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Friday, September 20, 2013

Reflection on the Health Accords: A Glass Half-Full?

Owen Adams is the Vice-President, Policy & Research at the Canadian Medical Association.

Buying Change
A common refrain about the 2003 and 2004 Health Accords is that “they bought time, not change”.  I think that if you take a step back to the largely forgotten 1997 report of the National Forum on Health (NFH) it may be seen that this was the initial impetus to several targeted federal investments that have resulted in reforms in health care in Canada. The NFH put forward key recommendations including calls for a national health information system, a transition fund to support innovation in home care, pharmacare, primary care and integration, and a national population health institute. These recommendations were acted on virtually immediately in the 1997 federal budget, including a $150 million Health Transition Fund (HTF).  This was followed by further targeted investments in the 2000 Health Accord, including an $800 million Primary Health Care Transition Fund  (PHCTF), and $500 million each in health information technology and medical equipment. Although there were undoubtedly several contributing factors, I think that these federal and provincial/territorial, investments have brought about change. For example, the use of electronic patient records by family physicians has more than doubled from 23% in 2006 to 57% in 2012. The HTF and PHCTF led to the development and widespread uptake of new primary care models such as Primary Care Networks in Alberta and Family Health Teams in Ontario.
Wait Times
With regard to the Wait Time Reduction Fund (WTRF) of the 2004 Accord and its initial five priority areas, I think the hope was that it would be “the rising tide that lifts all boats”. Clearly this has yet to happen. With few exceptions, governments have not expanded benchmarks beyond the initial five areas and in its 2013 report the Wait Time Alliance has reported that in many regions and specialties no substantial or sustained progress has been achieved in recent years. Although most jurisdictions have begun to at least measure and report on wait times beyond the initial five, this is highly variable across the country. The Organization for Economic Cooperation and Development has recently highlighted the role of Activity-Based Funding in lowering wait times and this is beginning to happen in Canada in several jurisdictions. One by-product of the WTRF that I would speculate will have a payoff in the medium term is that is has stimulated the growth of operations research in the health field in Canada, at places such as the Centre for Research in Health Care Engineering at the University of Toronto.  I would venture that such research will lead to improvements in health care productivity. I would add that the series of Taming of the Queue conferences has effectively created a community of practice for sharing experience in managing wait times across jurisdictions.

One failure of the Accords has been in the area of regular public reporting to Canadians using comparable indicators of health care performance and health outcomes,

which started with the 2000 Health Care Agreement in Canada. The provinces and territories published an initial set of reports in 2002 and a second set in 2004, but since that time, with the exception of Nunavut in 2011, only the federal government has continued the comparable indicators reports, the most recent being for 2010.
The cessation of these reports highlights the difficulty of holding governments to account to one another; at the end of the day, governments must be held accountable to their citizens. In this regard one disappointment is that no Canadian government has yet enacted a patient charter that would set out rights and responsibilities with respect to health and health care. Various proposals have been introduced over the years, and Alberta came close in 2010 with the passage and assent of the Alberta Health Act, which provided for a health charter, but it has not been proclaimed.
However, there has been a growth industry around indicator reporting and benchmarking by organizations such as the Conference Board of Canada, and the Canadian Institute for Health Information has developed a performance measurement framework and will be coming out with an initial set of indicators in the near future.
In closing, I think that one of the reasons that a transformed health system remains elusive is that we do not have a shared vision of what success will look like from the viewpoint of the end-user patient. Peggy Leatt and colleagues set out an appealing nine-point vision in 1999 (p.16) and I would commend readers to it.
Finally, I would add that no organization advocated more forcefully for the creation of the Health Council of Canada than the Canadian Medical Association, and its departure will leave a void, but I hope that its thoughtful and creative work such as the Health Innovation Portal will be built upon and not reinvented.

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