Canada 2020 Analytical Commentary: No. 01

The Circle Model An innovative alternative for health care in

Arianne Charlebois

February 2013

Analytical Commentary

Canada 2020 produces original research in a variety of formats. Our Analytical Commentary series presents unique insights into emerging trends and innovative solutions to big policy challenges. Papers are topical, accessible, and oriented towards drawing lessons for federal policy. About Canada 2020

Canada 2020 is a leading, independent, progressive think-tank. Our objective is to inform and influence debate, to identify progressive policy solutions and to help redefine federal government for a modern Canada. We do this by convening leading authorities from Canada and abroad, generating original policy thinking, and prioritizing effective communication. Our orientation is: • progressive and non-partisan • long-term, with an emphasis on key structural issues facing Canada • collaborative and outward focused • activist: we aim to influence the policy agenda.

Visit us online at www.canada2020.ca About the Author

Arianne Charlebois holds a BA in History from McGill University and recently completed her Master's degree from the Norman Paterson School of International Affairs at Carleton University.

Introduction

There are few Canadian institutions more emotionally charged or heatedly debated than Medicare. Free universal health care is an integral part of Canadian identity, as well as one of our greatest national concerns. In a 2008 survey, identified with Medicare more strongly than with any other Canadian ideal, including democracy and compassion.1

However, long wait times, rising costs and a lack of coverage have damaged the reputation of Medicare in recent decades. Attempts to increase efficiency within the public system have had, at best, an incremental effect and privatization is considered immoral by a large portion of the population. We have therefore reached something of an impasse.

Meanwhile, in the UK, an alternative model is emerging. In February 2012, the Circle Partnership, a privately owned healthcare company, was awarded a 10-year contract to manage a publicly-funded hospital. This model allows the UK’s National Health Service (NHS) to continue to provide free universal health care while introducing private-sector incentives to maximize efficiency. Still in its early stages, the model has shown promise in addressing similar concerns to those faced by the Canadian healthcare system.

This paper will discuss the Circle Partnership’s philosophy and operations and reflect on the applicability of this model to Canada.

The Circle Model The Circle Partnership is a British company founded in 2005. It represents the largest partnership of physicians anywhere in Europe. Doctors, nurses, and other Circle employees collectively own 49.9% of the company (a group of hedge and venture capital funds owns the rest). It is founded on the principle that employees who benefit directly from the company’s success will be motivated to work as efficiently as possible.

Circle runs several privately- and publicly-funded clinics. In February 2012 it became the first private firm to manage an NHS hospital when it was awarded the management contract for Hinchingbrooke hospital in Huntingdonshire.2 This was a change of scope and complexity for Circle: clinics operate on a smaller scale than hospitals and cannot provide complex procedures or inpatient services. Hinchingbrooke hospital, by contrast, is a full-service hospital that had accumulated a debt of £39 million and was facing closure. Following a competition, the government granted Circle a 10-year contact to run the hospital. The NHS continues to fund services and employ the staff, but Circle has taken over administrative responsibilities. Over time, Circle hopes to offer NHS employees an opportunity to become Circle shareholders.

The UK government provides hospitals with a set amount of annual funding. If efficiencies by Circle yield a surplus at Hinchingbrooke, profits will be shared by the hospital, the NHS, and Circle. Circle will keep the first £2 million of profit, 25% of profit between £2-6 million and 33% of profit between £6-10 million, after which all further surplus will go to paying Hinchingbrooke’s debts.3 If the hospital

1 continues to post a deficit under Circle’s management, Circle will earn nothing and has agreed in its contract to be responsible for the first £5 million of fresh debt.4

The Canadian Healthcare Problem The Canadian and British healthcare systems share many of the same problems. The UK faces soaring costs that have led to an unsustainable budget, as well as long wait times.56 These problems have been compounded by tight recession budgets.

In Canada, the biggest public concern about healthcare has been long – and growing – wait times, both in the emergency room and for access specialist care.7 A 2011 Commonwealth Fund study ranked Canada last out of 11 countries in all categories related to timeliness of care, whether in the emergency room, to see a specialist, to see a doctor when sick, or for surgery. By 1998 a majority of Canadians were calling for fundamental changes to the healthcare system.8 A 2010 Commonwealth Fund study showed that public opinion had not improved, with 52% of respondents believing that the system needed fundamental changes and 10% feeling that it had to be completely rebuilt.9 Again, the main complaint was wait times.

