Eleven Proven Solutions to Improve Public Health Care
By James Hutt, Provincial Coordinator
he Nova Scotia Citizens’ Health Care Network was founded in 1996 with a mandate to protect, strengthen and extend public health care in Nova Scotia. Since then, building on the work of previous health organizations, we have engaged in a number of campaigns and actions to promote universal public health care and improve the health care system.
Nova Scotia is about to enter a provincial election. In preparation, the Health Network is releasing an election platform that offers proven public sector solutions to improve the health of Nova Scotians and the efficiency of our health system.
The platform is categorized into solutions that will:
1) Protect the health care system from privatization
2) Strengthen it by saving money, reducing wait times, and providing better care
3) Extend the scope of coverage to increase the overall health of all Nova Scotians
We hope that all political parties will “steal” these ideas and make them part of their election platforms in 2013. Public health care is too important to become a partisan issue. Nova Scotians need real action from their provincial politicians to protect, strengthen and extend public health care.
All parties also need to commit to standing up for Nova Scotia and opposing the federal government’s cuts to public health care. The federal Conservative government is planning to cut funding for public health care by $36 billion from 2017-2024. This will be a loss of $154 million a year for Nova Scotia by 2024. This means fewer hospitals, fewer health care workers, and fewer physicians.
A new national health accord is key to improving health care and all parties should come out against the federal health care cuts. But while a national accord is essential, there are a variety of smaller steps the province can take to improve access to health care.
Eleven Proven Solutions to Improve Public Health Care
1. Proclaim Bill 144 – The Insured Health Services and Insurance Act –Cost: Neutral
- Bill 144 is designed to protect public health care; it bans queue jumping and reinforced bans on extra-billing and user fees. It also prohibits doctors from opting out of the public service.
- In addition, the bill provides the tools to shift from a fee-for-service model to alternative payment plans so that patients get the amount of attention and care they need.
- Bill 144 was passed in the legislature in December 2012. However, the bill still needs to be proclaimed to take effect. The government must proclaim the bill as soon as possible, while also conducting wide robust consultations to create or improve the regulations.
- In implementing the bill, the province should also look to other provinces for best practices.
2. Close private clinics, reverse privatization –Cost: Neutral, long-term savings as resources redirected to public
- Nova Scotia has two private, for-profit clinics which are suspected of violating the Canada Heath Act by allowing people to jump the queue.[i]
- Canadians decided long ago, and every single public opinion poll confirms it: health care should be based on your need, not your ability to pay.
- The two private, for-profit clinics should be brought into the public health care system as has been done in Manitoba and Ontario.
- Other private, for-profit contracts, like the Telehealth service, should be annulled and brought into the public health care system too
3. Legislate a moratorium on P3s for health care infrastructure Cost: Neutral, cost savings over infrastructure lifetime
- Public-Private-Partnerships, or P3s, don’t work, especially in health care. Countless examples across the UK[ii] and Canada show that P3’s consistently run over schedule and budget, and always under value for money spent.[iii] P3 = Public Pain for Private Gain.
- Private companies borrow at higher rates than governments. P3s promise the advantage of ‘risk transfer’, but this transfer has always proved illusory, and the public has been left to pick up the tab.[iv]
- The province should adopt a legislated moratorium on privatizing health care infrastructure.
4. Hire 200 nurse practitioners -Net savings: approx. $10.9 million
- Three decades of research has shown that Nurse Practitioners can provide the vast majority (80-90%) of services offered by a family doctor with comparable to superior outcomes, and with consistently better scores in patient satisfaction.[v] NP’s can order and interpret diagnostic tests, prescribe pharmaceuticals, and make referrals, among other advanced tasks.
- Nurse Practitioners provide these services with an average salary of less than half that of the average General Practitioner. Studies in the United States have shown that NP-managed practices had costs 23% lower than those run by other providers, with 21% fewer hospitalizations.[vi] Similar savings have been noted in long-term care where every dollar spent on nurse practitioners results in several dollars saved on physician treatment of major diagnostic conditions.[vii]
- Given the need for doctors in NS, hiring 200 NP’s and 40 physicians would give the province the equivalent capacity of 200 new physicians. By way of a rough estimate (counting each Nurse Practitioner as 0.8 of a doctor), the net savings would be $10.9 million annually.
