What can Sweden learn from Canada’s health system Michael M. Rachlis MD MSc FRCPC January 15, 2009 Tallberg Sweden

Outline Introduction to Canada and its health care system Canada’s health system’s problems, diagnosis, and solutions What can Sweden learn from Canada? How to manage health care wait lists 2

Tommy Douglas 3

(Data 2009 est. from CIA World Fact Book) CanadaUSAGermanySweden Population33 million304 million82 million9 million Area (km 2 ) 9,984,670 9,631,418357,021450,295 GDP ($US PPP) $38,400$46,000$34,200 $38,200 Gen Gov’t net liabilities as % of GDP 28.6%56.4%50.2% -16.7% Gini coefficient

(All data 2009 est. from CIA World Fact Book) CanadaUSAGermanySweden Infant mortality / Life Expectancy F M F M F M F M > 65 years14.9 %12.7%20%18.8% Migrants/ Birth rate/

Canada: Political Organization British parliamentary government The world’s most decentralized federation -- Ten provinces and three territories The federal government is responsible for foreign affairs, defense, and criminal law The provinces are responsible for health care, education, and social services Quebec has special status 6

Canada: Political Organization The federal government and the provinces share authority over public health, the environment, and other key policy areas 7

Canada: Political Organization Canadian governments fight constantly – Have you seen us play hockey? 8

9 Good luck next month. You will need it to beat Canada!

Canada Health Act principles Universality – All Canadian residents must be covered Comprehensiveness – All “medically necessary” physicians and hospital services must be covered Accessibility – No user charges for insured services Public Administration Portability 10

Canada’s Health Insurance First dollar coverage for medical and hospital care Mainly private coverage for dental and optical Mixed public private coverage for pharmaceuticals, long-term care, home care, and medical equipment Except for hospitals and doctors, coverage varies substantially from province to province – The wealthier provinces – Ontario and the west – have much better coverage for non Canada Health Act Services 11

Canada’s Health Care System Not “Socialized Medicine” Canadian health care, like other aspects of our social policy, is “mid-Atlantic” Canadian Medicare is characterized by “Private Practice: Public Payment” (CD Naylor. 1986) – Most doctors are self-employed and bill provincial health plans on a fee-for-service basis In most provinces, regional health authorities own and run hospitals, long-term care, home care, mental health, and public health 12

Ontario Area: 1,076,395 Km 2 (Second largest Province) Population: 13,150,000 (Most populous province)

Ontario Health Policy Local Health Integration Networks (LHINs) – Ontario’s version of regional authorities Ontario has retained its system of not for profit boards – 140+ hospitals – 585 seniors homes and community services – 70+ community health centres Recent major changes in primary care physicians remuneration and services. 14

Ontario’s local health integration networks – the LHINs The LHINs fund, but do not run, acute care, long term care, home care, and community health centres The LHINs contract with hospitals for acute care and community care access centres (CCACs) for long term care and home care. In turn CCACs contract with long term care centres and home care agencies. The LHINs have few professional staff Physicians and drugs are funded by the province Public Health is funded and run separately by the Province and municipalities 15

OECD Health Data 2009 (Most data 2007/8.) ment/16/0,3343,en_2649_ 34631_ _1_1_1_1, 00.html ) ment/16/0,3343,en_2649_ 34631_ _1_1_1_1, 00.html CanadaUSAGermanySweden Health Expenditures (GDP %) 10.0%15.3%10.6%9.2% Public % of Health Expenditures 70.7%44.5%76.9%81.7% Health Expenditures (US $/capita) $3678$6714$3371$3323 MDs/ RNs/ MRI Units/ (1999) Acute beds/

Canada vs. the US: No contest! All Canadians are covered but 47 million Americans are uninsured, and tens of millions more are under-insured Canada spends much less than the US Canadians get only slightly fewer services overall Canadian outcomes are as good or better Canadians live 3 years longer than Americans and our infant mortality rate is 20% lower. Single payer insurance boosts Canadian business – Health care costs are 1.5% of Canadian manufacturers’ payrolls vs. 9% in the US 17

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S Woolhandler Int J H Serv 2004;34:

Canadian health care outcomes on average are as good, or better than those in the US See: 20

Canada’s health system’s problems, diagnosis, and solutions 21

Canadian Medicare was designed for another time and was a compromise 1.It was designed for acute illness and Canada’s acute care system compares well internationally 2.But now the main problems are chronic diseases and Canada does poorly with these and with waits and delays. 3.Political compromise slowed the development of a more effective delivery system

We could prevent most chronic diseases > 80% of ischemic heart disease, lung cancer, chronic lung disease, and diabetes cases could theoretically be prevented with what we know now This would free up over 6000 hospital beds across Canada 23

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Canada has quality problems – but they are mainly similar to those of other countries and are related to the structure of the health delivery system not the values of equality and solidarity 25

Quality Problems in health systems 5-10% of deaths in developed countries are preventable hospital deaths – Canadian Adverse Events Study 9000 to 24,000 preventable hosp deaths/yr (GR Baker et al. CMAJ 2004;170: ) Medication and the elderly 26

Political compromise slowed the development of a more effective delivery system 27

The original vision for Medicare -- Swift Current, Saskatchewan 1945 Prepaid funding Services available on a universal basis, with little or no charge to users. Integrated health care delivery with acute care, primary care, home care, and public health. Group medical practice with doctors working in teams with nurses, social workers and other providers. Overall public health view of the system. Democratic community governance of health care delivery by local boards. 28

