Month: April 2017

I have been writing this column without a break for over two years: So I am taking a break for vacation and will be back in June.

Reverse 45 years of neglect of health centres

Dr. Trevor Hancock

17 April 2017

703 words

In the late 1970’s I was one of two family physicians in a brand-new community health centre (CHC) in Toronto. We were on salary and worked with a nurse-practitioner (NP) and a community board. These were the early, heady days of CHCs, with several CHCs established at the same time across Toronto and elsewhere.

It wasn’t easy, we were met with suspicion, resentment and some times outright hostility from the medical profession, for whom we were traitors, undermining physician autonomy and the fee-for-service system while bringing in NPs. But we were passionate, idealistic and committed to implementing the model proposed just a few years before in the Hastings Report.

This Report, released in 1972, was commissioned by Canada’s Ministers of Health and led by Dr. John Hastings, a distinguished professor of health administration at the University of Toronto. Its key recommendation was “the development . . . of a significant number of community health centres . . . as non-profit corporate bodies in a fully integrated health services system”.

The authors described a CHC as “a facility . . . enabling individuals and families to obtain initial and continuing health care of high quality . . . provided in an acceptable manner through a team of health professionals and other personnel working in an accessible and well-managed setting”. What’s not to like about that?

Ideally a CHC would be responsible for providing care to people living in a defined geographic area, coordinating their primary care with home and community care. Facilitated by a community board, the CHC would become involved with public health, various community-based organizations and local government in efforts to improve the overall health of the community.

But while a few CHCs were established, the model did not become widely adopted, in large part because of the opposition noted earlier. In fact CHCs mostly became seen as a way to provide health care to low income and disadvantaged populations. For example, there are only three CHCs here in Victoria, of which one is for adults over the age of 55 and another is for people who are homeless, vulnerable and living on very low incomes; only one, the Victoria Community Health Cooperative, is for the general population.

Thus average Canadians did not get to reap the benefits of this superior form of health care. This is a shame because a 2012 report from the Canadian Foundation for Healthcare Improvement noted “despite significant progress since 2000, the performance of Canadian primary care trails that of many other high-income countries”.

Fast forward 40 years and there is a growing interest in CHCs, including a much more favourable attitude amongst family physicians. Moreover, there is growing body of evidence that the belief espoused by the Hastings report – “that some shift from the present emphasis on acute hospital in-patient care to other forms of health care, including types of community health centre, offer a means of slowing the rate of increase in health services spending” – is correct. But unfortunately CHCs in BC have only received weak support from the government and generally lack core operational funding.

A newly-released position paper from the BC Association of Community Health Centres (BCACHC), which speaks for the 29 CHCs in BC, cites evidence that CHCs have been shown to reduce avoidable use of hospital emergency rooms, improve accessibility and comprehensiveness of health and social services in rural areas, and enhance the accessibility and effectiveness of mental health and addictions programs – all of which are Ministry of Health priorities.

Importantly, last month the BC Legislature’s Liberal-dominated Select Standing Committee on Health released a report in which it supported many of the elements of CHCs. Specifically, they recommended implementing “a community health centre model of care” and providing “adequate operational and capital funding for new and existing community health centres throughout the province”.

In an online petition to all three major party leaders, the BCACHC calls on the next government to “invest in 20 new community-governed Community Health Centres throughout British Columbia” by 2020. It’s way past time the province did so.

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I have been writing this column without a break for over two years: So I am taking a break for vacation and will be back in June.

© Trevor Hancock, 2017

 

 

Child poverty is outrageous and unhealthy

Dr. Trevor Hancock

10 April 2017

699 words

Canada is a wealthy country and within Canada, BC is a wealthy province. And yet we have levels of child poverty that are shameful, that exert a terrible toll on the health of children, and that blunt our human and social development. If it is true that the worth of a society is best judged by the way in which it treats its most vulnerable, then we fail miserably.

In its November 2016 BC Child Poverty Report Card, First Call, the BC Child and Youth Advocacy Coalition, reported that one in five children – one in five! – live in poverty. Even worse, almost half of the children living in single-parent families – most of them single-mother families – are living in poverty. Most damning of all, child poverty rates have barely budged in recent years, demonstrating a complete absence of political commitment to fix the problem.

In 1989, the House of Commons resolved to eliminate child poverty by the year 2000, which turned out to be a cruel hoax. BC’s child poverty rate climbed from 15.5 percent in 1989 to 25.3 percent in 2000. Between 2004 and 2007 it dropped to about 20 percent and has been around there ever since. In essence, we have come to accept that this level of child poverty is just a normal part of life.

Yet this is a fixable problem; other advanced industrial nations have almost eliminated child poverty. A 2016 OECD report, using 2013 data, notes “In Finland and Iceland the child income poverty rate is only around 5 – 6%, while in Denmark it is less than 3%”; using that measure of poverty, Canada’s rate is around 16 percent. So clearly, as my late friend and colleague Clyde Hertzman used to remark, “it doesn’t have to be this way.”

