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June 13-14, 2013, Toronto, ON

Discussion Paper: Canadian Health Policy Since Romanow: Easy to Call for Change, Hard to Do Steven Lewis

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INTRODUCTION

High-level health policy is a national preoccupation in Canada. Health policy

implementation is another story. There has long been widespread endorsement

of broad system goals; the reports produced through 2002, reviewed by Fooks

and Lewis1, produced by or in jurisdictions with diverse political perspectives,

cover much of the same ground, as shown in the following table.

Themes for Health Reform in Canada2

If the subject matter is broadly similar, so, too are the proposed solutions. Over

the past decade, health policy discussions and government intentions have

coalesced around common themes:

• Higher quality and greater safer care

• Fewer and shorter delays in care

• More effective and comprehensive primary care, focused on

improved chronic disease management

• Less waste and greater efficiency

• More effective teamwork among providers

• Improved and more cost-effective drug prescribing

• More integrated systems of care

• Patient-centred care, in all its dimensions

• Improved population health, and reduced health disparities

• A modern health information system

There is nothing uniquely Canadian about these aspirations; they are widely shared

by every healthcare system in every setting. They are so commonplace – and so

enduring – that they have come to resemble mantras that operate in the manner

of constitutional preambles, lofty statements of core values rather than action

plans or commitments for which the polity will be held accountable. Apparent

agreement on broad goals should not be taken cavalierly for agreement on policies

and practices to achieve them. Everyone may endorse, say, the need to reform

1 C. Fooks and S. Lewis, Romanow and Beyond: A Primer on Health Reform in Canada, Canadian Policy Research Networks, Health Network Discussion Paper No. HI05, November 2002 http://rcrpp.org/documents/15525_en.pdf.2 From Ibid.

primary care, but they may seriously disagree about how to get it done and the

price one is willing to pay to get it done in the face of resistance.

It is striking that with one partial exception (described below), no national or

provincial report since Romanow has taken a panoramic view of the healthcare

system and produced comprehensive recommendations for reform. This can

be viewed as either an admission that the system is impervious to change,

or a more mature understanding of how change is likely to occur. The most

comprehensive and ambitious of the three national reports – the work of the

National Forum on Health (1997) – was pretty much dead on arrival, doomed by

the acrimony resulting from Ottawa’s reduced cash transfers to the provinces.

The confusion of Kirby and Romanow reporting at almost the same time aside,

the main result was the federal government’s addition of forty-one billion new

dollars to its transfers to the provinces to cover the “Romanow gap”. But federal

reinvestment had begun in earnest in 2000, and one can view the health

accords of 2003 and 2004 as simply extensions of the fiscal policy that preceded

Romanow and Kirby. Despite the appearance of conditionality in the 2003 and

2004 agreements, in the end the money simply flowed, and with the election of

the Harper government in 2006, even the half-hearted jurisdictional reporting

requirements disappeared. Both Romanow and Kirby had recommended a

national Health Council, but the version created was in both mandate and

structure a pale imitation of what they had proposed, and it is about to be

disbanded in 2014.

An obvious reason for the lack of translation of national report

recommendations into concrete reforms is that healthcare is largely a provincial

Population Health Finance Primary Care Regionalization Drugs Health Human Resources Quality Governance Home Care

Alberta X X X X X X X

New Brunswick X X X X X X X

Ontario X X X X X

Quebec X X X X X X X

Saskatchewan X X X X X X X X

National Forum X X X X X X X X X

Kirby X X X X X X X X X

Romanow X X X X X X X X

Funded with generous support from the Joseph S. Stauffer Foundation.

responsibility. At the federal level, the Senate has been the locus of activity,

having produced major reports on mental health3 (which led to the creation

of the Mental Health Commission) and population health.4 At the provincial

level, there have been literally hundreds of reports on issues such as human

resources planning and inquiries into healthcare misadventures, and efforts

such Alberta’s Ministerial Advisory Committee to modernize the legislative

framework governing healthcare. But the era of the report to end all reports

appears to be over.

The most comprehensive recent health system examination is Ontario’s

“Drummond Report”, which devotes 70 of its 543 pages to healthcare analysis

and reform.5 It is an unsparing assessment of the system’s shortcomings,

among them inefficiency, lack of coordination, indifferent quality, uneven

access, and lack of comprehensiveness. The report’s 105 health-related

recommendations address two main themes: integration and coordination

3 Canada, Parliament, Senate, Standing Senate Committee on Social Affairs, Science and Technology, Out of the Shadows at Last: Transforming Mental Health, Mental Illness and Addiction Services in Canada, 1st sess., 38th Parliament, 2006, http://www.parl.gc.ca/content/sen/committee/391/soci/rep/pdf/rep02may06part1-e.pdf.4 Canada, Parliament, Senate, Standing Senate Committee on Social Affairs, Science and Technology, A Healthy, Productive Canada: A Determinant of Health Approach, Final Report of Senate Subcommittee on Population Health, June 2009, http://www.parl.gc.ca/Content/SEN/Committee/402/popu/rep/rephealthjun09-e.pdf.5 Commission on the Reform of Ontario’s Public Services, Public Service for Ontarians: A Path to Sustainability and Excellence (Toronto: Queen’s Printer for Ontario, 2012) www.fin.gov.on.ca/en/reformcommission.

of services, and finding the most efficient modes of delivery. The scope of

the proposals is far-reaching, addressing issues such as price, division of

labour, incentives, and strategies for reducing healthcare needs. Local Health

Integration Networks (LHINs) would expand and become more authoritative;

care would continue to shift away from hospitals and nursing homes to

community care; collective agreements, especially with physicians, would

change significantly; and a Commission would be created to drive reforms.

