A public-private health model for Canada

This month the Health Council of Canada published the 2012 Commonwealth Fund International Health Policy Survey of Primary Care Doctors. This informative study is based on a survey of more than 2,000 primary health-care workers across the country.

It focuses on how front liners perceive the system (Does it require minor or major change? Do patients get too much or too little care? Can they get diagnostic tests when they need them?) and how they themselves operate (Do they make home visits? Prescribe electronically? Monitor their own performance against targets?)

It provides a fascinating insight not just into how we are doing, but also into how we are doing relative to other countries. Sadly, the answer is “not that well.”

Canada’s health system sits more or less in the middle of the pack on physicians’ perceptions of how much change is required: 40 per cent of respondents say the system needs “only minor changes” and our doctors themselves are happy (82 per cent say they are satisfied or very satisfied with practising medicine).

But does their happiness come at the expense of patient care? The disparity between physician satisfaction and the measures in the survey that would seem to translate directly into patient satisfaction, is telling.

As the report notes: “Compared to physicians in nine other countries, Canadian primary care physicians are the least likely to routinely provide same-day or next-day appointments (47 per cent). They are also among the least likely to make home visits (58 per cent) or have afterhours arrangements so that patients can see a doctor or nurse without going to a hospital emergency department (46 per cent).” But doctors themselves may be oblivious to this, because Canadian primary care physicians are also among the least likely to work in practices that regularly review clinical performance against targets (41 per cent average, varying between 62 per cent for B.C. and 19 per cent for Quebec).

Overall, then, this is not an uplifting survey. It finds that “In overall national performance, Canada shows no relative improvement in any areas of access to care … since 2006.”

Canadians are always wont to compare our system to the U.S. This makes sense, but only in geographic terms. There are numerous examples of mixed public-private systems around the world that exhibit substantially greater cost effectiveness and better medical outcomes than our own. None is perfect and all systems struggle to rein in costs, but should we not be learning from elsewhere? And isn’t the Health Council survey a good place to start identifying our deficiencies?

At Canada 2020, we have been gathering information on an alternative public-private hybrid model currently being tested in the U.K. (a country in which 95 per cent of primary care workers say their patients can get after-hours service outside a hospital emergency department and where 96 per cent of physicians regularly review clinical performance against targets).

In 2012, The Circle Partnership was awarded a 10-year contract to manage a publicly funded, full-service hospital in Huntingdonshire. The National Health Service continues to employ most of the hospital’s staff. Health care remains free and universal at the point of delivery, but private-sector incentives have been introduced. Doctors, nurses, and other Circle employees collectively own 49.9 per cent of the company, while the rest is owned by a group of hedge and venture capital funds.

The model is relatively simple: if efficiencies by Circle yield a surplus at Hinchingbrooke Hospital, profits will be shared by the hospital, the NHS, and Circle. If the hospital continues to post a deficit under Circle’s management, Circle will earn nothing and has agreed in its contract to be responsible for the first £5 million of fresh debt.

It is too early to judge Circle’s success. On the one hand, the hospital’s emergency room, which regularly failed to meet targets in the past, was ranked first of 46 hospitals in eastern England after six months under Circle’s administration. Monthly targets for cancer treatment, which had last been met in June 2010, were being fulfilled every month and the length of a patient’s stay after hip or knee surgery fell from an average of 5.6 days to 2.6 days, allowing for faster turnaround of rooms.

On the other hand, Circle has yet to demonstrate its ability to keep costs under control (although it is early days yet). The hospital’s losses reached £4.1 million within eight months, just over double the £1.9 million of debt that Circle had predicted for the hospital by that point.

Here in Canada, no legislation prevents the introduction of private health-care administration. What’s more, our current system should lend itself well to the transition because Canadian primary-care doctors are already paid under a fee-forservice system, rather than earning a fixed salary.

It seems, though, that the largest roadblock to introducing a similar model to Canada lies in public resistance to change. Opposition to any linkage between the private sector and health care remains strong (back to that American comparison problem) and a number of Canadian facilities that have incorporated private incentives have been closed, despite their success (for example the Canadian Radiation Oncology Services clinic in Ontario and a private clinic at Montreal’s Sacré- Coeur Hospital).

But aren’t we Canadians openminded people? Surely we can open our minds to alternative ways to deliver universally accessible publicly funded health services. The Circle model may not be the perfect solution, but it is well worth watching from our shores if only for the reason that health care improves most when the medical community does what it does best: experiments.