History, Politics, and Transformational Change in Canadian Health Care: A Rejoinder.

Abstract

Abstract Our rejoinder addresses two common themes raised in the responses to our article concerning the potential role of psychological services in the future of public health care in Canada. The first concerns the current system's capacity to evolve beyond the medical-hospital illness model of the 1960s to incorporate psychological treatments aimed at illness prevention and health promotion. This would be more likely if psychologists were to participate directly in primary-care and home-based mental health-care reform. The second theme is the presumed negative role of politics rather than scientific evidence in decisions concerning public coverage or subsidy. We argue that democratic decision-making is the proper basis upon which decisions concerning public coverage are made, but it need not be in opposition to evidence-based decision-making. As recommended in the final report of the Commission on the Future of Health Care in Canada, the Health Council of Canada along with applied research institutes can make politicians and policy-makers more aware of the growing body of evidence supporting the efficacy of psychological treatments relative to the alternatives. We very much appreciate that our article (Romanow & Marchildon, 2003) generated sufficient interest to produce three formal responses (Arnett, Nicholson, & Breault, this issue; Hunsley & Crabb, this issue; Mikail & Tasca, this issue. While the future sustainability of public health care in Canada will require significant reform, we nonetheless resist characterizing the current system as entirely stuck in a 1960's model of medicare, one which illegitimately sets priorities or decides issues of public coverage on the basis of politics (Hunsley & Crabb; Mikail £ Tasca). Without doubt, the legacy of medicare is associated with some important rigidities, including the physician-centred nature of the system. We agree with Arnett et al. (this issue) that, with a broadening of their training and education, psychologists can play a vital role in transforming primary health care, illness prevention and health promotion, and the treatment modalities for chronic mental and physical diseases. The purpose of this article is to respond to some of the common themes raised in the three responses to our original article. The first theme relates to the way of best addressing the associated with our current system in order to achieve better outcomes, where more emphasis is placed on illness prevention and health promotion and on the psychological services that have proven their efficacy in these areas. The second theme is the extent to which politics rather than scientific evidence determines what treatments are included in, or excluded from, our current system of public health care, and the presumed negative impact this has on the integration of psychological services within our continuum of public healthcare services. In the conclusion of this rejoinder, we address both themes in the context of what we hope will be the next major step in transforming public health care in Canada. The Heavy Hand of History? The question of health policy reform automatically involves what we call the institutional rigidities that are the historical legacies of public health care in Canada. This is particularly true for the universal coverage extended to hospital and physician care in the 1950s and 1960s, the essential features of which are now protected under the five principles of the Canada Health AcI (CHA; 1984). Although we have always argued that transformational change is essential to the future sustainability of public health care, it is nonetheless misleading to think of Canadian health care as frozen in time since the 1960s. As we illustrate in Figure 1, the Canadian system is much more than the hospital and physician services that we commonly refer to as medicare. Indeed, less than one-half of health care in Canada can be described as medicare, an important fact to remember when assessing overall change. …