Why $8.5 Billion Won't Fix Saskatchewan's Healthcare System but a Little Imagination Might with Steven Lewis.

In this episode, I sit down with Steven Lewis, a veteran health policy consultant and former CEO of Saskatchewan’s Health Services Utilization and Research Commission (HSURC). With decades of experience at the intersection of policy, research, and system reform, Steven offers a "voice of truth" that cuts through the bureaucratic clutter.  

We dive deep into a critique of the broader Canadian "sick care" strategy. Steven explains why doubling down on hospital beds and a "scarcity narrative" is a failure of imagination, and he points us toward international models—like Scotland and Denmark—that prioritize health creation over sick care delivery. 

It's a timely conversation as Saskatchewan announced an $8.5 Billion investment in healthcare just following our discussion.  Will that finally solve our problems? 

Steven doesn't think so.  

Resource Links: 

Saskatchewan 2026-27 Health Budget

UHN Dunn's House

The Regina Hospital Physician Culture Report

Scotland’s Population Health Framework

Choosing Wisely 

Transcript

SPEAKER_03 0:12

Hey everyone, my guest today is Stephen Lewis, a veteran health policy and research consultant based in Vancouver. But before moving to the West Coast, Steven was a strong respected voice in Saskatchewan's healthcare system as former CEO of the Health Services Utilization and Research Commission and a passport member of the Health Quality Council. Steven doesn't shy away from challenging the status quo. His arguments aren't just instincts. They're grounded in decades of research and policy analysis. His insights are essential for anyone working in healthcare today. This is a long episode. We chatted for over two hours and I cut as much as I could. But Steven is endlessly engaging and the conversation deserves the time. I listen multiple times to the episode and I've always learned something new with each one. Enjoy my conversation with Steven. Hi Steven.

SPEAKER_00 1:03

Good morning. How are you?

SPEAKER_03 1:04

Good. How are you?

SPEAKER_00 1:06

I'm good.

SPEAKER_03 1:06

Good. How are things in Vancouver?

SPEAKER_00 1:09

Things are good in Vancouver.

SPEAKER_03 1:11

Yeah. Do you know Miss Saskatoon ever?

SPEAKER_01 1:14

Well, I miss my friends.

SPEAKER_03 1:16

Yeah.

SPEAKER_01 1:17

Saskatoon, but no. I mean, this is kind of paradise. I mean, it's just undignified to complain, but we had the easiest winter ever, but now it's kind of what people think of as Vancouver winter.

SPEAKER_03 1:31

Yeah, gray.

SPEAKER_01 1:32

Rainy, gray, a bit windy. Like it feels colder now than it did in January.

SPEAKER_03 1:38

Oh, really? Oh.

SPEAKER_01 1:39

But that means it's oh my god, it's like four or six. So, you know, whenever whenever people hear talk about winter, I just say, look, you're just a language doesn't exist. But we have had a big uh, you know, conceptual breakthrough that we have joined Saskatchewan in not changing our clocks.

SPEAKER_03 1:58

Oh, I heard that. Like, are you guys for sure doing that?

SPEAKER_01 2:01

Well, it's yes, and uh so we are never changing again, but now there's a big debate about why did we pick uh daylight time instead of standard time?

SPEAKER_03 2:11

Oh my god.

SPEAKER_01 2:12

Well, you can't win, right? I mean, look, the whole thing is ridiculous, and you you realize we're just superimposing a clock on something that doesn't change.

SPEAKER_03 2:23

But you know, we work in health system improvement, so we understand that.

SPEAKER_01 2:28

Yeah, at least they made a decision.

unknown 2:30

That's right. Yeah.

SPEAKER_03 2:32

So I was trying to think about how I first came to know you, and I know it was when I started at HQC, but to me, it feels like you just appeared out of the ether. Like I just in my head, you've always been a consultant. But then I was Googling you and realized that you used to be the CEO of HCRC, which I forgot HCRC even existed. So can you remind me what that organization was?

