Why are we not achieving lasting results in reforming the Canadian health system?

Johny Van Aerde, MD, PhD

 

EDITORIAL

Back to Index

Almost daily, there is a news story about interactions between a provincial government and physicians or their representative organizations. The variety is striking, ranging from collaborative conversations around what a sustainable health care system might look like to openly hostile confrontations.1-5 Why such a wide spectrum? Why are tangible results for sustainable transformation of our health system absent to limited, even in provinces where dialogue continues? A new vision for the Canadian health care system is urgently needed, a vision that is both inspirational and truly owned by each and all.

 

“Where there is no vision, the people perish” (Proverbs 29:18). Since the introduction of medicare, and even more so since the inception of the Canada Health Act, the vision of what health care means for Canadians has become more and more muddled. All stakeholders — government, citizens, patients, physicians, and other health care professionals, alike — have different agendas. To set a common direction for the health care system in provinces and territories, Canadians urgently need to redefine the purpose of medicare and determine what health care and its supporting system mean.6 Top

 

LEADS makes it very clear that, without a vision that sets direction, results cannot be achieved. LEADS is a leadership framework with five domains: lead self, engage others, achieve results, develop coalitions, and systems transformation.7 Each domain has four capabilities. The first capability under achieve results is “set direction,” which is defined as “inspire vision by identifying, establishing and communicating clear and meaningful expectations and outcomes.”8 The gridlock in many jurisdictions of our country is simply due to a lack of common vision. As a result, there is no inspiration and no ownership by stakeholders. Top

 

Canadians have inherited a health care system from the past — one that none of us owns today. “Vision can be leader-driven… or created collaboratively by engaging members of the organization; the latter approach is generally the most effective way to win broader acceptance for a vision.”8 Indeed, we own what we help create.7 By collaborating to revisit the vision and direction of the Canadian health care system, we, the stakeholders, would truly own what we help create. Top

 

Therein lies a double problem: we fail in our efforts to recreate a common vision on what health care should look like and we rely on something we don’t own, because we didn’t create the present system which is based on last century’s needs. What worked 50 years ago for care in local hospitals and physicians’ offices no longer applies in the health care world of the 21st century. Today’s demands have changed under pressure from an aging population, from patients with multiple chronic rather than acute diseases, and from a huge health care industry driving the system’s costs into oblivion.9

 

Ownership involves engagement at a systemic level, and that systemic engagement is lacking among all stakeholders. Politicians “own” health care only for the duration of a short election cycle; thus, long-term sustainable visions and changes lose to quick fixes to please the electorate. Over the last few decades, evidence indicates that governments are one of the two biggest obstacles to health care policy reform.10 Top

 

The provincial organizations representing physicians are the second biggest obstacle.10 Whereas physicians are the best advocates for each patient’s care, one at a time, they rarely engage in their patients’ care at a systemic level.11 Physicians don’t act as if they have much ownership of the system. Top

 

Finally, as tax payers, Canadians may “own” the system, but as consumers, they don’t. Indeed, citizens and patients want to ensure that their individual needs are served first, irrespective of the effect on the community. In an attempt to apply the principles of consumerism in a universal health care system and encouraged by an entire health care industry that contributes to employment and the economy, the system is moving toward a “tragedy of the commons.”12 The lack of feeling of personal ownership of the resource is leading to overuse, eroding it until it becomes unavailable to anyone.12 Top

 

Visions must be inspirational to trigger our passion for pursuing a better world.7 How inspiring is the 50-year old vision of our Canadian health system? How can we become passionate about something in which stakeholders in many provinces cannot find common ground or when consumers take its existence for granted? Many Canadian jurisdictions default to an American vision of health care: “triple aim,”13 i.e., better care, improved health, lower costs. Although attempts are being made to adhere to this view, the self-interests of stakeholders prevent those values from translating into the inspirational common vision needed to generate passion and set a direction toward action and real results.

Without a vision, the conditions for three further capabilities under LEADS’s achieve results domain cannot be met. Vision is needed to set direction, decisions then have to be strategically aligned with that direction and the available evidence, then action must be taken to implement those decisions, while, in the meantime, assessment and evaluation are needed to monitor the long-term outcomes. Until we practise the leadership skills necessary to achieve results, we will continue to tinker with issues, such as wait times and unproven practices of regionalization, rather than deal with the sustainable system transformation needed to improve Canada’s ranking in OECD health statistics. Top

 

According to the LEADS framework, one of the basic leadership skills needed is “set direction to achieve results.”7 As long as we avoid the conversation on the purpose of our health care system, it will continue to move toward collapse.14 As physician leaders, elected leaders, and citizen-patient leaders, it behooves us to have those difficult conversations. Will the real leaders step up? Top

 

References

1.Mark D. Another vote for “no” in Ontario. Toronto: Canadian Healthcare Network; 2016. Available: http://tinyurl.com/huuveaf (accessed 16 July 2016).

2.Collins L. The “new” anger among Ontario physicians (editorial). Medical Post 2016: 21 June.

