00:18:34.020has ever been able to renovate the delivery of those services or products. If you walk into
00:18:40.340Tim Hortons right now and tell everybody in your Tim Hortons, hey, I'm going to pay for all your
00:18:44.520coffee and donuts. And then you walk up to management and say, all right, I want you to
00:18:48.640change the way you make your donuts. And I want hotter coffee and a little more cream in my double
00:18:53.480double. Management is going to look at you and say, you don't, you don't know how to run a Tim
00:18:57.920Hortons. What are you talking about? Yes, you've just paid for all the services, but you can't
00:19:02.320change the management so i think that's what you're getting at right there it's very very
00:19:06.220difficult for provinces and the federal government to change the way services are delivered and we
00:19:12.800can't improve care without changing it at that fundamental level that you're talking about
00:19:17.360yeah i mean anyone who's ever looked at government spending reports which i suppose is not as amusing
00:19:23.500an activity as i'm making it sound but you'll know that there's this thing called march madness where
00:19:28.660every March you have these government departments that just blow money on new chairs, new desks,
00:19:34.060new computers because they had this room in the budget and they don't want it to be taken away
00:19:37.880the next year. So you have people that are spending up to their cap and it's not a question
00:19:43.100of what's the best use of this money, how do we best improve our performance and our output
00:19:47.700and I fear that's what's happening here now. I mean the federal government has not proven,
00:19:52.900certainly not this government, that it has an ability to do any level of central planning. So
00:19:57.580even putting this money to provinces and saying here's how you need to spend it
00:20:01.860like i'm not seeing the roadmap on how health care will be improved with this
00:20:06.940yeah so two points you raised there i'm glad you use the word central planning and that needs to
00:20:13.380be more a part of our dialogue so understandably 200 billion dollars captures the headlines and
00:20:20.360that's what we want to talk about and i'm glad you highlighted that actually this is only 46 billion
00:20:25.300in new dollars. The rest of that money was going to flow anyways, and it spread out over 10 years.
00:20:31.940Having said that, people still love to talk about the money. But really, what we should be talking
00:20:37.020about is the control that's at issue. So you look at their long list of things they want changed,
00:20:42.780even going back to March. I'm looking at a list by Health Minister Duclos. He said, well, these are
00:20:48.140our five priorities. But if you look at them, they're actually more like 10 or 15 priorities.
00:20:53.020So essentially, they're setting the marching orders, and I can't understand why they want
00:21:00.280control. It's like a dog chasing the car. What are you going to do when you catch the car?
00:21:04.300Furthermore, how do you even know you can control health care better than the provinces? And so
00:21:09.820it's a mixture of ignorance and arrogance. And to hear our prime minister almost fold his arms and
00:21:16.720say, we need better performance, and you're not going to get money until you show me performance,
00:21:21.880it's it's like saying that the beatings will continue until morale improves i just
00:21:26.440i can't figure it out and you also made a comment though about march madness and funding
00:21:31.480what we see in the hospital sector especially is that the worst performers often get the most
00:21:38.360funding now governments tweaked into this a few years back and they realize now that if you really
00:21:44.200come you know you really go over budget and maybe you need to be replaced as a board but never come
00:21:50.360in at budget i never come in below budget because it means your budget will get cut next year and
00:21:55.400so there's this bizarre political game going on when really patients want care and they want to
00:22:02.280know who to hold accountable for delivering that care how much latitude do premiers have
00:22:09.640to be innovative about delivery and and i i'm not talking about privatization here i am talking
00:22:15.800about private alternatives you can have universal coverage and private delivery there's nothing as i
00:22:21.480understand it that precludes that but but how trapped are premiers in this system so fantastic
00:22:28.760question you're asking like someone who i think ran for political party perhaps basically they
00:22:35.000have almost zero latitude so if you speak to these ministers of health or a minister of long-term
00:22:39.960care they say listen john the money's all tied up it's all tied up in salaries it's tied up in
00:22:45.800in contract negotiations and collective bargaining agreements. That's the wording I was looking for.
00:22:51.160And so there's very little wiggle room as far as injecting some creativity in how our system
00:22:57.120functions by tweaking the way funding flows. Having said that, Premier Ford's recent announcement
00:23:03.840where he says, you know, we're just going to shift more services outside of hospitals. We've had this
00:23:09.300shift going on for 40 years. It's a little bit absurd that people are saying, oh, this is terrible.
