The Decibel - Former health minister Jane Philpott’s plan to save health care

Episode Date: April 11, 2024

Long wait times and the never ending battle to connect with a healthcare professional is a reality most people know all too well. Especially for the 6.5 million Canadian residents who do not have a family doctor. It’s a problem that has existed for years because it isn’t easy to solve.Dr. Jane Philpott is the Dean of the Faculty of Health Sciences at Queen’s University. She is a family doctor, the former Minister of Health and recently published a new book, Health for All: A Doctor’s Prescription for a Healthier Canada. Dr. Philpott is on the show to talk about her ‘hopeful’ vision for primary care in Canada.Questions? Comments? Ideas? E-mail us at [e-mail]

Yes, so it is something that happened quite a long time ago. That's Dr. Jane Philpott, Canada's former health minister. My husband and I spent about the first decade of our career living and working in a country called Niger in West Africa. It's one of the poorest countries in the world. It was March 1991. They had their two daughters with them, Emily, just two and a half, and Bethany, eight months old. And it was at that time that a horrible tragedy took place. We woke up one morning and our daughter, who was two and a half,

she was our oldest child, she woke up with a fever and vomiting. But a few hours after she first became sick, she developed this horrible rash. It's the classic rash of meningococcemia, and you very rarely see it now in Canada. But it's this deep, ugly, awful purple because the blood vessels break under the skin. And when I saw my daughter with this rash,

it was indescribable, the panic that ensued, and we were two hours away from where we needed to go to get care. Dr. Philpott and her husband jumped in the car. He was in the front, and she was in the back, holding Emily. This journey, which I can remember like it was yesterday, where we were driving as fast as our little car could possibly go down this lonely highway in the south end of the Sahara Desert, trying to get to the hospital. And very sadly, Emily had a seizure and died in the car, and we were still only halfway there. Her other daughter came down with the infection, too.

She survived. I mean, obviously, I would never, ever wish such a horrible experience on anyone, but it was also the deepest learning of my life in terms of what it showed me and taught me about the world and how things that I had understood from an academic or factual point of view about how tragic it is when children die from treatable, preventable infectious diseases. And when it happens to you personally, it changes everything. In her new book, Dr. Philpott says that her daughter's death showed her she couldn't just passively accept such an unjust world. She writes that she decided to devote the rest of her life to the pursuit of fairness.

Dr. Philpott worked in family medicine for decades and was the federal health minister from 2015 to 2017. She's now the dean of the Faculty of Health Sciences at Queen's University. Her book is called Health for All. Today, Dr. Philpott joins us to talk about primary care, the fact that 6.5 million Canadians don't have a family doctor, and her proposal to fix Canada's health care system. I'm Mainika Ramanwelms, and this is The Decibel from The Globe and Mail. Dr. Philpott, it's great to have you here.

Thanks very much for having me. So we've already touched on the motivation behind your work, but let's actually talk about your work now and the model for health care that you talk about in your book. So you actually paint a very hopeful picture, I think I can say, of what primary care could look like in Canada. So let's describe it. What does health care for all, as you say, what does that actually look like? So the model that I describe in the book is that I believe that we need to build a system in Canada that ensures by right that every Canadian has a primary care home. So it's a bit more than saying that every Canadian would have

a family doctor, because in fact, that's not either realistic or ideal. I'm a family doctor, so I think it's great for everyone to be able to have a family doctor, but we don't have enough to go around. And the best way to be able to make this system work is to have family doctors working in interdisciplinary teams. Unfortunately, that's simply not available to almost a quarter of the people that are living in Canada. And I believe we need to build a system where that does happen. And I believe it's possible to do so. So what does that system look like? You talk about these teams or these care homes. Describe that for me. One of the first things that I have been saying, and it's really seems to be a metaphor that people grab hold of, is we understand what it's like for people to have access to public education.

So when we moved back from Niger and our kids needed to find a school, I never worried about whether I'd be able to find a school for our kids to go to. And if we moved to another town, I would never wonder, will they let my children sign up or will I have to go on a waiting list to get my kids in school? Because we've developed a system where everyone has access. That's what we need to do in the primary care world so that if a new neighborhood grows, in addition to planning schools, we plan the primary care home. And it's a place where family doctors work

alongside nurse practitioners and nurses, and in many cases, physiotherapists or occupational therapists or dieticians or social workers, depending on the needs of the community. But it's a team that you are attached to as the place that offers you longitudinal care that is publicly funded, that holds your medical records, that is integrated within itself, but also integrated into the rest of the health system. It seems like a dream to us because that's not what we have, but it's actually doable. And I know that many countries around the world have this. And you talk about this being very reachable.

