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Why is Transformation of Healthcare so Hard?

The need for change in healthcare has been obvious for years. Many studies have been conducted and recommendations made on what’s needed to meet optimally the needs of the population in the current and coming decades. But change itself has been very scarce.

One reason is that none of our 14 provincial/territorial/federal healthcare delivery ‘systems’ has a single governance; the place where the ‘buck stops’ with respect to what each does and does not accomplish and how well or poorly. It is only by default that Canadians hold their governments accountable for how well their hospitals, physicians, pharmacists, and other providers meet their changing needs for healthcare services. On the other hand that there are 14 ‘systems’ could be an advantage as it was when Saskatchewan’s pioneering introduction of Medicare was copied by other jurisdictions.

That there is no governance of healthcare’s delivery rests on David Naylor’s phrase “public payment for private practice”. Throughout Canada, healthcare services are provided in the main by private individuals, organizations and institutions that are answerable only to their owner/operators and/or their boards of directors. Our publicly funded healthcare systems are, in fact, healthcare insurance systems intended to remove, in part, the financial barrier between those in need of healthcare services and those who provide them.

Oxford defines system as a “complex whole, set of connected things or parts, organized body of material or immaterial things”. The key words are connected and organized, neither of which can be applied legitimately to the several elements that we refer to glibly as our healthcare ‘system’ – hospitals, physicians, nurses, physio-and occupational therapists, pharmacists, dentists, optometrists, home care, public health, etc. There are 23 separately regulated health professions in Ontario alone, over 200 hospitals, nearly 1,000 independent health facilities, and an indeterminate number of other community based organizations and agencies, all of which provide to the public some form of health or healthcare service. Making the transformative changes to knit this whole collection together, connecting and organizing all of them into a complex whole, thereby creating a genuine system, is a daunting prospect under any circumstances. It may well be mission impossible given that a substantial number of these many and varied providers, especially those currently operating what are considered to be independent businesses, do not accept the need for direction by a system’s governing body nor, indeed, for their particular healthcare business to connect with any other.

Another reason why change is so hard is that the hierarchies established over five decades of Medicare are well entrenched. Those at the top, hospitals, physicians, and nurses are understandably resistant to proposals for change that would diminish their standing or incomes. They fear the ‘zero sum game’ in our contemporary no- to slow-growth economy and resist change of the kind that, for example, would mean less funding for hospitals and physicians’ services and more for home and community services. No political party, whether in government or in opposition, relishes the challenge of countering the very public ‘death-in-the-streets’ rhetoric that they know would result from such proposals.

And then there are the bureaucrats on whom, under the status quo, governments depend for regulatory control. Bureaucracies, especially of governments, are notorious for their resistance to losing control, status, income, and employment, particularly if the changes recommended involve devolution of authority to regional or sub-regional agencies or to the providers of services themselves, as many reports have recommended.

Another reason for the absence of change is public complacency. For years evidence has been accumulating that healthcare services in Canada are both harder to access and of lower quality than those in comparable OECD countries yet cost the consumer/taxpayer more. But the myth persists that the Canadian ‘system’ ranks among the best in the world, relieving governments and political parties alike from ballot box pressure to lead transformative change. And at the ‘coal face’ where patients and families interact with providers, it relieves the latter from having to meet what should be much higher expectations for faster access, better communication, and higher quality services and outcomes all around.

Finally transformative change has not occurred because right up to the present day Canada and its provinces and territories have not faced a crisis sufficiently severe and prolonged as to overwhelm resistance to change or to shake the public’s passive acceptance of paying high costs for a narrow range of services of mediocre quality. Heretofore governments have had enough money to avoid the challenge of change. They have had enough to ‘buy peace in our time’ as it were, to wait for the economy to turn up again as it did in the mid 1990s. In this second decade of the 21st century everybody, governments and providers alike, could well be in for a very long wait.

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This post was originally co-authored by Dr. Chris Simpson, Dr. Ruth Wilson, Dr. David Walker, Don Drummond, and Dr. Duncan Sinclair for Queen's School of Policy Studies. 

Dr. Charles T. Low (ret'd)

Wed, 01/17/2018 - 16:12

All great thoughts.
Of course, this is not the first essay on change-obstacles.
What I am not seeing in any of them is: "Therefore, we are going to proceed with ... {x, y, and z}".
I think that we understand on some intuitive level that it will require more than an alphabet just to start to list categories of change-requirement.
Think "generational" project - daunting.
Think about how to manage "complex adaptive systems" - linear methods used in linear systems do not work in health care. If the CAS concept is not intimately familiar to change-agents, then we have a fundamental problem right from the outset.
That said, thanks again for airing this topic. Doing so is essential. We're not doing it right, and patients are suffering and dying needlessly in the meantime in numbers which no other modern industry would tolerate.

Dr. Charles T. Low (ret'd)

Ken Brown MD

Wed, 01/17/2018 - 18:44

This is brilliant. The federal government doesn’t take the lead in organizing a transcontinental healthcare system applicable across the country. Medical records should follow the patient across the country at the request of the patient. Medical care should be available across the country regardless of one’s province of origin which not the case if you live in Quebec. Terrific insight.

Ken Brown MD

Terry L. Hill, PhD

Mon, 01/22/2018 - 16:45

It is not clear to me if in the final analysis, you are arguing for a less-hierarchical, 'socialist' type all-for-one and one-for-all healthcare system across Canada, or, a workable two-tier system of higher quality, easier access, and cost effectiveness. Also, doesn't the 'buck stop' at the Federal Ministry?
It is true that bureaucracies suffer from "goal-displacement" (Merton) over time, which leads to constipated social change at the local level. Hospitals which face inwards require a strong Board as an advocating agency to redress resource distribution, new technologies placements, staffing issues, and meagre psychosocial patient assistance. The decentralization of hospital functions out into the wider community may be something else to look at, e.g., oncology centre, obstetrics & gynaecology centre, mental health centre, fracture/orthopedic rehab centre, chronic care facility, dementia, etc. Hospitals as a "one-stop-shopping" facility make sense in theory, but bureaucracy quickly grows to the point of obstructing (e.g., waiting times) efficiency of diagnosis and treatment processes. Perhaps a more decentralized system of health care might better serve.

Terry L. Hill, PhD

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