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March 09, 2006

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Who will deliver healthcare in British Columbia?

When the responsibility for healthcare is lodged in the government the failure of health providers becomes a public and political issue.

In last month's throne speech Premier Gordon Campbell declared his desire to begin a dialog with British Columbians on health delivery systems.

Good for him. Over the years the Premier has been too busy to attend the department of gerontology's Friessen lectures where health care delivery has been discussed frequently (www.sfu.ca/grc/Friesen/Friesen_index.html). Maybe he'll attend this year. And if it is dialogue the Premier seeks, the Morris J. Wosk centre for dialogue is available for rental. No better place for a dialogue than that.

Campbell wants to start with three questions I'd be delighted to answer: Do we care about the method of delivery? Why are we afraid of mixed-delivery systems? Why do we assume privatization means a U.S. style debacle? These are clear queries that can be answered easily. Afterwards, you know, we can, like, uh, dialogue.

Do we care?

Yes, we care about who delivers healthcare services in British Columbia. It is important for a host of reasons but most importantly, perhaps, to assure accountability. When the responsibility for healthcare is lodged in the government the failure of health providers becomes a public and political issue. That gets us results in a way that privatized delivery systems would not.

A sustained outcry by voters, for example, has resulted in a governmental commitment to cut wait times for joint replacement surgery. This occurred, with the timely assistance of new federal funding, because health is a governmental responsibility and Canadians everywhere were complaining. We prefer public delivery because it means public accountability.

When the Liberals were in opposition, they made a point of this, holding the previous government responsible for healthcare delivery problems. Indeed, Campbell's government campaigned in 2000 on a promise of improving a health system he described as broken. A vote for the Campbell Liberals, we were told, was a vote for more and better health services. If provincially delivered healthcare didn't matter to us you might still be in opposition.

Mixed models

Campbell's suggestion that British Columbians were "afraid to look at mixed health care delivery models" was a tad insulting. We are not afraid but are instead deeply suspicious, and with good reason. At best, private healthcare delivery is about the icing on the cake, not the cake itself. Understand that and the reason for our skepticism is clear.

Over the years, British Columbians have poured billions of tax dollars into B.C.'s health infrastructure and some, like me, don't see why that public investment should now profit private businessmen seeking to grow healthcare as a business. Why should we pay for private clinics to do surgeries our public hospitals were designed to accommodate? If the hospitals are unable to do their job then it is the government's business to seek better management, not give the game away to for-profit, private entrepreneurs.

We are suspicious because medical entrepreneurs advocating privatization are not acting out of altruistic, public concern. They are business people seeking a profit. In the U.S., the rule of thumb is that it adds an additional 20 per cent to the healthcare bill. Why should we pay the extra freight?

And at best, private clinics provide for the well-to-do and the wealthy. They do little for the health needs of the poor and working poor. When privatization is seen as an alternative to public responsibility, what is left to the public sector becomes ever more ragged, less serviceable.

Worse, privatization bleeds off the indignation of the tax paying, middle class. We scream today over inadequate healthcare delivery and services because it affects us, too. If we can buy our way out we will be less likely to demand attention be paid to deficiencies in the public service. That becomes a public health disaster in the making.

Nor will increased private healthcare delivery help in rural and semi-rural areas where service is needed but not necessarily profitable. Brian Day's False Creek clinic and the new Copeman Healthcare Centre serve the affluent, populated Vancouver area, not Alert Bay or Fort St. John, or Slave Lake. There isn't the client base in places like that to support private clinics.

After the throne speech Campbell travelled to Europe to explore the health delivery environment there. As SFU's geographers would have told him, that won't be of much help in answering British Columbian issues. European countries are typically small, densely settled, and relatively homogeneous.

British Columbia is a vast province with a few pockets of dense settlement. What works in one geography won't necessarily serve in the other.

And remember that countries like Germany, France and Holland all support higher tax schedules than we do. Their public-private mix comes only after a larger public contribution to health. You can't include an emergency doctor and nurse with paramedics - as the French do in their Parisian ambulances - without paying a lot more money than B.C. does today. Mixed delivery service only works well in countries where substantial public financing assures good care from the start. That's not B.C. today.

The U.S. example

The reason we are so quick to assume more privatization will result in a U.S. style healthcare debacle is obvious. We see the U.S. system in action on television, read about it in our newspapers.

Many of us know it first hand as a disaster in which more than 40 million people have no health coverage at all and millions more have inadequate, minimal insurance.

And really, there is to the B.C. government's healthcare approach a certain American flavor. Since taking office, the Liberals have cut hospital service capacity by between 12 and 15 per cent while increasing health spending by millions of dollars.

They have fired long-time workers and brought in out-of-province corporations to do the work.

Having promised more health service for less money we now get less health service - hospital capacity has been reduced by between 12 and 18 per cent - at a cost of millions more dollars. We pay our taxes and pay our health premiums. Off-loading responsibility will not necessarily build the health delivery system we deserve and we need.

In the spirit of dialogue it would be good for Campbell to remember we have a lot of expertise here at SFU. For his dialogue he might call Mark Wexler in our faculty of business administration, for example, or Michael Hayes in the new faculty of health sciences.

I can be reached through gerontology, of course. And in the spirit of economy Campbell would not have to fly to Sweden on a fact-finding trip. SFU and its resources are just a ferry trip from Victoria.

A bioethicist, gerontologist and medical geographer, Tom Koch is also a consultant in bioethics and gerontology for the Copeman Healthcare Centre.
















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