A Man for All Sections: Physicians, Heed Thy Hobbes

Steven Lewis

I dunno, maybe it's the season, but I feel especially moved by the plight of doctors at the bottom of the medical politics food chain. Ontario emergency room docs are just the latest in a long line of disgruntled groups crying foul over the agreement negotiated by their medical association. That agreement got the support of 79% of Ontario doctors, but most ER docs said no. Now they're mobilizing to pursue distributive justice by other means.

Unfairness in the relative income distribution of physicians is not an occasional aberration, a minor side effect of an otherwise exemplary allocation process. It is the inevitable outcome of a fierce competition within a guild that does most of its bare-knuckled work behind closed doors. Fee schedules are complex and no well-intentioned amateurs - the kinds who sit at the table on behalf of their peers - can possibly master the game with equal panache. Over time, power shifts and accretes, some groups gain the upper hand, and income disparities proliferate. There are winners and losers - all relative of course, since every full-time physician's income is at least upper-middle class. Provincial medical associations are the certified bargaining agents for all doctors - even for doctors who choose not to join. In general, the association and the government negotiate a total amount of money for physician compensation, and most of the details get worked out by the doctors themselves. Sometimes the government targets a top-up here, a fee code adjustment there, but overall, the physician categories - called sections - duke it out for shares of the booty. The mystery is not the injustices that follow, but why habitually shafted specialties, from primary care to rheumatology to geriatrics, stay with the medical herd. We outsiders don't really know - the doctors don't air their reasoning to outsiders - but we can speculate. First, they are a profession, and professions love nothing more than self-regulation and self-management। They might prefer the irritations of internal decisions to the prospect of subjecting the guild to external scrutiny and meddlesome guidance. Who ya gonna trust: your peers, or the bureaucrats? We are a band of brothers (and sisters), are we not? We look after our own - imperfectly, but we get you. Stay with us, and we'll harder for you next time. To continue reading please click here.

Spare the Policy, Spoil the Profession

Steven Lewis

The jig is up: Canada's publicly financed health care system does not reliably deliver safe, high quality, efficient care - and this after doubling spending in the past decade. Patient-friendly it isn't; the convenience of providers comes first. Need primary care after 5 p.m.? Go to emergency. Got four complaints? Make four appointments. Every serious analysis comes to the same conclusion: the system needs a major refit to improve access, quality, and value for money.

