Toronto centre hopes to cash in on growing demand for private health services

When the CMA held its 1996 annual meeting, part of the debate on the future of health care involved the "appropriate balance of the roles of the public and private sectors" in delivering health care. The King''s Health Centre in Toronto is now doing its own balancing act: providing publicly funded care to Canadians, and private care to non-Canadians and Canadians who can afford it. This article discusses some of the niche markets King''s is attempting to develop.     

NHS waiting list have been a boon for private medicine in the UK.

Health care: public, private or both? In Great Britain, about 13% of the population is covered by private health insurance, and everyone else is served by the public health care system known as the National Health Service, or NHS. Caroline Richmond, who examined the impact of private medical practice in Britain, says people become private patients for one compelling reason: to avoid the NHS''s notoriously long waiting lists for surgery. According to Professor Alan Maynard, a health care researcher, the mainstays of the private sector are the "three h''s" --hips, hernias and hemorrhoids-- along with some elective surgery, particularly in gynecology and opthalmology. Another small sector focuses on fertility regulation and cosmetic surgery. Although the levels are not monitored closely, physician consultants are not permitted to earn more than 10% of their income from private practice.     

Managed-care plans. Their future under national health insurance.

The nation''s health maintenance organizations, preferred-provider organizations, independent practice associations, and similar managed-care efforts are not well positioned to take a leadership role in a nationwide universal access or national health insurance plan. They--with the possible exception of some large staff and group health maintenance organizations--have been unable to show uniformly that they can contain costs, provide better access or higher quality of care, and achieve greater patient satisfaction than fee-for-service endeavors. As the United States pursues universal access as a step toward national health insurance, the managed-care plans will continue to increase their numbers of subscribers. They will not, however, be able to enroll large numbers of the young, low-income employees and their dependents who account for most of the 63 million people uninsured sometime during each year. Under national health insurance, there might be an option for some health maintenance organizations to negotiate capitated payments. The vast majority of the nation''s physicians, however, will reluctantly embrace a centrally managed fee-for-service approach rather than a salary or capitated reimbursement method, leaving only a trace of the competitive managed-care plan theme in a future, primarily monolithic, national health care system.     

Patients' accounts of being removed from their general practitioner's list: qualitative study

Objective To explore patients'' accounts of being removed from a general practitioner''s list.Design Qualitative analysis of semistructured interviews.Setting Patients'' homes in Leicestershire.Participants 28 patients who had recently been removed from a general practitioner''s list.Results The removed patients gave an account of themselves as having genuine illnesses needing medical care. In putting their case that their removal was unjustified, patients were concerned to show that they were “good” patients who complied with the rules that they understood to govern the doctor-patient relationship: they tried to cope with their illness and follow medical advice, used general practice services “appropriately,” were uncomplaining, and were polite with doctors. Removed patients also used their accounts to characterise the removing general practitioner as one who broke the lay rules of the doctor-patient relationship. These “bad” general practitioners were rude, impersonal, uncaring, and clinically incompetent and lied to patients. Patients felt very threatened by being removed from their general practitioner''s list; they experienced removal as an attack on their right to be an NHS patient, as deeply distressing, and as stigmatising.Conclusions Removal is an overwhelmingly negative and distressing experience for patients. Many of the problems encountered by removed patients may be remediable through general practices having an explicit policy on removal and procedures in place to help with “difficult” patients.     

Ontario's accelerated war against Medicare misuse another sign of leaner health care times.

A special-investigations unit is helping the Ontario Health Insurance Plan (OHIP) curb the fraud and abuse that has been draining millions of health care dollars from the province. The government is taking a tougher line on foreigners who use friends'' or relatives'' OHIP cards, people who use misplaced, stolen or counterfeit cards, and on snowbirds who deliberately bend residency requirements as they try to hang on to medicare benefits. In 1994-95, Ontario spent $74 million on health care for Ontarians travelling or living abroad.     

Effect of a training programme to reduce stress in carers of patients with dementia.

OBJECTIVE--To reduce the psychological stress and improve the skills in coping of people who care for relatives with dementia. DESIGN--Assessment and suitability of carers by questionnaire; assessment of patients and carers in a hospital outpatient clinic; allocation to groups according to date of application to study. Linkage of groups of four carers and programme coordinator by telephone conference calls over 12 months after programmes. Reassessment at three, six, 12, and, for those in the "wait list" group, 18 months. SETTING--The programmes were conducted in the psychiatry unit of a Sydney teaching hospital. SUBJECTS--Eligible patients were less than 80 years old, had mild to moderate dementia, and lived at home with their carer. Of the 96 patient-carer pairs in the study, 33 were in the dementia carers'' programme group, 31 were in the memory retraining group, and 32 were in the wait list group. INTERVENTIONS--Carers in the dementia carers'' programme received training in coping with the difficulties of looking after patients with dementia while the patients had sessions in subjects such as memory retraining. In the memory retraining programme patients were admitted and received the patient component of the carers'' programme while their carers had 10 days'' respite. In the wait list group carers waited six months before undertaking the carers'' programme. MAIN OUTCOME MEASURES--Effect of the programmes on carers'' general health questionnaire scores and the rate of placement of patients in institutions. RESULTS--At 12 months'' follow up the carers'' programme had resulted in significantly lower psychological stress among carers than the memory retraining programme (mean (SD) general health questionnaire scores at 0 months were 6.31 (6.23) and 3.60 (6.25) respectively, and at 12 months were 4.69 (5.58) and 7.40 (9.39); p less than 0.05.) In the wait list group distress scores remained stable, even after the carers and patients had undertaken the carers'' programme. Patients deteriorated over 12 months regardless of group allocation, but at 30 months, allowing for patients who died and could not be included in the analysis, 65% of patients in the carers'' programme group were still living at home compared with 26% in the memory retraining programme group. CONCLUSION--The intensive intervention programme described for carers of patients with dementia can reduce the psychological morbidity of the carer and delay the placement of the patient in an institution without increasing the use of health services by either patient or carer.     

