When David Caplan was named Ontario's minister of health a year ago this month, he inherited responsibility for the largest, costliest healthcare system in the country. He had big shoes to fill -- not just the combative former health minister George Smitherman's, but also, in a strange twist, those of his own mother, Elinor Caplan, who was the province's health minister from 1987 to 1990 and has remained active in health policy. Parkhurst Exchange pulled him out of the Queen's Park legislature to discuss his vision for Ontario's healthcare system.

EXPERT OPINION

PE Before you became health minister, your experience was in a variety of fields: real estate, business, education -- but not health. How are you enjoying your current job?
DAVID CAPLAN I must admit, if you can't get excited about public policy in healthcare then I don't know why you'd want to get involved in public life. You know, healthcare is one of the ways that Canadians self-identify. It's really core to the values that we hold as a people and it's always one of the top -- if not the top issue, one of the top two or three -- issues that Ontarians and Canadians identify as most important to them.

PE Not every politician is quite as pleased as you to get assigned to healthcare. It's important, of course, but also very controversial. Tony Clement once called it a "frequent graveyard of political aspirations."
DC Oh! I certainly don't consider it that way. One of the fun parts of it is that every day is different. One day might be issues pertaining to hospitals, the next one to pharmaceuticals, the next one to public health and pandemics, the next day related to physicians, the next day related to chronic diseases -- and replay that week after week. There has not been a dull day yet at the ministry of health and I'm really enjoying it.

PE When you were first appointed minister of health there was some rather unpleasant criticism that focused on personal issues such as your weight and your former smoking habit. Did you find it difficult to deal with?
DC Listen, I'm not naïve enough to believe that public life is a garden party. I understand it is a little bit rough and tumble. It's always challenging to separate what I would consider personal issues from the more important public policy ones. But what I always focus on is the job the premier has set for me, which is to deliver shorter wait times for Ontarians, in particular shortening the length of stay in emergency departments, and making sure Ontarians have access to family healthcare for all. All of the other stuff? That's just background noise.

PE Is it an advantage or a disadvantage to follow as health minister someone as colourful and controversial as George Smitherman?
DC [Laughs] Well, that's not my nature. George is unique -- I guess we all are, for that matter. One of things people in healthcare have noted to me is that we have very different styles. George is truly a change agent. He did a lot of heavy lifting for some fundamental change in our healthcare system. I think when people look back they'll look at his time as one of tremendous positive change for healthcare. My style is more along the lines of bringing people together, collaborating, building relationships, finding ways to have, as we call them in political circles, 'win-win scenarios' and to get people to help me to realize the potential and success that there could be as result of some of the reforms that George brought in. I commented on June the 20th, or around then when we had the swearing in, that my goal was to be the second best minister of health the province has ever had. I was not referring to Minister Smitherman, although he is a good friend and I have great admiration. My mother, 20 years ago, was a minister of health for the province of Ontario and, in my opinion, the very best one.

PE Did it feel inevitable to you that you'd end up health minister? You followed in the footsteps of your mother, Elinor, first by running for her vacated seat in the legislature, and then by becoming the province's health minister, just like she was.
DC Prime Minister Chrétien had appointed her to the new riding of Thornhill in 1997. It was a new opportunity. I was at the board of education at the time. I must admit I never dreamed I would be in the same portfolio. There's a special challenge because the legacy that she leaves, a day does not go by that somebody does not say to me, you know, "I worked with your mom," or incredible things she did during her time as minister of health. She is still quite active, or was. It's really strange, the relationship, and what it means, the boundary we have to put between ourselves and what she can do in healthcare now. She is one of Canada's leading experts on three elements: healthcare policy, healthcare economics and healthcare politics.

PE Will you follow her example by leaving for federal politics as well?
DC [Laughs] Well, you know, one of the things I have learned in politics is that you can't really have a lot of plans. It's a funny business. You're very much subject to the whims of the electorate. Right now, I am very happy what I am doing, serving Premier McGuinty in my capacity as health minister, or in whatever capacity I can serve, so I have no plans to do anything different.

