From the medical frontlines
A recent experience illustrates, at least to me, some of the issues which exist in the delivery of healthcare in Ontario. There is a good and a bad news story to tell. Following earlier postings (cmaule.wordpress.com), I concluded that Ontario, and I assume other Canadian provinces, have well trained and qualified doctors, nurses and support staff. It has modern equipment and operating theatres, some perhaps requiring further expenditures, such as the recent shortage of MRI equipment which seems to have been solved, at least in the Ottawa area where MRI wait times have been reduced. The treatment of emergency and life threatening cases seems to work well, although hospitals can be dangerous places due to a persistent high level of infections which arise after admission. Don’t hang around longer than you have to.
The statistics which are worrying are the wait times to see specialists, and the wait times for patients to be operated on by specialists. The reasons are complex involving different aspects of the healthcare system which include, amongst others, the constitutional dimensions of the system, the authority and responsibility of the different players, actions taken by patients and the methods of funding healthcare. Royal Commissions have studied these issues, so that what follows is a barebones description of what happens, as seen mainly from a patient’s viewpoint.
A typical path for a patient is fairly straightforward. A visit to a GP is followed by referral to a specialist perhaps with some X-rays, ultrasound and blood and other tests. The tests are conducted quickly but delays frequently occur in getting an appointment with a specialist. There appears to be a shortage of specialists, especially in some areas like urology, endocrinology and gerontology. What is a reasonable wait time? Opinions differ, but I would suggest 12 to 24 weeks for many non life-threatening cases. A year seems too long and an indication that the system is malfunctioning. What are some of the problems? Geoffrey Simpson in Chronic Condition and others have pointed to a number of them.
Operating theatres are not fully utilised and therefore have spare capacity, more than may be needed to handle any possible disasters. There are either not enough doctors, nurses and hospital beds to provide treatment and allow more patients to pass through the hospital system, or the administration of the system is faulty.
The single most important factor for lengthy operating wait-times appears to be the lack of hospitals beds and care for post-operative patients. Why the shortage? The main reason is that hospital wards are full of chronic care patients awaiting transfer to other facilities. The congestion is caused because of the lack of these facilities elsewhere in the system.
A diagnosis of the overall problem of wait times is complicated due to the system established by Canada to deliver healthcare. What follows touches on some of the main factors which seem to me to be important. In some ways Canada has a self-inflicted problem due to past decisions by different levels of government, with advice from interested parties and little input from patients except as tax payers. Other countries have better functioning systems, so it should be possible to see how delivery could be improved.
Who is responsible?
Healthcare is a provincial responsibility according to the Canadian constitution. At the same time provinces have agreed to treat patients from other provinces in certain cases. Thus elements of a nation-wide system are grafted onto one of provincial responsibility. In the case of emergencies, Canadians will receive treatment in any province regardless of their province of residence. In other cases, such as a patients deciding they would prefer to be treated in an out of province facility, that facility can refuse service, provide service and collect funding from the other province, or if this funding is less than that charged in the province of delivery ask the patient to pay the difference.
An example of what happens in practice is that Ottawa hospitals receive patients living across the provincial border in Quebec. Assuming non-emergency situations, the Ottawa hospital can accept patients and receive one or other form of payment or reject the patients, if it is just a case of preferring to be treated in the Ottawa facility. Both things can happen. But if the Quebec patient is treated in Ottawa and patients are treated in the order they arrive, then subsequent Ontario patients will have longer wait times. Service may be delayed to Ontario residents as a result of Quebec not providing certain services within a part of the province.
It could work the other way and at different provincial border locations throughout Canada. For example, a Cornwall, Ontario resident may find desirable healthcare providers in Montreal
This provincial healthcare scheme with certain universal or federal add-ons can have the following results. One province may decide that rather than expanding its own facilities it will depend on those of another province even though it has to pay that province. It may decide that it is cheaper to encourage its patients to travel across a provincial border than to invest in its own facilities. If so, the patients from the province providing the treatment will experience longer wait times. At one time, it was more lucrative for certain hospitals to treat out-of-province patients than Ontario patients. Apparently this is no longer the case but is illustrative of how a province based system with out-of-province features can affect delivery times.