Nurse Practitioner and Physician's Assistant Clinics in Rural California: Part I: Issues

The primary health care needs of at least 26 rural California communities are being served by nurse practitioners (NP''s) or physician''s assistants (PA''s). All of these have physician supervision and support. NP''s and PA''s have proved to be acceptable and effective. With 230 rural areas in California identified as having unmet health care needs, this type of service is likely to increase and should be supported.NP/PA clinics serve total populations or concentrate on Indians, Chicanos or the poor. Many barriers have been overcome, especially over the past four years, to allow these clinics to flourish and increase in number. The availability of nurse practitioners and physician''s assistants has increased due to support to schools and to school policies. Clinic funding has greatly improved; federal funds for general rural clinics, Indians, migrants, family planning and maternalchild health have been greatly supplemented by California state funds. Beginning in 1978, rural NP and PA services can be reimbursed by Medicare and Medi-Cal (California''s Medicaid program).Since 1975 state laws have defined PA and NP roles broadly, and these roles are more precisely defined at the local level. Although nurse practitioners and physician''s assistants generally cannot prescribe or dispense drugs (a major problem in many clinics), demonstration legislation allows special pilot projects to do both. As remaining funding and legal problems are corrected, NP''s and PA''s will serve an even greater role in rural areas.     

Bioethics for clinicians: 9. Involving children in medical decisions

Medical decisions involving children raise particular ethical issues for physicians and other members of the health care team. Although parents and physicians have traditionally made most medical decisions on behalf of children, the developing autonomy of children is increasingly being recognized in medical decision-making. This poses a challenge for physicians, who must work with the child''s family and with other health care practitioners to determine the child''s role in decision-making. A family-centred approach respects the complex nature of parent-child relationships, the dependence and vulnerability of the child and the child''s developing capacity for decision-making.     

Freeman Hospital: the will to survive.

The future looks uncertain for the Freeman Hospital trust in Newcastle upon Tyne. There are plans to rationalise the health service in Newcastle by shifting resources from secondary to primary care, and by providing more services locally for people who live in the region but outside Newcastle. These could reduce the level of contracts that purchasers place with the trust in the future. Staff at the trust say the service they provide is good value for money, but purchasers do not seem to take this into account. Instead of choosing from a "shopping list" of priced procedures, purchasers are forcing the trust to dovetail its prices to meet their budgets. There is also concern at the potential impact on the trust''s financial situation of reduced working hours for junior doctors and the Calman proposals on training.     

A new primary care rostering and capitation system in Norway: Lessons for Canada?

Providing every patient with a personal primary care physician or, from the physician''s perspective, establishing a stable roster or list of patients is currently being actively debated in Canada. Norway''s system of primary care medicine, similar to Canada''s, faces many of the same problems. In 1992 a trial rostering system with blended funding (capitation, fee-for-service and user fees) was established in 4 Norwegian municipalities. After 3 years of close monitoring, the results of system evaluations have attracted strong interest. This article reports on the benefits and problems encountered with the new rostering system in Norway. If Canada is moving in the same direction, some of the lessons learned may be helpful.     

The National Forum reports: Crisis? What crisis?

The National Forum on Health''s final report appears to have said what Canadians--and the federal Liberal government wanted to hear about the health care system. It called for preservation of the single-payer model and the 5 principles of the Canada Health Act, and also recommended that medicare be expanded to embrace pharmaceuticals and home care. Edmonton internist Tom Noseworthy, chair of the forum''s steering committee, said public anxiety about medicare is caused by the rapid pace of change, not its direction. However, the CMA''s Dr. Judith Kazimirski was quick to challenge Noseworthy and his criticism of those who say a crisis exists.     

Buffeted by harsh economic winds,medical schools turn a wary eye to the future

All parts of Canada''s health care system are facing fiscal pressures these days, but they are particularly great at Canada''s medical schools. However, Dr. David Hawkins of the Association of Canadian Medical Colleges is optimistic that all 16 of Canada''s medical schools will remain open, mainly because of the huge impact they have on health care in their local communities. “We don''t just turn out students — we raise the standard of health care in a whole community,” he says.     

Fighting the odds in the UK.