The Euro-Canada Health Consumer Index ranks countries based on patient outcomes as well as “patient friendliness,” which incorporates factors such as wait times and services covered. Canada placed 25 out of 34 countries in 2010.10 A lack of resources is a main factor in wait times for emergency treatment as well as specialist care and surgery: there are too few daytime operating room slots, operating room nurses, surgeons, and anesthesiologists.

Canada’s lack of doctors is a growing problem despite high salaries for doctors, both by Canadian and international standards, and increased funding for training positions. This is due to a number of factors, including poor work-life balance, long training times, fewer international medical graduates immigrating to Canada, and a high retirement rate. Another problem is fragmentation. Doctors work alone rather than in teams, and the administrative burden of passing patients with complex health issues from doctor to doctor, as well as lack of communication between doctors regarding a patient’s care, greatly increase wait times.

Lack of coordination and planning can also cause unnecessary bottlenecks.11 Moreover, under-funding of home care and long-term care have created additional stress on the hospital system. This cannot easily be addressed due to the growing costs of healthcare. Finally, because hospitals receive a set amount of annual funding, regardless of the number of services performed or patients treated, there is no financial incentive to move patients through quickly.

Other complaints in Canada include Medicare’s limited coverage, combined with costs that are growing at an alarming rate. The public system cannot afford to fund a full range of therapies, especially newer ones. Canada is also one of the only countries among those providing publicly funded healthcare that does not provide national prescription drug coverage.12 When Medicare was founded, most ailments were treated by a family doctor or at a hospital. Healthcare has evolved now to the point where many illnesses can be treated by technology in a clinic or at home – without the need to visit the hospital – or with medications. Unfortunately, the healthcare system has not kept up. Only

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70% of healthcare services in Canada are publicly funded, putting us in the bottom third of OECD countries on this metric.13

Canada’s aging population, increased incidence of chronic diseases, and rising obesity rates, combined with the growing costs of treatment as technology advances, are straining the system to its limits. Provincial governments spend 42-45% of their budgets on health care, and costs continue to grow faster than any other government program and as well as faster than revenues. A TD Financial Group report has forecasted that by 2030 health care spending will require 80% of ’s budget14.

It is notable that Canada spends significantly more per capita on health care than the UK and is consistently ranked in the top five countries in the world for per capita health care spending, but without cracking the top five for health care outcomes. Canada came sixth out of seven countries in a Commonwealth Fund study surveying the quality of healthcare systems in Canada, the United States, New Zealand, Australia, Germany, the Netherlands, and the UK. Only the U.S., a country without universal healthcare, was ranked lower than Canada.15

Importantly, the OECD has estimated that Canada could decrease healthcare spending by 2.5% annually if Medicare became as efficient as the most efficient performers in the OECD.16 Given funding constraints and growing demands on the system we clearly need to look anew at all opportunities to increase efficiency. Past Attempts at Efficiency There is a widely held belief that any form of healthcare privatization can be avoided in Canada by making the current system more efficient. Several attempts have been made to do just this, focusing, most recently on wait times:

• In 2004, $5.5 billion was dedicated to the Wait Times Reduction Fund to lessen wait times for specific common procedures. Wait times for non-prioritized procedures were not reduced, indeed some ultimately increased due to the heightened emphasis on priority areas.

• In 2005, the Patient Wait Times Guarantee allocated $612 million to provinces to create guaranteed maximum wait times in at least one priority area. By 2011 the provinces had instituted the guarantees, but few patients knew about them. Moreover, some guarantees were up to two times as long as those announced in 2005.

• In 2008, the Emergency Wait Times Strategy was instituted to ensure that 90% of patients in emergency rooms requiring complex treatment would be admitted or discharged within eight hours. By 2011 only 40% of patients were admitted within this limit. 17

Unfortunately for those who advocate improving the system without making any fundamental changes, results have not been good. A study of healthcare reforms in Canada between 1990 and 2003 revealed results that were moderate at best. Efficiency gains are easy to map out on paper but difficult to realize. This is partially due to the distance between health ministers and front-line healthcare workers. Moreover, effecting change can seem hopeless in such a large, complicated system.18 Finally,

3 doctors have resisted change in the past. This is human nature, which is difficult to overcome without the right incentives.19 A drastically different approach is clearly required. Experimenting with private care Despite resistance to the concept of privatization, a similar approach to the Circle model has actually been tried in Canada already, on a smaller scale. In 2001, the Canadian Radiation Oncology Services (CROS) was awarded the first contract in Canada for private delivery of publicly-funded healthcare. For the two years prior, the Ontario Ministry of Health had been spending approximately $375,000 per week to send cancer patients to the United States for radiation therapy because the Canadian system could not meet the demand for service. Despite government efforts to raise the capacity of radiation departments and to create new departments, the changes only enhanced capacity by 3%, just enough to meet the 3% growth in demand.