Types of surgery
A more general issue is that there are certain types of surgeries which are routine and repetitive, especially with an ageing population. Hip, knee and other joint replacement, hernia operations, and certain types of eye surgery are fairly standard procedures and could be treated in facilities which cater to the specialties. This happens in the case of the Shouldice Clinic for hernia operations in Ontario. It is a private clinic but is paid for under the Ontario healthcare scheme. Other specialized clinics could be established in order to make better use of resources. At present, too wide a range of different medical procedures are conducted in the operating rooms of general hospitals. If these regular surgical procedures were confined to specialized locations, public or privately owned, then wait-times would be reduced.
Privately operated specialized clinics are seen as creating a two-tier healthcare system. If such clinics are operated efficiently and relieve the pressure on general hospital facilities, then delays of surgeries due to the lack of beds for post-operative care would be reduced.
A related issue is that emergency facilities are used by patients who don’t have emergencies and should be treated in clinics. In part this is because patients are not registered with a GP, although this seems to be changing with the opening of walk-in clinics. Doctors however find that patients who do not get a prescription from one doctor will visit other clinics until they feel satisfied. In 1984, I was part of a commission in Ontario that examined the dispensing fee allowed for prescribed drugs. At that time the government had a record of all drugs prescribed and paid for in Ontario, but would not use the information to reduce the costs of overprescribing within the province. I think this situation prevails today.
An administrative wrinkle which complicates delivery in Ontario is the Ontario Hospital Act which gives certain responsibilities to the CEO of the hospital, but this does not include the services of doctors who are independent contractors reporting to the Chief of Staff not the CEO. In the case of fees charged, surgeon practices or malpractices, these are dealt with by the College of Physicians and Surgeons, a body of doctors regulating other doctors. This is not the case of the fox guarding the hen house, but the fox guarding the other foxes (or hens the hens). Obvious conflicts of interest may arise affecting both patient costs (either private or via taxation) and services provided.
Some forms of healthcare are either not funded by the government or are only funded in part and may be covered by privately purchased insurance, such as dental work, eye care, hearing aids and some prescription drugs. In Canada, it is estimated that about 70% of healthcare costs are covered by the government and 30% by a combination of private insurance and user pay. What the rationale is for public funding of some healthcare procedures and not others, such as eyes, ears and teeth, is a mystery to me. The original rationale for a public system was to address catastrophic illnesses. Over time it has been extended so that general public care is seen as an entitlement for almost all conditions. Once granted, politically it is close to impossible to withdraw.
A visit to a dentist, optometrist and hearing specialist is possible without a long wait. Their facilities are often spacious and well staffed in contrast to many general practitioners. This suggests that these skilled resources are organized, administered and paid for in a manner which allows for timely delivery of the services. In other segments of the system, as suggested, this is not currently the case. Thus my one year wait to see a specialist for a non-life threatening situation. But when age itself is a life threatening condition, then the wait is not appreciated.
Overall my view is that there are administrative shortcomings to the Ontario healthcare system which could be addressed to improve its performance and reduce costs or the rate of cost increase. Some might actually save money. The most important factor may be increasing the number of beds available for post-surgery patients which would require the assignment of other patients to facilities which specialize in their requirements.
I am grateful to David Rothwell who provided detailed remarks on an earlier draft of these comments. I alone am responsible for the above draft. I recognize that the administration of healthcare services is a highly complicated process. Many countries and jurisdictions do it, so that it should be possible to learn from best practices undertaken elsewhere, which may be adopted by Canadian provinces and the federal government. When healthcare and education account for 70% of provincial revenues in Ontario, and probably in other provinces, then we need all the help we can get to achieve cost efficiency, whatever that might mean. If my experience offers any lesson, it is that there must be room for improvement.
