Chapter 15: Lessons from Other Healthcare Systems
We are inundated with reports of Canadian emergency department closures, crowding, patient morbidity, mortality, dissatisfaction, and healthcare worker burnout. These are not unique to Canada; other countries with better performing healthcare systems are similarly challenged.
This chapter illustratively compares health policy approaches from several OECD countries and identifies potential best practices for Canada, covering the areas of workforce planning, system capacity, long-term care and private vs. public care. To provide inside as well as outside perspectives, we focus on countries in which at least one contributing author has clinical experience: Australia, the UK, and (in the long-term care domain) Sweden. Both Australia and the UK reliably score in the top four of the Commonwealth Fund’s 11-country comparisons, with the UK occupying the top spot for years, until funding cuts began to erode access and equity. [5] Sweden tends to be in a mid-range standing overall, but along with other Scandinavian countries is considered an exemplar in aged care.
Last year, the Canadian Medical Association (CMA) [1] and health policy experts [2,3] outlined healthcare concerns that require bold government action. To achieve our goals, it is essential to be a Learning Health System, [4] open to lessons from the experience of our peers as well as our own.
Workforce Planning
Workforce Overview
In 2021, Australia, the UK and Canada had 3.9, 3.1 and 2.8 physicians per 1000 population respectively. [6] Australia also has more nurses (12.8 nurses/1000) than Canada (10.1) and the UK (8.7) (7). Many Canadian physicians are independent contractors, invoicing their provincial healthcare system on a fee-for-service basis. [8] In recent decades, many physician groups have negotiated alternate funding arrangements (AFA) with their provincial health ministries.
AFA contracts pay a defined income for specified work expectations; however, typically they preserve the physician’s independent practitioner status and do not provide pensions, sick time, vacation, health, or dental benefits. [9] Unlike their Canadian counterparts, Australian and UK hospital physicians are salaried employees. Compensation packages for physicians in Australia include retirement funds, prorated sick, annual, and 10-year service leave.
In Canada, physicians-in-training are employed by the university and require supervision until they’re eligible for licensure after a 2- to 7-year residency/fellowship. In contrast, Australian and UK physicians are licensed after their first postgraduate year (Foundation Year 1) and can practice independently. Australia and the UK have a higher physician workforce than Canada because of their large unsupervised physician-in-training staff who work at disadvantaged hours (up to 12 years in some cases) for less pay than consultants.
Canada
Canadian provinces pursue workforce strategies without interprovincial integration. Overall, personnel planning is fragmented, with insufficient planners using unstandardized data. As an example, Ontario’s Ministry of Health has a Workforce Planning Branch, [10] but its three databases are disconnected, not linked to medical training data, and do not provide trends or supply-demand analyses. [11,12,13] In addition, past provincial workforce planning models have not differentiated between certified emergency physicians (FRCP and CCFP-EM) and family physicians who work ED shifts as part of comprehensive rural family practice. There is also insufficient data on the number of ED hours/year, and trends worked by family physicians. Consequently, workforce planners would be unable to estimate how many new FRCP and CCFP-EM training positions are required to fill the current and growing gap in ED coverage (see Chapter 2).
In Canada, private recruiters pursue overseas healthcare staff; however, these individuals often learn post-migration that they lack the qualifications to work here. [14] Some provinces, including New Brunswick and Alberta, [15,16] use financial incentives to “poach” healthcare workers across provincial borders. Canada’s licensure is provincial, and healthcare workers can only work where they are specifically licensed. As of 2023, Ontario has now recognized the credentials of workers registered in other provinces and territories. [17] This move towards national registration is positive but will likely facilitate further poaching from other provinces. [18]
In 2016, the Collaborate Working Group on the Future of Emergency Medicine in Canada, created by CAEP, the Royal College of Physicians and Surgeons and the College of Family Physicians projected a national shortfall of 1,518 emergency physicians by 2025. [19] However, the recommendations of the report were not implemented by governments, resulting in no meaningful changes to workforce planning.
Australia
Research has suggested that Australia’s approach to workforce planning and accreditation is superior to Canada’s because of its strong federal involvement. [20,21] The Australian federal government coordinates workforce planning, training, interdisciplinary engagement, integration, adaptation, and strategic planning across all health disciplines. It uses comprehensive supply and demand data that describes training, migration, workforce aging, service use, and population demographics.
