Former Federal Health Minister and now
Dean of Medicine at Queens
University, Jane Philpott is well qualified
to give a prescription for Canada-wide
Healthcare for All, published in her
book of that name by Penguin Random
House Canada early 2024. She begins by telling of running
mobile clinics in Niger, pointing to the
importance of healthcare. Repeating the
current wisdom that Canadians have a
broken healthcare system, she aims to tell
how the downward spirals can be
turned around so that healthcare can be
available across the Canadian
federation, irrespective of one’s wealth,
status or connections. Her book falls into four big sections
sandwiched between a short
introduction and an epilogue: Clinical;
Spiritual; Social; Political. In these
sections she uses human stories of
individuals and herself that are interesting
and bring human interest, but a summary like
this article has to set the
stories aside. The Clinical section
is where she makes her case for a
health care home for everyone. The book
appears to veer off topic since other
sections are not powerfully related to this
dream of hers, but they are
interesting nonetheless. Finally in the last
part of the last section she
returns to topic with a metaphor for
Canada’s healthcare as a romantic old
cottage that needs a rebuild. The Clinical section tells of
Philpott’s dream – that everyone
should have a health care home just as every
child has a school to belong to
for education and a desk and teachers and
library. Like me, she has been part
of community health clinics – a team of
doctors and nurses where you can call,
be known, have a doctor you know; and, if
necessary, another doctor will see
you or a trainee doctor will join your
doctor. Your doctor or the clinic can
commission
bood tests, bone scans and ultrasound and
get back to you. The status quo, the Canada Health Act,
CHA, only finances a person’s doctor
or a person in a hospital emergency room.
The various community health clinics
in Ontario can offer much more, but are
piecemeal and not for everyone. In our
community clinic, the wart on my foot was
referred to a nurse for weekly treatment
with my doctor checking in periodically and
signing off when the wart was gone.
Obviously, this is cost effective. In the
clinic my doctor has my file, but
others in the clinic can reply to a
telephone concern and the clinic has
arrangements for others to step in and for a
place to go after hours. Philpott is aware of other countries
where such an arrangement is the
norm – like the UK and Netherlands. And
evidence there shows that overall costs
come down. There is no need for the doctor
to be a businessperson running a
personal or shared company practice, as many
do in Canada. Other actors can be
part of an interdisciplinary team. Philpott makes a case that this place
of primary care is fundamental to a
person’s health and their healthcare as well
as being a key element in a
healthcare system. Philpott notes that the
Ontario family health teams she was
part of can reduce the use of Canadian
hospital emergency departments. However,
they have never become the norm in Ontario.
Her vision is for Canada – despite federal
provincial jurisdictions. Philpott’s experience with the federal
2015 program to resettle Syrian
refugees is that big national problems could
be resolved with federal
leadership, attracting cooperation from
provinces and municipalities and the
public when certain conditions are met. The
federal fiscal transfer could be linked
to an initiative like a pilot project in
primary health care – but avoiding the
risk of yet another eternal pilot project. A
primary heath care act could be
modelled on the simplicity of the Canada
Health Act. Yet such primary health care depends
on two “vulnerable species” in this
time: nurses and front-line doctors – family
doctors, pediatricians and
emergency physicians. Family medicine is
attracting fewer and fewer graduates,
family doctors are retiring and that
workforce is ageing. Philpott found satisfaction as a
family doctor in the people – the patients
and the community health clinic workplace
with its volunteers and trainees. Negatives
today include: the screening for
medical school; family medicine being seen
as less desirable than a specialty; family
medicine being seen as feminine and less
desirable; there are so many other
options; the broad challenging scope; the
pay gap; non-stop responsibility and
liability; a business and administrative
burden; work conditions exclude other
paid health professionals; a role seen as
gatekeeper for access to specialists. The response to these factors must
reform medical education and make
system-wide
reforms including a change to team-based
primary care. Training can be enlivened
if based on case studies. At Queens,
Philpott has a satellite campus dedicated
to training family doctors who opt for this
