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The Health System is a Hodge Podge


Hodge Podge


It is often said that the Canadian health system is not one system but 13 systems. This is because the Constitution Act, often referred to as the British North America Act of 1867, gave the major authority over health to the provinces and territories. The provinces were given the job of establishing, maintaining and managing hospitals, asylums, charities and charitable institutions, whereas the federal government was given responsibility for marine hospitals and quarantine.

Although there are similarities across the provinces, each province organizes health care a bit differently.

The longer I work in the health system, I realize it is neither one nor 13 systems. It is a collection, not a system.  A system is a coordinated and organized set of methods or plan.   A collection is something that is accumulated especially for some purpose or as the result of a process.  Hodge podge describes health care in Canada pretty well. Hodge podge is a wonderful Nova Scotian vegetable stew. I love it. But a hodge podge is also a confused and disorderly collection of things, a mess or a jumble.

There is no system, even within a given province. For example, in Nova Scotia, there are hospitals, clinics and doctor’s offices scattered throughout the province. They all have a similar purpose, to provide health care to Nova Scotians.  They are all paid from the public purse; they all require some form of provincially sanctioned credentialing.

But they are not coordinated and organized in a provincial plan, using the same methods. The care a patient with the same problem gets in Yarmouth may or may not be the same as he or she will get in Windsor, Sydney or Halifax. That would not be a problem if we didn’t have any scientific evidence about what drugs or procedures work best. But we have decades of accumulated evidence that in many cases points to specific evidence-based diagnostics and treatments. Practice variation means that care is not always appropriate.

The Organization for Economic Cooperation and Development has recently released Geographic Variations in Health Care. They see practice variation that is not due to variations in the need of the population is a serious, persisting problem.

But it is not just what health care is given that is a hodge podge. The fact that we have 50 or so collective agreements covering health care workers is a testament to the fact that health care is a collection not a system. Even doctors are paid in very different ways. Some are paid on a fee for service basis, some are paid in an academic funding plan, some are paid in other alternative funding plans and a small number are paid a salary. Ten different health authorities for less than a million people also speaks to the nature of our health care hodge podge.

Our health care system shares some information, but not in any co-ordinated way. Your health record may or may not be available to other health care workers that you consult. Tests are often redone because information is not available.


Are we making progress in turning our collection of health care into a system?  Yes, I think we are making small steps in the right direction. The reduction from 10 to 2 health authorities could make care more co-ordinated. The plan is to eventually have a single electronic health record for all Nova Scotians.  If it is ever implemented, it could be very helpful.

None of these will necessarily change our collection of health care to a system of health care.

I am not a fan of US health care. It is even more expensive and less effective than Canadian health care (see my blog on Canada’s Health System:  Are we making the grade?). However, the US Institute of Medicine has developed a very credible roadmap for health care. The most detailed description is the 2012 report Best Care at Lower Cost: the Pathway to Continuously Learning Healthcare in America.

The characteristics of a Continuously Learning Health care System are:

  • Real time access to knowledge e.g. guidelines integrated into the electronic health record and other evidence available in a usable form for all.
  • Electronic capture of the care experience. E.g. all health care captured in one easy to use record
  • Engaged empowered patients. g. a patient and family oriented system that informs and encourages the patient and families to be active in the decision making around health care.
  • Incentives aligned for value. E.g. recognition and payment that discourages good health care eliminated
  • Full transparency so that the rules are open and clear
  • Leadership instilled culture of learning
  • Continuously improving the health care system through collecting information on outcomes important to the patient and on patient feedback

These items seem pretty obvious but they would go a very long way in improving our health care system.

We don’t need a hodge podge of a health system. We should enjoy hodge podge at lunch and go for a Continuously Learning Health care system.



A recipe for Hodge Podge

~Dr. Patrick McGrath


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The Next Innovation

The Next Innovation                                                                                                     

By James Hughes – Guest Blogger

Our foundation hosted a workshop recently at which numerous remarkable Canadian innovations and initiatives in the mental health field were showcased. One featured the school superintendent for Red Deer, Alberta who, following a number of deeply saddening student suicides, led the adoption of a school board wide mental health screening tool. Every one of the almost 4000 children in the high schools managed by the school board was screened using evidence based assessment tools loaded into an ipad. Those who screened for mild or moderate mental illness were referred to evidence based online tools the school board had licensed from Europe. Those who screened for serious illness with suicidal ideation were immediately met by school staff (the parents were met as well) and referred to professional resources for follow up. About 1% of the children were at serious risk thus about 40 kids and families were met within 24 hours of the results coming in. The superintendent noted that half of these kids were not known by either the school or the parents to be facing any serious difficulties whatsoever.

Another initiative highlighted was a telephone based coaching service based in Halifax that is serving thousands of families whose kids (usually 6 to 12 years old) have significant behavioural challenges or anxiety. Professionally trained coaches work systematically with parents to equip them through a structured process over a dozen weeks to stabilize the specific problems the children are experiencing. The evidence has shown that the coaching service is effective not only from symptoms and functionality standpoints but is cost effective as well.

Strong evidence from Canada and abroad also shows clinical and cost effectiveness of supported employment programs for adults, early psychosis intervention, psychotherapy, assertive community treatment, integrated service delivery and others.

So, why are these programs and others like them, which improve outcomes for patients and can produce financial returns for government, not implemented across our healthcare systems? Only 1 in 4 young Canadians gets access to the mental health services they need. The quality of the services the lucky few receive is very uneven. Outcomes are not event tracked.  A presenter at the workshop told us that Canada is world class in creating innovations but has near failing grades in scaling up innovations across systems. What is blocking the progress of bringing proven knowledge and evidence based practice to all those who have or are at risk of mental illness?

This is the million dollar question but there are millions of Canadians suffering with mental illness whose voices have yet to be fully organized, channelled and amplified so that they may truly be heard by the politicians who, despite the best of intentions, seem to be deaf to their plight. It was patients that led the charge that transformed cancer and HIV care. Perhaps this is innovation that needs to be created next: the effective patient and family vehicle that transforms mental health care in Canada. I know the philanthropic sector would be supportive of such a potentially transformational initiative as this.


James Hughes is the President of the Graham Boeckh Foundation (GBF). GBF’s mission is to catalyse transformational change in the mental health services with a view to improving the lives of those with or at risk of mental illness.