Workforce models are analyzed iteratively, using varying assumptions, as well as estimates derived from stakeholder engagement. Retention scenarios are also inputted into workforce models. [22] The Australian government has developed many proactive 10-year strategic plans. [23,24,25] These address regional shortages by augmenting the rural and remote workforce, using immigration policy and controlling Medicare provider numbers to adjust the number of overseas-trained physicians, and by funding medical students. [26,27] State and territorial governments staff public hospitals, provide training placements, and identify workforce shortfalls.
Australia has a unified national registration that ensures standardization of all 15 regulated health professions and allows practice across state and territorial borders. [28] With global physician and nurse shortages, international recruitment is controversial; [29] an exodus of UK physicians to Australia and New Zealand has exacerbated UK shortages, and Australia has been criticized for poaching. [30,31] The Australian Nursing and Midwifery Federation has recommended an increase in domestic training and declared that aggressive international recruitment is unethical. [32] To promote worker retention and limit interstate poaching, the New South Wales parliament abolished wage caps for junior doctors, paramedics, nurses, and other healthcare staff. [33]
Post-pandemic, unanticipated senior staff departures created ED physician shortfalls, especially in rural hospitals. In response, the Australian College of Emergency Medicine (ACEM) developed guidelines for retaining senior emergency physicians. [34] Meanwhile, locums or junior on-call physicians cover nightshifts, [35] and senior ED physicians use virtual care links for review and supervision. [36] Many small rural hospitals that were previously managed by general practitioners have, in effect, lost their emergency departments, [37] and instead, nurses provide urgent care with virtual support. In some regions, the virtual ED physician is the only doctor available.
Australian virtual care also supports ambulance services, aged care, and primary healthcare networks; patient-initiated virtual consults with emergency physicians are available but require co-payment. This shift to virtual care has raised concerns about service duplication, lack of care coordination, care delays and questionable cost-effectiveness. [38]
United Kingdom
In England, workforce planning is national; however, it has been inconsistent, based on payroll data that does not adjust for part-time workers, and misclassifies providers by their contract status, rather than their function. The NHS is awaiting publication of an updated workforce plan.
England, as of June 2022, has a staffing crisis with 133,000 vacancies, of which 9,000 were medical. The Royal College of Emergency Medicine (RCEM) estimates the UK will need 6,300 whole time equivalent (WTE) EM consultants by 2038 but will fall 600 short. This does not account for changes that will extend consultant working hours overnight in major centres. In addition, many junior doctors are leaving to work overseas, and senior doctors are retiring early. Trends within the nursing workforce are poorly understood, but sustainability is a major concern. The NHS is adding non-physician roles for advanced clinical practitioners and physician associates, but their impact is uncertain, and many are leaving emergency medicine for primary care.
Learnings
Canada can learn from Australia’s federal involvement and nationalized approach to the integration of data, regulation of healthcare disciplines, workforce supply-demand calculations, and 10-year strategic plans. It aligns with the Savage Model [39] discussed in Section Two (Optimize Access Points), Chapter Six of this report. The Task Force endorses CMA recommendations that Canada develop a national workforce strategy and eliminate interprovincial mobility barriers. This should involve national, or at minimum, provincial workforce planning, using a standardized approach to data, measurement, and prediction as well as considering the effects of evolving provider work patterns and population aging. [40]
We recommend Canada expand physician capacity by increasing from the current 2.8 doctors per 1000 population to the OECD average of 3.6, [6] with distribution matching population need by type and geography. This can be accomplished partially through a judicious immigration policy, keeping in mind ethical concerns around poaching from countries with more severe provider shortfalls. Canada’s physician workforce should grow primarily by expanding medical school enrollment, and through providing opportunity for many more Canadians.
To benefit underserved regions, Canada should introduce incentives to attract physicians to high-need specialties, such as emergency medicine. The health workforce capacity could also be enhanced by promoting the concept of working to full scope. This would mean greater (and graded) responsibility for residents and trainees. To complement the physician workforce, roles for nurses, pharmacists, social workers, nurse practitioners and even volunteers could be expanded as members of the emergency team. Because of Canada’s licensing and training requirements, we are unlikely to move to the Australian model of licensed independent junior doctors; we therefore strongly advocate for increased training positions and national portability for emergency physicians.
