In the mid 1990s, when the government of Ontario was closing hospitals and laying off nurses at a brisk pace, Saint Elizabeth Health Care, a leading homecare provider, was going around hiring as many laid-off “wound care specialists” as it could afford, thinking they might come in handy in the burgeoning field of home care. Wound care specialists are usually registered nurses specially trained to deal with the aftercare from surgeries; emergency procedures and such work had traditionally been done during a patient’s post-op stay in hospital. Saint Elizabeth, which had begun in 1908 with four nurses who visited Toronto patients on foot or by streetcar, initially imagined it would send its newly acquired staff out to patients’ homes, but soon realized that was not a very efficient strategy. So they rethought the process.

Instead of having these wound care specialists—who are both expensive and highly skilled—visit six or eight patients a day, Saint Elizabeth set up wound care clinics. Many people who go home from hospital with a wound are ambulatory. And even if they are not at first, they are ambulatory after a few days, and capable of coming to see the follow-up specialists in a clinical setting. Clinics also mean that more patients can be seen per day. Saint Elizabeth operates 22 clinics that provided 113,000 wound care visits in 2013/14. In addition they provided 598,510 homecare visits for wound care. Improved wound care in the community allows shorter hospital lengths of stay and better patient outcomes.

The kind of innovative thinking and pioneering work in this field that is being adopted by individuals and organizations across Canada is the missing answer to our country’s healthcare problems. Improving the medical work and environment in hospitals is essential, but a combination of factors—primarily the aging of the population, the rise in chronic conditions and our slower-growth economy—is forcing us to get serious about the other massive piece of the healthcare puzzle: out-of-hospital care.

And by that term, I do not mean simply home visits by nurses and doctors. The out-of-hospital universe includes at a minimum these six components: primary health care including family doctors, home care, community pharmacy, community paramedicare/ambulance, palliative care and rehabilitation.

I will discuss several of these components later in this essay, but first, a little history.

In the 1920s, Canadians had a life expectancy of 55 years. By the 1950s, life expectancy had increased to 65 years. Now, in 2014, life expectancy is well over 80 years of age. The challenge is that we are not living longer in perfect health. We are living longer—much longer than our grandparents and our great grandparents—but we are living, in the vast majority of cases, with one or more chronic diseases and disabilities. Diabetes, asthma, heart disease and chronic obstructive pulmonary disease (emphysema) are the worst and most prominent culprits.

The other part of the historical background in Canada is this: what we proudly call Canadian medicare began as a public insurance program for hospital services. The second step was public insurance for doctor services. Both these steps were supported by the Government of Canada through 50/50 cost sharing. By paying hospitals and doctors through government, a genuine partnership was established between the provinces, which had the constitutional responsibility for health care, and the federal government, which had the money to allocate for health services. When this arrangement was successfully achieved in the late 1960s, hospital and doctor services represented more than 80 percent of all healthcare spending. If you had a family doctor, and most Canadians did, and you knew the location of your local hospital, you had a good chance of getting excellent care or at least the best care available.

Forty-five years later hospitals and doctors represent less than 45 percent of total health spending. Drugs, home care, long-term care, public health, complex chronic care and a vast array of other services make up the majority of health spending in Canada. And the insurance to cover these additional health services is a patchwork quilt. For example, 500,000 Canadians have no drug coverage either public or private.

In the 1990s we shifted 80 percent of hospital surgery to day surgery. We did not follow the lead of other developed countries that moved day surgery out of hospitals. Now we need to revisit that decision.

Many observers and experts who have studied the Canadian healthcare system—most recently Don Drummond and Jeffrey Simpson—describe it as somewhat expensive and not very efficient. The basic principles of Canada’s medicare are not in doubt: access to care for the whole population is a goal of every developed country including, at long last, the United States. What, then, is the

problem?