SPEAKER_01 2:53

Yeah, well, I started HCRC. I mean, it was I was the first. HCRC was the health services utilization and research commission, and it was essentially the forerunner of the HQC. Um, and so it was, I'll give you the short story. So, you know, Divine plundered the province. The austerity was huge, the health system was stripped. And when Romano won in '91, uh, they said, we need we need something to get a handle on what's going on in the healthcare system, some evaluation analysis, whatever. So um we said, look, we need to do this. Do you want to set this up? We it was it was quite, and we did stuff, you know, we did uh we did the naive version of of uh KT. You know, we produced a bunch of clinical practice guidelines. We did a big analysis of uh what happened when we closed the 52 hospitals. I uh I did it for I guess seven years as the CEO. And I I knew I knew as we were going along, I said, look, this isn't this is not working. We need to do something different. And I just figured, well, this is the best job I'll ever have. Uh it was fantastic, but I said, well, seven years is enough for me. So I so I said, I'm done. And then they morphed it into which was a good idea, um, the quality council.

SPEAKER_03 4:26

Right.

SPEAKER_01 4:27

Etc. And I was on the I was on the board of the quality council.

SPEAKER_03 4:30

Yes, that's where I first met you, yes.

SPEAKER_01 4:32

Yeah. But after, I mean, after 99, I guess, when I left HCRC, yeah, I hung out my shingle, and that was the that's the rest is history.

SPEAKER_03 4:40

And so what kind of work are you doing now?

SPEAKER_01 4:43

Well, practically none. I mean, I'm 74, volunteer work, but I do have a gig now. I have a gig at UBC, Center for Health Services and Policy Research. So that's that's my gig. And then I'm on uh I'm on the board of a community health center here. I'm the treasurer. That's an opener.

SPEAKER_02 5:02

I bet.

SPEAKER_01 5:02

Big time. And you know, I will, I will, you know, I I still give talks and webinars and stuff. Um, and we're starting up our Longwoods podcasts. Well, we've already done two, but we're not gonna release them until we have five. Um, and that's it. I don't want, I don't want to do paid work, honestly. You know, it would be unseemly for me to do a bunch of work, like it's not how I want to spend my night.

SPEAKER_03 5:28

Well, and also I feel like there's a bit of freedom in not being tied to an organization or not feeling like you have to represent uh an organization or toe the line or whatever, like a little bit more freedom and flexibility of things that you want to say and things that you want to do.

SPEAKER_01 5:43

Yeah, I mean, that's been that's been my good fortune um you know, forever, pretty much, that I've managed not to have to filter much and still survived. So, you know, that's that's good luck.

SPEAKER_03 5:59

Well, that's why I wanted to speak to you because I do appreciate your candidness and you've always been a voice of truth and cutting through the crap. And I remember when we did quality as a business strategy, like often you would stand up and just say what needed to be said. And I um I did a critique of the Saskatchewan Health Action Plan last week, just a short little podcast. But I thought it would be more fun to actually talk to somebody about it and go through it. And I just thought, well, there's no better person to talk about health policy and health strategy and plans than than Stephen. So I wanted to get any your assessment on the current state, not even just Saskatchewan, like just healthcare in Canada in general, like why governments are sort of doubling down on this sick care strategy. Then I thought we could talk a little bit about like what are we seeing in other jurisdictions that are doing things that are like really revolutionary and really changing. We talked about UK a little bit, we talked about Scotland, Denmark. I talked about on my podcast, like what are they doing? And then what are the policy levers? What are the things we need to do to help us get there? So let's talk about what your initial thoughts were about the plan that was released last week.

SPEAKER_01 7:09

I think, I think uh to give them some credit, the government's getting a little bit better at looking like it's planning and thinking about things. And I and I I think they genuinely do. Uh, there's nothing objectionable in the plan, but it's not really a plan. It restates aspirations. Uh, as again, I I would give them modestly high marks for committing to some actual quantitative targets. But this isn't a sea change in in any aspect. And there's no, there's really no how to it, right? Because the what is always easy. If you look at if you looked at every health plan in the country or every report from the last 30 or 40 years, there are little nuances of difference, but basically they all say the same thing. Everyone talks about primary care in roughly the same way. Everyone wishes they didn't have hallway medicine. Um, and uh but but they also uh all lack a few things. And one is some critical scrutiny of things like efficiency, low-value care, and they don't actually commit uh to outcomes. It's all process and it's all a scarcity narrative. We need more of this, we need more of this, and more of this. For example, we need more doctors, we need more nurses, and yet there's abundant literature that we have a very inefficient division of labor. We keep spending money on very expensive labor for things that could be done by less expensive labor. Uh and then we we do things that the ostensible beneficiaries of the care want a different form of care. So seniors care. There's lots of commitments across the country for we we need BC just said the the seniors advocate cites it approvingly, which is a bit odd. BC needs 16,000 more long-term care beds by such and such a year. Well, as we know, if you ask seniors, uh whom I am one, is that the future that you envision? Well, the answer is no. It doesn't mean we don't need long-term residential care beds, but basically, the only people who should be in long-term residential care beds are very physically ill people who are also severe cognitive impairment.