System Factors: Hospital Capacity and Time Targets
System Overview
Canadian healthcare governance is provincial; consequently, Canada has 14 separate healthcare systems, one for each province and territory, plus a federal system for First Nations people living on reserves, members of the armed forces and other specific populations. Provinces and territories currently provide 78% of health funding, while the federal government contributes 22%. [42]
Australia’s healthcare system is also federated with a similar division of federal and provincial powers; however, unlike Canada, there has been a trend towards more centralization with greater federal involvement. [20] Australia’s public hospitals are co-funded by federal, state and territory governments. The federal share increased from 40% to 50% by January 2020 because of the COVID-19 pandemic. [43] Funding is aggregated in the National Health Funding Pool, then distributed to Local Hospital Networks [44] that are third parties for local hospital networks, state health departments and providers. [43]
The UK has a National Health Service (NHS), nationally funded but administered by separate arm’s-length bodies for England, Scotland, Wales, and Northern Ireland.
While all three nations’ systems are somewhat devolved, Canada’s is the most decentralized, [2] and arguably the least actively managed.
In 2019, Canada had 2.5 hospital beds per 1,000 population, compared to Australia’s 3.8, and the OECD average of 4.4. [48] According to the World Bank, Australia’s 2019 health expenditure per capita of $5,427USD was greater than Canada’s $5,048; however, Canada’s expenditure represented a higher percentage of GDP than Australia’s (11.0% vs. 10.2%). [46] The UK, at the end of a decade of austerity measures, stood at $4,265 spending per capita (9.9% of GDP) [46] and 2.4 hospital beds per population. [45]
Canada
Most Canadian hospitals rely on global budgets negotiated with their health ministries, but Ontario, Quebec, and BC have shifted toward activity-based funding, where financing is dependent on the care and services provided. [47,48,49] The Ontario Ministry of Health (MOH) distributes funding largely through global budgets, Quality Based Procedures (QBP) and Health-based Allocation Models (HBAM). [48,50,51] HBAM allocates funding based on expected expenses that takes annual case volume with clinical, social, and demographic weight factors into consideration. It provides 38% of hospital funding, but there is a fixed total funding envelope, so if all the expected expenses at a hospital increases, the individual funding may not. [50] For QBP, which accounts for up to 30% of funding, a hospital must achieve specified quality outcomes for procedures, such as hip replacements.
Many Canadian jurisdictions have, at various times, set targets for ED wait times or length of stay. Generally, however, such targets have been too weakly enforced to constitute a meaningful policy lever. [52] Where the (non) achievement of targets has been attached to consequences, these tend to be carrots rather than sticks. Hospitals in Ontario, and formerly BC, did receive pay-for-performance funds for achieving time targets. [48,53,54] Such funds are often reinvested in flow-improvement interventions such as observation units, [9] a strategy associated with modest benefits in some jurisdictions, though not in others. [53]
Australia
Australia’s public hospitals operate mainly through activity-based funding, where the number, mix and complexity of patients are considered, [29,55] but some rural and regional hospitals receive block or global funding.
In 2012, evidence linking ED crowding with mortality prompted Australia to adopt the National Emergency Access Target (NEAT), under which 90% of all ED patients should leave the department within 4 hours. [56]
However, NEAT’s outcomes were mixed and ultimately did not reach the four-hour target.
The substantial investments to achieve NEAT included [57]:
Staffing augmentation, such as RN flow coordinators
ED physician in charge
Expanded working hours
More allied healthcare workers
New care models, and
New hospital policies.
The new care models included short-stay units, team-based care, fast track, senior physician at triage, admit streaming, medical and surgical assessment units, and discharge transit lounges. And the new hospital policies introduced single call admission, over-census escalation, direct admission, and bed allocation,
The initiative reduced 30-day mortality in Western Australia, but not in other states, [58] and most hospitals could not achieve NEAT, especially for admissions. [56] Unintended consequences became evident. As patients approached the 4-hour mark, staff became stressed to abruptly prioritize them, resulting in data manipulation, gaming, decision-making and compromised care quality. [56,57,59] NEAT also compromised communication, morale, teamwork, and education, negatively impacting organizational resilience, sustainability, and clinical outcomes. [60])
Despite NEAT, access block has persisted and worsened since COVID-19. A recent review by ACEM (the Australian College of Emergency Medicine) [61] recommended:
Reducing bed occupancy from 95% to 85% by increasing inpatient capacity
Establishing adequately resourced, meaningfully used short-stay units (not to serve as holding wards)
Expediting ED to inpatient transitions, and
Balancing time targets with patient safety metrics.
