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One thing the leader of the New Democrats on P.E.I. said he hopes will change is who pays for health care services

"Of course, there is no such thing as a perfect health system and it certainly doesn't reside in any one country," Mark Britnell, global chairman for health at the consulting giant KPMG, writes in his new book, In Search of the Perfect Health System. "But there are fantastic examples of great health and health care from around the world which can offer inspiration."

As a consultant who has worked in 60 countries - and who receives in-depth briefings on the health systems of each before meeting clients - Mr. Britnell has a unique perspective and, in the book, offers up a subjective and insightful list of the traits that are important to creating good health systems. If the world had a perfect health system, he writes, it would have the following qualities: the values and universal access of the U.K.; the primary care of Israel; the community services of Brazil; the mentalhealth system of Australia; the health promotion philosophy of the Nordic countries; the patient and community empowerment in parts of Africa; the research and development infrastructure of the United States; the innovation, flair and speed of India; the information, communications and technology of Singapore; the choice offered to patients in France; the funding model of Switzerland; and the care for the aged of Japan.

In the book, Mr. Britnell elaborates on each of these examples of excellence and, in addition, provides a great precis of the strengths and weaknesses of health systems in 25 countries. The chapter on Canada is appropriately damning, noting that this country's outmoded health system has long been ripe for revolution, but the "revolution has not happened."

Why? Because this country has a penchant for doing high-level, in-depth reviews of the health system's problems, but puts all its effort into producing recommendations and none into implementing them. Ouch. "Canada stands at a crossroads," Mr. Britnell writes, "and needs to find the political will and managerial and clinical skills to establish a progressive coalition of the willing."

The book's strength is that it does not offer up simplistic solutions. Rather, it stresses that there is no single best approach because all health systems are the products of their societies, norms and cultures. One of the best parts of the book - and quite relevant to Canada - is the analysis of funding models. "The debate about universal health care is frequently confused with the ability to pay," Mr. Britnell writes. He notes that the high co-payments in the highly praised health systems of Asia would simply not be tolerated in the West.

But ultimately what matters is finding an approach that works, not a perfect one: "This is the fundamental point. There is no such thing as free health care; it is only a matter of who pays for it. Politics is the imperfect art of deciding 'who gets what, how and when.' " The book stresses that the challenges are the same everywhere: providing high-quality care to all at an affordable price, finding the work force to deliver that care and empowering patients. To do so effectively, you need vision and you need systems. Above all, you need the political will to learn from others and put in place a system that works.

"After my first visit with Christine, everything about losing weight finally just clicked," says Cooper. Shaddick not only discussed daily calorie needs, but also explained the role of protein, fibre, and fruit and vegetables, including why, when and how he should be incorporating them in a healthy lifestyle. It was this knowledge that helped him to adapt to every situation, control his blood sugar, and ultimately facilitate weight loss.

I loved that while Dr. House gave me the diagnosis, he referred me to other members of my care team who have the specific expertise and education to help me make improvements to my health," says Cooper. To support his challenging lifestyle changes, his care team was available in person, on the phone or by email throughout his journey. Cooper also utilized CarebookT, the Centre's convenient online health-management system, to track progress, check test results and stay motivated. This high level of personalized care and attention along with support from his wife and family helped ensure his changes were sustainable. "Christine warned me that the weight loss would be slow because I was making a lifestyle change, but I wanted it to be slow. This was not a quick fix, this was a permanent change," says Cooper, who also upped his exercise regimen to a minimum of one hour of cardio per day. "I began planning what I would eat every day and sometimes even weekly. If I knew I had a client-dinner coming up, I would check the restaurant menu in advance to pre-select a healthy option," he says.

His efforts paid off. Only four short months since his Prevention Screen, Cooper was 28 pounds lighter with significantly improved health numbers. His good cholesterol levels were up; he had dramatically lowered his triglycerides and brought his blood sugar back down to a normal, healthy level. He no longer had Metabolic Syndrome, nor was he at risk of Type 2 diabetes. "It was a total game-changer," says Cooper. "I feel 100-per-cent healthier. I have more energy, strength, and better stress management - I feel like a success story!" Cooper plans to continue along his healthy path indefinitely, and looks forward to making further improvements to his health and fitness, while inspiring others to do the same.

