OPINION: We must change our mindset about our health care system*

Johny Van Aerde, MD, PhD, FRCPC

*CJPL thanks Healthy Debate for permission to publish Dr. Van Aerde’s article. The original can be found here: https://healthydebate.ca/2023/10/topic/change-mindset-health-care-system

Our health care system is complex. Because it is human made, its behaviour can be changed by intervening at specific leverage points or spots of influence. Some leverage points are weak because changes resulting from the intervention don’t make much difference; others are strong because they transform how the system works. Unless we choose different and more powerful points of influence, our health care system will continue to be stuck in the status quo.

Weak leverage points are external to the system and rarely change its behaviour. Examples include using numbers and quantitative parameters, constraints and standards, subsidies and taxes. Yet, these interventions are used most frequently because decisions can be made quickly and create the perception that they work, even though they only deliver short-term results.

People like quick fixes because the human brain is programed to think short term and denies the need for long-term investment. Politicians like short-term solutions because they satisfy and distract voters until the next election. But history shows that money transfusions are a weak leverage point that creates little change. Money transfers over the past decades have not improved access to health care; the burden of disease for Canadians has not decreased; and most outcomes and quality indicators have fallen below those of other Organization for Economic Cooperation and Development countries.

And not only the health care system, but health itself has deteriorated and continues to do so: diet-related diseases are now the leading risk for death, according to the Heart and Stroke Foundation, mainly because Canadians get half their calories from highly processed foods. Health Canada reports that obesity is one of the top preventable risk factors for many chronic diseases including type 2 diabetes, heart disease, and some cancers. Similarly, the rate of obesity and overweight increased from one in two adults in 1978 to two in three in 2017. Currently, one in three children is overweight. Other examples of deteriorating health and wellness are the increasing number of unhoused people and, recently, a reduction in average life expectancy because of the number of young people dying from street drugs.

“Last century’s paradigm of treating disease no longer works because the context of illness has changed.”

Strong leverage points are internal to the system and, as a result, change our way of thinking and our actions, leading to changes in the behaviour of the entire system. Among the strongest levers leading to transformation are paradigms or collective mindsets. Paradigms are shared ideas, beliefs, and assumptions that form the collective mental models on which a society’s culture is built and sustained by structures like goals, laws, rules, and policies.

However, last century’s outdated paradigm of treating disease no longer works because the context of illness has changed, the workforce and budgets are under tremendous stress, and, most important, all the societal factors that affect health and wellness are not reflected. A real paradigm shift would change our thinking and behaviour from curing disease for the individual to enabling and maintaining health and wellness for everybody. This necessitates redefining our health system’s purpose, not only in the context of changing demographics and advanced technology, but also in the context of limited workforce and finances.

Currently, our health institutions serve two masters: the patient and the government. The paradigm that health care must be controlled, owned, and closely directed by government must shift toward one in which the health system is kept at arm’s length from governments, making all citizens, not just patients and government, stakeholders and co-owners of the system. As a result, the public, not the government, would also determine ways of payment and delivery for health and disease services.

To accomplish that, the existing public health care model that gives the perception of being universally accessible must be replaced by one that truly offers more health services for Canadians. This means developing new models for both funding and delivery. As an example, the Enoch Cree Nation in Edmonton is piloting a new Indigenous orthopedic centre that is sovereign rather than private or public. Enoch will pay for and own the building, which will include other medical facilities, at a cost of up to $50 million. Alberta provided planning funds for the project and will staff the facility.

Western European countries offer examples of successful hybrid public–private partnerships (3P), in which citizens are offered more services, such as the Netherlands’ Buurtzorg nurse-led model of holistic care,¹ with superior outcomes compared to Canada. This requires determining the best models or mix of partnerships for funding and delivering health care by defining the roles of government, business, workers, and all patients. Successful western European countries clearly delineate which health services are covered by the state and which are not. They also invest more in social welfare² than in treating sickness. Defining the purpose of health and health care clearly allows them to strictly regulate the public–private fault lines so that care is delivered in an equitable and affordable manner, regardless of whether services are offered publicly, privately, or both. Unfortunately, the purpose of Canada’s health system has become vague and ill-defined since it was formulated 60 years ago.

