By Brian Day

In a recent Southam News - COMPAS poll on the role of the private versus public sectors in health care, 60 percent of Canadians expressed support for increased provision of health services by private suppliers. These findings do not surprise me. They represent the inevitable result of an increasingly informed public's reaction to the rationing of healthcare services that has become a defining feature of Medicare in Canada. The realization that only the last five features promised in the Canada Health Act -- universal, comprehensive, portable, accessible and publicly administered - are being fulfilled is now being recognized by the public.

I know all about rationing. As a young child being raised in a working class district of Liverpool after the Second World War, I was sent by my mother to the local grocery store, coupons in hand, to queue for the purchase of eggs, margarine and bread. I often returned empty handed. The memories of those days remain clear. As an orthopedic surgeon, the scenarios that I am now witnessing as patients of mine (350 of them at last count) join a line-up at the local hospital are similar. Only the commodity is different.

There is another difference. Unlike our governments, the post war British government did not deceive the public. Rationing was universally imposed. In Canada, our political masters have the advantage that less than one percent of Canadians is waiting for surgery. If you, or your loved ones, are not in need of surgery, you might be persuaded that easy access to a family doctor for less serious health problems, or to a hospital for an acute heart attack or head injury, is evident that all is well. Clearly, this is not the case.

I have spent the last 23 years observing the deterioration of the Canadian system. My main qualification for writing on this topic is that I have spent that time treating patients. I share their frustrations and observe their pain. I reflect on the absurdity of previously active people receiving wage-loss benefits that total in the tens of thousands of dollars, while they wait 12 months for a minor operation that would get them back to work in weeks. The added cost of the physical and psychological damage that occurs while waiting is incalculable. I tire of hearing misinformation - even lies - from some healthcare economists, policy analysts and other "experts" (including a select group of pontificating, non-practicing physicians and nurses). They delight in quoting each other and they immerse themselves in a quagmire of patronizing rhetoric aimed at upholding their own skewed, warped ideas. They earn a living from writing about these activities, and talk with authority about patients, whom they rarely speak with, let alone meet. Not suprisingly, with such qualifications, they are often believed by politicians, and even paid (with your tax dollars) to write reports and chair commissions.

IMPACT ON PATIENT CARE

Several years ago, the decay in the system reached a level that impacted severely affected my ability to treat patients. Beds were closed, my operating hours were reduced from 17 to under 7 hours a week, and equipment was increasingly worn or outdated. I realized that, because my patients consumed the hospital's budget, they were not welcome. The solution seemed simple and obvious. Large numbers of surgical patients needed a treatment facility, and access to the public system was being denied. Why not build a place in which to treat them?

The very idea of competition struck terror in the hearts of those in power. Flaws and inefficiencies in the public system would be exposed. To counter our initiative, provincial laws restricting citizens' rights to spend money on their own health care were strengthened. The principles of the Canada Health Act of 1984 were enacted into provincial legislation. In typical "Big Brother" style, the legislation was called the "Medicare Protection Act". Public-sector union leaders ignored the wishes of their members (polls of unionized workers taken in the operating room areas at the University of British Columbia Hospital showed over 95 percent support for our private facility). They also dismissed the potential for the creation of many new jobs for their workers. Catch phrases were popularized in expensive propaganda campaigns aimed at instilling a fear of the American bogeyman: "Do you want two-tier for profit U.S. style health care or free, universal, accessible, comprehensive, portable healthcare? " "Health care should be decided on need, not the size of your wallet," "This is the beginning of the slippery slope," etc.

Similar propaganda has entrenched an anti private sector feeling in the minds of many. Canadians did not protest when laws were passed that gave, not only foreigners, but also dogs, cats and horses greater access to healthcare services than themselves. How did Canada come to share, with North Korea and Cuba, the distinction of being one of three countries in the world that forced upon its citizens a state-run monopoly in the delivery of major health services?