So ideally, within 30 minutes of every Canadian, they would be able to access a place like this where they could get care basically at any time of day. Exactly. I mean, obviously, the 30 minute piece is, you know, within certain parts of Canada's geography is a challenge. It's a challenge. But the idea would be that it would be somewhere that would be easily accessible to your home or work. The reality of what we need is that commitment to say, we're going to make sure that everybody has this. And that is the front door to care. Because right now what happens is that there are close to 7 million people in the country that don't have a family doctor and don't have any other kind of primary care provider. And they are literally left to manage on their own,

which is, I think, shameful of us as a society that we've let that happen. Well, let's talk about the current situation then, because you say in your book that part of the reason why we need to change our approach to healthcare is because the current system is in a state of arrested development. That's the term you use. What do you mean by that? We've done some great things in Canada as it relates to health care. Most of those great things happened decades ago, though. So it was in the 1940s that Saskatchewan first introduced insurance for hospital care, and then the rest of the country picked it up. And then Saskatchewan introduced insurance for doctor care, and then the rest of the country picked it up. And then eventually that was all brought together under the Canada Health Act in the 1980s. So we've had a system

that has meant that if you had a medical concern and needed to be treated by a doctor or in a hospital, you could be sure that you would have access to care based on your need, not based on your ability to pay. And we sort of stopped there. That was not actually what the founders of Medicare envisioned when it was described all those decades ago. It was described to be much more hospital, and it doesn't always need to be a doctor that's delivering that care. But we've never modernized our laws and policies to be able to keep up with the way modern health care should be delivered, both to make better health care, but also to make it more affordable. I mean, why not? Like, it seems like such a basic question, but like, why haven't we done that, I guess? Well, I speculate in the book that I feel like we thought we would stumble into it through our good intentions because, you know, we're the place that has fantastic universal health insurance. And somehow we thought that that meant we had everything we needed and we

were very proud of our health system. And it didn't get the maintenance that it needed over time. And the cracks started to reveal themselves over the last 20 years when we started to try to tweak the system, but never fully committed to universal access to primary care. And then the pandemic happened and it just blew things apart and has left us in this state of disarray. And central to your idea really is that this should be enshrined in law essentially, right? You propose that the federal government pass a bill similar to the Canada Health Act called the Canada Primary Care Act, could be called that, that would basically standardize the quality of care across the country. What would a basic national standard entail? What would that include?

I came up with this idea as I was preparing for the book because the idea that I'm proposing in terms of everyone having access to primary care is not new. In fact, many other people have suggested that part of it for a very long time. Having been in government, though, and seeing how the tools or the levers of government work, it suddenly struck me that what we were missing was that we had never actually legislated this right to primary care. And that I reflected back on the Canada Health Act and the fact that the reason it worked was that it was enshrined in federal legislation and it set principles that the provinces had to ensure in order to continue to get the Canada health transfer.

If we were to do the same with primary care, we could use it to establish those national standards, and they would be very simple. And some of this has been developed by amazing colleagues, including Dr. Tara Kieran, who I refer to in the book with the Our Care group. And they have said that the standard should be that every Canadian should have access to a primary care team. It should be publicly funded. It should be integrated into the rest of the health care system. It should be accessible.

It should be accountable. And it should be culturally safe. So you could essentially set all of those standards and attach a portion of the funding that flows to provinces and build in mechanisms so that if Canadians don't have access to care, they can put up their hand as it were, and let it be known that they don't have care. That would be a way to say that like we add new schools to our school systems when the population expands, that we would add new primary care resources to that system as populations grow. You mentioned funding. So let's talk a little bit about money here, because this is, of course, a question that people have on their mind. How much would a system like this actually cost?

So here's what's really interesting, because as soon as you start talking about making something better, and governments being involved, everyone gets scared because we're already paying extraordinary amounts of money in our taxes and we think we don't want to spend any more. We'd like our system to be better, but we don't want it to cost more. The really amazing news with this is that it actually would cost less than what we're doing, which seems shocking, but it's true because we know that the countries that do this and do it well pay about the same or less than we do per capita on health care and they get better outcomes. Because what this means is that we would be essentially backing up the care to the earliest point possible that it can be provided

in order to either prevent illnesses from happening, right, or promoting health, screening for cancer, following diseases when they're in their early stages so that they won't get to their late stages. Instead, what we're doing is leaving a quarter of our population without all of that access. And by the time they need to get care, they're actually either too far beyond being able to potentially get the treatment that would have worked earlier, but it sure will cost a lot more. Okay. So in the long term, it sounds like this is financially sound. I am wondering, though, about the initial costs, like the upfront costs, because it seems like we would need a lot of public dollars to even maybe build these centers and establish them. So what is the

cost associated with that? Well, we've done a bit of analysis on this with my colleagues at Queen's University in Kingston, where we've been trying to develop a model of what this could look like. And it's mostly human resources costs, right? It's not like building more hospitals, which cost billions of dollars. The infrastructure of a primary care home is not extraordinarily expensive. It's the people that cost money. But we've calculated that it would cost about $500 per person of government funding per year to be able to provide that access, which I get it in a country of 40 million people. It adds up to a really big number. But again, it's actually going to save us money in the end.