It is clear that it takes more than vision and high-level policy to bring about

reforms. Healthcare is transactional and healthcare decision-making is highly

decentralized. Delivering better care more efficiently, working in teams, and

patient-centred care are nothing less than a cultural revolution. Policy can

remove barriers to change (for example by eliminating obsolete funding and

payment models) and enable change (for example by redefining and making

organizations accountable for performance). But ultimately cultural change

is a battle for the hearts and minds of practitioners – their sense of mission,

how they are educated, their hierarchy of values, their expectations, and their

willingness to organize their work around their patients. If they do not co-

create and embrace change, it will not occur on a large scale.

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Though not all of them can be described as policy per se, a number of

important trends have accelerated in the past ten years or so. These are:

1. A Focus on Quality and Safety

Inspired by the To Err is Human report from the Institute of Medicine in the US6

and supported by evidence from the Baker-Norton study of adverse events

in Canadian hospitals7, seven Canadian provinces have established health

quality and/or safety councils or their equivalents.8 At the national level,

the Canadian Patient Safety Institute works with provinces and healthcare

organizations on improvement methods and programs. Accreditation

Canada has incorporated additional quality measures into its standards, and

the Canadian Health Services Research Foundation has rebranded itself the

Canadian Foundation for Healthcare Improvement.

Most provincial health ministries have built quality improvement into their

business or strategic plans.9 Ontario’s Excellent Health Care for All Act10 is likely

the country’s most far-reaching legislative mandate for quality improvement.

It requires all organizations to establish quality committees, report publicly

on performance, develop evaluation protocols, survey patients at least

annually and employees at least biennially, and focus on improving the patient

experience. It ties executive compensation to the achievement of quality

objectives. The ultimate goal is to spread the quality improvement imperative

to every sector, with primary care a high priority. A number of Institute for

Healthcare Improvement (IHI) programs have been adapted to Canada, in the

form of innovations such as chronic disease management collaboratives, many

of which have targeted improved diabetes management. They are typically

launched with additional funding, and participation is voluntary.

6 L.T. Kohn, J.M. Corrigan, and M.S. Donaldson, eds., To Err is Human: Building a Safer Health System (Washington D.C.: Institute of Medicine, National Academies Press, 2000).7 G.R. Baker, P.G. Norton, V. Flintoft, R. Blais, et. al., “The Canadian Adverse Events Study: The Incidence of Adverse Events Among Hospital Patients in Canada,” CMAJ 170 (2004), 1678-86.8 “Current Patient Safety Organizations in Canada”, Health Canada, last modified May 25, 2012, http://www.hc-sc.gc.ca/hcs-sss/qual/patient_securit/orgs-eng.php.9 Health Council of Canada, Which Way to Quality? Key Perspectives on Quality Improvement in Canadian Healthcare Systems (Toronto: Health Council of Canada, 2013), http://www.healthcouncilcanada.ca/rpt_det.php?id=455.10 Excellent Care for All Act, 2010, http://www.e-laws.gov.on.ca/html/statutes/english/elaws_statutes_10e14_e.htm.

Unquestionably there is far more quality improvement activity in Canada than

a decade ago, when the movement was in its infancy. It is less clear whether

there has been a great leap forward in performance. Over the past thirty

years, premature mortality has declined by 45%, and avoidable mortality has

been cut in half; there were similar reductions in preventable mortality from

treatable causes.11 Better healthcare accounts for some of the improvement,

but secular trends and the impact of prevention explain the greater proportion.

It is difficult to sustain improvements when start-up funding ceases, or when

commitment to collecting and analyzing data wanes.12

A related focus is patient-centred care, endorsed and promoted by virtually

every jurisdiction and professional association. The main objective is to

organize care around the needs, preferences, and participation of the

patient, captured in the phrase, “right care, right place, right time.” Access,

convenience, timeliness, communication, respect, and shared decision-making

are commonly touted elements of patient-centredness. Canadian healthcare

does not excel in this regard.13 Instruments such as Patient-Reported Outcome

Measures (PROMs) and patient experience surveys track indicators and

generate data that capture some dimensions of patient-centredness.

2. Wait Time Reductions

This has been a constant refrain in Canadian

healthcare policy. The 2004 10-Year Plan to

Strengthen Healthcare called for “meaningful

reductions in wait times in priority areas such

as cancer, heart, diagnostic imaging, joint

replacements, and sight restoration by March 31,

2007, recognizing the different starting points,

priorities, and strategies across jurisdictions.”14

It created the Wait Times Reduction Fund as part of the increased transfer

payments from Ottawa to the provinces.

