Trevor Hancock is a professor and senior scholar at the University of Victoria’s school of public health and social policy
Canada’s Health Ministers met in Vancouver this week. All indications are that their talks were a lot about health care and funding, and very little about health itself. After all, let’s face it, our ‘health’ ministries are really ministries of illness care, there to manage a (very expensive) illness care system. And that system is there mainly to pick up the pieces once we become sick or injured or ‘unwell’ – not so much diseased as ‘dis-eased’.
Now don’t get me wrong, when the time comes when I need it, I would like a good illness care system there to look after me and – hopefully – restore me to pretty good health. And when I am too frail to manage, I hope it will be there to care for me with kindness and compassion. But wouldn’t it be better if I didn’t need it – or didn’t need it very much?
The problem is, we have been looking at this issue from the wrong end. We started with hospitals and sophisticated and expensive specialty care as the pinnacle of the system and then worked down. Its worth remembering that in Canada, following a 1948 federal program to support hospital building, publicly funded health insurance started by covering hospitals in 1958, but did not extend to care outside the hospital until 1968. No wonder health policy consultant Stephen Lewis once joked that ‘Saskatchewan is a Cree word for too many hospitals’.
Think about it – there are lots of media stories about the newest wonder drug or procedure, the heroic life-saving surgery, the latest hospital expansion and so on. As Monty Python memorably parodied it, every hospital wants a machine that goes ‘ping’. To which I might add that these are the machines and the stories that enable fund-raisers to go ‘ka-ching’!
But there are not so many stories about primary and community care – which is in fact where the majority of care happens. And as I pointed out recently, very little attention is paid to prevention and public health, and even less to the upstream determinants of population health. (A cynic might point out that these other parts of the system lack the budgets and resources for a good public relations department that can generate all these high-tech, feel good or crisis stories.)
So let’s look at this issue from the right end. Strategically, the first thing we need to do is to keep people healthy. In an Utopian world, we would all live in good health to a ripe old age, then quickly and quietly drop dead. Interestingly, that is a nightmare scenario for the illness care system – what would they do? The pharmaceutical industry would go bankrupt! Of course, that is not going to happen, but I suggest it is an ideal worth aiming for.
So if not everyone is going to be healthy forever, the second thing we need to do is enable them to stay healthy as long as possible. That begins with a focus on all the upstream factors that adversely affect our health, from poverty to illiteracy, from unhealthy communities and workplaces to the marketing of unhealthy products. It includes ensuring that everyone has access to good public health and clinical preventive services, especially those who are most disadvantaged but whose needs are often greatest.
Third, people need to be given the skills, capacities, resources and support that enable them to care for their own minor ailments and injuries, to manage their own chronic illnesses, and to remain living in their own homes or in the community. In fact, most care is self-care, and self-care is the largest part of the health care system. It is also the most neglected part; no health ministry in Canada has made it a priority or even paid it much attention.
Only once these key strategies are in place should we look to the health care system, starting with primary care and home and community care. We need to see the hospital as the place of last resort, only to be used when all else has failed. It’s time our Ministers stepped back and did some strategic thinking. We need to turn the system on its head.
Editor’s note: This blog was originally published as a regular column in the Times Colonist
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