Dr. John Haggie, a vascular and general surgeon from Gander, has been elected as Newfoundland and Labrador’s pick for the 2011-12 presidency of the Canadian Medical Association, pending confirmation this August. Dr. Haggie, who immigrated in 1996 from his native England, served as president of his province’s medical association in 2002-03, when the province's physicians, in their only strike ever, withdrew all services except for emergency care until an arbitrator awarded the doctor’s union a new contract worth almost all of what it had demanded. He’s since worked extensively with the CMA and the NLMA.

INTERVIEW

PE Why did you want the job?
JOHN HAGGIE After 15 years in medical politics, it seemed a logical extension of what I wanted to do anyway. There's a lot going on on the federal scene in terms of healthcare lobbying, and the concern I had was the concern of CMA, which was that it seemed that the federal government had put some money into some schemes and put a check mark next to healthcare and decided it's finished, and moved on. That was one facet that bothered me, and I don't think that is the case – healthcare isn't fixed, by any manner of means. And in terms of what I've been doing with CMA, the new healthcare transformation project and lobbying activities which they're working on at the moment fed into my interest, which is, coming from a poorer province, and certainly from a poorer region of that province, I see lots of patients who fall through the cracks of the healthcare system, principally in terms of pharmacare. They're the working poor. They don't have coverage through a social assistance program or the provincial drug plan, and yet they don't have enough wherewithal to afford insurance that would offset the costs of the medications. And that really is a fundamental flaw with medicare. It was designed at a time when acute care was the main issue and it was all hospital- and institution-based. In the 40 years since then, that's changed dramatically and most of the expense in healthcare expense has come in the drug field, and most of that is borne by the patients themselves.

PE If you think of universal pharmacare as a Canadian ideal, you could say that pharmacare is one of the areas where Quebec is more Canadian than the rest of Canada.
JH It is. And of course Quebec's system is an exemplar but in some respects it may not be ideal either, because it is certainly expensive and I think there's something that could be done there to improve matters. But certainly it can be held up as prototype that we can use as a test bed. I think the federal government has a responsibility to deal with fact there are ten provinces, three territories and at least two or three federal bodies, and each of these has effectively a different standard of healthcare for its recipients, the people for whom it has responsibility. And that’s not equitable. I think that needs to be addressed as well. Whilst you have the people in Quebec who are lucky to have a government that thinks pharmacare is important, why should the people in Newfoundland or Manitoba be disadvantaged because their provincial governments don't think the same way.

PE Maybe that means the people don't want a pharmacare plan? They've had a chance to elect politicians who have said they would change that.
JH One of the paradoxes of healthcare is that most people are satisfied with it right up until the moment they come into contact with the system – on a needs basis. So the people are are concerned about healthcare are more often the people who are in need of healthcare, and at any given moment 90% of the population is probably fairly well and they're concerned about other issues that come and go in their lives, such as raising a family, getting a job, fighting a recession.

PE Healthcare is definitely not an area where change happens fast. There hasn't been much success in recent years by CMA presidents in accomplishing the things you've mentioned: pharmacare, and getting the government to realize that it's been ignoring problems in healthcare.
JH You're right, and my challenge is to refocus them a little bit. You can go on ignoring things for so long but, at the end of the day, one of the pitfalls of politicians in general is they look to the short term, because of their mandate and the nature of the business they're in. They have to have get reelected every four or five years and they have to have a deliverable that is short term. It's difficult to do that with healthcare where probably the biggest impact on healthcare, the longest term, would be looking at the social determinants of health. There's a beautiful report, well crafted, that came out on just that topic.

PE You're talking about the Senate subcommittee’s report.
JH Yeah. They've got the answer to how you get healthy Canadians in 2040.

PE Yes, it was an excellent report and it came across everyone's desks, and then...
JH That's one of the problems with any scheme of transformation is you try to be too comprehensive, you try to present a complete plan. Sometimes, maybe, the plan is not actually as strong as some of its components. And you may be better focusing on one deliverable, one thing you can move. The difficult thing is, with the nature of government in this country with the federal/provincial/territorial split, is such that you can get this three-ring circus where everyone says it's not my responsibility to deal with its in its entirety. And you're held up because one limb, one part of the circuit, at any given moment, doesn't kind of agree with what the others are saying. It becomes a matter of jurisdictions, of turf. And it's difficult then to put the interests of the patient population first because people get concerned about their own little patch.

