Abstract

At the conclusion of my presentation to his Commission, Roy Romanow asked me what I thought was most urgently needed in Canadian healthcare. I answered "Leadership!" I explained that, while there are pockets of leadership in individual institutions and programs around the country, overall the system lacks clear vision and leadership. I was therefore pleased to see that Mr. Romanow described the first of his three overarching themes as being the need for "strong leadership and improved governance to keep medicare a national asset." The term "national asset" reminded me of Brian Mulroney calling our health system "a national trust," as well as of the debate at the time of repatriation of the Constitution when some voices promoted healthcare as a constitutional right! My view of the need for a sustainable visionary leadership is illustrated by the turnover in the Ontario Health Ministry since I have been involved in healthcare: Fourteen ministers and 12 deputy ministers, across the political spectrum, over a period of 27 years, averages 1.9 years per minister and 2.25 years per deputy minister, a description of public sector leadership reflected in all other provinces and at the federal level. No private corporation could succeed with such a turnover among its senior executives.

Executive public administrators have to manage three consecutive budget cycles before they can claim to have accomplished any change. Furthermore, they need to be on the job for five consecutive fiscal periods to demonstrate efficacy and sustainability of their decision-making. The nature of the political process, with its election every four to five years, tends to negate such outcome assessment of leadership.

Politicians see "health" as a stepping-stone to higher office. After all, providing oversight of a health ministry budget involves managing what is rapidly becoming half the provincial budget. In many provinces, the ever-expanding nature of its budget has given "health" priority attention in the Premier's office where most long-term healthcare decisions appear to be approved, if not made. In public administration, the deputy of health position is regarded as the "fall-guy" for a system beyond control. Most persons assuming the position regard it as right of passage to retirement as a healthcare consultant. It is difficult to identify any definitive vision amid these political imbroglios that characterize public health administration in Canada.

The Canadian public desperately needs new visionary healthcare leadership. Unfortunately Mr. Romanow has not provided such visionary leadership. Instead he has relegated the system to its post-World War II origins when Canada was primarily an agricultural country with half the population it has today and when "healthcare" was what doctors did from the contents of their "black bags."

While public consultation has its place in the democratic process, the question is: can such a ritual provide visionary leadership? A realistic vision of healthcare would describe a system of incentives and options that 31 million modern-day Canadian consumers can relate to. Mr. Romanow's conclusion that only public employees know how to deliver health services is a reflection of leadership by opinion poll that says, "My people are on the move, I must lead them."

A more constructive approach would have been the detailing of alternative futures by presenting scenarios that list the pros and cons of high public sector intervention, a mixed private /public collaboration, and a market-driven approach. Being presented with such choices, provincial politicians could better explain to their electorate why they are choosing a specific direction. Instead of providing such leadership, Mr. Romanow chose to present himself as "the defender of the faith."

New federal/provincial fiscal transfer arrangements are essential if the system is to remain truly Canadian. However, memories of federal health dollars being used to supplement provincial budgets, more in support of re-election than optimizing health services, makes accountability critical to such arrangements. Since provinces were invented largely to create jobs for the boys, accountability must be between Ottawa and the provinces, and not between Ottawa and programs.

The federal government's National HIV/AIDS Strategy exemplifies centralized intervention in local affairs, often with no coordination among provincial initiatives. The tragedy that was the Canadian Red Cross blood system illustrates gridlock in inter-provincial decision-making to collectively protect Canadians. The failure of all governments to implement a national vaccination policy and infection control strategy to protect Canadians, demonstrates Ottawa's inadequacy in exercising any authority over provincial health agendas. The combined provincial budgets for pharmacare would pay for a national drug formulary, if only the provinces would relinquish their direct administration over such affairs, as they have been obliged to do for the blood system. Given these examples of federal-provincial collaboration in health, the possibility of the feds involving themselves in grassroots homecare programs is frightening.

Leadership is urgently needed that explains to Canadians that managing health services involves overseeing socio-economic and political forces beyond government's control. These forces include an increasing proportion of older people living longer and who could enhance their remaining years from timely access to new health technologies and managing the adoption of expensive technologies through collaboration between suppliers and providers.

Ontario Ministers
of Health
Term Deputy
Ministers
Term
Hon. Frank Miller February 1974 - February 1977 Allan Backley 1975-78
Hon. Dennis Timbrell February 1977 - February 1982 Tom Campbell 1978-81
Hon. Larry Grossman February 1982 - July 1983 Graham Scott 1981-83
Hon. Keith Norton July 1983 - February 1985 Gerard Raymond 1984-85
Hon. Alan Pope February 1985 - May 1985 Dr. Allan Dyer 1985-87
Hon. Philip Andrews May 1985 - June 1985 Dr. Martin Barkin 1987-91
Hon. Murray Elston June 1985 - October 1987 Michael Decter 1991-93
Hon. Elinor Caplan October 1987 - October 1990 Margaret Mottershead 1993-97
Hon. Evelyn Gigantes October 1990 - April 1991 Sandra Lang 1997-99
Hon. Frances Lankin April 1991 - February 1993 Jeff Lozon 1999-00
Hon. Ruth Grier February 1993 - June 1995 Daniel Burns 2000-02
Hon. Jim Wilson June 1995 - October 1997 Phil Hassen 2002 - Present
Hon. Elizabeth Witmer October 1997 - February 2001
Hon. Tony Clement February 2001 - Present

Mr. Romanow's call for "evidence" in justifying private delivery systems is indicative of a pseudo-academic/bureaucratic conspiracy consuming his Commission. While it has its place, "evidence"-based decision-making is more an intellectual exercise than an instrument of health services management. Professors of health administration promote such intellectual endeavors as more efficacious than the ethical business practices that govern the rest of society. With his emphasis on "evidence," clearly Mr. Romanow was converted to this mythology.

The rationale for evidence-based justification arises from academic papers that compare Canada's publicly funded health system with the American system. Comparing highly specific aspects of both cultures provides interesting academic analysis. However, the market-driven American health system is totally alien to the Canadian experience. Instead of frightening Canadians with scenarios of hostile American takeovers, it would have been more constructive for Canadians to learn about examples of American information technology applications and accountability infrastructures, attributes that are sorely missing in Canada's public health system.

Only God doesn't need an advisor. Second to God, health ministers receive most of their advice from local provincial academics. Given the challenges facing the health establishment there should be some broadening of their advisory horizon. Within standard ethical business practices, advice from the insurance industry would provide insight about the demographic management of risk, and the medical supply industry could provide insight about making scientific discoveries available to the masses. It is unfortunate Mr. Romanow chose not to, or perhaps lacked the ability to, listen to such counsel.

Mr. Romanow is a retired politician from Canada's ground zero of healthcare - Saskatchewan. Consequently his conclusions are described as pre-destined. Many of us can identify with socialist beliefs. People who have not had such an epiphany cannot appreciate the mark the experience leaves on one's soul. The challenge is accommodating our beliefs with the values of the society and times in which we live. Unfortunately Mr. Romanow chose a value base of post-World War II Canada rather than taking the opportunity to present a vision of healthcare that serves the values of Canada's 31 million modern-day consumers.

About the Author

Tim Lynch
Health Services Reimbursement Consultant, Info-Lynk Consulting Services, Vancouver. Email: tim@infolynk.ca
www.infolynk.ca/romanow.html

Acknowledgment

The writer wishes to acknowledge critical appraisal provided by Dennis Timbrell, Toronto ON Mark McElwain, Toronto ON, Dr. Alan Thomson, Victoria B.C, and Dr. Robin Hutchinson, Ladysmith B.C.