Vol. 8 • Special Issue • 2007 HealthcarePapers New Models for the New Healthcare Strategic Levers for a High-Performing Health System Commentary from Gwyn Bevan, Adalsteinn D. Brown, Reinhard Busse, Anthony J. Culyer, Raisa Deber, Josep Figueras, Richard H. Glazier, Ida Goodreau, Elke Jakubowski, Louise Lemieux-Charles, David Levine, Steven Lewis, Gerry McSorley, Joe Murphy, Richard Prial, Ray Robinson, Jeremy Veillard, A. Paul Williams PM 40069375 www.healthcarepapers.com HealthcarePapers New Models for the New Healthcare • Vol. 8 Special Issue • 2007 IN THIS ISSUE INTRODUCTION 6 Strategic Levers for a High-Performing Health System Louise Lemieux-Charles EQUITY 12 Equity of What in Healthcare? Why the Traditional Answers Don’t Help Policy – and What to Do in the Future Anthony J. Culyer 27 Cost Control, Equity and Efficiency: Can We Have It All? Gwyn Bevan 35 Balancing Equity Issues in Health Systems: Perspectives of Primary Healthcare Richard H. Glazier 46 The Reform of Health and Social Services in Quebec David Levine 55 Balancing Equity Issues in Health Systems: The Example of Vancouver Coastal Health Ida Goodreau STRATEGIC PURCHASING 62 Strategic Purchasing to Improve Health System Performance: Key Issues and International Trends Reinhard Busse, Josep Figueras, Ray Robinson, Elke Jakubowski 77 Strategic Purchasing: The Experience in England Gerry McSorley 93 Strategic Purchasing in Home and Community Care across Canada: Coming to Grips with “What” to Purchase A. Paul Williams 104 Strategic Outsourcing by a Regional Health Authority: The Experience of the Vancouver Island Health Authority Joe Murphy 1 HealthcarePapers Vol. 8 Special Issue ALL THINGS CONSIDERED 114 Thoughts on the Day: Strategic Purchasing and Equity Raisa Deber and Steven Lewis 124 The Next Step on the Road to High Efficiency: Finding Common Ground between Equity and Performance Adalsteinn D. Brown, Jeremy Veillard, Richard Prial About the cover: Photo collage of DaVinci sketches. Illustration by Santiago Ku. 2 HealthcarePapers Volume 8 • Special Issue Editor-in-Chief Peggy Leatt Editorial Advisor Rick Roger Visit our online archive Editorial Director Dianne Foster Kent www.healthcarepapers.com Copy Editors Morgan Holmes, Wayne Herrington Publisher Anton Hart Associate Publisher/Administration Barbara Marshall Vol. 7 No. 4 2007 | Chronic Disease Prevention and Associate Publisher/Media Susan Hale Management Director, Design and Production Yvonne Koo Vol. 7 No. 3 2007 | The Public Health Enterprise Graphic Designer Jonathan Whitehead Vol. 7 No. 2 2006 | Using Networks to Enhance Health Services Delivery HOW TO REACH THE SUBSCRIBE ONLINE Vol. 7 No. 1 2006 | Ontario's Wait Time Strategy EDITORS AND PUBLISHER Go to www.healthcarepapers.com Vol. 6 No. 4 2006 | Pay-4-Performance Telephone: 416-864-9667 and click on “Subscribe now.” Vol. 6 No. 3 2006 | Quality Councils Fax: 416-368-4443 REPRINTS/SINGLE ISSUES Vol. 6 No. 2 2005 | Performance Reports ADDRESSES Single issues are available at Vol. 6 No. 1 2005 | Diagnostic Imaging All mail should go to: Longwoods $40. Includes shipping and Vol. 5 No. 4 2005 | Veterans Health Administration Vol. 5 No. 3 2004 | Safe Healthcare Publishing Corporation, 260 handling. Reprints can be ordered Vol. 5 No. 2 2004 | Mental Health in the Workplace Adelaide Street East, No. 8, in lots of 100 or more. For Vol. 5 No. 1 2004 | Regionalization Toronto, Ontario M5A 1N1, reprint information call Barbara Vol. 4 No. 4 2004 | Public/Private Debate Canada. Marshall at 416-864-9667 or Vol. 4 No. 3 2004 | Post-Romanow Pharmacare For deliveries to our studio: 54 fax 416-368-4443, or e-mail to Vol. 4 No. 2 2003 | Globalized Healthcare Berkeley St., Suite 305, Toronto, [email protected]. Vol. 4 No. 1 2003 | Leadership Development Ontario M5A 2W4, Canada Return undeliverable Canadian Vol. 3 No. 5 2003 | Complementary & Alternative addresses to: Circulation Medicine SUBSCRIPTIONS Department, Longwoods Vol. 3 No. 4 2003 | Post-Romanow Healthcare Individual subscription rates for one Publishing Corporation, 260 Vol. 3 No. 3 2003 | Evidence-Based Practice year are [C] $100 for online only Vol. 3 No. 2 2002 | Health Workforce and [C] $140 for print + online. Adelaide Street East, No. 8, Vol. 3 No. 1 2002 | Drug Policy For individual subscriptions contact Toronto, Ontario M5A 1N1, Vol. 2 No. 4 2002 | Reform Framework Barbara Marshall at telephone 416- Canada Vol. 2 No. 3 2002 | Academic Health Centres 864-9667, ext. 100 or by e-mail at EDITORIAL Vol. 2 No. 2 2001 | Physician Rationing [email protected]. To talk to our editors please contact Vol. 2 No. 1 2001 | Patient Safety Institutional subscription rates are Dianne Foster-Kent at 416-864- Vol. 1 No. 4 2000 | Home Care [C] $420 for online only and [C] 9667, ext. 106 or by e-mail