The CROS contract introduced private sector pressures and increased accountability. Because providers were paid a negotiated fee for services, increasing the efficiency of service provision increased profits. Suddenly doctors were willing to work evenings to enhance capacity and to innovate to find new solutions. Performance measurement and evaluation increased as well. With these changes, radiation therapists became 60-70% more efficient compared to hospitals and physicians doubled their efficiency. Furthermore, the program boasted a 100% patient satisfaction rate, with 94% of patients responding that they would recommend the clinic to friends.20

Despite this success, the CROS clinic was closed after three years due to public objections that it would harm Medicare.21 A similar story developed in in 2008. Montreal’s Sacré-Coeur Hospital arranged with a private clinic to perform publicly-funded surgeries two days per week. The clinic was paid the same rates as hospital doctors and the arrangement helped to tackle the 1,500 person waiting list for short-stay surgery at the hospital.22 The program was, however, abruptly cancelled by the Minister of Health after hospital unions fought the concept.23

In Alberta, private clinics offering publicly-funded services have come and gone over the years as political moods have shifted. Currently, the South Alberta Eye Centre in Calgary is thriving under this model. The clinic is owned by three surgeons and employs three more. Each is able to examine about twice as many patients as they did when working in the hospital, while still meeting all the specifications and quality standards set by the Ministry of Health. A small clinic makes it easier to organize operating times that are convenient for patients and doctors and allows for better control of patient flow.

In addition, the clinic performs half of its surgeries in off-hours in order to maximize operating room efficiency. The clinic and the hospital work closely together. When patients must be treated quickly they can be taken to the clinic, where wait times are much shorter. When patients require a range of hospital services for more complicated problems, they are sent to the hospital. Not only are more patients treated under this system, they are treated at a lower per-patient cost.

The Alberta government compared the costs of performing eye procedures at private clinics versus hospitals. They did not release the results, but leaks to the Calgary Herald showed that clinics delivered procedures at an average cost that was 28% lower than hospitals. The future seems bright

4 for the South Alberta Eye Centre. Although it was only awarded a one-year contract when it opened in 2011, the owners signed a five-year contract in 2012.24

How is Circle doing? Circle has already demonstrated its ability to impact wait times at Hinchingbrooke. The emergency room, which had regularly failed to meet its targets in areas such as wait times, was ranked first of 46 hospitals in Eastern England after six months under Circle’s administration. Monthly targets for cancer treatment, which had last been met in June 2010, were being fulfilled every month. The length of a patient’s stay after hip or knee surgery fell from an average of 5.6 days to 2.6 days, allowing for faster turnaround of rooms. This was combined with a reduced waiting time to receive surgery due to increased productivity in operating theatres. Notably, this was achieved without sacrificing patient satisfaction. The hospital, formerly one of the lowest ranked in its area, has risen to a ranking of 5 out of 46 hospitals for quality of care.

At the same time, the hospital’s safety rating soared from a red to a green on the colour-coded system in use in UK hospitals. Direct contact between nurses and patients rose from 51% to 62% and the hospital improved in areas such as patient satisfaction with the food and lower parking fees. Circle has claimed that these changes have improved patient satisfaction and resulted in significantly more applications to join the staff from talented doctors.25 Circle’s Remaining Hurdles In theory, private administration – with profit sharing – should provide the right incentives to lower costs. Additionally, employee ownership should motivate staff to seek new solutions and to work as efficiently as possible. It can make doctors more willing, for example, to perform surgery in the evenings when operating rooms are free.

