A health-care lesson for Canada

Posted on July 3, 2008 in Governance Debates, Health Debates

TheGlobeandMail – web exclusive commentary – A health-care lesson for Canada
July 3, 2008. IRFAN DHALLA

Sixty years ago, British health minister Aneurin Bevan officially inaugurated the National Health Service. Entirely free to patients and financed through taxes, the NHS was the first system of its kind – and its overnight success spurred similar reforms around the world. In Canada, these reforms started in the 1950s and culminated in the Canada Health Act, our own guarantee of health care based on need rather than ability to pay.

The British were ahead of us then and they are ahead of us now. In the past 10 years, the NHS has undergone a variety of reforms designed to improve the quality of health care and reduce waiting lists. Not all of these modifications have been successful, and some have been “rubbished” before the wrapping paper could be torn off. Yet, there is a growing sense that the British are doing many things right.

On the 60th anniversary of the NHS, there are a number of lessons Canada can learn from the British experience.

1. You get what you pay for. Recognizing that the quality of primary care was variable, the British government launched the world’s most ambitious “pay for performance” scheme to reward doctors for doing the right things, such as immunizing most children in their practices and achieving blood pressure targets. The bureaucrats expected doctors to meet 75 per cent of their targets; instead, they hit 97 per cent in the first year of the scheme. Similarly, the government reduced wait times dramatically by paying hospitals to meet benchmarks. The results are hard to argue with – 98 per cent of MRIs and 90 per cent of colonoscopies are now performed within six weeks.

2. If we’re going to pay for doctors and hospitals, we should also pay for prescription drugs. When the NHS and medicare were founded, the few life-saving medications available were almost always administered in hospital. Over the decades, however, scientists have developed dozens, if not hundreds, of medications that extend or improve life. The NHS covers these drugs, but medicare doesn’t. Perhaps because drugs are provided by the NHS, the British government has been much more aggressive about keeping prescribing costs down. As a result, pharmaceutical spending in the NHS grew at 1.7 per cent last year, compared with 7.2 per cent in Canada.

3. Quality is a national objective, not just the goal of each individual health-care provider. Ask a British doctor who sets standards for patient care and the answer will always be the same: the National Institute of Health and Clinical Excellence. Guidelines exist in Canada as to how patients with particular conditions should be treated, but they are produced by different specialty societies and are of variable quality. They can be hard to find, sometimes one guideline conflicts with another, and sometimes they are just plain unrealistic.

NICE’s guidelines are practical and supported by tools to aid with implementation. Moreover, NICE makes its decisions in a transparent manner free from government interference. Claude Castonguay, the father of Quebec’s health-care system, recently recommended a NICE-like body for the province – a good idea, but better would be a national body that would avoid the duplication and conflict that will occur when each province sets up its own standard-setting agency.

4. Pilot projects aren’t good enough. How often do we hear of one hospital or clinic doing something ingenious while other communities continue to do things the same old (less successful) way? Health care is bedevilled by the difficulty of spreading new knowledge from one place to another. The NHS hasn’t solved this problem entirely, but Britain has established a well-funded institute whose sole purpose is to promote the rapid spread of practices and ideas that work.

5. Privatization is not a panacea. The British have been experimenting with contracting out some NHS services to private, for-profit treatment centres. So far, there’s no evidence that the private sector is cheaper or better. Although official figures have not been released, there are increasingly frequent news reports of private centres having higher complication rates. If it turns out that using private providers within the NHS improves outcomes, we should take a closer look. But, until then, the British experience suggests we should resist entreaties from those who wish to marry big business with health care.

6. Not every illness requires a doctor. When I developed strep throat last year in London, I went to a walk-in clinic staffed entirely by nurses. I received textbook care for a common, minor illness that does not require a physician’s expertise. If you have a baby in the U.K., most, if not all, of your routine postnatal visits will be with a nurse. Similarly, Pap smears and routine health checks are done mostly by nurses. Of course, doctors are readily available for people with special needs or when an abnormality is found. But do we really need someone with 10 or more years of postsecondary education to see every patient at every visit? There are smarter and more cost-effective ways to use other health-care workers to improve quality and reduce wait times.

Perhaps the most important lesson we should learn from the NHS is that we cannot afford to rest on our laurels. Yes, we have an excellent health-care system, but anyone who works in it knows it could be better.

This is neither the fault of medicare’s architects nor of individual health professionals. Disease patterns and available treatments have changed over the past 60 years, as have our expectations. Some of the institutions required to consistently deliver high-quality care in the 21st century do not yet exist. But looking at the NHS on its 60th birthday is a good way to start thinking about how we can build them.

Irfan Dhalla, a physician at St. Michael’s Hospital in Toronto, is studying health policy as a Commonwealth Scholar at the London School of Economics

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