Day in Your Life
Aug 01, 2007
BC Business Magazine
image/photo: Paul Joseph
By Gary Mason
Brian Day chatters away as he works a probe through the triangular-shaped hole he has just cut in his patient’s knee. He’s talking about politics, he’s talking about Disney, he’s talking about advances in medicine. At any time, you expect him to ask the surgically masked posse around him if they know of any good recipes for barbecued salmon or vegetarian stir-fry. With a pencil-shaped surgical pick, Day, who becomes president of the Canadian Medical Association (CMA) this month, begins to strip away strands of tendon from the sedated patient’s hamstring. He pulls the tendon out through the half-inch portal he has created below the kneecap. It looks like an off-white ribbon of pasta.
Over the next hour, Day will use the tendon to build a new anterior cruciate ligament, commonly known as an ACL. The patient has torn his ACL badly and has come to the private Cambie Surgery Centre, founded by Day in 1996, to get it fixed.
Brian Day’s prescription for an overhaul of the Canadian public health system stems from his conviction that introducing sound business principles to health delivery would increase efficiency and reduce waiting lists. His specific recommendations include the following:
Perils and profits
Massively reduce the health-care bureaucracy, of which 80 per cent, Day estimates, is expendable.
Water down the power of health-care unions. Day says they have fought against the innovation and change that could improve the system.
Introduce user fees for doctor visits to reduce abuse of the system. Day estimates 50 per cent of visits to physicians are unnecessary.
De-insure many services. Day believes 25 per cent of all services in most sections of the medical services guide could be eliminated. Examples include bunions, varicose veins, breast reduction and nose jobs. Under his plan, the public system could still pay for eliminated treatments with a doctor’s letter saying they were medically necessary.
Voicing the mere notion of an expanded role for private health care in Canada is seen as fighting words by many. Tom Noseworthy, a physician and director of the Centre for Health and Policy Studies at the University of Calgary, says private clinics undermine the medicare system we have. Before long, he believes, people will be taking out private insurance to get a full range of treatment at private clinics and hospitals like Brian Day’s Cambie Surgery Centre. That would eat away at the foundation of medicare itself, he says.
Michael McBane, a physician and national coordinator of the Canadian Health Coalition, argues that Canada’s health-care system is not the inefficient, gas-guzzling beast portrayed by Day. In fact, he says that prior to Canada’s introduction of a single-payer system (where the government pays), health spending in Canada and the U.S. was escalating at the same rate.
“After 30 years of single-payer administration,” says McBane, “Canada now spends almost 50 per cent less than what Americans spend [9.9 per cent of GDP in Canada versus 15.2 per cent in the U.S.] while providing equal or better care.”
Day says Canada is missing the boat when it comes to the opportunities to generate hundreds of millions of dollars in revenue. Waiting lists, he says, are standing in the way of hospitals making buckets of money that would ultimately strengthen the health-care system in Canada.
He says many of the big hospitals around the world, such as the Mayo Clinic in Rochester, Minnesota, generate 25 per cent of their income by treating patients from other countries. Canada treats foreigners on an emergency basis but has to turn down requests from people from around the globe who want to come here for major surgeries.
“We get lots of requests to treat relatives of people here,” says Day. “We have a very large Asian population. That could be a major source of revenue. But we have to turn them down because politically and ethically it would be unacceptable to treat them ahead of Canadians on the wait list.
“Eliminating wait lists would give us access to the $2-trillion American health economy.”
By Day’s estimate, Canada could add $40 billion a year to its health-care coffers by charging foreigners to access our operating rooms and surgeons. It would also help retain many of the surgeons we are currently losing.
“Fifty per cent of our newly trained orthopedic surgeons and 50 per cent of newly trained neurosurgeons are leaving within five years of graduating because there isn’t enough work here,” says Day. “That makes no sense. We train them and then they take their expertise elsewhere.”
Most of Day’s recipe for improving the health-care system doesn’t have anything to do with private clinics. But he believes that one way of reducing waiting lists is to do what Britain is doing: contract out more procedures to private clinics. To his critics, this will eventually lead to the destruction of medicare and give us American-style medicine.
Day is said to be the best in the world at the operation. He has performed thousands of ACL reconstructions over the last 20 years and it shows. There isn’t a bead of sweat on his brow. He talks breezily with his medical team as he bores through bones, blood and saline solution occasionally gushing out from openings in the skin.
A monitor shows Day’s handiwork as he uses a scope to get rid of superfluous tissue around the area where the tendon will be grafted to the bone.
“Hammer, please,” he says.
