Brian Day: What Canada could learn
The following is
excerpted from an article by Dr. Brian Day (pictured here), president of
the Canadian Medical Association. It appeared in the Ottawa Citizen.
While Canadian governments maintain a system that leaves their citizens
without proper access to care, in the past four years the British have
introduced innovations and reforms that have achieved spectacular
reductions in waiting lists.
At the end of 2003 there were almost one million patients on hospital
waiting lists in England. By the end of 2007, that number had plummeted
and almost 90 percent of patients were receiving treatment in less than
How did they do it?
First, hospital funding has been changed from block funding (global
budgets) to a “payment-by-results” system. Hospitals are now paid for
each patient they treat, based on complexity. Payment by results has not
been without its critics, but it has been refined and has absolutely
proven its worth.
Second, the NHS has taken an aggressive approach to setting targets,
such as the introduction of an 18-week target for the completion of
elective treatments (this will be achieved this year), and four-hour
maximum targets for the treatment of emergency room patients (achieved
already and currently being reduced to a two-hour target).
Can Canada learn from the NHS? The answer is a resounding yes. Here are
the top 10 lessons:
1. Put patients first: The NHS shifted its strategy from supply-side
rationing to a patient-centred approach with a focus on choice and
2. An internal market: The U.K. has pressed for competition within a
publicly funded system based on quality and efficiency, and not on
3. Incentives: The U.K. uses incentives and bonuses based on achievement
of a comprehensive set of quality targets. To date only limited use is
being made of these approaches in Canada.
4. Commit to measure: It is often said that, “you can’t manage what you
can’t measure.” The NHS measured activity levels and wait times long
before it had the capacity and political commitment to deal with them.
In Canada, waiting lists continue to focus mainly on the five priorities
set out in the first ministers’ 2004 accord, and there is a lack of
comparability of data across jurisdictions.
5. Recognize health inequalities: With the 1980 Black Report, the U.K.
was the first nation to recognize that health inequalities persist
within a universal system. Efforts are under way to reduce those
inequalities. In Canada, we await similar guidance from the report of
the Senate Subcommittee on Population Health.
6. Decentralize: Over the past decade Canada has pursued top-down
control. The NHS recognized the importance of supporting bottom-up
change both at the GP practice level and through empowering individual
hospitals. Canada must learn from the success of this approach.
7. Emphasize innovation and leadership: There is a recognized need to
foster innovation and leadership through the NHS Institute for
Innovation and Improvement.
8. Performance assessment: The NHS has embraced measurement of
efficiency and productivity. Transparent sharing of data with the public
is mandatory through an “annual health check” of healthcare
organizations. Service quality ratings, ranging from excellent to weak,
are posted on an NHS website. A patient-focused system demands that we
match this effort in Canada.
9. Think big: England has committed to large-scale careful study and
experimentation, aimed at promoting excellence. This has required
investment and political leadership. In contrast, Canada has pursued
modestly funded time-limited pilot projects that have not generally
produced sustainable results.
10. Commitment to evaluation: Evaluation is a fact of life in the NHS.
There are numerous examples of audits and evaluation of system
performance. We in Canada must follow that lead.
Our health system is encompassed in a vicious circle, whereby rationing
of services leads to limited access, reductions in workforce, limited
investment in technology, long wait lists that negatively impact the
economy, resulting in funding pressures that force rationing – so
completing the “circle.”
Patient-focused funding can break that circle.
Dr. Brian Day, an orthopedic surgeon, is president of the Canadian