Most of the earlier efforts were aimed at reducing wait times for elective

surgery, and especially high volume procedures such as hip and knee

replacements and cataracts, and for services addressing life-threatening

conditions such as heart failure and cancer. Some provinces have made bold

commitments across the board. Saskatchewan set a target of a maximum

11 Canadian Institute for Health Information and Statistics Canada, Health Indicators 2012 (Ottawa: CIHI, 2012), https://secure.cihi.ca/free_products/health_indicators_2012_en.pdf.12 E.g., Health Quality Council, The Courage of One, the Power of Many: The Saskatchewan Chronic Disease Management Experience (Saskatoon: Health Quality Council, 2008), http://hqc.sk.ca/Portals/0/documents/chronic-disease-management-report.pdf13 Ontario Medical Association, “Patient-Centred Care,” Policy Paper, Ontario Medical Review, 77 no. 6 (2010), https://www.oma.org/Resources/Documents/Patient-CentredCare,2010.pdf.14 “First Minister’s [sic] meeting on the Future of Health Care 2004. A 10-year plan to strengthen healthcare,” Health Canada, last modified May 9, 2006, http://www.hc-sc.gc.ca/hcs-sss/delivery-prestation/fptcollab/2004-fmm-rpm/index-eng.php.

“Most provincial health ministries have built quality improvement into their business or strategic plans.”

A. Policy Trends in the Last Decade


three-month wait from the time of booking to treatment – the equivalent of

a wait time guarantee. Alberta Health Services has set targets of one month

to see a specialist and 14 weeks for elective procedures. 15 The more common

Canadian approach is to frame the targets in terms of serving a certain

percentage of patients (usually 90%) within a specific time frame.16 Despite a

decade of commitment to wait time reductions in five key areas, according to

the Wait Time Alliance, performance remains indifferent, even with a rather

lenient grading system that gives provinces an A grade for serving 80% of

patients within the recommended time. The 2012 report notes that unlike in

recent years, overall wait times are lengthening.17

3. Primary Care Reform

All jurisdictions are interested in reforming primary care. Substantively, there

is an important distinction that manifests semantically: primary healthcare vs.

primary care. The former is a more expansive concept, involving intersectoral

action to address the non-medical determinants of health as well as providing

comprehensive, team-based healthcare. Primary care is limited to the

healthcare system itself.

The Canadian Health Services Research Foundation (now the Canadian

Foundation for Health Innovation) published a comprehensive update of

primary healthcare reform in 2012.18 Findings included some promising

pockets of innovation, many of which originated with the Primary Healthcare

Transition Fund investment of $800 million at the turn of the century. Overall,

however, the authors found a lack of coherence in reform across the country,

tensions between old and new ways of delivery, and efforts hampered by the

absence of a useful health information system. A report based on a forum of

researchers and decision-makers to assess the status of reform concluded:

“The main barriers to reform were the lack of financial investments in the

reforms, resistance from professional associations, overly prescriptive

approaches that lacked adaptability to local circumstances and an overly

centralized governance model. The main facilitators were a strong financial

commitment using various allocation and payments models, the involvement

of professional associations throughout the process of reform, an incremental

and strong decentralization of decisions and adaptation to local circumstances.

Most benefits of the reforms so far seem to have occurred with regard to

patients’ experience of care and higher workforce satisfaction.”19

15 Alberta Health Services, Alberta Health Services Health Plan and Business Plan 2012-2015 (Edmonton: Alberta Health Services, 2012), http://www.albertahealthservices.ca/Publications/ahs-pub-2012-2015-health-plan.pdf.16 E.g., BC: “Wait Time Targets,” British Columbia Ministry of Health, http://www.health.gov.bc.ca/swt/overview/waittime_targets.html.17 Wait Time Alliance, Shedding Light on Canadians’ Total Wait for Care: Report on Wait Times in Canada (Ottawa: Wait Time Alliance, 2012), http://www.waittimealliance.ca/media/2012reportcard/WTA2012-reportcard_e.pdf. 18 A.L. Mable, J. Marriot, and M.E. Marriot, Canadian Primary Healthcare Policy: Status of Reform, (Ottawa: CHSRF, 2012).19 J.F. Levesque, R. Pineault, D. Grimard, et. al., Looking Backward to Move Forward: A Synthesis of Primary Health Care Reform Evaluations in Canadian Provinces (Québec: Institut national de santé publique du Québec, 2012). http://www.inspq.qc.ca/pdf/publications/1439_RegarderArriereMieuxAvancer_SynthEvalReforSoins1Ligne_VA.pdf.

The extent and pace of reform has varied. One overview listed BC, Alberta,

Ontario and Quebec – interestingly, the four most populous provinces

– as having the most ambitious plans, all negotiated with their medical

associations.20 These reforms most often take the form of organizing family

doctors into larger groups, with goals such as reducing the numbers of

people without a regular source of care (notably in Ontario) and providing

more comprehensive care (e.g., Primary Care Networks in Alberta, Family

Medicine Groups in Quebec). Physician numbers are rising. Fee-for-service

remains the principal payment method. There has been little expansion

of alternative models introduced decades ago, e.g., community clinics in

Saskatchewan, CLSCs in Quebec, and community health centres in Ontario,

despite some notably positive evaluations of their impact.21 There are a few

nurse-practitioner led primary care clinics on Ontario but there is a growing

trend toward a physician assistant model whereby nurses practice under

physician direction.