“I’ll have a nine by 30. Actually I’ll have a 10 by 30, please.”
An hour after scrubbing up, Day is stripping off his mask and hat to visit his next patient, an 87-year-old woman with a bad knee who was going to have to wait a year to get it fixed at a public hospital.
“Imagine that,” he says. “Telling a woman who’s 87 she’s going to have to wait a year. What kind of health-care system is that?”
Certainly not one that Day supports – at least not entirely. As he begins his one-year term as president of the CMA, the controversial Vancouver surgeon will use his new national platform to talk about his vision for Canada’s health-care program. It’s one he believes could be more efficient and deliver better service if it incorporated sound business principles.
Some see Day as the potential saviour of medicare, and many think he’s out to destroy it. So how did this British schoolboy arrive at the pivotal position in which he now finds himself? In many ways it’s an improbable story, replete with heartbreak and tragedy.
Brian Day grew up with the Beatles. Literally.
Day was born in Toxteth, the deprived working-class neighbourhood of Liverpool, England, on January 29, 1947.
His father, Moss, was a pharmacist, or chemist as they are called in Britain. His mother Florence, known to family and friends as Flo, opened a booth at St. John’s market selling nylon stockings and cheap jewellery.
When the couple realized that Flo often made as much in a day as Moss did in an entire month as a pharmacist, Moss quit and joined his wife in her business venture. (Years later he would return to pharmacy and do quite well.) In the early days, the family was quite poor.
Brian Day was a smart kid and after elementary school attended the Liverpool Institute, the city’s best high school for boys. He remembers two rather famous schoolmates who were a few grades ahead of him – Paul McCartney and George Harrison. He also remembers a kid who delivered firewood throughout Toxteth, a chap who would later become known as Ringo Starr. John Lennon lived in a flat in Toxteth in the early 1960s.
“It was an exciting time to be living in that area,” says Day, sitting in his medical-centre office. “There were about 10 or 12 bands that were really good when I was in high school. There were two or three that might have been as good as the Beatles at the time.”
One was Gerry and the Pacemakers. The Merseybeats and the Undertakers were two others from Liverpool that were also big back then. They all performed at the Cavern Club, made famous by the Beatles. In his teenage years, Day was a regular visitor to the musical hotspot and saw the Beatles perform there many times. The band often performed at lunchtime.
“They were terrific,” Day recalls. “McCartney and Harrison certainly had an aura about them, even in high school. They were already starting to become famous even then.”
Toxteth was a tough place to live. If you didn’t learn how to handle yourself at an early age, life could be miserable for a young boy. So Day learned to get pretty good with his dukes.
He was developing into a fine little boxer until he stopped growing at about five feet four inches tall. Along with the sur-vival techniques he learned as a kid, Day was imbued with a competitiveness that courses through his veins to this day.
Day had early dreams of becoming a pharmacist like his father. His father wanted him to be a doctor instead. Day honoured his father’s wish and entered medical school at the age of 17. He was interning a couple of years later and soon had to choose which kind of doctor he was going to be. After an initial interest in pediatrics, he eventually settled on orthopedics.
The University of Manchester, where Day studied, boasted some of the top orthopedic surgeons in the world at the time, including John Charnley, later to become Sir John, one of the pioneers of hip replacement.
Another city that was making a name for itself in the area of orthopedics was Vancouver. Leafing through a magazine one day, Day saw an advertisement for the Canadian city and was immediately drawn to the shots of snow-capped mountains, since he loved to ski. He thought it wouldn’t be a bad place to work for a year. Through connections some of his professors at Manchester had with orthopedic specialists in Vancouver, it was arranged.
Day arrived in the spring of 1973 and would never permanently return to his homeland.
There are many events that shape a person’s life – some profoundly. There have been three such profound events in Brian Day’s life.
When he was a 19-year-old intern at a London hospital, Day was working in the emergency ward. There was a terrible car accident that resulted in the deaths of two 17-year-old twins. It fell to Day to tell the parents.
“I was a 19-year-old kid who was a quasi-doctor,” recalls Day. “I had to tell this couple who were in their late 30s that they’d just lost their children. It was an awful thing to have to do. Medical training desensitizes you a bit. You see terrible things. I had to do terrible things that most 19-year-olds don’t have to do. Having to tell those parents about their kids had a lasting impact on me.”
Day was in Vancouver in 1981 when he received a phone call from his sister, Yasmin, who lives in Washington state. Riots were underway back home in Toxteth. It was bad. More than 140 buildings were destroyed, mostly by fire.