PE Your government and the OMA have made some progress on improving the province's recruiting and retention of physicians, such as establishing collaborative care models like Family Health Teams, creating a new school of medicine, lifting the pay cap for doctors, and more. But despite all that, up to a million residents of Ontario still don't have family physicians.
DC That's interesting. We have a lot of anecdotal stories and we have a lot of guesstimates but we don't have a lot of hard estimates and data. I have heard figures as low as 400,000 up to a million. That's why, as a result of our recent negotiation with the OMA, we have come up with a program called Health Care Connect, which is asking Ontario patients to self-identify, to be able to tell us who is out there who does not have access to a family physician who would like one, and then an active program to begin that matching, to attach them. I am going to look forward to hear what the data actually says. We are also working very hard to advertise and let Ontarians know there is this service available to them. I am expecting we will see uptake as people become aware of the service and make themselves known to us. That's the other benefit of it, by the way. As we are moving forward and we are going to go out this spring with our next calls for proposals for new Family Health Teams and nurse practitioner clinics, will be able to match areas where we see there are gaps in primary care with new capacity that we are going to put into and around the province of Ontario.

PE But even if the current number of orphan patients is 400,000, doesn't that indicate that some of the past things that have been done haven't succeeded to the extent that was hoped?
DC Well, in fact, if you look at Family Health Teams, over 2.5 million Ontarians are now enrolled in Family Health Teams. The first 150 have gone out -- it's been a tremendous event -- and we know that 650,000 Ontarians who did not have a family physician, who were unattached, now have one, thanks to the efforts of that work that began in 2003. So I think we can build on some of those successes and I think we're going to discover there are a lot of reasons why. Some of it might be geography and distance, some might be hard-to-serve populations, like the homeless or others. I don't think there is any one model which fits all, especially in a province as large and as diverse as Ontario. We are going to look to a number of different kinds of solutions to be able to meet people's primary care needs.

PE What is your goal with regard to how doctors' practices will be organized, especially for primary care? There have been a number of recent initiatives to move towards large, collaborative-care practices in which doctors are paid with a capitation or mixed capitation/fee-for-service model. Are Family Health Teams the ideal? Will solo practices disappear? What's the plan?
DC That's a hard question to answer, and a lot of it will be the result of feedback from physicians themselves. What we are hearing is they really like the collaborative models. For example, a physician said to me, "I don't want to be social worker. I want to do what only a doctor can do. But I want to have a social worker as a part of my practice so that my patients can get the service they need." That's the real beauty and the real strength of these multidisciplinary models is that you can serve the whole needs of the patient and doctors can do what only doctors can do.

PE The health budget seems to rise every year--
DC Well, this year, despite a contracting economy -- I think 2.5% -- healthcare spending is increasing 4.7%. And, overall, over the course of the last five and a half years, it has increased 45%, well above the rates of inflation.

PE And it seems like we keep saying this is a problem, every year.
DC Well, sure. Sustainability is a challenge.

PE But then after we say that we seem to go back to what we were doing and then when the budget comes out the next year we say, "Boy, this is only getting worse." And then we go back to whatever we were doing and forget about it again. We don't seem to have made much progress on that.
DC And I think that's why we've gone from the centralized model, where decision-making is essentially driven out of an office building in Queen's Park in downtown Toronto, to one which says people in local communities know the clients they serve, what the local partnerships are, how they can organize themselves to manage to be more efficient and to have a more sustainable healthcare system. That's why we believe in the system of Local Health Integration Networks and why we've driven hard to devolve that decision-making authority from the ministry of health in downtown Toronto to various communities right across the province.

