Unchartered Waters

There is a myth, perpetuated by both levels of government in Canada, that the Constitution explicitly assigns the responsibility for health care to the provinces. It does not. The Constitution does grant provinces jurisdiction over “hospitals [and] asylums” (excepting marine hospitals) and “generally all matters of a merely local or private nature.” The problem with contemporary health care, however, is that it no longer resembles what existed when the Constitution was written: much health care is delivered outside of hospitals; it is largely public; and, most importantly for the 21st century, it cannot be delivered effectively as a “merely local” service. The practice for several decades now has been to view health care as a collaborative venture between federal and provincial governments. This convention has been driven by a combination of economic necessity, political opportunism and technical utility, but it has allowed Canadian health care to develop over time as a reasonably fair and effective system.

In a masterfully strategic move, Ottawa has now limited its role to providing basic funding to the provinces. It will no longer make any effort to think about the organization of health care per se. This, we are told, falls under provincial jurisdiction. And, as the provinces devoted most of the 1990s to demanding an end to the country’s “vertical fiscal imbalance” without the imposition of federal conditionality, it would seem they have received exactly what they have asked for. Thus it is unsurprising that the Canadian public seems either confused (at best) or complacent (at worst) with the refusal of Ottawa to enter into a substantial healthcare accord with the provinces of the kind we saw in 2000, 2003 and 2004. This is worrisome. The debate over the renegotiation of the 2003 Accord on Health Care Renewal and the 2004 10-Year Plan to Strengthen Health Care has simply become a discussion about “how much” rather than “where to from here.” Even if previous accords were long on vision and short on implementation strategies, they at least articulated a set of goals and principles upon which all governments agreed. The conversation of what will happen when the 2003 and 2004 documents expire is not a renegotiation at all; it is merely a haggling over funding rather than an appraisal of what 21st-century health care ought to look like. This focus upon dollars over substance means that individual provinces will be left to grope their way awkwardly and precariously through an expansive and hugely complicated network of systems. Canadian health care will amount to 13 canoes paddling furiously in all directions across the high seas when what is needed is a compartmentalized, steel-hulled ocean liner.

What a relief, then, that at least one voice is willing to ask where to from here. And a quick review of Stephen Duckett’s proposals for healthcare reform in Where To From Here? Keeping Medicare Sustainable tells us very clearly that any attempt to keep medicare sustainable requires a highly reticulated system of communication, collaboration and cooperation at all levels. Very few suggestions in his book focus solely upon individual hospitals or even regional health districts. Rather, Duckett’s approach utilizes a web of national-level institutions that include not only Health Canada but also the Canadian Institute for Health Information, the Canadian Institutes of Health Research, the Canadian Health Services Research Foundation, the Public Health Agency of Canada, the Health Council of Canada, the Canadian Patient Safety Institute, and the Canadian Agency for Drugs and Technologies in Health, among others. He also sees a major role for a reconfigured Canada Health Act and federal-provincial healthcare accords. Governments are instructed to work together to develop goals and targets, facilitate exchanges of information, enable the transformation of primary care and collaborative team practice, discuss pharmacare, review potentially obsolescent health technologies, share best practice policy, ensure seniors’ health care, develop and publish consistent guidelines and benchmarks, revise the Canada Health Act, model workforce planning and review regulatory structures. The phrase “federal, provincial, and territorial leaders should” is a common one. There is still a great deal of room to develop individual pilot programs and to address regional concerns: this is a model of coordinated, not centralized, health care. But it is also very clearly not a model of health care premised on 19th-century delivery systems.

The issue Duckett addresses is how to keep Canadian public health care sustainable. The objective, he states, is simply to ensure that “the right person enables the right care in the right setting, on time, every time.” It assumes the value of both equity and efficiency. Duckett develops approximately 60 proposals for change “in priorities, approaches, and management.” None of the suggestions he makes is novel: setting pan–Canadian public health targets, transforming primary health care, developing integrated care organizations, restructuring seniors’ care, establishing clinical care networks, rethinking the scope of practice for healthcare professionals, and so on. This is not a criticism. On the contrary, by sifting through a massive amount of academic and clinical information across a number of cognate areas, he is able to distil a relatively workable set of proposals that could be applicable and advantageous to Canadian health care. Very few people who do not study health policy for a living would be able to amass such an encyclopedic volume of information, let alone extract and distil the most relevant and propitious options. Duckett has read it all so you don’t have to. Moreover, his account is a reasonable and judicious extrapolation of what the experts are currently telling us about best practices in health policy.

Duckett is an economist and a policy wonk, and this is apparent in what he says and how he says it. This is not a criticism either. His explanations are clear and the technical verbiage is quite minimal. This is an accessible book. But it is also like reading the biography of a racy movie star that contains no salacious details: we are left wondering why he only discusses policy proposals and not the real politics underlying them. He should know the real politics: Duckett recently left Alberta after serving briefly as the first CEO of the newly formed Alberta Health Services “superboard.” By his own admission elsewhere, Alberta’s healthcare system is expensive, performs poorly and has been badly managed over the past decade. But is this simply because of its organizational structure, or is it due to rampant political interference (including widespread allegations of physician intimidation and queue jumping)? Duckett does not deny that politics in general are a reason that the best health reform policies are ignored, undermined or buried, but he does not give us a clear explanation of just how they are linked. And, of all the people, in all the provinces, this former CEO could have written a compelling and fascinating account of how politics distorts and subverts the best attempts to improve the provision of health care. But he did not. And it is a pity.