Amid the chaos, Day’s father, Moss, carried on at his pharmacy. On July 13, 1981, while walking home from work, Moss Day was followed by two drug addicts, a father and son. They waited until Moss got inside his house. Flo wasn’t yet home.
Game, set, match By the spring of 1986, Brian Day’s first marriage, which produced two children, was over. Friend Ross Davidson, who was doing some work at UBC, had met a young medical intern at the hospital there who, five years earlier, had won the Canadian women’s tennis championship. Her name was Nina Bland.
As Bland tells the story today, Davidson mentioned to Day that there was a young intern with whom he thought his single friend should play tennis. Day fancied himself as a bit of a player. At first he wasn’t enthused, imagining he was going to be facing someone who would have trouble getting the ball over the net. Eventually he was persuaded.
Day and Bland met at the Jericho Tennis Club. They started warming up. It only took a minute for Day to see the woman had played the game before.
“And he says to me, ‘Maybe we can just rally today. We’ll play another day,’” Bland says over the phone, laughing. “I think he realized he wasn’t quite ready for me. So we ended up playing the next day and I beat him. He told me at the time he was going to keep playing me until he beat me.”
(Twenty-one years later, Day insists he has. If it happened, Bland doesn’t recall it.)
Eight years later they married, had four kids and Bland put her own medical practice on hold to raise them. What surprises Bland most is her husband’s ability to shirk off criticism. “He is very focused,” she says.
“He calmly goes about his business. People like him. That’s why he’s a natural leader. He unites people. He’s a logical, clear thinker. And it helps that he’s open about his agenda.”
The two men burst inside and bludgeoned Day’s father to death, leaving with the one thing they wanted most: keys to the pharmacy. The two men were eventually caught, but “justice” would leave Brian Day feeling cold.
“They got 18 months because their lawyer convinced the judge they were high on drugs at the time,” Day remembers. “That’s when I started to believe in the death penalty. They got manslaughter, and I think they were out in three months or something. I wasn’t in favour of the death penalty until then.”
The third profound event was the death of his mother in 1986. She was 61.
Flo was admitted to hospital near her home on a Friday evening with symptoms the hospital staff thought were consistent with someone experiencing a heart attack. That’s what she was treated for.
“That weekend she bled to death,” Day says. “She had a bleeding ulcer and no one diagnosed her properly. She had a totally preventable problem. And that sort of thing is happening here too. She was a victim of the British national health system at the time.”
Day remains angry and resentful about what happened to his mother. He admits it is one of the things that has compelled him to try to improve the Canadian health system. He doesn’t believe people should be dying in our emergency departments because the system is being mismanaged and doctors are being pulled in a thousand different directions.
All three events have, in their own way, helped inure Day to the sometimes harsh criticism he has faced for his views on health care. After your father has been beaten to death by a couple of thugs, the odd negative quote about you in the newspaper hardly seems worth getting upset about.
By the early 1980s, Brian Day was making a worldwide name for himself fixing knees. He went to Salt Lake City to train with a doctor who was pioneering arthroscopy, a procedure that allows doctors to examine and repair a person’s knees using straw-sized instruments. It would forever change the treatment of knee injuries.
Today Day laughs at the cynicism with which this new procedure was initially greeted. He was reported to the College of Physicians and Surgeons of B.C. by some of his colleagues for “making claims” that this surgery could do miraculous things. He was even portrayed by many in the medical community as a bit of a quack.
It wouldn’t be long, however, before Day would be recognized as one of the top orthopedic surgeons in the world.
Around the same time, the medical system in Canada was undergoing a change that at first was almost imperceptible. Advances in medicine, such as arthroscopic surgery, created huge demand from the public. Consequently, every new medical advance cost the health-care system more. The result is the problem with which the health-care system is still struggling today: waiting lists.
Hospitals have global budgets, a fixed amount of money they get every year from the provincial government. To stay within those budgets, hospitals in the 1980s had to start scaling back the number of surgeries doctors were doing.
“If you have a fixed amount of money, all you could do was ration the supply,” says Day.
At one time, Day had 22 hours of operating-room time a week. When it was reduced to five in the late 1980s, he’d had enough. He convened a meeting of doctors who were equally frustrated with what was happening.
“We basically decided we were like mechanics,” Day explains. “There were lots of broken cars but nowhere to fix them. So we decided, ‘Let’s build our own place to fix them if the hospital isn’t going to let us.’”