from the outset. The program has placements
in medical clinics and transition to
residency. Family doctor work conditions
need tackling, because holidays and working
part time can be difficult. Team-based
primary care with support frees doctors to
be doctors and to take their holidays. Philpott is trying to implement all
this with a model primary care unit
for geographical areas in Southeastern
Ontario – where all residents can have a
home for their health care. Patients are
attached to the whole team but have a
particular
doctor or nurse practitioner. Doctors are
paid a salary or by shift. There is
no clear preference by doctors themselves
for the payment model, but the fee
for service was least favoured. Learners,
volunteers and community partners
expand the capacity of the doctors The Spiritual section points
out that the World Health
Organization notion of wellness goes beyond
medical cures to spiritual or
mental wellness. She acknowledges her own
Christian background – she is the daughter
of a Presbyterian minister – but believes
that any spiritual resource including
humanism can give resilience and hope, a
component of wellness. Hope
is also part of the First Nations Mental
Wellness Continuum, FNMWC, that she offered
as a tool for mental wellness. Hope
can be viewed as falling between faith and
charity, but wherever its origin, it
is an essential ingredient to mental
wellness. Finding meaning can be important for
mental health in exceptional situations.
For Philpott that traumatic situation was
the death of her first child at a young
age. She sees “finding meaning” as making
sense of the surroundings and
experiences, social situation, joy, pain and
apparent future. In her case, the
context of the immense suffering of the
millions of adults and children dying of
curable conditions was a context that
helped. Belonging is also essential --
confidence that you are part of a family or
community and that you are connected,
knowing who you are and confident to be
who you are. It is a key in the FNMWC. Lack
of wellness is lack of belonging,
and loneliness. Residential schools
undermined belonging - as can child welfare
systems now. “Belonging” adds up to a secure
personal cultural identity,
assurance of being accepted in your
authentic identity and having a real
inter-personal social network. Having loving parents is a good start,
but other important elements are choosing
the people to spend time with, knowing and
loving yourself and your heritage,
volunteering, loving others unconditionally,
and seeking counselling if struggling
with any of this. Lack of belonging and
loneliness has serious effects on health;
primary care centres can be a venue for
coming together for health care advice or
teaching and so assist with belonging.
Seniors can be brought together for
socializing, physical activity and healthy
nutrition. Having a sense of purpose is what gets
you out of bed in the morning.
Philpott tells of her shift from being
mother to four children and part-time doctor
to working full time as a doctor for MSF in
its team in distant Niger while her
family remained in Canada. She later made a
shift to more academic study, then a
shift to politics – always to improve her
impact on front line medicine. Finally,
she is back in academe at Queens University
where she continues to impact front
line medicine in new ways - like this book.
Purpose means feeling one is not in
the world by mistake. One has daily
decisions to make about that. The Social section of the
book points out health care goes beyond
medicine. Health is affected by such social
factors as income, employment and
work conditions, education and literacy,
physical environments, childhood
experiences,
social supports and coping skills, healthy
behaviours, access to health services,
gender, culture, genetic endowment,
race/racism. Hence the WHO report in 2005:
Improve living conditions; Tackle the
inequitable distribution of power, money
and resources; and measure and understand
the problem and assess the impact of
action. From her experience as a volunteer in
a retirement home during the early
days of Covid 19 – among shortages of staff,
oxygen, protective clothing and
very sick residents, Philpott raises
quandaries about who speaks for health
needs. Her
underlying concern is being a
voice of the voiceless – although drawing
attention to important needs in a
crisis seems to me an obligation for a
person who has the power to attract that
attention. However, Philpott is on good
ground when she questions whether those
advocating for primary health care for all
are listening to all, and when she asks
how quieter voices can be better heard. In her Social section Philpott
talks about land, language, lineage
and loved ones, categories that she
discerned while working as a minister
responsible for federal indigenous services.
