New Brunswick's Minister of Health, The Honourable Madeleine Dubé, reviews the challenges faced by her province and describes how a renewed Accord can support needed changes —Report from a presentation at the 2011 conference of the MUHC-ISAI

The renewal of the Health Accord is being discussed with many different groups around the table at a national level just now and is a priority for everyone involved with the healthcare system across Canada. This national dialogue provides the opportunity to take stock of what we know now to be real challenges to health system sustainability, and through that, to our provinces’ financial sustainability. The renewal process is an opportunity to look back at the intentions and outcomes of the 2004 Health Accord, correct mistakes and ensure that current agreements evolve to match new realities, while also building on our successes and the positive momentum we have experienced.

The 2004 Health Accord

The 2004 Accord’s primary purpose was to address the funding shortfall created by federal cuts during the 1990s. The cuts had created significant challenges for provincial and territorial health system sustainability. The Accord restored that funding, although the annual 6% did not keep up with the pace of health spending growth in some provinces.

Since it was signed, New Brunswick has undertaken and maintained significant initiatives in virtually all of the Accord’s priority areas. Primary health reforms include the creation of a network of community health centres and collaborative practices, as well as the launch of a complete strategy for diabetes and the continued development of a strategy for preventing chronic disease. Health human resource strategies enabled new professions to be created, along with new training programs and an optimized scope of practice.

Accountability and reporting to citizens has been considerably improved with the establishment of the New Brunswick Health Council.

In 2006, the province launched its Wellness Strategy Action Plan. The implementation of the Strategy continues and its budget was increased 25% this year. In 2008, New Brunswick created a screening and prevention program for cervical cancer. In 2009, New Brunswick also announced the creation of a province-wide community-based screening program for colorectal cancer. Initiatives to manage wait lists have cut wait times almost in half for surgeries and cancer surgeries. When the Accord was agreed to in 2004, New Brunswick was working on a initiative to manage access to surgery and we are continuing to focus on improving wait times for all surgeries.

Since 2008, we have been publishing wait times in our provincial registry. Since that time, the average wait for surgery has dropped from 90 to 56 days; the wait time for cancer surgeries has dropped from 34 to 14 days; the number of patients waiting for surgery for more than 12 months has gone from 1950 to 676; and between 2007 and 2010, between 87% and 94% of patients who were ready to start treatment received radiation treatment within 28 days.

While the 2004 Accord was effective at restoring federal funding levels and supporting some of our province’s pre-existing priorities, it was ineffective in promoting broad system change, which was the overall intention when the Accord was signed. The intended development of a National Pharmaceutical Strategy and a National Immunization Strategy would have been positive change-drivers for the healthcare system; however, they were not fully developed. These represent the largest gaps between intentions and outcomes of the 2004 Accord.

The cost of drugs continues to rise. Prescription drugs are now the third largest component of New Brunswick’s healthcare spending, after hospital services and physicians. Drug costs in New Brunswick grew by 9.5% last year, reaching just over $180 million. Drug costs have doubled since 2000-01 and demand for vaccines also continues to grow, as does the list of new and expensive vaccines available. The cost of delivering and administering vaccines is an important issue to resolve.

It is helpful to look backwards as we move forward in these national dialogues. However, it is also important to realize that things change in 10 years, and we must realistically examine the current challenges we face, such as: the scope of our health services, the supply of health workers, an aging infrastructure, advances in science and technology, and financial pressures.

Through this national dialogue, New Brunswick, like other provinces and territories, will be looking for stable, adequate and predictable federal transfers but will also seek to provide leadership in addressing cost pressures in health care through innovative solutions. New Brunswick has an aging rural population, with many services spread throughout an area that is geographically small compared with larger provinces. I have serious concerns about New Brunswick’s ability to sustain the system we have today. It is clear that we have reached a tipping point in New Brunswick.

The challenges today

New Brunswick is facing significant financial pressures. This year alone we are projecting a $514 million deficit. The provincial net debt has grown by approximately $3 billion in the past four years and is projected to be over $10 billion at the end of this fiscal year. The interest on that debt is nearly $680 million a year. Both short-term and long-term savings need to be found.

Keeping the health system running costs about $5,800 dollars a minute, or $8.6 million a day, or $3 billion a year. And this is for a province with 750,000 inhabitants. These numbers include the budget of the Health Department, the regional health authorities and the long-term care system. In the past 10 years, the cost of health care has increased by $1 billion. These costs impede New Brunswick from supporting its education system, protecting vulnerable members of society, helping business and preserving the natural beauty of our province. Figure 1 shows the breakdown of our provincial spending for the current year. By 2015, health care will take up half of our entire provincial budget.

Source: Department of Health, New Brunswick

Our aging population presents another challenge. When people retire, their tax contributions and income both decline and they naturally require more healthcare services. Right when the province will need healthcare services the most, we will be least able to afford it. Right now, a quarter of hospital beds in New Brunswick are occupied by seniors who would be better cared for in another setting. If we do not change what we are doing, by 2021 all hospital beds in New Brunswick will be occupied by seniors, who could live happier, healthier lives in another setting, outside of the hospital system.

Our population is dispersed throughout our largely rural province. We struggle to recruit specialists to hospitals where the need for another practitioner is more about creating a reasonable work schedule than patient demand. Today’s young doctors want to work in teams. They want access to good equipment and they want quality of life. This is not about vanity but about providing patients with good quality care. The time has come to look at the old model and seriously ask ourselves whether we can do better.

In a recent survey conducted by the New Brunswick Health Council, 60,000 New Brunswickers stated they did not have a family doctor. Access is still a major problem.

