Scotland has identified clear priorities in health and measures them – why can’t we?

This past spring, I was sitting in a reception area at the Scottish Ministry of Health. On the wall next to me was a poster on which the indicators by which the Ministry was going to be judged were clearly outlined. I was so surprised that I literally got up from my chair to get a closer look.

The indicators covered everything from:

  • the determinants of health (e.g. reduce the proportion of individuals living in poverty, increase the proportion of young people in learning, training or work),
  • risk factors for disease (e.g. reduce the percentage of adults who smoke, reduce the number of individuals with problem drug use),
  • the healthcare system (e.g. improve end of life care, reduce emergency admissions to hospital),
  • the population’s health (e.g. reduce premature mortality, improve children’s dental health).

And, not only has the government identified the indicators – they also have an independent group reporting on how well they are doing.

I just checked the web sites of the Ontario government, the Ministry of Health and Long-Term Care and Health Quality Ontario, and I can’t see anything remotely similar. The government released “Ontario’s Action Plan for Health Care” early this year, but it didn’t include any specific targets.

The Ministry reports wait times for some procedures and tests, but that’s about it.

Health Quality Ontario reports on the quality improvement activities of hospitals and the quality of care of nursing homes.

However, there is no one place in Ontario where citizens and those working in population health and health care can go to see the health priorities of our government clearly and succinctly described, and how well we are doing.

I know that identifying areas for improvement doesn’t mean they will be achieved. One could argue that Scotland has identified too many priorities. However, they have identified them, and establishing clear health priorities does strike me as important for citizens and those of us working within the system.

What is it about Scotland that enables it to do this, while we can’t seem to do the same thing in Ontario?

The comments section is closed.

  • John G Abbott says:

    Glad to read this article. Recently, the Health Council of Canada published a paper on this very topic entitled: Measuring and reporting on health system performance in Canada: Opportunities for improvement. (http://www.healthcouncilcanada.ca/rpt_det_gen.php?id=370&rf=2) As you can guess, there are lost of opportunities! We presented examples both internationally and within Canada that could be used to improve performance reporting and accountability for results – but it all starts with a clear vision of what you want to achieve in the first place along with a specific set of goals – and it looks like Scotland got that figured out.

  • J Keller says:

    http://www.Gapminder.org/world or /data (for tables in Excel) aggregates Public Health data from around the world, including SES, etc.
    Hans Rosling a Swedish public health physician and his group

  • Claire Stevens, Voluntary Health Scotland says:

    In Scotland, the third or voluntary sector plays a big role in tackling health inequalities, improving health, providing care & support, & enabling people & communities to have a voice about. Ministers’ stated position is that the third sector needs to be at the heart of the public services reform agenda. Is this similar in Canada?

    Enjoying the discussion!

    • Andreas Laupacis says:

      Hi Claire.

      I enjoyed looking at the website of Voluntary Health Scotland (am I right that you are the Chief Exec?). An impressive number of reports on the site – the organzation is clearly very engaged in health policy.

      I was amazed by the number of organizations that are members (150, with another 162 associates) but i couldn’t find a list of who they are.

      This isn’t an area of my expertise, but I think the closest thing we have in Canada is the Health Charities Coalition of Canada – http://www.healthcharities.ca/about/vision-and-values.aspx.

      My sense is that this group isn’t as directly involved with health policy in Canada as VHS is in Scotland, although i’d be happy to be corrected if I am wrong. A challenge for any Canadian national organziation in health care is that health care is actually DELIVERED by the provinces, each of which has their own unique issues.


  • John Frank (Director, Scottish Collaboration for Public Health Research and Policy, University of Edinburgh)) says:

    Dear Canadian friends and colleagues:
    Delighted that you were impressed with Scotland’s efforts, Andreas, and there is much here to be admired. On the other hand, as our recent article shows (Frank and Haw. The Milbank Quarterly 2011; 89(4):658-93) at least one major target committed to here, ever since devolution over a dozen years ago — reducing the rather steep Scottish health inequalities by social class — appears not to have been met. On the other hand, I cannot find ANY Canadian or US publications, even in the grey literature, that even try to monitor such inequalities in health outcomes annually, apart from Russell Wilkins’ important work at Statcan over the last 20 years. Am I missing key Canadian work of this sort?