It was thanks to his health care team, who provided the right motivation, necessary support and knowledge, that he was able to change his game. He couldn't be more satisfied with the return on his investment in Copeman Healthcare, he says. "It's like a five-star hotel experience and it's worth it. Most people spend more on two dinners out a month or a new outfit. They just need to decide what is more important: life or a pair of pants?"

But stress is not the sole explanation. As both the coroner and the ombudsman note in their reports, the medical classroom and workplace are brutal: Bullying and psychological harassment are commonplace in hospitals, and the stigma about mental illness is pervasive in the medical profession. In short, medical education is too often imbued with a macho attitude that learners have to be broken down and toughened up and that those who can't take it are weak and unworthy.

Perversely, many physicians take pride in this boot-camp mentality. When efforts were made to eliminate the insane 100-hour workweeks of residents, old-timers quietly (and sometimes not so quietly) dismissed the younger generation as wimps. Even Quebec Health Minister Dr. Gaetan Barrette, when asked about medical-school suicides, reacted dismissively, saying: "The pressure they are dealing with is a lot less than it was 15 years ago." In fact, what's different today is not that young people are weaker, it is that expectations are so much higher and isolation is so much greater, in spite of (or perhaps because of) so-called social media. Medical students and residents are also headed into a world of uncertainty, not one in which they are guaranteed a life of privilege.

There is also an open recognition of the problem; when residents and doctors killed themselves before, it was hushed up - now it is at least talked about. But while the system has become adept at collecting data on depression and suicide, it has done little concrete to offer help and invest in prevention. Emilie Marchand, like all her classmates, had stellar marks and, from the time she was in high school, dedicated herself heart and soul to the goal of becoming a doctor - in her case a specialist in internal medicine. When she was in medical school she was diagnosed with a personality disorder and, in residency, suffered from bouts of depression so severe that she had to be hospitalized. She also had a previous suicide attempt, using the same drug, hydromorphone. But Ms. Marchand continued her studies full bore and - her friends testified later - lived in mortal fear that her illness would be exposed and her career derailed.

Increasingly, research is showing that so-called superperformers (such as those attracted to medical school) are particularly vulnerable. Paradoxically, the very qualities that make someone a good doctor - empathy, caring, perfectionism - make them vulnerable to burnout, depression and suicide. The students attracted to medical school are among the best and brightest of their generation. They are smart, talented and driven. But many are also anxious, overwhelmed and lost - sick, not weak.

We cannot simply respond to the wounded healers with the age-old admonishment, Cura te ipsum (Physician, heal thyself). We must create an environment in which our future doctors can learn to heal, beginning with caring for themselves.

The Alliance, a coalition of medical specialists, is calling on provincial and federal leaders to help fashion a "new national vision for health care," one that sets national benchmarks that go beyond the 2004 initiative that targeted five procedures: hip and knee replacements, cataract surgery, heart operations, diagnostic imaging and cancer radiotherapy.

We still don't measure nearly enough," said Dr. Chris Simpson, chair of the alliance and a former president of the Canadian Medical Association. "You can't fix what you can't measure."

At a time when more care is moving out of the hospital, Dr. Simpson said wait times for home care and long-term care beds should be monitored by all provinces, as should the number of patients in hospital because they cannot access these services.

When health ministers meet in January in Vancouver, Dr. Simpson said he hopes a partnership to establish such standards will be part of the discussion, rather than just the level of federal funding. "If we have made a collective mistake in the past, it is to say to the federal government, 'It's all up to you,' " he said.

The annual report card provides a snapshot of wait times across a range of measures gathered from provincially available information this summer. In doing so, it highlights the variation in the information available among provinces, and this year also notes that the federal government - responsible for delivering health care to First Nations, refugees, veterans, Canadian Forces and inmates in federal prisons - provides only limited data on its own performance.

