From Saturday's Globe
Medicare is often called a defining feature of Canada, but the problem with defining features is that they may induce smugness and resistance to change. What defines, also limits. When Roy Romanow said this week that Canada has perhaps "the world's best" health-care system, his boosterism gave us pause. How, for instance, does he know where Canada ranks on waiting lists, complication rates and spending efficiency when patients, the public at large and the federal Auditor-General cannot even determine how we are doing here at home? One week before the former Saskatchewan premier is to produce his much-anticipated national report on health-care reform, he is foreshadowing a conservative docu- ment. Mr. Romanow has often said his federal health-care commission is about values. But it is also about value. Let us take the opportunity to reform, rather than defend, a great Canadian institution. There is reason for hope. In the same speech, Mr. Romanow made strong statements about the need for greater accountability. As he noted, this is not simply about making the provinces more accountable to the federal government for the use they make of transferred health-care funds; it is about making governments at all levels accountable to the people who use and pay for the system. In a closed system, entropy sets in. Long before conservative policy thinkers began calling for less government control, Tommy Douglas, the father of medicare, intuited the dangers when government pays for, manages and evaluates health care. In a radio address in 1959, the Saskatchewan premier said the new, government-sponsored health system should be administered by a public body responsible to the legislature. Accountability is not a panacea. Beware anyone who offers a panacea in health care. On the other hand, it's as close to one as we've got. With open- ness, with information, will come new energy; most assuredly, people will rattle the windows once they can see inside. Medicare has not caught up to the modern necessity of transparency. The system asks Canadians to trust the government and health-care providers to take care of them. Citizens and consumers have long since decided information works better than trust. They have worked hard to educate themselves, to mine the Internet for information, to travel anywhere in North America for the best care. But they will almost always be at a disadvantage. They will usually not have the knowledge to be sovereign. They will rely on experts for advice and instructions on what pills to take and surgeries to undergo. And, as taxpayers, they will continue to pay because a nation's defining feature does not come cheap. Every major institution is coming to grips with the need for openness and accountability: the Catholic Church, the federal government in its tendering of advertising contracts, even the accounting industry. Medicare must now face up to scrutiny on many levels. But merely having the information is not enough. There must be a structure that allows for public participation and pressure on government. Saskatchewan, which launched medicare on July 1, 1962, once again leads the way. Next week, the province is to announce the creation of a Quality Council, an agency at arm's length from government that will open the health system to reveal virtually everything the public needs and wants to know about it. The broad idea should serve as a good model for a national (not federal) Quality Health-Care Commission. This council would be a kind of auditor-general for health care. It would hold the federal and provincial governments to account for spending; no more lawn tractors purchased with health-equipment funds. It would report on what value the health system achieves for the money spent. And it would offer a depoliticized forum for examining how the Canada Health Act, medicare's constitution, is being applied. As it stands now, Ottawa would not dare challenge, say, Quebec on MRIs, or Alberta on "enhanced services" available from for-profit clinics. The commission would investigate complaints about health-act violations. It would make rulings, but enforcement power would remain with the federal government. Saskatchewan's council is the brainchild of Ken Fyke's commission on medicare, which reported to the provincial government two years ago. Mr. Fyke might be called Mr. Romanow's Romanow, since it was then-premier Romanow who appointed him. "Put plainly, we do not have a quality-oriented health-care system because we have not made quality a priority," Mr. Fyke said in his report. "Consequently, there is waste, error and harm." It is worth recalling that one of Tommy Douglas's original five principles was "high-quality service." To expect quality without accountability is naive. "Fear of the truth," and the resulting embarrassment, is what stands in the way of higher-quality care, Mr. Fyke said, quoting Donald Berwick of the Harvard School of Public Health. The Quality Council as envisioned by Mr. Fyke would set goals and targets -- waiting times, for instance -- and see how the system measures up. This, he predicted, would "replace anecdote, opinion and interest-group pressures" as influences on policy. The council would prepare value-for-money reports on everything from prevention to intensive care. Is there duplication, overuse, underuse, misuse? Are waiting lists standardized? Are people being served in a reasonable time? The council would rank health districts and hospitals. Are some institutions better than others in performing various types of surgery? None of this will come easily. Canada has fallen behind on information technologies. Four years ago, the head of a leading Toronto hospital said he needed $100-million to modernize his information systems to catch up to comparable U.S. hospitals. An investment here is crucial. You can't manage what you can't measure, as the actuaries say. Canada must move beyond boosterism to look at the truth about its system's quality. It must let everyone know how much the system spends, what it spends its money on and what it achieves. As Mr. Fyke's quality guru, Dr. Berwick, says, "All improvement begins with the . . . whole-hearted admission that a gap exists between what is and what should be." Mr. Romanow is said to be wrestling with the idea of a national health-care overseer at arm's length from government. The idea should prevail.
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