Thank you very much. I really appreciate the opportunity to present to this committee today.
My name is Marjorie MacDonald and I'm representing the Public Health Association of British Columbia. I would like to acknowledge my colleague and vice-president, Dr. John Millar, who did much of the background work for this presentation. He was not able to come today to do this presentation, so I am doing it in his place. I hope I can do as good a job as he might.
The Public Health Association of BC is very concerned that health care financing in this country is becoming unsustainable because health care expenditures may begin to be outstripping government revenues. At the current rates of increase, it's predicted that expenditures will increase from about 40% of provincial spending currently to about 80% in the year 2030. So something does need to be done to address this issue now.
With respect to health care sustainability, there are three interrelated burning platforms that I want to speak about. These are all interconnected, and of course, they then connect to the solutions that I want to talk about as well.
The first of these is that the general health of the population is decreasing, and at the same time there are rising inequities in health status for some population groups in the country. The prevalence of chronic conditions has increased considerably over the past decade. The burden of most of these is preventable. For example, there's been an increase in the prevalence of heart disease by about 80%, some cancers by about 50%, diabetes by about 78%. Perhaps more worrisome is the fact that the prevalence of chronic diseases among the disadvantaged and marginalized segments of the population is much higher, so that is something that we do need to worry about. With the increasing prevalence of chronic disease, that can lead to decreased productivity of the labour force and a reduction in economic competitiveness.
The second thing is poor patient experience and quality of care. We've been hearing a lot that people have been complaining that their experience in the system has deteriorated and the quality of the care they are getting is not what it used to be. Most of the care for chronic conditions in this country is provided through a primary care system that was developed a long time ago to address the primarily acute conditions that were prevalent at that time, before the shifting transition to more chronic diseases in the population. Many arguments have been made that this really is the wrong business model.
In Canada our primary care system falls below a standard of care that's been achieved in high-performing systems in other locations, and leads to unnecessary hospitalization and expenditures. Related to that we know there's lack of access and attachment to a primary care provider for many people in the country. There are complaints about lack of coordination and continuity of care in the system. Information flows are impaired. Patients need to return to their physicians more than once to get prescriptions refilled, to get their lab test results. There is the lack of interoperable electronic health records, so information is not accessible from one segment of the system to another. People have short office visits with one problem per visit. That doesn't work when there's significant co-morbidity and very complex problems. In addition, it makes it difficult to deliver evidence-based prevention and care with this kind of system. It also means there's limited accountability back to the community and to patients, and limited patient engagement in governance of this system.
The third thing is the increasing cost of health care. I'm sure this committee has heard about that many times.
Government revenues are declining overall. There's the belief that small government is better government, that lowering taxes is a good thing, and that the industry needs to be deregulated. There is concern in the system about waste, errors, and inefficiencies. We know that the population is aging and that with an aging population the prevalence of chronic diseases is increased. With that, there's an increased burden of chronic diseases, as I've already mentioned, and much of that burden is preventable.
With these three interrelated problems, the solution is also a triple aim solution: to improve population health and reduce inequities, to improve patient care, and to reduce costs.
With respect to improving population health, a very important solution is to increase the investment in prevention, both primary prevention and secondary prevention. We have evidence now emerging that prevention can be very effective in reducing costs in the longer term. It will improve population health and thereby increase productivity.
To do this, however, we will need to address the social determinants of health. We need to address things like poverty and inequities, food security and food safety, homelessness, and early childhood development. That's a very complex task and raises many challenges.
I am going to go back and talk for a minute very briefly about some of the evidence that prevention is effective. Recent economic analyses have shown that a prevention strategy that's based on enabling healthier behaviour and creating safer and supportive environments and living conditions can slow the growth and the prevalence of disease and injuries and alleviate the demand on a limited primary care capacity.
For example, one study has shown for every 10% increase in public health spending, deaths from cardiovascular disease declined by 3.2%. This represented an increase in spending of only $312,000 U.S. at the local health agency level. To achieve the same reduction in cardiovascular disease deaths through clinical care interventions, we would have to invest $5.5 million. That's 27 times greater than public health spending, so there is a good return on investment for prevention strategies.
I don't think I'm going to talk about the next slide, because I might go over my 10 minutes if I do, but essentially it's a graph to demonstrate that enhancing prevention can, not initially but over the long term, reduce costs.
To address the second aim, it is important to develop and transform the primary care system in this country to a community-based primary health care system. To do this, there are six basic requirements that are based on the evidence.
We need to provide services within a defined geographic population so that everyone in the area has access to services. We need to provide a comprehensive range of services beyond what's provided now in our primary care system. We need to be able to address the social determinants of health; clinical prevention; the complex care co-morbidities; and end-of-life care.
What that requires, then, is that we do a much better job of bringing together a network of professionals: general practitioners, nurse practitioners, pharmacists, public health professionals, mental health and addictions professionals, and social agencies. We don't see very many primary care organizations in the country now that are able to offer that network of services and professionals.
We need alternative funding arrangements to provide incentives to enhance prevention, to encourage collaboration, and to use data and data systems that can inform care. A blended funding model is often suggested as the strategy to go forward.
Also, we need electronic data systems. These are essential to be able to achieve the benefits and efficiencies and to be able to access individual patient data as well as population health information in order to inform care.
We also need a shared governance structure that allows people in the community a say in what they need and a say in how their services and care are provided.
I'll turn now to possible government responses.
I've just noticed an error in my presentation. I meant to indicate that small increases in taxation have some public support, not strong public support.
A recent report by the Canadian Centre for Policy Alternatives in B.C. illustrated that small increases in taxation would produce a minimal burden on individuals and yet provide a significant revenue stream that could be used for health and social services.
Another would be healthy public policies. These are policies that go beyond the health care system and governance of the health care system to include a whole-of-government approach. The purview of some of these strategies and policies are outside the health care system at large.
For example, one strategy would be an obesity reduction plan. We need strong leadership at the federal level to promote government action to reduce calorie consumption. We could do such things as change agricultural policies, have point-of-consumption notices of caloric content in food. We could tax sugar sweetened beverages, ban marketing of junk food and beverages to children, and implement a salt reduction strategy. All of these things could lead to a reduction in the burden of chronic diseases.
Early childhood development and care, poverty reduction strategies, all of those things would be very important.
I don't have time to go any further into all of those, but more details are available on request in our larger report prepared by Dr. Millar. It is available if anyone is interested.
In all of these strategies, what is very important is measuring, monitoring, and recording. What gets measured gets done. So we need to develop common metrics, a coordinated pan-Canadian strategy that would develop indicators and databases to measure progress on these strategies. This type of thing is already the responsibility of CIHI, the Canadian Institute for Health Information, so infrastructure's already available and in place to begin this.
I'll just leave it there. I'll take any questions.