Yet we remain a nation of demonstration projects, taking two steps backward for every step forward. Of the many obstacles to transformative change, one looms larger than all the others: organized medicine. For the better part of 40 years organized medicine has more often than not stood in the way of efforts to re-engineer health care. It has pursued its own interests with brilliant success, and passed them off as the public interest. It has secured more money, the right to saturate one jurisdiction or specialty with doctors and neglect others, largely autonomous and unaccountable practice, and separate and unequal access to the councils of state and the boardrooms of health organizations. Don't blame organized medicine for the way it behaves; blame us, meaning the citizenry and the governments we elect. We're the enablers. Predictably, the system suffers: the documented shortcomings in safety, access and quality speak for themselves. More surprisingly, doctors are suffering too. Their own surveys unearth a litany of miseries, fantasies about leaving practice within a couple of years (they don't even when they say they will), overwork, ennui. So if it's not working for us, and it's not working for them, why does nothing change? We owe the doctors of Canada a serious apology for spoiling a noble profession. By kowtowing to organized medicine, we end up with collective agreements and policies that entrench the status quo and keep Canadian health care in the dark ages. Doctors who have nothing to do with medical politics nonetheless bear the consequences of the positions taken by their representatives. The culture of self-centeredness and privilege erodes idealism and produces generations of cynics who chafe under the rules of the game but lack the will to change them. Here are the main errors for which we need to atone: First, we have erred in how we pay most doctors, and for letting medical politics determine what and who are worth more and worth less. Allowing organized medicine to divide up the pie has distorted care patterns, undercompensated many doctors, obscenely enriched others, and pitted group against group. The doctors who use their hands outearn those who use their brains. The ophthalmologist who does 20 cataract procedures in a day earns more than the one who figures out 20 complex eye disorders in a week. The dermatologist's pay leaves the rheumatologist's in the dust. We stand by in learned helplessness as the medical associations concoct a reward system that produces ten times as many paediatricians as geriatricians, a steady abandonment of primary care, and a generation of doctors practicing at the low end of their capacities. Second, we should apologize for letting doctors practice in the 21st century with the tools of Bob Cratchit. Governments sign collective agreements that condone quill pen medicine - we're at the bottom of the G7 pack in adoption of the electronic medical record. Quality improvement tools and techniques are optional. There is no obligation to undergo practice profiling and recertification. Most doctors have no clue about the quality and effectiveness of what they deliver - and those that think they do are almost certainly wrong. The inevitable result: medical practice harms 10% of patients in hospitals; there is routine prescribing of dangerous dosages and drug combinations to the elderly; there is widespread failure to diagnose and effectively manage the most common and straightforward chronic diseases; primary health care patients get all of the evidence-based care they need only about half the time; and the list goes on. Research shows that the longer doctors practice, the more they decline. We would never neglect the career development of our pilots, car mechanics, or workers in fast food restaurants the way we have neglected the professional competence of doctors. And instead of organized medicine imploring governments and health organizations to analyze patients' anonymized data, feed back the results, and help doctors with QI, the CMA President makes ominous speeches about privacy. Third, it's been a mistake to leave unchallenged the attribution of access problems to shortages of doctors, and inflate medical school enrolments by two-thirds in re-sponse. Instead, we should have mandated strategies that could dramatically improve access right now, such as advanced access scheduling. Millions of Canadians can't get to see their family doctor the same week they call for an appointment while everyone in England, can and does in 48 hours. Do the process re-engineering, optimize the division of labour among professions, and then assess whether there are shortages, and if so, of what. And recognize that expanding enrolments in medical school won't solve the shortage of specialists in the disciplines that internal medical politics has consigned to the bottom of the income ladder. Fourth, we have erred in adopting organized medicine's view that all doctors' prob-lems, dissatisfactions, and anxieties are soluble in cash. When doctors tell us they can't be on call 24/7/365 in rural areas, we empathize and come to the table to help find a solution. Nurse practitioners? No thanks. Group-based practice? Can't sell it to the members. How about a hundred thousand bucks extra? Sounds good! So we inflate doctors' incomes to do the same things that sap their energy, ruin their home life, and keep them on a treadmill to depression, substance abuse, and burnout. Shame on us. Fifth, we've blundered in letting medicine dwell in splendid isolation atop the heap of the health professions. We allow the guild to keep competent others out of the sand box: nurse practitioners are threatening, let's go for physician assistants. The pharmacist who knows more than the doctor about pharmacotherapy remains a diffident subordinate instead of a true partner. The other guilds follow medicine's lead, and we wonder why interprofessional collaborative practice goes nowhere. If being separate and unequal made doctors happy and the system better, fine. But the job satisfaction survey data show the unhappy consequences of letting organized medicine get in the way of its own members' well-being. Fifth, we owe a mea culpa for letting organized medicine's media grandstanding, government-baiting, hyperbole, and fearmongering go unchallenged. Because we do not hold organized medicine to a higher standard of discourse and accountability, its rhetoric becomes bolder and it comes to believe its own propaganda, that every misdeed or wait list is everyone's fault but doctors'. We've turned organized medicine into expert blackmailers: more money, more machinery, a bonus here, a new medical school there. Attend a committee meeting? Pay us. Become true partners in the hard job of running the system? Nah, we like being independent contractors, not integrated team players. Staff the ER? Pay us fee-for-service, an hourly rate on top of that, a shift bonus on top of that. Set up shop in the poor part of town where the need is greatest and unmet? Charter of Rights! Freedom! We fed the beast and stood by as medical altruism and decency became entombed in a hard shell of self-serving cynicism. No one wins. Our biggest mistake is failing to demand more of both organized medicine, and individual doctors. We admit only superior students into medical school. We put them through intensive training (but not much education in citizenship, and how systems work). We then turn a blind eye to huge variations in practice and never evaluate them seriously. And because this is a proven recipe for substandard quality, we let organized medicine persuade us that the remedy is to pay extra for mere competence - participating in chronic disease management collaboratives, following the occasional clinical practice guideline. This is our fault and our folly. Lord Acton would have expected as much: Power corrupts, and we have given organized medicine too much power. The dysfunction is intergenerational: we have not sufficiently protected and nurtured opportunities for new generations to chart a different path. We have given medicine autonomy without accountability, and increased its allowance while its grades declined and it acted out at the table. Small wonder that practice is anarchic and error abounds. We didn't bring organized medicine up right, and we have only ourselves to blame for its values and behaviour. Apology is a precursor to reconciliation and recovery. We need to recognize our mistakes and become the partners organized medicine deserves to restore its dignity as a profession that advances the public interest and justice for its members. Collectively physicians are worse than the sum of their parts, and that harms all of them, and us. Our mistake has been to give organized medicine what it wants. It is time to give it what it needs, and help it understand the difference. About the Author Steven Lewis is a Saskatoon-based health policy consultant and part-time academic who thinks the health care system needs to get a lot better a lot faster.