Day called a meeting at the Vancouver Lawn Tennis & Badminton Club. In attendance were doctors, surgeons and the president of Vancouver General Hospital. There was a former deputy minister of health. There were accountants and lawyers. One of those in attendance was Ross Davidson, a well-known knee doctor on retainer with the Vancouver Canucks.
Davidson’s brother worked for a group called Southern Cross Healthcare in New Zealand, which ran private hospitals there. The company’s CEO, Peter Smith, would later come to Vancouver and give the group a briefing on how the Kiwis ran their private hospitals.
Day figured a private hospital could make a go of it in Vancouver by treating people who were exempt from the Canada Health Act. That group included people whose treatment was covered by workers’ compensation programs, as well as employees of the RCMP and the military, prison inmates and tourists.
“There was enough [workers’ compensation] business out there alone for us to survive,” recalls Day. “We figured changes to the present system had to be coming anyway because it couldn’t carry on like it was.”
It wouldn’t be cheap. The site of the old Cambie Hospital, a nursing home on Ash Street in Vancouver, was up for sale. At least part of it would need to be demolished, rebuilt and outfitted with the best surgical equipment. Day needed about $5 million to get started. Finding investors wasn’t easy – Day was looking for $100,000 from each – until he convinced a couple of high-profile businessmen to sink their money into the project.
“As a business model it made sense,” says Jack Poole, chair of the board of the Vancouver Olympics Organizing Committee, who was a major developer in town when he signed up to help Day.
“It was highly likely that the return on investment would be acceptable,” Poole comments. “But honestly, the money was the last consideration. It was really a desire to keep our surgeons from heading down to the U.S. I knew we would probably be okay economically, but we weren’t driven by economics to make the investment.”
Eventually Day convinced 22 people to pony up $100,000 each. The remainder was financed through the Royal Bank of Canada. The Cambie Surgery Centre opened in 1996, the first of its kind in Canada.
Kip Woodward, chair of Providence Health Care, an independent service provider to the Vancouver Coastal Health Authority, was also an original investor.
“I met Brian and liked what he had to say,” recalls Woodward. “He was very articulate, with grade-A credentials, and he had a new idea. For decades I had seen the needless complexity and posturing and politics in the public health-care system. Brian had an idea that focused on the patient and delivering the best care possible using a great business model.”
Woodward jumped on board.
When the idea of opening a private hospital first began to germinate in Day’s mind, the entrepreneur-supporting Social Credit Party was in power. The supportive political climate changed in 1991 when former Vancouver mayor Mike Harcourt led the New Democratic Party to electoral victory. Day fretted the NDP might quash his plan. “So we met with some senior members of the party, who shall remain nameless until they are a bit older,” Day says, smiling. “Basically we got their assurances that the party wouldn’t endorse what we were doing, but nor would it shut us down.”
According to Day, it wasn’t long before senior members of the NDP and the labour movement were walking through the doors of the private hospital to get treated themselves.
In the fall of 2005, Day opened an envelope from the CMA and found a notice inside. It was a call for nominations for president, a job of one year’s duration that is rotated around the country. As it turned out, 2007 was British Columbia’s turn to elect someone for the position.
“I’d been flogging away at trying to make the system better for so long that I thought, why not go for it?” Day remembers of his decision to put his name up for consideration. “To me it wasn’t about having more privatized medicine. It was about things like the over-inflated bureaucracy in the current system.”
Day often tells the story of the day Lorraine Varner, executive director at the Cambie Surgery Centre, sat down with the Coastal Health Authority to negotiate a contract. She had full authority to ink a deal on the spot. Across from her sat 21 people representing Coastal Health, none of whom had the same authority.
“I really believed the system can be made a lot better than it is,” Day says. “It’s inefficient. It’s run badly. It’s what you expect from a government which, as the Supreme Court of Canada says, has a de facto monopoly over health care in this country.”
When Day decided to go for the CMA’s top job, he was pitted against five other B.C. doctors, all of whom had previously been president of the B.C. Medical Association. Day had never even attended a single CMA convention. Still, he thought he could win.
“I represented change,” he says now. “The other five were kind of lumped together in a way. I stood out because I had a distinct position on issues and I didn’t represent the status quo in any way. And I knew doctors were as frustrated as I was with the way things are going right now.”
A couple of Day’s opponents for the position had been friends of his for 30 years. They had even been at the 60th-birthday bash Day’s wife threw for him this year. Jack Burak, who was defeated by Day in the B.C. balloting and mounted an unsuccessful challenge to his nomination from the floor of the August 2006 CMA annual meeting in Charlottetown, PEI, worked just down the street from him.
But Day refuses to hold a grudge against Burak or any of the challengers who attempted to cast him as a private-medicine bogeyman.