Recently the Canadian Institute for Health Information published a study that underscored the unevenness in Canadian healthcare delivery. It focused on efficiency and patient outcomes across all Canadian health regions. The study’s conclusions—which even I, a veteran of the medicare wars, found startling—were that “if all health regions were able to maximize their efficiency, deaths due to treatable causes could be reduced 18% to 35%, on average. This translates to the potential prevention of 12,600 to 24,500 premature deaths in Canada per year, without incurring additional costs.” In other words, sustainability means moving healthcare delivery to the highest level of efficiency that already exists. Better management and governance, not a miracle cure, are needed.

Canadians rightly value their hospitals and view the blue “H” atop them as a beacon of health care and hope. But hospitals do not hold the answer to keeping our healthcare services sustainable. Many services ranging from day surgery to cataract surgery to urgent but not emergency care remain trapped in hospitals due to history and tradition. The inertia of collective agreements, the power of vested interests and the comfort voters derive from the presence of their nearby community hospital are all factors.

The cost figures in the table above are from American health care. They show a vastly lower cost of treating minor but urgent conditions in the out-of-hospital setting.

Canadian costs are not available but the percentage saving would likely be in line with the American numbers. And these costs in Canada will cause a needed pressure to move more minor services out of hospital.

We need to focus on building our out-of-hospital healthcare system. And the encouraging factor here, as the CIHI study underlines, is that many of the necessary elements to accomplish this already exist. It is largely a challenge of reforming and reimagining the role of existing health services and focusing on meeting patients’ needs in their homes and communities.

When Tommy Douglas set out to publicly insure first hospital services and then physician services a decade later, he had a simple goal. He wanted to remove the financial barriers between those needing care and those providing care. Decades later Douglas described what still needed to be done: “Phase number two would be the much more difficult one and that was to alter our delivery system to reduce costs and put an emphasis on preventative medicine.” Medicare’s founder wrote that in 1979, but in fact we are only beginning to face up to his phase-two challenge today.

If we try to cope with the rising tide of chronic disease in our hospitals, the quality of care will decline, costs will skyrocket and our hospitals will be overwhelmed. There is already a mountain of evidence that we are intervening at the final stages of chronic disease, not early on when management is possible. We are becoming very efficient at replacing hip and knee joints worn out by an epidemic of obesity. We have expensive new medications for diabetes but little early intervention to limit the rapid growth of this disease.

Why do we need innovation in health service delivery? Why do we need a robust out-of-hospital healthcare system? Simply put, without such innovation we will not sustain our health services.

Healthcare systems, it is necessary to point out, always seem unsustainable. If you take any healthcare system at any point in time and you project forward using the existing techniques, existing medications and existing surgical techniques and match what we can do against the mounting burden of illness, you conclude that the system is unsustainable. Yet we always innovate our way out of this unsustainability. Sometimes it takes us a long time, during which the existing health system gets overwhelmed. Sometimes it happens faster. In our parents’ generation there were many people who lost their life or had a withered limb from polio. Now, thanks to the Salk vaccine, it would be very surprising in Canada to see a case of polio and yet, in the 1940s, there was a legitimate fear that polio would swamp our entire health system. In the 1990s, HIV/AIDS had the same overwhelming effect. Although no vaccine has yet emerged, medications have converted HIV/AIDS to a largely manageable “chronic” disease.

So what are some of these innovations that stand a good chance of making the Canadian system sustainable?

Community Paramedicine

Is anyone innovating their way out of the incredible pressure on emergency rooms these days? I would say yes. The innovator I have in mind is George McLellan, former president and CEO of Medavie EMS, which operates the ambulance services in Nova Scotia, New Brunswick and Prince Edward Island. According to McLellan, Medavie is not an ambulance company; it is an out-of-hospital healthcare service.

