Health care funding in surgical practice and the Canadian health care system
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* Robert M. Stone

In their 2 recent Editors’ Views (*Can J Surg* 2000;43[3]:164–5 and *Can J Surg* 2000;43[4]:244–6) on health care funding and surgical practice and the Canadian health care system, the coeditors are “right on the mark” in their analysis and in using the Journal to stimulate debate within the surgical community about our health care system. However, there is another dimension to the discussion that needs to be addressed: What have we done (are doing) to convince the patient and the Government that what we are doing is right? Although we are doing some things right in this regard, I would argue that our efforts are inadequate.

As members of a Canadian surgical community we must upgrade our peer review system in regard to the attention paid to morbidity and mortality, we must insist on evidence-based decision-making and we must champion health outcomes research in its broadest sense. We must accomplish these objectives in a context that encourages innovation and creativity.

My suggestions for moving in this direction include the following:

1.  **Taking the initiative within our own institutions as well as provincially and nationally to insist on the development of a national database that will give us the tools to do the job.** Recent newspaper editorials have commented that Tim Horton’s and Canadian Tire have better information technology than we do in the health care system. Meaningful outcomes evaluation cannot be achieved without this technology. Such a national database would be expensive but should be regarded in the same way our predecessors regarded the building of the railway or the introduction of medicare itself. Our university departments of surgery need to place high priority on the recruitment of surgeons with a scientific background in health outcomes research. Nonuniversity hospitals require access to this expertise, which may be provided by PhDs with this special kind of training. We need the data and to a large extent we don’t have it.

2.  **Lobbying for changes to the hospital accreditation process.** I have been responsible for a department of surgery in 3 different university-affiliated hospitals for 19 years. Not once in those years have I been asked by an accreditation committee to give an account of my stewardship. In most large general hospitals, surgery accounts for 50% or more of the budget. This is counter-intuitive and gets to Dr. Meakins’ comment about private sector management principles.

3.  **Pointing our discipline away from independent practice toward an interdisciplinary method of providing surgical services.** All of us who provide surgical care are very dependent on fellow professionals to complete our obligations to our patients. Teams, not individual practitioners, look after patients. Surgeons need to lead many of these teams but not all of them.

I would suggest that the Journal have a point–counterpoint page in which some of these ideas might be debated.