First, it is necessary to dispel a deeply rooted myth regarding the pressure that population aging will place on our public and universal health system. The apocalyptic predictions regarding disproportionate use of health services by seniors in the years to come must be tempered by recent scientific data. Evans et al (2001) and Barer et al (1987), among others, have clearly shown that it is hazardous to base any predictions on current use of health services. If we had applied only demographic projections to the use of health services in 1970, we would have seen an increase in the number of hospitalization days, but that number has actually fallen by two thirds. Using scenarios with constant age-sex utilisation rates, the projections predict an annual increase of 1 to 2% in health care expenditures over the next decades, which is affordable given projected economic growth (Rochon, 1994). Use of projections must take into account two important factors: the changes in demand for services, conditioned by developments in people's health and consumption habits; and the changes in the supply of services, determined by developments in therapies, practices, programs and policies.
Demand for services
The health of the new cohorts of seniors is expected to be much better than that of seniors now. Chen and Millar (2000) have shown, on the basis of the major Canadian surveys, that the baby-boomer generation has a lower prevalence of heart disease, hypertension, arthritis and functional limitations compared with the previous cohorts at the same ages. This cohort will therefore arrive at retirement age in better health as a result of better lifestyles, early treatment and prevention of chronic disease, as well as a decrease in exposure to environmental hazards, especially at work. An upward trend is already being observed in disability-free life expectancy at age 65. Over the past decade, total life expectancy at age 65 increased by 1.1 years among men and 0.7 of a year of this gain will be without disability. Women have gained 0.8 of a year without disability, while their total life expectancy at age 65 has increased by only 0.6 of a year (Martel and Bélanger, 2000). It seems that the compression of morbidity hypothesis announced by Fries 25 years ago is now manifest and that the life expectancy gains are mainly experienced in good health. However, the challenge remains, since it is still true that a significant proportion of the life expectancy at age 65 is accompanied by disabilities that alter the quality of life and lead to sizeable consumption of health services. Currently, 3.4 years out of the 16 total expected years among men and 6.5 years out of the expected 20 years among women are spent with disabilities.
There is little data on the anticipated health services consumption habits of the upcoming cohorts of seniors. It can be presumed that the baby boomers will have expectations and requirements that are different from those of the current generation of seniors. In addition, they will be the first generation of seniors able to claim that they have contributed all of their working lives to the funding of the current system and therefore legitimately to demand high quality services. This is in addition to their commitment to the development and maintenance of the current health system.
Another myth concerns the consumption of drugs by seniors. Population aging only marginally explains the large increase in drug-related spending over the past few years. In fact, most of the increase is due to the introduction of new, more costly medications to treat cardiovascular disease (Evans et al, 2001). The efficacy of these new medications has not proven to be significantly superior to that of the older, less costly ones. In addition, nearly 20% of the increase in drug costs for seniors is associated with the antilipemic treatments, the efficacy of which in this age group is still a matter of controversy (Savoie et al, 1998). There is, therefore, a loss of efficiency in this area that is not tied to population aging. In addition, a number of studies show that drug consumption by seniors is not optimal. Problems of underuse, overuse and misuse are reported (Tamblyn & Perreault, 2000). Some interventions have proven successful in improving the quality of prescribing by physicians and of compliance by seniors (Sellors & Dolovich, 2002).
It is important that interventions that improve the health of seniors and thus reduce the demand for services be implemented without delay. These interventions are not only in the field of public health and health care; they also relate to the social conditions of lifetime income, family and social relationships, transportation, housing, and a secure environment. There are also many health prevention interventions that could promote healthy aging. Canadian data indicate that 50% of premature deaths in older people are associated with modifiable life style (McWilliams et al, 1998). A number of studies have shown the benefits of quitting smoking (Rimmer et al, 1990), eating a balanced diet, and regular physical and intellectual activity (Rowe & Kahn, 1998) - even at advanced ages. The prevention of falls has also been shown to be effective in reducing hospitalizations for fractures and resulting disabilities (Moore et al, 1993).
In addition, specialized medical services, including geriatric services, and rehabilitation services must be made available to vulnerable seniors. Functional decline (Hébert et al, 1997) is not inexorable and more than one third of very old persons who have experienced functional decline recover that lost autonomy in the following year. Early rehabilitation programs have been proven effective for seniors (Wishart, 2001). These interventions are cost-effective and Tousignant et al (2001) showed that, for each dollar invested in a day hospital program, the marginal daily gain due to decreased disability was $2.16.
In short, the impact of aging on the consumption of services will not be apocalyptic and preventive, curative and rehabilitation interventions can be implemented to improve the health of seniors and contain the demand for services.
Supply of services
Recent research data provide some interesting avenues for improving the effectiveness and efficiency of the Canadian health system. Replacements of costly services with home care programs, service integration, improvement of communications and training of personnel are all proven avenues for action.
A number of studies have shown the advantages of substituting home care services for more costly institutional services (e.g., hospital, residential care facilities). Home care and other community services provided to frail seniors are always less costly for the state than care and services provided in institutions, even intermediate ones (Hébert et al, 2001; Hollander & Chappell, 2001). In terms of social costs (including placing a value on the family's interventions), home care remains advantageous up to caring for those with high levels of disability. A series of studies conducted in connection with the Health Transition Fund by Hollander and Chappell on the efficiency of home care services confirm that these services are a positive avenue for containing health system costs. However, home services are always the poor relations in the system and account for only 2 to 6 percent of the health budgets according to the provinces (Health Canada, 1999). A real shift in resources is needed to reverse the traditional hospital-centred approach.