No system, public or private, can cover all the health needs and wants of every person all the time. That requires another paradigm shift where “everything” and “all the time” are delineated.

Access to opportunities and choices leading to health and wellness should be a right for all, but to have the system cover everything for everybody all the time is unsustainable. The shortage of health workers demonstrates that point, as does the increasing financial pressure. Ask yourself, what good is universal access to chronic dialysis or a heart transplant for a person without a home or without access to decent food or income? What if today’s paradigm “right to free but limited access to disease care” shifted to “right to universal health and wellness?” That way of thinking requires not only equitable access to essential and health-promoting services, but also the limiting of access to non-essential or low-evidence items often pushed by media and self-interests.

Would Canadians reject the idea up front as an infringement on their freedom if access to some unhealthy choices was limited and discouraged? Or would they accept some personal responsibility in making healthier choices if they were available and affordable? For example, how would they react to a very high price for addictive and highly processed foods and drinks, smokes and alcohol, while the extra monies generated would be used to drop the cost of fresh, healthy and sustainable foods?

Much of the existing paradigm is enshrined in the Canada Health Act (CHA), a law that defines access to treatment of disease, not health. Why do we accept the unchallenged paradigm that the CHA is the be all and end all? Are we willing to rewrite the law such that it enshrines health and wellness in the Canadian fabric rather than just access to treatment of diseases?

Although laws can and should be adjusted to the changing times and cultural context, we have never revisited last century’s CHA, written at a time when we didn’t know as much about health and disease as we do today. We continue adding more buildings, different equipment, and expensive drugs to a dysfunctional health care system, but the system itself is structurally and culturally still the same as 60 years ago. What if, in re-writing the CHA, we no longer saw health and the health care system as costs but as investments, acknowledging that the health care system and a healthy society contribute to the economy. Health is wealth and wealth is health.

The most fertile condition for innovative and transformative ideas is at the time of collapse. That is why, now more than ever, we need to point out the anomalies and failures of the old paradigm and insert people with the vision of a new paradigm in places of public visibility and power. In the health system, it is not politicians but health care workers, in particular physicians, who need to play the role of advocates in partnership with patient groups and all citizens.

To expose and transcend an existing mindset requires our collective abilities and power. Do we as Canadians truly have the will and the skills to question what else is possible, or are we too preoccupied by self-interest and self-importance? Do we possess the art of real dialogue, and can we create safe forums for all to have conversations around redefining health, wellness, and health care? Or are we too hyped by subconscious persuasion and extreme polarization by political parties?

Recent polls show a sharp drop of trust in governments, and that might become an obstacle to accepting any change from politicians, even if it means an improvement. This is why the new paradigm for our health system must place the ownership in the hands of citizens, in partnership with balanced 3P arrangements. Would we act differently if we saw ourselves as owners of the health system, rather than it being government’s business, a view that absolves us from responsibility for our own and others’ health?

The most powerful leverage comes from new ways of thinking. Therefore, Canadians must stop tinkering with old, outdated institutions and find the courage to create interventions that make a foundational difference in the health care system, that reject the status quo, and that rebuild our dysfunctional and collapsed system.

The necessary conversations are difficult, but most of us are reasonable, middle of the road, and common-sense people. Indeed, we are Canadian!

References

1.Welcome to Buurtzorg. Netherlands. https://www.buurtzorg.com/

2.Buchholz K. These countries spend the most, and the least, on social benefits. Cologny, Switzerland: World Economic Forum; 2021.

Author

Johny Van Aerde, MD, PhD, FRCPC, is former executive medical director of the Canadian Society of Physician Leaders and founding editor of the Canadian Journal of Physician Leadership.

Correspondence to: johny.vanaerde@gmail.com