Another Health Council survey found that among those who do have family doctors, only 30% could see their doctor the same day or the day after they called. This is 15% below the national average. Only 22% had access to their family doctor after regular office hours. When people cannot access their family doctor, they turn to Emergency Rooms and drop-in clinics, imposing greater costs on the system. These statistics lead me to believe there are fundamental problems with the way our system is structured and that additional money alone will not solve the problem. This is further emphasized by the poor health results we achieve in the province.

Despite constant increases in health spending, New Brunswick is not a healthy province. We have the highest rate of obesity in the country and one of the lowest rates of physical activity. Mortality rates from lung cancer, colorectal cancer and breast cancer are above national averages, as is our rate of smoking, hypertension, diabetes and suicide; 72% of hospital beds are occupied by people with at least one chronic disease.

It is obvious that New Brunswickers must take responsibility for their health and that our health system should focus on access and on prevention. Individually, we can make small changes that will add up to a large difference. The system needs to improve primary care.

We also need to take a serious look at the way our resources are invested to make sure that the right services are provided in the right place, at the right time and as safely as possible. Do all our hospitals provide adequate high-quality services?

More than money

It is clear that addressing these challenges will require changes to the healthcare system more profound than the one-off transactional type of changes we have seen in the past. The challenges facing New Brunswick are considerable but we have several strengths and opportunities. We have a proud history of playing a key role nationally and provincially when it comes to leading substantive social change. Former New Brunswick Premier Bernard Lord played a leadership role in the development of the 2004 Health Accord.

Although our population is dispersed, the small size of the province makes creating partnerships of key stakeholders much more manageable. As a smaller population with a dedicated and experienced leadership, the province has a capacity for dynamic change far beyond that of many others. We have gone through major transformational change as a province before in order to protect and embrace our cultural richness, through the adoption of Equal Opportunity and Official Bilingualism.

We know from experience that major change is not without controversy, but the time has come to close the gap between healthcare providers and healthcare administrators and collaborate closely to make the changes that are needed. We know that these issues are not unique to our province. All Canadian provinces and territories struggle to provide appropriate services in rural places; New Brunswick is the second most rural province in the country, with 49% of the population living in rural areas. All of us are aware of the challenges of an aging population; New Brunswick’s age profile is older than that of most provinces, with much less immigration to shore up holes in our demographic. All Canadian health departments know that the key to healthy and productive populations is through addressing the key determinants of health.

In 2014, the Health Accord cannot simply be a “fix” of money to prop up the status quo, which is clearly unsustainable and unacceptable. New Brunswick is taking action to address its challenges and is taking responsibility and asking our citizens to do likewise. New Brunswick is in the middle of a major public discussion about primary health care. We have developed a framework specifically on management of chronic diseases because we know they are responsible for the majority of hospital costs. We have implemented the first stages of our electronic health record, and pilot groups of physicians are already using this tool to deliver better, more efficient care to the people they see. A further shift towards increased investment in prevention and health promotion is needed.

We are also working very hard at getting our provincial fiscal house in order. But we cannot do this alone as a government. We must work together at federal and provincial levels to build a 2014 Health Accord that enables the changes needed to ensure sustainability.

Collaboration and flexibility

Developing a health accord is not just about dollars. It provides an important opportunity for multiple provinces and territories facing common challenges to come together and take coordinated action with federal support. There are contributions that the federal government can make to accelerate action in areas of shared priority. For example, federal action from a legislative perspective on food quality would make an invaluable contribution and be a significant positive support to the provinces and territories.

In any new health accord, New Brunswick will be looking for the word and spirit of “flexibility.” We have learned that funding arrangements that recognize provincial-territorial commonality and respect provincial-territorial specific challenges have worked well in the past. Targeted funding, if it is a part of a new Accord, must be provided with enough flexibility for provinces and territories to address their populations’ most pressing needs — not simply federal priorities.

We also expect to be held accountable for the money we spend (or invest). We are very willing to engage in an accountability process with the federal government within the 2014 Accord, particularly in areas where there may be new federal spending. Yet increasingly, we are aware that accountability is required of all partners if our health systems are to continue to support us. There must be federal accountability for the populations it has a constitutional responsibility to serve. There must be accountability among healthcare providers, not only for providing high-quality care, but also for bearing in mind the cost to taxpayers of the services they provide. And there must be accountability among citizens for doing the things we all know are necessary to generate and maintain our own health, such as: eating appropriate diets, meeting physical activity levels, and taking the direction of our health providers so that conditions are less likely to become acute. Health care is universal in Canada, but it is not free. By promoting our own health and well-being, we help ensure that services will be there when we need them.

New Brunswick will look for a progressive 6% increase in the Health and Social Transfer, and it is important not only to keep up with annual increases, but to ensure that all other transfers remain intact at adequate and predictable levels. The 2014 negotiations must help provinces face the future and work to improve the health of our citizens and encourage a greater personal responsibility for life choices that keep people healthy.

I believe provinces and territories will work in collaboration with the federal government to establish a consensus on Health Accord renewal. A properly intended and structured Accord will help support New Brunswick in our development of a healthcare system that is sustainable and can handle the pressure points of new technology, drug costs and the clinical imperatives we currently face. The system must support evidence-based decision-making and a system-wide perspective, rather than individual agendas or interests.

In 10 years, we want a healthcare system in New Brunswick with population health indicators that meet or exceed the national average. We know that to get there, the health system must be more proactive, more patient-centred, more team-oriented, more effective and efficient, more results-driven and more technologically-empowered. The long-term health of the public healthcare system deserves our protection.

We face significant challenges across the country, but through collaboration, I am confident that we can realize improvements in quality and sustainability for generations to come.