In Don Drummond’s recent study of Ontario government spending, he recommended that Ontario should adopt what he called the “Nova Scotia model,” essentially what Medavie has done. It began with reimagining what one could do with an ambulance paramedic, if that paramedic had more training and could handle a certain level of crisis, and possibly would not have to drive every patient to the hospital emergency room. St. John’s Ambulance is known for training volunteers but it also provides training to professional paramedics. McLellan bought the St. John’s Ambulance training operation in New Brunswick and Nova Scotia, and was able to start training advanced paramedics to a higher skill level. Now in parts of Nova Scotia, fewer than 50 percent of people who call 911 are transported to hospital by ambulance. How does Nova Scotia manage to do this? First of all, the paramedics have a skill level at which they can do some basic diagnosis, and, second, they can attach the patient to monitoring equipment, so that a remote cardiologist or other specialist can read the same information he or she would be reading in the emergency room.

Medavie Extended Care Paramedics (ECPs) are also providing timely enhanced medical services in nursing homes; in 17 Nova Scotia long-term care facilities, ECPs carried out 1,890 patient visits under the supervision of a physician collaborative. Seventy-four percent were treated and released, 3 percent were immediately transported and in 22 percent of cases transfers were facilitated. This is vastly better than a complete separation of ambulance, where all cases are transported to hospital as a matter of policy. This innovation has been recognized with national awards for leadership and innovation from the Institute of Public Administration in Canada and Deloitte.

In addition to more highly skilled paramedics, Medavie EMS added call centres to make outbound calls (811) to patients, as well as receiving inbound (911) calls from patients. In addition to their ambulance duties, paramedics in Nova Scotia are staffing emergency rooms of smaller hospitals and also undertaking homecare visits. Their ability to stabilize patients is expanding the capacity of the out-of-hospital healthcare system.

Home Care

Wound care, as noted above, is a central and dominant activity of home care. Sixty percent of homecare visits involve wound care. What else can home care contribute to a robust out-of-hospital care?

An early pioneer of home care in Canada, Evelyn Shapiro, understood that independent living would enable seniors to avoid costly institutional care. She convinced the Manitoba government to introduce a province-wide homecare service in 1974. Shapiro also understood that to remain in their homes low-income seniors needed help with minor repairs and renovations. That was built into the system. A generation of Manitoba seniors benefitted greatly by remaining in their homes and receiving the care they needed. Taxpayers benefited from a less costly program than institutional long-term care.

Following in Shapiro’s innovative footsteps, Michelle Todoruk-Orchard of the Winnipeg Health Authority leads a nurse-led homecare and clinic team dealing with wound care. Their focus is treating post-operative wounds such as Caesarean section incisions, pressure ulcers, diabetic foot ulcers and venous leg ulcers. Their seven-day-a-week program has provided many patients with excellent care without a return to hospital.

A third area of essential homecare activity is end-of-life care. The vast majority of Canadians would like to die at home. Meeting this deeply held desire requires pain management in the home provided through homecare nurses. Absent quality care in the home, the burden on families and patients is too much for them to bear and hospitalization results.

Pharmacies

Another place where innovation is expanding the role of out-of-hospital care is in your local drugstore, but not without a sometimes fierce tug-of-war. The power struggle between physicians and pharmacists has centuries of history. In England these battles took the legal route and, in extreme cases, physicians smashed the shops of apothecaries who they believed were dispensing dangerous treatments to patients. For more than a century doctors dominated this field but the role of the pharmacy is once again expanding, largely because of the time pressure on physicians and the primary care system.

Pharmacies of today would astonish doctors of even a few decades ago. The range of medicines both over the counter and prescription, the level of information technology, and the diagnostic tests and equipment available exceed those of a small hospital at the outset of Canadian medicare. Filling prescriptions and advising patients on how to use them is only a part of what pharmacies do today. Vaccinations are being offered for the flu by many pharmacies. The blood pressure cuff has become ubiquitous in Canadian dispensaries, so people can keep an eye on their own BP levels. Prescription renewal by pharmacists eliminates the need for repeated physician visits. In several Canadian provinces pharmacists are reimbursed for reviewing medications. This is particularly important when our over-65 population averages five or six medications each, dramatically increasing chances for error or adverse drug interaction.

