Chris Simms: The British and Canadian health systems at 70 and 60

As both healthcare systems celebrate landmark years, they also share similar threats to their continued survival

Chris_simsThis July the British NHS and Canadian hospital insurance systems[1] will celebrate their 70th and 60th anniversaries, respectively. Both healthcare systems—like many in high income countries—are in crisis, although neither is about to collapse.

Health systems are known as complex adaptive systems (CASs) and this leaves them vulnerable to a whole host of weaknesses that can prey upon them. There is typically no single point of control within them, and the behaviour of groups and individuals belonging to these structures (including politicians, bureaucrats, providers, patients, and their communities) can be unpredictable, random, and chaotic. They tend to have their own values, rules, and objectives, and are often in conflict with one another—sometimes without knowing precisely why or with whom. Normally CASs adapt and self-adjust to internal changes or outside pressures—what the NHS select committee calls “its daily struggles”—through so called “single loop learning.” But when ongoing pressures accumulate or new ones threaten, simple corrective measures are no longer adequate.  

These pressures take the form of the very factors that drive health systems: a bulging demographic cohort (increasingly burdened by chronic disease, comorbidities, and fragility) attempting to pass through a structure rife with bottlenecks. The existence of these bottlenecks (at the input, throughput, and output stages) indicates an underfunded, understaffed, and under-performing healthcare system, which is weakened by a highly polarised and divisive political environment.  

A common (and not unexpected) thread to both crises is the links between austerity, access to effective healthcare, and outcomes. In Canada  for example, total health expenditure as a percentage of GDP has fallen since 2010, while waiting times have hit all time highs and performance indicators all time lows. The UK has witnessed similar trends.  

Another commonality is the failure to plan ahead and to rely instead on short term, reactive, ad hoc decisions. A recent NHS select committee report concluded that a “culture of short termism seems to prevail in the NHS and adult social care. The short-sightedness of successive governments is reflected in a Department of Health that is unable or unwilling to think beyond the next few years.” For example, rather than embrace the recommendations of the Barker Commission (the antithesis of short termism in the long span of its review, which looked back to 1948 and forward through the rest of the 21st century), the UK government has let social care decline to the point that it is little more than a “threadbare safety net.” Elsewhere, seemingly random promises of £350 or £100 million injections into the NHS are revealing indicators of this short termism.

In Canada where there is no national health plan and services are delivered by the provinces and territories, short termism is often the hallmark of cash strapped governmentsa reality exemplified in workforce planning, or rather the lack of it. Increased demand, staff shortages, and overwork manifest in physicians leaving the profession or retiring early, low morale, and very high levels of burnout. GPs’ feelings of being undervalued and not respected are worsened by deep inequalities, which see some specialists (such as radiologists and ophthalmologists) earn salaries five times greater than GPs. The NHS is similarly plagued by the linked phenomena of low morale and burnout, and is struggling to hold onto its workforce.

Too often the complexity of these health systems is met with ill conceived efforts to improve them, which take the form of centralisation of structures or concentration of power. In the UK this was seen in the unfolding of the 2012 Health and Social Care Act, which was put together by a handful of politicians in 12 days, and which ultimately breached the trust between the medical profession and politicians. Over the past four years, the government has played a blame game with the NHS crisis, alternately pointing the finger at NHS management, patients, and GPs and hospital doctors.

In Canada, an almost identical situation exists. Governments have sought to deal with complexity and the reality that there’s “no single point of control” by alternately centralising and decentralising services, assembling or dismantling local health authorities, all the while bemoaning the bureaucracy, professional associations, and irresponsible patients.

The paradox is that this July both the NHS and Canadian Medicare have a number of reasons to celebrate their successes. Medicare is still seen to embody Canadian values and the NHS remains a “national religion.” Cross country data also show that for most indicators the UK performs well against its peers.

However, neither the NHS nor Medicare is sustainable. Instead of being stuck on the endless loops of detecting and correcting errors, both healthcare services need a systems approach (double-loop learning), which occurs when the error is “detected and corrected in ways that involve the modification of an organisation’s underlying norms, policies, and objectives.”

The idea of taking a systems approach to these healthcare services is not new, yet its implementation has so far failed to materialise, perhaps falling at the hurdles of tackling difficult questions and confronting powerful stakeholders. It takes discipline to avoid knee jerk reactions to a crisis—the temptation is to concentrate power or eschew responsibility. Yet fiscal sustainability will only be achieved by taking into account the value of public health and prevention and what we know of the social determinants of health: you need to plan for the long term with patient centered care as the driving force.

Dr Chris Simms teaches at Dalhousie University, School of Health Administration, Halifax, Canada; he spent many years living and working in Africa’s health sector.

Competing interests: None declared.

[1] Canada later broadened coverage of goods and services consolidated in the Canada Health Act 1984.