00:23:15.040this is the end of the world no we're just going to increase mris and ct scans in the community
00:23:20.720like we've been doing for the last 20 or 30 years doing that though leapfrogs all of the management
00:23:27.920and the regulatory system that is attached to hospitals and so for a short time you'll be able
00:23:34.640to see innovation on the management side in these non-hospital facilities so ministers of health can
00:23:41.280do those sorts of things but it's very difficult to actually use dollars and be creative like we
00:23:46.540would hope they could be. One thing I know and I've been very fortunate I've had a family doctor
00:23:52.840my entire life when my doctor from childhood retired his daughter took over his practice and
00:23:58.940I mentioned at the top of the show that I was just coming off a bout of pneumonia and I mean
00:24:03.500when I called my family doctor I had an appointment a few hours later and I know that a lot of people
00:24:08.060do not have anywhere close to that level of access here. And you are right, because if someone can't
00:24:14.860get in to see a family doctor, what is it they want to do? They want to go to a hospital, they
00:24:18.300want to go to an urgent care system. You've got a lot of people in hospital that don't need to be
00:24:22.800there. And this seems to be this catch-all that no one has really come up with an answer to.
00:24:28.720Yeah, I'm glad you mentioned privileged access, because you're a prime example of someone who
00:24:35.000has connections and someone who um the person at the other end of the line will definitely pick up
00:24:41.160the phone and and the reason i i when i was a nobody they still picked up the phone though
00:24:45.880so i don't attribute it to privilege i just think it's a really good doctor but carry on
00:24:49.880it's all privilege man it's all privilege no uh one of the core fundamentals of our system is care
00:24:56.240regardless of the your ability to pay and it's sort of this beautiful um uh truth that we we
00:25:03.340design our whole system around but really the reality is that people who have some sort of
00:25:08.460access or they know somebody inside the system get better they are able to get better care for
00:25:13.640themselves and their family so the issue of privileged access is key you also ask though
00:25:18.480about accessing care in different ways you know should the hospital really be the place that we
00:25:24.640go as a default and canada has always had a hospital based or a hospital centric system
00:25:30.320And this flows, you know, 1957, the Hospital Insurance and Diagnostic Services Act.
00:25:35.240That was the first time we saw this dollar for dollar cost sharing where the government, federal government said, listen, provinces, we'll pay 50 percent of whatever you spend in hospitals.
00:25:44.780And they repeated the same deal with the Medical Care Act 1966.
00:25:48.760And those are the two pillars of Medicare as we know it.
00:25:52.500as you know, the first Trudeau government turned off that blank check approach of the 50-50 deal
00:25:57.780in 1977 with the established program as a financing act. And then provinces and the
00:26:03.280feds have been fighting about funding ever since. And that's what we're seeing right now.
00:26:07.720Well, I mean, on mental health care specifically, I mean, I've been very open about my own
00:26:11.740experiences with mental health challenges, but just looking at it from the system perspective
00:26:16.260here, I think one of the worst things you can do for a patient who is not in any acute medical
00:26:20.960situation is to have police pick them up on a mental health call and bring them into a hospital
00:26:26.260where the resources are already tied up and already stretched thin. And again, I would imagine there's
00:26:33.020probably a much less costly and better quality alternative out there, but it requires a complete
00:26:40.700rethink of the system. Well, part of what you're getting at with mental health care and many other
00:26:46.160services fall into this as well is that they are intangible it's easy to say we have a wait time
00:26:51.540for hip replacements we know your hip is worn out and we can measure it and we can you know pay
00:26:56.600then for the number of hips being done mental health care is very difficult because um it's
00:27:02.140you know james q wilson harvard professor talks about it being more a representative of a coping
00:27:07.720organization it's more like education or like peacekeeping when a police officer is out keeping
00:27:13.480the peace, how can you tell how much peace they're keeping? Can you pay them more if they keep more
00:27:18.340peace or punish them if they don't keep peace? Well, peace is a metaphysical concept. And you're
00:27:23.380getting at that with healthcare as well. How do we know that my advice to you to change your diet
00:27:31.300or whatever is going to do anything for you 20 years from now or 40 or 50 years from now? Will
00:27:36.740it make you live one year longer? How do we know that my advice was perhaps ignored and maybe you
00:27:42.380listen to someone else in your house or your friend or your mom or whatever and so what you're
00:27:46.860getting at is the intangible you're getting into an intangible thing where you know you hear not