There is quite a price to be paid for keeping it that way. It is paid most of all by children living in poverty, and is a price they will pay for the rest of their lives. But the rest of society also pays a price in lost human potential, lost economic production and increased costs for health, social assistance and other supportive services.

Working at UBC, Clyde was the founder of HELP – the Human Early Learning Partnership – which developed an international reputation for its work on what made children healthy. So much so that when the World Health Organisation established a Commission to examine the social roots of health and illness, Clyde was asked to head up one of eight ‘knowledge networks’, the one on early child development (ECD).

The network’s final report to the Commission noted that ECD “strongly influences basic learning, school success, economic participation, social citizenry, and health” – that is a pretty broad swathe of social benefit. They also noted that inequality in the availability of ‘socio-economic resources’ (in other words, poverty) resulted in inequalities in ECD. On the other hand, “any additional gain in social and economic resources to a given family results in . . . gains in the developmental outcomes of the children in that family”.

In a nutshell, poverty harms early child development, which harms social and economic development over many decades. Thus they concluded “investment in early childhood is the most powerful investment a country can make, with returns over the life-course many times the amount of the original investment.”

 

Such investments would include “family-friendly social protection policies that guarantee adequate income for all, maternity benefits, financial support for the ultra-poor, and allow parents and caregivers to effectively balance their time spent at home and work” as well as policies that guarantee “universal access to a range of early child development services: parenting and caregiver support, quality childcare, primary healthcare, nutrition, education, and social protection”.

That is an agenda for healthy children and adults, healthy communities and a healthy society. One would think that a wise government would take heed of this advice, especially as it came from a world expert right here in BC, and that a Premier and a government committed to a Family First approach would adopt such policies. Sadly, that has not been the case, and as a result, children and our whole society continue to pay the price.

© Trevor Hancock, 2017

 

‘Mincome’ is pro-health and against poverty

Dr. Trevor Hancock

2 April 2017

702 words

Last week I wrote about the health, social and economic benefits of a poverty reduction plan for BC. Not unreasonably, a reader challenged me to explain how we could afford that. “Just what price tag would you set on the actions you propose?”, he wrote, “Then we could move on to that tricky part about how well — or if — the plan works.” Fair enough, so here goes.

I wrote about the costs in my column on January 7^th 2015. As that is more than two years ago, I will repeat some of it here. In a 2011 report the Canadian Centre for Policy Alternatives looked at the total costs of poverty in BC. They estimated that overall, the annual direct costs to government from increased costs for health care, justice services and foregone tax revenues were $2.2 – 2.3 billion. Note that this is an understimate, because estimates of the costs of social services were not available.

The added health care costs alone related to poverty were estimated to be $1.2 billion, based on the potential savings in reduced health care utilisation if people in the lowest 20 percent of income had the same health status as those in the next 20 percent, which is only a modest change.

When they added up all the costs, including costs due to lost production, lost income and lost tax revenues attributable to poverty, they concluded that poverty costs between $8.1 and $9.2 billion per year. This is more than double the $3 – 4 billion they estimated it would take to markedly reduce poverty by investing in a poverty reduction strategy that would end homelessness and hunger, ensure access to affordable housing and child care, and improve pay and working conditions for people in low–wage jobs.

So on the face of it poverty is so expensive that we can’t afford it, and there might be an economically beneficial alternative. This seems like an idea that any fiscally responsible government would consider worth invesigating and testing, not just dismissing out of hand. Which is presumably why all the other provinces have developed some form of a poverty reduction plan.

One possible solution was tested in Canada 40 years ago – and seemed to work. Between 1974 and 1979 the federal and Manitoba governments collaborated on a project – Mincome – to provide a guaranteed annual income (GAI) to the residents of the town of Dauphin MB. The GAI is a form of negative income tax or refundable tax credit; its proponents claim it is particularly effective in aiding the working poor and is simpler and cheaper to administer than the many existing and overlapping programs. Regrettably, the research on Mincome was shelved – the data were collected but not analysed – amidst waning political support.

Mincome was available to all the roughly 10,000 people of the town and the 2,500 people in its rural municipality. However at any one time, “only about a third . . . of families qualified for support and many of the supplements would have been quite small”, according to Professor Evelyne Forget, an economist in the Department of Community Health Sciences at the University of Manitoba, who came across this forgotten study about a decade ago and analysed it.

In a report published in Canadian Public Policy she concluded “a relatively modest GAI can improve population health, suggesting significant health system savings”. Specifically, she found an “8.5 percent reduction in the hospitalization rate for participants relative to controls, particularly for accidents and injuries and mental health”, and she also found that “participant contacts with physicians declined, especially for mental health”. She noted that the reduction in hospitalisation would have amounted to savings of $4.6 billion annually in Canada in 2010.

Also important was the finding that people did not stop working – except for new mothers and teenagers. Given the health and social benefits of mothers spending more time at home with their infants and adolescents continuing on into grade 12, these are desirable outcomes.

Small wonder that Quebec has explored the idea, while Ontario is actively considering testing a basic income in several communities, based on a report commissioned from former Conservative Senator Hugh Segal. Would that the BC government were that forward-thinking and thoughtful.

© Trevor Hancock, 2017