Part 2. Published December 2009

This is a follow up article to the one which appeared September 2009 in which the authors proposed a new competition based model for health care delivery. The article was something of a “what would I do if I were King for a day !?” We have received much feedback to this article which has been accompanied by one underlying commentary, “great model but how would you implement it?!

This article is an attempt to offer principles derived from observation to answer this question by reaching back into our history and retrieving success factors which can be applied today to affect significant and necessary health care reform.

The Only Constant in life is change

It has been demonstrated that change in the form of innovation occurs at 1.5% per annum compounded (1) The adoption of innovation is however quite unpredictable and is subject to the incentives or disincentives in the environment. The adoption of innovation will be jagged and also subject to political interference in centrally governed and operated monopolistic delivery systems. The adoption of innovation is required to improve quality, safety and efficiency. If the adoption of innovation is frustrated the accompanying delivery system will be inefficient and dysfunctional.

Crisis, what Crisis?

There are many kinds of crisis which can serve as conditions for change or impediments to change in health care. These include political, financial and public health crises.

It is often remarked that the health care system is in a state of crisis and has been for more than 20 years. Many health care meetings and forums have led with themes of financial crisis for at least a generation. More recently public health concerns such as SARS and H1N1 have led to a different kind of focus and media hysteria. This is nothing new. H1N1 has been around since at least 1918 and one of the first and most significant events in the development of health services for all occurred in the heart of the Great depression, the worst financial crisis of the last 100 years. The going joke in the health care funding discussion in Canada is that there is always a funding crisis and if there wasn’t a crisis, that would indeed be a crisis.

Change matters: what can we learn from our own history

We are going to examine two landmark successes in change management from the history of the development of Canadian health care. Factors in the successful adoption of these innovations in health system delivery will be identified and applied to the proposed implementation of our model described previously. One of these examples is well known however the first is not so much.

These are in chronological order:

1. First Universal free diagnosis and treatment of Tuberculosis, January 1, 1929
2. First universal Medicare July 1,1962

We chose these milestones for review because the introduction of legislation for treatment of TB was the first chronic disease management model to successfully arise in response to a major public health crisis and the first to include government funded hospitalization for any disease. This system was completely novel, no system was in place previously simply a user pay ad-hocracy.

The second case study, government funded medical services was chosen because it was another truly innovative program which encountered considerable opposition to implementation. Both case studies are therefore novel, complementary and hold lessons for change management due to the significant challenges which had to be overcome to make them successful.

Conversely the introduction of province-wide hospitalization for any acute intervention in 1947 was not chosen as a case study because it was essentially an extension of the government funded TB hospitalization program of 1929 more broadly applied to acute hospital and episodic care. Its introduction in 1947 was not broadly opposed relative to the other two cases.

“Free treatment” for Tuberculosis (Public Health Crisis)

In the first half of this century tuberculosis (TB) was greatly feared and for good reason. A deadly disease easily spread it found its foothold in schools, factories, shops and homes across the world. Known as the White Man’s Plague it particularly ravaged native populations which did not have a natural immunity. No more so than in the province of Saskatchewan which in 1917, the year before the first recorded H1N1 outbreak, had the nation’s highest incidence of tuberculosis among its population or a rate of 50 per 100,000 population.(2)

Faced with the worst public health dilemma in the country the newly appointed head of the Saskatchewan Anti-TB League Dr. RG Ferguson planned his attack. Knowing that financial burden was a huge obstacle to seeking treatment in Sanitoria Ferguson began to gather data on infection rates. As secretary of the Saskatchewan Tuberculosis Commission which reported its recommendations in 1922 he was able to chart a course which would not only guide the direction of TB treatment for the next twenty-five years but influence health insurance schemes across the country for generations.

Chief among the Commission’s recommendations was to make the payment for diagnosis, treatment and hospitalization for TB a public responsibility. This had never been done before and was viewed with considerable skepticism by politicians at both the municipal and provincial levels. It took him seven years to get their support. How did Ferguson make this happen ? He worked tirelessly to gather grassroots support for free treatment of TB. Key to his success was developing coalitions of former patients, lay members of the public, professional colleagues and politicians.

The first resolution advocating free treatment for TB was introduced at the Saskatchewan Association of Rural Municipalities (SARM) in 1925. It was soundly defeated receiving only 6 votes of support out of 600 delegates. However the idea did not die and Ferguson found a new and powerful ally in the newly elected Liberal Premier of Saskatchewan, James G Gardiner. Ferguson and Gardiner had both attended the University of Manitoba together and held a mutual respect. Ferguson saw his chance to enlist the Provincial government’s cooperation and pursued it systematically. (Gardiner is perhaps better known for his famous debates with the Ku Klux Klan leadership in 1929 and playing a role in the creation of the United Church of Canada and later Sask Power).