The New South Wales parliament [33] adopted ACEM’s 85% occupancy recommendation, abolished healthcare wage caps to ensure retention, and implemented several service increases and process improvements. There was no time target recommendation because of concern about its punitive consequences. [33]
United Kingdom
Between 2003 and 2008, the UK shifted from global budgets to activity-based funding for hospitals. During this period, patient volumes increased, and length of stay decreased; however, as other major interventions were occurring simultaneously, it’s difficult to assess how much the shift in funding contributed to these outcomes. [62]
In 2004, the government implemented a new standard, which required 95% of ED patients to be admitted, transferred, or discharged within 4 hours. Early top-down efforts to achieve this were often obscured by data manipulation and failed. [63] Later efforts focused on demand management, hospital process improvement, and changes to emergency care. These did dramatically reduce the proportion of ‘long waiters’, although the change was achieved in part by hastily admitting patients nearing the 4-hour mark.
The average ED length of stay, however, did not decrease. [64] The 4-hour standard was last met in 2011, and system performance has since declined, despite many initiatives designed to meet this constitutional standard. Ambulance response times, offload delays, [65] and numbers of patients waiting more than 12 hours in emergency departments have all increased substantially. [64] Estimates by the Royal College of Emergency Medicine (RCEM) suggest that up to 500 UK patients die every week because of emergency care delays. [66]
An important part of the picture is that hospital capacity has decreased; there are now about half as many hospital beds in the UK as there were 30 years ago. [67] The UK’s beds-per-population ratio is now lower than in most OECD countries, [66] and hospital occupancy has risen well above the desired 85% level. The King’s Fund is an independent charity founded more than 100 years ago that conducts research to improve health care in the UK. It released a recent report that suggested the greatest bottleneck is post-acute care, where after hospitalization, patients need medical support, either at home or in a specialized facility.
Intermediate (transitional) care capacity sits at about half the level of demand, while budget cuts have significantly reduced the availability of community-based long-term care beds, which are funded by local councils, outside the purview of the NHS. [67] Without expanded system capacity and a complementary policy, the 4-hour standard is insufficient to improve access.
A 2019 National task force failed to generate promising new strategies, and the UK government now favours a return to the 4-hour standard, but with a lower threshold of 76%. Even if achieved, the RCEM believes this target will not reduce ED crowding. Instead, its recommended solutions to ED crowding include prioritizing evidence-based interventions, improving hospital capacity and social services, ensuring the emergency medicine workforce is adequate, and introducing meaningful transparent performance metrics. [68]
Learnings
In the Canadian model of global budgets, every arriving patient is a cost to the hospital. More patients mean more stress on hospital resources. This creates an incentive to limit patient care and reduce access. [69]
We recommend that Canadian hospitals shift from global budgets with fixed funding envelopes and no embedded growth towards activity-based funding, which has become the international norm. Under this funding plan, every arriving patient is revenue. This motivates efficiency, flow, and throughput, allowing hospitals to expand capacity to better meet patient demand. [49] However, we also recommend reviewing the positive and negative international experiences with activity-based funding before incorporating it into the Canadian context. [70] Flow targets provide clarity around expectations and can drive operational improvement, but they are only surrogate quality measures, and may lead to gaming or compromising patient safety. [71,72,73] They remain essential, but must be thoughtfully and carefully incentivized.
Aged Care
System Overview
International long-term care (LTC) comparisons are difficult because of data limitations as well as variability in definitions and reporting of LTC beds. [74] However, we know that despite an aging population, Canada has invested less in LTC capacity than many countries, about 1.4% of GDP. [75] Sweden tops the list at just under 5% of GDP, while the UK and Australia stand at about 1.5% and 1.2% respectively. A recent international comparison suggests that England and Canada have the poorest access to LTC. [76] In addition to their lower public spending levels, these countries also rely less on client and family co-payments, and limit access based on the available LTC budget. In Australia, Canada, and the UK, care workers for the aged are in short supply and often poorly paid. [76,77,78]
Canada
Canada’s LTC facilities may be publicly or privately owned (for-profit or not-for-profit), [79] but they are publicly funded and regulated by provincial governments [80,81] with federal contributions. [82] Residents typically provide co-payments, with details varying widely by province. [83] Home care and community services represent approximately 6% of the health budget and are funded in a separate envelope; [84] services and co-payments, if applicable, also vary by province.
