Middle of the health care pack

In 2007, the New York City–based Commonwealth Fund released its latest survey results, which compared the health care systems of Australia, Canada, Germany, the Netherlands, New Zealand, the United Kingdom, and the United States.¹ As the 2 Canadians in the Commonwealth Fund’s Harkness Fellowship Program in International Health Policy for 2007 to 2008, we met with our federal Minister of Health, the Honourable Tony Clement, just before the release of the study. We were present in Washington, DC, at the release and heard the reactions of the health ministers (or their representatives) from all 7 countries.

The 2007 International Health Policy Survey focused on the views of adults (aged 18 years and older) and their experiences with their health care systems. We were immediately struck by the policy and practice relevance of this year’s core topics: access to care, chronic care, coordination of care, patient-centred care, and patient safety. Approximately 12 000 adults were interviewed, and Canadians represented approximately 25% of the sample (n = 3003), a greater proportion than usual owing to financial investment from the Health Council of Canada. (This investment had been made in support of additional future analyses relevant to special populations in this country.)

The results: Canada placed roughly in the middle of the 7 countries on most topics. Given the investment in and attention to health care renewal in recent years in Canada, we can now use this evidence to inform our future efforts and to simply do better. Canadian patients, health professionals, and policy makers would undoubtedly like Canada’s physicians to be leaders and role models on the international playing field, and the survey results reveal areas for improvement.

Room to grow

The results point to 3 areas that require improvement. In Canada these areas have recently received investment and attention; however, it seems appropriate to consider whether or not enough of the right things are being done. The first area is access to and use of the primary care system. Canada ranked either last or next to last in questions dealing with timely access to regular doctors, availability of evening or weekend appointments, the amount of time physicians spent with their patients, and reminders for preventive or follow-up care. It is not surprising, therefore, that adults in Canada were the heaviest users of emergency departments (EDs), with 16% of patients reporting having visited EDs for conditions their physicians could have treated if they had been available. Indeed, a full 45% of people with chronic conditions in Canada had visited EDs in the past 2 years. As the study’s authors put bluntly, we have “symptoms of a primary care system under stress.”¹

Fortunately, there are promising developments in improving scheduling for primary care practices, such as advanced access methodology,² which support same- or next-day appointments without increasing either service volume or physician dissatisfaction.

The second area requiring attention is patient safety. Seventeen percent of Canadians surveyed reported experiencing medical, medication, or laboratory errors in the past year. This number increased to 28% for patients with 2 or more chronic conditions and 30% for those who saw 3 or more physicians. The Canadian Adverse Events Study first described the magnitude of this problem in our country.³ Since then, Forster et al have observed how systematic deficiencies in the transitioning of care can lead to many adverse events.⁴ Research has also demonstrated the valuable insights that patients provide on how to reduce this problem.⁵

The Canadian Patient Safety Institute has become an important stakeholder for fostering change, and hundreds of teams in hospitals are participating in the national patient safety campaign, “Safer Healthcare Now!” Along with the other health ministers present, Minister Clement participated in the formal letter-signing campaign for the new World Health Organization initiative, “Action on Patient Safety: High 5s.”⁶ Canada will be taking the lead on one of the 5 initiatives, medication reconciliation.

The third issue links quality of primary care to patient safety. While 91% of adults in Canada have regular physicians or places of care, only 48% report that these physicians or places of care are very or somewhat easy to contact by telephone, always or often know their medical histories, and always or often help coordinate their care. The results of the survey indicate that having such a “medical home” reduces visits to the emergency room and unnecessary tests, and increases after-hours access, quality of patient-provider communication, and coordination of care. Adults who report having a medical home are much less likely to report any medical, medicine, or laboratory errors (17%) than those without (29%). Clearly access and quality of care are more related to services provided by a regular medical doctor or at a regular place than to simply having access to a usual source of care.

Positive outlook

Canadians, though, do offer positive views regarding health care renewal. Only 12% of Canadians (compared with 34% of Americans, for example) felt that the health care system should be rebuilt. These findings emulate the results of the 2007 Canadian Medical Association’s commissioned health care report card, where only 9% of Canadians surveyed gave a grade of “F” for the quality of the system in general.⁷ The Commonwealth Fund also recognized an improvement over time, noting that “public views in Canada and New Zealand have grown steadily more positive in the past decade and are now comparable to views in Australia and the United Kingdom.”¹

Overall, there was some good news to be found in the results of this survey but also areas for improvement. Either way, we can learn from our Commonwealth Fund partners to improve Canada’s health care system.