By Michel Clair, Nuala Kenny
Mr. Michel Clair, who advocated a greater role for private care in his 2001 commission report for the Quebec government was invited to take the "yes" side in the debate. Dr. Nuala Kenny, a founding member of Canadian Doctors for Medicare as well as a Sister of Charity and paediatrician took the “no” side. —Report from a presentation at the 2008 conference of the MUHC-ISAI
No debate about private funding
The debaters made it clear that the funding and delivery of health care would need to be debated separately. Mr. Clair also warned that there would not be much of a debate on the private funding issue: he was hardly a proponent.
“In my view,” said Mr. Clair, “the greatest achievement of our system in Canada is public funding. I support a high level of public funding for health services and am not in favour of duplicate insurance to implement a two-tier system. Public funding is in accordance with my personal values and with our social, political and economic values.” Dr. Kenny agreed: “Public funding is the crucial issue,” she maintained, “because it ensures that everyone is covered for necessary services, which fulfills the equity requirement.”
Would more private delivery improve health care?
Mr. Michel Clair: Yes
The delivery of health care services is not an integral part of our social values. I believe more private delivery would improve health care for the five following reasons:
Actual competition in the delivery of many services would create a very positive systemic stress on public delivery to improve efficiency. No centralized management or monopoly, no matter how good, can do better than competition to increase the productivity and efficiency of a huge economic sector like health care delivery.
Introducing more private delivery would be one way to improve the system’s capacity to measure whether producers — be they public, not-for-profit or for-profit — are meeting cost and quality criteria. Private enterprises are accustomed to quality control, financial and operational control. Transparency and good governance in the private sector is based on those specific values.
More private delivery would give a new impulse to innovation, because private companies regard innovation as a means to increase profit. The potential for innovation is huge in our system, but implementing research results, be they clinical, technological or administrative, is always an enormous challenge within a monopoly. For the private sector, introducing the latest research findings is a matter of survival and competitiveness.
4. Prevent two-tier health care
Private delivery, embedded in the Canadian health care system as an essential partner pursuing the same general goals and the public interest, could act as a powerful lever to prevent the rise of a parallel private system for rich people. There are a large number of high volume areas, either for diagnostics or surgery, that could take advantage of the private sector’s capacity to provide high quality and high efficiency low cost services. It is a strategy to harness private energy towards public interests instead of ignoring it and letting it build a privately funded competitive parallel system.
5. Better budgeting
More private delivery would bring changes to budgeting rules. No Ministry would ever fund a private company on a historical basis. Private delivery would therefore ensure the introduction of cost-per-unit budgeting systems. Citizens would have greater choice of providers, who would be paid by a public purchaser on exactly the same basis as public providers. That would create tremendous momentum in the system to start providing rapid and easy access to services, instead of managing waiting lists.
In conclusion, more private delivery of publicly funded services is a tremendous opportunity to improve the productivity of our health care system as a whole. Private delivery is both good in itself, and it would be good to the system as a whole. It would mobilize the energies of private investors and managers to modernize our delivery system in pursuit of public interest goals. It would also improve the quality of services, the pace of innovation, and produce efficiency and easy access to services. To make more private delivery possible, we need to put an end to the confusion between delivery and funding and start regarding private delivery as an essential partner in the modernization of our system, instead of just a money-making pursuit.
Would more private delivery improve health care?
Dr. Nuala Kenny: No
Our system has used private delivery from the beginning, only it has been private not-for-profit delivery. In contemplating more private delivery, the for-profit element requires careful scrutiny, for three main reasons.
1. Not all services turn a profit
Many European countries require that the same fee be paid for a service whether it is provided by a public or private provider. Not all needed health care services are amenable to the requirements of making a profit and there is a danger that increased reliance on for-profit private delivery would promote the development of health services that are profitable at the expense of those that are not and leave us without an appropriate full spectrum health system.
2. Public money may buttress profit-making
We have, in Canada, seen public health care institutions contract with private for-profit delivery operations in hopes of shortening wait lists and injecting extra money into the system. That might make sense to clean things up and set a level playing field, but the risk augments when public money is called in to buttress private for-profit health providers. Recent reports published from Australia state that some $3 billion in public funds are being spent every year now to keep private for-profit health care providers going. We need to guard against mechanisms that permit that kind of bail-out.
3. Market mechanisms bring risks
New Brunswick Ambulance is a fantastic example of public money protecting public health care and developing a partnership with a private corporation to create a system that has run very effectively. We should not encourage private delivery out of enthusiasm for the market in and of itself, but rather ask in what way the preservation of our public equity health system could be expressed in market activity.
Positive accounting is one area where the private sector could contribute significantly to meeting the goals of an equitable public health system. Our general accountability at all levels is very poor and has to be improved. We should learn from for-profit organizations how to demand accountability from the corporation to the shareholders and start providing that to Canadian citizens, as shareholders in the health system.
Market mechanisms are well-suited to increasing choice and treating patients as consumers. There are some potential benefits to that approach but it is often ill-suited to the sickness/illness encounter. The market is also about competition, which can bring positive changes but also has some negative sides, especially when applied to health care. Competition requires advertising, which involves the creation of need and promotes specialization. The kind of private for-profit technological fixes we have been looking to in Canada will not help us improve health promotion, disease prevention or chronic illness management: i.e. the full health care continuum.
If we separate funding and delivery in our discussion of the benefits of more private involvement, we have lots to talk about. What we need at this stage in the discussion are clear examples: if we are going to use European examples they cannot be generic and we need to ask what kind of protection they offer the public system, what limitations they impose on practice, and what kind of accountability they demand.