ALBERTA HEALTH ACT SUBMISSION

Seniors’ Action and Liaison Team (SALT)


SUBMISSION ON THE PROPOSED ALBERTA HEALTH ACT

This submission comments on the proposed Alberta Health Act, on the report of the Minister’s Advisory Committee on Health, and on the experiences of individual members of SALT who have attended community consultation meetings.

Members of SALT belong to the last generation of Albertans with first-hand experience of paying out-of-pocket for all their health care. Although there is no doubt that changes in the current health care system are needed (above all to provide stability and freedom from unnecessary political interference), SALT would oppose any change which treats health care as a commodity to be bought and sold on the so-called “free market”.



The Alberta Health Act



From an administrative perspective, the consolidation of multiple pieces of related legislation into a single omnibus Act could make sense. However, there is an important caveat: if this is purely for administrative convenience, the purposes and protections in the existing Acts must be transferred in their entirety into the new Act. Conversely, if it is intended to amend the purposes and/or to remove some of these protections, these changes should be announced explicitly and reviewed during the consultation process. SALT therefore requests the Government to:

• Publish summary descriptions of the essential provisions of each Act to be consolidated into the Alberta Health Act; and

• Undertake to preserve or improve the substance of these provisions in the new Act (not merely in the regulations); or

• Explain why it is considered necessary to amend them.



SALT has strong reservations about any move to reduce or devolve regulation of the health care system. Throughout recorded history, in every sphere of human activity, there have always been unscrupulous individuals who took advantage of loopholes. The world is currently dealing with crises caused (in part) by deregulation, under-regulation and/or under-enforcement. When, as now, the debate is (literally) about matters of life and death, there is no acceptable margin of error.



For completeness, and in keeping with the principle of full disclosure, the Government should also publish details of the actual problems caused by conflicts between and among the existing Acts, and explain why these cannot be resolved by simple amendment of the current legislation.



“A Foundation for Alberta’s Health System” (Report of the Minister’s Advisory Committee)



Others have commented on the lack of detailed information in the Advisory Committee’s report. In addition:

• The reference to “aligning non-health legislation” (report, p. 28) needs clarification. Is it intended that all the relevant legislation in the areas of “housing, employment, education, children and youth, environment and social services” will need to be amended? If so, in what way(s)? If not, what does this reference mean?

• The implied assumption that individuals with serious medical conditions have true freedom of choice (report, pp. 12, 33, 38, 40) is fallacious and should not be used in the development of policy.

• The report (pp. 3, 40) refers to the projected increase in the proportion of seniors in the province and the commensurate need for their care. However, current practices do not provide for appropriate response to this demographic change.



The report makes repeated use of the terms “best evidence”, “accountability”, “transparency” and “trust” in relation to the delivery of health care. SALT respectfully suggests that these terms are equally applicable and desirable in the development of new legislation.



The Consultation Process



Ideally a consultation should begin at the beginning, with a discussion of the problems and/or the merits of policy changes which might require amendment of the legislation. Both the on-line survey and the community workshops take amendment of the legislation as a given and discuss its possible content. There was concern among the participants at one workshop that this essential first step had been omitted. There was also concern about the difficulties experienced in securing invitations to the earliest workshops, although this might have been less of a problem in the second half of the process. However, an average turnout of 40 participants per workshop (as of June 20) does not appear to indicate great enthusiasm in the project on the part of the public. The format for the workshops (small groups, each with a facilitator) has both advantages and disadvantages, and could perhaps have been changed to a “town hall” format for some of the meetings or part of each meeting.



It is understood that reports from each workshop will be posted on the Internet at some future date. It would be highly desirable if all the submissions received during the Advisory Committee’s initial consultation and the workbook prepared by the Committee members were made available in the same way.



With these reservations, SALT’s responses to the questions discussed at the workshops are:



1. What is working well, and where should improvements be made?

a. The health system is at its best in dealing with emergency situations, and at its worst when treating chronic conditions.

b. It is instructive to compare the two:

• In an emergency the time scale for initial diagnosis and treatment is short, sometimes very short, the treatment is dictated by the nature of the condition rather than the nature of the patient and the goal is a “cure”. Chronic conditions, on the other hand, may require years for a complete diagnosis, the range of possible treatments can be very broad, the selected treatment can vary from one patient to another and the focus is on management of the condition.