This is an important chapter
showing how federal politicians can improve
the well-being of whole communities
of citizens – in this case Indigenous
people. However, this is not formally tied
to the quest for Canada wide access to
primary healthcare that is the thesis
behind the book. However, she writes about
problems in the child welfare system
for indigenous children that arise from her
discussion of a particular situation
in Manitoba. There, a First Nation child per
day is taken from its mother and
family for a variety of reasons by automatic
triggers – such as the mother is a
minor, it happened with the last child etc.
The impact of separation on
children and their families is serious, as
it was with the residential schools.
In this case, there was a Call to Action in
the report of the Truth and Reconciliation
Commission that could be implemented.
Federal Aboriginal Child Welfare
Legislation with regulations could enable
Aboriginal governments to run their
own child welfare agencies, taking
residential school legacy into account and
making
placements of Aboriginal children that were
culturally appropriate. A new law
was enacted thanks to Philpott. Political is the
final
section. Again, a large part of this section
is not formally tied in to justify
or expand on the book’s quest for universal
access to primary healthcare. Only
in the final pages does Philpott return to
that dream. Philpott begins this section
telling how she ended up being elected. She
had no particular party base, but
chose Liberal after Stephen Harper was
elected in 2011. She viewed politics as
medicine healing the whole society and she
was nominated in her home riding on
her own terms. She also worked as co-chair
of Trudeau’s leadership campaign.
After her election, she was appointed
Minister of Health. Philpott found it helpful in her
portfolio as Minister that she was
familiar with medical issues and jargon and
so able to move issues quickly for
patients she had known - like someone
dependent on drugs. She was active in
legalizing cannabis – not that this was her
own priority. But she knew criminalization
of drug use led to enormous harms for people
and populations. She gave a talk
at the UN on an approach that has upstream
prevention, compassionate treatment
and harm reduction. She knew Canada could
not “arrest our way” out of a drug
problem. There were no accurate figures, but
growing numbers of opioid deaths. Current
legislation did not reflect the aim of harm
reduction that Philpott felt should
be there. Within a year there was a national
harm reduction plan for opioids.
She was also aware that a safe injection
site is not a panacea – the people
remain addicts - but they also remain alive.
And she oversaw legislation that
enabled regulated safe injection sites
across the country. She also looked at models in other
countries responding
to drug use. Portugal used an
approach of social justice plus medicine,
avoiding the harms of criminalization
and providing supports from housing to
education, to counselling and to treatment.
Philpott sees this as whole person
decriminalization. The Swiss approach was
different, but relied more on public health
than policing and prosecution.
Clean heroin was used as a treatment in a
respectful supervised setting,
shifting life to some normalcy by harm
reduction and sometimes by abstinence.
Philpott wanted a major move on the opioid
file on account of the many overdose
deaths, but was told public opinion would
not support that. However, she managed
to enable physician assisted heroin
treatment and the importation of heroin to
do it. Moving out of government meant an end
to her initiatives, but Philpott
is aware of politics as a force for good –
even though it can be abused. The section wonders about using
medical skills in politics. Philpott left
politics in a special way. She felt obliged
to resign from cabinet because she
felt that staying would be interpreted as
support for the government’s action
concerning then Attorney General Jody
Wilson-Raybould. She had hoped to carry
on as a Liberal, but after her resignation
from cabinet she was removed from
the Liberal caucus and became an independent
MP. Philpott notes doctors have training
and acquire a range of skills. Should
parliamentarians have training? She notes
some options before turning to the concept
of notes – SOAP notes - that doctors put
into medical records as a potential
general tool. SOAP stands for subjective,
objective, assessment plan. The
subjective is the patient history and
symptoms – listening to the patient well
and asking good questions. Objective
includes the findings from examination and
any tests. Then comes an assessment – what
are possible explanations – the doctor’s
diagnosis of what is the root cause. Finally
comes a plan – other tests, a
treatment, check in again and reassess - and
it is written down. Philpott
suggests this approach could be used
by politicians. Listening is hard – spending
time to find out the patient’s, or
the segment of society’s, story and history.