The study, which gives a grade to provinces across a range of procedures, finds those provinces that got high marks last year - Saskatchewan, Ontario and Newfoundland and Labrador - continue to do well.

Both studies point to the success of Saskatchewan in cutting wait times as evidence of what can be done with a focused effort and both note that the improvement came from more than increased funding.

In five years, the number of patients in Saskatchewan waiting more than six months for surgery dropped by 96 per cent, the Alliance report card finds, thanks to a $176-million investment over four years and also because of innovative practices. Bacchus Barua, a senior economist at the Fraser Institute and author of its wait-time study, said measures such as a pooled referral system helped give Saskatchewan the shortest wait times in the survey.

The report from the Fraser Institute is based on a survey of specialists and tracks the time between the initial referral and the appointment with a specialist as well as the time between seeing a specialist and treatment. At the national level, it found the median wait time from referral to treatment was 18.3 weeks, almost the same as the 18.2 weeks recorded in 2014, but almost double the 9.3 weeks recorded in 1993 when the survey began.

Across Canada, wait times have stabilized, but they have stabilized at a very high level," Mr. Barua said

Saskatchewan had the shortest total wait at 13.6 weeks and Prince Edward Island had the longest at 43.1 weeks, although the small sample size in PEI makes that result less reliable. Among specialties, the longest waits were for orthopedic surgery at 35.7 weeks and the shortest were for patients in line for radiation oncology at 4.1 weeks, the study said.

Death notices are being written as you read this. CCACs (Community Care Access Centres) are about to be decapitated — to save the patient. For a little-known acronym, CCACs play an oversized role in the lives of the elderly. They deliver home care, nursing care and community care — be it regular bathing or changing bandages — outside a hospital setting.

But 11 years after the government promised new regional health agencies would trim waste and deliver better care, the opposite has happened too often, and how patients fare depends upon where they live.

Last year alone, Ontario’s Health Ministry funnelled $25 billion through the networks to hospitals, nursing homes and community agencies. But while the networks oversee more than half the health-care budget, the ministry does little to hold them to account, even when the care they oversee becomes worse.

The ministry instead monitors hospitals, tracking wait times and how often patients quickly return to the ER or a ward — and the verdict isn’t pretty. On most measures, performance has stagnated or worsened.

But those near the front lines are less confident — only one in five health service providers say the LHINs are on track.

The government promised LHINs would chip away inequity in access to health care but the opposite has occurred, Lysek found. In 2012, patients in the worst-performing region waited five times as long for semi-urgent cataract surgery as those in the best performing region. That gap has grown to 31-fold.

KEY FINDINGS Key findings In the auditor general’s report: Many LHINS didn’t establish quantifiable targets or performance measures. The performance gap among LHINs is increasing. Health Ministry takes little action to hold networks accountable. The networks don’t consistently monitor the quality of health services. Some networks don’t track patient complaints at all. Too little has been done to cut wasteful spending by providers who duplicate office work and fail to work together to lower costs of purchases.

In Alberta, where private MRI facilities advertise and operate, the median wait time for an MRI is much longer (80 days) than in Saskatchewan (28 days). Furthermore, the wait has lengthened in the public system in Alberta since privatized facilities came on the scene. The explanations are complex, but siphoning human capacity (doctors and technologists), as well as other resources, from the public system into the private and more lucrative stream plays a big role. So does the market generation of increased demand by deceptive advertising and promotion of privatized services.

Medical tests should be ordered in accordance with evidence-based guidelines about their usefulness and indications. Patient access to MRI is currently prioritized in Saskatchewan health-care facilities on the basis of medical need, from Level I (a life-threatening diagnosis or treatment requiring MRI within 24 hours) to a Level IV (stable patients needing long range diagnosis or management allowing for delay of 30-90 days).

