Joint Center for Bioethics, University of Toronto
Amid mounting pressure for a massive injection of funds into Medicare, one of Canada’s leading medical policy think tanks says money alone will not cure what ails the country’s public health care system.
Analysis by the Joint Centre for Bioethics at the University of Toronto shows health authorities need to change the way they make spending decisions to ensure Canadians get adequate medical services.
“Canada needs to get its health care priorities straight,” said JCB director Peter Singer.
“Any programme to reform Medicare must include a dynamic national system of learning and knowledge sharing about priority setting.”
The JCB analysis follows a major Canadian Senate committee report into the future of Medicare and precedes by a few days the release of the Romanow report, both of which follow national inquiries. The Kirby report in the Senate says extra billions of dollars a year are needed to sustain Canada’s public health system.
“Both of these reports, but particularly Romanow, focus on the financial sustainability of the health care system,” said Douglas Martin, president elect of the International Society University of Toronto Joint Centre for Bioethics for Priorities in Health Care and leader of the JCB study team. “But the key issue in sustainability is how priorities are set. Everything else flows from there.”
The JCB analysis is based on a far-reaching xx-year investigation into several aspects of priority-setting in the Canadian health system including;
• The extent to which members of the public can and should participate in the decision-making process.
• How health authorities set priorities for expenditure on new drugs and new medical technologies; and
• How a new concept called “accountability for reasonableness” can be used as a leading framework for priority setting.
Investigators found there is no single, widely accepted procedure to determine whether health care technologies should be funded. Priority setting occurs without central coordination at various institutions such as hospitals, regional health authorities, provincial drug benefit formularies and groups concerned with health technology assessment.
The advantage of this decentralized arrangement is that each institution can make decisions that are deemed best for the population it serves. However, with no central co-ordination, there is also no central accountability for decision-making regarding health technologies.
“These decision making processes are a ‘black box’,” said Martin. “There is a lost opportunity for learning and sharing lessons across institutions across Canada.”
Through its investigation, JCB has developed the “accountability for reasonableness” approach, an ethical framework that describes, evaluates and improves decision-making processes. The approach has already been tested successfully in several JCB-affiliated health care institutions and should now be extended across Canada, the JCB says.
Accountability for reasonableness is a process-oriented framework that specifies four conditions:
Publicity – making priority setting decisions and the reasons for them publicly accessible enables wider public debate on tough limit-setting decisions.
Relevance – rationales for priority setting decisions should appeal to values and principles fair-minded people agree are relevant to limit-setting in each context
Appeals – an appeals mechanism is necessary for two reasons: it shows respect for those who disagree with a decision and provides them with a way of engaging with decision makers in a dispute resolution procedure designed to prevent or ease conflict; and it contributes to the public deliberation and, therefore, to the growing case law of priority setting decisions.
Enforcement – enforcement ensures that the first three conditions are met and may be voluntary or regulatory.
The JCB study identified the inability to accommodate particular contexts as the principle limitation of the generic accountability for reasonableness framework.
“Clearly, the conventions and core values that shape priority setting in a hospital, for example, will differ from those in a regional health authority,” said Martin. “Therefore, learning how to apply accountability for reasonableness in particular contexts is an important next step for Canadian health care institutions.”
The JCB analysis concludes that more than a money infusion, Canada needs to emphasize improvements in the way health care institutions set their spending priorities.
An important component of that campaign is a platform to collect and share information about different priority setting practices among different organizations, using accountability for reasonableness as an ethical framework against which these experiences can be assessed.
“Such a platform could exploit Canada’s leadership and experience in developing a national health infostructure, similar to the Canadian Institute of Health Information,” said Martin. “Our proposal is for an institutional clearing-house that would facilitate cross-institutional learning, focussing on qualitative description, analysis and sharing of good practices.”
University of Toronto, Joint Centre for Bioethics
Innovative. Interdisciplinary. International. Improving health care through bioethics.
The JCB is a partnership among the University of Toronto and eight fully affiliated hospitals.
The centre’s mission is to provide leadership in bioethics research, education, and clinical activities. Its vision is to be a model of interdisciplinary collaboration in order to create new knowledge and improve practices with respect to bioethics. The JCB does not advocate positions on specific issues, although its individual members may do so.
The goals of the JCB are:
• To foster interdisciplinary research and scholarship, link education to research, and disseminate research findings to improve policies and practices.
• To support undergraduate, graduate and postgraduate educational programs in bioethics.
• To support clinical ethics activities including continuing education for health care providers, ethics committees, ethics consultation, and projects to address specific issues arising in JCB hospitals.
• To foster collegial discussion of bioethics issues throughout the JCB participating institutions, and to serve as a resource for the media, policymakers, and community groups.
Coverage highlights:
| Canadian Press |
| Southam News |
| Broadcast News |
| Press Canadienne |
| Nouvelles Tele-Radio |
| Newspapers |
| Toronto Sun |
| Ottawa Citizen |
| Montreal Gazette |
| Calgary Herald |
| Windsor Star |
| Edmonton Sun |
| Kitchener-Waterloo Record |
| Halifax Daily News |
| Peterborough Examiner |
| Sault Star |
| Charlottetown Guardian |
| North Bay Nugget |
| Kelowna Daily Courier |
| Timmins Daily Press |
| Barrie Examiner |
| Corner Brook Western Star |
| Portage la Prairie Daily Graphic |
| Northern Daily News (Kirkland Lake) |
| Northern Daily News (Kirkland Lake) |
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