Throwing money at health care simply isn't working

It's what we get for our investment that counts, writes Steven Lewis.

Canadian health care is in more gruesome disarray than normal — 6.5 million people without a regular source of primary care, interminable waits to see specialists, massive surgical backlogs, cancer patients shipped south for care.

In such crises, governments, providers and the public rally around the time-honoured solution: open the cookie jar. The premise is that health care fails because of scarcity. The system is basically sound, but just not big enough. The workforce is overworked and underpaid. Essential needs are unmet. Care is callously rationed.

This seems plausible, especially if we ignore history and facts. In 1997, things looked just as grim. Per capita health-care spending had been flat for half a decade. Governments went on a massive bender, and by 2010 per capita spending had increased by 54 per cent (all figures inflation-adjusted).

And? The Commonwealth Fund in the U.S. ranks health systems in 11 rich countries. By 2011, Canada was the fifth-highest spender, but our system ranked 10th. The U.S. was in last place despite spending nearly twice as much per person as Canada.

The U.K. health system was in a worse state than ours in the 1990s and, like Canada, it invested boatloads to try to fix it. By 2011, it still spent the second least among the 11 countries, and 25 per cent less per person than Canada.

But it ranked first overall, and first in seven of the nine indicators, including co-ordination of care, quality, safety, efficiency and patient-centeredness.

It's an old but rarely heeded lesson: it's not how much you spend, but how you spend it and what you get for it. The U.K. spent with purpose and a coherent plan, set performance targets and held people accountable for results.

Unlike ours, its system had been seriously underfunded and, unlike us, it got a big return on its investment.

Canada just spent. Most of it went into providers' pockets, some bought new technology, some bought more services. But there was, and is, no real accountability for performance. The U.K. reimagined, retooled and rebuilt. Canada dropped money from the sky and hoped. What if the problem is not too little money, but too much? Canada is a rich country that can afford to prop up an inefficient system. We underinvest in home care and house too many people in expensive nursing homes.

Physicians have identified dozens of overused services — estimates are that as much as 30 per cent of health care is useless or harmful — but there is no concerted effort to eliminate the waste. It's Oliver Twist's fantasy scenario: “Please sir, I want some more.” Comin' right up.

Primary care is the bedrock of all successful systems. It is a Canadian disaster. The faux consensus on what needs to be done dissolves in the corrosive acid of bad policy, turf protection and interest accommodation.

It fails those who need it most and the casualties end up in the expensive end of the system. Solution? Bigger ERS, more beds.

Only a country with too much money and too little sense makes students complete an undergraduate degree before starting physiotherapy training. You can get into medical school in the U.K. directly from high school.

The ophthalmologist who did my cataract surgery has 13 years of post-secondary education. In India, high school graduates with six months of training do this work just as well. It took a decade in Canada to let pharmacists prescribe a few drugs. The workforce is over-credentialed and badly deployed.

If necessity is the mother of invention, abundance is the goddess of inertia. Governments will nickel and dime homeless shelters, arts programs, people with disabilities, minimum wage rates, even schools. Health care? The chequebook is always open.

Another U.K. lesson: when its system ranked No. 1, it was 10th in health outcomes. A decade later it ranked fourth and ninth in health outcomes, ahead of Canada (10th), and (the U.S. 11th). In rich countries, health care can't make the population healthier.

Spending is not the problem; it's getting nothing for it time and again.

Austerity is not the answer, but we must abandon groundless faith in more of the same. Abundance has deferred change. Please sir, no more thin gruel.