This system works and prioritizes appropriately. While patients sometimes feel that an urgent MRI will make a difference to their outcome, this is rarely the case. When it is the case, patients are prioritized and get urgent access. Allowing private MRI's based on ability to pay and jump the queue will trample this well-developed, equitable system. It will allow the wealthy or anxious to bypass this system and result in two-tiered care.

We live in a society obsessed with health. Selling fear of sickness is profitable. But access to MRIs is not our most urgent health-care need. To suggest otherwise is to obscure the social and economic determinants that define who is healthy and who is not, and to further shift resources away from the sick towards the worried well.

The Wall government and the private MRI operators that will profit from this legislation have proposed a two-for-one deal, suggesting that one public MRI scan will be done for every private MRI performed. Don't be fooled. This will not get around the problem of prolonging public wait lists since it will siphon resources from the public system. If we really need more MRIs, why not increase capacity in the public system instead?

While MRI can be a useful tool, when inappropriately used it can lead to overdiagnosis or "false positives." This then triggers a costly cascade of subsequent investigations or interventions to reassure either physician or patient MRI technology has important limitations, and frequently finds unrelated non-significant abnormalities that frighten patients. For example, 90 per cent of healthy individuals over 60 years of age with no symptoms of back pain show degenerative abnormalities on MRI. Similarly, the vast majority of adults over 50 show knee damage on MRI and only clinical assessment by a doctor identifies whether or not these findings are significant. Early MRI has not been shown to improve outcomes in low back pain and may actually make for worse outcomes. A doctor examining for red flag symptoms can identify the very small number of patients for whom an MRI is useful.

Many MRI scans are therefore unnecessary. Allowing patients to purchase an investigation they don't need wastes resources, bypasses the role of an informed health-care provider, and may in the end actually harm patients with needless investigations and interventions. Physicians are engaged in initiatives to "choose wisely" in testing. Throwing the door open to investigations based on ability to pay, rather than medical need, flies in the face of sensible approaches to health resources.

And the queue-jumping is not just limited to getting an MRI. It will extend to preferential and quicker access to treatment options, such as specialist care and surgery based on the MRI results if positive.

Let's promote greater equity, not less, and preserve health care based on need, not two-tiered care based on ability to pay. Let's trust health-care providers to counsel patients about the right test at the right time and to prioritize patients appropriately. The marketplace has no role in these decisions.

Dr. Sally Mahood is a Regina family doctor and an associate professor, Family Medicine, University of Saskatchewan.

One big problem with the proposed summit: it could lead to increased tensions if the feds try to attach strings to how the provinces should spend any new money. The provinces have reason to worry: In the 1980s and nineties, as the federal fiscal situation deteriorated, Ottawa contributed less and less to the public health-care system, while prohibiting provinces from pursuing private-sector alternatives.

In the first years of the last decade, as the fiscal situation improved, the Liberal federal government was prepared to offer more robust funding, but insisted on new national standards for health-care delivery in exchange. Provincial governments resisted that federal intrusion in their jurisdiction. The struggle culminated in that 2004 first-ministers meeting in which the premiers browbeat the new Martin government into those massive increases in spending.

If Mr. Trudeau attaches conditions to increases in federal health care transfers, expect Quebec to demand that it be allowed to opt out of any program, but still get all the money. Expect Alberta to demand the same. It's called asymmetrical federalism, and it can quickly get ugly. Another major problem is that, given other Liberal spending commitments in infrastructure, fighting global warming, postsecondary education and so much else, the finance minister, whoever he or she may be, might not be able to balance the federal budget by the end of the mandate, as Mr. Trudeau has promised.

The Liberals have also promised to work with the provinces on a pharmacare strategy, which would inevitably involve funding for subsidized prescription drugs for low-income seniors.

If increased health-care commitments - along with everything else in the Liberal platform - cause federal finances to deteriorate to the point that Ottawa is running an entrenched structural deficit, the national debt will increase. At the same time, Canada's credit rating will start to decay, interest payments on the debt will consume more of the budget, and people will start saying, "Like father, like son."

