The Circle Model An innovative alternative for health care in Canada - Arianne Charlebois February 2013
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Canada 2020 Analytical Commentary: No. 01
The Circle Model
An innovative alternative
for health care in Canada
Arianne Charlebois
February 2013Analytical 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,
Canadians
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
2
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
Ontario’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
Quebec
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.
5
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
6
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.
7
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.
8
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,
Ottawa,
Ontario,
arianne.charlebois@gmail.com
Canada
2020,
210
Dalhousie
Street,
Ottawa,
Ontario,
info@canada2020.ca
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
(Toronto:
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.
9
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,”
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