SPEAKER_02 9:51

Yeah.

SPEAKER_01 9:52

You should be able to look after everybody else in some other arrangement, either enhanced assisted living, good home care, whatever. And it and even things like as in Denmark, do some urban design thing, at least in cities, about environments where people can stay integrated in the community. But we're still doubling down on the old ways of doing things. And when you think about just those decisions, I mean, now incredibly a long-term residential care bed is close to a million dollars. You know, that's what it used to be.

SPEAKER_03 10:30

Like to build it?

SPEAKER_01 10:32

Yes, and hospital beds. When you see new urban hospitals, it's approaching five million dollars a bed.

SPEAKER_02 10:39

Yeah.

SPEAKER_01 10:40

Like the capital investment is enormous, right? So these are these are opportunity costs where we we just seem to be hostage to path dependency. We just keep doing more of or fine-tuning um what we used to do. So back to the Saskatchewan plan. Look, if if they accomplished everything they said they would, you know, well, how many times are we going to have the definitive full frontal assault on wait times? But then look what we do with wait times. I will look at the wait time data quite regularly in Saskatchewan because that is the one publicly available data set that's really interesting.

SPEAKER_03 11:22

Yeah.

SPEAKER_01 11:22

Because you can see the distribution of wait times. And you say, well, what is going on here? That 15% of people for non-emergency surgery in Saskatoon and Regina for, let's say, orthopedics, um, will be done in under three weeks. And yet 15% wait over a year. Like the the injustice of this and the failure to manage wait times. You know, there's no wait time management system. There's a system that chronicles wait times. And then, of course, they the the graphs end at a year, but there are people who wait way more than longer. And of course, that's what drives public narrative, right? They see people waiting 18 months, a few people, but not trivial numbers of people, for at least some procedures, and they say, Well, this system is failing. So when you and you look at all of it together, you say, Well, um, do systems incrementally get better? Well, in some areas they do, and sometimes we are successful with whack-a-mole and fix a bit of a problem here. But uh I think the short summary is there's a lack of imagination and there's a lack of mobilizing the people who work in the system to do something fundamentally different. You know, the irony is while a whole lot of people on the supply side make a very nice living off the healthcare system, you have a miserable workforce in a system that looks increasingly inaccessible. And when the system is inaccessible, people don't even have time for a conversation about quality. They just want to get in the door first. So it's it's a perfect storm that has arisen by this these accretions. I mean, when you think, how did it come to be that six and a half or seven million people don't have a regular source of primary care? It doesn't happen overnight. So this has been going on for a couple of decades.

SPEAKER_03 13:34

Yes.

SPEAKER_01 13:35

And yet it's not considered a crisis. You know, people talk about it and wring their hands, but they don't really. And nobody's marching in the streets, and no government is is really held to account for it. And we keep saying, well, the solution to that is to build new medical schools, which is just mathematically absurd. You cannot train your way out of a primary care access shortage problem if you think it's going to be family doctors doing it in the same way they've already done it. Right. They're working less than they used to. They don't want to work full-time in full service uh primary care. And you there are more retiring than three new medical schools are going to produce across the country. So that the system does something that on the surface a grade six kid could figure out isn't going to work out, is simply baffling.

SPEAKER_03 14:32

Agreed. And I think today's budget day in Saskatchewan. I think in the plan it talks about billions invested in beds, long-term care facilities, urgent care centers. Like I just think of like what could those billions do to help us stay healthy, to keep us from becoming patients. I just had this conversation with a consultant in the UK. He talks about failure demand. And he talks about how so much of our system, like a failure, is a patient being admitted to hospital. That's failure of our primary care systems, our prevention systems, or whatever to deal with it before they get to the point where they have to go into hospital.

