Access within a Fragmented Healthcare System: A Nurse's Perspective on Romanow

Access to healthcare remains both topical and problematic in Canada, although the reasons for this have changed over time. This issue is usually framed in terms of ensuring equal access to services. Changing the perspective on access to one framed in terms of ensuring comprehensive, effective and efficient healthcare highlights the problems associated with fragmentation of care delivery. Attempts to reform or restructure healthcare delivery with the goal of improving integration and coordination are constrained by the legislative context in which we understand the Canadian healthcare system. In this paper, I provide an overview of the legislation underpinning Canadian healthcare, particularly the foundational principles of Medicare as defined in the Canada Health Act, 1984 and the values underlying this legislation. Then I examine the issue of our fragmented healthcare system and articulate why I regard access as problematic. Finally, I argue for integration and coordination of services with reference to the Romanow (2002) report. I consider the reforms suggested by Romanow in the context of the existing legislation and the implications for nursing leadership. Peter came for haemodialysis on Tuesday, Thursday and Saturday afternoons. One day I discovered during a routine foot check that he had an ulcer on his left foot that would require daily dressings. Peter’s vision and manual dexterity were limited, so I called home care nursing to arrange to have a home care nurse change the dressing on his nondialysis days. The home care nurse asked: “Where are you calling from again? ” I repeated that I was calling from the haemodialysis unit of Hospital A. There was a pause, then: “Well, that explains why Peter is never home on Tuesday and Thursday Access within a Fragmented Healthcare System: A Nurse’s Perspective on Romanow Eleanor F. Ravenscroft, RN, MSN, CNeph(C) School of Nursing, University of British Columbia Vancouver, BC Nursing Leadership On-line Exclusive • June 2005 2 afternoons for us to check his blood sugar. I didn’t know he was on dialysis! You know, we’ve been seeing him for six months at the request of the diabetes clinic – do they know? ” This vignette illustrates the problem of access in the context of fragmented healthcare delivery even within a regionalized (and, theoretically, more coordinated) provincial healthcare system. Had services been better integrated, the diabetes clinic, home care and haemodialysis unit could have worked together to monitor Peter’s diabetes. At least two home care visits per week could have been eliminated, as we checked Peter’s blood sugar at each dialysis treatment. Peter’s access to care would have been improved by virtue of each care provider’s comprehensive understanding of his health challenges. Duplicate testing and unnecessary appointments due to fragmented service provision cost both Peter and the healthcare system time and money. Such financial and human resource costs to the healthcare system contribute to longer waits for services, increased healthcare spending and reduced access. As this vignette illustrates, comprehensive and integrated care is also likely to be more effective and efficient. I argue that the issue of access in healthcare remains both topical and problematic across Canada, although the reasons for this have changed over time and the manifestation of the problem may vary among provinces and territories for reasons that will be discussed later. The problem is usually framed in terms of ensuring equal access to healthcare (Armstrong 2002; Deber 2003), and it can be argued that equality of access has largely been achieved (Mhatre and Deber 1998). If, however, the issue of access is reframed in terms of ensuring comprehensive, integrated healthcare, then I argue, as does Romanow in his 2002 report for the Commission on the Future of Health Care in Canada, that access to care continues to be problematic because of fragmentation in care delivery. I argue for the integration and coordination of services, and refer to the Romanow report to show how this can be done. I also argue that attempts to reform or restructure healthcare services with the goal of improving integration and coordination are constrained by the legislative context through which we view healthcare services in Canada. Deber et al. (1998: 423) identify three dimensions of healthcare services: “financing – how services are paid for; delivery – how services are provided to recipients of care; [and] allocation – how resources flow from those who finance care to those who deliver it. ” The legislative context of Canada’s health services both underpins the current financing, delivery and allocation of health services and provides the foundation for change. In this paper I will first provide an overview of the legislation underpinning Canadian healthcare. I will give particular consideration to how the foundational principles of Medicare are defined in the Canada Health Act (CHA), and how these definitions continue to influence healthcare services in Canada. Then I will examAccess within a Fragmented Healthcare System: A Nurse’s Perspective on Romanow 3 ine the issue of our fragmented healthcare system and articulate why I regard it as problematic for access. Finally, I will consider the reforms for Canadian healthcare suggested by Romanow in 2002 in the context of the existing legislation and the values underlying it, and how nurses might contribute to future policy development intended to improve access to healthcare. Overview of Legislation The current Canadian healthcare system remains heavily influenced by its foundational legislative history and the Canadian structure of government, that is, a confederation of provinces and territories with responsibility for governance divided between the federal and provincial or territorial governments. The Constitution Act, 1867 clearly established healthcare and other social programs, such as education, as a provincial rather than a federal responsibility; this distinction continues to influence the Canadian healthcare system over 130 years later. The Act frames discrete provincial or territorial systems of healthcare delivery rather than one unified national system. While each province/territory must conform to federal legislation (the CHA) to ensure federal financing of healthcare services, there is considerable provincial/territorial freedom in the delivery and allocation of these services. What follows is a brief review of the history and content of the CHA and a discussion of its implications for healthcare services provision in Canada. In 1957, the federal government laid the foundation for Canada’s health insurance system by passing the Hospital Insurance and Diagnostic Services Act (HIDSA). This was an attempt to persuade provincial governments, by means of financial incentives, to administer and partially fund a universal hospital insurance plan. In 1968, medical insurance was added through the passing of the Medical Care Act, requiring provinces or territories to have healthcare insurance schemes that complied with five criteria to qualify for the transfer of funding from the federal government. By 1971, all 10 provinces had some form of medical and hospital insurance program (Iglehart 2000). Passed in 1984 in an attempt to reinforce federal control of healthcare, the CHA replaced the HIDSA and Medical Care Act and confirmed the commitment of Canada’s people to a healthcare system that adhered to the five funding criteria of the Medical Care Act (Iglehart 2000). These criteria have come to be regarded as the foundational principles of what is now known as Medicare. The CHA ensures some consistency in service provision across jurisdictions but leaves the method of delivery (including coordination and integration of services) to the discretion of the individual province/territory. This arm’s-length approach is reinforced by the federal government’s reduced influence since the mid-20th century, as reductions in transfer payments and remodelling of the federal financial contribution to health4 Nursing Leadership On-line Exclusive • June 2005 care allowed provincial and territorial governments more flexibility in the allocation of funds. Since 1984, the provincial and territorial governments have primarily led changes to the allocation and delivery of healthcare in Canada, resulting in differences in access across provinces/territories. The importance of the guiding principles of the CHA to Canadians was recently reaffirmed in the Report of the Commission on the Future of Health Care in Canada (Romanow 2002). Although healthcare delivery and allocation of resources are largely determined at the provincial and territorial level, I maintain that access remains problematic primarily because the CHA’s delineation of the foundational principles of Medicare restricts our thinking about the three dimensions of health services, namely, delivery, allocation and funding at the federal and provincial/territorial levels. Foundational Principles of Medicare The five foundational principles of Medicare are defined in the CHA as: 1. Public administration: The administration of the healthcare insurance plan of a province or territory must be carried out on a nonprofit basis by a public authority; 2. Comprehensiveness: All medically necessary services provided by hospitals and doctors must be insured; 3. Universality: All insured persons in the province or territory must be entitled to public health insurance coverage on uniform terms and conditions; 4. Portability: Coverage for insured services must be maintained when an insured person moves or travels within Canada or travels outside the country; and 5. Accessibility: Reasonable access by insured persons to medically necessary hospital and physician services must be unimpeded by financial or other barriers. These definitions restrict healthcare delivery in the 21st century in a number of ways. In particula