Waiting in Pain the politics

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Waiting in Painthe politics

• Canadian Pain Society Annual Conference
• May 26, 2007
• Carolyn Bennett MD MP

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• It is easier to find men who will volunteer to
  die, than to find those who are willing to
  endure pain with patience.
• Julius Caesar

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• Canadas most cherished social program
• Sustainable only if
• Canadians have confidence that they will get the
  care they NEED, when they need it.

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• Wait times has become the talisman for how well
  our system is working.
• Politics in Canada is the art of making the
  NECESSARY possible.
• Shortening wait times is VERY necessary and
  therefore very POLITICAL

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chronology

• Spring 2004, Canadian Policy Research Networks
  hosted "Taming of the Queue Wait Times
  Monitoring and Management." Sponsored by the CMA
  and other national health organizations,
• Election June 2004 Liberal Commitment to
  Benchmarks
• Ipsos Reid Poll Health care professionals' views
  on access to health care
• The Taming of the Queue  a discussion paper
  released by the CMA and CNA in July, 2004 that
  shows how the Canadian health care system is
  failing to provide timely health care services.
• First Ministers meeting 2004 42B commitment
  to inidicators, benchmarks, targets by 2007
•  
• In the spring of 2005, The Taming of the Queue
  II, a report on the colloquium by the director of
  CPRN's Health Network, Tom McIntosh, provides a
  province-by-province overview of recent
  developments in wait-time management, as well as
  summaries of conference presentations by experts
  from Canada and abroad.
• Wait Times Alliance March 2005 Interim report
• June 2005 Chaoulli decision

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Concerns

• 5 things only
• When does the clock start
• Family doctors and patients
• Appropriateness of care
• Lack of clinical guidelines.

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3 years later

• Still focus on same 5 things..
• doesnt seem reasonable..
• Work on clinical guidelines still a dogs
  breakfast
• Expectations of patients should/could be our
  greatest tool
• Public policy follows public opinion

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• CONSENSUS
• Waiting in pain is unacceptable
• How long is too long ??
• The problem with benchmarks..

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Chaouili.Justice Binnie

• The public policy objective of health care to a
  reasonable standard within a reasonable time is
  not a legal principle of fundamental justice.
  There is no societal consensus about what this
  non-legal standard mean or how to achieve it.
• It will be difficult for those designing and
  implementing a health plan to predict when judges
  think its provisions cross the line from what is
  reasonable into the forbidden territory of what
  is unreasonable.

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Chaouli.. Justice Binnie

• 176
• While the existence of waiting times is
  undoubted, and their management a matter of
  serious public concern, the proposed
  constitutional right to a two-tiered system for
  those who can afford private medical insurance
  would precipitate a seismic shift in health
  policy in Quebec. We do not believe that such a
  seismic shift is compelled by either the Quebec
  Charter or the Canadian Charter

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Real System for Health

• Patchwork quilt of non- systems
• 2003.SARS 44 people died
• France ..1.. WHO
• 14,000 people died in heat wave

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Reality

• Integration is imperative
• Care . Centred on the patient..
• EMR essential
• boutique care is unsafe
• Specialist to specialist to specialist begets
  broken telephone
• Quality must be paramount
• Quality care requires a real system
• Best care teaching practices attached to
  university
• Openness to complementary therapies

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Justice system

• Community
• Police
• Courts
• Corrections
• Parole
• Courts
• Community

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Financial system

• Credit rating
• ATMs
• ombudsman
• vs.
• health and health care non-system

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Financial system

• Would we tolerate not being able to get from
  the bank machine at midnight in London, Beging,
  Iqualuit ? regardless of what bank we banked
  with ??
• How do we tolerate our last ECG not being
  available when we arrive at the ER with crushing
  chest pain.

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Institute of Clinical Evaluative Sciences.. Jack
Tu MD

• Do we have our priorities in the right place?
• In Canada, estimated patients who die
• Waiting for cardiac surgery 120
• Inappropriate secondary prevention after MI 750
• Because of smoking 20,000

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• "To Every Complex Problem there is a Simple
  Answer Neat, Plausible, and Wrong".
• H.L. Mencken

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The Best Care AnywherePhillip Longman
Washington Monthly 2006

• Ten years ago, veterans hospitals were
  dangerous, dirty, and scandal-ridden. Today,
  they're producing the highest quality care in the
  country. Their turnaround points the way toward
  solving America's health-care crisis.

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New England Journal of Medicine, 2003

• compared veterans health facilities 11 measures
  of quality with fee-for-service Medicare.
• all 11 measures, the quality of care in veterans
  facilities proved to be "significantly better.

Longman
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Annals of Internal Medicine

• compared veterans health facilities with
  commercial managed-care systems in their
  treatment of diabetes patients.
• 7 / 7 measures of quality, the VA provided better
  care.

Longman
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National Committee for Quality Assurance

• ranks health-care plans on 17 different
  performance measures.
• how well the plans manage high blood pressure
• how precisely they adhere to standard protocols
  of evidence-based medicine such as prescribing
  beta blockers for patients recovering from a
  heart attack
• the gold standard in the health-care industry
• who do you suppose this year's winner is
• Johns Hopkins? Mayo Clinic?
• Massachusetts General?
• Nope. In every single category, the VHA system
  outperforms the highest rated non-VHA hospitals.