Archive for September, 2014
The last time I was asked to become involved with armed adversaries, some years ago when undertaking national service, I would not have appreciated it if my side had told the opposition what we would do and not to do if they attacked us. This is not how one usually plays lethal or non-lethal games. And yet this is pretty much what the US and its allies are saying when they state that they will not put boots on the ground in combating terrorist fighters in the Middle East. You don’t tell your opponents on the sports field in advance what plays you will make, and you don’t tell people who are pointing a gun at you that you will not defend yourself, especially when they may behead you. Even Gilbert and Sullivan might have had difficulty in dreaming up such a scenario for a musical opera.
And yet this is the situation politicians have created for themselves and their forces in the Middle East. The US President and his allies including Canada have said they would help. Like the others, Canada is being asked by some to spell out exactly how far it will go in letting its forces intervene in Iraq and Syria. Canada’s parliamentarians want a debate and some want to know what instructions the troops will have. Will they be allowed to shoot if the occasion arises? This is not just silly, but dangerous for those on the ground. The ISIS forces must either be laughing or at least welcoming the good luck they enjoy from having stupid adversaries.
I would expect Canadian troops will be there to assist the anti-ISIS forces, but exactly what they are allowed to do should not be spelled out in public. To do so would be to arm the enemy and place the Canadian forces in more danger than they will already experience. If the NDP requests more detailed information, then they should be held morally and financially accountable to the troops and their families as well as to the Canadian public for any adverse consequences. Have a debate by all means, but don’t ask for detailed tactical information.
On a related topic, why is it that the Iraq army, after all its training by the allies, is so incompetent? A New York Times journalist gave some answers. First, the professional army of Saddam Hussein was disbanded by the US. Many of these soldiers are now working for ISIS. The replacement Iraq army has few trained professionals and those who command pay the troops while receiving kickbacks from them. At the same time, there is no effective chain of command where orders are passed down and executed. The Iraq army is a poorly run criminal organization except for the transfer of monies to the bosses. In contrast ISIS appears to be fairly well administered, although they have other problems which will become more apparent. This is a war where the enemies’ mechanized vehicles are often Toyota trucks with machine guns mounted on them. Use of captured sophisticated tanks and planes require not only fuel supplies, which ISIS has, but parts and mechanics to service the equipment, which may be in limited supply. Moreover, large items are easier to detect and destroy.
For me, the moral of this story is that when a country fights a war that is largely unconventional relative to many past conflicts, such as the use of beheadings by the enemy, poison gas and fighters living amongst civilians, then it has to be fought using unconventional methods. These may in the future become conventional, such as the bombing of ISIS targets in Syria without asking permission from the government of Syria, if one still exists. Apparently this took place on Septemeber 22, 2014.
The public has to be educated in both the nature of the conflict and the means which our side will need to use. I would hope that our politicians will take the lead in providing this education and not undermine the forces sent to the front lines on their behalf.
Chris Hadfield, An Astronaut’s Guide To Life On Earth, (Random House, 2013).
The title tells it all. Based on the many years that it takes to become an astronaut and be sent on missions, what is it that the rest of us mortals can learn? Hadfield’s answer is informative and educational. How one conducts one’s daily life, interacts with other people, learns from them as well as instructs them is crucial to understanding both personal success and team achievement. Astronauts have to be team players, each of whom may have specialties unfamiliar to others but necessary for mission success. Respect and trust are important attributes. This can be especially difficult to achieve when working with people trained in different countries, but who are brought together on a common mission where all have to cooperate in a highly sensitive environment. Mistakes can not only cost millions of dollars but jeopardize lives.
