Premier Ford may have found a way to slice the tie that binds politics to patient care in Canada. It could save Medicare.

Last week, Premier Ford announced plans to expand publicly funded health services outside of hospitals. It created a string of headlines about “private care”, “for-profit” healthcare, and “private clinics.” The panic is legitimate, but the content of the panic is not.

The plan changes the management of Medicare, which warrants panic for some. If successful, Ford will dilute the number of services falling under the Public Hospitals Act 1990 and expand services outside the Act itself. It upsets our hospital-centric health-care system built on decades of deals, patronage, and log-rolling.

But the truly innovative bit is this: his plan shields government from health-care performance failures, at least for the expanded services. It inverts the current risk calculus in health care.

Hospitals create significant risk for government, over which governments have little control. When hospitals fail, as they often do, they just ask government for more funding. Government wears the failure plus bears the pain of increased funding, with no guarantee it won’t happen again.

Non-hospital facilities go bankrupt when they fail to offer quality services within budget. Insolvency risk forces non-hospital facilities towards quality, service, innovation, and efficiency in order to remain viable. Survival depends on their own performance.

Creative destruction?

This change will frustrate union agreements (power). It will reorganize hospital services (funding). And it will bloat surgical incomes (envy). Those who long for true, laissez-faire, free-market health care will not be happy either. And this could sour the civil service, given the existential threat to its control of health services.

What causes all the discord?

The premier’s plan inflames a deeper debate. Is Medicare about the public administration of health insurance, or is Medicare about the public management of medical care? Do we have provincial insurance plans, or do we have provincial health-maintenance organizations (HMOs)?

Many assume medicare is both: administering insurance and managing medicine. We have health insurance and HMOs.

This sounds simple, but it is impossible to implement. A CEO of a large hospital said, “It is not clear to me who runs the hospital. Compared to what I’m used to, it’s challenging to get things done.”

Public administration of insurance

The Canada Health Act 1984 emphasizes public administration, which it adopted from the Medical Care Act 1966, as one of its key founding principles (including comprehensiveness, universality, portability, and accessibility).

The Canada Health Act spells out what administration means and what, exactly, the public is supposed to be administering:  

“Public administration

• 8 (1) In order to satisfy the criterion respecting public administration,
  • (a) the health care insurance plan of a province must be administered and operated on a non-profit basis by a public authority appointed or designated by the government of the province”

The late Malcolm G. Taylor, a medical historian, described in (painstaking) detail the history of Medicare in Health Insurance and Canadian Public Policy, (1978, 2009). Many consider Taylor’s book the definitive study of Medicare in Canada. Public administration of health insurance seems beyond debate.

How, then, did ‘management of medicine’ enter the mix?

Public payment = government risk

Parliamentary democracy rests on the opposition holding government to account. Accountability requires control. Thus, government needs some control over the things it promises to provide.

Note, the need to control stems from the promise to provide. You cannot promise to act without the power to take action and fulfill your promise.  

When it comes to hospital services, the Ontario government’s locus of control rests with the Public Hospitals Act 1990 and the network of regulatory bodies and statutes involved. A platoon of civil servants works to maintain, regulate, oversee, licence, inspect, and accredit public hospitals.

There is more. Hospitals themselves develop libraries of Rules and Regulations, policies, and procedures to shape clinical performance. Collective bargaining agreements stipulate what management can and cannot ask nurses to do. Physicians’ hospital privileges outline rights and responsibilities to access resources and maintain those rights. A towering stack of agreements, memoranda, and historical precedent grows up inside the public hospital system, with each hospital having a culture and heritage of its own.

Ford’s plan inserts itself into this 50-year-old approach, which struggles to maintain its own status quo, never mind increasing output.

Failure must be an option

Management experts debate whether the potential for failure is a prerequisite for success. It may not be, but it sure increases one’s effort to avoid it.

No matter how poorly a hospital performs, no one goes broke if it fails. Patients may endure waits, indignity, and mistreatment. They may suffer and die. As long as a hospital remains close to the mean, no one gets fired.  

Administrators always spend someone else’s money. They worry about efficiency, but only in so far as inefficiency risks reprisal from the ministry of health. As long as performance looks as bad as neighbouring hospitals, you can just ask the government for more money.  

Ford’s plan changes this. It expands services to facilities in which financial failure is a real option.

Short-term gain, Long-term pain?

Ford’s plan should expand services and improve efficiency, at least in the short term. It weakens the corporatist-style iron triangle between government, doctors, and unions, as discussed earlier in The Hub.

However, success depends on the new legislation. It could be an amendment to the Independent Health Facilities Act 1990, or it could be a new bill. Maybe legislators will promise piles of new operational funding, which would make non-hospitals more like hospitals. By the time the bill reaches committee, it may have picked up enough regulatory lint to make the PHA look svelte in comparison.