4. Cost Containment

Until about 2011, there was little commitment to cost containment. For over

a decade spending increased faster than at any time in history. Now that all

governments except Saskatchewan are running deficits, there is much greater

interest in reducing the rate of spending growth. In 2013-14, overall health

spending is budgeted to grow by 2% - the lowest since the late 1990s – and

ranges from minus 3% in Newfoundland and Labrador to 4.2% in PEI.22 Ottawa

has announced that its escalator clause in transfer payments will decline from

6% to a minimum of 3% in 2018-2019, the actual number tied to nominal GDP

growth (which includes inflation).23 Recent experience shows that short term

cost containment in itself is achievable – governments can and do implement

relative austerity. Historically it has proved difficult to sustain restraint without

fundamentally altering the forces that drive costs; the restraint of the mid-1990s

gave rise to the long period of rapid spending growth that ended only recently.

The main instruments for containing costs are harder bargaining with

healthcare unions; continued efforts to decant services from hospitals; and,

more recently, reducing the price of generic drugs to 18% of the brand name

price for several high-volume pharmaceuticals.24 Concepts such as value-for-

money, appropriateness, and prudent adoption of new technologies, largely

absent from healthcare policy discussions for many years, are now front and

20 B. Hutchison, J.-F. Levesque, E. Strumpf, and N. Coyle. “Primary Healthcare in Canada: Systems in Motion”, Milbank Quarterly 89 no. 2 (2011),256-88, http://www.cqco.ca/common/pages/UserFile.aspx?fileId=250526.21 R.H. Glazier, B.M. Zagorski, and J. Rayner, Comparison of Primary Care Models in Ontario by Demographics, Case Mix and Emergency Department Use, 2008/09 to 2009/10, ICES Investigative Report (Toronto: Institute for Clinical Evaluative Sciences, 2011), http://www.ices.on.ca/file/ICES_Primary20Care20Models20English.pdf.22 “Health Spending Going Up 2.0 per cent in 2013-14,” Health Edition, May 3, 2013, http://www.healthedition.com/archives/050313_m.pdf.23 I. Bailey, and B. Curry, “In Surprise Move, Flaherty Lays Out Health-Spending Plans Til 2024,” Globe and Mail, updated September 6, 2012, http://www.theglobeandmail.com/news/politics/in-surprise-move-flaherty-lays-out-health-spending-plans-til-2024/article4247851/.24 Council of the Federation, Provinces and Territories Seek Significant Cost Savings for Canadians for Drugs, News Release, January 18, 2013, http://www.councilofthefederation.ca/pdfs/NR-CoF-Generic20drugs2028Final29-Jan2018.pdf.


centre.25 At the same time, however, there has been renewed interest in

funding and payment models such as activity-based funding (ABF) and pay-

for-performance (P4P) that tie dollars to volumes (BC, Ontario and Alberta all

use some forms of ABF). Alternative funding programs (AFPs) for physicians,

designed to remove incentives to over-service patients by decoupling

payment from volume, have been recently criticized by the Auditor-General

in Ontario26 and by New Brunswick health minister Ted Flemming, who said:

“We’ve put in a system now where all salaried doctors are going to shadow-bill

just as if they were fee for service and we’re going to see who works for a living

and who doesn’t.”27

Quality experts estimate that up to 30% of healthcare spending is waste, which

has generated consider-able interest in tools and techniques to eliminate

it. 28 Adapted from the production improvements that created the Toyota

phenomenon, Lean is an increasingly prominent feature in Canada.29 Lean is

the core strategy for improvement in both the Saskatchewan Ministry of Health

and in the government at large. The province is investing up to $40 million over

4 years to provide intensive Lean training to 1000 healthcare managers and

providers and support a thousand projects.30 In British Columbia, Lean projects

have reduced duplicate tests and wait times and reduced the inputs required to

produce desired outputs.31

Two-thirds or more of healthcare spending is generated by physicians.

Most continue to be paid fee-for-service. More critically, their numbers are

growing at an unprecedented rate. In 2011-12 medical school enrolment was

84% greater than in 1997-98,32 and the number of practitioners is growing

much faster than the population. There are few levers for ensuring an ideal

distribution of doctors by geographic area, which means that most continue

to cluster in larger urban areas. If incomes depend on activity, the spectre of

supply-induced demand looms large.

25 Health Council of Canada, Value for Money: Making Canadian Health Care Stronger (Ottawa: Health Council of Canada, 2009), http://www.healthcouncilcanada.ca/rpt_det.php?id=169; Canadian Institute of Health Information, Health Care in Canada 2010 (Ottawa: CIHI, 2010), https://secure.cihi.ca/free_products/HCIC_2010_Web_e.pdf; “Appropriateness Projects,” Canadian Association of Radiologists, http://www.car.ca/en/about/reports/appropriateness.aspx; A. Morrison, Appropriate Utilization of Advanced Diagnostic Imaging Procedures: CT, MRI, and PET/CT, Environmental Scan, Issue 39 (Ottawa: Canadian Agency for Drugs and Technologies in Health, 2013), http://www.cadth.ca/media/pdf/PFDIESLiteratureScan_e_es.pdf.26 Office of the Auditor General of Ontario, 2011 Annual Report (Toronto: Queen’s Printer, 2011), http://www.auditor.on.ca/en/reports_en/en11/2011ar_en.pdf27 J. Pritchett, “Salaried Family Doctors’ Productivity to be Measured: Health Minister Wants to Know What Salaried Do,” New Brunswick Telegraph-Journal, January 18, 2013, A1. Shadow billing is the requirement for non-FFS physicians to record and code their activities as if they were practicing under FFS.28 M. Smith, R. Saunders, L. Stuckhardt, and M. McGinnis, eds. Best Care at Lower Cost: The Path to Continuously Learning Health Care in America (Washington, DC: The National Academies Press, 2012), http://www.nap.edu/openbook.php?record_id=13444&page=R2.29 Council of the Federation, From Innovation to Action: The First Report of the Health Care Innovation Working Group (Ottawa: Council of the Federation, 2012), http://www.councilofthefederation.ca/pdfs/Health20Innovation20Report-E-WEB.pdf.30 “Lean,” Saskatchewan Ministry of Health, http://www.health.gov.sk.ca/lean.31 BC Ministry of Health, Lean in British Columbia’s Health Sector: Annual Report 2010-11 (Victoria: BC Ministry of Health, 2011), http://www.health.gov.bc.ca/library/publications/year/2011/Lean-in-BCs-health-sector.pdf.32 Canadian Collaborative Centre for Physician Resources, Canadian Physician Resources – 2013 Basic Facts (Ottawa: Canadian Medical Association, 2013), http://www.asklepios.ca/multimedia/CMA/Content_Images/Policy_Advocacy/Policy_Research/PhysFacts2013-E.pdf