We only spend about 6% of our health care dollars in this country on primary care. That's way below the average of our comparator countries who spend somewhere between 8% and 12%. So it's not actually about spending more, but it's about shifting where we're spending earlier in the health spectrum and making sure that we're providing people with that care early on. We'll be right back. Another question that always comes up when we're talking about health care, of course, is federalism in Canada, right? So health care is a provincial responsibility. Funding comes from the federal government, but the provinces usually set out what they want to do with some stipulations, of course.

And there's often frictions with national programs, right? So the federal government tells the provinces they have to do something. There's kind of the friction that the provinces don't necessarily want to do those things. So I guess, why would they be amenable to a federal law about these healthcare standards? The reason I believe they would be amendable is because it matters so much to Canadians. At the end of the day, our governments are there to serve us. And there are few things that matter more to the people of Canada than their health and well-being and that of their families. And we have seen over the years that when great things happen in this country, they happen not through arguing between orders of government and some forcing their way upon another, but getting governments

to sit around a table together, ideally first ministers, the leaders of the federal government and the provinces and territories to say, we can actually do this for our people. This is not the federal government imposing its will upon provinces, but agreeing that this is a shared priority and that it's doable and that it's what Canadians want and need. But I have to wonder about this, though, because I think about like the environment. Canadians care about the environment, right? But like something with the carbon tax, we see this playing out right now, like even this month. We have this already in place, but there's still so much friction between the premiers and the federal government. So I guess what would make

this situation any different? Well, it's a great question. I would speculate that the carbon tax related policies are much more polarizing in terms of the policy itself. Although, of course, all Canadians want to be able to protect our planet. This is a bit more tangible for Canadians to understand what it would look like. And I hope that through the book and setting this hopeful vision of what could happen as that shared vision arises, and as politicians start to hear at the door that we would like a system with guaranteed access to primary care, that there's something that happens to politicians once they start to perceive that there is an aggregation of public will around a theme of what is possible. We've seen it happen in big projects. It doesn't happen as much recently as it used to, I would say. And maybe that speaks to the challenges of our much more polarized politics that we are enduring these days. But I think Canadians are well past ready for our politicians

to sit down together and collaborate on health. And so I have to ask, when you were health minister, was this health care model, this solution, something that you pushed in that position? To be honest, no. It was not something that we, you know, I obviously as a family doctor thought it was a great idea. I was kind of getting my sea legs as health minister and doing the medical access legislation and the cannabis legislation, a whole bunch of work we did on drug policy and we negotiated a health accord, but we didn't get as far as this.

And then I ended up getting moved to another portfolio, which I also enjoyed, but meant that I had to leave the health piece behind. Also to build a fair picture, the concept of using legislation as a tool to implement this idea was not something that had occurred to me when I was health minister. So now I hope I can share that idea with those who are there now and that they will pick it up.

That's interesting. So it actually took you being out of government to really think about the legislative part of this or how this could work in that sense? It did, yes. So, you know, the idea of legislating a right to primary care is, as far as I know, I'm the first person that's ever suggested this. So I'm excited that it seems to have, you know, had some legs and people are talking about it as if this is a something that would work. I think it's the way that we're going to get past the impasse, because as I said, the idea of this universal access is not new. So I'm super happy that through this book, I'm hoping it will spread the idea further beyond and then

attach to it this idea of legislation as the clincher, the piece that will take us from, wouldn't that be great to actually let's make this happen and let's hold people to account to deliver. Yeah. I want to dive a little bit more into this idea of how this model would work, because I think some people do have concerns too about some of the details. One Globe and Mail reader said about the model that you're suggesting, Canadians do not want to be assigned to a clinic. They want to choose their doctor to ensure they have a good doctor. So, Dr. Philippot, what happens to patient choice in this model? Excellent question. And the good news about being one of the last ones to the party is that you can learn from those who've been there before. So as I said, you can look to many countries in Europe

that have similar models and have been doing this for decades. In some countries, you get the option once a year, sometimes it's twice a year to be able to switch into a different practice group. You are always assigned to a particular primary care team, but they'll be able to guarantee that they have a place to go for care. Another huge issue in healthcare is, of course, shortages of medical professionals, of doctors. If we can look at some of the numbers in Canada, we've got about 96,000 doctors, about half are family medicine practitioners, but we are seeing fewer medical school graduates are listing family medicine as their number one choice. And there's a growing number of vacancies actually for residents of family medicine as well. So yeah, I guess, does Canada have enough doctors to actually make that model a reality?

