I will explore with you some ideas for what I see is needed in leadership, governance and decision making from the provincial Health Minister.
Provincial leadership sets the framework for our health care system – within the national framework of the Canada Health Act and its principles, to which should be added the principle of accountability. Health care is a complex system which must respond to the needs and wishes of people and communities, and provide access to a full range of physical and brain health care. Complex systems do not perform optimally with centralized top-down micromanagement.
First – the relative roles of the province, the regional health authorities or RHAs and their boards, communities, health care professionals and residents. The governance principle of subsidiarity is important – certain responsibilities belong to the province, others at the RHA level and yet others with the local community and with individuals.
Direct provincial authority is needed over:
- The funding framework
- Province-wide specialist coverage
- The Information technology framework
- A Province-wide prevention framework
- Quality control and critical incident (or medical error) investigation and management
- Research as the leading edge of improvement
- A province-wide Emergency Response System.
Responsibility for day to day oversight and/or management of hospitals, personal care homes and public clinics and for regional care resides with the RHAs. Decisions about individual patients rest with the patient aided by health professionals.
Now, I will cover certain operating principles.
1) Care needs to be patient-centred. Much of today’s health care is organized around health professionals. Putting patients’ needs first is a dramatic shift. One part is each person having a health care home.
2) Democratization of health care is coming. Patients will have a greater role in their own diagnosis and care. For example emerging smartphones and apps can check your vital signs, do your EKG and lab tests and then interpret the results. People will demand quick electronic access to health professionals.
3) A culturally sensitive central role for people in decision making is vital. The system must accept input from individuals and from communities whether geographic or ethnic in nature.
4) Effective cooperation and coordination among First Nation, Metis and Inuit people, the federal and the provincial governments and health care professionals is essential for optimal health and for full implementation of Jordan’s principle – that there be equality of care.
5) Costs within the whole system need to be known. No longer can we have the same procedure done in two places – one at a cost of $85 to the system, and the other at a cost of $500 as has happened. Rationalizing operations throughout the system must be possible.
6) To have a sustainable system, new expenditures should priorize areas where the system can be improved while saving long term costs.
7) Health professionals do their best work when they have good conditions to provide excellent care.
Now to the Minister’s role to address the seven elements to deliver on these seven principles.
1) The funding framework needs to move from global budgets for RHAs to budgets based on services delivered as called for in the 2002 Kirby report. This aligns the funding model with the goal of delivering high quality services and provides an incentive to provide excellent patient-centred care. It does not necessarily mean fee-for-service for doctors as we do it now. For example, physicians looking after children might receive a fixed fee for a child from birth to one year of age, with the fee being slightly higher where the physician achieves certain benchmarks like greater than 90 percent of children receiving all required immunizations. There could also be an adjustment for particularly complex children. This approach moves away from incentives which reward the number of patient visits, calls and emails toward incentives which focus on results.
Ontario has already moved to funding hospitals based on services delivered. The transition has so far gone well and has allowed funding to respond well to the changing population bases for hospitals
2) Province-wide multidisciplinary specialist networks. Cancer care, under direct provincial authority, crosses regional health authority boundaries and is such a network. We cannot afford a similar structure for all specialties, but we must have effective networks along the lines of Alberta Bone and Joint Health. Such networks – with a provincial reporting framework – can ensure province-wide multidisciplinary team coverage, information gathering, optimizing health through prevention, strong research and the organization of province-wide consultations using video links and other electronic means. An example of a multidisciplinary team is including psychiatrists, psychologists, neurologists and neurosurgeons in Brain Health care – and indeed including some psychologists services under medicare as we have proposed.
3) Information technology framework. Health information technology is complex. For effectiveness it must be, for the user, simple, seamless, interoperable, interconnected, accessible, readily improvable and with the appropriate level of privacy and consent. It should act like a single system, built upon a large variety of what I will call “lego blocks” which easily connect together. To have in-province, the expertise to build, adapt and maintain a superb system, Manitoba should have one of the best health information technology training programs. A certain proportion of our annual health care budget needs to be spent on Health I.T., and a provincial structure to ensure the money is spent wisely and the system works well.
4) A Province-wide prevention framework. Scattered, piecemeal approaches to prevention have not and will not work with complex problems like diabetes. The costs in human lives and in tax dollars of poor results are too high. We need an integrated, coordinated province-wide effort using current knowledge and action research to strategically and effectively field test strategies for effectiveness in a way that builds on existing local community conditions, culture and traditions.
5) Quality control, audits and critical incident (or medical error) investigation and management. When a plane crashes, a centralized, standardized approach is used to investigate, identify the cause and implement local and systemic solutions. Implementing this in health will improve care by learning continuously from critical incidents. We also need quality controls to bring all care to a high standard and so that we are not performing unnecessary procedures. For example, several years ago, a careful study showed 10 percent of carotid endarterectomies were in patients whose conditions were such that the procedure would do more harm than good.
6) Research as the leading edge of system-wide improvement. Our system underinvests in research, creativity and innovation. A close connection between those at the highest levels in our provincial health care system and those involved in the research to bring improvements is critical. A balance of provincial investment in basic and applied research is needed. The Manitoba Centre for Health Policy is a good example of observational research. But we need much more action research to test ideas and concepts in the field together with appropriate controls and rigor. For example, Manitoba’s Dr. Heather Dean, in the late 1990s, showed that children with type 2 diabetes could, in a camp where they got exercise and good nutrition for two weeks, normalize their blood sugars– basically their diabetes as we measure it, went away. But this was never followed up with the research at the community level to determine the best way to implement it there. Neglect of research to guide health care improvements cannot continue.
7) A province-wide Emergency response system. Whether emergency is described as a heart attack, a stroke, a fentanyl overdose or a larger issue like a flood or an epidemic, the system must work quickly to integrate the components needed for quick response and access to emergency care.
This approach will give a provincial framework which responds well to individual and community needs. Services which are used well will be supported with funding. Services which are not used as much will receive less funding. Communities will know that if they develop excellence in health service delivery that excellence will be supported. Health care professionals will be comfortable, indeed excited, in a system providing excellent front-line care using multidisciplinary teams. No longer will excellent service built in communities be easily destroyed by arbitrary centralized decision making.
To conclude, I have outlined a high level framework for our provincial health care system. The framework will give greater independence of decision making by communities, individual Manitobans, health professionals and RHAs. Because the framework optimizes and incentivizes good decisions, there is less need for central micromanagement. With a focus throughout the system on delivering patient-centered care we can, I hope, restore trust in the system as well.