Last week, Ontario Health Minister Deb Matthews unveiled "An Action Plan for Health Care" in a speech to the Toronto Board of Trade.
It was an hour of grand ideas.
Who could possibly take issue with a plan to make Ontario health care more patient-centred, community-based, efficient, cost-effective, accessible, and sustainable?
Who doesn't want health care delivery to be faster, safer, cheaper, better? Who doesn't want a seamless system, from the birth of every child by a midwife through to a gentle death in palliative care, with care delivered in the community by a team of loving health professionals at every stage in between?
"Our goal is to make Ontario the healthiest place in North America to grow up and grow old, by making sure families get the best health care where and when they need it," Ms. Matthews said.
But we've been served these bromides so many times before that they have lost their fizz.
When are we going to see specific, concrete goals? When are we going to see large-scale action rather than an endless series of grand pronouncements and feel-good pilot projects? For example, instead of vague talk of birthing centres, why doesn't Ontario set a specific target of half of all babies being delivered by midwives within five years? (It is a perversity that the leading cause of hospital admission in this country remains childbirth. Where is the evidence to justify this practice?) Every province and territory faces the exact same challenge: reining in health spending. And they have all responded the same way: with banalities and more of the same.
In a report released last week, the Conference Board of Canada put Ontario's challenge in stark terms, saying if the province wants to balance its budget by 2017, it needs to limit program spending increases to 0.7 per cent a year. Ontario has limited health spending increases to this level only once in its history. (We will come back to the how of this in a moment.) There are really only two ways to control health spending: 1) Reduce the services covered by public health insurance – which doesn't reduce overall health costs but shifts them to employers and consumers; 2) Deliver existing services more efficiently (read: cheaper).
In her speech, Ms. Matthews addressed the first point briefly, saying: "If there is not evidence to support a procedure or a test, we don't want to pay for it."
Nice sentiment but how are you going to do it concretely? How are you going to determine what's in the medicare basket of services and what's out? Health Quality Ontario has helped examine the evidence but it doesn't have any real power to determine what services are listed or de-listed.
Medicare – public health insurance – is supposed to pay only for "medically necessary" care but, in reality, the list of services covered is virtually open-ended.
Last week, news reports suggested, for example, that Ontario would no longer pay for elective cesarean sections, a perfectly sensible policy. There was an outcry and the minister quickly backed down. So the province limits itself to delisting trivial things like vitamin D tests. That's hardly going to wrestle to the ground a $47-billion annual health budget.
So let's look at how to make health-care delivery more efficient and cost-effective. One of the pillars of Ms. Matthews's plan is to ensure "the right care, at the right time, in the right place." She promised to do so with a series of initiatives:
* Better access to primary care: The minister said everyone should be able to get an appointment within a day. How? That's not really clear;
* Stand-alone surgery clinics: Build clinics that do specialized surgery like cataracts or hip replacements and move these procedures out of hospital. A good idea, one that's been the norm in some countries for decades;
* More home care: Ontario will offer three million more hours of home support to get patients out of hospital sooner. Again, nice on the surface, but the reality is that home-care services available to any given patient are quite limited.
It's not enough to say you want to shift care to the community without addressing the flip side of the equation. Community care will only save money if you close hospital beds or, more to the point, entire hospitals. But Ontario is building new hospitals not closing them. How does that jibe?
When action plans are announced, as they are routinely, the elephant in the room always remains unaddressed.
In health care, almost two-thirds of all spending goes to wages. This is not, in itself, outrageous. Health care is and should be labour-intensive.
In the early 1990s, when overall health spending fell, the goal was achieved brutally, through massive layoffs of nurses and support staff.
Since 2003, Ontario has added 3,000 physicians, 12,000 nurses and 1,000 nurse practitioners to its payroll. That's what's driving health spending, not an aging population.
Are layoffs in anybody's action plan? The only alternative to cutting staff is to ensure every health professional works to their full scope of practice – meaning, practically, that we stop having highly-paid health professionals do what lower-cost employees can do.
Contract talks with the Ontario Medical Association are imminent. Will the province be able to chip away at doctors' turf protection and hold the line on salaries? History tells us no.
Yet, a 1 per cent increase in physician compensation costs as much as home care for 30,000 seniors. That is just one example of the stark tradeoffs that await.
Until politicians realize that their calculators have a subtraction key, health-care spending will never be reined in.
For the Action Plan for Health Care to have any meaning, there has to be action at the bargaining table, not just soothing words at the Board of Trade.