Even if we get light, enabling legislation, the regulatory state always finds reasons (safety!) to metastasize and control new entities. The corpulent tentacles of policy and protocol always threaten to divert attention toward paperwork and checklists instead of patient care. Finally, public-sector unions will compete to sign up staff, creating its unofficial second layer of management.  

The first change to management in decades

Hospitals can run well, offer industry-leading services, and remain entirely on budget, if not for all the patients to be seen. Non-hospital facilities do not share the luxury of mediocre performance. They must remain efficient—always vigilant and intolerant of waste and sloth.

Ford’s expansion is not private care. It is a shift back to Medicare’s founding principles. Premier Ford has started to slice apart payment for care and management of medicine. He aims to disentangle political risk and service delivery.

The three-step plan could get hijacked. It could be diverted to create an even greater tangle than we have now. But there is solid reason for optimism. Let’s hope Ford can see it through soon.

“I am great OZYMANDIAS,” saith the stone,

The King of Kings; this mighty City shows

The wonders of my hand.” — The City’s gone, —

If this sounds almost familiar, it’s because it’s from the poem “Ozymandias.” But not that “Ozymandias.” This version was written by Horace Smith as part of a competition with his friend Shelley to compose sonnets on a common theme, in this case a passage from Diodorus Siculus’s Bibliotheca historica. (These competitions were a productive pastime for the Romantics: Percy’s wife Mary wrote the novel Frankenstein as part of a similar contest with Lord Byron while the Shelleys were staying nearby on Lake Geneva during the dreary non-summer of 1816.)

Shelley’s and Smith’s sonnets both describe a broken colossus crumbling in the desert above slightly different paraphrases of the inscription that Diodorus Siculus records as “King of Kings am I, Osymandyas. If anyone would know how great I am and where I lie, let him surpass one of my works.” Both poems are parables about the impermanence of worldly renown, and Shelley’s version, with its mawkishly didactic lesson about pride and hubris, is a staple of the high school English curriculum.

The moral is artistically effective and the message memorable, but they are false. No matter how much Shelley tries to convince us that the works of great men are ultimately in vain, his poem’s very existence belies its intent. The truth, inescapable, is that the works of Ozymandias—or Rameses II, as he is better known—do endure, and not just in Shelley’s well-known (and Smith’s less well-known) poem. They can be found from the Nile Delta to Abu Simbel, and we still stand before them in awe. Look on his works ye mighty, or ye average Joe, and despair. 

I was reminded of Shelley’s poem in the Pergamonmuseum in Berlin last year, as I read the mortuary epitaph of the neo-Hittite King Panamuwa I. Carved on a colossal statue of the Hittite storm-god Hadad, the long inscription begins, with echoes of Diodorus Siculus:

I am Panamuwa, son of Qarli, king of Y’DY, who have erected this statue for Hadad in my eternal abode. The gods Hadad and El and Rašap and Rākib-El and Šamaš supported me. Hadad and El and Rākib-El and Šamaš and Rašap gave the scepter of dominion into my hands. Rašap supported me. So whatever I grasped with my hand […] and whatever I asked from the gods, they granted to me.

Reading it, I was struck by just how wrong Shelley was. There, standing in the grand centre of the capital of a country whose power and wealth he could not have imagined, on display to visitors from around the world, was a statue erected by a regional warlord to his immortal memory. Three millennia later, and three thousand miles from where he died, millions of people have read of King Panamuwa’s feats and marvelled at his monument. So much for the tragic evanescence of worldly fame.

Shelley and Smith appear to have understood the weakness of their artifice, as both poets altered their source material to make their points. In Diodorus Siculus’s account, the statue is not “a colossal wreck” and there are no “vast and trunkless legs of stone” (or, in Smith’s version, “a gigantic Leg”). He describes the figure as “seated … the largest of any in Egypt” and “marvellous by reason of its artistic quality and excellent because of the nature of the stone, since in a block of so great a size there is not a single crack or blemish to be seen.” The implication is clear: the greatness of Osymandyas is well-attested by his surviving monument. 

Nor could the poets avoid the awkward fact that they were writing a poem about the fleeting memory of a pharaoh they knew by name. The fictional Ozymandias may be a forgotten titan, but the real Rameses II is probably the only pharaoh most people can name, other than the comparatively inconsequential boy King Tutankhamen. Shelley may not have lived to see him portrayed in Technicolor by Yul Brynner or in sadistic prose by Norman Mailer, but even he was excited enough about the arrival of one of his surviving sculptures in London in 1818 to be inspired to poetic competition. 

It was a perverse conceit to compose a meditation on ephemeral repute based on an example of enduring renown. Poets may be, as Shelley once boasted, “the unacknowledged legislators of the world,” but the greatest of actual legislators are also acknowledged in their lifetimes and remembered long after. This may be, in part, thanks to the work of poets and other artists, as Shelley implies when he praises the skill of Ozymandias’s anonymous sculptor. But artistic subjects are chosen for a reason, and in this case crediting the artist for his subject’s enduring memory means forgetting who was in the position to commission whom.