No progress in health care, including technological advancement, will ever happen until we fix the governance of our health care system.
I was chair of the governance sub-committee of the Halifax Chamber of Commerce’s Health Care Committee 10 years ago. About five years ago, I chaired the Nova Scotia Wait Times Advisory Committee for a couple of years. It’s clear that the hands-on health care experts are the doctors, nurses and administrators; the rest of us are ignorant bystanders.
But our present governance system prevents the experts from acting.
The governance problem is that the people who conceive the health care project — the government — are:
•The same people who define the scope of the project — what’s in and out.
•The same people who set the budget for the project.
•The same people who raise the money for it through taxes.
•The same people who build the facilities and install the other capital assets it needs.
•The same people who operate it.
•The same people who fund those operations.
•The same people who measure — or don’t measure — the results.
•The same people who judge it after the measurements are made.
The system is bizarre.
After all, the reason we have a government and a civil service is to set standards and exercise oversight, so as to hold other people accountable. But when government or the civil service step into a management role, they become management. At that point, there is no one left for management to report to, no one left to exercise oversight, no one left to hold management accountable, no one left to do the job that government and the civil service were set up to do in the first place.
Politically, this state of affairs is understandable. In health care, the government is the full and only payer, so all problems are laid at the feet of the government. Consequently, the government feels vulnerable and wants full control.
But with the best will in the world on the policy and administration side (and there is no question about that), and with the highest skill levels at the delivery end (and there is no question about that either), our health care system as it now exists simply cannot work in an optimum manner, because there is no accountability mechanism.
So, how do we build accountability into our health care system? Here are a few ideas:
•Let the Department of Health develop the scope of the health care project, fix the budget and set the standards that health care providers have to meet. Then let the department get out of the way.
•Let there be a separate Crown corporation to operate the system itself. Let it be self-sustaining, have its own board of directors, hire the CEO and management, and report to the Department of Health and the public through quarterly and annual reports. Let this Crown corporation have the responsibility for spending the budget and entering into contracts for services with the hospitals.
•Privatize the hospitals, as they did under the socialist government of Sweden. They will enter into contracts with the Crown corporation for the supply of health care services. Terminate those contracts if they don’t meet budget, or fail to meet the applicable standards.
•Let those private hospitals in turn sub-contract for all their services, with the surgeons, the X-ray technicians, the cleaning staff, the pharmacists, and everyone else.
•Set up an independent government agency to measure the results. This agency does not report to the Department of Health. It reports to the public.
•If you really want to get radical, go to a consumer-driven, market-based system. Let the public’s money follow the patient. Your hospital only gets paid if the patient or his GP chooses you, instead of someone else. The U.K. began moving down that path under the (socialist) Labour government.
Better governance will do nothing to fix the problems of the health care system. Only those in the system can do that, through their enterprise, innovation and determination.
But good governance is an essential pre-condition.
Without accountability mechanisms, including financial consequences, no one will set out on the path to improvement.
I realize changing health care governance is anything but easy. But it is not impossible. It is being done elsewhere, such as Sweden and the U.K.
All it takes is political courage, and maybe not very much of that. After all, every government gets defeated eventually. So my practical, non-courageous question to our politicians is this: Instead of getting defeated for doing nothing, why not get defeated for doing the right thing?
George Cooper, QC, is a practising lawyer and chairman of the board of directors of Halifax law firm McInnes Cooper. He is a member of the AIMS Board of Directors.