It is unfortunate, then, that Circle has yet to demonstrate its ability to keep costs under control. The hospital’s losses reached £4.1 million within eight months, just over double the £1.9 million of new debt that Circle had predicted for the hospital by that point. A report by the UK’s National Audit Office states that the risks of Circle’s savings proposal were not fully considered when the company was awarded the contract, encouraging it to be over-optimistic about costs.26

Less than a year into a 10-year contract, it is too early to draw definitive conclusions as to the merits of the Circle experiment. It is true that the company has posted higher losses than planned, but also true that Circle never planned on making money in the short term; most of the savings are expected to be generated in the latter years of the contract. In addition, Circle took over a hospital £39 million in debt with dismal ratings across the board. A large initial investment was required to improve quality and boost efficiency. Time will tell if Circle can deliver both quality and cost-efficiency, but the experiment is off to a strong start and has already addressed some of the worst concerns faced by the NHS.

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Applicability of the Circle model to Canada Circle has received positive reactions in the UK, but is the model transferable to Canada?

No legislation prevents the introduction of private healthcare administration in this country. The 1984 Canada Health Act (CHA) sets out what is and is not allowed under Medicare. One of the pillars of the Act is the concept of public administration, which has led to the misunderstanding that the CHA does not allow for any form of private medicine. The Act does not allow the use of private fees in public medicine; for example, co-payments and user fees are banned. It does, however, allow the government to designate a private authority to deliver healthcare, provided that this entity is responsible to, and funded by, the government.

An interpretation manual published by the CHA explains that the organization running a publicly- funded hospital cannot earn a profit on its operation, although hospital surpluses are allowed.27 An organization founded and owned by doctors could therefore introduce private-sector incentives – such as fee-for-service payment schemes that incent greater throughput – without contravening the CHA. The more money that is saved, the more can be invested in securing further efficiency gains.

Furthermore, the current Canadian healthcare infrastructure should simplify the transition to a Circle model. Canadian primary care doctors are paid under a fee-for-service system, earning money for services provided rather than a fixed salary. This means that they are more akin to private agents working under a contract with the government than government employees. Our primary care system already resembles the model’s combination of public funding and private delivery, which should make it easy to convert hospitals to the same concept.28

A Canadian Circle model would certainly work slightly differently than it does in the UK where hospitals and doctors are provided with a set annual budget and for-profit medicine is allowed to operate in the same sphere as publicly-funded medicine. The outcomes could, however, remain the same: higher efficiency and improved healthcare. The Public Perception Problem The first roadblock to introducing the Circle model to Canada is a significant one, which lies in Canadians’ deep emotional attachment to the idea of Medicare. There is strong opposition to any linkage between the private sector and healthcare, likely because of the proximity of the American system of fully-privatized medicine with all its problems.

In Canada, private insurance for services covered by Medicare was illegal until 2005, when the Supreme Court deemed that excessively long wait times for medically necessary services within the public system demanded a private option. Without private insurance, private medicine has been unaffordable, despite the fact that no legislation precludes it. Even with this ruling, private medicine remains rare and controversial in Canada, particularly outside Quebec.29

The provision of free universal health care based on need rather than ability to pay is seen as a moral obligation. Moreover, there are fears that the profit motive will cause health care providers to cut corners and prioritize profit above quality of care.30

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At the same time, hospital unions oppose creating jobs outside of the public system, for fear that, those jobs will not be unionized and politicians are loath to risk championing such a contentious issue as privatization of health services. Even in Quebec, which identifies less strongly with Medicare than the rest of Canada, the provincial government has stopped licensing new private clinics due to public resistance.31

By contrast, the British system is more accepting of private medicine, and private clinics are an established part of healthcare in the UK.32 Building on this, the Blair government passed legislation that allowed for private administration of hospitals in exceptional cases.33

Nonetheless, there does seem to be a recent softening of opinion in Canada and a recognition that without fundamental change, our health system is in jeopardy. This could provide the opening for increased private delivery of public services.

The recession has squeezed healthcare tighter than ever as budgets are slashed. Before 2008, Canadian hospitals delivered a total of 10,500 cataract surgeries per year, with 75% of operations performed within 16 weeks. Currently they deliver 8,500 surgeries per year, with wait times up to 46 weeks. Circumstances such as these have created more public interest in, and acceptance of, private clinics.34

Nonetheless, governments must remain aware of the public’s aversion to the word “private” and promote the idea of change accordingly, with emphasis on the impact on wait times and a potential to expand Medicare coverage, rather than on the efficiencies created by private-sector incentives. The positive reaction to the South Alberta Eye Centre serves as an example that private clinics can deliver public health care efficiently and without public protest. Governments must take the opportunity now to expand those benefits across Canada. The Federal Role Although the amount of federal funding to provincial healthcare is shrinking, federal dollars are still transferred to the provinces to assist with health funding. The federal government therefore has a responsibility to taxpayers to contribute to shaping Medicare. While it cannot directly impact the introduction of a Circle model in Canada, it can nudge it in the right direction. In particular it could provide leadership and an avenue for communication and continuity between provinces. In the past, federal governments have distributed incentives and punishments to provinces in order to shape Medicare to a certain standard. This practice could be repeated, though the current federal government has recently been at pains to distance itself from healthcare decision-making.35 Another avenue for engagement would be for the federal government to arrange meetings between provinces to encourage communication of best practices, including new structural models, such as Circle.

