"Scalpel please." (while Canada's major health care spending cuts have saved money, critics claim quality is diminishing, threatening patients' lives)

Canadians have enjoyed one of the best health care systems in the world. But that's changing. According to the March 1994 issue of Fraser Forum, provincial governments gradually have capped their budgets for health care. They've put a lid on hospital budgets for operating expenses, for special surgical procedures such as heart by-passes and hip replacements, and for the acquisition of technology. They've also hit doctors' incomes.

According to a national study, Canadian health-care costs have increased over the last 30 years out of proportion to population and economic growth. In 1961, the cost of health care was equal to 6% of the country's Gross Domestic Product (GDP). By 1991, it was almost 10% and totalled $63-billion.

The study, called Sustainable Health Care for Canada, estimates that Canada could save up to $7 billion a year and still have the same quality of health care. It would be done partly by replacing expensive services with less costly ones, and by better use of new technology and scientific advances and a move away from the tendency to use every possible test and treatment on every patient.

Hospitals account for 40% of health-care costs, and the report says almost $1 billion could be saved by reducing hospital admissions by 20% and cutting the length of stays by 20%.

More information is needed on the cost/benefit of treatments, This would help doctors and patients evaluate possible treatments, and hospitals and clinics could see which treatments offer the best value for money.

The report says that much of what doctors are doing now might be done more effectively and cheaply by other health professionals; one study found that nurses could do 63% of the work of doctors at 38% of the cost. The study also suggests that the provinces get together and save money by imitating each other's best health-care practices

By January 1996, efforts to reduce duplication of services and improve efficiency of patient care were planned across Canada.

Saskatchewan led the way when it announced in the spring of 1993 that it would close 52 of its 132 hospitals. Rural institutions were deemed to be too small to offer top-quality care or even operate efficiently, and many were turned into community health centres.

Other cost-cutting drives have been carried out in provinces such as British Columbia where one hospital and 900 acute-care beds were closed. Alberta plans to close four hospitals by 1997 and convert eight hospitals to community health centres. The province also reduced out-of-country benefits and increased health-care premiums.

In January 1996, Manitobans braced themselves for $75-million worth of bed closings, job losses, labour strife, and service cuts in its $1.8-billion health budget.

In 1996, the Institute for Clinical Evaluative Sciences said Ontario must start closing hospitals and integrating its health care system to avoid steady erosion of the hospital system. The province has closed a hospital and merged 14 others, closing 4,000 beds. The study of provincial health care patterns found some encouraging changes in the two years since its first study was released though: lengths of stays in hospitals were down with only a very slight trend to readmissions as a result. More day surgery is being performed, and surgeries that enhance life, such as hip and knee transplants, are on the rise.

By 1995, Quebec announced plans to close seven hospitals and convert six others into long-term care facilities, eliminating a total of 2,500 beds.

In New Brunswick, 51 independent hospitals were replaced by eight regional hospital corporations and 250 hospital beds have been closed.

Five Halifax medical centres made up of 11 buildings and employing 7,000 workers were scheduled to become one hospital by 1997. The merger is expected to put 800 to 1,000 people out of work and some facilities will be closed or have radically different functions. In Nova Scotia as a whole, one hospital closed, another shut its acute-care beds, and three others converted to community health centres.

Prince Edward Island converted one hospital to a community health centre. And, New-foundland replaced individual hospital boards with eight regional boards and plans to close three hospitals.

Most provinces also have reduced services and cut out-of-country benefits.

With such massive staffing cuts, hospital closings, and reductions in services, can we still have a good health-care system?

Canada's Health Minister David Dingwall thinks so. He says most economists agree that better management and health-care reform could solve funding problems. And many believe that, even taking the current round of spending cuts into account, there is more than enough money to meet current needs. Japan, for example, spent only 6.6% of GDP on health care in 1991. However, the Japanese live longer than Canadians Can average of 79 years, compared with 78 years in Canada) and their infant mortality rate is lower. Many experts even maintain that medicare can flourish well into the next century, despite the increasing number of elderly and dwindling financial resources, according to a recent article in Maclean's magazine.

Doctors and the general public aren't so sure.

In 1995, Alberta's doctors launched a province-wide advertising campaign denouncing cuts to health care. The doctors warned that the elderly and chronically ill were already beginning to suffer from the government's cutbacks to health-care spending. The Alberta Medical Association said: "The quality of service we can provide is hurting. And the right of all Albertans to have access to quality health care is being threatened...Any more across-the-board cutting will cut Into the very heart of the care system itself. As physicians we can't let this situation go on. Because it will certainly get worse." At the same time, the United Nurses of Alberta announced a work-to-rule campaign and their willingness to join a general health-workers' strike. And, two-thirds of Albertans disapproved of what was happening to health care.

Recently, the Ontario Medical Association (OMA) said there was a gap of more than $500 million between the payments doctors will receive this year and the services they will provide. The volume of doctors, services that Ontario needs is rising each year because of population increases, an aging population, and the discovery of new diseases and treatments. Without increased funding, the OMA predicts that by the turn of the century, Ontario will be spending, in real terms, about $270 per capita for doctors' services, down by almost $100 from the 1992-93 level.

In a report released in September 1996, the Nova Scotia Nurses, Union (NSNU) said the province's health-care spending cuts have contributed to the deaths of at least two people and the continued suffering of many other patients who rely on the provincial home-care program. According to the report, 90% of the 700 nurses responding to a survey said they think spending cuts are affecting the level of care they are able to provide. About 60% of the nurses believe that people in the province are being put at risk by delayed admissions to hospitals, and 78% think patients are put at risk by early discharges and inadequate homecare. The nurses say the cuts have forced doctors to discharge very ill or injured patients whose families have to arrange care at home for them.

Charlene Long, secretary-treasurer of the NSNU, bluntly said: "If anybody tries to tell you that the level of care required is being met, they are dreaming in Technicolor..."

SUGGESTED ACTIVITIES:

1. About 800 patients a year from Saskatchewan and Manitoba go to the Gimbel Eye Centre In Calgary for cataract operations. This amounts to about 20% of the private centre's cataract trade. Patients pay up to $3,300 for operations by ophthalmologist Howard Gimbel who, since setting up his private clinic in the 1980s, has pioneered several of the cataract-removal techniques in use today around the world. Many of these patients would have gone blind waiting their turn in the public health-care system. Should Canadians be able to get faster treatment if they can afford to pay for it? Discuss.

2. At present, most doctors are paid on a fee-for-service basis. This means they receive a payment for each patient they see. Critics say the system encourages doctors to see as many patients as possible income. One reform that's been suggested is to put doctors on a salary. Supporters of this approach say it will encourage doctors to provide better care and will reduce costs. What do you think?