SPEAKER_01 15:08

Well, so sure. But but let's I mean, I think I think we have to recognize that we don't live in a rational, utilitarian, marginal utility calculating world. We're all we're all a mass of cognitive biases, right? That's what the behavioral economists have shown us. We have we're very poor at risk assessment and we discount future benefits a lot. They know the same stuff we do. You know, they're not stupid about this stuff. There's lots of people in the health ministry and elsewhere who know that if we succeeded at secondary prevention in particular, let alone primary prevention, you could reduce demand on the system at some future point. But people expect service now. Like you can't reallocate a bunch of money from the sickness care system and survive politically. You can't reduce access to the things because what people don't fear the lack of community investment and home care like they fear, oh my God, I didn't get a mammogram on time. Or uh, if I'm in the hospital, I'll be sitting in a lying on a stretcher for three days in the hallway. We're all motivated by fear and hope. The hope may be misguided that the big glitzy healthcare system is going to fix this up. But when you look at middle class people, their social determinants are just fine. So, what do they need from the healthcare system? Well, unless they're unlucky genetically, and it's not that they're all healthy, but they're predictably healthier than marginalized people, they're going to need the high end of health care. So, of course, that's where the investment is. That's what they need. And if they lose confidence in the government because they said, Well, I have to wait for cancer treatment when I could die, and you're spending this money uh in the community or giving these NGOs money to do things or safe injection sites that will save lives. I'm not up for that. So we have to, we have to, you know, we've seen the enemy, and it is us in some ways. The politically powerful constituencies in this country are heavily invested in the sickness care system. And the proof of that is look how the voluntary dollars flow. Yes, some people give money to food banks and community agencies, but a lot more goes to cancer, heart, children's hospitals. Billionaires tend to give their money. They give their money to a new hospital wing or a cancer research center. And again, I'm not saying these are bad things, but at the margins, these are already very well-funded areas from public funding. And I guarantee you that instead of giving $100 million to build another wing at Princess Margaret Hospital, if you gave $100 million to an outreach program that did risk assessment on the frail elderly in the community and then put services in place so those people could live a high quality life in the community for as long as possible, you would get more returns. But just because you could do that doesn't mean that it's going to happen. Because again, uh we are in a very short-term instant gratification world. And we're also in a very technologized world. You know, we've always been enthralled by the Loma Linda hospital double heart-lung transplant on a neonatal person. Then here's a successful program that kept 50, 85-year-olds out of a nursing home for an extra 18 months because they got a place to meet and socialize. And someone was looking after a bit of food security, and there was a volunteer network around them, and people looked in on them, and they had an OT assessment so that they managed to fall proof their house a little bit better by spending a thousand bucks on the kitchen. You know, that's not glitzy, but that makes a big difference. So we have we have to learn from this and say, why is the public not actively campaigning for a system that would actually produce more? And as you asked at the beginning, why is Canada seemingly even less imaginative than some other countries? And that's a very good question. And my short answer to that is because Medicare was such a brutal political fight that began with a civil war in Saskatchewan, it has become this kind of litmus test for our sense of self. And we think, well, we have Medicare, even though the core of Medicare now is far too narrow, it violates the principle of comprehensiveness every day, it's very hard to change the architecture because we get so tribal about things. The other difficulty is that when it eats up 40% of provincial budgets, you can see why provincial governments really don't want to talk about expanding the scope of Medicare without a lot of federal money. And they will do the minimum. Like nothing in the Canada Health Act prevents you from publicly insuring drugs, physio, OT, mental health, but because it's not required, most won't do it because they'll say, look, we have other places we need to spend money. And there are limits to this. And then when you see the middle class starting to lose such faith in primary care access that ordinary people will spend $5,000 a year to sign up for a primary care practice as a membership fee under the ruse that this isn't violating the Canada Health Act, because they they no longer believe they can get regular access to care. Well, if the middle class starts to desert primary care in larger numbers, well then the system as a public system is genuinely at risk of collapse.

SPEAKER_02 21:45

Yeah.

SPEAKER_01 21:46

That is that's not even the canary in the mineshaft anymore. This is happening under our noses.

SPEAKER_03 21:53

Do you feel like this is an intentional strategy by governments? To move the system towards more privatized it's not it's not uniform.

