It hardly needs saying that Canadian health care is in an unhealthy state.
Some 6.5 million Canadians lack access to primary health-care providers. Waitlists for many essential services are long, and data on wait times often inadequate. Doctors and nurses have been exiting the country, their professions or public sectors jobs in high numbers.
The vast majority of Canadians now say they support major health-care reform and would like to see immediate action.
The question is: what should reform look like?
Few Canadians are better qualified to opine than cardiac surgeon Dr. Hugh Scully. Scully helped implement successful reforms in cardiac care in Ontario in the 1980s and 1990s — reforms that remain in place today, not only in Ontario but across the country.
Scully’s lengthy CV includes time as professor of surgery and health policy at the University of Toronto, president of the Canadian Medical Association, president of the Ontario Medical Association and former chief negotiator for the medical profession with the government of Ontario, alongside many decades of practice at Toronto General Hospital.
Canadian Affairs Publisher and Editor Lauren Heuser sat down with Scully to get his views on what Canada’s health-care reform efforts should prioritize.
LH: You have previously spoken about successful health-care reforms that took place at the level of subspecialties like cardiac care and cardiology. Can you tell me about those reforms and what made them successful?
HS: You may remember in the late ‘80s there were headlines about waitlists for cardiac surgery and cardiologists. A group of us got together … and formed the Cardiac Care Network of Ontario. We introduced an accountability [system] for the services rendered.
We interviewed the 72 cardiac surgeons in Ontario, some of whom had long waitlists, some of whom did not. We’d say, ‘Why do you have long waitlists?’ Invariably, the answer was, ‘Because I’m very good.’
I said, ‘Prove it to me.’ And they showed us their results. […]
[Ultimately], an officer was placed in each of the hospitals who was responsible for looking at these physicians’ wait times, surgery results, time in the operating room, time in recovery, complications developed, the number of patients who returned to the hospital [and other factors].
An annual report was created for each surgeon and cardiologist at each hospital. If doctors met the standard, their funding was renewed. If they exceeded the standards, they were [rewarded]. If they didn’t meet them, they were given the chance to improve … if they then still didn’t meet the standards, they would be reviewed to determine whether they were still qualified to practice.
What happened over a course of years is we eliminated the waiting lists. Over 10 years, we saved $1 billion that could be used for other areas in health care … The honesty of the billing procedures improved significantly … And at the end of the day, the patients were the beneficiaries.
That organization still exists today — there is still the accountability for all of coronary surgery. By the end of the ‘90s, our results were as good or better than anywhere else in the world.
LH: Have these reforms been taken up in other provinces and other subspecialities?
HS: It was taken up across the other provinces — the results have been applied across the country within the discipline of heart care.
How do individual physicians or hospitals or individual provinces become accountable? That’s still a work in progress.
What is missing in the system is accountability. The provinces expect a certain amount of funding from the government. But there is still not a dependable way of accounting for how those funds are spent.
If we [can introduce accountability], I am confident we can do a lot more with public funding than we’re able to do at the present time.
I’ve also come around to believing that the best way to pay physicians at any level is a salary with benefits … I have yet to speak to more than one or two physicians who would not prefer to be on a regular salary. Physicians can budget their lives around that. Stabilizing that compensation system will be much more efficient.
LH: In an interview with Canadian Affairs regarding her upcoming book, Dr. Jane Philpott, a former health minister and dean of health sciences at Queen’s University, argued that Canadians should be guaranteed family physicians — just like a student is guaranteed access to a teacher regardless of where their family lives. Is that idea feasible? If not, what do you think would need to change to make that happen?
HS: First, let me say that Dr. Jane Philpott is really a leader in health care. She is one of the few physicians who has been a leader in the policy arena as well. She is very creative.
As to whether physicians can be assigned, we don’t have enough of them. In terms of physician-to-population ratio, this country is low on the scale.
Both in family practice and specialties, the demand for paperwork is completely out of control … People are beginning to leave the profession because of that paperload … One of my colleagues, [who is a global leader in his field], spends more time on paperwork than in operations. That’s a ridiculous waste of time and effort. That’s an error that needs to be addressed.
We also need to address the workforce issue. Both male and female physicians are generally working fewer hours than they used to. [When I was in the early years of my practice], we were working well over 100 hours a week. That’s ridiculous, and shouldn’t be demanded of anybody. [But it means] we do need to have more physicians, and we need them in many areas.
LH: Why is it that medical schools cannot increase the number of students they admit into their programs?
HS: It’s not up to the medical schools. The government regulates how many students universities can admit — it’s worked out between the government, universities and hospitals.
Provinces have cut back on the number of students funded in these schools, while our population has grown.
We also need to have more nurse practitioners and nurses. And there needs to be a better understanding between doctors and the nursing profession.
LH: There have been recent reports about high attrition rates from the nursing profession and a growing reliance on nurse staffing agencies. Is the reliance on such agencies a problem?