- The province should train and hire 200 new nurse practitioners and help integrate them into hospitals, long-term care facilities, family practices and community health centres across the province.
5. Advance Midwifery Care in Nova Scotia – Hire 25 new midwives. -Savings: $1 million
- Nova Scotia lags far behind other provinces in allowing midwives to practice in our hospitals and our homes. Many families still cannot access a midwife because there are none practicing in their community, or because the midwives that are practicing have more patients than they can handle.[viii]
- Midwives offer a more holistic approach to maternal and perinatal health care, including pre and post-birth support, and consistently score higher on patient satisfaction surveys.[ix]
- The province should ensure midwifery care is an option for all pregnant women across the province. Midwives should have hospital privileges and the ability to consult with other practitioners as necessary.
- There is solid evidence attesting to the safety of home births for low-risk pregnancies and other provinces have successfully employed this option.[x] Midwife-assisted home births should be available across the province.
- A 2003 Evaluation by the Ontario Ministry of Health found that compared to physician-attended births, midwife-attended hospital births cost an average of $800 less while midwife-attended home births cost an average of $1800 less. Savings were realized through lower C-section and episiotomy rates, lower readmission rates and shorter hospital stays.[xi]
- Given that midwifery training is limited to a few schools across the country, none of which are in Atlantic Canada, the province should engage the other Atlantic Provinces and the federal government to explore training midwives in Atlantic Canada.
6. Launch an inquiry into the state of long-term care in Nova Scotia. -Cost: $500,000
- Nova Scotia’s seniors are not receiving the care they deserve in our long-term care facilities. Seniors, their families, and front-line health care workers constantly report that long-term care facilities are understaffed, under resourced, and overworked.
- Today in Nova Scotia about 50% of the long-term care are now in private, for-profit hands[xii]. Studies have consistently shown that for-profit facilities cost more and provide inferior care.[xiii]
- The province should call a public inquiry into the state of long-term care. Local experts should run the inquiry, not consultants, and focus on input from care providers, family advisory groups, and broad public engagement.
- Provincial staffing regulations in long-term care were devised in the 1970s. These desperately need to be updated to keep up with the dramatic changes in the number and acuity of residents, and the complexity of their care.
- The government needs to further its commitment to our elders and chronically ill. Nova Scotia needs more support for home and community care, and greater services that maximize the independence and choices of our loved ones.
7. Mental health, addictions and harm reduction. -Cost: $10 million
- The provincial mental health care strategy is a good step forward, but it does not have nearly enough funding to be successful. Likewise, we applaud the province’s recent investment in mental health programmes and services, but this remains a drop in the bucket.
- Canada has a crisis on its hands when it comes to mental health care. One in five Canadians will experience mental health issues in their lifetime and one in seven will experience a problem with drugs and alcohol.[xiv] Yet those with mental health issues often face stigma and cannot get access to necessary programs and supports, especially in rural areas.
- Nova Scotia also continues to treat addictions as a criminal issue, instead of a health care issue. Putting people with addictions or mental health care issues in jail is not a solution. The evidence is clear, countries who treat addictions as a health care issue have lower rates of drug and alcohol use. Portugal[xv] and the Netherlands[xvi] are two examples.
- To start addressing mental health and addictions the province needs to invest seriously in harm reduction programs in all parts of the province. This means investing in peer-support programs, opioid maintenance, needle-exchanges, safe crack kits, a safe injection site, access to condoms,, opening a wet homeless shelter, support for sex-workers, access to HIV and Hepatitis C testing, programs in prisons, and other initiatives that meet local communities’ needs.
8. Create an aging and dementia strategy -Cost: $3 million
- Our seniors deserve the right to age with dignity, safe in their homes and communities.
- At present 50% of home care and long term care facilities are in private, for-profit hands.
- The current system of nursing homes and retirement facilities needs to be completely revamped in light of underfunding. Inadequate staffing levels, poor diets, limited stimulation, and increasing user fees such as possible parking charges.
- Continuing/Long-Term Care must become a fully insured service under the Canada Health Act, in which there will be a complete continuum of services available to assist seniors to stay in their homes as long as possible and to receive adequate supports when needed in Long-Term Care.