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Conclusion

The Circle Partnership has had success in privately-managing an NHS hospital in the UK. Although it is too early to determine its ability to contain costs, it has improved quality of care and wait times drastically, only six months into its 10-year contract. Smaller-scale examples in Canada have proven to be just as beneficial and have demonstrated their ability to reduce costs per patient as well.

In a country strongly opposed to fully privatized medicine, a partnership between private health care providers and Medicare is a compelling option to address the wait times and soaring costs that plague the current system. A full restructuring of Medicare is not required, and the negative public perceptions surrounding the concept of private medicine can be managed under such a partnership.

Current economic and political conditions make this an ideal time to act. The Canadian healthcare system was founded on the same principles as the British system. The ideal at the core of the CHA – universal medical care based on need rather than ability to pay, with healthcare delivered free at the point of care – mirrors the British system and was introduced as national policy shortly after the introduction of the NHS.

It is time we followed their lead once again. The Circle model has many lessons for Canadian healthcare: it demonstrates that public-private partnerships need not be a path to fully-privatized medicine; that private healthcare providers do not cut corners and can in fact improve quality of care; that private sector incentives can encourage medical staff to find innovative new solutions to problems that affect efficiency; and that private providers can deliver care without contravening the ideals of universal healthcare. These lessons can help Canada move forward and allow our health care system to evolve with our healthcare needs.

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Appendix

Acknowledgements

Canada 2020 would like to thank Arianne Charlebois for this contribution to our research program. For more of Canada 2020’s work on health, visit www.canada2020.ca.

Acknowledgements

Arianne Charlebois, , Ontario, [email protected]

Canada 2020, 210 Dalhousie Street, Ottawa, Ontario, [email protected]

Footnotes

1 Ibid, 271. 2 “Circle Story,” Circle Partnership, December 10, 2012, http://www.circlepartnership.co.uk/about- circle/circle-story. 3 James Gallagher, “Hinchingbrooke Hospital ‘Profit Deal’ Revealed,” BBC News, May 2, 2012, http://www.bbc.co.uk/news/health-17925731. 4 Nigel Hawkes, “NHS Hospital is Taken Over by a Private Social Enterprise,” British Medical Journal 343 no. 7341 (2011), doi: http://dx.doi.org/10.1136/bmj.d7341. 5Robert J Blendon, Cathy Schoen, Catherine M Desroches, Robin Osborn, Kimberly L Scoles, and Kinga Zapert, “Inequities in Health Care: A Five-Country Survey,” Health Affairs 21, no. 3 (2002), doi:10.1377/hlthaff.21.3.182. 6 “Overview – The Health and Social Care Act 2012,” UK Department of Health, April 30 2012, http://www.dh.gov.uk/health/files/2012/06/A1.-Factsheet-Overview-240412.pdf. 7 Kim Sutherland, Sheila Leatherman, Susan Law, Jennifer Verma, and Stephen Petersen, “Chartbook: Shining a Light on the Quality of Healthcare in Canada,” Healthcare Papers 12, no 1 (2012), http://www.longwoods.com.ezproxy.library.dal.ca/content/22860. 8 Robert J Blendon, Cathy Schoen, Catherine M Desroches, Robin Osborn, Kimberly L Scoles, and Kinga Zapert, “Inequities in Health Care: A Five-Country Survey,” Health Affairs 21, no. 3 (2002), doi:10.1377/hlthaff.21.3.182. 9 Arlene S Bierman, “The PROMise of Quality Improvement in Healthcare: Will Canada Choose the Right Road?” Healthcare Papers 11, no 3 (2011), http://www.longwoods.com.ezproxy.library.dal.ca/content/22559. 10 Jeffrey Simpson, Chronic Condition: Why Canada’s Health-Care System Needs to be Dragged into the 21st Century (: Penguin Group, 2012), 159. 11 Braden J Manns, David C Mendelssohn, and Kenneth J Taub, “The Economics of End-Stage Renal Disease Care in Canada: Incentives and Impact on Delivery of Care,” International Journal of Health Care Finance and Economics 7, no. 2/3 (2007), http://www.jstor.org/stable/30221727.

