The easy lifting has already been done

The challenges facing the health care system are massive and despite some occasional messages to the contrary, the overwhelming opinion is that the health care system is not sustainable.

Despite the mounting chorus, internal and external, telling us that the system isn’t sustainable, surprisingly little has been done. We have been nibbling around the edges of change for two decades and we continue to have a hospital centred, acute episode focused, non-integrated system of care with funding and payment models that are inefficient and outmoded compared to OECD peers. We are not realizing the health dividend from current investment.

It is true that if we were to start over with a blank page, we would never design a health care system that looks like the one we have now. We would have fewer hospitals and they would be more strategically located and used, we would have new facilities that provide highly efficient, cost effective care, we would have new classes of health care providers doing important but less complex work of doctors and nurses at more appropriate rates of pay, we would have a different funding model and new payment models, we would have patient accountability for health and an emphasis on disease prevention/chronic care management in addition to the continuing need for acute episodic care, we would have a strategy for cradle to grave care that would not make hospitals the repository for the results of poor planning and investment. Quality in all of its dimensions would govern how we operate and we would be integrated into team based care. And lastly, the health care system would be self governing, responding to societal need with political influence dramatically reduced or eliminated.

It is evident that we are not heading to this place. Why? Because all of the light lifting has been done. Everything else is not just difficult, but very difficult. I see the roadblocks being mechanistic, financial, and political.

Mechanically, change is very complex. How do we moved from siloed care to integrated care when we are not trained, funded, or cultured to do so? How do we train the next generation when our training comes from the past? How do we move patients to “team” from “my doctor”? Eating an elephant seems impossible.

Financially, there are limited resources unless new revenues are found, either from increased public funding or elsewhere. Without resources we cannot make strategic investments that will save us money; consequently we will continue to work inefficiently, trying to push a wheelbarrow faster and faster, when what we know we need and cannot afford to buy, is a sports car.

And most importantly, we are politically strangled on many issues. Many of us see changes that are technically easy, would immediately save money, and make our current system work better, but are daunting because of the political firestorms that would erupt from patients, providers, institutions, and politicians alike.

It’s all heavy lifting.