It is not uncommon for those who promote "Medicare" to praise the system following their own treatment. What they fail to mention, however, it is that during their hospital stay they have typically enjoyed privileges such as private rooms and preferential status in the scheduling of procedures. I have never heard anyone criticize the evils of "two-tier health care" who did not themselves (with more than a touch of hypocrisy) enjoy the benefits of extended "two-tier" private insurance. Braces for arthritis, splints for broken necks, treatment of abscessed teeth, artificial limbs for amputees, physiotherapy treatments, more effective (and expensive) drugs, and private rooms and nursing within a public hospital are just a few of the privileges these insurance schemes offer. The debate on "two-tier" medical care is irrelevant.

Who is to blame for the incompetence we observe in the running of our healthcare system? Is it the politicians who develop policy, the civil servants who implement it, or the overstocked administrative pool in some of our hospitals? The answer is ,"All of the above". Canada is certainly well provided with the Ministers of Health - 13 of them (each with deputies and assistant deputies) for a population of 30 million. By comparison, France, with double the population, has only one. Canadian medicare has mushroomed into a government bureaucrat's dream. Better "management" has been the excuse and justification for this overgrown, self-propagating epidemic. It is worthwhile to recall the Oxford Dictionary definition of "management" (as used in some older English dialects) as "the spreading of manure". This definition has appeal to those who are tired of hearing the so-called experts preach that we have enough money in the system, and all we need now, is better "management" of our system.

Consider the following examples of your health tax dollars at work. This summer, a patient of mine was sent to a private American hospital for elective surgery at a cost of $20,000 (government-funded), while operating rooms in Vancouver closed at 3 pm. The procedure could have been done here at a cost of $2,000. At Vancouver Hospital, a foreign visitor with unlimited insurance and a ski injury is billed $540 for repair of a knee injury (cost to the Canadian taxpayer $6,000). Patients on a six-week waiting list for biopsy of a possible breast or prostate cancer observe other patients being admitted each week, ahead of them, for suction treatment of fat thighs or cosmetic face-lift surgery, These private patients, in public Medicare-funded facilities, are charged $290 for procedures costing the taxpayer 20 to 30 times that amount. Major hospitals close for "reduced activity days" every five weeks, despite massive surgery wait lists. There are many other equally outrageous examples. No wonder there is a fear of competition and comparison with an efficiency run parallel private system.

THE INTERNATIONAL PERSPECTIVE

The private sector can help preserve and protect our Medicare system, and we will need its help as we struggle to cope with 10 million aging baby boomers. Let us not focus on the U.S. model as the alternative, but consider learning from experiences in the Scandinavian countries, Belgium, Switzerland, Germany and elsewhere. In none of these do patients suffer from the terrible waiting lists that we have. All enjoy both universal coverage and a private system that complements and augments the standard of health care delivery. To describe Canada's system as the best in the world is patriotic, but untrue. In fact, for the price we pay, it is probably the worst in the world. In no other system of comparable cost (ours is reported to be the second most expensive) is there such extreme rationing. Increased privatization is not a means for the rich, or influential, to avoid queues. In our existing system, they somehow work their way to the front of the line anyway. Expansion of the present extended health ("two-tier") insurance schemes that over two-thirds of the public already enjoy will allow ordinary people to receive a level of care equal to that of a prominent political figure of a professional athlete.

Medicare in Canada is not threatened by allowing an injured golfer, skier or worker to spend a few dollars a month for private health insurance that will allow early treatment. The real threat is the status quo, which forces them to join the same queue as patients in need of urgent treatment for serious or life threatening diseases, thus prolonging the wait for all. Highly paid professional athletes, who expose themselves to injury for personal profit, and others who participate in high risk activities such as rodeo, boxing, hockey and martial arts should take out private insurance coverage that will cover the medical costs of their injuries. Those who pay $55 a day for a ski ticket can afford to pay an extra dollar in insurance. The fact that our state denies them that right is not only an arrogant and outrageous denial of civil liberties, but also fiscally irresponsible.