There are about 29 long term care (LTC) beds per 1,000 people over 65. [74] Long waits suggest that this is insufficient to meet demand: in 2021, more than 38,000 Ontarians were on a recent LTC waitlist, with a median wait time of 171 days. [85] Shortfalls in long term care also drive the Alternate Level of Care (ALC) phenomenon, in which patients who no longer require acute hospital care cannot be safely discharged, [86] and as a result, ALC patients, including those waiting for LTC, occupy 17% of Canada’s hospital beds. [87]
The Conference Board of Canada has determined that Canada will need 199,000 more LTC beds by 2035, a doubling of current capacity. This will cost an estimated $65 billion over the next 13 years, along with $130 billion in operating expenses. (2019 $CAD). While substantial, the benefits outweigh these costs, as it will unburden the hospital system, improve access to acute care, support 123,000 new jobs, and have a net positive effect on the economy. [88] However, it’s important to note that estimates are based on current patterns of care; innovations that enable more people to age at home may reduce the need for beds.
Australia
Aged care in Australia is under federal jurisdiction, [89] with services including care homes, short-term, respite, transitional care, and four levels of home care. [90] As in Canada, the government subsidizes aged care with an expectation of co-payment from residents. Not-for-profit, for-profit, and government providers deliver aged care services.
In 2008, [91] the most recent data indicated that the average waiting time for residential care was 24 days.
As of 2015, the country had 111 aged care spaces (81 residential and 30 home care) per 1000 people aged 70+ and aimed to raise this to 125 by 2021-22. [92]
In 2022, patients with alternate level of care needs occupied 6.5% of Western Australia hospital beds. [93] But since COVID-19, residential care has become less popular, and home care is now favoured, with the result that wait times for aging in place have increased.
Separate from their traditional home care services, Victoria and Tasmania make substantial use of Hospital in the Home, [94] a virtual ward that provides acute care for patients who are considered part of a hospital’s case mix. Each patient separation, or departure from hospital, is funded as an inpatient admission. A 2009 review revealed that one year of Hospital in the Home admissions (n=32,462) would have filled a 500-bed Australian hospital. [95] To support aged care, some regions have implemented virtual emergency services, and EMS residential outreach; [96] however, pre-existing GP support models within care homes also reduced ED transfers. [97]
Sweden
Under the Swedish Social Services Act, municipalities deliver aged care, funded by municipal taxes and government grants. [95] Municipalities must ensure that housing and residential areas accommodate older and disabled persons. A focus on enabling patients to live at home for as long as possible is a hallmark of the Swedish and other Scandinavian systems, combined with facility-based care as a last resort rather than a default option. [98,99]
Home services and special housing are provided publicly and privately, with a maximum copayment of 2,300SEK (about CAD$300) monthly, which is adjusted based on income. [100] Sweden has created mobile multi-disciplinary geriatric teams for complex older persons who need more services, along with transitional units with physician oversight, and community ambulance nurses specifically trained to care for older persons.
Municipalities have only three days to transfer hospitalized ALC patients back into the community. If this goal is not met, the municipality pays the additional hospital costs; [101] as a result, Swedish hospitals have few ALC patients.
Learnings
We support the Conference Board of Canada’s conclusions that large investment in LTC is necessary. This should begin immediately and continue as a 10- to 15-year health system priority. There is room for stronger federal input, particularly if this comes with funding, interprovincial standardization, and national strategic planning.
We recommend immediate investment in LTC transition capacity to address crippling ALC levels. This would:
Expedite hospital outflow.
Mitigate acute care and emergency access block.
Decrease unit costs for ALC patients now stranded in acute hospitals.
Improve rehabilitation and functional outcomes for older patients.
These units should be based on population needs, and reserved for their intended purpose—otherwise, they become holding units that fill up rapidly, yielding no benefit. [102] To prevent hospital transfers, LTC programs should introduce virtual support services, and partner with community paramedics to provide unscheduled care.
Substantial home care and LTC investment is critical, but should not occur without associated accountability expectations, including the extension of overcapacity protocols to the hospital–community transition (see Section 3: Accountability).
Canada should shift further towards the Scandinavian model of aging in place, offering a menu of subsidized home-based and residential services at different levels of intensity. Resident/family co-payments should be set in a way that is consistent and equitable across residential care settings; increasing the role of co-payments may be appropriate where the alternative is self-funded housing, and where fees are income-adjusted to ensure equity.