- A provincial dementia strategy must be developed and put in place as soon as possible
9. Eliminate fee-for-service payment for physicians -Cost: Neutral
- Fee-for-service is how the majority of Nova Scotia’s physicians are paid. The fee-for-service model doesn’t work for patients or for physicians[xvii].
- Fee-for-service is a historic compromise that was made when Medicare was created in Saskatchewan. Unfortunately, fee-for-service rewards physicians for getting patients in and out of the doctor’s office as quickly as possible, and as many times as possible. It also provides no incentive to take on new patients.
- Nova Scotia is a national leader in alternative models of compensating physicians. More than one third of Nova Scotia’s physicians are on Alternative Payment Plans (APPs), most notably in emergency rooms, academic settings and select community health centres.[xviii]
- The new changes to the Health Services and Insurance Act create more avenues to move physicians off fee-for-service.
- The province should work toward eliminating fee-for-service as a model for compensating physicians and should explore alternatives.
10. Merge all pharmacare plans -Cost: Neutral
- Nova Scotia currently has 5 different pharmacare plans. Each program has its own criteria, regulations and formularies[xix]. This creates duplication and confusion among patients when applying for pharmacare. The programs are: Drug Assistance for Cancer Patients; Department of Community Services –Pharmacare Benefits; Diabetes Assistance; Family Pharmacare; and Seniors Pharmacare.
- Nova Scotia consumes by far the highest volume of drugs per capita in Canada. Nova Scotians also pay the second highest out-of-pocket expenditures per capita in Canada[xx].
- In the long-run, the solution is a National Pharmacare Program that would provide universal coverage to all Canadians and would actually save $10.7 billion at the same time[xxi].
- Short of a new national program, Nova Scotia can take some steps to improve access to pharmacare and ease of applying for patients. The province should merge all 5 pharmacare plans into one and standardize the application process, formulary and eligibility criteria. This will also reduce administrative costs.
- The province has made great strides in capping the price of generic drugs with the Fair Drugs Pricing Act, and also in collaborating with other provinces for bulk purchasing. NS should work with other Maritime provinces to expand on joint strategies to contain costs, while moving to provide universal, free pharmacare coverage for all children and seniors. These important steps will increase access to needed medicines and reduce strain on hospitals.
- The province should also conduct a feasibility study on creating a publicly owned generics drugs manufacturing plant to produce the prescription drugs required in Nova Scotia at a lower cost.
11. Open 10 new Community Health Centres and provide support to existing facilities -Cost: $40 million plus $500,000 to fund the NS Federation of CHC’s[xxii]
- Community Health Centres (CHCs) are internationally recognized as the most holistic way to provide care for patients. At community health centres physicians work with a team of health care workers including nurse practitioners, social workers, mental health care workers, dieticians and others to ensure all of a patient’s health care needs are being met.
- CHCs are board governed and democratically run by the local community and the patients registered at the centre. CHCs focus on health promotion; not just on treating patients when they are sick or injured, but also on the social determinants of health and keeping people healthy in the first place. Countless reports and studies have recognized the importance of addressing these determinants as a means to reduce costs and improve health outcomes.[xxiii]
- Nova Scotia has nine community health centres, located in far reaching rural areas, First Nations reserves, as well as urban areas. These include Eskasoni, Hants Shore, North End, Rawdon Hills, W.B. Kingston CHCs to name a few. No two are alike – all offer services and service providers according to the social determinants of health that affect the populations served. One of the largest obstacles to strengthening a team-based, holistic approach to care is the major gaps in funding, if any, received by the Department of Health and Wellness to assist with the daily operations of these facilities. The extremely dedicated volunteer board members of CHCs work hard at fundraising efforts to maintain the facilities, purchase medical and office equipment, and subsidize the cost of services and programs.
- CHCs are internationally recognized as the most cost-effective model of primary health care with positive outcomes with regards to chronic illness and the social determinants of health. They are the model for the future of health care, lowering costs and maximizing patient and community participation.
- Nova Scotia should increase and stabilize funding for existing CHC’s and open 10 new CHC’s to keep its citizens healthy and reduce costs. The Public Health Agency of Canada estimates that every dollar spent on health promotion results in an estimated six to eight dollars saved in health care costs.[xxiv]
Total Cost: $42.1 million, about 0.9% of the annual health care budget.