In 1984, the Canada Health Act defined and reaffirmed the five principles of Medicare as expressed in the 1964 Royal Commission on Health Services by Justice Emmett Hall. This Act is responsible for much that is wrong with Canada's health system. Justice Hall, often referred to as "The Father of Medicare" in Canada, died in 1995. It is of interest to note that his son, Dr. John Hall, is an orthopaedic surgeon who left Canada to practice in the U.S.! He is one of many talented physicians who have left Canada because of its rationing and declining medical standards. It is axiomatic that those with the greatest skills, expertise and talent are in greatest demand elsewhere, and therefore find it easiest to leave.

The root of our government's painfully patronizing dismissal of citizens' rights to spend their own hard-earned (and heavily taxed) money on their own healthcare is the Canada Health Act. Few citizens have ever reviewed the Act which, in "Big Brother - style," is heralded by politicians as a "defining feature of the Canadian identity" (as if there was no Canada before 1984.) "Orwellian" is the perfect description for its content, and it cannot be merely a twist of fate that it was proclaimed in 1984.

Contrary to the views expressed by Jim Saunders in the last issue of Hospital Quarterly, I do not support the principles of the Canada Health Act, and the appended table explains why (see table 1). Another outstanding individual who recently left Canada was Mr. John Tegenfeldt, CEO of the Vancouver-Richmond Regional Health Board, an NDP appointee and leader of the province's largest regional health authority. His premature departure was prominently reported in the media, although the real impact of the story was missed. The Board had recently reaffirmed, in a letter published in the Vancouver Sun, its opposition to increased private sector involvement in healthcare. Tegenfeldt, one of our most experience and talented healthcare administrators in now in Beijing, China, overseeing the development of a private hospital in a cooperative venture between a Canadian corporation and the Chinese government. The irony is that it is legal to build such a facility in Communist China - but not in Canada.

THE CAMBIE SURGERY CENTRE (www.csc-surgery.com )

The Cambie Surgery Centre, a new freestanding private facility, is unique in Canada. It has been developed and constructed during the tenure of what is perhaps the most left-wing government ever to exist in Canada. It has attracted attention out of all proportion to its size and potential impact, having been featured in numerous local and national radio, television and print media outlets. Alexa McDonough, the federal leader of the NDP, and Bob White, the leader of the Canadian Labor Congress, led a march from the Vancouver Hospital to our facility in order to protest the "evils" of "two-tier" medicine.

The facility has been open for two years. The building was designed after an extensive planning and design process, which involved consultations, visits to and detailed study of specialized buildings of its type in a number of other countries. Interestingly, and on the advice of others with similar experiences, we engaged an architect who had no prior experience in this field. Those who would eventually work in the facility - doctors, nurses and others - were intimately involved in its design, and worked closely and at times tediously with the architect and builder. For example, many experienced anaesthetists, nurses and surgeons spent endless hours working and reworking the floor plans of the operating-theatre and recovery-room areas. The building is located in the heart of Vancouver, adjacent to the city hall and a block away from the largest teaching-hospital campus in the city. It is a freestanding, compact structure, and is 8,200 square feet in size. It contains three operating rooms, seven short- and five long-stay beds. The long-stay rooms are all private. We feel that communal living in shared rooms is a leftover from the nineteenth-century institutionalized hospital building, and has no place in the design of a modern health care facility. Whether you are sick or simply undergoing a minor elective surgical procedure, living in the same room with a stranger is surely unacceptable in this day and age.

The facility is a multi-specialty surgical center (there are no clinic areas or doctors' offices), and there are over a hundred accredited physicians. The commonest procedures performed are orthopaedic, plastic, dental, opthalmological, urological and general surgical. Milestones at the center have included many "firsts" for surgical procedures performed outside of public hospitals, and have included laparoscopic and hip surgery. The facility and its operating rooms have been built to conform to full hospital standards as defined in 1995. The building, which is probably the most earthquake-resistant building in Canada, has been designated a post-disaster facility for the City of Vancouver.

