In health care, we rarely pay any attention to Canada's three northern territories and to the lessons they can teach us.
After all, Nunavut, the Northwest Territories and the Yukon account for a tiny percentage of the $191-billion in annual health spending and their health systems are, in some ways, markedly different from the systems of most provinces.
In the North, there are few family doctors, virtually no specialists and only a handful of hospitals; the nursing station and the nurse are the mainstay of health-care delivery. The land mass is mind-bendingly large and the population sparse; medical transportation to southern facilities accounts for a big chunk of health budgets.
Yet territorial health systems face challenges similar to their provincial counterparts: never-ending demand for acute care, ever-growing numbers of people living with expensive chronic conditions, rapidly changing demographics, constant shortages of health professionals, soaring health budgets that seem impossible to contain and uncertainty about health transfer payments from the federal government.
However, in the North (perhaps given the small size of the territories), there seems to be more resolve to admit to and tackle those problems when they are made clear, as the Yukon is doing.
Canada's Auditor-General, Sheila Fraser, recently subjected the Yukon's Department of Health and Social Services to a review. Her report, released last week, was scathing, but the Yukon has pledged to act on every finding, something rarely seen elsewhere in the country. And there is a lot of work to do.
Ms. Fraser's report is enlightening.
The Yukon has a population of 34,150 - with three-quarters of residents living in the capital, Whitehorse. Total health spending last year amounted to $148-million, plus an additional $28-million for continuing (long-term) care. Spending on social programs was $109-million more. While these numbers are small in the grand scheme of things, they have increased 47 per cent in just five years.
The Yukon may have the population of a small town, but its health system is still a system, with a similar mandate to other jurisdictions, and we should expect it to deliver.
Ms. Fraser said she set out to answer two fundamental questions with her audit: "What are you trying to achieve? And how do you measure progress?"
The answers were less than comforting. In fact, the Auditor-General delivered a withering analysis of the shortcomings of the administration of the Department of Health and Social Services. To wit:
* It has no idea whether it's providing the right programs to improve the health of Yukoners;
* It lacks clear plans and priorities;
* It routinely goes over budget, in violation of the law;
* It fails to adequately collect, compile and analyze even the most basic health data;
* It has no health human resources plan.
Ms. Fraser found the road to hell paved with good intentions.
The Department of Health and Social Services has a strategic plan that identifies goals, objectives, strategies, mission and vision, but it's not of much use because the "goals and objectives are not measurable."
While the government identified many health priorities in planning documents, it did not rank the priorities "nor produce plans to address them that include resources, timelines and targets."
Ms. Fraser found that the department rarely makes a business case before deciding on programs and services it will deliver. (A notable exception, she said, was a decision to purchase an MRI machine for Whitehorse General Hospital, which will save a lot of money spent sending patients south for scans.) Even a decision to build two new hospitals was done seemingly by the seat of the pants.
More than one in five Yukon health and social services employees are expected to retire within the next five years, but there is no plan to replace them.
One of the most troubling aspects of the Auditor-General's report is the lax standards for data collection. Specifically, the Yukon is one of four jurisdictions in Canada where physicians are not obliged to use ICD (International Classification of Diseases) codes. Practically, what that means is that half the time the department does not even know what patients are being treated for.
Needless to say, with such basic information lacking, there are no electronic health records and the department has a fundamental inability to analyze and plan.
Finally, Ms. Fraser noted that the department routinely overspent its budget, even when granted supplementary funds. It blamed the unexpected cost increases in services provided by other jurisdictions. (In health care, overspending is always somebody else's fault!)
The refreshing part of the Auditor-General's report is that it included responses, and the Yukon government has promised to implement every single recommendation. I've never seen Ottawa or any province do so - not even close.
While the audit was strictly about the Yukon, the questions Ms. Fraser asked are pertinent and timely for every one of Canada's 14 health systems - 10 provinces, three territories and the feds (status Indians, armed forces, RCMP and veterans): "What are you trying to achieve? And how do you measure progress?"
The near-universal inability to answer is discomfiting.
Right now, it is impossible to say whether Canada's medicare system as a whole (or even its component parts) is achieving its goals because those goals, where they do exist, are vague and difficult to measure.
Similarly, we don't know if our defining social program is providing value for money because there is so little effort to measure performance.
And we don't know if medicare is sustainable because we have not invested in long-term projections.
All told, it makes for a public-policy void more vast and empty than our northern territories.