Madam Chair and members of the Standing Committee on Health, it is a real honour to appear before you as a witness. The remarks I will be sharing with you this morning are really my own personal insights from working as a leader for over 30 years in health care administration, and also from working with the Canadian College of Health Leaders on both a national and international basis. In my remarks, I'm using that as a lens to provide some insights.
As leaders, we certainly take great pride in many aspects of our health system. There are many things we do well. A lot of these things we don't talk about; we're just busy doing what we're doing. But we also recognize that our health system is under a lot of strain. The strain is coming because our population is aging quickly, and we're also facing a growing prevalence of chronic illness. Our system was not designed for that type of patient. We were designed primarily around acute care and physician care, and we haven't really evolved our system sufficiently to handle those patients.
You might wonder why that is a big deal. It's a big deal because we're still a young country. If we look at ourselves compared to Europe, we're much younger, but if we look at Canada in 30 years' time, we'll be older than Europe. So if we're struggling at being young, we have to make changes to prepare for what is also coming.
This challenge we face is occurring despite considerable effort on many fronts, including the work of organizations, regions, health providers, and staff to improve service. If we look at the leadership agenda in the country, it's all focused on improvement, change, and safety. There's no question that governments have committed funding levels to support improvement, so why are we in this situation where we're struggling? It's an important question. I think the more important question is, how do we get out of struggling? How do we move forward? That, to me, is the more important question looking forward.
Why are we here? There are lots of reasons, but I want to focus on three things that I think have created a bit of the dynamic we face. First off, by virtue of how governments insure health services, we have focused health delivery primarily on hospitals or acute care and physician services, and, consequently, that's where care is funnelled to. We have some things that are insured outside of that, but primarily our major insurance platform is geared to those two venues.
As a consequence, what do we see today? We see hospitals being congested, often patients in the wrong setting. I think Ontario has said that 25% of their hospital beds are occupied by patients who are in the wrong setting. We often hear this expressed in terms of emergency department waits. Those are consequences of hospitals being congested, and then the patients can't move where they need to move. Also, we have patients waiting to see a physician. We have physician shortages, so of course patients are queueing up to see physicians, either family doctors or specialists. These two venues are also the most expensive, and we have patients concentrated there. If we look at that, that's an important factor to consider as well.
Secondly, I think it is fair to say that the consumer—and when I say “consumer”, I'm talking about patients, clients, or whatever terms we choose to use—is largely marginalized in our decision-making. We have quite a paternalistic system. Patients could assume more responsibility if they were enabled to do so and if we respected them in a way where they were actually engaged as a team member in health care. We have a lot of work to do on that. We do some things well, but there's a lot that we could do better.
Also, our health system is fragmented. There are many structural and professional divisions across the country. There is limited coordination of effort across the country, resulting in inefficiencies, duplication, and inconsistencies. Dr. Bohm's presentation...that's unique and is being developed for Manitoba, but it's probably being developed in different ways in other parts of the country—everybody trying to achieve the same thing. We lack a national health agenda for a $200 billion industry. We should be concerned with that.
How do we then look at improving efficiency and performance of our health system? We could start by talking about countries that have similar values—that's very important—that are serving an older population, that are achieving better outcomes at lower cost, because that's really the agenda we're trying to tackle.
Let's look at a country such as Sweden. Sweden is a country that we have visited many times for study tours. Let's see how they've tackled all three of those issues that I mentioned.
First off, the backbone of the Swedish health system is primary care and not acute care, and every citizen is connected to a primary care network. That primary care network links very closely with hospitals so that patients can move in and out quite easily. There's a lot of information sharing, a lot of knowledge transfer, so when the patient is admitted, their history of what happened in primary care moves in. When they get discharged, what happened in the hospital visit and the discharge orders move out. It's very smooth.
There's an electronic health record that connects primary care to acute care, so that information sharing is smooth. The primary care units are team-based and patients can have appointments with any member of the team quite readily.
The role of acute care, though, not to be undermined, is very important, but it's focused. The hospital care is very specialized. Hospital capacity is protected: it's used for hospital care. Patients who require care in other settings move along very smoothly, so the hospitals do not get backlogged caring for patients who are in the wrong setting.
The hospitals are very efficient. They utilize Lean tools, as was discussed earlier, to streamline their processes in the nursing units, emergency departments, and clinical and diagnostic areas.
There is a national focus on improving the quality and safety of care to the elderly. This is very important, because Sweden has the oldest population in Europe. The population is much older than in Canada. There's a major effort to care for the elderly in their homes rather than in institutions. The average length of stay in nursing homes in Sweden is one year, and that reflects the effort to keep people at home as long as they can. Also, palliative care is strongly supported in the home setting.
In terms of a national agenda, patient safety and quality of care are part of the national agenda. I'll give you one example where they have really done very well, and that's that whole issue of hospital-acquired pressure ulcers or bedsores. In Sweden, the incidence of patients who get them during hospital care is 5%. In Canada, it's between 20% and 25%. We perform very poorly on that front, relative to other countries.
There's also a very strong national focus in Sweden on medication safety for the elderly, because we know that many of our hospital admissions and emergency visits are due to medication issues with patients who end up having to be admitted because they're not taking their medications right and so forth.
Infection control is very strong in Sweden. We struggle with handwashing in Canada. The handwashing compliance level in Sweden is almost 100%. But it's not just that; in patient care settings, nothing below the elbow is allowed in the patient rooms: no sleeves, no jewellery, no gel nails. We have debates on that in Canada, but in Sweden you're absolutely forbidden to have gel nails and jewellery and anything below the elbow in patient rooms. Their infection rates are very low. Their standards are very high and their consistency rate is very high.
When you look at how their system works, it's clearly evident that it was designed with the patient in mind. We have a lot of difficulty with handing patients off from one sector to another. In Sweden it's very smooth, because patient movement is orchestrated between the sectors and the patient just moves.
When we talk to them about alternative level of care patients, hospital patients in the wrong setting, they do not have that issue, and they look at us as if to say, “Well, what are you talking about?”
There is a very strong commitment to efficiency in processes through the use of Lean thinking. They actively tender for services if they're struggling with an area that they want to improve. They can do projects where they'll tender for those services—to the private or public sector—and they use that as a way of getting improvement.
They view industry differently than we do. We tend to view industry as vendors; they sell us commodities. They view industry as knowledge brokers. These companies are global companies working in hundreds of systems. Their view is that they can get innovation from those companies because of their scope of exposure, so they view them as a knowledge partner. That's also very important.
Consumers are actively engaged in personal wellness, but they're actively engaged in selecting their care options. Patient choice reform in Sweden is a very strong movement, where the patient can choose providers. For many of the services where they choose to go, the money goes with that choice. That incents providers to offer high quality to attract a patient who then brings them funding.
The last issue I would say about Sweden is they spend a lot less than we do, but they have better outcomes, and it's quite remarkable, considering that it's an older population. Their insured basket of goods includes dental care for the young and the elderly, a national pharmacare program, a national primary care network, and home care, all insured and they're spending less money. They've achieved that with 97% public funding.
It's a publicly funded health system. They view health as a business and they're planning to the year 2025.