The concept for the development of this center evolved over a 10-year period. Initial plans for a larger hospital-type structure were scaled down because of the political climate. Cambie Surgery Center is owned by a private "for profit" corporation. Ownership is 100 percent Canadian, which benefits taxpayers, since, unlike public facilities, the center's taxes are paid to all three levels of government. Although most shareholders are physicians, the majority of the corporation's directors are not. The Director of Patient Care (an RN) and a Medical Director (a physician) supervise all nursing and medical aspects of the center, and report to a medical management committee. The Director of Finance and Business reports to a management team and the board of directors. The center has created the equivalent of 15 new full-time jobs. Nursing wages exceed those in the public sector. The center is equipped with "state of the art" equipment and instruments, which it often lends to the local public hospitals (at no cost). Its patients (and their insurers) finance the center, and unlike in a Canadian public facility, patients and doctors are the providers of revenue, as opposed to the consumers of a fixed global budget. Patients and doctors notice the difference. The volume of work has increased progressively, doubling in the second year.

Many of our patients are from abroad. This group is now being targeted, since we are able to greatly "under-price" care in other countries. Patients from the U.S., Cyprus, Australia, New Zealand, Germany, Japan, Taiwan, Hong Kong, Britain, Russia and other former Soviet Union countries, Mexico and South America have all been treated at the facility. It is ironic that there are restrictions on access for local citizens that do not apply to non-residents, a situation reminiscent of the "special shops" for visitors and tourists in the former Eastern Block countries. The analogy is both valid and alarming.

AN UNSTOPPABLE EVOLUTION

Millions of dollars (taxpayer money) have been spent on advertising and propaganda, in an attempt to indoctrinate the public against the concept of access to private surgical care. None of these measures has been, or will be, successful. We can all take an interest in debating the ethical issues, the pros and cons of private versus public, and the terrible nature of "two-tiered medicine", but the process we are observing is an unstoppable evolution. It is Canada that is out of step with the rest of the world. We will not develop an "American style two-tier system", but we will keep medicare and expand the parallel private system to fill the need created by massive demands which the public system can no longer support. Such systems exist in every other civilized nation on earth. The fundamental question remains, What is so evil about spending one's own money on one's own health? Apparently, this is considered acceptable if the remedy is of unproven benefit, but unethical if there is scientific proof of clinical benefit. This is illustrated by the following recent quotation: "As a government, we must respect and allow room for Canadian's freedom of choice  when it comes to natural health products. Canadians should have the broadest  range of options available to them." Allan Rock, Federal Minister of Health, reversing a decision on the regulation of  "private for profit" herbal remedies, Oct. 4, 1997 The economic benefits for Canada of an expanded role for the private sector in the provision of health services are potentially massive. We share a border with our largest trading partner, and healthcare there is a $900 billion industry. Surgeons' fees in Canada are 10 to 20 percent of those in the U.S. and the beneficial exchange rate means we can sell Canadian healthcare expertise at a discount price. If we can gain just a few percentage points of that industry, we could help solve our debt problems, and develop Canada's biggest-ever job creation project. All hospital workers, including nurses, doctors and hospital managers, would reap the benefits of this expanded industry. If Canada had factories that could produce cars at less than half of the cost of production in the U.S., would we close the facilities for much of the time, and introduce laws that forced our citizens to go to the States to buy cars? No, we would be making cars here and selling them to both Canadians and Americans. In health care, we are estimated to spend a few billion dollars yearly on cross-border shopping for healthcare services that could (were it not for politics) be purchased here for less than half the price. This practice could be used as a definition of stupidity. Our federal and provincial governments, and the legacy of the Canada Health Act, are to blame.