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12 Braden J Manns, David C Mendelssohn, and Kenneth J Taub, “The Economics of End-Stage Renal Disease Care in Canada: Incentives and Impact on Delivery of Care,” International Journal of Health Care Finance and Economics 7, no. 2/3 (2007), http://www.jstor.org/stable/30221727. 13 Howard Chodos and Jeffrey J MacLeod, “Romanow and Kirby on the Public/Private Debate in Healthcare: Demystifying the Debate,” Healthcare Papers 4, no 4 (2004), http://www.longwoods.com.ezproxy.library.dal.ca/content/16849. 14 TD Bank Financial Group, “Charting a path to sustainable health care in Ontario”. May 27 2010. TD Economics Special Reports. Online: http://www.td.com/document/PDF/economics/special/td- economics-special-db0510-health-care.pdf 15 Jeffrey Simpson, Chronic Condition: Why Canada’s Health-Care System Needs to be Dragged into the 21st Century (Toronto: Penguin Group, 2012), 157. 16 Jeffrey Simpson, Chronic Condition: Why Canada’s Health-Care System Needs to be Dragged into the 21st Century (Toronto: Penguin Group, 2012), 195. 17 Ibid, 164-167. 18 Jeffrey Simpson, Chronic Condition: Why Canada’s Health-Care System Needs to be Dragged into the 21st Century (Toronto: Penguin Group, 2012), 210-219. 19 Jeffrey Turnbull and Owen Adams, “The Healthcare Quality Agenda in Canada,” Healthcare Papers 11, no 3 (2011), http://www.longwoods.com.ezproxy.library.dal.ca/content/22555. 20 Tom McGowan, “Private Management of a Public Service: What Can be Learned from the CROS Experience?” Healthcare Papers 6, no. 4 (2003), http://www.longwoods.com/content/16479. 21 Jeffrey Simpson, Chronic Condition: Why Canada’s Health-Care System Needs to be Dragged into the 21st Century (Toronto: Penguin Group, 2012), 226. 22 “Operation in Private Clinic a Good Thing,” CBC News, February 6, 2008, http://www.cbc.ca/news/canada/montreal/story/2008/02/06/qc-rockland-clinic-02-6.html. 23 Jeffrey Simpson, Chronic Condition: Why Canada’s Health-Care System Needs to be Dragged into the 21st Century (Toronto: Penguin Group, 2012), 226. 24 Jeffrey Simpson, Chronic Condition: Why Canada’s Health-Care System Needs to be Dragged into the 21st Century (Toronto: Penguin Group, 2012), 201-205. 25 “Circle’s 6 Months at Hinchingbrooke,” Circle Partnership, August 3 2012, http://www.circlepartnership.co.uk/about-circle/media/circle's-6-months-at-hinchingbrooke. 26 “The Franchising of Hinchingbrooke Health Care NHS Trust,” National Audit Office, November 8 2012, http://www.nao.org.uk/publications/1213/hinchingbrooke_health_care.aspx. 27 Jeffrey Simpson, Chronic Condition: Why Canada’s Health-Care System Needs to be Dragged into the 21st Century (Toronto: Penguin Group, 2012), 148. 28 Jeffrey Simpson, Chronic Condition: Why Canada’s Health-Care System Needs to be Dragged into the 21st Century (Toronto: Penguin Group, 2012), 225. 29 Damien Constandriopoulos, Julia Abelson, Paul Lamarche, and Katia Bohémier, “The Visible Politics of the Privatization Debate in Quebec,” Healthcare Policy 8, no 1 (2012), http://www.longwoods.com.ezproxy.library.dal.ca/content/23005. 30 Tom McGowan, “Does the Private Sector Have a Role in Canadian Healthcare?” Healthcare Papers 4, no. 4 (2004), http://www.longwoods.com.ezproxy.library.dal.ca/content/16853. 31 Jeffrey Simpson, Chronic Condition: Why Canada’s Health-Care System Needs to be Dragged into the 21st Century (Toronto: Penguin Group, 2012), 223. 32 Robert J Blendon, Cathy Schoen, Catherine M Desroches, Robin Osborn, Kimberly L Scoles, and Kinga Zapert, “Inequities in Health Care: A Five-Country Survey,” Health Affairs 21, no. 3 (2002), doi:10.1377/hlthaff.21.3.182. 33 Peter Davies “Hinchingbrooke: The Shape of Things to Come?” British Medical Journal 343, no 7692 (2011), doi: http://dx.doi.org/10.1136/bmj.d7692.

