Complexity in Canada’s failing monopoly healthcare: Is it fixable?

Chicken, ostrich or a sheep. What about an armadillo? Snake? Take your pick of these or another when answering: “Which animal best embodies how Canadians see their political healthcare leadership when it comes to dealing with the ongoing crisis in healthcare?”Seriously, the challenges facing our state-run healthcare system are of such a magnitude that some people including so-called leaders don’t want to think pragmatically about it. Politicians and others are failing to address the crumbling foundation and are instead trying to plaster over cracks on a reactive basis. Why are elected officials of all stripes failing so badly when it comes to stabilizing and sustaining healthcare in Canada? Fundamentally, Canadians need to ask themselves if politicians across the country are ignorant of our ever-growing state-run healthcare crisis or if they are intentionally operating on sales pitch mode to convince Canadians they are getting the services they need, even when they know that’s not happening.To date, the drips and drabs of incoherent healthcare policy changes aren’t making a significant difference despite the cheerleading of insiders and various lobbyist organizations. Hallway healthcare is worse than ever and the crisis in family practice is causing reverberations now and will continue to do so into the future. The ages-old political modus operandi is to make a production of kicking the can a little further down the road beyond the next election date, not to address access so that people can get the care they need when they need it. If politicians can sell the public that their measures are working despite the reality that they aren’t, then they stay on. Political mission accomplished. Meanwhile, various groups are throwing what they see as solutions at the wall to see what sticks and what government would be willing to fund. But these suggested “solutions” are lacking an understanding of the complexity in healthcare.A national accountability officer?Recently, the Canadian Medical Association announced it wants a national accountability officer created to help track the $196 billion in federal funding over ten years, citing the need to “embrace proven solutions to ensure this historic-level funding truly transforms our health system.” But it won’t. The last federal money dumps didn’t either. They just bought time. And given financial and demographic realities, we are out of time for navel gazing, spouting aspirational goals and playing intergovernmental blame games.Pragmatic measures are needed that take into consideration what is rapidly coming down the healthcare pipe with an aging and growing population along with the costs of expanding scientific and technological advances including upfront costs of precision medicine, artificial intelligence, digitalization and robotics. CMA president Dr. Joss Reimer is reported to have said “enhanced accountability is crucial to successfully implementing durable changes in our health care system.” However, in Canada we already have multiple entities attempting to achieve this, including auditor generals at both federal and provincial levels who specifically report on ministries of health, as well as financial accountability officers and a parliamentary budget officer. There are ombudsmen of all kinds, and organizations that assess health quality. There are numerous groups who evaluate health care spending and effectiveness including the Commonwealth Fund, the Organization for Economic Co-operation and Development, not to mention all the various home-grown think tanks. On top of all that is the reality of the combination of federal and provincial contributions which muddy the water of accountability. Since there is no clear division of responsibility neither level of government can be held accountable. The issue of accountability for healthcare funding is not going to be solved by a national accountability officer—the problem is structural; it is constitutional. It certainly doesn’t require another highly paid bean counter. The concept of a national accountability officer may play well in the media and sound good to the public, but the federal government couldn’t even address the fiasco of the Phoenix pay system efficiently or recoup the overpayments stemming from its COVID-19 pandemic spending spree, so it is highly doubtful that a national accountability officer will provide anything more than an increase in bureaucracy. Instead, let’s get on with necessary reforms that are consistent with better functioning healthcare systems around the world rather than creating another landing pad for some highly paid bureaucrat or worse, a political appointee.What if this isn’t fixable?Pragmatism requires the consideration that the challenges in our current complex single-payer state-run healthcare system are not fixable. This “what if” scenario should be contemplated. There may be no solutions within the current complex system.In the recent report “Challenges of implementing complexity in healthcare,” the authors describe the humility required to recognize that complex problems cannot be solved; they can only be managed. While complexity and systems thinking are mentioned in the CanMEDS guide for medical education, an analysis of educational programs in Canadian medical schools showed “an almost complete lack of education on complexity or systems thinking.”