1. health and fitness

AGING
IMMIGRATION
ÉCONOMIE
HEALTH CARE
Building a
Better Future
RELATIONS WITH ABORIGINAL PEOPLES
ÉDUCATION
interculturalisme
INEQUALITY
Bâtir un
avenir meilleur
When Canadians go to the polls later this
En se rendant aux urnes plus tard cette année,
year, many of them will be making their choice
based on their impression of who can best
manage persistent economic uncertainty. Others
will be concerned about caring for older loved
ones or having the means to adequately provide
for their family. Others still will be assessing each
party’s response to global terrorism and domestic
radicalization.
To help inform voters’ choices, Policy Options
asked leading researchers and practitioners in
diverse fields to identify a pressing policy issue
that should be a priority in the election and to
make the case for how decision-makers can best
address it. While it certainly is not an exhaustive
list, taken together, their responses provide a
compelling agenda for public debate that all
political leaders should consider.
beaucoup de Canadiens donneront leur voix
au parti qui leur semble le mieux apte à gérer
l’incertitude économique persistante. D’autres
seront préoccupés davantage par les soins à
prodiguer à leurs aînés ou les moyens de subvenir
aux besoins de leur famille. D’autres encore
évalueront les mesures préconisées pour lutter
contre le terrorisme international et la radicalisation
des jeunes d’ici.
Pour éclairer le choix des électeurs, Options
politiques a demandé à des chercheurs et des
spécialistes reconnus de déterminer quel enjeu clé il
faudrait mettre au cœur de la campagne, et comment
nos décideurs peuvent s’attaquer à cette priorité.
Sans former une liste exhaustive, leurs réponses
composent un solide programme qui enrichit le
débat public et devrait inspirer tous nos dirigeants.
Improving social services
It’s time to rethink Ottawa’s
role in health care
Steven Lewis
The federal government needs to leave the management of the health care
system to the provinces and focus on the one function that must be national:
building a health information system that speaks unvarnished truths to
Canadians about the system’s performance.
Ottawa doit confier la gestion du système de santé aux provinces pour
se concentrer sur une tâche d’intérêt national : la création d’un système
d’information sur la santé qui donnera aux Canadiens l’heure juste sur le
rendement de leur système et agira comme moteur de changement.
t
hat health care has not yet emerged as an issue in
the upcoming federal election campaign is strong
evidence of the altered state of Canadian federalism. There are principled debates about the virtues of
strong and weak federalism, and the constitutional tidiness
of leaving provincial governments firmly and exclusively in
charge of their health care domains. But if the theory of federalism is contestable, the state of the health care system is
not. Canadian health care, once our defining social achievement, is stuck in a high-cost, low-performance rut.
Medicare became a national program because the Hall
Commission, created by the Diefenbaker government, recommended it in 1964, and Lester Pearson’s minority government passed enabling legislation. The commitment to
pay for half of the core hospital and medical services was a
deal too sweet for even recalcitrant provinces like Quebec,
Ontario and Alberta to turn down. Beginning in 1977,
successive federal governments decided that co-ownership
of medicare was more burden than asset, and reduced their
financial and political stakes. At one point Ottawa financed
41 percent of public spending; today it is 20 percent, or 30
percent if we count the three-decades-old tax point transfers to the provinces. There are no meaningful conditions
attached to federal dollars.
Despite changing demographics and new ways of
delivering services, the basic architecture of medicare has
Steven Lewis is president of Access Consulting Ltd. and adjunct
professor of health policy at Simon Fraser University. He is the coauthor of Bending the Cost Curve in Health Care (IRPP, 2013)
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OPTIONS POLITIQUES
MARS-AVRIL 2015
remained static for four decades. We have a persistently
mediocre system alongside a much diminished federal role.
Whether this is a cause-and-effect relationship or mere
coincidence is not subject to proof. All we know is that
although we have seen the doubling of spending in real
terms between 1998 and 2010, the near-doubling of medical school enrolments, regionalization (and its elimination
in three provinces) and a thousand demonstration projects,
none of these things have achieved the much-called-for
wholesale renovation. The Commonwealth Fund ranks
our system 10th among 11 high-income nations countries
based on measures of access, quality, efficiency, equity,
and the health of the population. Notably, we rank 11th
on timeliness of care and 10th on efficiency. Compared
with the systems of our European counterparts, ours is less
timely, less efficient and less comprehensive. So it is at least
worth considering whether there is an important role for
Ottawa in improving the system. If there is, can the feds get
back into the game without meddling unduly in provincial
affairs? What issues should the federal parties debate in the
run-up to the next election?
Federal parties should have important and useful
things to say about medicare and envision roles beyond
the writing of cheques. As they contemplate their health
platforms, they would do well to heed the lessons of history. First, Ottawa cannot be the white night riding to the
rescue of surgical patients who wait a year for new hips
or old people benumbed by drug cocktails, because it has
no role in managing the system beyond its constitutional
Improving social services
responsibilities for certain groups (First Nations and Inuit,
federal inmates, the RCMP and members of the armed
forces). Second, it cannot hold the provinces accountable for how they spend federal dollars. Health accords
and other agreements are statements of broad intent, not
enforceable contracts. Once the ink is dry, the money
flows to the provincial consolidated funds and there is no
realistic way either to trace the dollars from their origins
to their putative destinations or to tie contributions to
performance. Third, the federal government cherry-picks
areas in which to invest at its peril — it is the height of
presumption for the federal government to substitute
its judgment about what the jurisdictions need for their
judgment, and it is unlikely that priorities will be identical
everywhere. Fourth, there will be zero appetite for new
programs like universal pharmacare without long-term,
ironclad cost-sharing commitments. Fifth, Ottawa must be
sufficiently humble and wise to resist oversimplified and
inaccurate diagnoses of the problem (too few doctors,
not enough imaging machines) that precipitate massive
spending on the wrong solutions.