To avoid that, Mr. Trudeau will have to rein in provincial expectations. But there is a political price to be paid for convening first-ministers conferences and then failing to meet the premiers' demands. It's why Stephen Harper avoided them.

Currently 76,000 vulnerable seniors live in nursing homes. Thousands more are on regional waiting lists. Hospitals consider them "bed blockers." Private retirement residences aren't equipped to meet their needs. Their families can't take care of them or get enough home care to keep them clean, safe and stable. "I think we see nursing homes as a symbol of failure - failure of the individuals to care for themselves, of families to care for older people, of the medical system to cure them," Armstrong said. "It's something we don't want to think about because we intend to avoid such places when we grow old." That attitude has led to underfunding, understaffing, low wages and high turnover in nursing homes. Care providers don't have time to listen to residents, respond to their needs, help them eat, talk to them or alleviate their boredom. Food service workers lock the dining room between meals. Clothes vanish in the laundry. Government-required paperwork takes precedence over caregiving. It is not unusual to see a dozen seniors - some with dementia, some in wheelchairs, some heavily sedated - lined up in front of a television staring vacantly at a rerun of I Love Lucy.

"They deserve better," Armstrong thought. So she pulled together a team of 26 researchers from six countries (Canada, Britain, Sweden, Germany, the United States and Australia) to reimagine institutional long-term care. Could it be a humane, dignified, financially viable option? The team included doctors, pharmacists, architects, economists, psychologists, social workers, historians, philosophers and communication experts. It began by collecting success stories from Europe and North America and identifying the most promising practices and best ideas in the field. That was five years ago. Armstrong and her colleagues have now done 25 site visits in 10 jurisdictions; interviewed thousands of long-term care residents, workers, managers, policy-makers and advocates for seniors; published 50 academic papers and released an 86-page public report entitled "Promising Practices in Long-Term Care."

Last week, she and co-author Donna Baines, of the University of Sydney in Australia, led a panel discussion in the dining room of Hart House at the University of Toronto. "The reception was very positive. People are excited by the possibilities." It will take many more community forums - and a lot of public pressure - to change the mindset at the ministry of health and long-term care. It regards the elderly as a financial burden and nursing home workers as an expense to be controlled. For one evening, Armstrong and Baines managed to change the public dialogue from failures and shortcomings to promising practices. They provided proof that nursing homes don't have to be grim, depressing places. They offered hope to desperate families, exhausted caregivers and aging boomers contemplating their future.

Armstrong acknowledged afterward that it will take a prodigious effort and a significant public investment to reach the level of long-term care regarded as normal in countries such Germany, Sweden and Britain. But even without a cash infusion, she argued, there are ways to make life better for the residents of Ontario's nursing homes: Label their clothes properly before sending them to the laundry; allow them to make a cup of mid-afternoon tea or go to the fridge for a beer; let them eat chocolate or ice cream if they wish; make the decor less hospital-like and more like a home. Give personal care precedence over paperwork. Reorganize who does what to bolster teamwork and reduce staff turnover. These reforms are not costly. Three principles are vital for high-quality long-term nursing care, the researchers concluded: It fosters person-to-person relationships. It respects individual differences, while striving for equity. It offers dignity to older citizens regardless of their infirmities.

One of the biggest impediments to progress, Armstrong said, is the province's knee-jerk response to scandals. Any time something goes wrong in one of Ontario's 629 nursing homes, the ministry of health imposes blanket regulations. These one-size-fits-all rules reduce the ability of care providers and nursing managers to tailor their practices to the needs of residents. "We've become so obsessed with safety and standardization that we've taken the life out of living." So far, there's been no sign of interest in the project from Queen's Park. That is not likely to change until Ontarians open their eyes and raise their voices. Instead of complaining after their elderly parent is admitted to a nursing home, they need to speak out for everyone's parents. Instead of giving up on long-term care, they need to push back when policy-makers offer visiting part-time help.