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34 Jeffrey Simpson, Chronic Condition: Why Canada’s Health-Care System Needs to be Dragged into the 21st Century (Toronto: Penguin Group, 2012), 205. 35 Jeffrey Simpson, Chronic Condition: Why Canada’s Health-Care System Needs to be Dragged into the 21st Century (Toronto: Penguin Group, 2012), 150.

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Blendon, Robert J, Cathy Schoen, Catherine M Desroches, Robin Osborn, Kimberly L Scoles, and Kinga Zapert. “Inequities in Health Care: A Five-Country Survey.” Health Affairs 21, no. 3 (2002):182-191. doi:10.1377/hlthaff.21.3.182.

Chodos, Howard and Jeffrey J MacLeod. “Romanow and Kirby on the Public/Private Debate in Healthcare: Demystifying the Debate.” Healthcare Papers 4, no 4 (2004): 10-25. http://www.longwoods.com.ezproxy.library.dal.ca/content/16849.

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Constandriopoulos, Damien, Julia Abelson, Paul Lamarche, and Katia Bohémier. “The Visible Politics of the Privatization Debate in Quebec.” Healthcare Policy 8, no 1 (2012):67-79, http://www.longwoods.com.ezproxy.library.dal.ca/content/23005.

Davies, Peter. “Hinchingbrooke: The Shape of Things to Come?” British Medical Journal 343, no 7692 (2011), doi: http://dx.doi.org/10.1136/bmj.d7692.

Gallagher, James. “Hinchingbrooke Hospital ‘Profit Deal’ Revealed.” BBC News, May 2, 2012, http://www.bbc.co.uk/news/health-17925731.

Hawkes, Nigel. “NHS Hospital is Taken Over by a Private Social Enterprise.” British Medical Journal 343 no. 7341 (2011). doi: http://dx.doi.org/10.1136/bmj.d7341.

Manns, Braden J, David C Mendelssohn, and Kenneth J Taub. “The Economics of End Stage Renal Disease Care in Canada: Incentives and Impact on Delivery of Care.” International Journal of Health Care Finance and Economics 7, no. 2/3 (2007): 149-169, http://www.jstor.org/stable/30221727.

McGowan, Tom. “Does the Private Sector Have a Role in Canadian Healthcare?” Healthcare Papers 4, no. 4 (2004): 45-50, http://www.longwoods.com.ezproxy.library.dal.ca/content/16853.

“Operation in Private Clinic a Good Thing.” CBC News. February 6, 2008. http://www.cbc.ca/news/canada/montreal/story/2008/02/06/qc-rockland-clinic-026.html.

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“Overview – The Health and Social Care Act 2012.” UK Department of Health. April 30 2012. http://www.dh.gov.uk/health/files/2012/06/A1.-Factsheet-Overview240412.pdf.

Simpson, Jeffrey. Chronic Condition: Why Canada’s Health-Care System Needs to be Dragged into the 21st Century. Toronto: Penguin Group, 2012.

Sutherland, Kim, Sheila Leatherman, Susan Law, Jennifer Verma, and Stephen Petersen. “Chartbook: Shining a Light on the Quality of Healthcare in Canada.” Healthcare Papers 12, no 1 (2012): 10-24. http://www.longwoods.com.ezproxy.library.dal.ca/content/22860.

“The Case for Change – The Health and Social Care Act Explained,” UK Department of Health. April 30 2012, http://www.dh.gov.uk/health/files/2012/06/A2.-Factsheet Case-for-change-240412.pdf. “The Franchising of Hinchingbrooke Health Care NHS Trust.” National Audit Office. November 8 2012. http://www.nao.org.uk/publications/1213/hinchingbrooke_health_care.aspx.

Turnbull, Jeffrey and Owen Adams. “The Healthcare Quality Agenda in Canada.” Healthcare Papers 11, no 3 (2011): 24-29, http://www.longwoods.com.ezproxy.library.dal.ca/content/22555.

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