Mr. Gordon Ritchie (Dauphin):
Mr. Speaker, it is with considerable interest that I rise to speak on this bill. Perhaps it is somewhat sad to have to speak about a program, which was of considerable value, being phased out. In retrospect, it seems obvious that it is really a return to the 1960s when there was a vast push by the federal government to inflict on the provinces a heavy burden in the comprehensive health care system, over provincial objections in many cases. The principle of universality was thrust on the provinces, a move which will now have to be limited. We recognize now that these plans cannot be continued. I should like to say to my friend, the hon. member for Yorkton-Melville (Mr. Nystrom), speaking of the record in the province of Manitoba, that in the last 13 months 12,000 new jobs have been created, almost as many as the government of Mr. Schreyer created in the last three years.
Speaking of the health resource fund, it seemed like one of the better ones in that it trained people in the health professions or in occupations associated with the health professions, and in conducting research in the health field. Now that the fund is being wiped out by the federal government, the tab will have to be picked up by the provincial taxpayer or the programs will have to be deleted altogether.
It is unfortunate that the type of programs financed by this fund will fall short, and that any research program that was started in the previous three years will be wasted in view of the fact that programs are based on a five-year period. In fact, most of the programs which are in the mill, so to speak, will be of little value. Furthermore, education and research, have been the most promising fields for governments so far as health return is concerned, because the education of professionals in the area of health has brought a return over many years.
I should like to say that when the Fathers of Confederation designated the provinces to care for the health, welfare and education of their citizens, they chose very wisely. The strains on confederation in the last ten years can be directly attributed to the move of the federal government into the tax Field through income tax in order to finance the federal government's incursion into health, welfare and education, areas which rightly belong to the provinces. Previous Liberal administrations have inflicted on our citizens grandiose health plans which we find we cannot now sustain. The federal
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government is washing its hands of the dollars needed for health care and allowing the provinces to make do as best they can, all the while attempting to force on the provinces expanded language training, thus moving into areas under their jurisdiction.
I would like to use this opportunity to discuss some of the problems associated with medical practice and health care. This bill only deals with one small portion of health care, but I should like to point out the differences between the health professions and the government and the direction of medical care in this country. Also, I should like to point out some means by which we might avoid some of the bad features of the socialized government health care system which we have at present. Although 1 will speak mainly of physicians in the health care field, I would like to include also other professionals involved in the health care delivery system. When I use the term physician, other disciplines in the health field are included.
There are many points of conflict between doctors and politicians, but the most fundamental one is their differing attitudes toward individual patients. Doctors who devote their professional lives to the care of patients like to feel that they have a duty to their patients on an individual basis in a one to one relationship. This is where the conflict arises between the attitude of the doctor and that of the politician who claims to have a much wider responsibility for the health of the people, so that he is not primarily interested in providing the best possible care for individual patients but is more interested in providing that care for as many people as possible, within the constraints of the available resources. The tension between the groups arises because of the demands of the individual and the priorities of the doctor, and the demands of the group and the priorities of the politician.
Politicians and doctors in their respective ways attempt to act for the good of individuals, but the doctor's action is a narrow one while the politician's is much broader. The conflict between the two groups may be summarized thus: the politician wishes to ensure that scarce skills are used for the general good, while the doctor who is confronted by a sick patient sees the good of the patient as the dominant factor. Doctors struggle for what they consider to be professional freedom and independence, whereas politicians put the need of public provision and public decisions over private decisions in health care.
Mr. Enoch Powell, the minister of health in Britain in the previous Conservative administration, has pointed out that one of the basic attitudes of the medical profession is respect for the independent and individual professional judgment made for the benefit of individual patients, whereas the politicians' concern is with the general consequences of individual decisions or, as he stated:
The politician practices the subordination of individual judgments, while the doctor glories in the development and exercise of it.
There are other aspects to the politician. Politicians can achieve nothing without power, and in order to attain power in a democratic society they need votes. To win votes, they must convince the voters that their programs are worthy of support.
Health Resources Fund Act
Therefore it is easy to see that in the decades gone by, packages of health care programs, growing greater and more elaborate, have strained our resources, along with other transfer programs, to the extent that one-quarter of every dollar spent by the federal government has to be borrowed. Certainly this cannot continue. Of course politicians must be concerned with the health of the nation in broad terms. The scope of modern medicine is so broad and costly, and the expectations of the public so high, that politicians have become more involved in health care programs, particularly where there appear to be inequities both in terms of access and in the ability of individuals to provide for their own medical needs.