Show Me the Way to Stay Home

Nursing Leadership (CJNL), 21(4) 2008: 29-32 Show Me the Way to Stay Home Lynn M. Nagle

As the health system continues to evolve through the implementation of the electronic health record and other information technology initiatives, it is imperative that governments undergo a paradigm shift and recognize the need for strategic investment in home care (CHCA 2008a:7). Among my closest baby boomer contemporaries, recent life experiences have revealed an increasingly pervasive challenge - maintaining the independence of aging parents. As one of the major issues facing middle-aged Canadians today, the provision of emotional, material, and physical support and care to this cohort takes a toll on family caregivers. The lay caregivers of Canada save taxpayers millions annually by avoiding the cost of institutional care. Although given comparatively less airplay these days, there is also tremendous cost avoidance afforded to the healthcare system because of home-based, family-delivered care for chronically ill children and young adults. A significant number of Canadians are doing their bit to supplement the gaps in service: family and friend caregivers constitute up to 80% of the care delivered in the home (Canadian Home Care Association [CHCA] 2008b). More than 10 years ago, it was estimated that 2.85 million Canadians were caring for a family member with long-term illness (Cranswick 1997), equating to more than $5 billion of unpaid labour annually (Fast et al. 2002). Given the country's demographic trends, one can only surmise what those figures might be in 2008. 'Twas ever thus that a majority of families assume responsibility for certain aspects of care for their loved ones, but limited attention is afforded these contributions.