00:27:53.460everything that can be measured matters and not everything that matters can be measured and so
00:27:58.740now you're talking about something that is very difficult to measure but it matters a great deal
00:28:04.200and so it tends to fall off the budgets and spreadsheets and all these beautiful charts that
00:28:09.640you see from our health system planners but we end up in the crisis that we're in right now because
00:28:15.360of it so suppose you are the health minister of a province it doesn't really matter which one
00:28:22.580and the government has given you whatever your province's share is of this 46 billion dollars
00:28:28.700over the next 10 years which when you break it down over 10 years plus over 10 provinces and
00:28:33.120three territories it's not even as huge it's even less significant an amount but let's say you're
00:28:38.920given this what is the most in your view tangible change you could put in place with that money
00:28:46.600so you've limited me to just talking about money usually i try to answer that question
00:28:51.080by saying i want to talk about governance first let's do both i mean let's do okay how how can
00:28:56.120you most efficiently spend that money pretending that the current governance restrictions are not
00:29:01.480there okay so it's usually three things i talk about number one we know we have to figure out
00:29:05.960governance who's in charge right now canadians don't know who to hold accountable do we hold
00:29:11.160the feds accountable do we hold the provinces accountable do we hold our local hospital
00:29:14.760accountable who do we hold accountable for access to care so that has to be clear number one number
00:29:20.120two we need to expand core services so when i talk about core services i'm talking about life or limb
00:29:28.040and that's sort of the fundamental that's the moral high ground in medicine whatever you do
00:29:32.440when someone comes in you have to save life or limb first mental health falls in there it is a
00:29:38.200life or limb issue so we need to expand services around life and limb issues the second thing
00:29:45.640the third thing actually or the second thing with with concrete things that i would change
00:29:50.440with respect to funding is to constrict and this is the part people don't like to constrict
00:29:56.680things that are inappropriate so we have to have a discussion first about appropriateness are all
00:30:03.720the services that we spend money on actually appropriate for the current environment we live
00:30:10.600in right now medicine can offer far more than anyone ever dreamed it could offer in the 1960s
00:30:16.520when we were coming up with this public health insurance approach in canada and so we've massively
00:30:23.240expanded what we can do and what we can offer. And then provinces are pressured to keep at
00:30:28.580offering, you know, PET scans or MRIs for anterior knee pain, or you could go on and on with the
00:30:34.480things that we probably shouldn't be doing. The obviously wrong things are fall under the
00:30:40.920choosing wisely campaign where they encourage doctors to stop ordering useless tests, but
00:30:46.280that's only a fraction. We need to have a robust discussion to say, what do we have Medicare for?
00:30:52.200Is it simply a redistribution program, like Roy Romano calls it?
00:30:56.460He calls it our great redistributive program in Canada.
00:30:59.580Or is it to provide a safety net for core life and limb issues?
00:31:04.220So that's where I would focus on, expanding those services, contracting the more useless ones.
00:31:08.980But number one, we have to get governance fixed up.
00:31:12.360Yeah, and again, we all get stuck, and you and I have spoken about this in the past,
00:31:16.780in this very false dichotomy between a Canadian health care system and an American health care
00:31:22.340system. I was just listening to a show my friend Mark Stein did, and he just was talking about the
00:31:27.120difference between the UK system and the French system. They're both completely government funded,
00:31:31.780but one is vastly superior to the other. So there are degrees of quality within every system,
00:31:37.260within every permutation and combination here. And, you know, there are things that I think
00:31:41.840shouldn't be third rail issues one of them and again i'm not even advising that the government
00:31:46.800does this but i i certainly think there should be a permitted discussion is having a co-pay when you
00:31:51.920go to a clinic or when you go to a family doctor perhaps everyone gets you know three free visits
00:31:56.780a year and if you go over that you have to pay some nominal fee or something like that like but
00:32:02.080the fact is there are what i think are ideological uh people that are resistant to any change
00:32:08.740whatsoever and they'd prioritize uh equality of care over quality of care yeah great comments and
00:32:16.060you've really opened a wide up door wide wide door for a whole bunch of discussions which is great as
00:32:21.300we're winding down just to like throw the bomb of copay in there but anyway carry on so we have
00:32:26.100the 28 universal health care systems around the world and i think we can be strong in saying
