Needed: physician leaders
Johny Van Aerde, MD, PhD
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Why is the Naylor report doomed, even if those who commissioned it had supported it? This article refers to new evidence of the link between creative health care reform, government involvement, and quality of care. Based on this analysis, it looks at what role physicians can and should play in health care reform.
No one will blame you if you missed it. Most Canadians did! The Naylor report,1 Unleashing Innovation, was released and shelved faster than the New Horizons probe flew past Pluto.
A year ago, the federal government commissioned the report, but, when the time came, the same government canceled its press release. The report’s existence was announced tepidly on a Friday afternoon in the middle of a hot, lazy summer, with no scheduled parliamentary sessions until after the federal election. The media opined on why this announcement was followed by a roaring political silence.2,3 Top
The Naylor report is a synthesis of quantitative and qualitative evidence obtained from the literature; from conversations with thousands of Canadians who deliver, administer, and use our health care system; from entrepreneurs in business and industry; and from new research commissioned specifically for this report.
This information was carefully analyzed and reflected on by a group of knowledgeable people from the worlds of academia, health care, and business, led by Dr. David Naylor, past-president of the University of Toronto. The committee’s mandate was to identify the five most promising areas of innovation in terms of reducing growth in health spending, creating financial sustainability, and improving accessibility and quality of care. It was also charged with recommending five ways in which the federal government could support innovation in these areas.
The more than 150-page report is well written. It provides clear definitions of all words that could be open to misinterpretation, and it contains a good summary of the evolution and history of the Canadian health care system. It goes on to identify key themes emerging from the research and how they were derived. It also contains information on present and potential stakeholders affected by the need for innovation. The report describes how all this information was obtained and culminates in thoughtful analyses, reflections, and recommendations made by the committee. Although it contains many warnings that our health system has aged badly and is underperforming compared with other developed countries, it also exudes praise for many positive aspects of potential and ongoing successful local initiatives. Top
The five areas proposed for innovation are:
Although other writers have addressed many of these items previously,6-8 the Naylor report juxtaposes and integrates them. What is new and refreshing are the two actions the report suggests to make these innovations happen: the creation of a new Healthcare Innovation Agency of Canada (HIAC) and a health care innovation fund (HIF). The HIAC would be formed by consolidating and expanding the mandate of the Canadian Foundation for Healthcare Improvement, the Canadian Patient Safety Institute, and, after completion of its current ongoing projects, Canada Health Infoway. It would be an arm’s length organization, without direct governmental influence, with the mandate to manage the flow of dollars from the HIF to “coalitions of the willing.”1
The overall objectives of the HIAC and HIF would be to support high-impact initiatives proposed by stakeholders and governments, to break down structural barriers to change, and to accelerate the spread and upscaling of promising innovations. Allocations would be based on “rigorous adjudication against transparent specifications, having particular regard for measurable impacts on health outcomes, creation of economic and social value, sustainability, scalability, and a commitment by partners to sustain those innovations that are demonstrably successful” (p. 122).1 Top
One of the final sentences in the report reads, “The Panel has been left in no doubt that a major renovation of the system is overdue, and is chagrined and puzzled by the inability of Canadian governments — federal, provincial, and territorial — to join forces and take concerted action on recommendations that have been made by many previous commissions, reviews, panels, and experts” (p. 125–6).1 That triggers the following questions: in general, what are the chances that reviews and recommendations by panels and commissions actually lead to action and, specifically, what are the chances of this policy report surviving, even before it was released and buried?
In Paradigm Freeze, Lazar and colleagues analyze 30 cases from five provinces (Saskatchewan, Alberta, Ontario, Quebec, and Newfoundland) around six representative health policy issues: regionalization, needs-based funding, alternate payment plans around primary care, for-profit delivery, wait times, and drug cost coverage.9,10 In essence, the authors compare the reforms that actually took place with the recommendations set out in well-researched, major reports commissioned by government-appointed commissions, task forces, and advisory councils between 1990 and 2011. Taking the five provinces as a whole, the outcomes of policy reform have been meager with almost no change. Top
In looking at the underlying reasons for the lack of policy reform, the authors note two independent variables that had a major positive influence on reform decisions in the 30 cases: change in government or political leader, when the election platform included health care reform (13/30); and a fiscal crisis or perception thereof (13/30). The barriers to reform were insider interests, mainly of provincial medical associations (27/30), public opinion (9/30), and values Canadians held around their health care system (16/30) as reflected in the medicare model or the Canada Health Act. The influence of media was weak by comparison (4/30). Knowledge from interjurisdictional learning and from the research community worked in favour of placing items on the reform agenda of the government (12/30), but did not necessarily influence the choice of policy. Top
Lazar et al.9 conclude that there has been little fundamental change in Canadian health policy over the past four decades and the interplay of ideas, interests, and federal/provincial institutions has led to a “paradigm freeze” by perpetuating the status quo. The evidence they present suggests that the chances of reform on a very large scale — the type of transformational changes Naylor and other writers advocate — are slim at best. “Without some sort of insurmountable disruptive force, either a major shift in medical science or technology or a catastrophic economic or political crisis, fundamental health policy reform in Canada is unlikely.”9 In short, based on historical evidence across Canada, the Naylor report was doomed even before it was released, no matter how good the content. Top
However, although not the focus of Paradigm Freeze, Lazar et al.9 note that small-scale reform has occurred through the creative efforts of health care professionals and health systems managers, independent of government influence. According to the Naylor report, those same abundant, yet fractionated and dispersed, creative efforts and forces in the Canadian health system could have been integrated and coordinated by an HIAC through collaboration within and between provinces, with the federal government.