Approximately 900,000 Canadians access home care on a regular basis (CHCA 2008a). Home care is the fastest-growing sector in healthcare, and it is predicted that between 1996 and 2046 the number of people needing it will double (Home Care Sector Study Corporation 2003). It has long been a cornerstone of Canadian healthcare, but sadly, home care gets short shrift when it comes to public funding. In a study of the long-term care systems of 19 OECD countries, Canada was found to invest 0.17% of its GDP in such systems compared with the overall average of 0.35% (Organisation for Economic Co-operation and Development [OECD] 2005). Why is there not greater equity with other sectors in the funding of home- and community-based care? It seems obvious there are some potentially significant financial benefits to be derived by investing in community and home care services that keep Canadians out of high-cost institutions. With shorter hospital lengths of stay and higher discharge acuities than ever before in our history, where is the infrastructure to support recovery at home? Interestingly enough, a tremendous amount of rhetoric is directed to the need to focus on primary care, chronic disease management and aging at home. How can any jurisdiction effectively deliver on these agendas without some concomitant investment in community-based supportive technologies? We certainly do not have an endless supply of health human resources to deliver on the services needed to support same. Is it realistic for any jurisdiction to expect that without information and communication technology (ICT) investments, effective home and community support can be achieved? Assistive technologies to support individuals and family caregivers exist (e.g., remote monitoring of chronic disease and smart devices for those with dementias and sensory impairments), but are they widely utilized? Surely the cost of such supportive technologies would significantly offset the costs associated with short-term hospitalization or long-term institutionalization. Grim forecasts of pending shortages of health professionals, particularly nurses, should provide compelling enough reason to consider technology solutions to optimize efficiency and effective use of resources in every sector. Equipped with point-of-care technologies, nurses in the community could access client data and information from other providers and settings, collaborate with other members of the healthcare team on-line and ultimately contribute to improved clinical outcomes. Estimates suggest that access to remote technologies could extend nurses' capacity to visit more clients (up to 3-4 times more) and maximize access to this increasingly scarce commodity (Thobaben 2000). As the nursing profession is also aging, it behoves jurisdictions to consider deploying solutions to further support nurses in the delivery of home and community care. A recent publication by the CHCA (2008a) included several recommendations directed to investment in ICTs and other technologies to support the delivery of community-based care for lay and professional caregivers alike. In particular, the need to link community care, including primary healthcare teams and home care, to other sectors is highlighted as essential to enable "improved integration, communication and collaboration" (CHCA 2008a). Financial investments in ICTs to support the provision of home and community services remain relatively insignificant when compared with those being directed to other sectors. While infrastructure supporting the advancement of electronic health records in institutions has been emerging as a priority in every Canadian jurisdiction, few have recognized the need to move beyond institutional brick and mortar to the communities where the greatest amount of care is delivered by professionals and family caregivers. In our technology-obsessed society, one cannot help but wonder why more solutions are not being deployed to support and sustain the unsung heroes of home- and community-based care delivery. The current delivery of community-based care is undervalued and not integrated with the rest of the healthcare system, yet it is on the verge of becoming the single most important point of service delivery. The recent launch of the Canada Health Infoway-funded "VON Caregiver Portal" ( www.caring-connect.ca) is an excellent demonstration of the capacity to lend support to hundreds of thousands of Canadians seeking information and solace from others in comparable circumstances. As all providers of care (read "my generation") are also aging, relying entirely on families and communities to keep citizens out of hospitals will not be sufficient. The demographics, the statistics and the trends tell a clear story - community- and home-based care, while not a panacea, can go much further still in offsetting the continuing escalation of healthcare costs. I look forward to an acknowledgement by "the system" that there is merit in extending the reach of supportive ICTs. That acknowledgement will be clear when there is an increase in public funding for supportive infrastructures and technologies. If given the choice, I want to age "at home" rather than "in the home." How about you? About the Author Lynn M. Nagle, RN, PhD Assistant Professor, Lawrence S. Bloomberg Faculty of Nursing, University of Toronto; Senior Nursing Advisor, Canada Health Infoway References Canadian Home Care Association (CHCA). 2004. Home Care: a National Health Priority (Position Statement). Ottawa, ON: Author. Retrieved October 17. 2008 < www.cdnhomecare.ca/media.php?mid=357 > . Canadian Home Care Association (CHCA). 2008a. Integration through Information Communication Technology for Home Care in Canada. Ottawa: ON: Author. Canadian Home Care Association (CHCA). 2008b. Portraits of Home Care in Canada. Ottawa, ON: Author. Cranswick, K. 1997. Canada's Caregivers. Canadian Social Trends Backgrounder, Ottawa, ON: Statistics Canada. Fast, J., L. Niehaus, J. Eales and N. Keating. 2002. A Profile of Canadian Chronic Care Providers, a Report Submitted to Human Resources and Development Canada. Alberta: University of Alberta, Research on Aging Policy and Practice. < www.ales2.ualberta.ca/hecol/rapp/ > . Home Care Sector Study Corporation. 2003. Canadian Home Care Human Resources Study - Technical Report. Ottawa, ON: The Home Care Sector Study Corporation. < www.cdnhomecare.ca/media.php?mid=1035 > . Keefe, J. and P. Fancey. 1998. Home Care in Canada: an Analysis of Emerging Human Resource Issues. Final Report. Halifax: Mount St. Vincent University. Organisation for Economic Co-operation and Development. 2005. Long-Term Care for Older People. Paris: Author. < http://oberon.sourceoecd.org.ezproxy. library.uvic.ca/vl=2717272/cl=17/nw=1/ rpsv/cgi-bin/fulltextew.pl?prpsv=/ij/ oecdthemes/99980142/v2005n11/s1/p1l.idx > . Thobaben, M. 2000. "Change and Growth in Home Care: Telehealth Care." Home Care Provider 5(2): 47.

Scary Headlines We Don't See

Steven Lewis

Recycling isn't always a good thing. News of syringe reuse in Alberta and Saskatchewan health regions provoked the predictable avalanche of concern, outrage, fear and puzzlement. How could it happen? Who's at risk? What's the root cause: penny-pinching? incompetence? negligence? Naturally, the media are all over it – at least several hundred stories and tens of thousands of Google-generated web results. Thousands of patients fear they may be the unlucky victims of the latest endoscopy and anesthetic misadventures.