SPEAKER_01 22:06

No. I mean, I think you could argue that it may be intentional in Alberta. I can't tell if the Alberta government's approach to this is just incompetent and delusional, that it believes its own propaganda that if you allow doctors to practice in both the public and the private system, there's going to be a win-win because the evidence is so contradictory and so on. Or whether they are essentially doing a Republican communication strategy. You make stuff up, you keep promoting it, and people start to believe it. You just keep pushing it. So I don't know. But I don't think, I don't think generally in in Canada, governments actively want to undermine Medicare. I don't. I think they're struggling, and I think they have some learned helplessness on the policy side about how to fix it. I mean, they're all pretty terrified of the medical unions, and they keep getting out foxed in negotiations. And because when you have uh a public service where, you know, it used to be you had a lot of expertise that stayed in place. You had corporate memory in various departments. I mean, when I was a kid, my first job was in Saskatchewan Health, and uh there were some legendary public servants who had 20 and 30 years of experience. Well, now the the theory is you just move senior executives around and you can learn the file and be a deputy for a few years and then move on. Well, I don't think it works that way. And I think on the other side, whether it's the nursing unions or the medical unions or other, they have a lot of corporate memory and strategy. So they out fox governments all the time and manage to extract more money. And the other thing governments uh uh have never bit the bullet on is this arm's length relationship between medicine and the system. It's always a contractual agreement, separate parallel, and they're never fully in, right?

SPEAKER_02 24:15

Yeah.

SPEAKER_01 24:16

When they regionalized, primary care, community care was never part of regionalization. So you leave the foundation of the system as this basically autonomous cottage industry, where a whole bunch of practitioners decide how many patients they're gonna have, how they're gonna practice. Some may negotiate something other uh then fee for service, but they can stay on fee for service. And there's no real monitoring of how's the system working out? What's the quality of care? Well, again, it doesn't take a genius to conclude that all these literally thousands of autonomous actors making their own decisions, this isn't going to look like a system. That would be a mathematical miracle if it actually met all of the community's needs and if it actually standardized care around some evidence-based pathways, and that there was, you know, good resource stewardship and so on. So as the old adage goes, the system is designed to fail in exactly the ways in which it fails. So then the then the challenge is how do you undesign it? Well, you have to fight some battles. But you there's no point in fighting a battle that you can't win. And a lot of the winning is in who owns the narrative. Like right now, the public has much more faith on the provider side than it does in the policymakers and in their governments, the governments that they choose and elect. So health ministries know where the skeletons are, they know where the waste is in the system, they know where the unfairness is in the system, but they never tell anybody. Like they don't have a narrative that says, look, we're trying to use your tax dollars wisely, and we see a whole bunch of unfairness in the system. So we need to manage this, and we need real discipline in how this system does its work. And we need to do what New South Wales does, which is we have an organization that explicitly looks at low-value care and how to get it out of the system. Where in a Canadian health plan have you ever seen reference to low-value care and in implementing choosing wisely at scale, all of these things where we know there are dozens and dozens and dozens of overused procedures and tests that deliver no added value for patients, for clients, for citizens, and yet they're lucrative. Yeah. So when anyone says we can we can we can fix the system if we only can add another 5% and only have a little more of this, it's the same as building another lane on a freeway. It just gets you more traffic. So, my view, which is heretical, we don't have a scarcity problem, we have an abundance problem. Because when you have this much money in a rich society that you can throw at healthcare, sure you can buy another MRI machine. You can always, you can always say, you know, there's this new cancer drug, and it might add three months of life for someone. That's worth $40,000 a year for somebody. Well, you wouldn't do that in the education system, you wouldn't do that in the social sector, right? I mean, the scrutiny that we uh that we apply to non-healthcare spending is much more rigorous and disciplined than it is in healthcare. I did this at the conference the other day. It was the uh UBC Health Policy Conference, and there's a lot of talk about equity, and that equity is the underlying theme or the cross-cutting theme in a quality framework. And I said, so I was a discussant, and I said, you know, we talk about equity. You know, if you ask people, do you believe health disparities should be reduced and that we should have more equitable outcomes? No one's gonna say no.

SPEAKER_03 28:41

Right.

SPEAKER_01 28:42

But that's not what motivates them. I said, people will subscribe to these values, but what really motivates them, as I said earlier, is fear and hope. And I don't see a commitment to equity. I see in society at large growing disparities, particularly in wealth, uh, a bit more than income. But still the wealth concentration is enormous. So I use the analogy, you know, think of think of a government and government departments, public sector spending categories as a group of people. One of those people is obscenely rich, the healthcare guy.

