Reflecting on my recent visit to Canada, and discussions with many key people on challenges facing Canadian health care, I am struck by the extent to which Canadian policy makers are groping for direction, with both feet firmly glued to the floor!
New ideas abound, and intelligent and thoughtful people are proposing challenging ideas, but at the same time, I find a narrowing in the solution space — changes are needed and quickly, but we can only go so far, or do so much. Perhaps whilst a mood of crisis pervades some circles, complacency prevails?
Andrew Cohen, in his While Canada Slept: how we lost our place in the world, has cogently articulated a malaise in the Canadian self-image. Senator Michael Kirby and his colleague Senator Wilbert Keon, have proposed the introduction of competition into Canadian health care, and not the least challenged the prevailing mythology that surrounds our health care system. As legal challenges to the Canada Health Act proliferate and the Supreme Court reflects on the way ahead, it is worth noting that regardless of the legal outcomes, there will be ructions at the policy level, and we need to anticipate them. Experience in Europe, where the European Court of Justice rulings have altered the cross-border health care environment to the surprise and denial of the member countries, should suggest that it is time to shelve the mythologies in Canada.
My discussions with my colleagues in Canada suggest that some key issues are paramount, and I share these as much to offer these thoughts to others as to suggest they offer a framework for a policy agenda:
Learn from others
Canadians are not learning from the experiences of other countries and may have retreated to certainty of the mythologies. Sure, people make the pilgrimage to selected reforming systems, and some folk bring their hot ideas to Canada, but sustained international engagement on practical learning is weak. Perhaps it is the fear/fascination with the US that says that Canadian health care is at least “not like that!”, but much can be learned from other systems and the agenda for learning needs to take into account the strengths of the Canadian system, and the weaknesses of others. Countries with strong policy-driven reform programs attract interest like bears to honey, but in many cases deficiencies in the service delivery system undermine these plans. What is needed is greater engagement internationally at all levels of the service delivery sector, and in particular major reform of health management training is needed.
Disrupt the existing service delivery paradigm
The hot money is that competition is the way forward, and as Kirby and Keon have also suggested deal with labour market rigidities. But let’s look at competition. Raw, brute competition between hospitals in Canada is most likely to occur on University Avenue in Toronto, and probably no other place. The public’s interest is is service. If we start with the disruptive potential of patient choice, we find that it is not competition between providers that will improve services and drive efficiencies, but competition around quality, service options, and the opportunity of new providers to enter the market easily and offer services people want. Ministers of Health who profess to protect the public interest by blocking service innovation at the Rainbow Bridge, are shielding us from service improvement by playing to the bleachers. Labour market rigidities exist partly because health care professionals have become institutionalized around their roles and now successfully protect this, cartel-like. But patient-centric reform will call on these same professionals to explore how they can be leaders and innovators. Why bother try to improve services if you can’t create that service because of systematic barriers to service-led reform?
We only need one thing: Innovative Contestability: permit innovators to drive service-focused reform to challenge the existing service providers; this will unbundle service configurations as patients vote with their feet for the service that meets their needs.
Develop citizen-centred e-health
The concern that health system productivity is not improving is widespread and is caused in part by the failure of the service delivery paradigm to be able to reform. Central, though, to this thinking, is the view that new information and communication technologies will drive productivity and service improvement. Why should that be true? In other sectors of the economy, massive investment in information technology has taken in some cases decades to get to work properly, and most major projects generally fail to deliver the benefits that were breathlessly promised. What industry does know, though, is that a focus on service improvement and productivity is led through customer responsiveness, not an internal focus on organizational change. Customer engagement in health care will drive productivity improvement, and e-health technologies that fail to start with patient use as a key driver, will not lead to productivity gains. Patient access though to their electronic health record or prescription database will ensure that it is accurate, complete and current, as this quality inspector of one has a greater vested interest in its accuracy than any health professional.