• In an emergency, there is no doubt that the treatment is “medically necessary” (defined for the purposes of this discussion as essential for the preservation and maintenance of life). On the other hand, for chronic conditions what is “medically necessary” is much more diffuse and difficult to define.

It is probably not a coincidence that the differences between these two extremes result in perceived differences in quality of care, and (for chronic conditions) increased responsibility and costs placed on the patients and their families.



2. What principles for our health system would be right in the Act?

a. It is a primary responsibility of any government to ensure the safety and security of its people (some would assert it is the only responsibility). Given this, and given the fact that the Government will have the ultimate responsibility for resolving any adverse consequences, the role and responsibilities of Government should be one of the principles included in the Act.

b. The Alberta Health Act should respect not only the principles of the Canada Health Act but also its intent. For example, a reading of the Canada Health Act suggests that all “medically necessary services” should be included in “insured services” whether or not they are provided in a “hospital”.

c. Contracts involving public funding should be published, and the Auditor-General should have unrestricted access to the financial records of any agency which receives public funds.

d. Given the shifting interpretations of words like “fair”, “equitable”, “universal”, “accessibility”, and the measurement of selected “outcomes” apparent in policy and public reporting over the last decades, a definitions section is important.

e. With respect to the principles suggested in the Advisory Committee’s report, the questions are: if these were to be implemented, what specific differences would be apparent to an ordinary person; and what changes would be suggested for the occupational preparation of health care professionals?



3. The proposal for a patient charter

a. A patient charter would have little real value unless it was enforceable in law. However, this would increase the amount of associated litigation and therefore the costs. A patient charter would thus be a two-edged sword.

b. In order for a patient charter to have any real effect on the delivery of health care, one or more of the determinants of health (as defined by the World Health Organization, these are: income, gender, social status, education, physical environment, social support networks, genetics, access and use of health services) will need to change. Of these, income and education would be most readily changed. Is the Government considering implementing a guaranteed minimum income policy or modifying the K-12 curriculum?

c. While it is entirely reasonable to ask individuals to take responsibility for their own health and wellbeing, the notion that “blame” could be assigned (by whom?) and somehow factored into the treatment received (and responsibility for the costs) is entirely abhorrent.

d. In what specific ways would a patient charter differ from current “best practices”?



4. What approaches should be encouraged, and what are the “no-go” areas?

a. The record of the past half century suggests that the Government’s commitment to public health care (particularly public delivery) has been less than enthusiastic. There have been repeated attempts to limit its scope despite all indications that such initiatives do not have popular support. Perhaps it is time to acknowledge the preferences of the population.

b. We need a public debate about services that should be included in the publicly-funded health care system to provide a basis for legislative reform.

c. Increasing private-sector involvement (i.e., from investor-owned corporations and/or “not-for-profit” agencies serving primarily as contracted service providers) is not acceptable, nor is the provision of capital subsidies to these organizations.

d. Means testing for the Alberta Seniors’ Benefit is placing a disproportionate burden on middle-income seniors. Continuation of this practice (as contemplated in the Pharmaceutical Strategy which is currently on hold) is not acceptable.



5. How should people be informed/engaged about future initiatives?

a. Members of SALT have participated in a number of Government-sponsored consultations in recent years. The results have always been disappointing. With hindsight, the usual impression has been that the key decisions had already been taken and the consultation was merely an exercise in public relations. There has been no sense that the input had been willingly sought or, when given, seriously considered. In addition, in some cases (Vision 2020, the Continuing Care Strategy and the Pharmaceutical Strategy) there was no opportunity for meaningful input.

b. There appears to be a sense of disengagement among the general population, as demonstrated by the declining turnouts at general elections. The proportion of the electorate who did not (or could not) vote in the 2008 election was very high and arguably sufficient to severely compromise the Government’s legitimacy.

c. The Government should acknowledge that, when policy issues related to health, education or social services are under review, the people of Alberta are the principal stakeholders and should be the principal decision-makers. Service providers, technical advisors and private consultants have a legitimate role in the implementation of policy, but not in its determination.

d. SALT submits that the onus is on the Government to establish a climate which enables and encourages meaningful participation in future initiatives – to “speak plainly and build trust.”

Conclusions


The information presented to date on the proposed Alberta Health Act is insufficient to permit reasoned assessment of the proposal or to grant informed consent.

There is a need for a public review of the basic assumptions used in the development of the Act.

Submitted on behalf of SALT

John Wodak, Chair



July 7, 2010