By Bernard Lord, Fabrice Brunet, Lise Denis, Maria Mastracchio-Lafontaine
Mr. Bernard Lord, Special Advisor, MUHC-ISAI, brought together four distinguished experts at the 2012 conference of the MUHC-ISAI to explore what actions need to be taken to enable healthcare institutions in Québec to strategically expand their international activities and partnerships. Panelists were Dr. Fabrice Brunet, Director General of the CHU Sainte-Justine; Ms. Lise Denis, Director General of the AQESSS; Ms. Maria Mastracchio-Lafontaine, Co-chair of the MUHC Users’ Committee; and Dr. Wendy Thomson, Director of the School of Social Work, McGill University and Chair of the Expert panel on activity-based funding. —Report from a presentation at the 2012 conference of the MUHC-ISAI
Winning acceptance for globalization
Bernard Lord: How can we reassure patients and government that international collaboration is a good thing and can increase the capacity of our institutions?
Lise Denis: Our academic health centres already have an international presence and really have no choice in the matter. It may be for organizational reasons or humanitarian aid, or it may have commercial objectives. Our researchers are increasingly called upon to work with researchers in other countries. They publish more than 5,000 articles in respected international journals every year. We also have an academic presence as we receive a great number of Fellows here and send our students abroad for training. The area that may arouse some concern is our ability to export our technology and knowledge for educational for commercial reasons, and generate revenues. This is the question of the hour.
Maria Mastracchio-Lafontaine: I consider international collaboration to be a solution, not a problem. I would like to see collaborations that help us understand how patients in other countries participate in their health services, contribute to their improvement and use them responsibly.
Fabrice Brunet: When our institutions take on international work, their goal is not just to gain experience but also to bring something back to their main mission, which is to improve health care and health for Québec’s population. The return on investment can take different forms: it may be money to reduce the burden on our taxpayers or knowledge that comes from learning how organizations in other countries operate.
Wendy Thomson: It is a globalizing world. We have to be out there and I believe we will see a return, but our healthcare system has not been designed to be global or allow for exchange in any clear way. We protect it by closing its exposure to the market; it has no internal mechanisms to conduct the exchange of knowledge or services. The public has already paid for our healthcare assets, and currently services are rationed through waiting. Our hospitals do not have the autonomy to operate strategically and exchange in a global world in such a way that they could realize commercial benefits.
Under these conditions, there is a public perception that these are scarce resources. Our cherished public health care institutions and doctors are much needed at home and we do not want to share them without getting some public benefit in return. I think everyone appreciates that there is a return, but in Québec we do not have the kind of transparent financial systems, pricing systems and accountability that are evident in the London hospitals I observed. Successful Trust hospitals in England are pretty autonomous and know the cost and value of the services they provide and where they are efficient, competitive and innovative. They might choose to expand the successful aspects of their activities on a global scale and sell those services where there is a market for them. The hospital accounts for these transactions transparently, and is allowed to keep that money and reinvest it, whether in capital investments, additional services or increased staffing.
In Québec, hospitals are not allowed to keep money earned through global activities. Before we venture further into global collaborations, Québec has got to find a way to develop the machinery that will assure public accountability and hospital viability.
A matter of vision
Lise Denis: It also takes vision at the government level. We have not felt, in the past few years, that there was a clear view of our organizations’ potential to export research products and engage in international exchanges. There have been gestures, but always on a case by case basis, not as a global vision. We hope that this will be articulated more clearly and that it will support the activities of our academic health centres. That would make it easier to identify promising ventures, and more precisely price them and measure their impact. As public funds are at play, public accountability, transparency and the rendering of accounts for international work become essential.
Fabrice Brunet: International work has to be part of our vision, not something we do on the side. We have to demonstrate a real return on investment. That requires determining the cost per unit of what we are providing. And we have to understand that the cost of production differs from one country to the next. We can learn from others by comparing this cost per unit and find ways to improve the efficiency of our own system.
Bernard Lord: How can we move ahead in Québec to increase our international presence and ensure that our collaborations are fruitful?
Maria Mastracchio-Lafontaine: There is a lack of communication between the academic health centres even within the city of Montreal. We need to open our doors and be ready to exchange with and learn from colleagues in other Montreal hospitals. Collaboration should start at home.
Fabrice Brunet: That is extremely important. Before going to seek knowledge at the international level, why not start by increasing collaboration between our own centres? The Conférence des centres hospitaliers universitaires (CHU) du Québec has brought organizations together to see how we can work together to improve teaching, research, care and management. Pooling our knowledge will bring improvements to all our institutions. At some point, however, our competencies and resources will reach their limit because we are engaged in a global competition. Montreal and Québec must attract ever more brains and resources to keep progressing.
Lise Denis: Exchanges also go beyond the medical arena. One area where we are particularly advanced is aging. Québec’s population is aging faster than anywhere else in the world save Japan. We have worked extensively to integrate services for seniors and initiate intersectorial research that integrates social as well as medical dimensions of aging. Québec has a headstart here and it would be interesting to share this knowledge with other countries. On the other hand, it would be good for us to learn about issues where we are less advanced. Obesity and mental health are also issues that call upon resources beyond health care.
Companies that want to contact us do not know where to turn. A common access point could help with that problem. At the Strategic Forum organized by the Conférence des CHU and the Chambre de commerce de Montréal last October, an industry representative invited institutions and government to lay out their game plan, their vision and their strengths. The idea of creating a common access point is a step in that direction. It would streamline processes and showcase our areas of expertise.
Wendy Thomson: My preoccupations about how to allow our organizations to take full advantage of these opportunities may appear as kind of a “downer.” However, unless we know what health services cost and can differentiate between those that are of good quality and efficient, it will be impossible to enter the international healthcare field productively. If we are controlling inputs based on local requirements but selling exports based on international needs, these mandates are not going to align. The Québec public is not going to get a fair deal.
Lise Denis: We need to consider the legal context in Québec that imposes more constraints than our colleagues in Ontario may face. We need more flexibility to establish international partnerships. It is a matter of survival as much in research as to improve the quality of our health services.
Wendy Thomson: We have this energy and excitement to get out there and acquire excellent knowledge and show others the excellent skills and contribution we can make. But this may mean we have to actually change the way we do things back at the ranch, and sometimes that feels a little bit harder.