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Canada’s example: NHS needs more leadership and honesty

The government will have to be more upfront about the need to change the way patient care is delivered in the NHS in England. This was the main conclusion of a joint seminar between the Nuffield Trust and Canadian Health Services Research Foundation that aimed to explore how two Canadian provinces – with health systems that were broadly similar to the UK’s – went about undertaking major reform in the midst of a severe economic downturn.

A report from the two organisations gives a detailed account of the cost saving measures which politicians and officials from Ontario and Saskatchewan took taking in response to Canada’s falling GDP at the beginning of the 1990s. In addition to staff cuts and wage restraint, substantial numbers of hospitals were also merged, closed or converted to provide other health services.

Ontario delegated this task to a restructuring commission, while ministers in Saskatchewan led an intensive process of consultation and dialogue with stakeholders and the public across the province.

While both Canadian provinces took very different approaches to making savings, there was a common awareness that local health organisations were unlikely to undertake fundamental reform without support from the political centre, regardless of the financial pressures.

Senior Nuffield Trust Fellow, Ruth Thorlby comments: “The Canadian experience suggests that irrespective of how they choose to negotiate change, politicians need to be upfront with the electorate about the need for reform, and the future direction of travel, even if it means unpopular changes to hospitals.

“In the NHS, budgets are under real pressure and hospital services need to change, but ministers have not been direct with the public about what this might mean for local services. This cannot continue if they want to take communities with them.”

In Saskatchewan, over 600 meetings were held at which politicians tried to address the considerable opposition from health professionals and the public. The government also provided strong support to local health boards in planning new services.

In Ontario, a new government, elected on a mandate for radical change delegated the task to an independent commission, which undertook all the planning, consultation and implementation work itself. At the end of the process the number of hospitals had reduced from 225 to 150, with all resulting savings reinvested in other areas of the health sector, particularly long term care, albeit often with a time lag.

Waiting times in some surgical specialties grew as a result but the changes do not appear to have had a negative impact on mortality and other measures of quality.

Maureen O’Neill, CEO of the Canadian Health Services Research Foundation, said: “The question for Canada is – in the absence of pressing fiscal calamity – will there be the political energy to invest in making what is an OK health service a really good health service.”

Attendees at the event concluded that there were a number of potentially useful lessons for the NHS in England. Chief among these is that a coherent narrative is essential to demonstrating the need for reform. An important first step is for the government to clearly communicate why budget cuts are unavoidable – something that is largely absent from the current health debate in England.

Local organisations need support and cover from the centre, the report concludes. In Saskatchewan, 30 newly formed health boards undertook the reform process, but their time table was driven by the provincial government which also attended face to face meetings across the province. In Ontario, an executive body with a clear, time-limited mandate was able – partly by overcoming institutional and local loyalties – to implement change.

Thought also needs to be given to sustaining reform beyond a financial crisis, the report says. One of the striking features of Canada’s experience is the speed with which health spending growth resumed once the worst of the recession was over. By 2008, per capita expenditure was the same as it would have been had growth continued at a pre-recession rate.

Read the full report.

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