In 1934, the Canadian Medical Association produced guidelines for a national health program funded and administered by the state. That was eight years before the release of Sir William Beveridge’s plan for a National Health Service in Britain (which later formed the basis for Canada’s medicare system).
While Canadian governments maintain a system that leaves their citizens without proper access to care, in the past four years the English 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 per cent of patients were receiving treatment in less than three months.
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 CMA’s top 10 lessons from the NHS:
1. Put patients first. The NHS shifted its strategy from supply-side rationing to a patient-centred approach with a focus on choice and quality.
2. Create an internal market. Beginning with General Practice Fundholding in the early 1990s, the U.K. has pressed for competition within a publicly funded system based on quality and efficiency and not on price.
3. Recognize the importance of 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 measuring. 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 underway 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. Assess performance. The NHS has embraced measurement of efficiency and productivity. Transparent sharing of data with the public is mandatory through an “annual health check” of health care 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. Commit 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 remains in a time warp. It is caught 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. The Beveridge NHS plan was a partial template for Canadian medicare. The NHS has now evolved for the better. Patients have reaped the rewards, and have been empowered through a patient-focused care model. Universal care and excellent access can coexist.
Politicians appear reluctant to challenge the status quo. In a Pollara poll (December 2007), 68 per cent of Canadians believed our health system needed a major overhaul or a complete rebuild. Politicians should not fear reform and progress. The lessons are there to be learned.
Dr. Brian Day is the president of the Canadian Medical Association.