at Vol. 1 No. 3 2000 | Rethinking Medicare Vol. 1 No. 2 2000 | Integrated Healthcare $520 for print + online. [email protected]. Author Vol. 1 No. 1 1999 | Primary Care For institutional subscriptions, guidelines are available online at please contact Rebecca Hart at http://www.longwoods.com/pages. telephone 416-864-9667, php?pageid=18&cat=250 ext. 105 or by e-mail at ADVERTISING HealthcarePapers [email protected]. For advertising rates and inquiries, Subscriptions must be paid in please contact Susan Hale at 416- New Models for the New Healthcare advance. An additional 6% Goods 864-9667, ext. 104 or by e-mail at and Services Tax (GST) is payable [email protected]. on all Canadian transactions. Rates PUBLISHING outside of Canada are in US dollars. To discuss supplements or other Our GST number is R138513668. publishing issues contact Anton Hart at 416-864-9667, ext. 109 or by e-mail at [email protected]. Healthcare Papers is published four times per year by Longwoods Publishing Corp., 260 Adelaide St. East, No. 8, Toronto, ON M5A 1N1, Canada. The views and opinions expressed are those of the individual contributors and do not necessarily represent an official opinion of Healthcare Papers or Longwoods Publishing Corporation. Readers are urged to consult their professional advisers prior to acting on the basis of material in this journal. Healthcare Papers is indexed in the following: Pubmed/Medline, CINAHL, and Ulrich’s. No liability for this journal’s content shall be incurred by Longwoods Publishing Corporation, the editors, the editorial advisory board or any contributors. ISSN No. 1488-917X. Publications Mail Agreement No. 40069375. Printed by Harmony Printing © September 2007 4 INTRODUCTION HealthcarePapers 5 Strategic Levers for a High-Performing Health System Louise Lemieux-Charles, PhD Chair and Professor, Department of Health Policy, Management and Evaluation, University of Toronto Origin of this Collection • Provision or change of funding to health Over the past four years the Ontario Ministry service providers of Health and Long-Term Care (MOHLTC) • Facilitating and negotiating health serv- has been engaged in transforming the prov- ices integration ince’s health system, a process that includes • Issuing integration decisions decentralizing decisions pertaining to the delivery of services. This decentralization is Ontario’s LHINs have embarked on their occurring through the devolution of decision- strategic planning journeys; however, the making to the newly created Local Health extent to which decisions will be decentralized Integration Networks (LHINs). The LHINs’ is still under discussion. mandate is described in the Local Health Acknowledging the need to explore System Integration Act (Government of challenges arising from such a fundamental Ontario 2006) and includes the following key transformation, MOHLTC policy-makers, elements: members of the University of Toronto’s 6 Strategic Levers for a High-Performing Health System Department of Health Policy, Management cal allocation of healthcare resources ought and Evaluation (HPME) and senior-level to be allocated in proportion to the popula- health system decision-makers developed tion’s need in each area; access/utilization of a conference program that would showcase healthcare ought to be equal for all members national and international experiences in of society; and equity and efficiency in health decentralizing decision-making as it pertains and healthcare usually conflict and, when they to equity and strategic purchasing, two areas do, equity trumps efficiency. Culyer argues that that are especially challenging from a policy perspective. The symposium that resulted – Strategic Levers for a High-Performing Health System – was held in Toronto on … showcase national and 1 November 20 and 21, 2006. It afforded a international experiences in wide-ranging opportunity for the airing of many perspectives on these topics, includ- decentralizing decision-making ing the views and experiences of practitioners as it pertains to equity and from various Canadian and international juris- strategic purchasing, two areas dictions who have encountered challenges in providing an equitable approach to healthcare that are especially challenging while seeking efficiencies in care delivery. from a policy perspective. This special issue of Healthcare Papers brings together most of the Strategic Levers symposium proceedings. We believe that the these propositions are impractical because it is concepts, approaches and solutions explored unclear what policy steps follow for those who and analyzed in this collection will serve as wish to embody them. He presents an alterna- valuable references and models for people tive set of principles for equity in health and