Applying these lessons would appear to leave Ottawa
no place at the table, especially in the current environment, where federal-provincial relations are at a low
ebb. But this conclusion would be premature: there are
important and unoccupied niches that would best be
pursued on a national basis. In a well-functioning
federal state, responsibilities accrue to the
level of government best positioned to
fulfill them. Some should be devolved
and some should be centralized. A
corollary is that in some cases, uniformity doesn’t matter (indeed it
may be counterproductive), while
in others, it is critically important.
It is essential to have a uniform
railway gauge and a single census. It would serve no purpose for
Ottawa to be in charge of municipal
zoning by-laws or to impose uniform
liquor tax rates.
We have a persistently mediocre system
alongside a much
diminished federal role.
Where, then, is the promising
federal space in health care? The
biggest unmet need is intelligence: the
provision of meaningful, real-time information to help clinicians, patients, managers, and governments make better decisions.
Health care systems are immensely complex, with
thousands of moving parts. They are all vulnerable to
major and unjustified variations in what is done, how it
is done, and what all the activity achieves. In my city, Saskatoon, a woman who has breast cancer and is operated
on at Royal University Hospital will most likely have
istock
POLICY OPTIONS
MARCH-APRIL 2015
13
Steven Lewis
Ottawa
should lead the world
in accessibility of information
so patients can make informed
about their care.
a lumpectomy. If she goes to St. Paul’s Hospital she will
almost certainly have a radical mastectomy. Patient-centred
and self-aware systems are alarmed by unwarranted variation and use high-quality information to support improvement. In Canada, clinical practice is highly autonomous.
Few clinicians know whether their practices differ from
their peers’, and no one is responsible for examining, let
alone reducing the variations.
National agencies like the Canadian Institute for
Health Information (CIHI), the Canadian Patient Safety Institute, Canada Health Infoway and the Canadian
Foundation for Healthcare Improvement have mandates
to make the system smarter but their impact is limited, for
reasons beyond their control. CIHI is a classic product of
a dysfunctional federalism. It is funded mainly by Ottawa
but governed mainly by provincial public servants or their
nominees. The provinces’ agreement to send data to CIHI
is always contingent, and the quid pro quo is to take blunt
and fearless truth-telling off the table. Canadian governments’ reluctance to disclose and publicize the sobering
truth about health care performance weakens the case for
the transformative change to which they routinely pay lip
service, but never achieve.
We need a federal political debate around health care
that speaks to the government’s role in telling the truth to
Canadians about its performance and strategically investing
in culture change. Whether cash transfers to the provinces
escalate by 6 percent, 4 percent or 0 percent annually will
not make one whit of difference to the quality, timeliness or
efficiency of care if the culture remains intact. The mantra
and core strategy of high-performing systems is data-driven,
continuous improvement. Clinicians seek and use data to
refine their practices, eliminate useless and harmful interventions, and improve patients’ experiences. System leaders
align policies and incentives to quality and efficiency goals.
Hierarchy, tradition and the convenience of providers count
less; evidence and the needs of patients count more. Nothing is sacred, and transparency trumps the sensitivities of
insiders. An open health information culture is to health
care what the fourth estate is to democracy.
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OPTIONS POLITIQUES
MARS-AVRIL 2015
decisions
If promoting such a culture is Ottawa’s principal job, it
will have to reconceive its partnership with the provinces
and rethink its investment strategy. Its cash transfers should
be conditional on the provinces agreeing to a new charter
that ushers in a new world of health-information-system development, analysis and enhanced public reporting. Federal
agencies should be liberated to describe reality as it is and be
governed by champions of transparency. The government
should invest substantially in health intelligence centres
across the country and user-friendly information portals
accessible to providers and the public. Ottawa should aspire
to lead the world in ensuring that the public and patients
have access to all relevant information to help them make
informed decisions about their own care. Unencumbered by
the responsibility to deliver health care beyond its constitutionally mandated obligations, Ottawa is uniquely posi­
tioned to talk directly to the citizenry. Its commitment to
seeking truth and disclosing it unvarnished has the potential
to generate what has hitherto been lacking: an engaged and
informed public that demands better.
The party that throws down the intelligence gauntlet with
skill and passion will begin to reframe health care federalism.
That would be a public service in itself. The health information debate is an entry point to the larger discussion of the
role of science in policy-making, the relationship of government with the research community, and whether governments or citizens are the rightful owners of government-­held
data. If health information is vital infrastructure, its architecture and use should be thoughtfully designed, continuously
improved and standardized. Canada generates a lot of health
care data but not much actionable health information.
Sunk costs are high and returns are low. A system steeped in
ignorance of its performance, denial about its defects and
overconfident in its ability to self-correct cannot spend its
way to greatness. The federal government should be the system’s microscope, mirror and confessor. To the extent that
it works at all, the health care system succeeds in spite of its
information system. Only with federal leadership, resolve
and investment will it improve because of it. n