It is true that in the old days a woman could buy a pregnancy test at her local drugstore (or a more distant one if she had reasons for keeping the information strictly private). Now pharmacies also sell a whole range of diagnostic tools from digital thermometers to diabetes test strips. The pharmacy with wide distribution and proximity to population is a well-located centre for diagnostic and self-care support.

Palliative Care

A fully developed and properly funded palliative care system is an essential element of the out-of-hospital healthcare system. More than 80 percent of Canadians surveyed would prefer to end their life in the comfort of their own home. Yet most Canadians still die in the discomfort of hospitals. This failure to meet the final wishes of patients is not only unfair; it is also extremely expensive. Palliative care is far better organized in Europe and even in the United States. Aetna’s Compassionate Care (Palliative) Program has achieved 82 percent reductions in inpatient hospital bed use at end of life and 77 percent reductions in emergency room visits.

When Doctors’ Hospital was closed in downtown Toronto in 1997, an innovative entrepreneur named Brian MacFarlane built a community health centre, palliative care centre and surgical services out of its remains. Dubbed the Kensington Health Centre, it runs a first-class hospice, with tangible benefits for its own end-of-life patients and for the patients now able to access freed-up beds in the city’s other hospitals. And the Windsor branch of Saint Elizabeth Health Care has expanded in-home end-of-life pain management to the extent that 80 percent of its patients are able to die, as they wished, at home.

Palliative is a crucial piece of the puzzle and much more innovation in this area needs to be encouraged and funded. However, there is a great deal of inertia and many obstacles to be overcome, such as proper funding for hospice and negative attitudes about death with dignity.

There are nervous times ahead for Canada’s healthcare system. The reduced Canada Health Transfer due to take effect in 2017/18 will force more efficiency across the country, although the 2015 federal election could change things. As proposed by the Harper government, the reduced transfer will cut in half what provinces have been receiving. The increase will fall from 6 percent per year to a formula based on GDP growth with a guaranteed increase of only 3 percent. Provinces will be forced to flatten provider pay and find major economies. The fiscal pressures requiring our health care to live within a slower growth path will not abate. They are deeply rooted in our demographics.

Canada urgently needs to build a much more robust out-of-hospital system to meet the current and expanding demands of an aging population. Fortunately, major components of the needed system already exist and are being made more effective through innovation and the leadership of pioneers. Taken together, reworked primary care, home care, telemedicine, pharmaceutical services and an expanded role for paramedics form a viable foundation. Increasingly scarce healthcare dollars need to go to services, not to layers of bureaucracy imposed on top of service delivery. What is needed are passionate, visionary leaders and a willingness on the part of health care’s stewards—both financial and regulatory—to facilitate transformation, not to block it. Only with a transformed approach to health service delivery will medicare be sustained for our children and grandchildren.

Michael Decter is the board chair of Patients Canada, Medavie Blue Cross and The Walrus Foundation. He has served as Ontario’s deputy minister of health and chair of the Canadian Institute for Health Information. He is the author of Healing Medicare: Managing Health System Change the Canadian Way (McGilligan Books, 1996), Four Strong Winds: Understanding the Growing Challenges to Health Care (Stoddart, 2000) and the co-author with Francesca Grosso of Navigating Canada’s Health Care: A User’s Guide to Getting the Care You Need (Penguin, 2006).

Related Letters and Responses The graphic symbol of Canada’s increasingly poor performance in health care is Exhibit ES-1 of the Commonwealth Fund’s country rankings in healthcare delivery. Placing fifth out of six in 2010, Canada has fallen to tenth out of eleven in 2014. Clearly, things need to change. Michael Decter argues that Canada must move health care out of the hospital system. He is absolutely correct. Care provided primarily in hospitals is inefficient, expensive, inconvenient and (with the growth of hospital-borne superbugs) often dangerous. But this is not a new argument. And most countries have made substantial progress away from hospital-based models. So the intriguing question is not...