Frontier Centre: What is people-centred healthcare?
Vaughn Glover: If you want the long definition you can read my book. The short version is that people-centred health is a radical idea that health, healthcare and our health system should put people first. It is based on the reality that each person manages and is responsible for their own health. More specifically people centred means taking each piece of the health system puzzle and ensuring it is responsive to and respectful of the needs, the values and the perspectives of the patients.
FC: Why is our present healthcare system not a people-centred health system?
VG: The best way to answer this is to highlight a few issues. First of all, it’s not a health system, it’s an illness system. It was designed that way. Tommy Douglas’s primary objective was that we did not want people suffering and dying from preventable and treatable illnesses and we did not want them going bankrupt trying to provide these services. Unfortunately politics took it over and how a party deals with the health system has slowly become the key to getting elected. So now we have a very much politically-centred system, governed by an insurance act for illness. Another big issue is there are two keys stakeholders in policy in Canada. The stakeholder with the most influence is the provider’s, primarily dominated by the medical profession at this point in time. The other is the government (provincial and federal), which is really the bank or the payer. It is assumed that they are going to put people first but when you analyze the system and how decisions are made you find that decisions are too often based on what will win the next election or what will keep particular provider group’s in the centre of the system.
FC: How do you overcome the politics where the provider groups have a huge stake in the status quo and will put a lot of resources into preserving the status quo?
VG: Well I think you have to do what I talked about today, you have to go back to some fundamental issues and get the people who are in the middle of the system to ask and answer some very basic questions such as: What is health, what is the purpose of the health system, what are the principles of health, what type of working model best supports an informed client, and how do you manage a people-centred system? Stop trying to figure out how you’re going to fix until you have figured out what you want to do. In other words you have to clarify a long term vision of what we want our health system to do. If in fact we want a health system, then treating illness is only one piece of the puzzle. If we believe that the needs, values and perspectives of the individual should come first then the system must be people first. As this increasingly informed public begins to realize that the first priority of the current system is not the health of the people then they will demand change and the stakeholders will have to listen.
FC: When you say people should be controlling the money that pays for healthcare, what’s your view on health savings accounts?
VG: Once again, you can not figure out how you’re going to fund something until you know what you want to do. Thus a people-centred, funding model must be congruent with the answers to the five questions: What is health, what is the purpose of the health system, what are the principles of health, what type of working model best supports an informed client, and how do you manage a people-centred system? I believe a health savings account approach could achieve the objectives of a people-centred System. Another important piece is if you want a people-centred system, somehow you have to have a funding mechanism whereby the doctor is accountable to the patient to be rewarded. The fact that in the current system, the patient has no concept of what he/she was billed for, what the fees are or does not have any opportunity to comment on the quality of care that was provided, just lends itself to an ineffective system. When you analyze the current system, the only person that should be in the system is taken out. Health savings accounts are a funding option that can work but there are many other options. I want to state that regardless of what funding system is implemented it is my belief that everyone should continue to access a defined level of support for illness and emergency care. The problem is defining the limitations of what we can do with our public funds.
FC: In the existing system, we have the health department as the purchaser of the service and also the provider of the service. What do you think about that? In Europe they have separated the purchaser and the provider so that there is at least a little element of competition in the system.
VG: Well there certainly should be an element of competition in the system. The role of government is similar to that of any insurance company. They receive premiums for health insurance thru taxes and it is their responsibility to determine how these funds should be used. Where I have a big problem is with the fact that the insurer is interfering in the relationship between the provider and their client. In a people first system, it is the responsibility of the provider to present options and help the client to determine what options best supports the clients goals and objectives regardless of what support the person has. Then the client should work with their providers to determine how best to use the support options available to achieve their goals. The fact that the options Canadians are given, are determined by the limitations of the insurance company is not acceptable.
FC: We have an ideological thing here where there is a substantial segment that says the government must own all hospitals. Are you saying that that’s not necessary?
VG: Who owns the hospital is not important but I personally believe that hospital facilities should be not for profit. For example, all the hospitals in eastern Ontario are doing major fund raising and I suspect it is the same in Manitoba. I don’t know of any that are funded completely by public funds. This creates great diversity in the quality of care and services that are provided and is just another example of the multi tiered system that has always existed. This is a form of privatization and certainly is not universal, but I am very comfortable with this approach.
FC: If you were to privatize a hospital, surely you would get some controversy?
