areas, particularly in health services. We need federal investments in training, infrastructure and a true national pharmacare program. We need commitments to the social determinants of health: access to clean water and secure housing, early child development programs; not just daycare. "We need to invest in areas that will pay off in terms of prevention and better treatment. People forget that Tommy Douglas, the father of Medicare, first tore down rural outhouses and provided electricity and clean water to residents of rural Saskatchewan before he moved on to put public health care delivery into place. "Public health preventative measures work hand in hand with a properly funded health care delivery system to protect everyone's health. We need a national plan and national investment. If we don't plan and manage, the economic black hole nightmare can come true, but there is no need for that to happen. Look at what happened after WWII in Canada, when massive public investments in infrastructure and housing projects triggered private sector investments. The economy is a twin engined plane and it needs both the public and private sectors to fly." 'For-profit medicine is slower' Michael Rachlis is a researcher who thinks we could fix what ails the Canadian health care system without adding on layers of for-profit enterprises. Rachlis, a physician and health policy analyst based in Toronto, is the author most recently of Prescription for Excellence: How Innovation is Saving Canada's Health Care System. In this well-reviewed book, Rachlis argues that it would be unnecessary and counterproductive to introduce more market-based mechanisms into our health care system. He cites a number of exciting and successful experiments within the publicly funded system in Canada that have demonstrated that it is possible to create new efficiencies and improve clinical results without resorting to for-profit alternatives. "The main reason to object to private sector expansion is that we just don't need it. For-profit medicine tends to be slower and more expensive, and its expansion won't improve the public system. If doctors work in both a private and a public system, it creates an incentive to keep the public system poor. Really, for a private system to thrive, it requires subsidies from the public system," Rachlis told The Tyee. "Medicare is at crossroads," Rachlis wrote in the Globe and Mail in 2004. "The right shrieks privatization while the left pleads for more money. It is possible to solve Medicare's problems with innovation, without private finance or for-profit delivery. In fact, for-profit care tends to increase costs while decreasing quality." Efficiencies pay off The Tyee asked Dr. Rachlis about the experiments within the publicly funded health care system that inspire his confidence the system can be saved by internal innovation. Here are a few of the many he cited: The Trillium Health Centre in Toronto, the largest freestanding day surgery centre in North America, with eight operating rooms, performs 3,000 cataract surgeries a year and 25,000 other day surgeries. The success of Trillium, Rachlis says, illustrates the immense impact that public sector day surgery clinics can have on reducing wait lists and improving clinical outcomes. The Sault St. Marie Group Health Centre breast cancer project illustrates, Rachlis says, the enormous increases in efficiency that can be realized by creating teams of professionals who address the needs of patients in a coordinated fashion, and the great gains to be realized by applying queuing theory to case management. Women who attend at this Health Centre for a mammogram, for example, can often get needed ultrasound and biopsy procedures the same day at the same facility, rather than having to make separate appointments for each new procedure and waiting days or weeks until all the necessary diagnostic data is available. This centre has reduced the average delay from first mammogram to final diagnosis from 107 days down to 18. Rachlis says similar results are being generated in projects in Victoria, Winnipeg and Montreal. The Hamilton Health Service Organization Mental Health and Nutrition Program is another experiment Rachlis cited in his conversation with The Tyee. The program, up and running on capitation funding since 1994 (payment per patient being helped rather than on a fee for service basis) and now employing 60 counselors, 200 family physicians and 2.2 full-time equivalent psychiatrists, serves over 80 percent of the Hamilton population. The team approach to treatment and use of queuing theory to manage flow of patients from professional to professional means that Hamilton was able to increase the number of patients receiving mental health treatment by 900 percent in the first year, while reducing referrals to outpatient psychiatric clinics by 70 percent. Rachlis believes that the use of queuing theory to remove bottlenecks in case management can work wonders to reduce wait times and increase good clinical outcomes. Beyond that, the creation of clinical teams that use the skills of doctors, nurses, and other health professionals appropriately can, in time, eliminate almost all wait times without resorting to private, for profit alternatives. In his book, Rachlis describes an approach called "advanced access" that is successful in most cases in eliminating long waits for access to medical treatment and, at the same time, reduces costs to the health care system. The combination of public system day clinics, advance access work on queuing in the system and the creation of teamwork systems that maximize the effectiveness of every worker, he argues, can save our Medicare system, reduce costs and wait lists and avoid the risks of profit taking, reduced service quality and fragmentation that attend for-profit intrusions into the system. Politics without end In the end, the decisions made about Canadian health care reform will come down to political will as much as abstruse economic analysis. Proponents of market-based reforms will continue to argue our current system is unsustainable and only the magic of the market can fix it. Fans of the social equity impacts of a public health care system who believe a publicly funded system is not only fair but less wasteful than one trying to generate profits as well as health will view these claims with skepticism and call for reforms within the public system such as those suggested by Michael Rachlis. And the political struggle over which vision wins out is not likely to let up, no matter what reforms are ushered in … or out. In Sweden, for example, where voters turfed a conservative government that had begun privatizing hospitals, electing the party that banned such policies, the conservatives continue to agitate for another crack at it. Johan Hjertqvist, the Swedish pro-business commentator whose work was cited in an earlier installment of this series, said in an email to The Tyee: "In the long run, this policy is hardly sustainable. It handles present opinions within the government coalition but addresses no real world problems and solves even fewer ones. A potential centre-right government (elections in September) will lift the ban and support alternatives." Meanwhile, in the United Kingdom, the privatizing reforms our premier admired while in London continue to spur vigorous political debate, including a story in the March 30 issue of The Guardian that reports the massive computer system being installed in the National Health System as part of privatizing reform is now in disarray, with the key private contractor blaming its subcontractors for not delivering necessary software on time. The firm in trouble is Accenture: opposition MPs are expected to call for a full review of a project that has been plagued with delays, software problems and doctor dissatisfaction. This is the same Accenture that has been the focus of a major political debate here in BC over a government decision to contract out many BC Hydro functions to the firm. 'Canada has a good system' What should Canadians take from such headlines in countries so recently visited by BC's premier? Perhaps that the term "crisis" can too easily be abused. "Canada has a good system now. Is there a crisis? No, we've heard that forever. The system needs improvement, but that's true of every system in the world," said Steve Morgan, an assistant professor at UBC's Centre for Health Services and Policy Research. Before weighing in on the health care reform debate, Canadian voters may well want to inform themselves thoroughly about experiences in other jurisdictions and useful experiments here at home. To do so, they are going to need more data than has been generated to date by Gordon Campbell and his weeklong fact finding tour of Europe. Vancouver journalist Tom Sandborn is a regular contributor to The Tyee.