Matters of Life and Death. André Picard
within those programs, there is a near total absence of vision and goals.
The role of our health bureaucrats is to hold the line on spending as best they can and, above all, ensure that the names of their political masters don’t appear in damaging headlines. Improving patient care is rarely the number-one priority. The way our system is funded—predominantly with block transfers to hospitals and fee-for-service payments to physicians—encourages volume of procedures and the status quo. It does not reward quality of care or responsible stewardship. In fact, when an individual or a program goes out on a limb and makes changes to improve efficiency or cost-effectiveness, the benefits often accrue to others; perverse disincentives are commonplace and counterproductive.
These problems and frustrations are not new. The Naylor report cites an example from 1974, when Canadian researchers published a landmark paper showing that nurse practitioners could do 70 percent of doctors’ work with no difference in outcomes or patient satisfaction. Using nurse practitioners also saved money, but hiring more of them was hampered by the fact that, generally speaking, doctors are paid on a fee-for-service basis and nurses are salaried. Over four decades later, that same bureaucratic hurdle remains. Most other Western countries acted on the research: nurse practitioners are an integral part of health-care delivery and most physicians are salaried. But in Canada, nurse practitioners are still grossly underused—except in pilot projects, of course. We still negotiate physician and nurse contracts separately, and our management of health-care human resources is a mess. Until you get workers with the right skills in the right place at the right time, you will never deliver seamless, patient-centred care and you will never control costs, because labour accounts for two-thirds of all spending. As the nurse practitioner story and countless not-acted-upon research findings have since illustrated, innovation is hampered by policy gridlock. The managers of the system are largely powerless and beholden to the whims of politicians; moreover, with few exceptions, they are profoundly mistrusting of entrepreneurship and pathologically risk-averse.
For decades, we have produced reports about the need to transform health-care delivery and funding while simultaneously clinging to the same old way of doing things. It’s a fundamental disconnect between evidence and action. If you don’t take risks, you will never innovate. So how do we break the log-jam? According to the Naylor report, it has to begin with leadership, and it should come from Ottawa.
One of the panel’s central recommendations is the creation of an independent health innovation agency to not just fund pilot projects but to promote scaling up, to use searchable repositories of successful programs, to offer financial incentives and to encourage regulatory change—all with the aim of spurring innovation. More resources alone will not ensure the scaling up of good ideas. There needs to be partnership, commitment and monitoring to ensure implementation. In short, it’s not more money the system needs, it’s culture change—a shift from perpetual pilot projects to embracing innovation and best practices.
Canada needs a “coalition of the willing” to fix health care
Which country has the world’s best health system? That is one of those unanswerable questions that health-policy geeks like to ponder and debate, and serious attempts have been made at measuring and ranking. In 2000, the World Health Organization (in)famously produced a report that concluded that France had the world’s best health system, followed by those of Italy, San Marino, Andorra and Malta. The business publication Bloomberg produces an annual ranking that emphasizes value for money from health spending; the 2015 ranking placed Singapore on top, followed by Hong Kong, Spain, South Korea, Japan and Italy. The Economist Intelligence Unit compares 166 countries and ranks Japan as number one, followed by Singapore, Switzerland, Iceland and Australia. The Commonwealth Fund ranks health care in eleven Western countries and gives the nod to the United Kingdom, followed by Switzerland, Sweden, Australia and Germany.
The problem with these exercises is that no one can really agree on what should be measured and, even when they do settle on measures, data are not always reliable and comparable. “Of course, there is no such thing as a perfect health system and it certainly doesn’t reside in any one country,” Mark Britnell, global chairman for health at the consulting giant KPMG, writes in his book, In Search of the Perfect Health System (Palgrave Macmillan, 2015). “But there are fantastic examples of great health and health care from around the world which can offer inspiration.”
As a consultant who has worked in sixty countries—and who receives in-depth briefings on the health systems of each before meeting clients—Britnell has a unique perspective and, in his book, offers up a subjective and insightful list of the traits that are important to creating good health systems. If the world had a perfect health system, he writes, it would have the following qualities: the values and universal access of the United Kingdom; the primary care of Israel; the community services of Brazil; the mental-health system of Australia; the health promotion philosophy of the Nordic countries; the patient and community empowerment in parts of Africa; the research and development infrastructure of the United States; the innovation, flair and speed of India; the information, communications and technology of Singapore; the choice offered to patients in France; the funding model of Switzerland; and the care for the aged of Japan.
In his book, Britnell elaborates on each of these examples of excellence; in addition, he provides a great précis of the strengths and weaknesses of health systems in twenty-five countries. The chapter on Canada is appropriately damning, noting that this country’s outmoded health system has long been ripe for revolution, but the “revolution has not happened.” Why? Because this country has a penchant for doing high-level, in-depth reviews of the health system’s problems, but puts all its effort into producing recommendations and none into implementing them. “Canada stands at a crossroads,” Britnell writes, “and needs to find the political will and managerial and clinical skills to establish a progressive coalition of the willing.”
The book’s strength is that it does not offer up simplistic solutions. Rather, it stresses that there is no single best approach because all health systems are the products of their societies, norms and cultures. One of the best parts of the book—and quite relevant to Canada—is the analysis of funding models. “The debate about universal health care is frequently confused with the ability to pay,” Britnell writes. He notes that the high co-payments in the highly praised health systems of Asia would simply not be tolerated in the West.
But ultimately, what matters is finding not a perfect approach but one that works: “This is the fundamental point. There is no such thing as free health care; it is only a matter of who pays for it. Politics is the imperfect art of deciding ‘who gets what, how and when.’” The book stresses that the challenges are the same everywhere: providing high-quality care to all at an affordable price, finding the workforce to deliver that care, and empowering patients. To do so effectively, we need vision and we need systems. Above all, we need the political will to learn from others and put in place a system that works.
Taking patient-centred care from rhetoric to reality
Patient-centred care is a term that gets bandied about a lot these days. But what does it really mean? How does our health system need to change to make it truly patient-centred? What reforms and innovations are required on a systems level? How do front-line care providers need to change to make care truly patient-centred? And how do patients need to behave differently? These are all questions that need to be answered if we’re going to move from feel-good rhetoric to doing-some-good reality.
The US Health and Medicine Division of the National Academies of Sciences, Engineering, and Medicine defines patient-centred care as “care that is respectful and responsive to individual patient preferences, needs and values.” That’s nice and inspiring and all-encompassing. It means everything and nothing. There’s a well-worn expression: “I don’t know anything about art, but I know what I like.” Patient-centred care is a bit like that; you know when you experience it—and especially when you don’t—but you can’t necessarily articulate the characteristics.
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