It is interesting to note that in the United Kingdom the dialogue between doctors and the state has been a long and continuing battle. Medical physicians in the United Kingdom have been attempting to preserve some independence, while the state has attempted largely to control their actions and limit their freedom of treatment. One of the great difficulties was the approach of the state to health care programs. The conventional feeling was that poor health is the direct result of poor medical care, and that if the health of the nation could be brought up to standard, then the need for medical treatment would diminish. But time has proven that the demand for health and medical care is insatiable, and that we can expect ever-increasing demands on the nation's resources of money and workers to feed this persistent expanding demand.
Medical care brings with it infinite demand on finite resources. Furthermore, it brings to the political side the necessity to make decisions as to whether primary care should be provided. Should primary care be provided by an office staffed with highly and expensively trained doctors, or should this be done by less trained and presumably cheaper professionals? Should there be increased services for the elderly and infirm? In what manner should these increased services be carried out?
At the present time there is a drive to reduce acute care beds on the basis that they are expensive and unnecessary. But, in practice, acute care beds are occupied by the productive age group of society. Keeping them out of hospital beds only prolongs their absence from work. Outpatient treatment is now in vogue. In the days of fee for service medicine, outpatient treatment was a means of saving money. But it has its drawbacks: how can we expect many people to drive 50 miles in order to attend at a hospital each morning?
Medicare and hospitalization have been installed for a number of years. They were patterned on the private experience previous to the inauguration of the health care program. But so many years have passed now that the experience of private medicine has been blurred and no longer provides signposts for guidelines. New planning must come into effect, and it must be done by people who have little actual contact with the medical world for which they will be responsible. It must come from either Ottawa or the provincial capitals. With the thrust of the bill before us, it would seem that Ottawa is
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Health Resources Fund Act
tending toward getting out of this area. In the long run it will be good idea, but it poses a number of problems.
At the present time we have reached a situation where the health care system requires reorganization. Some questions must be asked. How can the health care program be constructed and administered? We must decide on the global sum available to finance such a program. How will the global sum be apportioned regionally and locally? How can individuals attain access to the system? How will physicians and others in the system be paid? In what manner will they be paid?
The obvious disadvantage of such a system is that political expediency may make the state decide to construct a health care system which does not recognize the genuine needs of patients. Because health care is more infinite in its demands and resources are finite, perhaps politicians will have to minimize expenditures on health care so that other social policies can be pursued. Politicians run from one social program to another expending their energies, particularly in an attempt to ingratiate themselves with the electorate. An attempt at distributing resources to provide an adequate level for all certainly will downgrade the maintenance of high standards and threaten excellence. The creation of a monopoly in health care will remove freedom of choice almost completely, except in a few cases.
What about physicians themselves? Individually patients usually trust their physicians, but society as a whole does not care much for doctors. Of course doctors are no different than any other professional. I should like to refer to what Samuel Hartlip once wrote of Puritan times. It reads as follows:
The liberty of our Commonwealth is most infringed by three sorts of men- priests, physicians and lawyers. The one deceives man in matters belonging to their souls, the other in matters belonging to their bodies, and the third in matters belonging to their estates.
Indeed the profession seemed to be under some kind of attack. Now some suggests doctors must administer a proper professional altruism, while others think the public expects too much of doctors. In a general way, perhaps society expects doctors to display unalloyed altruism, and indicates surprise and indignation when doctors take on the habits of the larger society of which they are a part.
Students of the welfare state have expressed some views as to where we are going. One suggestion was that the welfare state, as we understand it, more properly should be called "the entitlement state". People accepting welfare from the state now feel they are entitled to a considerable portion of the nation's largesse, regardless of their contribution to it. Perhaps it can be described as the expectation of the ultimate responsibility of public authority that individuals are not permitted to suffer persistent deprivation and despair. We have reached the stage where we feel no one should be deprived, but this poses a challenge to both freedom and responsibility.
One can well ask how we can revive and preserve in an entitlement state the sense that rights must be earned. Entitlement is not a one way street. Society demands a contribution to the whole, not each individual securing for himself as much as he can. The transition from a welfare state to an entitlement
state will result in great disruption of benefits, unless individuals capable of accepting responsibility for their welfare are encouraged to do so.
