Fixing primary care? Focus on the demand
Dr. Trevor Hancock
2 July 2019
The primary care crisis has been getting a lot of attention in the community and in this newspaper recently. But the focus so far has been on the supply side – we need more doctors and other primary care providers, more services and a better system, everyone says. I have seen little or no discussion about the demand side; how do we reduce the demand for care, so that we don’t need as many care providers? After all, we would all be better off – economically, socially and of course in terms of health – if fewer people were unhealthy and needing care.
Two key demand reduction strategies have been consistently ignored, downplayed and underfunded by governments in BC and across Canada for years. The first is a serious provincial-level and society-wide commitment to promoting the health of the population and preventing disease and injury; it includes a serious commitment to clinical prevention, which I will explore next week This will reduce the need for care by reducing the burden of disease, injury and disability in society. The second missing strategy is to reduce the demand for care by increasing people’s capacity for self-care, so they don’t need to seek care for health issues they could manage themselves; I will discuss that in two weeks’ time.
Sadly, the neglect of prevention is not limited to the health care system, but is a society-wide problem. The decision by the Victoria Police Chief to disband the Crime Prevention Unit, and by the federal and provincial governments to invest in the Alberta tarsands pipeline and the LNG industry respectively are recent prime examples of short-term thinking, with expensive and health-damaging long-term consequences.
Part of the problem is that governments, like businesses, are focused too much on the short-term. The next election is at best four years away, and you want to show impact quickly. While some prevention can indeed show benefits over the short-term, it often only does so over a period of many years, even decades or generations. So we get short-term fixes to gain votes or make money, and pass on the real challenges to future generations to cope with – let them make the hard choices.
It does not help that the NDP has not shown much commitment to prevention over the years. Too often, both here and elsewhere in Canada, the emphasis has been on increasing services and expanding access, rather than looking at reducing demand.
So what would a provincial health care demand reduction strategy look like? First, the government would have to recognise that the creation of a healthier population is not simply the responsibility of the Ministry of Health, but of the whole government and the wider society. A 2011 report from the Senate of Canada provided guidance: Governments should establish a Population Health Committee of Cabinet, chaired by the Premier, and develop a provincial population health improvement strategy involving all Ministries.
Since this is actually a societal problem, it will also be important to set up a BC Population Health Council to advise the Committee and assist in making changes in society. In addition to select Ministers, such a Council would consist of leaders from all sectors – business, labour, the non-profit sector, academic and faith communities and others; there is a precedent in the Premier’s Council on Health established in the late 1980’s in Ontario – and abruptly disbanded by newly-elected Conservative Premier Mike Harris in 1995, proving that then, as now, Conservatives are not supportive of prevention either.
Such an appraoch would mean examining the health impacts of existing and proposed policies across all sectors, and in particular looking at and recommending policies in both the public and private sectors that will reduce the excess burden of disease related to poverty. This will require a technical support group of public health experts and policy analysts, probably best led by the Provincial Health Officer.
So we have a choice: Continue to accept that there is a large burden of disease and to see this as a problem of supply, which we can never fully fix, or see it also as a problem of demand, and make a serious, long-term, society-wide commitment to improve the health of the population. Which would you prefer?
© Trevor Hancock, 2019