SPEAKER_03 29:23

Yeah.

SPEAKER_01 29:24

And I I said, you know, when I was listening to this talk about equity, the the thing that kept going through my head was the figure 195 million US dollars, which was what somebody paid for an Andy Warhol painting a couple of months ago. When you have that much wealth concentration, there is no such thing as a marginal utility calculation. There is no discipline, it's meaningless, right? There's unlike the rest of the world, you have this is literally uh a realm where there are no constraints and no rationality at all in spending. And that is sort of what healthcare is in relation to the other public needs and public goods that we have. And when you have this giant rich guy around the table, it keeps sucking up what's available. Even in the very in the recent BC budget, which is quite austere because there's a big deficit here, healthcare got is going to get 4%. You know, it's it's always the last place that's going to get any kind of austerity, despite its very obvious uh limitations at the margins, and despite I would say expert consensus that at a very minimum 10%, but more likely 30% of care is low or no value. And some of that's even harmful. The polypharmacy, the uh excess screening that turns up a whole bunch of false positives and leads to all sorts of invasive further investigations. These are not only harmful, but they cost money. So, you know, you ask the you you talk to the insiders. I mean, I was at a I was at a seminar where an orthopedic surgeon said within a minute, he said at one point, you know, the access, I'm a cynical mid-career orthopedic surgeon, but I can tell you access to imaging is terrible in this province. I mean, it was BC. And then he said, Well, we know that 90% of the MRIs we order are useless. We don't, they're they're unnecessary. So I said, wait a minute, you just said two things. There's lack of access to imaging, but you said 90% of the MRIs you and your colleagues order, you know, are not going to be helpful. I said, you know this in advance. He said, Yes. So I said, then why do you order them? Because our patients insist on it or expect it. And my reply was, seriously, I never I don't think I can demand from my doctor to order an expensive test that I don't need. And I would expect my doctor to say no. So there's this learned helplessness that is also feed the beast, feed the beast. And then he also said things like, Well, and if we if we do hold the line on something, then it's just most convenient to blame the government for rationing.

unknown 32:37

Right.

SPEAKER_01 32:38

Well, this is kind of the so the cynicism and the buck passing and the refusal, so there's no unified view of this, right? We don't have a unified partnership between policymakers, governments, and the people who work in the public system. It's an adversarial relationship in many ways between government and the supply side, and the public are just whipsawed. We're the collateral damage in the bystanders in these kinds of things. So you put it all together, sort of psychologically, in a sense, and where the small P politics are, and the assumptions people make that are challengeable, unless there is a concerted effort to get over that and to agree and get some public agreement on look, uh, we can't spend our way out of these problems. We do need to do some things fundamentally differently. There are a lot of entitlements that we have to somehow get back, whether it's a very high degree of clinical autonomy uh compared to other countries. I mean, there is literally no scrutiny, no evaluation of variations in practice that have no justification. Uh it's it's almost a don't ask, don't tell system. We had the report in Regina, uh, I guess last year on physician culture in Regina. I mean, that was the most damning report I ever read.

SPEAKER_03 34:18

Yeah, yeah, yeah.

SPEAKER_01 34:20

It was horrifying. And it was the first one that actually opened up Pandora's box, and you could see this is what flies out of there. These are the behaviors that are tolerated. And yet, what happened?

SPEAKER_03 34:36

Yeah.

SPEAKER_01 34:37

You know, are things different in Regina now? Did they change this culture? Was there accountability for changing it? Was there public outcry? No. So we're all complicit. We're all complicit in the status quo. We like to grumble about it. And yet the appetite for genuine, decent scale experimentation still seems extremely limited.

SPEAKER_03 35:05

So let's talk about some systems out there that you feel are coming to terms with the sustainability of their healthcare system and understanding that we can't keep doing because I feel like we're not maybe not there yet, but there are some systems that are starting to get to that sense of we have to do things differently, we have to design things differently. What are your favorite systems that are out there that you think are not perfect, but are moving in that direction or having conversations more than we are having here?

