Different time zone, different continent, different health system. Canada has rushed headlong into summer, missing spring almost all together, or so we have been told. Something similar could be said for its health system. Like Australia, it funds access to “medically necessary care” via a funding stream called Medicare. Like Australia, it has many provinces making local decisions regarding how their health system will run. However, each of them takes an interest in primary care as all funding and policy direction comes at a provincial rather than federal level. This context has provided its own experimental opportunities, ensuring the health sector has matured more quickly than perhaps primary care in Australia.
Accreditation has a much longer history in Canada than Australia and they are still setting the benchmarks. The most recently produced standards have turned language and focus on its head. Attention is now on ensuring Client and Family Centred Care across hospital, specialty and primary care. Providing care with patients rather than to or for them creates new opportunities in governance, designing services and of course delivery of care. Questions are even arising regarding whether patients should be involved on accreditation survey teams, taking the patient survey process applied in Australia to a whole new level! Clearly, integration, quality and the patient experience will become a greater focus in Canada’s healthcare system with the rise of the patient voice through the Client and Family Centred Care movement.
In addition, the data collected via accreditation is seen as a shared community resource. Published reports on trends are now commonplace. For example, one of the more recent was on infection control across the sector with data de-identified and analysed to drive policy and process change. Hospitals and care providers are required by law to publish their reports in some provinces, providing insights into care environments and the ability to compare service providers.
Canada has led the world in the development and introduction of the medical home concept. Initially resisted, the introduction of capitation payments occurred in 2002 in Ontario alongside the introduction of very generous incentive payments. This move supported the creation of Community Health Centres. They were designed to reduce both the number and isolation of general practitioners and create more inclusive healthcare teams more accessible to their patients. This model has been copied in most of the provinces but funding certainty remains an issue everywhere. It has delivered a greater number of practices that can see a higher volume of patients through introduction of new models of care eg Nurse Practitioners, nurse and allied health involvement in care, shared care between general practitioners and other physician groups. In addition, improved after hours and acute services rostering has been mandated for Community Health Centres as a way of addressing hospital emergency presentations. Incentives for preventative health measures are broad eg including mammogram rates and FOBT screens. Chronic disease incentives also take in CHF and schizophrenia and a variety of conditions not explicitly monitored in Australia. The combined package of funding measures has resulted in Ontario general practitioners now boasting some of the highest income levels in North America. It is perhaps not surprising therefore, that government is now capping the number of centres which can participate in the medical home funding.
Whilst the quality movement is strong in Canada, its weakest link is primary care. Through funding for Community Health Centres, the government forced some general practices to adopt accreditation. The remainder adopt accreditation as a voluntary measure, so participation is poor. What is significant is that accredited practices include patients in their compulsory governance structures. These governance mechanisms are used to monitor how a practice is performing against incentive targets. Doctors can also access data regarding how they perform within their practice against their colleagues. So whilst the coverage of medical homes is far from comprehensive, the political realities seem to ensure it will stay as it is popular with both patients and doctors.
The other growing political reality is the need for a vision for primary care. The government has produced a vision with six core themes, all of which will continue to stretch the responsiveness of the Canadian system to patient needs:
- client and family centred
- collaborative and interdisciplinary
- integrated across the system
- wellness based
- inclusive of community agencies and resources
- focused on prevention, education and action.
Based on what we have seen, actions which continues to strive towards quality and patient responsiveness will continue to be hallmarks of the system in Canada.
Tracey Johnson, General Manager and Churchill Fellow 2014