We should not necessarily adopt Sweden’s municipal model; after all, a municipal model also exists in the UK, but underfunding and poor integration with the NHS make it more of a hindrance than a help. However, Canada should consider introducing mechanisms that allow money to follow the patient to the most appropriate location along the continuum of care. Processes should also integrate the governance and operations of acute and community care programs to ensure a smooth transition of care.
Private vs. Public Healthcare
Canada
Many argue that Canada should allow privatized healthcare, as other countries do, to offload public demand and improve access for all. However, evidence suggests this approach may bleed resources from the public system, improving access for those able to pay, but leave public wait times unchanged. [102] In discussing this, we must distinguish financing (who pays) from delivery (who gets paid).
The Canada Health Act mandates public financing of medically-necessary physician and hospital services, but other healthcare is financed privately or through a mix of public and private financing. This includes drugs delivered outside hospital, services by non-physicians, outpatient dentistry, most long-term care, and procedures not deemed medically necessary, such as cosmetic surgery. Presently about 30% of Canadian healthcare is financed out-of-pocket or through private insurance. Each province has some form of Pharmacare, [103] but have high patient co-payments and/or co-insurance. This is in contrast to both Australia (104) and the UK, [105] where drug benefit programs are national and heavily subsidized.
Care delivery is also largely private. Many clinics are privately-owned, and most physicians are self-employed contractors who determine when they work, how much they earn, and what patients they see. There’s high corporate involvement in for-profit pharmacies and long-term care facilities. Most concerning is that companies have moved into the provision of virtual urgent care which generates more health cost but unclear value. [106] Some provinces use private for-profit clinics to address elective surgical backlogs, such as cataract surgery. [107]
Is Private Better?
Will private care delivery offload the public system? It is unclear. Private facilities can mobilize resources quickly and may add care capacity, but private delivery, especially by corporations, carries risk. There is evidence that for-profit hospitals and nursing homes deliver poorer-quality care. [108,109] Private clinics tend to skim high-volume, low-complexity (high profit) work, and some offer privately-financed options that bend or breach Medicare principles. Private facilities also poach staff from the public system. Since COVID-19, provider shortfalls, high workloads and stress, job-related burnout, and relatively low wages have driven many providers—particularly nurses—to private agencies where they have more control, better hours, and higher wages. Hospitals are then forced to re-hire these agency nurses, paying them higher wages as well as agency profit margins. [110] Canadian nurses are also finding higher pay and better hours in the USA, [111] leaving understaffed Canadian hospitals, ED closures, longer patient waits and greater stress on those left behind. [112] Privatization introduces market forces that may be good for providers, but bad for patients and public financing. It seems inevitable, however, that privatization will increase over time.
Australia
In Australia, rural and remote care, academic medicine, and complex cases are concentrated in public hospitals. However, 40% of hospitalizations, 60% of surgical admissions (mostly elective), and 1% of emergency admissions are to private hospitals. [113,114] Private (for-profit and not-for-profit) hospitals charge patients and their insurance carriers and receive government subsidies for insured services. [113] These hospitals tend to skim “easy” patients and transfer those with more complex conditions to public hospitals. Conversely, public hospitals purchase capacity from private hospitals for patients who are low-complexity, insured, and convalescing. [114]
Long public wait times drive patients into the private system, which provides Australians a choice but creates inequity. [115] Better compensation also draws providers to private settings, [114,115,116] but private hospitals do not provide full-spectrum care, so system integration and planning are weakened, and subsidies provide less return on investment. [114] Private surgical care could reduce public wait times if it increased surgical capacity by adding surgeons or operating time. But if it shifts surgical capacity (surgeon time) from public to private settings, it will not shorten public wait times, and it has not. [114,116]
United Kingdom
Despite universal healthcare, 10% of the UK population has private health insurance, either self-funded or through employment. [117] This is primarily to access elective or specialized care when waiting times are long, and it creates inequity. The UK government uses private healthcare to reduce wait times for elective surgery (such as hip replacement) and diagnostic imaging (eg CT or MRI), in the hope of increasing inpatient bed capacity. Based on the ability to pay, patients with urgent, emergent needs, low complex issues or day surgery can access NHS or private care. But complex patients with less urgent problems who need an inpatient bed may face long waits for treatment in NHS facilities; this is because private providers tend to choose simpler cases. Unintended consequences abound. For example, specialties that can provide private care are more attractive, and patients often pay higher rates to have problems addressed by private doctors, sometimes in NHS facilities. Patients with the ability to pay for outpatient care, such as physiotherapy, may do so.
