Monthly Archives: November 2019

Getting to a People-Centred Health System


(Originally published as an Intelligence Memo from C.D. Howe Institute  –November 6, 2019)


From: Duncan G. Sinclair, David Walker, Chris Simpson and Don Drummond
To: Canada’s health ministers

Re: Getting to a People-Centred Health System

Notwithstanding its iconic standing as one of Canada’s defining characteristics, medicare, our publicly funded health insurance program, is widely recognized to be in need of fundamental change.

It was designed primarily to ensure a younger population’s access to in-hospital and physicians’ services, divorced from ability-to-pay considerations.

But now we face a greater challenge to optimize the health and well-being of people, many of them aging, with multiple chronic conditions, some preventable. Once developed, few are curable but their ill effects can be significantly ameliorated by appropriate care. That appropriateness now involves many institutions in addition to acute-care hospitals, especially care in people’s own homes and communities.

The providers needed now to help people optimize their health are a range of different care givers working in teams; the care itself extends well beyond medical/nursing and other ‘traditional’ services to helping people also access the social determinants of health.

The system’s once narrow purpose is no longer sufficient; the disconnectedness and lack of communication among its elements is embarrassing. Begun as a component of Canada’s social safety net in a period of economic optimism now long past, the financial sustainability/affordability of health and healthcare services is also under serious question. So are the structure and future modus operandi of those services in a digital age not conceived of in medicare’s early days. It’s (over) time for a serious systemic re-think and major structural and operational change.

Start with the purpose.

Helping people to recover from the effects of their illnesses, injuries, and disabilities remains an important component of the larger, overarching goal of optimizing the health of Canadians, ensuring each individual has access to the services each needs to be as healthy and well as s/he can be throughout the whole of their lives.

So the basic purpose should be to foster wellness, the preservation of good health in addition to its restoration when threatened or lost. Achieving that requires nothing less than a culture change, a shift in focus from patients to people, helping the latter do everything they can to prevent their becoming the former. There is much that can be done to reduce people’s growing dependency on the so-called healthcare “system” were it to be genuinely person-centred and its goal primarily focused on people’s health and wellness.

Second, we must expand its reach. Hospitals and physicians provide essential services but so also do nursing and retirement homes, rehabilitation and mental health facilities, the providers of home care and other community services, including housing, income and personal security, respite, community support, and other health determinants.

How can we afford to expand access to this wider range of health-supporting services now financed primarily by users who can afford them and/or by charitable giving?

Other developed countries expand the range and effectiveness of their systems by using a greater admixture of public and private insurance and out-of-pocket spending, concentrating funding from their public purses on first-dollar coverage of those with limited private resources and incomes. With the same 70:30 split between public and private financing in Canada, we could easily do better to extend the reach of an expanded and real health/healthcare system to the whole of our population, the well off and the now largely excluded poor, to a much wider spectrum of health-supporting services.

And our so-called “system” should become a real one with all of its elements connected and smoothly and transparently co-ordinated. Fulfilling these characteristics (long overdue) of a functional system is within easy reach as the technologies of our digital age make informed communication increasingly easy among all elements of the system down to its very roots in the personal interactions between service providers and the individual people they serve.

Thorny policy issues remain to be sure, safeguarding the privacy of health records principal among them, but with good will and the beneficial result of healthier Canadians in mind, they can be resolved.

Let’s get on with the creation of genuinely people-centred health systems in every Canadian province and territory.



Duncan Sinclair
Don Drummond
Chris Simpson
David Walker
**Members of the Health Policy Council, Queen’s University6

The views expressed here are those of the authors.


Toward Healthcare’s Culture Change


(Originally published as an Intelligence Memo from C.D. Howe Institute  –November 5, 2019)


From: Duncan G. Sinclair, David Walker, Chris Simpson and Don Drummond
To: Canada’s health ministers

Re: Toward Healthcare’s Culture Change

Many Canadians have bought into the unsubstantiated hype that our healthcare system is the best in the world, and our political leaders know well that voters get nervous about proposals to change it.

Currently, there is some discussion about how to pay for extending medicare’s first-dollar coverage beyond in-hospital and physicians’ care to prescription drugs. And inclusion of addictions and mental health care and dentistry have also been mentioned. Ironically, no provincial or territorial system has a primary focus on optimizing people’s health. Rather, the focus is on the repair of ill-health, the restoration to health of patients rendered unwell by disease, injury, disability, or other misfortune.

Obviously, this purpose remains vital, but contemporary needs demand the system’s expansion to encompass two additional imperatives:

a) meeting the changed needs of people, many of them aging, who suffer from multiple, chronic conditions that are amenable to wellness-enhancing treatments provided in their own homes and communities by multi-professional teams of care givers; and, more fundamentally,

b) motivating and educating people in ways to maintain life-long good health. Such expansion requires change in the very culture of healthcare.

What might bring this change about?

One stimulus is the fast-growing use of the technologies of our digital age, hardware and software. As more and more people acquire wearable devices that monitor an ever-wider array of physiological parameters, they will look to physicians, nurses, and other providers for advice on what observed changes may mean and what to do about ominous ones. With 5G broadband communication, one can envision ever-vigilant AI algorithms warning both individuals and their caregivers of early signs of illnesses leading to corrective measures, lifestyle and otherwise, to head them off. Such devices also offer entirely new, more dynamic ways of measuring health status and the outcomes of treatments.

Technologies also already exist to consolidate every person’s health and care record in a single file under the control of the person to whom it applies, a record shareable with every institution, team, or other provider in the system from whom she or he may seek service.

These will both enable and force effective communication and connectedness among the whole range of health service providers and drive workable protocols to make smooth and easy the transfer of patients among institutional and other providers that our current ‘systems’ don’t facilitate, but a genuine health/healthcare system should and would.

Another stimulus of culture change yet on the horizon is the development of more effective measures of health and well-being. Those in use, infant mortality, life expectancy, quality of life years, and the like, are highly aggregated and reflective of change only over relatively long periods of time. Others, like data on the incidence of cancer, heart disease, stroke, et cetera, are really measures of the rate of failures of health, much like hospital readmission rates, a back-handed approach to measurement of outcomes and of health itself.

Research is needed on both personally and professionally applied measures of health and wellness and their application to sub-populations, those provided healthcare services by a given team, for example, or those living in a specific region. Digital technologies will enable individuals to assess their own health against the aggregate of that of their peers in their communities, and providers will be able to compare their patient outcomes against populations served by other teams.

Those same measures should also be linked to accountability-based funding strategies to foster competition, especially among primary care teams, to provide ever better ways to optimize population health.

A third very powerful stimulus of change is provided by healthcare providers themselves.

The professional satisfaction of an increasing number, especially of young physicians and other health professionals, is strongly linked to their success in helping the people they serve achieve the best possible health and wellness.

The still predominant fee-for-service compensation system and its schedule of benefits constitute powerful incentives to provide ever-increasing numbers of often higher-cost services that are not always closely linked to any beneficial patient effect. Increasingly, physicians and other health professionals, especially newer generations, do not want to subject themselves to the fee-for-service treadmill. They welcome the introduction of compensation systems that reward them well for their expertise and long years of training but also provide them with the benefits and amenities needed to protect balanced lifestyles.

Taken together, these several stimuli have the capacity to change the culture of healthcare and create a genuine health and healthcare system that is truly people-centred. Let’s go for it.

Duncan Sinclair
Don Drummond
Chris Simpson
David Walker
**Members of the Health Policy Council, Queen’s University

The views expressed here are those of the authors.