Could Saskatchewan become the best place in the world to practise medicine?
Susan Shaw, MD, and Ivan Muzychka
Over the last 18 months, the Saskatchewan Medical Association has been leading discussions and actions around health system redesign. This work, which continues to evolve as the environment changes, aims to maximize opportunities to strengthen not only relationships within the system, but also the role physicians can and should play to make Saskatchewan the best place in the world to practise medicine and receive care.
KEY WORDS: health care system transformation, physician-led change, integrated system, collaborative approach
More than 50 years after introducing medicare to Canada, Saskatchewan is again re-examining and exploring how best to redesign the health care system to better meet current and future needs of patients and families. The province’s health system has seen profound change over the last two years. Starting in January 2017, it has been transitioning from 12 health regions to a single health authority. Parallel to this development, the Saskatchewan Medical Association (SMA), in partnership with colleagues in the Ministry of Health, has been engaged in a vigorous discussion about the merits of physician-led health system redesign. To date, the feedback has been positive even if the route toward consensus and action has been circuitous.
The leadership of the SMA has helped the province’s physicians more actively imagine the development of a fully integrated health system. Through leadership education, discussions, and negotiations, physicians are attempting to shift the basic structures that typically drive the dynamics of health care systems in Canada. If they succeed, benefits will flow for physicians and patients alike. The mainspring of this new vision of health care is physician leadership.
Modernization or transformation?
Health system redesign discussions began in 2015 with work to update the fee schedule to better reflect the more modern practice of medicine, a project that was born in negotiations over the previous two years. The process to update the fee schedule engendered wider discussions about urgently needed fundamental changes in the broader health care system. It brought to the fore issues related to work–life integration, continuity of care, and stewardship of resources, to name but a few. Those working on fee schedule modernization quickly agreed that an update would only provide a mere tweaking of the system where a significant overhaul was actually required and desired.
Many problems that were initially identified as compensation challenges seemed to be attached to deeper underlying issues. Compensation debates and conflicts were often anchored in management structures and relationships and in the dynamics of the health care culture and tradition. In other instances, changes in demographics and advances in technology were at the root of a particular compensation problem. The predominant thinking was that many of the issues could be more constructively addressed through a larger re-imagining of the whole system.
During 2015 and early 2016, the modernization discussion matured into a wider and deeper conversation among SMA board members, many committee leaders, and even members. As these discussions evolved, they were more accurately labelled explorations into “health system redesign.” Their focus was on how to optimize Saskatchewan’s quadruple aim: better health, better care, better value, and better teams. At this stage, physicians agreed with the idea of health system redesign, but wanted more information and specifics on what it would entail and how it would look if implemented. Top
Provincial and Canadian contexts
The doctors started these exploratory discussions within a dynamic political context. In 2015, the provincial government faced significant revenue reductions as oil and potash prices dropped. An overall downturn in the Canadian and United States economies added more fiscal challenges. Not surprisingly, such relentless fiscal pressures made governments careful about budget allocations across all portfolios, not just health.
At the same time, physicians, as well as other members of the health care system, were becoming increasingly frustrated. In 2014, the Commonwealth Fund ranked Canada 10th out of 11 peer countries.1 Physicians, and others, were discouraged that despite considerable effort and funding, Canada did not consistently achieve good results when it came to quality, safety, and access.
By 2016, more and more stakeholders had added their voices to the notion that transformational change was the only viable path to significantly improve the health care system. Fiscal sustainability continued to be an issue. Most provincial governments started looking for ways to hold health care costs steady. In many jurisdictions, health care consumed almost 40% of the budget.2 Such expenditures were seen by many as unsustainable and, if not checked, might pose a threat to quality of care.
Some governments decided to act unilaterally. In Ontario, a bitter dispute between the Ontario Medical Association (OMA) and the provincial government erupted when, among other issues, the Ministry of Health and Long-Term Care made unilateral adjustments to the fee schedule to hold costs down. The dispute ultimately led to acrimony, not just between the OMA and government, but between the OMA leadership and its members. This example served as a cautionary tale and provided an impetus for Saskatchewan physicians to keep discussing the merits of collaborative health care transformation.
Engaging physicians in the discussion
The SMA board felt strongly that it needed to hear from its members on the topic and brought health system redesign discussions to the floor of its spring 2016 Representative Assembly.