Two years later a new motion to ask the provincial government to take over control of the Sanatoria passed by a slim margin however the provincial government replied that they could not afford it. A year later a breakthrough was achieved and the two sides compromised as SARM passed a resolution agreeing to a cost sharing arrangement with the Provincial Government. In the course of discussion Ferguson had arranged for one of his ex-patients from the Fort Qu’Appelle Sanitorium, now cured, and employed at the San for almost a decade to stand up and by his presence demonstrate what could be done with accessible and effective treatment. This time the resolution passed unanimously. A similar resolution was later passed by the Saskatchewan Association of Urban Municipalities and by the United Farmers.

Ferguson now had the necessary ingredients to champion legislation supporting free treatment to the Premier JG Gardiner and he began by inviting all sitting members of the provincial legislature to visit and tour the Sanitorium at Fort Qu’Appelle,. More than half of the members attended. In December 1928 Gardiner’s Liberal government tabled the Saskatchewan Sanitoria & Hospitals Act. It passed unanimously on January 1st 1929, nine months before the stock market crashed. Prophetically the Honourable J Latta , Minister of Municipal Affairs characterized the new Act as “ a great social experiment, and a costly one at that.” Despite the devastation wreaked by the drought and depression on Saskatchewan funding for TB treatment continued and it was not uncommon for some municipalities to spend more on TB in a given year than they did on roads, a stunning turn of events in the ‘dirty thirties.”.

In 1930 a private members bill was tabled to remove the “free” clause from the legislation prompting the Minister of Public Health Dr. JM Uhrich to rise in the House and thunder, “Let our fight be with Tuberculosis, not with the Tuberculous.” The bill was roundly defeated. The concept of free treatment had now achieved a foothold in North America.

The outcome was a program which by 1948 had reduced the death rate by roughly two thirds, or down to a rate of 17 per 100,000 population, and was emulated across the country. It became so popular that the provincial CCF government effectively adopted its principle of public funding and administration to cover all forms of hospitalization in 1947.

What were the success factors that made free TB treatment happen ?

Born in North Dakota Ferguson had grown up on the farm in Yorkton Saskatchewan. He later served as a Methodist Minister for a year before entering Medical School. He was a crusader against TB who could communicate to a diverse population and who organized a broad coalition of support. (i.e., in May 1935 the Pasqua, Piapot and Moscowpetung Indian bands made him an honourary Chief among them for his work in combatting TB among native peoples) Ferguson capitalized on broad based fear of TB and galvanized the population by demonstrating that quality accessible (evidence based) treatment could work and reduce this threat. . He then utilized the broad public support to ensure government action by convincing the stakeholders that the cost of inaction was higher than the cost of change to a new way of doing things.

In a nutshell Ferguson’s success was achieved by getting the key stakeholders; government, politicians, public, and professional colleagues to agree that change (government funded treatment) in the form of new legislation, although perceived to be costly, warranted support and the status quo (user pay) posed a greater risk to everyone due to a greater probability of infection and death.

Example 2. First Universal Medicare aka “The Doctor’s Strike”

The introduction of medicare (government paid medical services) in Saskatchewan in 1962 was preceded by a complex and hard fought political battle between a labour government (CCF) and members of the Saskatchewan Medical Association, supported by sympathetic groups such as members of the American Medical Association.

In the 1960 provincial election Tommy Douglas’s CCF (NDP) promised to introduce legislation for comprehensive medical coverage, with affordable premiums subsidized by government.

The government’s argument for the legislation was that it would improve disease prevention, early diagnosis and treatment, promote medical research and education and reaffirm the value of human life.

The CCF won the election in spite of the visceral opposition of the province’s 900 doctors and the College of Physicians and Surgeons. The opposition also garnered support from the Keep Our Doctors committees (KODs) and members of the American Medical Association who characterized the new legislation as the first steps towards communism. (3). Many members of the KODs were in fact wives and other family members of doctors.

The Act was introduced by the Premier, Tommy Douglas but received royal assent only after Woodrow Lloyd had become Premier in late 1961. At a meeting in May 1962 the doctors determined that they would not practice if the Act came into full implementation. On July 1, 1962 the Act came into force and most doctors closed their offices, took holidays or refused to see patients outside of hospitals. Ironically the mortality rate in Saskatchewan dropped during this time largely because of the decline in surgery. (3)

The strike lasted 23 days and made international news which was often sympathetic to the government’s position. The local media however was another matter. They supported the doctor’s position and demanded that the government back down. Nevertheless as the strike continued the government continued to stay on message and public opinion in Saskatchewan turned against the doctors. Many doctors were recruited from the UK (ironically a labour government gave immediate licensure to what were essentially strike breakers) to provide medical service. The resolve of the striking doctors began to diminish and eventually they were allowed to opt out of the new system although none of them chose this option. The outcome of course is that the new program came to be considered a great success, was emulated across the nation and doctor’s incomes went up.

Why was this implementation successful ?