Hadfield’s book achieves two things, a detailed and personal description of what is required to be chosen as an astronaut, and what happens in fulfilling the job both on land and in orbit. There is much more that astronauts can tell us and maybe they have in other books. The following are questions which arose in my reading of this book:
- How does an astronaut balance family and work life? Hadfield does a good job of including members of his immediate family in the narrative, but there are many questions that the reader would like to learn from family members. (Maybe they would prefer not to share them.)
- How do the parties interested in space collaborate to persuade governments to provide the substantial funding required for something where the payoff, if it exists, is a long way off? Space travel is at the other end of the spending spectrum from building a highway or school, where the results can be seen relatively soon after the funding decision is made, and politicians can claim credit which will benefit them at the polls.
- How do you get a crew of astronauts and their ground handlers from different countries with different languages to operate as a team to build the equipment and manage it for launch, in orbit and for return to earth? The close cooperation which astronauts from Russia, the US, Canada and other countries have had tells you that it can be done, but how? What are the issues and how are they managed? Personalities play a part but so does the management and set up of the project.
- Once space travel is found to be possible, what are the next stages of exploration and how can financing be provided, either privately or through continued government support? This type of question must have faced Columbus after discovering the American continent. He was able to find valuable commodities for trade which encouraged others to provide further risk capital. How money can be made out of space or space travel is not yet obvious, at least to me?
None of these questions are criticisms of Hadfield’s book. They represent the type of issues which emerge from its content, and will be of interest to those concerned with this frontier for exploration. The book also helps to remind readers that earth is a minuscule object in the solar system, and, if it disappeared by being hit by a large meteorite, no-one elsewhere, if such people exist, would notice. In a universal context, we really don’t matter.
Numbers provide information about different aspects of the world. But how reliable and useful is the information? Daily temperature, pressure and rainfall are accurate about the past and provide a forecast of the future. Short term forecasts tend to be more reliable than longer term ones. Economic statistics like GDP (Gross Domestic Product), inflation, employment/unemployment, interest rates, and stock market prices are recorded for the past often with forecasts for the future. How reliable are these statistics which each often measures a group of activities not one variable like temperature and pressure? This is the case with GDP which measures the output of all sectors of an economy.
Canada is chastised for not spending 2% of GDP on defense, a level reached by some other NATO countries. But what if the GDP of different countries is not a reliable comparative measure of a country’s yearly output? And what if different countries include different items in their defense expenditures? I will leave the latter for the defense gurus to discuss, and suggest why GDP has always been an approximate measure of output and today is increasingly so and more unreliable as a comparative measure.
Consider the following, much of which can be found in Diane Coyle’s excellent book, GDP, A brief but affectionate history (Princeton 2014):
- In 2010, Ghana’s GDP was increased 60% overnight when the country’s statistical agency changed the weights assigned to each sector of the economy when calculating GDP. Previously the weights for 1993 were being used.
- Six other African countries are undertaking a similar exercise which may increase their GDP by as much as 40%. Nigeria, already a large African economy, may then exceed South Africa, at present the largest on the continent.
- The service sector of all OECD economies now accounts for a larger share of GDP than previously, over 75% in many cases. Services output is notoriously difficult to measure in contrast to goods. How do you measure the advice given by a lawyer, accountant or economist? By the amount paid for the advice. But what happens if it is given for free (probably an unlikely case)? In the first case there is a record for inclusion in GDP, but not in the latter, even though production has taken place.
- Each country’s underground economy is by definition not measured. Services are often activities which are more susceptible to being exchanged without a record being kept, thus diluting the accuracy of GDP accounting. Tax measures often influence the size of the underground economy.
- There are many other examples of services which don’t get recorded. The woman who marries her chauffeur, the man who marries his housekeeper both cause GDP to decline while there is no change in the underlying economic activity – although other aspects of their lives may change drastically.