In advance of that assembly, the SMA prepared a discussion paper titled “The future physician role in a redesigned and integrated health system.”3 The paper was emailed to members and circulated on social media; the general feedback was positive. The paper was not prescriptive, but its purpose was clear:
The purpose of this discussion paper is to launch a dialogue among our members about the compelling reasons for change and how we want to participate in the change process. Like good medicine, it begins with observation and diagnosis; without agreement on what the issues and problems are, no course of action or prescription is likely to lead to the desired outcome. The perspective is global rather than local, and grounded in one overarching ambition: to make Saskatchewan the best place in the world to practice medicine. If we achieve this goal, Saskatchewan will be the best place in the world to stay healthy, and the best place to receive health care. Our professional ambitions are indistinguishable from our ambitions for our province and our people.3
At the representative assembly, members shared their reactions to the discussion paper and gave SMA leadership the go-ahead to begin dialogue on how to co-create a fundamentally redesigned health care system. That physicians should be involved in fostering positive change in the system was widely accepted with little debate.
Following the assembly, the SMA and the Ministry of Health hosted an intensive two-day “visioning session” that brought together 25 leaders from the SMA, ministry, regional health authorities, college of medicine, and Saskatchewan’s Health Quality Council. More than half the participants were physicians. Participants explored the factors contributing to high-performing health systems around the world, along with what would be required to put these ideas into action in Saskatchewan. The group focused on the ideal role of, and relationship with, physicians in a more fully integrated and redesigned health care system in Saskatchewan. Top
From this work came agreement on four core elements necessary to support health system redesign, create better partnerships with doctors, and provide better care for patients: strong physician leadership, better relationships and effective governance, use of data to optimize care, and alignment of compensation models.
Centrality of physician leadership acknowledged
On another front, the government of Saskatchewan was exploring ways to restructure its health care regions. In mid-2016, the minister of health appointed an advisory panel tasked with reviewing the regional health authority structure with a clear mandate to reduce the number of regions.
After consultation with the public and stakeholders and after examining other structures, the panel recommended the creation of a single provincial health authority. One of the panel’s recommendations, however, pointed to deeper, more positive changes afoot in the province. The advisory panel recommended that physicians “play an active role in the planning, management and governance of the health system to achieve shared responsibility and accountability for health system performance.”4
These words were an explicit and public recognition that physician participation in health care management was necessary to achieve better outcomes. Such a statement in a policy document — one that was subsequently accepted by the government’s leaders — was a first in Saskatchewan and possibly in Canada. The SMA had spent close to a year emphasizing the importance of physician leadership and advocating greater involvement of physicians in health care management. This development — coming in early 2017 — was rightly seen as an achievement. For its efforts, the SMA could point to having realized a significant change in the way physicians were perceived by government. A key point is that health system redesign dovetailed with the SMA’s strategic direction that sought to enhance physician participation and leadership in health care design.
In July 2017, the Ministry of Health created a transition team tasked with managing the move to a single provincial authority. Two physicians — Drs. Kevin Wasko and Bruce Murray — joined the team as full members. More physicians contributed to the transition process, many recruited by the SMA. Collectively, their work ensured the intentional integration of physician perspectives into new structures and processes emerging from the transition to one health authority.
Listening to our physicians
As noted above, throughout 2016, physicians across Saskatchewan were exploring how to redesign the health system to improve the quality of care for patients and the quality of work–life integration for physicians. At the fall 2016 Representative Assembly, delegates continued to support redesign in principle with a commitment to listen and learn from their colleagues. Concerned that SMA leadership not get too far ahead of the general membership, the delegates encouraged SMA leaders to seek out more input from the broader community of Saskatchewan physicians. Top
Subsequently, the SMA surveyed all members in January 2017. Physicians were asked for their views on team-based care, data and accountability, compensation, and physician participation in health system redesign. Close to 650 physicians participated.
The survey showed that most physicians in Saskatchewan believe in their ability to help lead and redesign a health system. They believe that a more thoughtfully designed system would provide better care for patients and better value for the public. The survey clearly indicated that most doctors are outward-looking, wanting to influence the system beyond their own practices. Physicians are also supportive of a team-based approach to care, with decision-making shared among other health care professionals.