SPEAKER_01 35:34

Well, the first caveat is everything looks rosier when it's farther away. So I think everybody has struggles. But I will give you a few, and they're different examples of getting it right. I think a country that has done the best job of really trying to go upstream and take a population health approach to service is Scotland. Scotland's a small country with five or six million people, but it's taken a very thoughtful approach. And if you read a report from Scotland about what we're doing and what we're trying to do, uh I think they have done a very good job of joining up the upstream and the downstream. But it also shows when you look at the hard outcomes, Scotland's still not particularly healthy. And some things are just difficult. And this is true of the Northern European social democracies, which do take equity more seriously, I think, than anybody else. And they've even said, look, it's really hard to reduce uh social determinants of health-related health disparities, even with free post-secondary education in some of these countries, much bigger spending in the social sector, very good childcare, universal maternity leave, and so other social benefits, it's still hard because there are a whole lot of forces out there that are like from food security, which is difficult, and and and designing communities so that they're walkable, recreation, everybody's got problems with addictions, mental health, the stresses of modern life. These are these are tricky things to do. I think if I was going to be a senior in a country, I'd pick Denmark. Wow. Well, that shows commitment. And they also have, again, it's a social democratic culture where they have decided collectively, you know, uh, yes, people have families, and families should do their part for their family, for their elderly people, but you don't could script them and work them to death. I mean, you're what what what their approach to intergenerational equity is you live near your parents and so on. Of course, we expect you to do some things, but the the heavy lifting related to healthcare needs, that's the state's job. You should have quality time with your parents when they get old. So they have they have essentially said, um, we're a relatively we're a higher tax, higher benefit society. We collectivize more of our issues, and we have a more egalitarian society, and we think that works better. And wealth concentration matters. The more unequal uh wealth and income are in a country, the harder it will be to achieve better health outcomes, full stop, and you will have more crime, and you will have more homelessness, and you will have more million dollars frequent flyers that you you have to deal with. You're you're basically choosing to mop up rather than prevent the leak in the first place, and that's a so that's a broader conversation. So there is there there are limited things that we can do. You cannot buy more health status for the population with more health care, right? We could triple health care spending, and I guarantee you, life expectancy, even among the people you spent it on, would not go up more than three months. And of course, the more money we spend on health care, it's actually a cause of inequity because it is an opportunity cost for those investments in the social sector that would almost certainly do more good for more people in terms of because you know, to put it crassly, that's where the low-hanging fruit is. Really unhealthy people in a rich society, that society has enough money to make these people healthier. Because, you know, secure housing, uh, more food security, a higher minimum wage so that they actually can work and have a decent life on a minimum wage, which you can't pretty much anywhere in the country, especially now. So with the proverbial gun to our heads, if we had to say we have to increase the healthy life expectancy of the bottom 20% by two years within 10 years, we would know what to do. We would reallocate spending, we would we would make sure the tax system was different and more literally progressive than nominally progressive because it looks progressive until you see all the loopholes. So it's it's it's a question of will and priority, and whether there is it in the end of the day, uh a political movement that would prioritize more equity. And we look more like the US than we look like Europe, and it's not like Europe's uh Eden, but there are countries that do this a lot better than we do, and then finally, on healthcare systems, the best performing healthcare systems in the US, like Kaiser and Geisinger and the other ones, they actually get a pretty good combination of quality and cost. And that's because they evaluate, they're data-driven, and because they're integrated systems, because they're insurance systems, I mean they're little islands of sanity and the absurdity of that system, they will do things like we're gonna buy you a gym membership. They make the rational calculation about where to spend their money, because again, the best of them, they have one fixation keep people out of the hospital, because that's where all the money goes, and it's so expensive. So they will they will do anything to keep people out of the hospital. We don't. And my only my big goal is look, I don't, I think failure is inevitable, but let's fail differently. Like failing in the same way is what's depressing. Yeah, you know, that's that's that's to me the the saddest part of all of this.

SPEAKER_03 42:54

Russ Sakhoff has this quote, he says, um, it's better to do the right thing wrong than the wrong thing right. And we keep trying to do the wrong thing more right, and we never look at because everybody's too scared to do the right thing wrong.

SPEAKER_01 43:11

You know, I don't even know where the fear comes from because you know, there's this notion that just to take organized medicine, that you can't talk to them and that they're not interested in doing any of this. I think it varies a lot from province to province.

SPEAKER_02 43:31

Yeah.