I would regard this bill as a high water mark. In a sense it can be used to signal a new era. It can be used to ensure that those who can afford to provide their own health benefits will do so at their own expense, either totally or partially.
The criteria laid down by the federal government in many cost-shared programs always were too rigid. Many provinces had different plans to limit and provide control over the infinite demands of free health care service. Even though the federal government still provides a large amount of money, it should loosen demands and constraints in order to allow the provinces leeway to innovate and make health care delivery systems suitable to peculiar circumstances and regions.
The retention of the fee-for-service provided a much better method of payment to physicians than a total salaried or a per capitation service. A salaried system would be inappropriate because it is very difficult, as we are now finding within the civil service, to measure productivity. At one time it was thought that fee-for-service would be expensive and make for excessive medical income, but it seems to have turned out just the opposite. Medical fees have not risen as fast as the wage structure has in the early 1970s. Those who practice in offices have had their overheads substantially increased to the point where 50 per cent of their gross fees now go to overhead expenditures, as compared with 35 per cent a few years ago. Nearly all the offices of which I am aware have had little increase in actual dollars in the last few years, and if you consider inflation they have suffered a decrease in their income. This has resulted in the migratrion of physicians to the United States, particularly those who are ambitious, energetic and perhaps individualistic and who have generally found that the practice of medicine in that country has less bureaucratic interference, and that they can practice a better standard of medicine in their own individual way.
Under the present fee structure in Canada it is impossible for a physician to spend much time with an individual patient and still have a high enough income to make the profession worth while. Many doctors have stated that each year they average one or two more consultations per day. An older practitioner once said there is no way under the present fee structure that he could give the time he would like to give to individual patients and still make an adequate income or even keep his office overhead at bay. Nevertheless, the fee-for-service system has allowed physicians to give extra service and consultation to patients who wish it over and above what the medical plans allow. The plan has allowed these physicians to charge extra, enabling them to limit this demand and at the same time satisfy their patients' requests for greater care. Perhaps the provincial agency could encourage physicians who wish to practice in this manner to take on patients who may wish the extra care.
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However, there is a tendency for bureaucrats to be suspicious of both physicians and patients who depart from the accepted pattern. Doctors are limited in practising outside the plan even though there is a demand for their services over and above what the plan allows. In fact if this demand grows, it indicates, presumably, that either fees are too low, the government's pay is too low, or that there are not enough physicians to go around.
As I said, Canada has lost some of its doctors to the United States. I do not consider the loss serious, however, because we are probably in an oversupply situation, and with the immigration of doctors into Canada from other parts of the world, I am sure that we have adequate numbers, even though they may not be distributed quite the way people would like.
At the hospital level, it is obvious that great changes are taking place and that bureaucratic administration, of necessity, seems to be an all-encompassing grey blanket over the time of physicians and other health care professions. I would estimate that fully one third of a physician's time in a small general hospital is taken up with paper work, which takes away from the medical treatment for patients, but seems to be necessary to get through the bureaucratic jungle of a hospital. The accreditation service of hospitals may have originally been a help, but it has created a vast waste in terms of the time of physicians, management and other staff within the hospitals, who must get ready for the visit of the often uninformed inspector who comes from an entirely different environment.
It seems to me that hospitals should be encouraged to set aside a small number of beds for patients who desire privacy or admission at their convenience and are willing to pay for it. I have already stated that there is an infinite demand for medical service today, but only finite resources. The rate charged for those wishing these special services would have to be high enough to return to the hospital enough extra income to provide for some of the amenities, but more than that, would provide extra funds at the administrative level for their own use. One of the great difficulties of hospital management is that they have no money to spend on their own, but are controlled by the provincial paying agency.
Of necessity, health care and health decisions must be made by managers who are not themselves health professionals, and it is difficult for them to understand the rationale of health decisions. The management of hospitals and general medical care must become more divorced from the day to day operations of medical care. Unless conditions change, many professionals now in the health care field will leave and take up other endeavours where the pay and conditions of work are better and where they would not have to work under a non-understanding bureaucracy.
I am glad that I have had this opportunity, Mr. Speaker, to put on the record some of my thoughts with regard to health care, of which this bill forms a small part.
Export Development Act
Topic: GOVERNMENT ORDERS
Subtopic: HEALTH RESOURCES FUND ACT