Although Lazar et al.9 do not substantiate their statement on creative initiatives without governmental policy and reform, that topic is exactly what Braithwaite et al.11 researched recently. In a study of 30 developed and developing countries, not including Canada, they asked whether big-picture reforms and policies at the national level improve quality of care and patient safety and, if so, how. In all countries, the aim was to enhance delivery of quality health care and, thereby, improve the health system and the health of society. Despite the barriers and rampant inertia against change in all health care systems, people refused to give up and believed that initiatives by those in authority would ultimately have a positive effect. Top
One finding stood out very clearly: the relation between governmental reform policies and quality or safety outcomes at the frontline was absent (or weak, at best) and it was situation-dependent.11 In other words, big reforms, i.e., national or provincial initiatives and policies, are often not well linked to local quality and safety initiatives, and there is no guarantee that any particular reform measure or series of measures will result in improved quality and safety. Politicians’ claims that their reform policy has caused an improvement are often made without any baseline measurement or without a stringent method for measurement.6,11 Similarly, most politicians hide failures; thus, no one learns from the mistakes.6,11 In short, globally, quality and patient safety are influenced most by local initiatives and work by people who are close to the action, where the rubber hits the proverbial health care road, not much or not at all by any national policy or reform initiative. Top
In view of these findings, and given that the Naylor report now lives in the dungeons of Ottawa, our health care system will continue to age with minimal reform — and a real danger of becoming extinct. What can we, physicians, do? How can we play a leadership role in the reform of our health system?
Braithwaite12 found that medical leaders make things happen. Using sophisticated collaborative leadership skills, they have the capacity to influence upper echelons of health systems and policymakers (in some countries even as ministerial advisors). Physicians are also the translators of policies in the health care organizations in which they work. Physicians not only play a key role in running clinical services and in enabling safe care of high quality, they are also the most effective translators and occupy the space between reform policy and organizational functioning and clinical care. Therefore, physician leaders seem to be the key players who can make or break reform,12-15 using modern leadership skills for successful systems transformation.16 Top
Whereas politicians and policymakers tend to employ the tools of management and micromanagement, they do not practise leadership in the area of health care. Braithwaite12 suggests that this is a void into which physicians can and should step. This is where physicians can and have to provide leadership: of health care reform in policy arenas and of clinical care processes leading to quality improvement.12 To optimize the chance for success, physicians must acquire the necessary leadership skills, as identified in a recent study on Canadian physician leadership by the Canadian Society of Physician Leaders (CSPL).17,18
The Naylor report1 also mentions that physicians should take on leadership roles in the innovation and transformation of the Canadian health system: “Canada’s physicians have made huge contributions to healthcare, but the current mode of organizing and funding healthcare is holding them back from a larger leadership role” (p. 7). The CSPL’s study not only revealed this same point, but also, “The lack of training in physician leadership skills was identified as a strong barrier to physician leadership.”17 Top
Our study also found that we like making life miserable for those among us who try to innovate or be creative: “The negative attitude toward medical leaders is present throughout the entire medical system — from medical school through residency to clinical practice — and it is a limiting factor for physicians who want to develop leadership skills and take on leadership roles.”17 Often, this attitude originates from fear of losing the profession’s autonomy when changing from an individual to a systemic level of engagement with health care. This fear is overstated, as there are many examples in the United States health care system of very high-quality organizations — the Mayo Clinic, the Cleveland Clinic, Kaiser Permanente, the Geisinger Health System, Virginia Mason Medical Center, Intermountain Healthcare, and McLeod Regional Medical Center — where each physician fulfills a leadership role and still maintains her or his autonomy, sometimes even within a fee-for-service model.1,19 Top
Our study concluded that “health system transformation toward improved patient care requires physicians to engage in life-long leadership development for which the system will have to find resources. The identified need for learning and for attitudinal changes toward physicians who want to engage in leadership activities constitutes a large void that can be filled by the combined efforts of the CSPL and the CMA’s Physician Leadership Institute. The question is whether the health care system and the organizations within it are willing to make the structural and cultural changes required to make this happen and to free up the necessary time and finances.”17 Top
Because the Canadian health system is complex and, like an aging patient, is becoming less and less adaptive, it may well soon end up on life support. If physicians choose not to become engaged in its reform, it will die. The evidence shows that a federal, collaborative reform policy is unlikely to appear in the foreseeable future; reform initiatives leading to improvement and patient safety are driven locally rather than at a governmental scale; and physicians with modern leadership skills are the natural elements of the health system to take up leadership roles in its transformation. In view of that evidence, we need to ask ourselves how can all physicians develop the skills they need to become engaged as leaders in our health system’s reform? What personal, cultural, structural, or political barriers need to be removed and why? And, finally, how can our organization, the CSPL, help us on the difficult road toward that goal? Think about it, before it is too late! Top
1.Advisory Panel on Healthcare Innovation. Unleashing innovation: excellent healthcare for Canada. Ottawa: Health Canada; 2015. http://www.healthycanadians.gc.ca/publications/health-system-systeme-sante/report-healthcare-innovation-rapport-soins/index-eng.php (accessed 18 July 2015).
