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A version of this commentary appeared in the Toronto Star

We’ve heard it from many quarters now: The fiscal sustainability of Canada’s health care system is under threat as health expenditures are increasing faster than government revenues.

Rising health care budgets are largely attributable to increased utilization of medical technologies, drugs and health human resources, as recent studies attest (although population increase and aging also have some, smaller effect).  Also driving costs is an increasing burden of chronic disease, which includes conditions such as obesity, diabetes, hypertension, heart disease, stroke, cancer, mental health conditions, muscle and joint disease, and others.

The solution lies in nothing less than a transformation of our primary health care system in Canada.  We need to provide comprehensive, integrated, community-based services which will improve population health, reduce inequities, reduce healthcare expenditures and contribute to the sustainability of our publicly funded health system.

One essential step toward this transformation would be a coordinated Pan-Canadian effort to develop indicators and databases that will support accountability in healthcare and drive the required changes.

The truth is, we already know how to reduce the burden of chronic disease.

Chronic diseases are to a very large extent caused by the conditions under which we grow, live, learn, play, work and engage with each other and our communities. These include our food, physical activity, use of alcohol, drugs and tobacco, employment and working conditions, income, early development, education, housing and the environment.

While many of these factors lie within social, political and economic realms outside of the health care system, there is still much the health care system can do to prevent and manage chronic disease and reduce its impact on the health of the population and health care expenditures.

Move away from the old ‘business’ model of health care:

The health care system was designed long ago to attend to a high prevalence of acute, infectious disease rather than our current pattern where chronic conditions prevail.

The old business model provides poor service for people today with chronic conditions,  particularly when there are several co-existing illnesses. As a result, the current primary care system is characterized by poor access and prolonged waits for patients, a lack of attachment to a provider, time-limited consultations and repeated, unnecessary clinic visits. It has become inefficient and wasteful of resources and hence is contributing to public and professional dissatisfaction and rising health expenditures.

There are a few fundamental changes that could significantly improve quality of care and reduce health care costs.

Primary health care organizations should serve a geographically defined population and provide comprehensive services that include health promotion, health protection, prevention and clinical care through integrated inter-professional teams.

These teams should include public health professionals, community care and social agencies as well as family physicians, nurses, nurse practitioners, pharmacists and many others. This may be best achieved through development of facilitated networks, and with aligned financial incentives that may include a blended payment model.

Electronic data systems, such as electronic health records (EHR) and population data systems and quality improvement programs could also improve health efficiencies.

Finally, we need a governance structure that allows the people being served to have a voice in health quality improvements, and for providers to be accountable to those being served.  It should also promote a culture that is focussed on positive relationships between and among providers, patients and the community.

Time to develop common metrics:

But how can such a massive transformation be achieved?

The Harper Government has announced that for the 2014 Health Accord, the Canada Health Transfer will continue (~ $30B per year) with an ‘escalator’ of 6% until 2017 (somewhat reduced after that).  However, like the health agreements of governments past, there has been no mention of direct measures for accountability by the provinces to the federal government.

With no accountability in place, how can we be sure our opportunity for health system transformation won’t be missed?

The Harper Government through Minister Aglukkaq has offered a possible solution: the development of ‘common metrics.’

Such indicators, when supported by appropriate data, would enable tracking progress on the fundamental changes needed to transform our health system, and allow jurisdictions to make comparisons of system change related to service, and outcomes related to improved health and reduced inequities.

‘What gets measured gets done,’ in other words. But this will require resources and cooperation among the provinces.

Developing ‘metrics’ may not sound ‘sexy’ but could be what improves accountability, performance and sustainability in Canada’s publicly funded health care system.

John Millar is an expert advisor with EvidenceNetwork.ca.  He is also Clinical Professor, School of Population and Public Health, University of British Columbia.

March 2012

This work is licensed under a Creative Commons Attribution 4.0 International License.