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What can Sweden learn from Canada’s health system
Michael M. Rachlis MD MSc FRCPCwww.michaelrachlis.com
January 15, 2009 Tallberg Sweden
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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
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Tommy Douglas
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(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
Gen Gov’t net liabilities as % of GDP
28.6% 56.4% 50.2% -16.7%
Gini coefficient
32 45 27 23
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(All data 2009 est. from CIA World Fact Book)
Canada USA Germany Sweden
Infant mortality /1000
5.1 6.3 4 2.8
Life Expectancy F 83.81 M 78.65
F 81.13 M 75.29
F 82.26 M 76.11
F 83.26 M 78.59
> 65 years 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 10.15
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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
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Canada: Political Organization
• The federal government and the provinces share authority over public health, the environment, and other key policy areas
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Canada: Political Organization• Canadian
governments fight constantly– Have you seen
us play hockey?
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Good luck next month. You will need it to beat Canada!
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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
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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
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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
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Ontario Area:1,076,395 Km2
(Second largest Province)
Population:13,150,000(Most populous province)
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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.
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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 municipalities15
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OECD Health Data 2009 (Most data 2007/8.) http://www.oecd.org/document/16/0,3343,en_2649_34631_2085200_1_1_1_
1,00.html)
Canada USA Germany Sweden
Health Expenditures (GDP %)
10.0% 15.3% 10.6% 9.2%
Public % of Health Expenditures
70.7% 44.5% 76.9% 81.7%
Health Expenditures
(US $/capita)
$3678 $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 6.7 25.9 7.7 7.9 (1999)
Acute beds/103 2.7 2.7 6.2 2.1
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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
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0
2
4
6
8
10
12
14
16
18
% o
f GDP
Health Spending as share of GDP
From: http://www.oecd.org/document/30/0,3343,en_2649_34631_12968734_1_1_1_1,00.html 18
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S Woolhandler Int J H Serv 2004;34:65-78.19
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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
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Canada’s health system’s
problems, diagnosis,
and solutions
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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
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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
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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
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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
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Political compromise slowed the development of a more
effective delivery system
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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.
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Canada’s problems are due to the failure to re-tool an ineffective and inefficient delivery system
20 litres/100 km 5 litres/100km
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We could fix almost all Canada’s problems with innovation and quality
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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
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“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)
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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%.
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See also Institute for Healthcare Improvement
www.ihi.org
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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
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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
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What causes queues for care?
• Usually there is enough overall capacity
• Queues develop because of temporary capacity demand mismatches
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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
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Endoscopy Queues in Birmingham
Capacity (Max) Actual capacity Demand
Activity Waiting list
0
20000
40000
Week
Minutes
WL Initiative
Backlog !
What’s going on here?
Why is there still a backlog after 2 wait list initiatives?
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Capacity and demand for Endoscopy in Birmingham – Average Capacity is almost always greater than average demand!
0500
100015002000
25003000
3500
40004500
Theatre time(minutes)
Cidex leak
Capacity (Max)
Actual capacityendoscopists
Demand
Activity
0500
100015002000
25003000
3500
40004500
Theatre time(minutes)
Cidex leak 0
500
100015002000
25003000
3500
40004500
Theatre time(minutes)
Cidex leak
Capacity (Max)
Actual capacityendoscopists
Demand
Activity
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Variation in clinical systems
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Staffskills
illness holiday
motivation
trainingshifts
Patients
Resources
Process
Rooms
suppliesmachines
age
sex
race education
motivation
diseaseunclear
guidelines differ
complications anaesthetics
We control 80% of variation!
GP Discharged!
Information
transcription
transport
applicationsAll Different
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Variation kills quality AND patients
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Six Steps to reduced waiting
1. Map the process2. Eyeball the map3. Eliminate redundant stages4. At each stage measure demand and
Capacity5. If Capacity is greater than demand…6. If Capacity less than demand…
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1. Map the process• Follow the patients
through the process using their eyes
• Don’t miss the informal stages
• Measure time at each stage
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2. Eyeball the map
• Use a patient-centred view
• Are there redundant stages?
• This is the time for creativity
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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
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4. At each stage measuredemand 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
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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?
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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
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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
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Smoothing capacity
• Do you have the data?• Can you match your capacity to your
demand?• What are the barriers to flexibly using
your capacity?
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6. If Capacity is less than demand…
• Shape demand • Smooth capacity
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6A. If your Capacity is now greater than demand…
• Go to Step 5
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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”
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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!
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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.
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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.
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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)
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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
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Courage my Friends, it is Not Too Late to Make a Better World!
Tommy Douglas
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