When big, complex, bureaucratic systems know they have a problem, they try to fix themselves. This results from a mix of motives. There is a natural impulse to improve the system for the benefit of end users. There is an equally natural impulse to avoid the intervention of outsiders in the repair of internal system failures. So, it is with Ontario’s health care system. Good people in the system want to find ways to serve the public better and want to do it themselves. It’s a beast of a system! With a $63.5 billion budget, it consumes 42% of Provincial spending.
The bigger the system, the more room there is for isolated failures to become prevalent, and for ineffectual repair efforts to yield more hope than impact. This problem-tolerant environment persists in part because of a tendency to understate the magnitude of a problem, even a critical problem.
Here’s a case in point: There is a provincial health agency called, “Health Quality Ontario.” It’s dedicated to making “our health system healthier.” Its mandate is pretty clear. It’s the organization within the healthcare system that’s expected to monitor system performance and advocate for improvements.
That’s a huge responsibility, which it gives every appearance of performing with sensitivity and diligence. However, it’s part of the system it’s evaluating, so it would be understandable if it tends to diminish the scale of the problems it identifies. After all, if it magnifies a problem, this may attract unwelcome scrutiny from outside, which systems naturally resist.
Health Quality Ontario has taken on the herculean task of understanding and addressing inequities in Northern and Southern Ontario healthcare services. It’s quite bold in declaring that 800,000 Norther Ontarians suffer a terrible inequity in the quality of care they receive, relative to Southern Ontarians.
But having identified this as an equity issue, it would be reasonable to then measure how terrible this inequity is, in terms that everyone can understand. It is here that the fine motives and brave rhetoric of the agency struggle against the innate resistance of the system to outside scrutiny and the risk of change that comes with it.
Look at the infographic they present in their signature study on the subject. It provides a really useful metric for judging whether or not Northerners are underserved relative to Southerners, and how this inequity translates into real life consequences.
What it says is that the years of life lost to avoidable death in the North East is roughly 45% greater than the provincial average, and about 90% greater in the North West. What this suggests is that our universal healthcare system is significantly worse at preserving life in the northern regions.
But how much worse? It obscures this by comparing the regions to the province as a whole, without isolating the South. Of course, this can be deduced from the data if the casual reader knows a little algebra.
Without doing any math, it’s pretty clear that the South must have a much lower number - a fraction of the provincial average – to offset the high numbers of years lost to avoidable death in the North. And, if the South number is that low, then the disparity between North and South is some obscene multiple of the southern rate.
By obscuring this comparison, the subtle hand of the system can be seen to camouflage its problem. This buys time for it to properly internalize and digest the problem, ruminating until, in its own good time, a solution comes out.
Meanwhile, people are needlessly dying. Not to put too fine a point on it, a clearer sense of the disparity in death rates might change the priority given to this problem and the urgency with which the system addresses it.
Here’s another example drawn from the same report. This chart is intended to show that age-standardized mortality rates have come down over the past 20 years, and if you look closely, the North has improved slightly more than the South.
Yet, once more the report avoids the direct comparison of North to South, choosing instead to use a provincial quotient rather than reveal the true disparity. In this case, using per capita rates, the math is a little less daunting. If in 2012, two of the three regions had rates of 5.7/1,000, and the average for all three was 4.4/1,000, then the third region must have had a rate of 1.8/1,000.
This is a far more dramatic and frankly honest way of comparing the regions. The difference between a southern mortality rate of 1.8 and a northern rate of 5.7, is 3.17. That means that the northern mortality rate is 317% greater in the north than in the south. Rather than a fractional disparity between 4.4 and 5.7, the disparity is actually a multiple. In the way the system’s monitor has stated what is actually a profound, pervasive, life and death problem was presented as a much more tolerable inequity.
Undeniably good people are doing good things to shrink the gap. We all need to acknowledge that. The question in my mind concerns how they are addressing the problem.
When a problem is understated, when a disparity is represented as a fraction rather than a multiple, it is treated with less urgency. Also, when the degree of inequity is obscured or minimized, the system can justify using incremental measures where a complete rethink is required.
Beyond this bystander’s gripe about misleading or obscure representations of data, there is the broader and more profound concern about the defensive instincts of systems, and their tendency to hide or diminish the extent of their problems.
One final note; systems are assemblies of interdependent parts. Incremental thinking about systems can provide short term results, but when profound problems occur, they are rarely solved by mitigating negative effects at the fringes.
Systems can grow and evolve organically, to be sure. But when they’re broken, with life and death consequences, it becomes an urgent design challenge, requiring objectivity and a will to change. This typically requires an external perspective, in addition to all the well meaning and expert people working within the struggling system.