Other highlights from the survey included:
The vast majority (88%) of respondents thought that the profession needs to promote public reporting on health system performance. Other findings of note: 86% want to know how their practice compares to that of their peers; and 76% are using data from their practices to improve their own performance.
Of greatest interest and concern, half of specialists and two thirds of general practitioners also reported that they were at “risk of burnout.”
Learning from others
The survey encouraged the SMA and Ministry of Health to continue to work in partnership on health system redesign. A working group continued to explore how to test the principles of health system redesign with a focus on the skills, roles, and relationships required for physicians to successfully take on greater leadership responsibilities, locally or at a provincial level.
By winter 2017, there was a general consensus that health system redesign would not be a newly created program of policy initiatives. Rather, it was more likely to be a systematic implementation of best practices emulated and scaled up from health regions in Saskatchewan and across Canada. Many of the challenges in health care, some reasoned, have already been solved. However, the solutions often exist in small units, in hospitals, or in one region. Many of these success stories have never been applied system-wide. Thus began the work of exploring models and best practices that could be scaled up and adapted to the Saskatchewan context.
The SMA and Ministry of Health continued to explore the underpinnings of the role of physicians in high-performing health care systems. Building on work done during the July 2016 visioning session, the SMA and Ministry of Health invited Drs. Bernadette Loftus and Murray Ross to discuss the Kaiser Permanente approach to physician and system leadership with more than 50 leaders and stakeholders. Interestingly, the Kaiser Permanente lessons were easily mapped to the principles that had been previously identified by Saskatchewan health stakeholders. Clearly, some of Kaiser Permanente’s practices presented potential pathways to achieving better care, better health, better value, and better teams. Top
Connecting the dots
The theme of the spring 2017 Representative Assembly was “Health care redesign: ideas to action.” By now, a year had passed since this important discussion had begun. It was time to “connect the dots” and make abstract concepts more concrete. Examples of the four pillars of redesign were shared by Saskatchewan physicians leading change within the province. SMA members presented to their peers the results of cutting-edge work related to emergency department waits and flows, appropriateness of care, and data and accountability initiatives related to electronic medical records. A panel of physicians openly talked about the strengths and weaknesses of a variety of compensation models. Presenters noted that these topics were not a set of disparate activities, but were in fact examples of ongoing health system redesign work.
Delegates were keen to explore different compensation models, and the idea clearly emerged that compensation issues are not only economic questions, but also relate to workload, burnout, and overall physician satisfaction, all key elements of health system redesign discussions. Much work in this area remains to be done, but holds promise.
As of November 2017, discussions continue about creating a pilot site in Saskatchewan where physicians and Ministry of Health officials can test redesign ideas. Physicians are identifying barriers and opportunities related to possible redesign/co-design efforts. The Saskatchewan Health Authority has developed a new leadership structure with four physician executives working as dyad partners with provincial vice-presidents. The SMA continues to foster debate and discussion on how enhanced physician leadership can help to transform the health care system.
The discussions happening in Saskatchewan may well have national significance. Physicians elsewhere face the same problems that motivated Saskatchewan doctors to take action. However, a fortunate confluence of environmental changes in Saskatchewan — including political commitments and a general optimism about health care, together with larger changes such as amalgamation of health regions — are creating fertile ground for possibilities that could yield results not seen elsewhere.
If redesign principles are shown to be the mechanism to successfully usher in a more integrated health care system, Saskatchewan might again be the birthplace of a new chapter in Canadian health care history. A significant transformation cannot happen without an authentic dialogue with physician leaders. It looks like that dialogue might finally be happening.
1.National health expenditure trends, 1975 to 2016. Ottawa: Canadian Institute for Health Information; 2016:20.
2.Davis K, Stremikis K, Squires D, Schoen C. Mirror, mirror on the wall: how the performance of the U.S. health care system compares internationally. New York: Commonwealth Fund; 2014. Available: https://tinyurl.com/pacv7o5
3.The future physician role in a redesigned and integrated health system. Regina: Saskatchewan Medical Association; 2016:4.
4.Optimizing and integrating patient-centred care. Regina: Government of Saskatchewan; 2017:5.
Susan Shaw, MD, is chief medical officer with the Saskatchewan Health Authority. When this article was written, she was the Saskatchewan Medical Association’s director for physician advocacy and leadership.
Ivan Muzychka is the senior communications advisor for the Saskatchewan Medical Association.
This article has been peer reviewed. Top