PE Rural medicine was a major focus of your campaign. Can you be more specific on what you'd like to see done?
JH I think one of difficulties which I've seen at the CMA is sometimes it's difficult to find a rural perspective. The last truly rural president might have been Sunil Patel or Dana Hanson. The rest of the guys have come from urban environments, by and large. I've been lucky enough to live and work in communities as small as 3,000 people and work in clinics in communities as small as 600 people. I think that gives you a different kind of idea. I was kind of hoping – and this may be naïve – that the 20% of people who don't live within 100 kilometers of the U.S. border, may get some acknowledgment somehow from the system that their healthcare costs and their healthcare woes and access are significantly different from the patients who, say, live in urban downtown Toronto, for instance -- where a lot of the cost of healthcare comes from actually getting to the physician or getting to a primary care provider. We’re trying to use substitute or alternate primary care providers in the system and that does have a lot of merit. There’s a lot of scope there to broaden that, and it doesn’t have to be just one group. It doesn’t have to be a pharmacist who prescribes or a nurse who prescribes -- there are physicians’ assistants in the pipeline. And it can be a mix, and that mix may be best prescribed, as it were, locally, depending on people who live and work in those areas, because it’s a challenge to practise on your own in a small community, whether you’re a nurse practitioner or a physician or a physician’s assistant. It presents its own challenges. And not everybody who goes through that kind of background training wants that.

PE That idea is not totally accepted yet. Some of the provincial medical associations have expressed their concern about other medical professionals prescribing and taking on more responsibility.
JH I think, to be fair, it comes from the aspect of patient safety. You know, physicians who prescribe as part of their routine activity have gone through a long training to diagnose and come up with a plan. It’s not just simply writing something down on a piece of paper. That’s just the final step in a long -- or longish, potentially -- train of activity. What we’re looking at is that we should have great emphasis in medical training and residency to make sure that the end result of that process is as safe as we can make it.

PE It sounds as though you are more comfortable with the idea of assigning more responsibilities to non-physicians than some other provincial medical association leaders are.
JH I have been fortunate enough to work with a whole variety of different care providers. Regional nurses were the people who provided a lot of the services to people in the north coast of Labrador, so it’s what I worked with when I came to Canada -- it isn’t new, it isn’t different. The only comment I would make is, from a patient’s perspective, I would like to feel like whoever writes that prescription has the same level of background or insight into what they’ve actually done when they give me a drug. You look at the  literature from Baker and Norton and the Canadian Patient Safety Institute -- medication errors are a huge deal. It’s not an innocuous activity, writing a prescription. To be fair to my colleagues, their concern when they talk about who’s prescribing and who’s not, comes from that kind of background. You know, “What happens if the process is a kind of a knee-jerk instead of a considered one? What happens if there is a side effect of the treatment? How’s that going to be managed and by whom?” But there’s the other group who turn around and say it’s just a turf protection issue and you don’t want to give anything up. I don’t think the medical profession has that as our prime concern.

PE It’s an interesting question. In five or ten years, it wouldn’t be surprising if we look back and see that the expansion of non-physicians’ scopes of practice was the most important reform to come out of this period.
JH I think access to pharmaceuticals in general, with all sorts of social changes, may actually change. You can almost find a situation now where it’s possible in certain places to go online and find a pill and have it delivered to your house, whether you live in Canada or England or the States or Bahrain, you know?

PE You’ve also talked about introducing something called “leadership training” to residency programs. What do you have in mind?
JH One of my other activities is currently I sit on the committee on education and professional development. But when I came to Canada, you’re exposed to a different system. You think it’s the same because it sounds the same: you talk about hospitals and you talk about surgeons and consultations. But I was trained in a different environment, and it was kind of a culture shock. Nobody teaches you quite how the system works, and I ended up falling in a series of courses run by the Canadian Medical Association called the Physician Manager Institute. They filled in that gap for me. What I’ve seen in England and here is that, for various reasons, in the time I have been in practice physicians have not been involved in decision-making, in planning, in management of healthcare. At all levels, with a voice that actually means anything. I think some of it has been, if one views it charitably, as the system forcing them out, but I think physicians have felt uncomfortable in areas where they have no training and no background and so they let themselves abdicate decisions to other groups -- the managers in the healthcare system, the bureaucrats in the departments of health. I think it’s time, perhaps, that trend needs to be reversed, and the way I see of doing that is to use these kind of Physician Manager Institute courses and certificates and credentials to reverse that trend a little bit. This spans all disciplines. At some point every attending physician, every family doctor, will run up against administration issues, against management issues. If we don’t prepare them properly then they are disadvantaged, they can’t understand how best to make their case to people who work in a different environment -- not a clinical environment, where the buck stops with one or two people, but more of a committee-based team approach, based on management and budgetary decisions. We don’t have any background there. I think we need to remedy that. We can empower a whole generation of physicians behind us. At the end of the day, that’s going to produce a better system for the people who need to use it, the patients.

PE You moved from England in 1994. Why did you leave? Was it frustration with the system there or a more personal decision?
JH It was a little bit of both. You have to realize that the England I trained in, for surgery particularly, was not as much a training scheme so much as an apprenticeship. It was a very steep pyramid which kept control of matters surgical in the hands of 700 trained surgeons in the U.K. by their definition, i.e. you were appointed a national health consultant. Now, that’s 700 for a population that was at least twice that of Canada. There was no room for anybody else’s voice and that was difficult to cope with. And there were some personal, family reasons I wanted to look further afield. But, yes, there were some frustrations with the system, both in the way the system was delivering patient and the way the system was delivering surgical training.