Assessment is hard – it means
politicians declare what they think the root
cause is. What is the plan - or do
we check in to re assess? She gives an
example of the application of this
method in listening to a young woman wanting
to rent a place of her own and ending
up with a plan for manufacturing more homes. Philpott turns to other medical
skills: managing uncertainty; making and
owning up to mistakes; gentle persuasion,
and professionalism. Educators must
try to ensure that the doctors they train
will show professionalism. And she
found some of that professionalism in the
government secretariats. She herself
felt that things like Question Period in the
House of Commons should be
approached in a professional and serious
manner rather than as a point-scoring
game or a place where pro forma general
answers prepared by staff were read.
Philpott would like to see parliament
performing like a health care team, where
the prime minister has breakfast with groups
of MPs who share their stories and
situations. The section ends with a parable about
a crumbling cottage – an actual cottage
on Philpott’s husband’s side. Built by his
grandfather, it fell into a state of
disrepair so that it was not a pleasure to
use as it once had been. It needed a
champion to rebuild it so it could be
enjoyed by present and future family.
Philpott
uses this as a metaphor for Canada’s health
care. Canada’s healthcare needs decisive
action and not more hand wringing. Canada
can
only become a healthy country if it has good
governance. Those with the
biggest responsibility are those in
authority in the federal, provincial and
municipal governments. The political determinants of health
are the deepest roots of the country’s
well-being. Social and economic determinants
are key and they are upheld by
those in power. Philpott notes that none of
the problems and solutions in her
book are new in the world of health policy.
Health workers are exhausted. They
work hard to keep people alive and well but
when they try to improve the
conditions of care they struggle to make
progress. We can’t fix broken health
systems unless our political leaders make
this a top priority. We must urge
them to do so with our votes. The people on
the front lines will be happy to
co-create the design and reconstruction of a
health system that works for
everyone. There have been few leaders to
attempt health care reform – Paul Martin
was the last to provide funding for
healthcare but he lacked conditions and he
lacked plans to deliver primary care and
home care. Philpott asserts that
healthcare is the mother of everything.
There is a problem of timidity, and
angst that it will take too long. However,
both Tim Houston in Nova Scotia and
Wab Kinew in Manitoba came to power with a
platform based on healthcare. Leaders tackling healthcare need to be
driven by equity, fairness and
justice so that healthcare can be for the
common good and for every person. Our
leaders have much power and we who elect
them need to be sure we elect people
with the right motivation. Given the many people struggling to
access medical are, companies have
stepped in who attract willing paying
customers who need medical care. Governments
have let it happen. As more pay to get care,
everyone else is worse off –
longer waiting lists and more staff
shortages. Philpott adds a few paragraphs on what
would need to happen as prelude to
the dream of universal access to primary
healthcare she had stated in the first
chapter. She
sees at least one federal
party bringing health care for all as a top
priority, and seeing the social
components like affordable housing, lower
food costs, action to combat climate
change, and indigenous rights as parts of
that. Canadians are advocating for
rebuilding the foundations around a base of
universal primary health care. Some
provinces have moved in this direction.
Federal leaders commit to this
healthcare for all by 2035 and it means
team-based care in every community –
just like schooling. There is a
federal/provincial gathering on the topic
after
the election of a government linked to this,
together with Indigenous, Inuit
and Métis leaders. The leaders commission
their officials to co-develop a work
plan. Recognizing this will require shifting
budgeting to primary care with lowered
costs down the road, there is agreement that
federal funds will be directed to
this. They have their first discussion about
the Canada Primary Care Act that
will lay down the principles that Canadians
may expect regarding access and
services from primary care teams. The short epilogue repeats the story
and times of Monique Bégin and The
Canada Health Act. The Provinces had a mixed
variety of charges and fees and
were not solidly behind it; the medical
community was critical, and yet when it
somehow came to a vote it was unanimously
adopted and has lasted several
decades. Philpott imagines a similar story
about our current time with terrible
pandemic, divisions and odds. It doesn’t
have to end in disaster. We can create
Medicare 2.0.