3.Jayabarathan A. Taking one for the team: why I voted yes to the Nova Scotia fee deal. Toronto: Canadian Healthcare Network; 2016. Available: http://tinyurl.com/zwm9us8 (accessed 2 July 2016).

4.The future physician role in a redesigned and integrated health system. Saskatoon: Saskatchewan Medical Association; 2016. Available: http://tinyurl.com/hf22c3x (accessed 28 July 2016).

5.Supporting facility-based physicians. Vancouver: Doctors of British Columbia; 2016. Available: http://tinyurl.com/zdmpfac (accessed 2 July 2016).

6.Picard A. The path to health care reform: policy and politics. Ottawa: Conference Board of Canada; 2012. Available: http://tinyurl.com/p4y9grn (accessed 22 Jan 2016).

7.Dickson G, Tholl B. Bringing leadership to life in health: LEADS in a caring environment. New York: Springer; 2014.

8.O’Connell D, Hickerson K, Pillutla A. Organizational visioning: an integrative review. Group Organ Manage 2011; 36(1):103-25.

9.Reinhardt U. Why we should bend the cost curve and how. In: Marchildon G, Matteo L, editors. Bending the cost curve in health care. Toronto: University of Toronto Press; 2015.

10.Lazar H, Lavis J, Forest PG, Church J. Paradigm freeze: why it is so hard to reform health-care policy in Canada. Kingston: McGill-Queen’s University Press; 2013.

11.Bujak J. How to improve hospital-physician relationships. Front Health Serv Manage 2003; 20(2):3-21.

12.Meadows D. Thinking in systems. Vermont: Chelsea Green; 2008.

13.Triple aim for populations. Cambridge: Institute for Healthcare Improvement; 2016. Available: http://tinyurl.com/zmgzmg3 (accessed 28 July 2016).

14.Van Aerde J. Panarchy, the collapse of the Canadian healthcare system, and physician leadership. Can J Phys Leadership 2(4):103-9.

15.OECD health statistics 2016. Paris: Organisation for Economic Co-operation and Development; 2016. Available: http://tinyurl.com/m4xzzg8 (accessed 29 July 2016).

 

Author

Johny Van Aerde, MD, MA, PhD, FRCPC, is editor-in-chief of the CJPL and past-president of the Canadian Society of Physician Leaders.

 

This article has been reviewed by a panel of physician leaders.

Top

 

Visions must be inspirational to trigger our passion for pursuing a better world.7 How inspiring is the 50-year old vision of our Canadian health system? How can we become passionate about something in which stakeholders in many provinces cannot find common ground or when consumers take its existence for granted? Many Canadian jurisdictions default to an American vision of health care: “triple aim,”13 i.e., better care, improved health, lower costs. Although attempts are being made to adhere to this view, the self-interests of stakeholders prevent those values from translating into the inspirational common vision needed to generate passion and set a direction toward action and real results.

Almost daily, there is a news story about interactions between a provincial government and physicians or their representative organizations. The variety is striking, ranging from collaborative conversations around what a sustainable health care system might look like to openly hostile confrontations.1-5 Why such a wide spectrum? Why are tangible results for sustainable transformation of our health system absent to limited, even in provinces where dialogue continues? A new vision for the Canadian health care system is urgently needed, a vision that is both inspirational and truly owned by each and all.

 

“Where there is no vision, the people perish” (Proverbs 29:18). Since the introduction of medicare, and even more so since the inception of the Canada Health Act, the vision of what health care means for Canadians has become more and more muddled. All stakeholders — government, citizens, patients, physicians, and other health care professionals, alike — have different agendas. To set a common direction for the health care system in provinces and territories, Canadians urgently need to redefine the purpose of medicare and determine what health care and its supporting system mean.6 Top

 

LEADS makes it very clear that, without a vision that sets direction, results cannot be achieved. LEADS is a leadership framework with five domains: lead self, engage others, achieve results, develop coalitions, and systems transformation.7 Each domain has four capabilities. The first capability under achieve results is “set direction,” which is defined as “inspire vision by identifying, establishing and communicating clear and meaningful expectations and outcomes.”8 The gridlock in many jurisdictions of our country is simply due to a lack of common vision. As a result, there is no inspiration and no ownership by stakeholders. Top

 

Canadians have inherited a health care system from the past — one that none of us owns today. “Vision can be leader-driven… or created collaboratively by engaging members of the organization; the latter approach is generally the most effective way to win broader acceptance for a vision.”8 Indeed, we own what we help create.7 By collaborating to revisit the vision and direction of the Canadian health care system, we, the stakeholders, would truly own what we help create. Top

 

Therein lies a double problem: we fail in our efforts to recreate a common vision on what health care should look like and we rely on something we don’t own, because we didn’t create the present system which is based on last century’s needs. What worked 50 years ago for care in local hospitals and physicians’ offices no longer applies in the health care world of the 21st century. Today’s demands have changed under pressure from an aging population, from patients with multiple chronic rather than acute diseases, and from a huge health care industry driving the system’s costs into oblivion.9

 

