Integration across continents: what can the NHS learn from Canada?

We’re all familiar with the challenges facing the NHS: the tightening budgets, the ageing population, the rising tide of chronic disease and how we organise services to provide a coordinated and seamless experience for complex patients.  What is perhaps comforting is that we are not alone.

At a recent conference, the Canadian Health Services Research Foundation (CHSRF) brought together 150 chief executives of various health providers from across the country to discuss these exact issues.  They were kind enough to invite me too, and now that I have recovered from the jetlag, I’m able to reflect on what a fascinating experience it was.

The challenges are the same in Canada but the context is different.  For a start, Canada has a federal system of government so health systems and policy are determined at provincial level.

Secondly, health provision in Canada must meet the needs both of large urban populations (with all their associated challenges) and of dispersed rural populations.  And when I say ‘dispersed’ and ‘rural’, I’m not talking Herefordshire – I’m talking 40,000 people, speaking eleven official languages, scattered across an area around the size of France and Spain combined.

It’s easy to dismiss other systems as ‘too different’ to learn from. I disagree. The fact that the Canadians are grappling with the same challenges, albeit with some greater contextual extremes, offers us a significant opportunity to learn.

I’m not saying they have it cracked – far from it – but necessity has required them to come up with some interesting innovations.

In the very remote areas, any sort of acute episode involves a plane ride to hospital.  That works out pretty expensive, so there is pressure to keep people well and provide proactive care.

The shortage of doctors means that, in remote areas, nurse practitioners must run clinics and provide the majority of primary care.  As a result, nurse practitioners have expanded their skills and stretched the scope of their role, only referring to a GP when absolutely necessary.

The use of teleconferences with doctors has also become part of everyday business in many areas where virtual diagnosis and treatment can be offered.

Of course, these approaches are not unfamiliar to us in the NHS but the Canadian experience of their implementation, and emerging evaluation, is definitely one to watch.

From discussions at the chief executives’ forum, what made the biggest impression on me was that the Canadians think we have it relatively easy in the NHS.

In Canada, decision-making in health is almost completely devolved to the provinces, which are largely free to pick and choose strategies developed by the federal government.  This has led to a patchwork of different systems with different levels of access to primary care.  Even within provinces, there is huge variation in access to primary care.

Many of the Canadians I spoke to think that in our ‘single system’, it should be easy to implement integrated care. 

Of course, that underestimates the challenges of coordinating care across primary, secondary and social care sectors but it is a helpful reminder that, in recognising the value of localism, we must be aware of the challenges of maintaining equitable access across a devolved system.

The trip brought home to me that in this period of significant change in the NHS, it is more important than ever that we recognise the value of learning from other countries – their triumphs and mistakes offer us insight into our own system, its shortcomings and advantages.

And it’s not just a one-way street – I saw many examples of NHS innovations being implemented in the Canadian context, from a virtual ward to a version of the Productive Ward. They are also testing out ‘family health groups’ which are multi-disciplinary teams based around GP practices.

I for one will be keeping a keen eye on their development.