NHC's Michael Decter: Wavemaker

The new chairman doesn't merely want to monitor care —
he wants to change it. Solo GPs are an anachronism

By Hugh W Coulthart

"A few years ago I wrote a piece in MacLean's magazine in which I described the solo family practice as an anachronism in this modern technological day and age," Michael Decter, Chairman of the National Health Council (NHC) told the audience in late January at a Health Law Conference at the University of Toronto. "A few weeks after that," he went on, "I called my younger brother, who is a family doctor in Brandon, Manitoba, to see how he was. He told me, 'Well apparently I'm an anachronism, but apart from that I'm quite well.'" But don't expect the Council under Mr Decter's chairmanship to defer either to the political contingencies of governments or physicians. Expect instead what the council was intended to be: a third voice that speaks directly to the people of Canada about health care.

FINANCE ONLY
Mr Decter's understanding of the council's role is rooted in its origins. "Both Mr Romanow and Senator Kirby recommended a Health Council. They both came to the view that the current relationships among the governments in Canada were dysfunctional and were not giving the public or the health system a source of dispassionate, arms-length and independent advice. All issues became issues of finance..."

"I would go further and say that the nature of how we began medicare -- which was for governments to step up as the insurers and pay the bills -- put them in an almost perpetual adversarial position vis-"-vis hospitals and physician organizations. There's a dysfunctional aspect here too. When a medical association is bargaining with the government over the level of compensation for physicians, all other issues are put aside for a time." As the third voice, the Council's role will be to see that those "other issues" are kept on the table. In Mr Decter's view, the Council won't fulfill that mandate if it only functions as a passive monitor. To illustrate how this might be done, Mr Decter turned to primary care. "There's no change in Canadian health care that is as easy to understand and as hard to achieve as the reform of how we deliver primary care. The challenge is that primary care is still delivered by solo practice family doctors who don't have a governance structure. In fact they're so busy looking after their patients that they don't have time to go often to meetings to discuss why what they're doing isn't optimal."

The chairman sees an active role for the Council in effecting the changes necessary to achieve the accord's objectives. "The first ministers agreed that 'within eight years' -- now it's seven -- that '50% of Canadians should have access to an appropriate health care provider.'" That phrase is very important because it opens up a broader concept of who can deliver primary care -- 24 hours a day, seven days a week. And there's specific funding to achieve this. "The Council certainly has the task of monitoring this, but simply saying, okay, this is year two, we're at 9.7%, is squandering the potential. The real question is, where does it work, and how did it get to change. So the Council, in my own view, if it's living up to its own mandate, will not only monitor but provide good advice across the country on how best to move this along faster."

To illustrate his point, Mr Decter said you need look no further than the Group Health Centre in Sault St Marie "to see not only a community clinic that's been named provider of primary care in that area, but to see a group of physicians practicing as a team, to see multidisciplinary practice of nurse practitioners, specialists, and a whole range of health care providers. This is what a reformed health system will look like."

Identification and analysis of positive models exemplifies what Mr Decter means by the Council playing a constructive role. "The monitoring that we will do, the tracking, will be balanced by some genuine activity to be constructive, to share ideas, to share knowledge. I don't see the Council setting out to punish the guilty. I don't think that joining the blame game will be constructive. If anything, I'd say that we spend far too much of our time in Canadian health care trying to figure out whose fault it is, rather than figuring out how to fix it." Clearly Mr Decter intends to spend his time fixing it.