    • Andreas Laupacis says:

      Hi John. I checked with a few folks more knowledgable than I am about health inequalities, and none of them knew of any groups regularly reporting on health inequalities in Canada. I was pointed to the following sites in the USA (thanks to Pat O'campo!): http://www.cdc.gov/minorityhealth/CHDIReport.html http://www.macfound.org/press/from-field/widening-gaps-life-expectancy-reflect-race-gender-and-education/ http://www.census.gov/newsroom/releases/archives/income_wealth/cb11-157.html Andreas

      • John Frank (Director, Scottish Collaboration for Public Health Research and Policy, University of Edinburgh)) says:

        Dear Andreas: Very thoughtful of you to send these weblinks along — our team here is trying to find out (by websearching) if any OECD countries do a good job of regularly analysing time-trends in SES-related health inequalities, based on routinely collected health outcomes at the population level. So far, we’ve found none, except the 2008-11 Scottish reports that we critique in our Milbank Quarterly paper in December. Perhaps some HealthyDebate readers may know of such analyses somewhere. [We note that a 500+ page report issued some months ago in the USA, by federal analysts, purports by its title to analyse such health disparities, but on closer examination it includes only a handful of graphs largely self-reported, survey- collected outcomes — mostly by respondents’ basic education level, from record linkage to the National Health Interview Survey with cross-sectional analyses ( only — not time-trends) for one routinely collected “hard” outcome: life expectancy. The other 475+ pages of the report are, as usual for the USA, all about race, ethnicity, geography and gender as axes of health inequality. Plus ca change…]
        BW, John

  • Jeff Johnson says:

    Completely agree! So many things in health care delivery or policy seem so obvious and simple – like identifying targets, clearly and succinctly, and actually putting in place measurements systems to monitor those parameters. I am perplexed – why isn’t it so simple to do?

  • Sholom Glouberman says:

    I think it would be a very good idea to see Sir Harry Burns’ talk on the Equally Well Initiative in Scotland. The idea of concrete objectives derives from the actual state of the population.Sir Harry speaks about evaluation and the role of patients and citizens in setting their goals, trying different things and allowing for failure as well as success. You can see Sir Harry’s comments on Vimeo.com. It is not up to the Ministry of Health to set these goals but to allow them to emerge from what local people want to work on. So the fat that we con’t have an overall evaluation has something to do with how we set our goals (which gives us the parameters for measuring) and how we work on them (which gives us meaning to the measurement).

    At the Patients’ Association we are working on concrete measure of Patient and Family Centered Care. Be happy to tell you more if you like.

    Regards, Sholom

    • Jeremy Petch says:

      Sounds interesting, Sholom. If you’d like to share the Patient’s Association process with our readers, please consider submitting a guest post: http://healthydebate.ca/guest-post-submission

    • TapOff says:

      . . .”The idea of concrete objectives derives from the actual state of the population.Sir Harry speaks about evaluation and the ***role of patients and citizens in setting their goals***, trying different things and **allowing for failure as well as success**[lessons learned]**. . . ”
      Well Well :-) !
      We have LiHNs and CHCs within…..a structure for a re-work to me.

  • Dr. Judith Glennie says:

    One would think that the various Health Councils at provincial and federal levels could take leadership on this kind of initiative. I certainly agree that it’s long overdue – and is linked somewhat to political will, I would imagine. Thanks for raising this, Andreas. jlg

  • TapOff says:

    Yes, it is almost as though not identifying concrete targets provides “Plausible Deniability”.
    The Scottish targets are also pretty darned standardized, hence measurable. The data are relatively accessible given the criteria are agreed upon by the gang at OECD of which we are a signatory.


Andreas Laupacis

Editor-in-chief Emeritus

Andreas founded Healthy Debate in 2011. He is currently the editor-in-chief of the Canadian Medical Association Journal (CMAJ)

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