HS: The premier of Ontario restricted nurses’ pay increases to two per cent a year, at a time when the cost of living was rising steadily. So many nurses [left for private agencies.] They are still in the hospitals, but being paid significantly more now.
Hospitals and the like are working with fixed budgets. If they have to move to paying for more highly paid individuals working with staff agencies, then they have to cut back on other services. That’s a huge issue. The private services are providing an invaluable service, but it’s not a fix.
LH: Are there other countries that have health systems you think are worth emulating, either because they have achieved better accountability mechanisms or outcomes for spending?
HS: I recently was very honoured to give a guest lecture at Cambridge University on the role of physicians in health care. In preparation for that, I looked at the UK’s system. And it turns out they have even bigger problems than we have.
The Scandinavian countries have done health care very well. In those countries, there are more physicians per capita. There is a more realistic expectation from families about what they can expect and should be able to access.
LH: You mentioned previously all the stakeholders who had to come together to achieve reform in the cardiac surgery and cardiology subspecialties. Who are the key players that need to be at the table to achieve health-care reform?
HS: There needs to be representatives from across the disciplines — physicians, nurses, nurse practitioners, [and professionals in] rehab, physio, psychology and support of the elderly.
LH: And from the government?
HS: At the government level, the average life expectancy of a deputy minister of health is now 18 months. How do you get someone to get on board with reform when that takes five to 10 years?
LH: With that in mind, do you have any optimism about health-care reform being possible?
HS: I am optimistic, because there is more and more talk about accountability at all levels.
This interview has been edited and condensed for clarity.
Our health care system is rather depressing. I wish I could be as optimistic as Dr. Scully. I am a retired family physician and can relate to the frustrations and stressors on Canada’s family physicians today. It was not unusual for doctors of my era to work 80 to 100 hours a week. We took care of our patients in the hospital, assisted in surgeries, delivered babies and did house calls. As hectic as this sounds we didn’t have the myriad of forms and tons of paperwork to do as today’s family physicians must face. Something has to change but I am not sure what the answer is. Yet we are living longer than ever, in spite of the decreased access to medical services. Are we panicking unnecessarily?
What should health care reform look like? Dr Scully says accountability is the key. Set hard targets and eliminate wait lists; reward good performers and punish sluggards. What we need is a no-nonsense, business-like approach.
When Dr Scully was in the UK, did he ask about the history of targets and wait lists there?
Tony Blair came to power in 1997 on a promise to fix the NHS. The “internal market” developed by the old Tory government — choice is a holy word for free marketeers — would go. Wait lists, some longer than 18 months, would be slashed. Funding would be increased enormously. To his great credit, Blair had the courage to tell voters that taxes would need to rise, and they agreed.
Health care budgets got heroic increases. Administrators developed a rigorous system of inspections and standards. To ensure accountability they developed targets galore, like a four-hour deadline for treating 98% of emergency admissions and a nine-month limit on surgical wait lists. These targets were enforced by “fierce performance management,” said Hannah Brown, then a senior editor at The Lancet.
And it worked. Wait lists plummeted. The enormous cash infusion was gratefully welcomed.
But all was not peaceful in Blair’s Cool Britannia. “It was management by terror”, said Julian Le Grand, a government health adviser. The heavy focus on specific targets led to “fiddling the figures and gaming—changing things around a bit to make sure you meet the target”. Health care workers were demoralized. Current and former Econ 101 students will get a strong smell of Taylor-Fordism in all of this. Britains’ doctors didn’t respond happily when treated like workers on a production line.
By 2002 it was obvious the reforms had failed. An emphasis on accountability and hard targets were seen as analogous to a wartime centrally planned economy: they had swept away some anachronisms and even supercharged performance by predefined measures; but ultimately they distorted the system badly. Blair’s government abandoned targets and moved towards softer measures of performance that focused on patient experiences and outcomes.
Hard targets have their uses. They allow managers to easily compare data for common medical procedures and interventions like the cardiology procedures addressed by Dr Scully and his colleagues. But they are no panacea. I work in palliative care. How would you hold me accountable? What should my targets be? During my last years in hospital acute care I was under more and more pressure to discharge patients prematurely and turn over beds quickly (the higher the turnover rate the greater the complaints from patients and the lower our morale, just like health care workers in Blair’s NHS). In palliative care most of my patients get a celestial discharge; should I ask them how they feel about a faster throughput?
We can learn from Britain’s attempt to impose accountability through targets. A mechanistic, nuance-free, money-first approach to health care will always fail. An economist once told me that he could tell me the price of everything and the value of nothing. Years ago the policy analyst Donald Savoie asked, Whatever Happened to the Music Teacher? Turns out that musical training has lousy measurables compared to science / math / technology. Perhaps we should accept that a good education, a good person, and a good health care system all resist tidy definition and mechanistic management. If you operate education or health care systems like production lines, you do so at your peril. Or rather, the students’ and patients’ peril.
So yes, we want and need accountability. But let’s show some humility, let’s be cautious about implementing policies to get there.