To be blunt, there is little about the Canadian healthcare system and how it works that fosters and encourages patient centred care, and there is much about it that stymies efforts to develop and deliver truly patient (or family) centered care. Much of how the system works is even in direct conflict with improving health outcomes. As a result, we have a system that is relatively expensive, while performing poorly particularly with respect to measures of access to healthcare services.
This might seem to be a harsh criticism of a system that is held in high regard by many Canadians (many of whom are actually non-users of the system, and so may hold beliefs about it that are in stark contrast to the realities faced by actual patients). However, there are a number of critical ways in which the system hinders the development and delivery of patient centred care.
A patient centred system would be accountable to patients for the services that are delivered. The reality is that there is little meaningful accountability. Currently, the only avenue for patients to be compensated for harm caused by the medical system (either by medical error or negligence) is to pursue a medical malpractice claim. Sadly, doing so is often a tale of David and Goliath, where the harm caused by the error or negligence must be very significant and the evidence exceptionally clear in order to merit the substantial resources needed to pursue the claim. In part this is because of a medical protective association that seeks to aggressively defend every claim that is made, and as a result many meritorious claims are never pursued and many patients never receive compensation for the harm that they have suffered. Absent compensation for harm caused, the other avenues for accountability include the Patient Care Quality Offices, the Colleges of Physicians and Surgeons across the country, the media and patient advocacy groups. Sadly, as a result of their limited powers to remedy the harms caused, many patients with poor experiences never have their voices heard as the cost of doing so simply exceeds the expected benefits. In the Canadian system patients are not even routinely surveyed about their experiences of care and outcomes. As a result, there is likely a large under reporting of poor experiences of care or outcomes. A no-fault compensation system similar to what exists in New Zealand would be a meaningful step in the direction of patient centeredness.
A patient centred system would reward care that meets the needs of patients and penalize care that fails to meet the needs of patients. The reality is that the doctor who makes a patient make 3 appointments (one for each issue needing to be addressed) gets paid more than the doctor who accommodates a patient’s need to have your appointments consolidated or who spends a bit more time with a patient to ensure questions are adequately answered, or who provides access to information before the appointment so that the patient can come prepared. The reality is the doctor who forces his or her patients to come into the office has an advantage over the one who is open to being available via email or phone to address minor concerns. The reality is that there is no incentive for a doctor to go above and beyond – because at the end of the day they will be paid exactly the same (or worse) as their colleague who does the bare minimum. Further, given the relative scarcity of doctors, patients who are dissatisfied with their care are often trapped between a rock and a hard place, where the choice is a doctor with whom they are dissatisfied with or no doctor at all. There is no reason for doctors to actually care about whether or not their patients are happy (except for the intrinsic desire to deliver good service) or to solicit feedback from patients about the care that was received. There is no reason for doctors to be innovative in order to set themselves apart from their competition. At the end of the day the doctor who delivers the most services (regardless of the quality of services delivered) takes home the fattest paycheque. There might even be a disincentive to actually improve the health of patients, as healthy patients do not see doctors and absent service use, there is no pay. Further, many doctors are in a conflict between serving the interests of their patients and serving the interests of the broader healthcare system.
A patient centred system would be transparent. Medical records in this country are often held for ransom (it is not uncommon for doctors’ offices to charge fees to patients if and when they change doctors to transfer the file to the new care provider). Test results and referral letters are rarely communicated or shared directly with patients absent an office visit. Few patients have care and control of their medical information. In order to gain access to information about our bodies, a referral for tests or imaging is needed. Data about the system is often hoarded and the metrics that are publically available are carefully scrutinized to limit the amount of potential political fallout that might result from their publication. Patients are largely kept in the dark about things that critically impact their lives such as hospital policies and practices or even the expected amount of time that they will wait before gaining access to the care that they need.
A patient centred system would be truly comprehensive and co-ordinated. A lot has changed since medicare started – including the options for treatment of many conditions. Pharmacological care, dental care and optometric care are all excluded from the publicly funded system. Not to mention many para-medical services including those provided by psychologists, massage therapists, physiotherapists, chiropractors, nutritionists, and others. Further there is limited communication between different care providers and navigating the system as a whole is often a daunting task for patients.
A patient centred system would respect patient choice and patient autonomy and recognize that different people value different things. There remains a culture of paternalism in medical care. As an example the approach to maternal request caesarean in Canada – where many Canadian women have difficulty accessing the care they desire. As another example, the prohibition against the purchase of medically necessary care means that the supply of care and access to care is regulated regardless of patient preferences.
There is considerable reason to believe that a system (similar to that in many European countries) that allowed for privately funded medically necessary healthcare services in addition to more comprehensive publicly funded healthcare services would be more patient centred than the current system.
However, absent significant changes and considerable courage on the policy front – patient centred care in Canada will happen in spite of the system because of those driven by a higher purpose to make the lives of others better rather than because of it.