- While consumers tend to focus on items which are more expensive today than yesterday, many things have decreased in price and some are now consumed for free. They are not included in GDP as currently measured but do constitute part of a country’s economic output. I use to pay for long distance phone calls. Many today are free with access to the internet. Facetime is free. Skype calls are a fraction of what was formerly charged for long distance calls. Emails substitute for letters and the costs associated with writing and delivering them. In each case the nature of the economic output has not changed but it is no longer measured for inclusion in GDP accounting.
- Consider the production and distribution of videos, music, television, newspapers, books, magazines, education (online), all of which are affected by communications technology. Their real output has increased but measured in monetary terms their per unit value has declined. GDP relies on figures which measure monetary not real output, and with the growth of services this is far more difficult to do.
Other uses of GDP
Countries are classified as high, medium and low income based on GDP per capita. Their responsibilities and treatment will depend on where they rank. At times, a country may want to advertise that it has moved up the scale, such as its attractiveness for foreign investment. But for receipt of foreign aid, it may prefer to stay as a less developed country. Ghana’s sudden increase in GDP per capita in 2010 may result in it no longer being a recipient for certain types of aid and require it to make a larger contribution to the budgets of international organizations.
A country’s treatment for trade preferences is also determined by its level of per capita GDP. Ghana has become a middle income country and is now required to negotiate a free trade agreement in order to keep its preferences in the EU, and will be removed from Canadian GSP (General System of Preferences) in 2015
The foregoing represents only some of the difficulties in measuring and interpreting GDP. These have increased over time especially due to technological change. Like changes in weather conditions, changes in GDP get widely reported. The increasing unreliability of the latter should be an issue of concern for those using this information. GDP data often result in adjustments to fiscal and monetary policies, and inform investors about buying and selling securities.
In the medical arena, doctors prescribe on the basis of indicators like temperature and blood pressure. If the readings are false then the treatment may kill the patient. In the realm of economics, false or misleading information can undermine the health of an economy. This occurs now in the case of an important economic measure. Next time you read about change in a country’s GDP, interpret it with a few grains of salt.
Other economic statistics should also not be taken at face value, like the unemployment rate, inflation and the current account surplus or deficit on the balance of payments. In contrast, the current price of a stock, the interest rate and terms for various types of private and public debt are numbers which mean what they say. The moral is that familiar numbers do not always mean what they appear to say…..there is some quotation about skim milk made to appear like cream, but I have lost the source for this saying
One thing which concerns me today is that the present looks a lot like 1939 with Putin playing Hitler and the west unable to decide how to respond. Canada is reported to have sent five jets to the Baltics but they are unarmed, and one ship to the Mediterranean, that’s about half the operational Canadian navy! Not only do we not know what the world will look like five and ten years hence, we don’t know what it will look like tomorrow.
In 1914, Queen Victoria’s relatives headed England, Germany and Russia, countries which went to war over how to divide up Europe and parts of the world. England and Russia had their empires and Germany wanted one. From 1919 to 1939 they took a time out. Later play resumed with much the same teams but different coaches. The boundaries of Europe and the Middle East were redrawn after 1919. Today, borders are being fought over in Eastern Europe and the Middle East.
Or looked at another way, WW1 took place as the Ottoman, Austro-Hungarian and Russian empires were in decline. The British Empire was near its peak and the American one on the rise. After WW2, the British Empire was relegated to the second division, and the USA became the sole super power, with the USSR its only adversary but not a very strong one except for its nuclear weapons. Now there is a weaker American Empire, a weak Russian Empire trying to redraw boundaries in Eastern Europe, and a vague Islamic empire made up of feuding parts. Weakness signals unrest. And none of this includes those parts of the world where half the world’s population lives – China, India, Pakistan, Indonesia and neighbouring Asian countries. They have both their own and interrelated problems because of regional and international interdependence.
In 1914, the German invasion of Belgium triggered England’s declaration of war; in 1939, it was the German invasion of Poland. What might it be for NATO in 2014? Putin has already said (August 2014) that he could occupy Kiev within two weeks. This may say more about his arrogance than good judgment, but the latter seldom prevented the outbreak of wars.