 Estimated based on costs: $24.6 million (200 x $123,000 in NP salary & benefits) versus savings: $35.5 million for 80% less physicians(200 x 0.8 x $222,000)
 If we estimate savings at $1000 per birth, an increase of 25 midwives province-wide, attending an average of 40 births per year, would result in $1 million in savings annually
[i] Ontario Health Coalition, Eroding Public Medicare www.web.net/~ohc/Eroding%20Public%20Medicare.pdf
[ii] Pollock, A.M., Shaoul, J. and Vickers, N. (2002). Private finance and “value for money in NHS hospitals: a policy in search of a rationale?” British Medical Journal: 324, May 18, 2002;
[iii] Mehra, Natalie. Flawed, Failed and Abandoned – 100 P3s – Canadian and International Evidence. Ontario Health Coalition. March 2005.http://www.web.net/~ohc/P3s/Flawed,%20Failed,%20Abandoned%20-%20Final.pdf
[iv] Gaffney, D. et al. (1999). The private finance initiative: The politics of the private finance initiative and the new NHS. British Medical Journal: 319, July 24, 1999. http://www.bmj.com/content/319/7204/249.full
[v] Bauer, J. (2010). Nurse practitioners as an underutilized resource for health reform: Evidence-based demonstrations of cost-effectiveness. Journal of the American Academy of Nurse Practitioners 22, 228–231
[vi] Sptizer, R. (1997). The Vanderbilt University Experience. Nursing Management, 28(3), 38–40.
[vii] Chenoweth, D., Martin, N., Pankowski, J., & Raymond, L. W. (2008). Nurse practitioner services: Three-year impact on health care costs. Journal of Occupational and Environmental Medicine, 50, 1293–1298.
[viii] Research Power Inc. (2010). Implementation of Midwifery in Nova Scotia. Prepared for: Nova Scotia Department of Health & Reproductive Care Program of Nova Scotia.
[ix] Chalmers, B. et al.(2008). The Canadian Maternity Experiences Survey: An overview of findings. Journal of Obstetrics and Gynaecology Canada 30:3.
[x] Janssen, P. et al. (2009). Outcomes of planned home birth with registered midwife versus planned hospital birth with midwife or physician. Canadian Medical Association Journal 181(6-7), 377-383.
[xi] Ontario Midwifery program, Ministry of Health and long-Term care, 2003. “Ontario Midwifery program evaluation”
[xii] Statistics Canada. (2011). Residential Care Facilities 2009/2010. Catalogue no. 83-237-X
[xiii] Commodore, V.R. et al. (2009). “Quality of care in for-profit and not-for-profit nursing homes : a systematic review and metaanalysis.” British Medical Journal, 339: b2732;
[xiv] Provincial Mental Health Strategy, Together We Can, www.gov.ns.ca/health/mhs/reports/together_we_can.pdf
[xv] Hughes, Caitlin. Stevens, Alex. “What Can We Learn From the Portuguese Decriminalization of Illict Drugs?” British Journal of Criminology. Oxford University Press. July 21, 2010.
[xvi] Van Laar, Margriet; Gruts Guus; et al. “The Netherland Drug Situation 2011.” Report to the EMCDDA by the Reitox National Focal Point. Trimbos Institute; Utrecht. 2011
[xvii] The Canadian Health Services Research Foundation, Mythbusters series, http://www.chsrf.ca/PublicationsAndResources/Mythbusters/ArticleView/10-01-01/13b5e8bb-e7c2-4544-8da5-b1aa5d9e38db.aspx
[xx] Andre-Gagnon, Marc. The Economic Case for Universal Pharmacare: Costs and Benefits of Publicly Funded Drug Coverage for all Canadians. Ottawa: Canadian Centre for Policy Alternatives, 2010.
[xxii] Canadian Centre for Policy Alternatives – Nova Scotia. “Strengthening Connections, Connecting Communities: Nova Scotia Alternative Provincial Budget 2013.” Halifax: CCPA, 2013.
[xxiii] See for example Romanow, Roy, Building on Values: The Future of Health Care in Canada. Commission on the Future of Health Care in Canada. Final Report. 2002.
[xxiv] Public Health Agency of Canada. (2009). Healthy Aging. Prevention of Unintentional Injuries Among Seniors.