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Brian Day: CMA’s next president supports private health care
The Lancet Vol 368
www.thelancet.com
October 14, 2006
By Michael McCarthy
 Delegates
to the Canadian Medical Association’s (CMA)
General Council stunned many in Canada’s medical
establishment in August when it elected Brian Day to
be the Association’s next president. A Vancouver-based
orthopaedic surgeon, Day is Canada’s leading proponent
of expanding the role of private health care in the Canadian
public health-care system. Day’s detractors call him “Dr
Profit” and claim he wants to set up a two-tiered US-style
system that will favour the rich over the poor. 59-year-old
Day told The Lancet that his election to lead the CMA shows
that Canadian doctors are ready to give private health
care a bigger role in the Canadian system. “The message
is that they’re not afraid of new ideas.” Day will serve as
the CMA’s president-elect over the next year and assume
the presidency in the summer of 2007.
A business ethos was something Day learned during his
childhood in Liverpool, UK. His father, a pharmacist, could
not find work during the hard times after World War II. “He
and my mum used to work in St John’s Market selling nylon
stockings and cheap jewellery.” Eventually, his father was
able to open his own chemist’s shop. Day went on to study
medicine at the University of Manchester, Manchester,
and completed his internship and residency at the United
Manchester Hospitals and Hammersmith Hospital in London.
In 1973, he came to Vancouver to train in orthopaedic
surgery at the University of British Columbia. He went on to
specialise in trauma care and sports injuries and became a
leader in the then new specialty of arthroscopic surgery.
In Day’s view, the Canadian health-care system worked
well in the 1970s and early 1980s when the cost of care was
still fairly low. But from the middle of the 1980s, expensive
new technologies, complex operative techniques, and costly
drugs began to drive up expenditure. To slow the rise, Day
says, Canada’s public health system began to ration care by
restricting access to services, and the waiting lists for services
began to grow. “My operating-room [OR] time was whittled
down from 22 hours per week to 5 hours a week”, says Day.
“I had 450 patients waiting to get into the hospital, and yet
I had only 5 hours of OR time.”
Such restrictions accelerated Canada’s brain drain, Day
contends. At the time, he was chair of the Residency
Academic Program of the Department of Orthopaedics at
the University of British Columbia. “Over a 6-year period, of
the 16 residents we graduated only five were left in Canada”,
Day says. “They didn’t want to leave, but we couldn’t give
them any OR time.” Today, the average time between
referral by a patient’s family doctor to treatment for an
elective orthopaedic procedure is 40.3 weeks, according to
an annual survey of waiting times in Canada by the Fraser
Institute, a conservative think tank based in Vancouver.
To prevent the development of a two-tiered healthcare
system, the laws governing Canadian health care ban
private insurance coverage of core health services. But there
are exemptions, including worker compensation patients,
military personnel and the Royal Canadian Mounted Police,
and members of the First Nations. So Day, together with
22 other physicians, decided to set up a private health
centre to deliver surgical services for these patients. “We
felt we either had to do something about this or we were
going to have to leave”, Day says.
The for-profit facility, called the Cambie Surgery Centre,
was vehemently denounced as an attack on the Canadian
health system, but the clinic did well. Most of the business
came from cases of injury at work. Day says the left-leaning
provincial government in power at the time tolerated the
new centre because the clinic was saving the government
millions of dollars in work-loss compensation payments
by getting patients on waiting lists back to work quickly.
The centre now treats about 5000 patients a year and has
contracts to treat publicly funded patients on government
waiting lists. Day says the centre thrives because it is run
in a businesslike way with management overhead costs
far lower than the public system. Managers of the public
system have no incentives to innovate because they have a
monopoly and patients have no choice, Day asserts.
Despite his enthusiasm for private health care, Day says he
does not favour privatisation of Canada’s public system nor
does he want to replace it with a US-style system. “Even the
Americans don’t want the American system”, he says. “Why
would we adopt it?” Instead, he suggests, Canada should
consider adopting elements of European health systems,
such as those of France, Germany, and Switzerland, that
provide universal health care through a mix of public and
private programmes. Those countries provide a better service,
without long waiting lists, at comparable cost, he says. Day
hopes that by taking the best from those systems Canada
“can design the best health-care system in the world”.
Day thinks health reform in Canada is inevitable. Last
year’s decision by Quebec’s Supreme Court to strike down
the province’s ban on private health insurance was “pivotal”,
he says. The Court ruled that the ban was unconstitutional
because “widespread” delays in the public system were
denying many patients access to care. Day now believes it is
“pretty well accepted across the country” that “the status quo
is not acceptable”. Having won the support of members of
the CMA, Day seems confident that “the majority of doctors
think as I do: that there is a role for the private sector.”
The Lancet is the world's leading independent general medical journal. The journal's coverage is international in
focus and extends to all aspects of human health.
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