Longman
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Institute of Medicine

• the VHA's "integrated health information system,
  including its framework for using performance
  measures to improve quality, is considered one of
  the best in the nation."

Longman
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RAND study

• Americans receive appropriate care from their
  doctors only about half of the time.
• The results are deadly.
• 98,000 killed by medical errors
• 126,000 die from their doctor's failure to
  observe evidence-based protocols for just four
  common conditions hypertension, heart attacks,
  pneumonia, and colorectal cancer.

Longman
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VHA advanced IT

• deeply reduce medical errors
• improve diagnoses
• implement coordinated, evidence-based care.

Longman
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But learning from the lesson offered by the
veterans health system could point the way to an
all-American solution.

• As the health-care crisis worsens, and as more
  become aware of how dangerous and unscientific
  most of the U.S. health-care system is, maybe we
  will find a way to get our minds around these
  strange truths.
• Many Americans still believe that the U.S.
  health-care system is the best in the world, and
  that its only major problems are that it costs
  too much and leaves too many people uninsured.
• But the fact remains that Americans live shorter
  lives, with more disabilities, than people in
  countries that spend barely half as much per
  person on health care.
• Pouring more money into the current system won't
  change that. Nor will making the current system
  even more fragmented and driven by short-term
  profit motives.

Longman
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Dr. Donald M. BerwickPresident, Institute for
Health Care Improvement one of top health-care
quality experts in US

• praises the VHA's information technology as
  "spectacular."

Longman
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A real system

• But when you get seriously sick, it's not just
  one doctor who will be involved in your care.
• These days, chances are you'll see many doctors,
  including different specialists.
• Therefore, how well these doctors communicate
  with one another and work as a team matters a
  lot.
• "Forgetfulness is such a constant problem in the
  system," says Berwick of the Institute for Health
  Care Improvement.
• "It doesn't remember you. Doesn't remember that
  you were here and here and then there. It doesn't
  remember your story."

Longman
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IHI Don Berwick

• IHI is a reliable source of energy, knowledge,
  and support for a never-ending campaign to
  improve health care worldwide. 
•  The Institute helps accelerate change in health
  care by cultivating promising concepts for
  improving patient care and turning those ideas
  into action. 

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IHI - What we will accomplish

• We will improve the lives of patients, the health
  of communities, and the joy of the health care
  workforce. We will accelerate the measurable and
  continual progress of health care systems
  throughout the world toward  Safety
   Effectiveness  Patient-Centeredness
   Timeliness  Efficiency  Equity
• We will be a recognized and generous leader, a
  trustworthy partner, and the first place to turn
  for expertise, help, and encouragement for
  anyone, anywhere who wants to change health care
  profoundly for the better.
•  

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IHIOur Measurable Goals

• We aim for health care for all with  No
  needless deaths  No needless pain or suffering
   No helplessness in those served or serving  No
  unwanted waiting  No waste

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Alberta Bone Joint Health Institute

• Founded by J R Bud McCaig, business man and
  former Chair of Calgary Regional Health Authority
• 10 million endowment
• Dr. Cy Frank, Scientific Director CIHR

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Alberta Bone Joint Health Institute

• The Alberta Bone Joint Health Institute is the
  umbrella organization for bone and joint health
  care, research and education throughout Alberta.
• A not-for-profit organization and registered
  charity, our work is supported by partnerships
  with universities, regional health authorities,
  medical and health practitioners, researchers,
  educators, government and private donors.

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Alberta Bone Joint Health Institute

• A time of urgent need
• Model tested on hip and knee replacements
• Putting patients at the centre
• Delivering health care in a multi-disciplinary
  team environment
• Encouraging patient choice with innovative
  compensation models
• Aligning efforts across health regions
• Diverting services to single-purpose focused
  facilities from overcrowded hospitals
• Making all publicly funded health services
  evidence-based
• Improving efficiency and asset utilization, and
  reducing demand on taxpayers
• Ensuring the public health care system is
  sustainable
• A satisfying journey through the health care
  system

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Alberta Bone Joint Health Institute

• Significant improvement in patient and health
  care provider satisfaction, driven by
• A decline of approximately 80 in consultation
  waiting time
• A decline of 90 in surgery waiting time
• A decline of 30 in hospital stay
• Faster recovery and enhanced patient engagement,
  accountability and education
• More efficient utilization of scarce - and
  expensive - health care resources including major
  gains in the number of surgeries per day per
  operating room

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• Waiting in Pain.
• Unacceptable
• Must become as important as a quality indicator
  as not receiving appropriate post MI care.
• Are we asking the right questions ??????

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Way forward

• SYSTEMgtgtgtPatient centred reforms.
• Patient Captain of Health Care Team
• Family Doctor Playing Coach
• PLAYERSgtgtgtgtMedical Education
• Multidisciplinary
• Hospital to Community
• EVIDENCEgtgtgtgtgtgtgtResearch. multidisciplinary

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Role of government

• Measure. Surveillance
• Complex adaptive system
• Remove perverse incentives
• System, players, research