A Word About the American Healthcare System
Explorations of what Canada can learn from other health systems is often meet with resistance, for both good and bad reasons. The good is that we can’t simply import another country’s health system without also importing its history and culture; nor can we expect to find a magic bullet among the myriad features and initiatives that happen to exist abroad. The bad reason relates to the fear that looking beyond our borders means looking south to the heavily-privatized American system.
Based on inequities, the USA scores dead last in Commonwealth Fund comparisons, administrative inefficiencies and ballooning costs of its multi-payer system. [5] This is why we did not include it in our comparative discussion. However, there are models of care within the US, such as the not-for-profit Intermountain Healthcare, [118] from which we can learn. Intermountain Healthcare is the pioneer of incorporating quality improvement into clinical care as a Learning Health System. [119])
Learnings
All 38 countries in the OECD (Organisation for Economic Co-operation and Development), including Canada, have private delivery of publicly-funded health services.
Canada differs from Australia and the UK (and all other OECD countries) in that private, for-profit hospitals aren’t allowed under the Canada Health Act. Conversely, Canada also has more privatization in some sectors, such as Pharmacare and long-term care, when compared to Australia, UK, or Sweden. While private hospitals offer the promise of decanting patients from an overburdened public system, they also have a deleterious impact on the health workforce and exacerbate societal inequities. Highly-privatized systems do not fulfill the equity facet of the Quintuple Aim, which makes them incompatible with Canadian values.
Our current healthcare system is not nearly as accessible as it should be, does not consistently achieve patient or provider satisfaction, and has mixed population outcomes. Until we do better on these measures there will continue to be conflict between those calling for more privatization and those defending the promise of Medicare. There is another way, but a critical part of the Canadian healthcare redesign puzzle requires us to be a Learning Health System, [4] one that’s open to the experience of others and balances the best of all systems in pursuit of the Quintuple Aim. [120]
Recommendations: Lessons from Other Healthcare Systems
Canada has a relatively poor-performing healthcare system, and we can learn from others. Our review of international practices suggests that high-performing systems are more centralized, integrated, and collaboratively managed than Canada. There are no magic bullets, but several potential innovations are highlighted in the list below:
Develop a national workforce strategy with strong federal input using a standardized approach to data, measurement, integration, and prediction.
Eliminate interprovincial mobility barriers.
Increase physician capacity, primarily through medical school expansion, targeting the OECD average of 3.6 per 1000 population with appropriate distribution matching population needs.
Introduce market-based incentives to attract physicians to practice in areas of most need (e.g. generalist-specialist mix, marginalized populations, and rurality).
Encourage health professionals, including medical trainees, to work to full scope.
Increase peer-to-peer support by telemedicine for rural physicians.
Shift away from global hospital budgets toward activity-based funding, but tailor it to the Canadian system with appropriate guardrails.
Under an accountability framework, develop system-wide flow targets aimed at improving access to long-term care, acute care, emergency care, diagnostic imaging, specialty access and primary care. Incorporate incentives that discourage gaming, and progress toward these targets in a graded fashion. We strongly recommend 85% hospital occupancy. Consider short-stay units that are not holding areas.
Make long-term care the priority target for new spending but ensure this investment is linked to an accountability framework and performance measurement.
Evolve toward an aging-at-home model. Consider increasing patient and family co-payments adjusted to ability to pay, and having home care patients considered part of a hospital ’s case-mix for funding allocation.
Add LTC transition spaces and community overcapacity beds that would serve as rapid intake buffer capacity to improve access to care and hospital outflow. Consider policies to incentivize rapid re-integration of hospitalized ALC patients back into the community.
Introduce virtual support and community paramedics to augment home (and facility) care and reduce transfers to hospital.
Implement overcapacity protocols that bridge the hospital-community outflow interface.
Acknowledge the reality that provider compensation in the public system must be competitive with the private system.
Consider privatization only in areas where evidence resulting from comprehensive comparisons with other healthcare systems suggests an improvement of patient and population outcomes. At a minimum, there should be no equity threats. If implemented, closely monitor the system for—and regulate response to—unintended consequences.
Collaborate with international partners to develop more comprehensive international recommendations for health system improvement.
Learn from and collaborate with other countries to be an effective Learning Health System.
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