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.
~Dr. Patrick McGrath