5. Health Human Resources

Three major questions define the HHR sphere in Canada:

• Numbers – Health science education enrolment levels,

international recruitment and licensure policies and practices,

geographic distribution.

• Division of labour – what is the most efficient way to deploy the

HHR workforce? How can the vision of interprofessional collaborative

practice be realized? How do we ensure that all professionals work to

their maximum scope of practice? What are the implications for the

regulatory regime?

• Credentials – What is the appropriate entry-to-practice credential

(ETPC) for occupations? On what basis should this be determined?

What is the relationship between ETPC and lifelong competency?

Have increases in ETPC in nursing, occupational therapy, physical

therapy, and other occupations improved healthcare quality, safety,

and efficiency?

Until recently there was a commonly held belief that Canada had a general HHR

shortage, and the solution was to increase enrolments in many programs, often

by substantial amounts. These measures took place without a fundamental

re-examination of the division of labour, known to be sub-optimal for decades.

Canadian research was among the first to show that nurse practitioners could

do much of what family doctors do. A great deal of nursing research has

shown that only a third or so of hospital nurses’ time is spent on direct patient

care. Licensed practical nurses frequently report that their registered nurse

supervisors do not understand their full capabilities even though their ETPC

is now a diploma instead of a certificate. Medical specialists often complain of

inappropriate referrals of patients whose needs should be met in primary care.

The increased production of graduates coincided with the upward arc in

healthcare spending that has only recently flattened. Just as the number of

new graduates fully reflects the expanded training program capacity, spending

growth is slowing. The early results are already in: specialist unemployment

looms for up to a sixth of newly certified practitioners.33 There may be greater

reluctance to delegate tasks to other professions if jobs become scarcer.

33 P. Rich, “Bleak Job Outlook in Some Specialties Sparking Concern,” Canadian Medical Association, Sept. 9, 2011, http://www.cma.ca/bleak-job-outlook-specialties. The Royal College of Physicians and Surgeons is due to release a full report on the subject in 2013.


6. Pharmaceutical Coverage and the

Quality of Prescribing

Though Canada publicly funds a smaller proportion of prescription drug

costs than every other advanced OECD country except the United States, no

jurisdiction has moved to expand coverage in recent years. Governments

have reduced the price of generic drugs, and overall drug spending has

slowed down after an extended period of rapid escalation. The patchwork

of coverage and the combination of government, third party insurance, and

out-of-pocket financing has made the pursuit of a national pharmaceutical

strategy difficult. There seems to be little government appetite to bring drugs

fully into the medicare tent. On the quality improvement front, Health Canada

and the Canadian Institutes for Health Research created the Drug Safety and

Effectiveness Network (DSEN) to support research on and evaluation of re-al-

world drug consumption patterns post-approval. There have also been some

setbacks, e.g., the widely criticized suspension of government funding for the

BC Therapeutics Initiative.34

34 P.C. Webster, “UBC Takes Over Therapeutics Initiative after Provincial Cuts,” CMAJ May 6, 2013, http://www.cmaj.ca/site/earlyreleases/1may13_ubc-takes-over-therapeutics-Initiative-after-provincial-cuts.xhtml

7. Regionalization

Every province except Ontario had regionalized healthcare by the late 1990s.

The major trends in the past decade have been the elimination of regions (AB,

PEI); reducing the numbers of regions (BC, SK, MB, NB, QC); and a perceived

repatriation of power by provincial governments. Ontario established the

LHINs, which may be described as quasi-regions, with less authority than full-

fledged regions elsewhere, although both the initial vision and the Drummond

Report contemplate more expansive powers over time.

Regionalization was to be the catalyst for more effective service integration

and a more population-based approach to health and healthcare. However, a

number of structural features created obstacles to change. Physician services

remained outside the regional purview, as did pharmaceuticals. Governments

retained control over critical decisions such as new facilities, mergers, and

closures, which reinforced the public perception that the regions were mainly

agents rather than fully accountable authorities. Local boards remained in

place in Ontario, and elsewhere in non-governmentally owned facilities which

entered into affiliation agreements with regions. New money was often tied to

government-mandated volume targets, limiting regions’ discretion over how

budgets should be allocated. Collective agreements in some cases impeded

the movement of personnel between organizations or sectors.