“What’s the point?” asks Day. “They’re all good people.”
There is a lot Day would love to accomplish in the short 12 months during which he has his hands on the levers of power at the CMA. But he’s also realistic. A year isn’t long. It’s barely enough time to initiate a debate on some of his more contentious ideas.
Day figures his early years as a boxer have prepared him for what lies ahead. “It’s great training for politics,” he says. “In boxing you compete, fight, whatever, and if you lose, you put your arm around the other guy and walk off as friends. You don’t always win. But it doesn’t mean you don’t try like hell.”
How exactly would the government reduce those waiting lists? By contracting out more operations to private clinics, which can do them cheaper and faster. It’s a plan that would admittedly put money into the pockets of people such as Day himself.
Having had plenty of time to think about the problems afflicting the Canadian health system, Day has formulated a prescription for its cure. At the core of his envisioned solution is his belief that Canada’s health-care system is like a corporate behemoth in big trouble, and the solution is to “approach it more like a business.”
The system has, in Day’s view, grown fat and lazy and, because it enjoys virtual-monopoly status in this country, has long forgotten about the needs of the patient.
He believes Canada should be looking to Great Britain for some answers. The National Health Service, which administers health care in the U.K., recently introduced reforms that bring a business focus to the relationship between hospital and patient: patients are viewed as consumers and the hospital as a company trying to land their business.
If a patient in London needs a knee replacement, she would see her doctor, who would refer her to a specialist. After determining that surgery is required, the specialist would sit down with the patient and talk about where it might be performed. The patient is offered several choices.
Every hospital presented to the patient has a scorecard of facts and figures. For instance, the patient can compare hospitals according to their records for particular treatments or to factors such as cleanliness, rates of hospital-acquired infections, fee schedule, waiting times and even available parking.
Each hospital’s funding increases in proportion to the number of patients it treats. This is known in health care as “activity-based funding,” and Day wants to bring it to Canada. In short, it works because the money follows the patient. When a patient shows up at Hospital A for a knee replacement, his “business” represents a source of revenue, which comes from the government, not the patient.
In Canada, on the other hand, each hospital is given a fixed budget at the start of the year, so each patient represents a liability, drawing down on the available funds. The British system forces hospitals to compete for business, says Day. “It brings market forces to bear on the business of medicare.”
In Canada hospital funding has nothing to do with efficiency or patient satisfaction. Royal Columbian Hospital in New Westminster, for instance, annually receives a fixed amount of money from the provincial government that is based, among other things, on the number of medical procedures performed there the previous year (a number that is determined by the previous year’s funding, rather than by efficiency or patient choice). In other words, the hospital receives the funding regardless of how it performs from a customer-satisfaction standpoint. “So where is the incentive to deliver better service to the patient?” Day asks.
Is the British system perfect? No. One British government survey found that half the patients seeing doctors about medical procedures were not being offered a choice of hospitals. (They are supposed to get at least four.) Another raised questions about the idea of setting up competition between hospitals. The report suggested the policy “may have adverse or, at least, unpredictable consequences.” It warned hospitals may be tempted to avoid treating patients with more complicated needs as a way of improving performance ratings, which in turn are needed to attract patients and bring in revenue.
Day says the new consumer-oriented focus is only a couple of years old and needs more time to work out kinks before it can truly be judged.
Not everyone’s convinced. Danielle Martin, who chairs the board of Canadian Doctors for Medicare, says what’s happening in Britain is a travesty. Private hospitals, she insists, are taking the healthiest patients, leaving the public system with the most complex cases. She predicts more physicians and nurses will move to the private sector as a result.
“We should focus on the many initiatives now underway [in Canada] to streamline care, reduce waiting lists and promote innovation,” Martin says.
But waiting lists in Canada aren’t shrinking, points out Day. In Britain there is empirical evidence that efficiencies brought in by hospitals have had a profound impact on waiting lists, nearly cutting them in half. The goal is to eliminate them entirely by 2008.
Waiting lists are more than a pet peeve of Day’s. He says they are costing the system billions of dollars because patients’ conditions usually continue to deteriorate while they are waiting for surgery. That might mean patients will need more physiotherapy, which costs money, or they may develop other complications that require other forms of medical intervention. “It just makes bad business sense to have waiting lists because it actually drives up costs over time,” says Day. “It’s been proven.”
To clear up the backlog of people on waiting lists in Canada, Day says, provinces need to bite the bullet and spend the money necessary to get people healthy as soon as possible. “It will save the government money over the long run.”