2.Picard A. This report is a must-read to diagnose ills of Canada’s health care. Globe and Mail 2015; 22 July. http://www.theglobeandmail.com/news/politics/globe-politics-insider/this-report-is-a-mustread-to-diagnose-ills-of-canadas-health-care/article25626630/ (accessed 22 July 2015).
3.Simpson J. Why a key health-care report was dead on arrival in Ottawa. Globe and Mail 2015; 22 July. http://www.theglobeandmail.com/globe-debate/why-akey-health-care-report-was-dead-on-arrival-inottawa/article25608277/ (accessed 22 July 2015).
4.Jameson JL, Longo DL. Precision medicine — personalized, problematic and promising. N Engl J Med 2015;372:2229-34.
5.Topol E. The patient will see you now: the future of medicine is in your hands. New York: Basic Books; 2015.
6.Marchildon G, Di Matteo L. Bending the cost curve in health care: Canada’s provinces in international perspective. Toronto: University of Toronto Press; 2015.
7.Picard A. The Path to Health Care Reform: policy and politics.Ottawa; Conference Board of Canada; 2012. (accessed July 22, 2015).
8.Simpson J. Chronic condition: why Canada’s health-care system needs to be dragged into the 21st century. Toronto: Allen Pane – Penguin books; 2012.
9.Lazar H, Lavis J, Forest PG, Church J. Paradigm freeze: why it is so hard to reform health-care policy in Canada. Montréal: McGill-Queen’s University Press; 2014.
10.Van Aerde J. Paradigm freeze: why it is so hard to reform health-care policy in Canada. ( book review). Can J Physician Leadership 2014;1(Fall):30-1.
11.Braithwaite J, Matsuyama Y, Mannion R, Johnson J. Healthcare reform, quality and safety. Burlington, Vt: Ashgate Publishing; 2015.
12.Braithwaite J. Health reform: international perspectives. Presented at the International Medical Leaders Forum, Hong Kong, 29 May 2015. http://www.wfmm.org/document-repository/cat_view/26-2015-%20wfmm-leaders-forum-presentation.html (accessed July 22, 2015).
13.Baker R, Dennis JL. Medical leadership in health care systems: from professional authority to organizational leadership. Public Money and Management 2011;31(5):355-62.
14.Spurgeon P, Mazelan P, Barwell F. Medical engagement: a crucial underpinning to organizational performance. Health Serv Manage Res 2011;24(3):114-20.
15.Dickson G, Tholl B. Partnerships for health system improvement (PHSI): leadership and health system redesign. Cross-case analysis final report. Ottawa: CHLNet; 2014. http://chlnet.ca/wp-content/uploads/PHSI-Cross-Case-Analysis-Report-2014.pdf (accessed July 30, 2015).
16.Dickson G, Tholl B. Bringing leadership to life in health: LEADS in a caring environment. New York: Spinger; 2014.
17.Van Aerde J. Understanding physician leadership in Canada. Can J Physician Leadership 2015; 1(4): 30-1. http://www.physicianleaders.ca/assets/cspejournalspring.pdf#page=30 (accessed 5 June 2015).
18.Van Aerde J. What do physicians need to lead? Can J Physician Leadership 2015; 1(spring): 3-7. http://www.physicianleaders.ca/assets/cspejournalspring.pdf#page=3 (accessed 5 June 2015).
19.Van Aerde J. Physician leadership development. Edmonton: Alberta Health Services; 2013. http://www.albertahealthservices.ca/hp/if-hp-phys-physician-leadership-development-report.pdf (accessed 23 July 2015).
Johny Van Aerde, MD, MA, PhD, FRCPC, is editor-in-chief of the CJPL and past-president of the Canadian Society of Physician Leaders. He is clinical professor of pediatrics at the University of British Columbia and the University of Alberta and an associate faculty member at the School for Leadership Studies at Royal Roads University in Victoria. He is also on the faculty of the CMA Physician Leadership Institute.
This article has been reviewed by a panel of physician leaders.