Ya gotta wonder. Some things in healthcare are complicated, but some are simple. Wash your hands. Give the heart attack patient an aspirin. Chuck the syringe. How is it that the system does dramatically complex stuff well and screws up simple stuff routinely? Good people quit thinking – happens to me, happens to nurses. It's the night watchman's challenge: how do you stay sharp for the ten thousandth iteration of a common and low-risk task? It's not impossible: Six Sigma for aviation; Sick Sigma for healthcare.

There's a lot to be pissed about in healthcare – just read Baker and Norton on safety, McGlynn and Katz on the staggering failures of primary care, Sinclair on the Winnipeg baby deaths, pathological pathology in Ontario … The media spotlight shines on the farces and cover-ups, retails heart-tugging victims' tales and psycho-biographies of perpetrators felled by bad judgment, hubris or both. Scandal! Hearts of Darkness!

Meanwhile, the quality improvement and patient safety mavens ruefully observe yet another absurdity and gamely stick to the script du decade: people are good, systems are faulty; put away the lash and enrol people in collaboratives; re-engineer, don't recriminate. Politicians and administrators face a parallel reality: how does chalking it up to "system error" satisfy the deeply ingrained yearning to make the bastards pay? Quality Improvement, meet the Vengeance Posse. Enjoy your conversation.

So, how should the media report on the syringe reuse debacle? The problem is not so much what the media have said about it – the reporting has been reasonably balanced, noting the very low risk of serious harm and pressing (unsuccessfully) for statements from experts on the odds of being unlucky. The unmet challenge is to interpret the issue in context. How risky is syringe reuse compared with filling your prescription or walking into an emergency room? Should people be more worried about high-profile misdeeds or the risks inherent in substandard everyday care?

Here are some candidates for full monty media coverage – practices that without question harm more people than reused syringes, inconvenience the public and patients, drive up costs or create gaps in the system.

Health Region Knows Handwritten Prescriptions Put Patients at Risk but Allows the Practice Anyway

Despite overwhelming evidence that handwritten prescriptions harm and even kill patients, the local health region has not taken steps to halt this practice in its facilities. Nor has the province required system-wide electronic prescribing and the use of software to alert doctors and pharmacists to contraindicated drug combinations. The thousands of seniors on six or more medications should be extremely worried since they have a 94% chance of suffering an adverse drug reaction.

Doctors Don't Have to Adopt Electronic Health Records If They Don't Feel Like It

Electronic health records are used by fewer physicians in Canada than in any other G7 country, and that seems to be fine with the governments who pay them on our behalf. Many patients have complex conditions treated by several providers, and everyone faces the risk of getting sick away from home and visiting an emergency room in another town. There's almost no chance that their complete health record will be available instantly to the specialist or the emergency team. Customers of banks without ATMs and who enter deposits and withdrawals manually in passbooks and wide ledgers will be familiar with Canadian healthcare practices.

Many Patients Not Allowed to Tell Doctor What's Ailing Them in Single Visit

Patients who inconveniently have several symptoms and health complaints should not bother their doctors with more than one per visit. Many physicians impose the one-complaint-per-visit rule on their patients. Even though some regulatory bodies frown on the practice, it remains widespread. The policy is in response to a fee schedule that discourages doctors from spending time with patients who have complex health issues.

Higher Credentials Result in Less Training for Some Healthcare Workers

Think that newly minted graduate with a master's degree in physiotherapy (PT) has more training than the baccalaureate graduate of old? Think again. PT is just one of several professions that have ramped up their entry-to-practice credential requirements. But it's not a master's degree on top of an undergraduate PT degree; it's on top of any degree. The result? Now it takes six years to turn out a physiotherapist with two years of discipline-specific training, instead of four years to produce one with four years of discipline-specific training.

Of course, the media should jump on the syringe reuse story – it is newsworthy, it should not happen, it is a (small) threat to public safety. But it's also important to tally up the harms throughout the system. In Canadian healthcare, more people die every day from avoidable error than the combined toll from the most high-profile and egregious misdeeds. Canadians should worry more about the general standard of practice than about the prospect of falling victim to brazen or malicious incompetence. And the media could provide a great service by shedding bright and constant light on these routine, persistent and costly failures.

To respond, please comment below.

Steven Lewis is a Saskatoon-based health policy consultant and part-time academic who thinks the health care system needs to get a lot better a lot faster.