PE The system here, of course, is not perfect either. Do you agree with some of the CMA’s recent presidents that the Canada Health Act should be rewritten?
JH I think the problem is the Canada Health Act has reached almost a totemic sort of standing. It’s not a tablet passed down from Mount Sinai. It was written by people, and the principles in there have worked well. But I think whether you call it reopening the Canada Health Act or writing an addendum to the Canada Health Act as a supplement, it needs to reflect the fact that things have changed since it was written and passed into law. The five principles have served everybody well but they’ve also acted as though there are only those five and nothing else. I think that’s paralyzed, perhaps, the process of improving things for the patients because people have said, “No, if it’s not in there then we don’t have to bother with it.” Pharmacare is an example. That’s not in there. Equity of access isn’t there. Quality isn’t there. These are things that science and research have shown are issues with healthcare delivering anywhere, and it applies in Canada as well. So I think it’s difficult because it’s very easy to hide behind a piece of legislation that matters to Canadians. Politicians want you to feel it matters because then they don’t have to change it. It can be both an item for good, in that it’s a standard that has stood the test of time, but it can be used for kind of the dark side, if you want, because you can hide behind it and say we can’t touch it, when really and honestly it can be added to.

PE And what exactly do you want to add to it?
JH Issues about quality. Transparency and accountability. And if it’s universal, does that mean we do everything for everybody all the time, or can we agree on necessary treatments that should be universally available? Should you have your varicose veins done because you don’t like the look of your legs and should I pay for that? Those kind of questions have never really been asked, but if you’re going to do that you need a transparent mechanism to do it so people don’t feel someone is handing down a decision arbitrarily.

PE Dr. Jock Murray, who used to be the dean of medicine at Dalhousie, once said, “No country can afford everything for everyone right now, so pick two.”
JH As an attention-getter, as a focusing tool, that’s probably a good place to start the discussion. Because sustainability is the issue. If you look at the growth rate of healthcare expenditures, I think in 1996 it was projected that by 2030 or something we would have doubled our healthcare expenditure as a percent of GDP -- it would go to 12% from 6% or something. It’s actually at 11% and a bit now, and that’s 20 years ahead of schedule. So you’ve got to ask yourself where that growth came from, and again I come back in a circle: the bulk of that growth has come in pharmaceuticals. Now, how do we deal with that? How do we make it so that when I get old and senile, someone is going to have the wherewithal to look after me? I think to hold up a piece of paper [the Canada Health Act] -- valid and important and as landmark it was at the time -- as unchangeable and immutable, I think, quite honestly, is a little unrealistic and it also prohibits any sensible discussion and any way of moving forward of making things better than they are and making them flexible for the future.

PE That seems to have been the message from most of the CMA presidents in recent years, although nothing has actually come of their efforts in Parliament yet.
JH It’s difficult when legislators have such tight control over the agenda for legislation and, given the current players in the field, it can be difficult to make an impact. I am unfamiliar with the day-to-day workings of the Ottawa scene and one of the things I hope the year as president-elect will help me with is how to operationalize those ideas, and I am really grateful I do have a year in which I can learn and hopefully get myself in a better position to do the job. I think to do it cold, now, would be an enormous hill to climb.

PE You were the president of the NLMA when the association staged a 17-day job action in the fall of 2002, which resulted in a big arbitration settlement for doctors in the province.
JH $54 million.

PE Which was essentially what was being asked for.
JH It wasn’t far off. We didn’t get everything but the true measure of that was over the following three years, the physician numbers in the province increased by nine percent. That’s something I am kind of proud of. I was just the front man, but it was something that was a very positive thing at end of it though it was quite hard going during.

PE Most of our readers don’t know you very well, perhaps because you’re from out east --
JH Yes, we’re on the edge.

PE Well, so people can get to know you, I wanted to ask whether you have any hobbies or interests outside of medicine?
JH I have been a serial hobbyist. I tend to find that things move on. I have a Canadian pilot’s licence and I did that with enthusiasm for about five years until circumstances beyond my control forced me to take break. I have a cabin, or a cottage, as you would say, on a lake and I spend the winters going up there on a snowmobile. And I have an RV I take ’round in the summer and like to go the mainland or travel around a bit. Beyond that and reading policy papers for the CMA or the NLMA I don’t really have that much more free time. I’m recycled. I have an extended, blended family, I think is the politically correct way of saying it. So I’ve got children scattered from B.C. to Newfoundland and some still at school. So between those demands it keeps me out of mischief.

PE With those demands, it’s impressive you find any time for hobbies.
JH As I say, I’m a bit of a serial enthusiast. And in the U.K. I was a good pistol shot. I did that for a few years.