PE How do we know that is going to help control spending?
DC We're already seeing some examples of good local innovation. One of the biggest challenges we face right now is something we call ALC, alternative levels of care. People are in acute care beds in hospitals who would be much better served in longterm care beds or in rehab or complex continuing care or even in their own community, in their own homes, with some support around them. In Timmins, with a little bit of help and support, they were able to reduce their ALC numbers by 40% by developing something they called "wraparound" where they took somebody who was in an acute care bed and put them in a community situation, wrapping around the services they would need to live independently. It was a unique, local solution. And at, I believe, a total cost of a quarter million dollars they were able to reduce the ALC numbers by 40%. Now, the way things would normally work in the past, the ministry of health would say "We have a great idea or we heard about a great idea -- everyone will do it. You'll all do it this way, you'll all report on it this way, we're all going to audit it a certain way." And it wouldn't work. But those folks in Timmins knew who their local partners were on the ground and they were successful for it. And I'm not saying that if you're in southern Ontario you'll do the same thing, but learn from what they've done and try to apply some local knowledge and innovation in delivery healthcare services, and we're seeing other examples. Just in the one year that Local Health Integration Networks have had any allocation ability, we are starting to see good examples of local innovation and good examples of more sustainable healthcare practices and value being driven for healthcare consumers and healthcare practitioners and I find it very heartening.

PE Are we to expect, then, if we look back at the year since the Local Health Integration Networks have been permitted to allocate money themselves, that we're going to have actually saved some money?
DC I think what we'll see is greater sustainability. I think there's still a long way to go, and obviously we're going to pick the low-hanging fruit first. But if people have confidence they can have some ability to lend some shape over healthcare decision-making and healthcare delivery in their local community, they'll buy in to it, and I think we have a much greater chance of success on sustainability than if it was driven centrally from very good, very well-intentioned, but people who are only in an office building in downtown Toronto.

PE I notice you were careful not to mention the word "private" when you discussed controlling the health ministry's spending. Can the public system maintain its quality and at the same time control spending without passing on some of the costs to patients either through higher taxes or through some variety of private financing?
DC I think that the public healthcare system can in fact improve the quality. That's the focus I have had. What I want to do is raise the quality of the healthcare experience, of healthcare service, because all of the literature I've read says that when you increase quality you increase efficiency and you increase sustainability and cost-effectiveness. That's the real way. The mistake I think governments have made in the past is they've tried to contain costs first and what you've seen is a degradation of quality. If you raise quality, and that's the goal, almost by definition it will logically follow that cost-effectiveness will result.

PE One of the biggest political issues of the decade is environmentalism and climate change, as you well know as the former infrastructure minister, and doctors are becoming increasingly interested in the issue. Can the government help reduce the energy used and the pollution created by the healthcare industry?
DC That's an interesting question and a good one. For example, one of the things we have started in capital construction in Ontario, and I know this quite well from my previous role as infrastructure minister, we are requiring all new government buildings to meet LEED standards -- Leadership in Energy and Environmental Design -- to result in less energy usage, less water usage, more efficient practices, different building materials and the like. That's one thing we can do. By the way, we are one of first jurisdictions to develop something called Generic Output Specifications, a very large and technical document which for example has infection control as part of the building design. So there are a lot of things we can do there. And we are building in smart building practices as we go ahead and invest considerable dollars, we are going to see true transformation. We are very interested in other ways and means to be able to address adaptation and climate imperatives. We are very interested in an understanding of the need to be much more energy-efficient. We can save a lot of money if we can be more energy-efficient. If we can find ways to do that within the context of the medical system, we are very interested in pursuing those solutions. It's very impressive work and it's going to stand us in well in stead for many years to come.

PE How much of a role did the SARS outbreak play in the preparations and the response to the H1N1 flu?
DC What has been relayed to me is that even before the World Health Organization had reacted, there were two jurisdictions in the world -- one was Ontario and one was British Columbia -- which saw this, and that was the result of learning the lessons of SARS, that the public health network sprung into place, the communication protocols, the connection between medical people, the information flow, was all enhanced to be able to prepare us for detecting the influenza strain, to be able to contain it and, if need be, to be able to control it. And, I've got to tell you, I've been so proud and I admire the medical practitioners who sprang into action immediately. Ontarians should feel very confident they have excellent system to be able to protect.