00:32:31.120universal care just means everybody in your country gets care there are many different ways
00:32:35.520to achieve that end 28 different countries around the world have universal health care 23 of the
00:32:40.88028 have some form of cost sharing now when you get into patient cost sharing one of the mistakes
00:32:46.880people make and i just wrote a large paper on this actually for mcdonald laurier institute
00:32:51.120is that they think they'll get cost sharing to increase revenue in fact that doesn't work
00:32:57.200the countries that use cost sharing they always have robust exemptions for the very old the very
00:33:04.320young the chronically ill and that sort of thing so once you narrow who you're going to focus the
00:33:10.560cost sharing onto you do have a measurable change in in how many times people will go to the doctor
00:33:17.600for the same problem for their anterior knee pain which is the bane of an orthopod's existence
00:33:22.720and so there there is some role for it to play however however it actually may cost the system
00:33:28.880more if you imagine a long lineup at tim hortons and everybody in that lineup wants you know one
00:33:35.760tim bit and there are two or three people in there with a large order the average cost for that long
00:33:43.200tim hortons lineup will be very low whereas if every single person in that lineup wants a dozen
00:33:48.880donuts and 15 coffees the average cost per customer is very high it's the same with health
00:33:54.880care if you use user fees to get some of those low value people out of that line you may drive up
00:34:01.920and most studies suggest you will drive up the average cost per patient but that's the right
00:34:07.120thing to do so we should do it to improve efficiency and improve horizontal equity so
00:34:13.760that you and i if we're earning the same amount of money and we have similar genetics and you go to
00:34:18.640the doctor every two weeks and i go to the doctor once a year why do i have to play the same health
00:34:23.920premiums so there's an argument to be made for them but it's not the magic solution that some
00:34:28.860people think it is well i appreciate it very much and just on the note of ideology i have to share
00:34:34.600this comment there was a service that started up in canada a few years ago called maple which lets
00:34:38.960people for a nominal fee whatever it is see a doctor virtually and and get a prescription if
00:34:44.880they need or anything like that and in my as to my understanding all of the doctors on maple are
00:34:50.800employed within the public system, but in their off time, they sign up and they take, you know,
00:34:55.820however many patients a day or a week. And it's a net increase in the amount of care available in
00:35:02.460this country. It costs the public system nothing. It costs taxpayers nothing. Jagmeet Singh last
00:35:08.200week was saying we need to prohibit it. We need to close what he's calling the maple loophole.
00:35:13.360Yeah. So I've been on a number of interviews actually debating what he's been saying. He's
00:35:20.240been saying things like in BC they're buying up all the private clinics and so I don't know we
00:35:24.340can have another you know Air Canada or whatever but to your point about increasing access that's
00:35:29.500a key point that I think the public really needs to know about and I'll use a concrete example so
00:35:34.460in Ontario we have a certain number of IVF cycles so people who can't get pregnant they
00:35:41.140want to get pregnant they go to fertility service and they can get something called IVF
00:35:45.240in vitro fertilization. Ontario funds 5,500 of those a year. That number of procedures could
00:35:55.660support, you know, five clinics. A large clinic will do around 1,000 procedures a year. Because
00:36:01.820Ontario allows private billing for IVF services, infertility services, we actually currently have
00:36:10.06013 clinics in Ontario. That's this 2020 data. So in other words, people who want their publicly
00:36:17.180funded IVF services now have clinics much closer to home. We have them far up in the north,
00:36:23.540all across southern Ontario. So 13 instead of five or six, because we've allowed a greater
00:36:30.340number of or a blend of public and private billing for IVF. And you have to realize that each one of
00:36:37.280those clinics hire staff and they have rent space and they have equipment and so not only is it
00:36:43.540better for patients it's better for the economy it's better for the health care workforce so it's
00:36:48.340better overall so this book this uh fear-mongering about um any any blending at all is just not borne
00:36:56.700out by the data dr sean whatley author of the book when politics comes before patients why and how
00:37:03.000canadian medicare is failing but he doesn't just come with doom he comes with a bit of hope and
00:37:07.280with suggestions and i think leaders in government should very much heed those sean always a pleasure
00:37:12.920thanks for coming on today my pleasure thank you thank you that was dr sean whatley we have to end
00:37:19.820things there my thanks to all of you for tuning into this edition of canada's most irreverent
00:37:24.960talk show back on friday with fake news friday and then next week with more of this program thank