Similar to the previous example regarding TB the introduction of this Act had a champion who could communicate its value, (in comparison to the status quo), very effectively to a diverse audience. Tommy Douglas was a charismatic leader who had already been successful in introducing free hospitalization in 1947 (although with considerably less opposition). Like Ferguson he had enjoyed a short career as a Minister (Baptist) before entering politics. Douglas held the twin posts of Premier and Minister of Public Health during the last four years of Ferguson’s tenure so it was not surprising that in his address at Ferguson’s retirement he said “Not before in the history of this province has there been such a universal expression of regard for one man. Few men have the opportunity in their lifetime to give such service as Dr Ferguson has to his generation and to his age. Still fewer would be so successful in rising to the opportunity.” The two men sat at opposite ends of the political spectrum but shared a passion for public health (4).

While the actions of government were perceived by the medical profession in Saskatchewan as very threatening the government was able to get its message across that it would leave its citizen’s better off and the population accepted this logic in-spite of the emotional blackmail offered up by the doctors, their College and the KODs. The government had succeeded in positioning itself as the guardian of the public’s best interest in spite of the opposition of an organized medical profession. It was truly a remarkable achievement to manage such a political crisis so effectively and against such a popular and sophisticated adversary as the 900 doctors.

Necessity is the mother of invention

Too often an apparent lack of financial resources is used as an excuse not to make fundamental change in the public service. We believe the opposite to be sometimes true and that an absence of resources may in fact be a helpful pre-condition to fundamental systematic change. It can assist in gaining political support by galvanizing public opinion behind an option which does not require additional funding, since the public may have come to silent agreement that the status quo is no longer affordable and they have also come to accept that government had no other choice but to make major changes in a crisis.

“We are under-funded . If we only had more money we could deliver a better service” is a familiar refrain in health care circles. The reality however is that when cuts are made in a highly centralized ‘top down” bureaucracy they often reflect political expediency rather than efficiency. For years health administrators have been saying that they have cut services to the bone or cut off the fat. Perhaps its time to start delivering services differently rather than simply cutting them out.

In looking at the profound change and innovation of the two examples above one thing seems clear. Saskatchewan was an economically poor province, particularly during the depression of the 1930s when up to two thirds of men of working age were unemployed. The introduction of free treatment was not enabled by a robust economy but rather it may have been encouraged by the poverty of its citizens. If surplus resources in health care are the necessary pre-conditions for fundamental change it may never happen.

The two case studies reveal the following themes surrounding their success.

A champion who was able enlist support for the change and to communicate a message that the key stakeholders (public) accepted to be true. This message was essentially that their chances of survival and quality of life would be better after the change (new legislation) than they were before and they would not be bankrupted in the process.

In both cases both the champion and government had the wisdom to confront the hard facts about the financial barriers to combating disease, its treatment and prevention. These allowed them to go directly to the people with a clear message unfettered by self interest.

Don’t let a good crisis go to waste

If we were to apply these principles to the implementation of the competition model we have described previously we propose that it would look like the following.

The Ministers of Health and or Premiers of each province would become partners and champions for change. Immediately governments would have to reposition their role from the current reactive approach of defending everything that goes wrong in a centralized system to a more of a guardian role whereby they champion what is in the public interest. As we have described in our model the de-facto owners of the current system are the health care providers (ie., doctors, nurses, unions and to some extent bureaucrats) not the payers or the public. Government must re-establish its credibility and earn back the public’s trust. The way to do this is to respond to health crises and health care reviews (i.e., BC’s Conversation on Health) by confronting the hard facts and accepting that the system must be radically changed. Governments must tell the public that it is in agreement that the current system is not good enough and needs to be reformed. Just as in the case studies above this can help the government reclaim the mantle of public interest, take the moral high ground and initiative back from the providers.

Government must position itself as having higher expectations for health care than the providers. Insurance is one thing but government needs to stop defending the health care delivery system and instead propose a system founded on competition clearly articulating how this will work better by making the providers compete for the patronage of the public. Ii must communicate the value of change in terms of its improved health benefits to the public rather than yet another fatiguing round of “restructuring” of the acute care system.

The timing for this could not be better as the Canadian Medical Association has already come to this conclusion itself and recently passed a resolution at its AGM in favour of competition. Therefore government already has a powerful and trusted stakeholder which shares this vision.

On the other hand unions are likely to feel threatened by competition and may attempt to characterize it as privatization in order to frighten the public into thinking that universality and accessibility will be at risk. Some existing bureaucracies which already own and operate health care services are likely to feel threatened by a fundamental change or dissolution of their role.

If government(s) can agree on a definition of competition with the medical profession and jointly communicate its benefit directly to the public the credibility and legitimacy of both groups will rise and this can be leveraged into more political support for major change. Against an unsustainable and dysfunctional status quo the fundamental change required to achieve this new vision is not only possible but inevitable.

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