VG: I don’t think it matters, myself, but as I said, I think hospitals should be not-for-profit. Now, the people that run and work in the hospitals, have to continue to be rewarded so in reality there has never been anything in our system that is not for profit. Not for profit, doesn’t mean you don’t run a good business. It means that the excess off the top goes back into the business. I get very upset when I hear about companies in the States where they run hospitals and have 60 and 70 percent profit per year on their hospital. That is not people centred. However, if we look at how health care is managed in Canada, I have difficulty seeing the difference between running a hospital based on financial reward and running a hospital based on what will win the next election. I think they are both wrong and both for profit, and we must have a model that is based on what best serves the needs of the people.
FC: Your one chart had the pyramid with the doctor on the top and then you inverted it with the doctor at the bottom in the people-centred model. Quick comment on that?
VG: I truly do not believe we have a doctor shortage in this country — for many reasons. I believe that most doctor’s spend 60 to 80 percent of their time doing things they don’t have to do. If we were to examine what team model would best support the health of the people and effectively and efficiently use the skills of all the providers, I think it would be very different from how most offices function now and what the reward incentives are now. In a people-centred system you would invert the pyramid of power. For example, an effective people centred working model for a doctors office would be very different from the typical office where the doctor sees and does everything with a minimal support team. This evolving model would invert the pyramid of power and put the patient at the top. Ideally each doctor would have a team that included a nurse practitioner, a nurse, client-coordinator – communicators, an effective system of electronic health records, all supported by secretaries and business staff. If this became the norm then there would be no shortage of doctors and these teams could actually move beyond treating illness to health care and that would be an exciting change. Let me add, that the way the doctors practice currently is the way they are rewarded in the system, so for this inversion of the pyramids to occur, the system must evolve first.
FC: How long before we see a tumbling of the walls and a movement towards people-centred healthcare?
VG: Well I don’t see it as a tumbling, I see it as an evolution and it has already started. We have a wonderful foundation to build on and we should be proud of what we have accomplished. However, illness and emergency care are only the beginning. We are limited in what we can do with our public funds, and we must accept reality. I believe the evolution to the next level of our nations journey to a wellness model has already begun. The interesting fact is that this evolution is not being led by politicians or providers but by an increasingly informed population that will no longer accept what ever the system is willing (or forced) to give them.
FC: So when is the change? Do you figure is it happening now, in five years?
VG: I believe when Canadians begin to realize that the current Canada Health Act is actually an insurance act that they will demand to know what the options are. I think it is time to have open discussions about what a health act and health principles would look like and how they would affect the quality of life we enjoy? When people realize the options I think the evolution will occur very quickly. How I see it happening is in models. I see it happening in models in industry and in provider groups. For example, medical doctors are beginning to develop people-centred models. These models have existed for a long time in dentistry, chiropractic, physio, optometry, massage therapy and all provider groups outside the publicly funded system. It is happening in communities, and they can’t stop those models because they’re outside the system. Major companies and industries are moving to more people centred models in order to fulfill the needs of their increasingly informed employees and clients. When you put it all together, it will be a very exciting Canada, — an exciting future. If people centred models begin to develop in other aspects of our lives then the evolution of our health system will be inevitable.. The government will have no choice but to evolve to a model that is respectful of and responsive to the needs, values and perspectives of the individual.
FC: Are you a pessimist or an optimist?
VG: Very optimistic. I think we’re in a wonderful situation. I believe that Canada will be a world leader again. I think we’re in a perfect position to develop the world’s first people-centred health system.
FC: You’re aware that Canada does not do very well in international comparisons?
VG: Yes I realize we don’t do well on many studies, but these do not reflect our potential. These just means we need some leadership to create a vision that the people embrace and then there is no doubt we will rise to the occasion. I think the key is to harness our entrepreneurial spirit and our passion for health and health care and begin to look outside the illness box. Nobody has more passion for healthcare than Canadians. I know we were a world leader in the 1960’s and I believe that we are going to be a world leader again.
FC: See some political leadership coming down the road?
VG: I don’t see the leadership coming from politicians. It is my experience over the past 15 years of trying to make a difference, that politicians make decisions based on what will win the next election. Telling people that we must evolve to a model where each person must accept responsibility for their personal health and well being, may be the truth, but it does not win elections. I believe the people will lead the way and the politicians will follow. It sounds like an impossible dream but that is the reason we have founded the Canadian Association for People-Centred Health. We are committed to researching designing, sharing and implementing ideas on how our health system can be more responsive to the needs of the people. We are also committed to being a voice for the people and to creating a platform where the peoples’ voices can be heard. We invite all Canadians to join with us to explore ways our health system can once again be a world leader.