Caroline Richmond reports on miscellaneous winners and losers from the health care scene in the United Kingdom. The winners include a young patient who is holding her own against formidable medical odds after receiving heroic treatment for leukemia, and the country''s osteopaths, who have won the right to compile a statutory register. The losers are the venerable St. Bartholomew''s Hospital, which appears to have lost its battle to stay open, and a 32-year-old man who almost made it to medical school by posing as a teenager.     

Narrowing the health gap between a deprived and an endowed community

A 15 month campaign by a primary health care team in Stockton on Tees raised the uptake of preventive care of its patients in a severely deprived area to a level generally exceeding that of a more endowed neighbouring community. This was achieved by opportunistic attention after unrelated consultations, writing twice to each household with a list of its outstanding items necessary for preventive care, using health visitors to encourage attendance, and occasionally undertaking preventive care in patients'' homes. Extra clerical staff were needed to implement the new recording and monitoring procedures introduced.With rigorous monitoring and organisation general practitioners may improve the uptake of preventive health care by their more deprived patients.     

Grampian Health Board's joint drug formulary.

OBJECTIVE--To develop a model for creating a joint general practice-hospital formulary, using the example of ulcer healing drugs. DESIGN--A joint formulary development group produced draft guidelines based on an earlier hospital formulary, which were sent to interested local general practitioners for consultation. Revised guidelines were then drawn up and forwarded to the health board''s medicines committee for approval and distribution. SETTING--Grampian Health Board. SUBJECTS--Nine members of joint formulary development group plus local general practitioners who were invited to comment on a list of 11 ulcer healing drugs. MAIN OUTCOME MEASURE--Degree of coincidence of drugs selected by hospital doctors and general practitioners. RESULTS--The ulcer healing drugs selected by the panel of general practitioners and by hospital doctors were highly coincident. The cost of one day''s treatment with drugs varied considerably between hospital and general practice--for example, one drug cost 46p in hospital and 1 pounds in general practice and another cost 1.26 pounds in hospital and 1.01 pounds in general practice. Overall, six drugs cost more in hospital and five cost more in general practice. CONCLUSIONS--A joint formulary for use in hospitals and general practice in a health board can be devised fairly simply by consultation as virtually the same drugs are used in both types of practice. It should influence the health board''s expenditure on drugs and affect the choice of drugs when a patient is discharged from hospital or is referred to any hospital in the region.     

Identifying and treating pregnant patients at risk from alcohol.

Heavy alcohol consumption during pregnancy has been associated with retardation of fetal growth and abnormal fetal development. Pregnant women whose offspring are at risk because of alcohol abuse can be identified and counselled by health professional providing prenatal care. Offspring born to women who had been drinking heavily and subsequently abstained from or reduced their intake of alcohol before the third trimester demonstrated improvements in growth and in regulation of sleep-awake states. The existing health care delivery system can be modified in a cost-effective manner to treat pregnant women who are problem drinkers. Physicians'' attitudes and behaviour are critical for the success of this strategy.     

Culture and Disability Behavior

A substantial amount of literature suggests that illness behavior in the United States is a product of a patient''s core culture; equally credible findings do not support this contention. Most students and graduates in the health care professions believe that illness and disability behavior are affected by a patient''s culture, but they are hard put to find convincing examples of that relationship. In experience with medical students studying the social and cultural bases of illness behavior, with patients who are disabled and with persons who claim disability in the absence of physical disease or disabling psychopathology, I observed no deviant disability behavior that was typical for the members of any cultural group, and no behavior was displayed by the members of one cultural group that was not seen in members of other cultural groups. No cultural stereotypes were upheld. I did find evidence that disability behavior is influenced by personality factors, social situations and the gains derived from the disability status. Evolving concepts of “entitlement,” which are closely related to socioeconomic status, also have a significant influence. The impact of feedback from others in a person''s many social and medical subcultures is a more crucial determinant of illness and disability behavior, except in those for whom illness and disability behavior is determined by the limitations imposed by the disease or by a personality structure resistant to cultural expectations and social feedback.     

The health of Indians in Canadian cities: a challenge to the health care system

It is well known that Canadian native people living on reserves have high morbidity and mortality rates, but less is known about the health of those who migrated to urban centres. Several studies have shown that these people have high rates of mental health problems, specific diseases, injuries, infant death and hospital admission. In addition, there is evidence that cultural differences create barriers to their use of health care facilities. The low socioeconomic status, cultural differences and discrimination that they find in cities are identified as the primary blocks to good health and adequate health care. More epidemiologic studies need to be done to identify health problems, needs and barriers to health care. Federal, provincial and civic governments along with the appropriate departments of faculties of medicine should begin working with native organizations to improve the health of native people living in Canada''s cities.     

Will hospital closures mean physician unemployment in Ontario?

Dr. Duncan Sinclair, the former dean of medicine who heads the commission charged with restructuring Ontario''s health care system, said something dramatic was needed to revamp the system. He wasn''t kidding. His commission recently called for the closure of 3 hospitals in Ottawa and 10 more in Toronto. In a wideranging interview with Charlotte Gray he talks about the commission''s goals and their potential impact on physicians.