This omission does not compromise what Duckett does have to say. His major theme is the sustainability of the public healthcare system, and he argues, accurately, that a public system is a good place to begin when thinking about the sustainability of health care in general. “In my view,” he states, “there is no need to introduce substantial private funding; no need to change the five criteria for complying with Medicare arrangements in any major way; no need to revisit the values shared by Canadians. There need be no access/quality/-sustainability trade-off, as all three are achievable.” The complementary theme here is that “Canada does not need ‘big bang’ reform” (and, he adds, “the track record of big bang proposals is not good”). He is correct on both counts. Because of Britain’s centralized control of the National Health Service, for example, that government has been able to impose reform after reform upon the system, from Margaret Thatcher’s handbagging of the NHS in 1987 to the present Conservative/Liberal Democrat coalition’s Health and Social Care Bill. The problem is that potential improvements are often wiped out by the destabilizing effects of continuous systemic change (the phenomenon of “reform fatigue”). Conversely, the cumulative effects of small, sensible policy changes can lead to remarkable results. This, as Adam Gopnik has argued in The New Yorker, explains the phenomenal drop in America’s crime rate in the past decade: “small acts of social engineering, designed simply to stop crimes from happening, helped stop crime … a series of small actions and events ended up eliminating a problem that seemed to hang over everything. There was no miracle cure, just the intercession of a thousand smaller sanities.” A thousand smaller sanities might go far in keeping Canadian medicare sustainable as well. But to put them in place, we must do more than simply bicker over transfer payments. We have to engage in the arduous process of organizational reform, and we must do so in a systematic rather than piecemeal way. The kinds of things that we ought be doing are already well documented, and Duckett has 73 dense pages of citations to prove the point. Increasingly, the most interesting question in Canadian healthcare reform is not “what should we do” but rather “why aren’t we doing what we know we should do.” Is it organizational gridlock? Political opposition? Insufficient capacity for collaborative activity? The lack of leadership? Again, Duckett would be in a position to theorize about the underlying dynamics of reform (or the lack thereof); let us hope that he has the appetite for a sequel.

The world into which this book was born was certainly not a propitious one for the message contained within it. In a very brief and forlorn postscript written in January 2012, Duckett acknowledges the federal government’s disengagement with health policy renewal and notes that his recommendations “have continuing relevance as they address real contemporary issues, issues that will not go away with the federal announcement.” Indeed they will not. Left unstated is whether, and how, any form of leadership can be mobilized from within the vacuum left by Ottawa’s exit. Duckett does try to remain optimistic by noting numerous measures that provinces can execute on their own, but even so the insight that such reforms work better when coordinated across provinces is still pertinent. The glib presumption that individual provinces must bear full organizational responsibility for health care is a premise based upon a twisted framework of partial knowledge and political opportunism. If this assumption is widely accepted, then most of Duckett’s sensible and thoughtful policy suggestions to reinforce a sustainable public system are dead on arrival. Perhaps this is exactly what Ottawa wants. The federal government has signalled quite clearly that it is willing to leave the less well off provinces to their own devices when it comes to health care. Is this a principled adherence to the concept of open federalism, or is it an attempt to pressure these provinces to turn to market solutions in the provision of health care? Several different scenarios are possible for 2014 and beyond. One is that the strategy of market-preserving federalism pursued by Ottawa achieves its goal of making privatization look appealing to cash-strapped provinces. Another is a seismic transition in the nature of Canadian federalism. Current thinking about healthcare federalism involves an implicit dichotomy. On the one hand, there is the command-and-control model of Ottawa as benevolent enforcer: if the federal government did not impose the Canada Health Act on intransigent provinces, the act and the principles underlying it would dissolve forever. On the other hand, if the provinces were left to their own devices, the result would be a disorganized and haphazard free-for-all. This is no small worry: there is evidence that federal systems are at a clear disadvantage vis-à-vis unitary systems when it comes to implementing essential reforms. This explains widespread editorial exhortations following the federal-provincial health talks in January 2012 to keep a strong federal role and ensure the conditionality of health transfer payments. But is this dichotomy itself obsolete? Is it possible to have a non-hierarchical, horizontally integrated, well-coordinated system of healthcare governance without an authoritative federal supervisory role? Can the provinces impose this organizational discipline upon themselves?

Certainly provinces are under no legal requirement to follow the precepts of the Canada Health Act, and Ottawa for years has shown little interest in attempting to enforce it. The reason that the provinces adhere to the principles of the act is because their electorates seem rather attached to them. And, despite the well-publicized tiffs among provinces, a notable level of administrative communication and even collaboration has developed between provincial departments and through the Council of the Federation. New and innovative theories of governance provide models of collaboration that do not require Ottawa to administer and discipline provinces as if they were incorrigible schoolboys. In contrast to the top-down, linear model of federal healthcare governance, alternative theoretical conceptions of federalism posit a voluntarist, consensus-oriented and discursive relationship among governments where accountability rests upon disclosure, transparency and peer review. From this perspective, Ottawa’s refusal to engage in the substantive aspects of healthcare reform merely facilitates the development of a different kind of federalism altogether. Realists, of course, will scoff: when it comes to protecting provincial interests, they argue, the rhetoric of provincial comradeship will disappear quickly enough. They may be right. But with Ottawa vacating the field of social policy, the alternatives to this approach may just be grim enough to make provinces think seriously about the possibility of a coordinated Canadian healthcare system without Ottawa at the helm.