In their earlier days, health regions were assigned mandates to improve

population health. Quebec and PEI regions had mandates that included other

sectors. The more recent focus has been on the healthcare system itself, one

result of which is that the anticipated major reallocation of funding up-stream

to health promotion, preventive health, and primary care did not take place.


A number of factors combine to make change difficult in Canadian healthcare.

Among them are:

1. Collective Agreements with

Medical Associations

The collective agreements between governments and their medical

associations powerfully influence healthcare culture, policy, and practice.

The agreements enshrine a number of features and incentives rarely found

in high-performing health systems, the most important of which is that most

doctors are independent contractors to the payor, with little accountability for

quality, no role in resource stewardship, and no obligation to adopt a systems

perspective. The legacy is that of a cottage industry of independent practices

whose clinical decisions lay claim to most of the system’s resources. Medicine in

Canada is separate and unequal, a privileged status that impedes collaboration

with others and makes the status quo lucrative. Quality improvement remains

voluntary rather than a core expectation.

2. Funding Is Tied to Activity,

Not Excellence or Health Impact

Do governments want to pay the healthcare system for doing things, or

achieving results? There is a difference between paying for inputs (providers,

buildings, equipment) to produce outputs (number of procedures, patients

seen, tests performed) versus paying for outcomes (improvement in health

status attributable services provided). But old ways of thinking die hard.

Governments on the one hand have encouraged physicians to abandon

fee-for-service because it rewards procedures over cognitive work, address

simple problems one at a time in short encounters instead of a more holistic,

comprehensive, and convenient visit, and dependency over self-management.

Yet as noted above, physicians are often required to shadow bill as if still on fee-

for-service, which suggests that the gold standard is the pattern practice they

were supposed to abandon. Doctors risk being branded as unproductive if they

see fewer patients in a day even if they achieve better results for complex cases.

Similarly, health regions and hospitals that succeed at secondary prevention

may see their rates of certain kinds of procedures decline. Other things

being equal, this is what healthcare is supposed to do: reduce pathology

and therefore the need for interventions. Again, however, there is general

reluctance to fund on a population basis (a fixed amount of money to look

after a defined population), an approach that creates incentives to prevent

health breakdown and avoid having to provide expensive care. Most pay-

for-performance systems define performance narrowly, with an emphasis on

activity such as screening tests and immunizations. Ontario’s Health Based

Allocation Model is based on the principal that money should follow the patient

– an intuitively sound idea, but one that raises the question of how to reward

wellness and avoided service needs. Moreover, if funding systems in the end

make no distinction between avoidable and unavoidable needs, and appropriate

and inappropriate services, they will reward activity irrespective of impact.

Put another way, Canadian policy and funding models have not been designed

to reward the achievement of a healthier population that needs less care and is

more effective at self-managing. This fundamental misalignment discourages

redeploying resources towards programs that prevent or defer health

breakdown and tethers providers to accountability for improving access and

increased volumes in the short run. Reducing health disparities and improving

population health require longer term investment that cannot produce

dramatic and tangible results in the next fiscal year. If government vision

wavers and if the discount rate applied to future benefits is too steep, success

will continue to be defined in terms of busyness.

3. Quality Improvement Remains

Optional

There is an abundance of QI activity across the country, especially in

hospitals. Yet participation, especially among physicians, is largely voluntary.

Neither regulatory bodies nor collective agreements require a commitment

to continuous quality improvement as a core professional obligation.

Accreditation Canada has added quality indicators to its criteria but in the end,

hospitals with a 50% hand-washing compliance rate remain open for business.

The public has virtually no access to information that might influence its

decision-making, e.g., surgeon-specific complication and mortality rates, or the

success of family practices in managing chronic diseases. There is little practice

profiling and clinicians rarely know whether their practices vary significantly

from those of their peers. Canada remains a laggard in the implementation of a

fully functional electronic health record.

As a consequence, QI tends to involve self-selected, highly motivated clinicians

and organizations. These early adopters have produced some impressive

results, but spread remains a serious problem and the gap between the pockets

of excellence and the rest of the system widens. The problem is unintentionally

compounded when governments pay clinicians extra for participating in QI

activity or achieving specific but narrow performance targets. This signals that

QI is something extra, deserving of financial reward, rather than being a core

and universal expectation.

B. Specific Obstacles to Large Scale Change


4. The HHR Agenda Is Uncoordinated

HHR policy and practice are the result of the interplay of many interests:

universities and colleges, professional associations, accreditation bodies,

governments, and employers. Given provincial jurisdiction over ETPC and

in some cases licensure, the potential for variation abounds. Furthermore,

provinces negotiate individually with their unions, which over time can create

discrepancies in wage rates that influence migration. There is a pan-Canadian

health human resources strategy and at times there are efforts to address

common issues, such as ETPC. But local interests and imperatives may result in

decisions tak-en in isolation that may eventually have far-reaching implications

– e.g., approving an ETPC increase. In addition, perceptions of shortages may

create local expectations of increased enrolments at different times, resulting

in individual measures that collectively miss the mark. Developments in one

profession may affect another, e.g., when one therapy discipline moves to

masters-level ETPC, others are more likely to follow. Once the first province

adopted the baccalaureate as the ETPC for registered nurses, it was only a

matter of time before it became a nation-wide standard.