The Conference Board Answers Steven Lewis

Anne Golden

We at the Conference Board of Canada are avid readers of Longwoods publications and newsletters. We were very surprised after reading the essay prepared by Steven Lewis that appeared on the July 1 e-letter. His essay, titled The Conference Board: Rank Amateurs with an Agenda, left us perplexed by its snarky and unprofessional tone, its limited ability to appropriately interpret the data presented in the summary, and its poor understanding of benchmarking methodologies-which, by the way, is one of the Conference Board's core competencies. We have been involved in benchmarking projects for over a decade, and have been hired for our benchmarking expertise in countries such as Australia and Ukraine.

As Mr. Lewis appropriately pointed out, we did not release a full-scale report. What was released on June 30 is, in effect, an executive summary. However, the methodology and list of indicators are included on the website (under Methodology and Details and Analysis, respectively). The rankings and a full analysis of each indicator will be added to the website in September. At that time, a section will be added to the methodology with full details on data sources.

When the Conference Board talks about "health" in the report card, we are talking about "health status". It is therefore appropriate to make recommendations about the factors that affect our health status-such as the health care system and lifestyle choices. The purpose of the health category in the Report Card on Canada is to assess the health status of average Canadians. We have chosen to include and rank diseases that are the top burdens in Canada. We think that this approach is more appropriate than ranking diseases which do not affect many Canadians. So, for example, we do not include mortality due to malaria. While it may be a health burden in many countries, it is not in Canada.

Mr. Lewis was puzzled by results from Italy (A) and Denmark (D) given that the two indicators he pointed out (life expectancy and infant mortality) were on opposite ends of the scale. Having him be more thorough to review the list of indicators on the web site under Details and Analysis, he would have seen that in addition to life expectancy and infant mortality, there are eight other indicators. Denmark does worse, relative to Italy, on six of these indicators.

Mr. Lewis rightly pointed out that our inclusion of heart disease in a sentence about the increasing rates of chronic diseases, like diabetes, was incorrect. We have made a correction to the website.

We agree with Mr. Lewis that there is undoubtedly an alignment between progressive democratic systems and health outcomes, and we have done work on this subject. However, this report only focused on the examination of 10 health status indicators. In this phase of the research we did not analyze the factors influencing this ranking. However, this will be the purpose of an upcoming phase of this project after the September release.

We also agree with Mr. Lewis that primary health care reform is essential if we want to make a difference-we raised this issue in last year's report card. Primary health care reform will undoubtedly be referred to again when we expand on the Overviews in the September full release. The Conference Board has been consistently supportive of the publicly-funded health care system and a strong supporter of primary health care reform. In fact, we have provided support to federal and provincial governments over the past few years to advance primary health care in this country and primary health care issues have been studied in depth in several other Conference Board publications. For Mr. Lewis to suggest otherwise is irresponsible and disrespectful.

We are the foremost, independent, not-for-profit applied research organization in Canada. We are objective and non-partisan and we do not lobby for specific interests. Our only agenda is to improve the health of Canadians. The Report Card on Canada clearly states that its overall goal is to assess Canada's quality of life relative to peer countries, and that "Most Canadians would agree that without health, quality of life is severely compromised." All of our work in the health care field has one goal-to improve the health, and by extension the quality of life, of Canadians. We are proud of our achievements and firmly believe we are contributing to a better Canada. By exposing Canada's weaknesses, we aim to bring increased focus to these areas for improvements.

To respond, please comment below.

Anne Golden is President and Chief Executive Officer of The Conference Board of Canada.

The Conference Board: Rank Amateurs with an Agenda?

Steven Lewis

The Conference Board of Canada has published a summary that ranks Canada's health (or is it health care, or is it both) as 9th best out of 16 selected rich countries (the least rich is Italy, where the food, wine and climate are so good that it is hard to imagine why anyone so blissfully located would even notice a little less purchasing power). We get a B. The aforementioned Italy, along with Japan, France, Sweden and Switzerland, get As. In a shocking upset, the Americans beat somebody - in this case, get this, Denmark. According to a recent UK survey reported on 60 Minutes, far from being melancholy, the Danes are the happiest people on earth, even though their life expectancy trails ours by 3 years and Japan's by 4.5. Maybe they're too happy to notice. Maybe they have other priorities, like universally free post-secondary education.