“One of the non-intuitive characteristics of complexity management is that the best practices are generally self-organized rather than top-down solutions. Education of the main agents in the healthcare system has a significant probability of creating self-organizing management techniques, and in turn, inspiring more research which may act as a catalyst for innovation and change. The collective, socially organized wisdom of medical practitioners who are free to think in complexity terms will likely produce breakthrough methods of practice and management.” In a National Post op-ed with one of the authors being a former CMA president, “Opinion: Release Canadian health care from the chains of failing government monopolies”, the question is asked, “Why is it so hard to fix healthcare in Canada?”“We look to governments, federal, provincial and territorial to fix it. Politicians and their multitude of starry-eyed apparatchiks that come and go every few years take great joy in rearranging the deck chairs. Over the years, some have even tried to overlay structures like regional health authorities to put some distance between them and their political authorities, but it never lasts; the pendulum always swings back to more politics, and the only thing politicians do is throw more money at it and reinforce the status quo.“The power accumulated in the prime minister’s and premier’s offices mean they run healthcare along with their political children, interest groups and favoured consultants carried along by the prevailing wind, robbing citizens of their ability to choose.”The article pointedly states, “If you want to fix healthcare for the generations, get it out of the hands of politicians” and recommends a publicly funded health insurance model similar to that recommended in 1964 by the Hall Commission that was not to be state medicine but based on freedom of choice and self-governing professions and institutions. But concepts from the 1960s will not be enough to allow for the necessary flexibility and adaptability needed by a future healthcare system, while the funding needed for the future of growing complexity in healthcare is simply not keeping up. The sputtering Canadian economy poses a significant risk to healthcare and our standard of living that must be addressed. The Business Council of Canada’s report, “Engines of Growth,” describes the vicious cycle of over-spending: “Canada cannot borrow its way to prosperity. Higher deficits and debts will inevitably lead to program cuts and higher taxes. These will have to be shouldered by future generations, whose governments will need to service a larger and burdensome debt at the expense of all the important missions of government. A true partnership is required between the public and private sectors to advance economic growth.”The report goes on to outline 17 recommendations to ignite growth including productivity initiatives and talent development, but nowhere does it mention the need to address the short-comings of Canadian healthcare or measures that could be taken to improve productivity of the workforce through improved access to care, especially for long-COVID and its potential impact on GDP. This is an omission that warrants further understanding.With Canada’s GDP per capita trending down for five consecutive quarters, the report acknowledges the following: “Per capita economic growth is not an end in itself, it is a means to other ends. It is a vehicle to raise workers’ wages, lift living standards and fund social programs, including taking care of the most vulnerable people in our society.”As Canada’s population ages, despite programs intended to reduce chronic diseases and keep seniors healthy and active, there will be an increasing number of vulnerable people. Planning for this eventuality is critical to proper functioning of the healthcare system. Despite efforts to address the need for more long-term care and more community care, governments are still running from behind and investments in support are needed beyond the acute care system.In the C.D. Howe Institute report, “Another Day Older and Deeper in Debt: Fiscal Implications of Demographic Change for Canadian Governments,” a financial shortfall for Canada’s healthcare system of $2 trillion is estimated. The demographic shift will financially strain Canadian governments and as the number of seniors drastically outpaces the working-age population even with immigration, healthcare costs as a percentage of GDP are anticipated to double by 2067. This issue has been known for decades and yet politicians have for the most part avoided taking measures to address it. They have consistently kicked the can further down the road.Politicians and health leaders have a responsibility to acknowledge the crumbling foundations of state-run healthcare and to look to proven options that work successfully in other countries consisting of hybrid healthcare systems that provide public health insurance as well as private insurance options, subsidized private insurance and direct pay options.It is said that the most “disruptable” industry in the world is health care. It deserves leadership from politicians, healthcare providers and administrators who have appropriate understanding of complexity and the unique challenges ahead, keeping in mind that if we want to fix healthcare for the generations, it must be pried out of the hands of politicians . . . whether they be chickens, ostriches, or sheep.Dr. Merrilee Fullerton is an Ottawa physician and former MPP for Ontario from 2018 to 2023. Dr. Fullerton’s book “A Physician in the Political Arena” can be read here. This item originally appeared on her substack blog site

Complexity in Canada’s failing monopoly healthcare: Is it fixable?

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