Canada’s problems are due to the failure to re-tool an ineffective and inefficient delivery system 20 litres/100 km5 litres/100km

We could fix almost all Canada’s problems with innovation and quality

We need to change the way we deliver services “Removing the financial barriers between the provider of health care and the recipient is a minor matter, a matter of law, a matter of taxation. The real problem is how do we reorganize the health delivery system. We have a health delivery system that is lamentably out of date.” Tommy Douglas 1982

“Many attribute the quality problems to a lack of money. Evidence and analysis have convincingly refuted this claim. In health care, good quality often costs considerably less than poor quality.” Fyke Report 2001 (Saskatchewan)

Quality provides sustainability An Alberta aftercare program for congestive heart failure patients leaving hospital reduced future hospital use by 60% with $2500 in overall net cost savings per participant. Vancouver's Royal Columbian Hospital reduced post heart surgery pain complications by 80% and length of stay by 33%.

See also Institute for Healthcare Improvement

Good News! We could have elective specialty consultations within one week – The Hamilton Family Medicine Mental Health Program increased access for mental health patients by 1100% while decreasing psychiatry outpatients’ clinic referrals by 70%. – The program staff includes 150 family doctors, 80 mental health counsellors, and 17 psychiatrists and provides care to 300,000 patients 35

Good News! We could have elective surgery within two months – In most parts of Ontario arthritis patients are assessed within two weeks for joint replacements and have their surgery within two months 36

What causes queues for care? Usually there is enough overall capacity Queues develop because of temporary capacity demand mismatches

Temporary capacity/demand mismatch in a system with only 10% variation twice a week Monday, Tuesday, Wednesday: 10 patient demand, 10 units of capacity, no waiting list, no waste Thursday: 9 patient demand, 11 units of capacity, no waiting list, 2 wasted units of capacity – lost forever Friday: 11 patient demand, 9 units of capacity, 2 patients put on the waiting list After one year 104 people are waiting and there’s moral panic. BUT average capacity equals average demand

Endoscopy Queues in Birmingham What’s going on here? Why is there still a backlog after 2 wait list initiatives?

Capacity and demand for Endoscopy in Birmingham – Average Capacity is almost always greater than average demand!

Variation in clinical systems 41 Staff skills illness holiday motivation training shifts Patients Resources Process Rooms supplies machines age sex race education motivation disease unclear guidelines differ complications anaesthetics We control 80% of variation! GP Discharged! Information transcription transport applications All Different

Variation kills quality AND patients

Six Steps to reduced waiting 1.Map the process 2.Eyeball the map 3.Eliminate redundant stages 4.At each stage measure demand and Capacity 5.If Capacity is greater than demand… 6.If Capacity less than demand…

1.Map the process Follow the patients through the process using their eyes Don’t miss the informal stages Measure time at each stage

2.Eyeball the map Use a patient-centred view Are there redundant stages? This is the time for creativity

3.Eliminate redundant stages Edmonton Alberta decreased delays for diabetic education from 8 months to 2 weeks by not insisting patients see an endocrinologist on the first visit Sault Ste. Marie decreased delays from mammogram to definitive diagnosis by 75% collapsing visits for mammogram, ultrasound, and biopsy

4.At each stage measure demand and capacity Demand should be measured prospectively with regard for appropriateness Capacity should be identified with regard to the actual length of time to provide services Measure variation

We want to meet the demand for appropriate care. Too much healthcare is inappropriate Wright et al CMAJ 2002 – 25% of cataract operations were questionable Are CAT and MRI scans overused?

5.If Capacity is greater than demand… Work down backlog Identify temporary capacity/demand mismatches Reduce variation to eliminate or decrease capacity/demand mismatches – Re-shape demand – Smooth capacity

Re-shaping demand Can you do anything to prevent illness and reduce demand for your service Can you deal with your service demand in a more efficient fashion? – What are the alternative courses – What are their advantages and disadvantages What are the barriers to reshaping demand for your service

Smoothing capacity Do you have the data? Can you match your capacity to your demand? What are the barriers to flexibly using your capacity?

6.If Capacity is less than demand… Shape demand Smooth capacity

6A. If your Capacity is now greater than demand… Go to Step 5

6B. If your Capacity is still less than demand… Which resources are the constraint? – Capital? Personnel? Others? Add appropriate new resources Find the new bottleneck – There will always be one part of the process which runs slower than others Continue to “chase the bottleneck”

What can Sweden learn from Canada’s experience? Only public finance can control costs AND provide universal access Public finance is business’s best friend Public health insurance improves equality and efficiency but does not automatically lead to improved quality Canada’s health care policy-making is very complicated! 55

What can Sweden learn from Canada’s experience? Primary health care is the most important part of the system. Canada’s poor international performance for chronic disease management and waits and delays is due to inadequate primary health care. 56

Delivering health services without adequate primary health care is like pulling your goalie in the first period. You score lots of goals but lose every game.

For profit patient care tends to be more expensive and of poorer quality – see PJ Devereaux et al -- but the most effective argument is Tony Soprano”s: “Fuhgetaboutit!” (Forget about it, you don’t need it)

Summary Canada has 14 health care systems Canadian Medicare greatly outperforms the US system Sweden can learn from Canada: – Public systems control costs while providing universal access – But you need to re-organize the delivery system to improve quality 59

Courage my Friends, it is Not Too Late to Make a Better World! Tommy Douglas 60