Ownership involves engagement at a systemic level, and that systemic engagement is lacking among all stakeholders. Politicians “own” health care only for the duration of a short election cycle; thus, long-term sustainable visions and changes lose to quick fixes to please the electorate. Over the last few decades, evidence indicates that governments are one of the two biggest obstacles to health care policy reform.10 Top

 

The provincial organizations representing physicians are the second biggest obstacle.10 Whereas physicians are the best advocates for each patient’s care, one at a time, they rarely engage in their patients’ care at a systemic level.11 Physicians don’t act as if they have much ownership of the system. Top

 

Finally, as tax payers, Canadians may “own” the system, but as consumers, they don’t. Indeed, citizens and patients want to ensure that their individual needs are served first, irrespective of the effect on the community. In an attempt to apply the principles of consumerism in a universal health care system and encouraged by an entire health care industry that contributes to employment and the economy, the system is moving toward a “tragedy of the commons.”12 The lack of feeling of personal ownership of the resource is leading to overuse, eroding it until it becomes unavailable to anyone.12 Top

 

Visions must be inspirational to trigger our passion for pursuing a better world.7 How inspiring is the 50-year old vision of our Canadian health system? How can we become passionate about something in which stakeholders in many provinces cannot find common ground or when consumers take its existence for granted? Many Canadian jurisdictions default to an American vision of health care: “triple aim,”13 i.e., better care, improved health, lower costs. Although attempts are being made to adhere to this view, the self-interests of stakeholders prevent those values from translating into the inspirational common vision needed to generate passion and set a direction toward action and real results.

Without a vision, the conditions for three further capabilities under LEADS’s achieve results domain cannot be met. Vision is needed to set direction, decisions then have to be strategically aligned with that direction and the available evidence, then action must be taken to implement those decisions, while, in the meantime, assessment and evaluation are needed to monitor the long-term outcomes. Until we practise the leadership skills necessary to achieve results, we will continue to tinker with issues, such as wait times and unproven practices of regionalization, rather than deal with the sustainable system transformation needed to improve Canada’s ranking in OECD health statistics. Top

 

According to the LEADS framework, one of the basic leadership skills needed is “set direction to achieve results.”7 As long as we avoid the conversation on the purpose of our health care system, it will continue to move toward collapse.14 As physician leaders, elected leaders, and citizen-patient leaders, it behooves us to have those difficult conversations. Will the real leaders step up? Top

 

References

1.Mark D. Another vote for “no” in Ontario. Toronto: Canadian Healthcare Network; 2016. Available: http://tinyurl.com/huuveaf (accessed 16 July 2016).

2.Collins L. The “new” anger among Ontario physicians (editorial). Medical Post 2016: 21 June.

3.Jayabarathan A. Taking one for the team: why I voted yes to the Nova Scotia fee deal. Toronto: Canadian Healthcare Network; 2016. Available: http://tinyurl.com/zwm9us8 (accessed 2 July 2016).

4.The future physician role in a redesigned and integrated health system. Saskatoon: Saskatchewan Medical Association; 2016. Available: http://tinyurl.com/hf22c3x (accessed 28 July 2016).

5.Supporting facility-based physicians. Vancouver: Doctors of British Columbia; 2016. Available: http://tinyurl.com/zdmpfac (accessed 2 July 2016).

6.Picard A. The path to health care reform: policy and politics. Ottawa: Conference Board of Canada; 2012. Available: http://tinyurl.com/p4y9grn (accessed 22 Jan 2016).

7.Dickson G, Tholl B. Bringing leadership to life in health: LEADS in a caring environment. New York: Springer; 2014.

8.O’Connell D, Hickerson K, Pillutla A. Organizational visioning: an integrative review. Group Organ Manage 2011; 36(1):103-25.

9.Reinhardt U. Why we should bend the cost curve and how. In: Marchildon G, Matteo L, editors. Bending the cost curve in health care. Toronto: University of Toronto Press; 2015.

10.Lazar H, Lavis J, Forest PG, Church J. Paradigm freeze: why it is so hard to reform health-care policy in Canada. Kingston: McGill-Queen’s University Press; 2013.

11.Bujak J. How to improve hospital-physician relationships. Front Health Serv Manage 2003; 20(2):3-21.

12.Meadows D. Thinking in systems. Vermont: Chelsea Green; 2008.

13.Triple aim for populations. Cambridge: Institute for Healthcare Improvement; 2016. Available: http://tinyurl.com/zmgzmg3 (accessed 28 July 2016).

14.Van Aerde J. Panarchy, the collapse of the Canadian healthcare system, and physician leadership. Can J Phys Leadership 2(4):103-9.

15.OECD health statistics 2016. Paris: Organisation for Economic Co-operation and Development; 2016. Available: http://tinyurl.com/m4xzzg8 (accessed 29 July 2016).

 

Author

Johny Van Aerde, MD, MA, PhD, FRCPC, is editor-in-chief of the CJPL and past-president of the Canadian Society of Physician Leaders.

 

This article has been reviewed by a panel of physician leaders.

Top