Contested Ground: Why innovation isn’t enough

Michael M Rachlis MD MSc FRCPC LLD (Hon)

www.michaelrachlis.com

TorontoApril 2016

Outline

• Access to primary health care is crucial for patients and health system performance• Canada has very poor access• We could have much better access• Why don’t innovations spread faster?• How could we facilitate innovation with better

politics?

3

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.

Where is Carey Price?

76 7263 58 58 57 52 52 48 41

0

25

50

75

100

Access to Doctor or Nurse

%

514 14 15 16 16

22 26 2833

Same-day or next-day appointment

Waited six days or morefor appointment

Source: 2013 Commonwealth Fund International Health Policy Survey in Eleven Countries. Question asked differently in Switzerland.

6

80 80 76 75 7259 54 51 51 4639

0

25

50

75

100

Specialist Appointment Wait times

%

3 3 6 7 1017 18 18 19

26 29

Less than four weeks Two months or more

Source: 2013 Commonwealth Fund International Health Policy Survey in Eleven Countries.

22 22 24 27 28 28 28 31 3239 41

48

0

25

50

75

Used an ER in Past Two Years

%

Source: 2013 Commonwealth Fund International Health Policy Survey in Eleven Countries.

Doctor Can Electronically Exchange Patient Summaries with Doctors Outside their Practice

8

5867

5854

46

59

46

33 3023

14

8275

70 6760 57

4942

34

22 19

0

20

40

60

80

100

NOR NZ NETH SWE UK SWIZ FR US AUS GER CAN

2012 2015

%

Source: 2015 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.

With current resources Canadians could (usually):

• Have elective surgery within two months

• Have elective specialty input within one week

• Have same day access to primary health care

The Alaska Southcentral Foundation

• Created in the 1980/90s with devolution of the responsibility for care of some Alaska natives from the US Indian Health Service to a consortia of Alaska Native Bands

• 65,000 “customer owners”

• 1800 staff, budget ~ $250 Million

• During the past decade they have been recognized as one of the world’s best health systems

The Hamilton Mental Health Program

• The Hamilton Family Medicine Mental Health Program increased access for mental health patients by 1100% AND decreased psychiatry outpatients’ clinic referrals by 70%.

• The program staff includes 22 psychiatrists, 148 family physicians, 150 Nurses and Nurse Practitioners, 20 Registered Dietitians, 80 Mental Health Counsellors, 10 pharmacists and provides care to 340,000 patients

Referrals to the Hamilton Psychiatric System

Program Started

Program Expanded

Toronto Arthroplasty ModelCentral

IntakeAssessmentAdvanced Practice Physio

SurgeonConsult

Surgery Post-Op Discharge Follow-Up

Referring Physician

Holland Centre

andToronto Western

Holland Centre

Holland CentreMt. SinaiSt. Michael’sSt. Joseph’sToronto East GeneralToronto Western

Why don’t innovations spread faster?

There are lots of other issues but the lack effective clinical governance is arguably

the biggest elephant in the room

18

Of the 230 Vancouver psychiatrists who see patients, what percentage said they would definitely see a referral in a timely manner?

•75%?

•45%?

•15%?

•3%?

Goldner et al., 2012; Can J Psychiatry, 56:474-80.

What are the rules which prevent effective clinical governance?

• All high performing health systems have high performing medical groups and effective clinical governance but Canada’s insurance model makes it almost impossible to create high performing medical groups in the community

• Canadian doctors should do their work very differently but it is almost impossible to pay them to do so• Provincial medical associations mainly control the allocation of

Medicare dollars

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

Courage my Friends, it is

Not Too Late to Make a Better

World!

Tommy Douglas(paraphrasing Tennyson)