Canada has moved to remove labour mobility barriers and governments and

regulatory bodies communicate regularly. Yet the system remains complex,

and one wonders if the fragmentation is essential given that the European

Union allows the free mobility of personnel between countries despite long

and deep cultural and language differences.

Notwithstanding these challenges, there may be even more fundamental HHR

problems to contemplate. The regulatory framework developed to ensure

minimal levels of competence and safety in an era that delivered neither.

The focus has been on individual characteristics and behaviours for both

licensing and discipline. The insights from the QI movement have shifted the

understanding of both excellence and error from individuals to environments,

and from ETPC to continuous, contextual learning. The explosion of healthcare

knowledge and technology led to increased specialization, which has increased

the capaci-ty to address specific problems while creating a challenge to holistic,

integrated care. If primary healthcare is to be the backbone of the system,

the role of the generalist will again become important. If team-based care is

essential for effectively doing the main business of contemporary healthcare

– chronic disease management – curricula may have to change to make

teamwork a core learning domain. Long-standing professional hierarchies have

to break down if every provider is to be empowered to con-tribute optimally.

5. Unconditional Federal Funding

The lack of a prominent federal government role in shaping health reform

has often been implicated in analyses of why change is slow and incremental.

Romanow’s plea that new money buy change ultimately went unanswered.

Some argue that change is more difficult when money is abundant because

there is less pressure to become more efficient. The new money was

telegraphed years in advance, and it was hardly surprising that bargaining

groups would line up to grab most of it. Nothing prevents interprovincial

cooperation on policy initiatives, but in the absence of a guiding federal

hand to ensure both sustained commitment to seeing reforms through and

a reasonable degree of standardization, it has proven difficult to make progress.

Historically, conditionality meant uniformity, which may be oversold as a

virtue, but which did create a reasonable approximation of a national health

system. It is possible to implement non-uniform conditionality in the form

of asymmetrical federalism. That option – usually invoked with respect to

Quebec – is likely to find favour among those who favour a more decentralized

federation with a less activist federal government, while preserving fiscal

transfers to which real accountability is attached. Pure decentralizers favour

replacing Ottawa’s cash contributions with additional tax point transfers in

order to define the jurisdictional boundaries as cleanly as possible.35 Each

option produces different consequences; it does seem clear that generous

unconditional cash transfers are inherently inflationary and over time will

exacerbate the differences among the jurisdictions.

C. The Politics of ProgressDaunting though these challenges may be, every country faces them to varying

degrees. In Canada there is a rationale for and many calls for change. What gets

in the way?

The gulf between aspiration and execution is the unifying characteristic

of Canadian health reform. The simplest explanation for the persistence of

this phenomenon – which borders on tautology – is that governments are

unwilling to spend the political capital required to set healthcare on a new

course. The country is cautious in its embrace of reform and instinctively

brokers solutions that accommodate powerful interests. The status quo

survives unflattering rankings in international comparisons of performance

that at most elicit a short-term flurry of discussion before a return to business

as usual.36 The major reforms tend to be structural and administrative:

regionalization and deregionalization, facility mergers, and changes to funding

models.37 The actual care experienced by Canadians evolves incrementally.

A more nuanced explanation is that some goals trump others, proof of which is

revealed by what governments do rather than what they say. By this measure,

access to care – time to see specialists, wait times for diagnostics and surgery

– is paramount. Billions have been spent on adding capacity and there is far

35 See, e.g., K.J. Boessenkool, Fixing the Fiscal Imbalance: Turning GST Revenues Over to the Provinces in Exchange for Lower Transfers, University of Calgary, School of Public Policy, SPP Research Papers 2010, 10(3), http://policyschool.ucalgary.ca/sites/default/files/research/gst-boessenkool-online3.pdf.36 K. Davis, C. Schoen, and K. Stremikis, Mirror, Mirror on the Wall. How the Performance of the US Health Care System Compares Internationally, 2010 Update (New York: Commonwealth Fund,2010) http://www.commonwealthfund.org/~/media/Files/Publications/Fund20Report/2010/Jun/1400_Davis_Mirror_Mirror_on_the_wall_2010.pdf; B. Eisen, and A. Björnberg, Euro-Canada Health Consumer Index 2010 (Winnipeg: Frontier Centre for Public Policy and Health Consumer Powerhouse, 2010), http://www.fcpp.org/files/1/ECHCI201020Final.pdf.37 H. Lazar, “A Cross Provincial Comparison of Health Care Reform in Canada: Building Blocks and Some Preliminary Results”, Canadian Political Science Review 3 no. 4(2009), 1-14; J. Dixon, Healthcare Reform in Canada (Kingston, ON: The Monieson Centre, 2013).


greater monitoring of and reporting on wait times than on outcomes, quality,

efficiency, or equity. Similarly, there is a much greater appetite for increasing

health science education program enrolment than for reinventing the

workforce and the workplace. Reducing health disparities requires major and

coordinated investment outside the healthcare system over many years, an

unlikely scenario given Canada’s commitment to low taxes.