Recent health reforms in some Canadian provinces have produced a net increase in home services, but further analysis shows that it did not really benefit frail older people. For example, Chappell (2001) and Penning et. al. (2002) report that, with current health reform in British Columbia, there is indeed a removal of acute care beds from the system, a shortening of hospital lengths of stay, increases in out-patient surgeries and modest increases to home care budgets. However, home care is being changed from a chronic care support system for seniors to a medical support system for intensive post acute care for hospital (including outpatient) discharges. In other words, expanding home care alone is not the answer; it must be expanded appropriately.
One of the proven ways to improve the health system's efficiency is to reduce duplication and fragmentation of services and to improve continuity of care. A number of integrated services network models have been tested in Canada, ranging from simple linking to complete integration. The move from hospital to the home is a pivotal event and a number of research efforts have shown that it is effective to pay special attention to these transitions. Doing so reduces subsequent visits to emergency by 27%, improves drug compliance (Afilalo, 2001), and reduces functional decline (McKusker et al., 2001). An experiment with co-ordination of services for seniors is under way in two regions of Quebec (PRISMA project: Hébert, 2001). The preliminary findings show that this model could be applied generally and that it has favourable impacts on older persons' autonomy and reduces residential placement rates, as well as reducing the caregivers' burden, without a cost increase (Durand et al., 2001). Two experiments with complete integration of services (SIPA in Montreal and CHOICE in Edmonton) have also shown significant effects on hospitalizations and emergency visits (Bergman et al, 1997; Pinnell Beaune, 1998). It is now time to translate these findings into policy and programs and to apply these new models to our health system. In all of these experiments, two elements have proven important for avoiding fragmentation and duplication of services: standardized assessment of the needs of seniors using a common tool and secondly, rapid transmission of information through use of information technologies (e.g., computerized clinical record).
Translation of the research findings into new policies and interventions is essential for improving the supply and appropriate use of services. That is one of the mandates of the Canadian Institutes of Health Research. Such translation can occur at the clinical level only if the workers have appropriate professional training for interpreting and integrating the knowledge springing from the research. It has to be said that the specific training of workers in gerontology and geriatrics is still deficient in Canada. Consequently, care of seniors is still perceived as second-class and is even demeaning. The work tools and conditions are far from optimal. High levels of burden, stress and injury are reported among health workers who also experience high rates of absenteeism. What is worse, some research has shown that tasks normally performed by professionals are being carried out inappropriately by untrained personnel, particularly in people's homes and in certain residential institutions out of a desire to economize (Hébert et al, 2001). This shifting of care has impacts not only on the quality of services, but also on these alternative providers' ability to apply recent scientific findings. Adequate training of all professional and non-professional providers, particularly in the care of seniors, is the most effective way to reverse these trends.
There is no scientific data supporting the current trend toward entrusting the private sector with management and delivery of care and services. To the contrary, the American experience shows (Reinhart, 2001; Relman, 2002; Deber, 2000) that the share of the gross domestic product allocated to health is larger (13.9%) in a privately funded system than in most states that have a publicly funded health system (Canada: 9.1%; France: 9.6%; Germany: 10.7%; Australia: 8.4%; United Kingdom: 6.9%). In addition, the quality of health services in the United States is not superior. Quite the contrary is true. A number of indicators, such as life expectancy and infant mortality show that the United States falls far behind the countries that have a public health system. Canadian studies show (Bravo, 1999; Hébert et al., 2001) that costs are not lower in private institutions and that the quality of services may suffer as a result. The administrative costs in public institutions are below 12% in Canada, while private institutions and insurers in the United States have administrative costs between 15% and 30%. On top of that, there is profit. The public health expenditures per capita in Canada have decreased steadily since 1992 and many current problems result from such under funding (Deber, 2000). It is now time to reinvest in our health care system.
In conclusion, we believe based on our best research evidence that the anticipated population aging will not have the apocalyptic consequences of which simplistic projections warn us. We also find no evidence that the public and universal health system will be placed in jeopardy. In fact, this system is the best for responding to population aging, since it enables improving the efficiency of the supply of services. Some means, such as home care and integrated service networks, have proven themselves. It is necessary to continue finding effective ways to improve the health of seniors and thus further contain demand for services. Research is the best way to find innovative solutions. Canada's capacity for research on aging must be built up and that is the Institute of Aging's priority strategic direction. Training more researchers, encouraging their development by putting in place teams and research centres on aging, increasing the sources of funding for research are the actions favoured by our institute. Moreover, Canada may benefit from international biomedical and clinical research, but only Canada can examine ways to improve its own health system. That is why the Institute of Aging has identified research on health policy and services relevant to seniors as one of its five strategic priorities.
The creation of the Canadian Institutes of Health Research and the Institute of Aging in particular has breathed new life into health research in Canada by bringing research into line with the health priorities of Canadians and promoting translation of the research findings into better services, products, programs and policies. To maintain an effective and cutting-edge health system, it is essential that there be sufficient investment in research and development. The institutes are a powerful tool for development, as long as their funding is sufficient to meet the challenges involved. The Commission should acknowledge the important role played by research in Canada in improving the health care system and recommend sustained support to the Canadian Institutes of Health Research and to its mandate of translating research findings into better services, practices, programs and policies. Further, the Commission should lend their support to urging policy makers to implement innovative programs and services based on the evidence provided by Canadian research on aging.
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