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Let’s be more than a ‘nation of pilot projects’

A version of this commentary appeared in iPolitics.ca and King’s County Record

The formation of an innovation working group was the major result of the provincial Premiers’ meeting in January. This is a welcome idea, and the formal announcement promises collaboration, transformation—and innovation, with a focus on health professional scope of practice, limiting cross-provincial competition for those professionals, and clinical practice guidelines.

The trouble is that the list of topics selected by the premiers will do little (except indirectly) to address the fundamental challenge facing health care systems everywhere: controlling expenditure increases.

Existing research very clearly shows the greatest driver of increasing health costs is an ever-growing intensity of service use.  People at all ages are seeing more doctors and receiving more services than ever before. Some of this increasing use may be beneficial, but research evidence also shows that there is waste and inappropriate care in the system as well.

If we want to innovate and transform our health care system, we need to have some sense of the direction we are moving toward.  What does the ideal health system for Canada look like?

There is a general consensus emerging that Canada should be moving toward a system of integrated care with a patient-centred focus, paying particular attention to people as they move across the different parts of the system.  There is also general agreement that this re-orientation can happen—indeed has been happening, though in small steps—across the country.

This description of an ideal system has been articulated by stakeholders from across the country and across the political spectrum, from voices as diverse as Don Drummond, former chief economist with Toronto-Dominion Bank, to the Canadian Centre for Policy Alternatives. Even more encouraging is the increasing evidence that moving toward this ideal is one way to control health care expenditures.

There is, or at least can be, a happy coincidence of higher quality, more patient-centred care that actually costs less overall.

The origins of a desire for a truly integrated, seamless, patient-focused system are probably obvious. The need for health care often arises when people are in vulnerable positions, when individuals and their families are confronted with difficult news and hard choices. People deserve to be supported well in these situations by a system that is tailored to address an acute event or a new, chronic reality.

The system’s need for a patient-focused orientation is also clear. A small number of people account for a large share of health care expenditures. This is true in heath care systems everywhere. These expenses are not driven by trivial use, but by complex conditions—for example, frail older people or people with complex mental health conditions. Given the expense for these groups, even small improvements in care resulting in (for example) decreased emergency department and acute care use, would have a significant impact on overall expenditures. This is precisely why better care and lower costs can go hand in hand.

So, what hinders innovation? One key factor is Canada’s habit of being—as one former politician once described us—a nation of pilot projects.

There are plenty of innovative projects going on, but these are typically small-scale, often region-specific, and can suffer from not having clear plans for permanence if what is tried proves successful.

Enter the premiers’ announcement of an innovation working group. If the premiers are committed to an innovation agenda, and the innovations they envision are to have an impact on controlling costs, the mandate for this group needs to be expanded as soon as possible.

And there are key things an inter-provincial innovation working group on health care ought to do, such as catalogue the current experiments across health authorities and provinces that are aimed at “bending the cost curve,” particularly for identified population groups like the frail elderly.  It should then find the evidence of success (or failure) for these initiatives, and clearly articulate what is needed to help the successful innovations spread.  Finally, it could agree on how future experiments could be shared across the country.  The last point is particularly important because this is where it could achieve economies of scale for innovation.

Health care services are not now, nor do they need to be, organized and delivered in precisely the same way across provinces. But all provinces do face similar challenges, and it is wasteful in the extreme to think that they all have to do all of their own experimentation and learning independently.

Provincial cooperation for modernizing our health care systems is an exciting—and timely—announcement. A commitment to cooperation is especially encouraging given the federal government’s indifference to how the provinces manage their health care systems. Let’s hope the premiers follow through and work on issues that could actually make a difference, in both the short and longer terms, for improving health care delivery.

Kimberlyn McGrail is an expert advisor with EvidenceNetwork.ca and associate director of the UBC Centre for Health Services and Policy Research and assistant professor in the UBC School of Population and Public Health. 

February 2012


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