What gets done is a function of what’s on the agenda, and the agenda is often

set by high-profile interest groups such as the Wait Time Alliance, professional

associations, unions, patient advocacy groups, and industry. Many groups

enjoy high public credibility and are adept at portraying themselves as public

interest advocates. They largely created the scarcity narrative that drove

the massive spending increases. Provider groups managed to avoid taking

responsibility for the system’s dysfunctions. Governments, armed with a

growing body of damning evidence about quality, safety, and inefficiency, have

only recently tried to reframe the analysis. They have belatedly recognized that

cash cannot solve problems created by long-festering perverse incentives or

the failure to spread more integrated approaches to care. They have begun

to understand that collective agreements that allow medical associations

to apportion incomes among specialty groups skew supply and thwart the

development of self-organizing teams. Their desire for change may be real,

but – like the creation of medicare itself in 1962 – it cannot be had without

disturbing the peace.

The hope, of course, is that significant reform can occur without taking on

powerful interests. That would require common ground about both what is

desired and acceptable means to pursue it. The devil is in the details, and it is in

the details that rhetorical consensus breaks down. It is not possible to change

the division of labour without changing relative numbers among occupational

groups. It is not possible to dramatically increase funding for community care

and mental health without decreasing it elsewhere in a constrained fiscal

environment. Challenging ETPC enhancements – the next on the horizon is the

PharmD – will not endear policy-makers to the professions. Requiring doctors

to have formal and ac-countable relationships with health regions is sure to

face major resistance in some quarters.

By and large, the default change management strategy is to pursue a wide

range of ground-level projects that will morph into a cultural shift over

time. Scaling up success requires both good will and sound policy. There

is more measurement of and reporting on institutional performance, and

on the surface more substance in organizational performance agreements

with governments. So far the missing piece appears to be enforceable

accountability. The arrangements that govern physician services have changed

only modestly, and many fundamental obstacles to a more integrated system

remain intact. Ambitious attempts such as the Medical Makeover project led

by the Fraser Health Authority in BC fell short of the hoped-for breakthrough in

physician-system relations.38 Top down has to meet ground up at least halfway.

38 Fraser Health, Medical Makeover: Redesigning Physician Services for Tomorrow’s Health System, Report of the Summit Meeting (Vancouver: Fraser Health, 2011), http://www.medicalmakeover.ca/documents/Medical20Makeover20-20Final20Summit20Report.pdf.

With the federal government at least temporarily self-exiled from substantive

involvement in health system reform, can jurisdictions band together to

achieve collectively what they have been unable to achieve individually? The

Council of the Federation has begun to cooperate on strategies to address

issues of common interest, including a yet-unspecified HHR agenda. FPT

initiatives have historically been voluntary, and in most instances every

jurisdiction retained authority to go its own way. Agreements therefore tended

to take the form of the lowest common denominator. There was little joint

strategizing, and the initial hard work of achieving major change remained in

the hands of individual provinces. For example, Ontario did the heavy lifting

on generic drug pricing, fighting and winning a pitched battle with generic

manufacturers and pharmacists. That political victory paved the way for

replication elsewhere.

The Council is just getting going, and it remains to be seen if it will sustain

momentum and have the resolve to harvest fruit that lies higher up the tree.

If history is not to be destiny, there is no more important cooperative effort

than rewriting the compact with physicians and developing a cohesive,

pan-Canadian strategy for rolling it out. It will take concerted effort and a

united front to refashion the healthcare workforce to achieve the efficiencies

urged by Drummond and others. Common approaches to measurement,

public reporting, and quality improvement, combined with accountability

agreements that really matter, would diminish the political risks inherent in a

single jurisdiction going it alone.

If there is reason to be skeptical of what horizontal cooperative federalism can

achieve in the foreseeable future, there may be cause for optimism about what

provincial governments can accomplish on their own. Given the combination

of tighter money, an emerging surplus of physicians, the persistence of access

problems, and even supply-side acknowledgement of waste and inefficiency,

conditions may be ripe for bolder initiatives. The politics of the supply side

are evolving, and solidarity on some key issues may be eroding. The recently

ratified OMA agreement reduces fees in some high-income specialties to a

greater extent than elsewhere, leading to schisms in the ranks. The emerging

surplus of doctors may create greater interest in new business models

of practice. Reduced rates of spending growth may en-gender a greater

willingness to assume roles in resource stewardship.

Neither classic Canadian incrementalism nor dramatic change is inevitable.

The world’s intelligence net-works failed to predict the dismantling of the Iron

Curtain in 1989 or the Arab Spring of 2011. Rationale for change is incontestable:

for what the system costs, it does not deliver compared to other countries.

Whether the warrant is sufficient depends on whether policy-makers are able to

assemble a coalition for which the status quo is simply unacceptable, and which

is strong enough to withstand or wait out interest group resistance to change.


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@MoniesonHealth : : Conference Twitter Hash Tag: #QHPCC

Steven Lewis

Steven Lewis is a health policy and research consultant and Adjunct Professor of Health Policy at Vancouver’s

Simon Fraser University. He recently completed a tenure as Visiting Scholar at Simon Fraser. Steven spent seven

years as CEO of the Health Services Utilization and Research Commission in Saskatchewan. He has served

on various boards and committees, including the Governing Council of the Canadian Institutes of Health

Research, the Saskatchewan Health Quality Council, the Health Council of Canada, and the editorial boards of

multiple journals. His published works cover topics such as reforming and strengthening medicare, improving

healthcare quality, primary healthcare, regionalization and integration, and the management of wait times.

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