What can Sweden learn from
Canada’s health system
Michael M. Rachlis MD MSc FRCPC
www.michaelrachlis.com
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)
Canada
USA
Germany
Sweden
Population
33 million
304 million
82 million
9 million
Area (km2)
9,984,670
9,631,418
357,021
450,295
GDP ($US
PPP)
$38,400
$46,000
$34,200
$38,200
28.6%
56.4%
50.2%
-16.7%
32
45
27
23
Gen Gov’t
net liabilities
as % of GDP
Gini
coefficient
4
(All data 2009 est.
from CIA World
Fact Book)
Canada
USA
Germany
Sweden
Infant mortality
/1000
Life Expectancy
5.1
6.3
4
2.8
F 83.81
M 78.65
F 81.13
M 75.29
F 82.26
M 76.11
F 83.26
M 78.59
14.9 %
12.7%
20%
18.8%
Migrants/103
5.6
2.9
2.2
1.7
Birth rate/103
10.3
14.2
8.2
10.1
> 65 years
5
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
Good luck next month. You will need it to beat Canada!
9
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 Km2
(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.)
http://www.oecd.org/docu
ment/16/0,3343,en_2649_
34631_2085200_1_1_1_1,
Canada USA
Germany
Sweden
00.html)
Health Expenditures 10.0%
(GDP %)
15.3%
10.6%
9.2%
Public % of Health
Expenditures
70.7%
44.5%
76.9%
81.7%
Health Expenditures $3678
(US $/capita)
$6714
$3371
$3323
MDs/103
2.1
2.4
3.5
3.6
RNs/103
8.1
10.5
9.8
10.8
MRI Units/106
Acute beds/103
6.7
2.7
25.9
2.7
7.7
6.2
7.9 (1999)
2.1
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
Health Spending as share of GDP
18
16
% of GDP
14
12
10
8
6
4
2
0
18
From: http://www.oecd.org/document/30/0,3343,en_2649_34631_12968734_1_1_1_1,00.html
S Woolhandler Int J H Serv 2004;34:65-78.
19
Canadian health care outcomes on average
are as good, or better than those in the US
• See: http://www.openmedicine.ca/article/view/8/1
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
% Long Waiting Times
K Davis.
Commonwealth
Fund April 2006
(Germany, Canada, USA)
Elective surgery
wait > 4 months
Specialist wait
times > 4 weeks
ER wait > 2 hr
PHC appt > 5 d
0%
20%
40%
60%
24
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;170:1678-1686)
• 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 km
5 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
www.ihi.org
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
Why is there still a backlog
after 2 wait list initiatives?
What’s going
on here?
Capacity and demand for Endoscopy in
Birmingham – Average Capacity is almost always
greater than average demand!
Theatre time
(minutes)
Capacity (Max)
Actual capacity
endoscopists
Activity
4500
4000
3500
3000
2500
Demand
Cidex leak
2000
1500
1000
500
0
25/03
18/03
11/03
04/03
25/02
18/02
11/02
04/02
28/01
21/01
14/01
07/01
31/12
24/12
17/12
10/12
03/12
26/11
19/11
12/11
05/11
29/10
22/10
15/10
08/10
01/10
/2002
/2002
/2002
/2002
/2002
/2002
/2002
/2002
/2002
/2002
/2002
/2002
/2001
/2001
/2001
/2001
/2001
/2001
/2001
/2001
/2001
/2001
/2001
/2001
/2001
/2001
Variation in clinical systems
Process
Staff
motivation
skills
holiday
illness
shifts
GP
training
machines
supplies
Rooms
All Different
unclear
Patients
age
motivation
disease
guidelines
race education
differ
sex
complications
anaesthetics
transcription
Discharged!
transport
applications
Resources Information
We control 80%
of variation!
41
Variation kills quality AND patients
Six Steps to reduced waiting
1.
2.
3.
4.
Map the process
Eyeball the map
Eliminate redundant stages
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