A fantastic question. I'm glad you asked because in my current role as Dean of Health Sciences at Queen's University, I'm also Director of the School of Medicine there. And this is something that is absolutely part of what we need to do. And that's why we couldn't flip the switch immediately. We don't have the health human resources to implement this model. If I were to magically be able to do it tomorrow, there aren't actually enough family doctors, nor enough of some of the other providers.

So, for example, primary care nurse practitioners or physician assistants, we don't have a lot of in this country. So we need a bit of lead time to be able to train that workforce. But I can tell you that the medical schools of Canada are working hard on this issue. We're doing a lot of innovation. More spots are opening up for family medicine. We're introducing new schools or campuses like ours at Queen's that is dedicated to students who want to become family doctors. But the reality is that this really is a complex scenario where you have to also be addressing the conditions of work because all of the new campuses and new programs and residency spots in the world will not drive people to value and seek after a position in family

medicine if we don't make the conditions of work appealing. And so that's why making sure that we establish these systems where there will be administrative supports, where doctors do not have to do the work of hiring their staff and signing their lease and paying the hydro bills in their facility. It's really quite onerous. And we need to develop a system so that our doctors and nurses are doing the clinical health care work that they are best at and that we have administrative assistance and clinical assistance who can support them to be able to do some of that work that you

don't need to be a doctor to do. As you mentioned, Dr. Philpott, you're the Dean of Health Sciences at Queen's University. You oversee its medical school. Last year, over 5,000 people applied to be a student there, but the school only accepts about 140 students or so a year. So if we're short on doctors, like why don't schools like yours expand the number of students?

I mean, isn't that a way we could boost those numbers? It is a way that we can boost the numbers. And I'm happy to say that every medical school in Ontario is expanding. And we've had a couple of new schools that are coming online very soon. But this is actually a phenomenon that's happening across the country. Really exciting to see both on East Coast and West Coast that there are new medical schools happening. It will take time though, right? It takes a very long time to go from a student into medical school to having them graduating and practice ready.

So it's not going to be a quick fix, but I know I am reassured by that. And as I say, we are doing the work to make sure that we give medical students positive experiences in community-based comprehensive family medicine and helping them to see it as a beautiful way to practice, which I believe it is. In the last few minutes, I want to talk about politics a bit.

You yourself had a little bit of a difficult journey. Prime Minister Justin Trudeau expelled you from the Liberal caucus, along with then Justice Minister Jody Wilson-Raybould. And in your book, Dr. Philpott, you say that you're not sure if you'll end up in politics again. I'm curious, so you haven't turned your back on politics. I don't have any immediate plans to return to politics. I don't think there's an obvious door that's open that would make sense right now. I loved being in politics. I think it's an incredible privilege to be able to take one's ideas for how to be a healthier country and to be able to actually act on those. I'm wondering, have you reached out to any of your former liberal colleagues about this model, about these ideas and about the potential,

I guess, implementation? I've had some good conversations with some of them. In fact, even through the book coming out in the last few days, I've had some really nice feedback. Looking forward to more conversations with colleagues at the federal level, but also provincial colleagues, I think, are really, really interested in this work. And I have worked relatively closely with folks in Ontario as well, and hope that we can have conversations across the country on this. Just lastly, I want to ask you about timing, because you set what you consider to be a realistic goal for this Health for All vision, which is 2035, right? So that's about a decade away,

just over a decade away now. What can we do in the meantime to improve primary care in Canada? I would say that if we're going to hit that 2035 target, we need to start today. You know, so it sounds like it's a long way off, but we're not going to get there unless we get this work rolling immediately. And, you know, I would say that we are from the point of view of trying to do those amendments to medical school approach to family medicine expansion and improving the conditions of work. And there's a lot of work that's happening with medical organizations to support family doctors. But we have to get started on building this collective vision. I am hoping that the book is going to spur this lively conversation with people who are going to talk to their neighbors and friends and colleagues.

And then eventually, as the idea catches on and becomes, I guess, an organic movement of sorts, that the politicians will hear about it and get to work. Because if we are actually going to reach that target of guaranteed universal access 10 years from now, we need politicians to act today. Dr. Philpott, thank you so much for taking the time to be here. Thanks for having me. That's it for today. I'm Maina Karaman-Wilms. Our producers are Madeline White, Cheryl Sutherland and Rachel Levy-McLaughlin. David Crosby edits the show. Our producers are Madeline White, Cheryl Sutherland, and Rachel Levy-McLaughlin.

David Crosby edits the show. Adrienne Chung is our senior producer, and Angela Pachenza is our executive editor. Thanks so much for listening, and I'll talk to you tomorrow.