Sustainability is not the issue: Let’s focus on quality ========================================================= * Paul C. Hébert * Jane Coutts * Daniel Rosenfield * Noni MacDonald * Matthew Stanbrook * Ken Flegel It’s no exaggeration to say that people have been proclaiming a crisis in Canadian health care for decades. Perhaps that rhetoric is wearing thin, because according to leaders today, our health care system is no longer in crisis; it is simply unsustainable. When and if health is raised as an issue, it would not be surprising if politicians and interest groups warn us that skyrocketing health care costs will either cause governments to grind to a halt or drive taxpayers to the verge of bankruptcy. Don’t believe it. The truth is that the 6% to 8% per year increase in provincial health care expenditures per capita is sustainable, assuming that we see ongoing economic growth and stable tax revenues.1,2 So what should health professionals and voters alike embrace as an election health focus? Without any hesitation, we should all ask how governments propose to deliver quality health care — arguably the most important issue this decade — because the 2003 First Ministers’ Accord on Health Care Renewal3 and the 2004 10-Year Plan to Strengthen Health Care4 expire in 2014. Barring a fragile minority, the government we elect May 2 will lead the negotiations for a new accord and therefore have a powerful opportunity to help shape Canada’s health care system. Health accord renewal should become a central issue in this election campaign, as the next prime minister and government will determine the funding that provinces and territories receive in transfer payments for health care. They will also be given the opportunity to make the provinces accountable for reaching common goals that could improve overall health outcomes in Canada by simply attaching enforceable conditions to any agreement. So far, health care has been a notable but not central issue in the federal campaigns. The New Democratic Party gives it considerable prominence in its platform, and leader Jack Layton has emphasized the importance of choosing the right party to handle the accord negotiations. The Liberal Party campaign is more focused on family — and includes a promise of employment insurance benefits for people caring for terminally ill relatives. The Conservative Party has had little to say on health except to offer 100 rural physicians to address health care needs. So far, none of the parties has proposed a comprehensive plan, let alone what we truly need: a vision for radically transforming our health care system — a shared goal that will allow us to leave behind the interminable debates on funding and power. Current promises fall short of founding principles and programs that would form the basis of future health accords. We need to shake off the habits and attitudes of 20th-century health care that have led to a narrowly focused, discontinuous and often wasteful system that doesn’t do enough to prevent illness or promote overall health, often fails to satisfy patients and wears out the people who care for them. Focusing on the six dimensions of high-quality care (safety, patient-centredness, effectiveness, timeliness, efficiency and equity5) will drive the changes we need to make Canada’s health system a cost-effective — and, yes, sustainable — model for the 21st century. What would focusing on quality mean in action? First, it will all depend on information. We cannot have quality care without the fast and thorough implementation of electronic health records for primary care providers so that all Canadians can take the fullest possible advantage of information technology.6 Complete and effective electronic health records are essential for measuring, monitoring and public reporting of indicators of care. We can only implement changes to improve care when we know the needs and how they are dealt with and the results of care at individual, team, institutional, regional and provincial levels.7 Information also means implementing existing high-quality evidence into practice and, where evidence is lacking, generating new information to inform care. We cannot wait for those building blocks before we act on what may be the hardest change of all — the shift to patient-centred care. Such a shift aims to respect patients as partners, putting their needs, circumstances and knowledge at the centre of care. It does not mean, however, that patients get all the care they want. Rather, it means that the public is engaged in determining funding priorities8 and is more responsible for its own care, especially in the management of chronic diseases. It also emphasizes prevention and health promotion as much as treatment and cure. At the federal level, that will mean expanding evidence-based prevention programs (e.g., those for smoking cessation and those aimed at curbing the obesity epidemic), greater public engagement in priority setting, stronger disease surveillance and better monitoring of food and drug safety. A shift to patient-centred care also means putting the right incentives in place and demanding patient-focused outcomes and open and transparent public reporting. Health care delivery is a provincial and territorial responsibility. But federal government leadership in the coming negotiations can make quality the focus of transformative changes in health and health care across this country. In the coming weeks, we will propose a number of ideas for improving the quality of health care in Canada. If that’s a priority for you, we urge you to assess which party and leader will best be able to negotiate future health accords and, more important, a vision of quality care for Canadians. ## Footnotes * **Competing interests:** See [www.cmaj.ca/misc/cmaj\_staff.dtl](http://www.cmaj.ca/misc/cmaj_staff.dtl). ## References 1. Dhalla IA, Guyatt GH, Stabile M, et al. Broadening the base of publicly funded health care. CMAJ 2010;183:E296–305. 2. Economic Survey of Canada 2010. Paris: Organisation for Ecomonic Co-Operation and Development; 2010. 3. First ministers’ accord on health care renewal. Ottawa (ON): Health Canada; 2003. Available: [www.hc-sc.gc.ca/hcs-sss/delivery-prestation/fptcollab/2003accord/index-eng.php](http://www.hc-sc.gc.ca/hcs-sss/delivery-prestation/fptcollab/2003accord/index-eng.php) (accessed 2009 Mar. 20). 4. First ministers’ meeting of the future of health care 2004: a 10-year plan to strengthen health care. Ottawa (ON): Health Canada; 2006. Available: [www.hc-sc.gc.ca/hcs-sss/delivery-prestation/fptcollab/2004-fmm-rpm/index-eng.php](http://www.hc-sc.gc.ca/hcs-sss/delivery-prestation/fptcollab/2004-fmm-rpm/index-eng.php) (accessed 2009 Mar. 20). 5. Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington (DC): The National Academy of Sciences; 2000. 6. McGrail K, Law M, Hébert PC. No more dithering on e-health: let’s keep patients safe instead CMAJ 2010;182:535. 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