As for the A-list, there are two Axis powers (Italy and Japan), and two - Switzerland and Sweden - that stayed out of WW2 (well, 3 if you count France). All 5 are rather social democratic, but so is Denmark. By contrast, joining Denmark on the D-list are Ireland, the UK, and the US. We get a B, but grudgingly, and the Board notes ominously that we are in danger of tumbling to a dreaded C.

Teasingly, the Conference Board released its ranking but not a full-scale report that, one hopes, will, at its promised release in September, reveal the methods, assumptions, and data on which it is based. In polite company this would be termed peculiar; in academic circles, irresponsible and even contemptible; in most of the media (Longwoods of course excepted), as a gift headline story requiring no further work. Based on essentially no information, can we make sense of the Board ratings and rankings?

Tellingly, there are confusions. The lead sentence in the summary is, "Given increasing rates of diabetes and heart disease [this latter is false by the way], Canada has no choice but to adopt a new business model for health care that focuses on both preventing and managing chronic disease." From that a sentient reader would infer that the Board is rating and ranking our health care system. But half-way down, the summary says, "It is important to keep in mind that this grade assesses the overall health status of Canada's population; it is not intended to rank the health-care system (italics mine)." So what's with the new business model for health care if health care isn't being evaluated?

If it's health we're examining, let's look at health. Of the 16 chosen countries, Canada ranks 2nd on life expectancy and 11th on infant mortality - the most commonly used composite measures of health. The Board is alarmed by our relatively high heart disease and escalating diabetes-related mortality rates. OK, but logically, if we're living longer than everyone but the Japanese and if our tickers and pancreases are letting us down, our other organs must be thriving. We have to die of something (perhaps confusion is a leading cause of death at the Board). Why weight some causes over others? There might be a defensible reason, but let us in on it before assigning a number.

Let's compare Italy (A) with Denmark (D). Italy is 7th on life expectancy and 15th on infant mortality rate. Denmark is 15th and 8th respectively. So if we're rating health, not health care, why are these countries at the opposite ends of the scale? The answer, I suspect, is that the Board is conflating elements of both health and health care in its method, and come September we might discover precisely how.

The confusion compounds when we look at the Conference Board's prescriptions for success. The Board correctly points out that the top-performing countries have progressed by addressing the non-medical determinants of health, among them listing: environmental stewardship; health promotion; education; early childhood development; income, and social status. By its own assessment then, social democracy seems to be the pathway to population health, but the Board pointedly refuses to go there. The solutions are "a new business model for health care," "greater receptivity to innovative technologies and health-care delivery systems," better information technology and "new approaches to prevention and management."

I'm a pretty harsh critic of our health care system and advocate a major overhaul. Like the Board, I'm all for investing in health information systems, managing chronic diseases better, and improving accountability. But like anyone familiar with a vast population health literature and a basic understanding of the law of diminishing returns from health care, I know that these measures will not reduce health disparities or greatly improve overall health status. The Board summary is silent on the one element of health care that might make a difference: primary health care reform. Instead it offers up the standard industry tonics of more and fancier gadgets and coded calls for privatization.

Might the Conference Board have an agenda other than improving the health of Canadians? When think tanks promote new business models for health and innovative delivery systems as solutions to problems that on their own analysis originate elsewhere, look for the method in the apparent madness. It's usually a call to feed the beast - the diagnostic imaging and drug manufacturers, the private sector management contractors, the advocates of private and parallel health care systems. It's perfectly legitimate to tout these reforms, but at least do it forthrightly and explain why Canada should choose this route rather than the broader health-enhancement strategies pursued successfully by others.

I'm new to the rating and ranking game, but in the spirit of the Board, I'll give it a go.

Transparency of method:	F
Plausibility of ratings and rankings:	D
Awareness of factors affecting health:	A
Internal coherence:	F
Likelihood of prescriptions improving health:	F

I'm glad to have the Conference Board in the population health choir, but sad to see its accurate understanding of why some countries are healthier than others dissolve into shilling for industry and solutions destined to raise costs, misallocate resources, and miss real opportunities to make a difference.

To respond, please comment below.

Steven Lewis is a Saskatoon-based health policy consultant and part-time academic who thinks the health care system needs to get a lot better a lot faster.