SPEAKER_01 43:32

And I think in some ways, I mean, I even I did some work for the SMA in my time. And you know, I think I think the SMA, like the CMA, has evolved a lot. And that actually there is more appetite for some fundamental change there than in the government. You know, the government still has these antiquated notions of productivity. And value for money. And it's all activity-based. Well, the point isn't to do activity. It's like saying, you know what? The best possible waste management system is to collect more garbage. No, it isn't. You want less garbage. Well, it's the same. The point of healthcare is not to have more of it, it's to have less of it. Because you don't need it. We still have this notion that the productivity equals doing stuff and doing more stuff. And when you even when you look at the surgical plan, we're going to do more and more and more and more surgery. Has there been one assessment, even a simple one, like collect patient reported outcome measures? On are all the hips adding value a year later? What are the patients saying a year later after they've received a new hip? Or notoriously back surgery, right? Which we know is grossly overused. When we talk about medical imaging, so you do a thousand MRIs. What should we expect as the yield in terms of a uh novel clinical information that you didn't already have, or so really, and ideally a change in how you manage the patient? Is it new information 5% of the time, 10% of the time, 30% of the time? I don't know, but you have to have the conversation when you keep seeing the utilization go up. And in how many cases did this change management? Well, again, what should I expect as a taxpayer and even as a patient who has to go through these tests? We never have that conversation. And we don't think about it because we have so much abundance. You won't remember this, but in the 1990s, and I think even up to the early 2000s, Saskatchewan had one MRI machine. So the clinicians got together and they said, Well, we have to have a protocol. Like, how do we stack up access to this? Because we only have one. And they did it. And they had it, they had a here's the criteria, uh, here's what we would order, and it worked. And then we got another one, and then we got another one, and then we got another. And so now we have I don't know how many in the province, but now there's no, there's no, there's no, you don't need a big justification. And same with CT. And all these technologies, right, that are extraordinary technologies, but every the use of every technology is invariably going to have diminishing returns. We in healthcare don't seem to care much about the diminishing returns than when they set in.

unknown 47:05

Yeah.

SPEAKER_01 47:06

Well, again, if you said, okay, it there's more need in a contemporary classroom now, there's a lot more mental health problems, a lot more disadvantaged. So we're going to have a teacher's aid. You put a teacher's aid in, and you say, Well, there's people are there's a lot more tutoring and individual work going on. Let's get another teacher's aid. And then let's get, do you think you'd be adding three teachers' aid to a classroom without someone evaluating the difference it was making? You wouldn't in the education system, right? Like, and and name your other system. So healthcare's privileged position in our psyche reinforces all of this. Like, we think it's a good thing. It sort of makes me sad when a hospital foundation buys another machine. Yeah, another university health network just did in Ontario. You, the big UHN, right? The biggest system in the country, world renowned, they're investing in housing for the homeless, their own money and with their own foundation.

SPEAKER_02 48:15

Yeah.

SPEAKER_01 48:16

Because they kind of realize we just can't have this back-end system. It's we see it in front of our eyes in downtown Toronto. What happens when we don't look after beat people's fundamental needs? So, in spite of the system, they're big enough and rich enough that they can do some of that innovation.

SPEAKER_03 48:41

Yeah.

SPEAKER_01 48:41

But it shouldn't have to be, you know, uh a voluntary foundation funding it.

SPEAKER_03 48:47

Yeah, that kind of stuff, right?

SPEAKER_01 48:49

I mean, when when it's you know, it's kind of grotesque when we rely on philanthropy to step in to provide people with literally the essentials of life. The healthcare system does not have the authority to solve the underlying problems, but the obligation, both internally and on the part of governments, to make sure that you're getting value for money out of the healthcare system and to have these allocative conversations is really important. And if you can't, and and the politics of it are to me fundamentally about communication. Uh, if if if you can't communicate to the public that keeping spending increases going and going and going and escalating and escalating and escalating on this scarcity narrative, it doesn't actually accomplish very much. We never hear the stories of abundance. It's never on the front page of the newspaper that you know 75% of MRI scans for this condition are avoidable or near throscopies waste this much money. Let me give you one example. At this conference I was at, a uh a researcher from Calgary showed us data on cardiology testing. Uh the difference between the testing patterns of cardiologists on salary working in public hospitals and community-based cardiologists who have their own machines and their own testing apparatus. The over the last 10 or 15 years, for the public sector, hospital-based cardiologists, the testing patterns are flat. In the private sector, there's in the private in the public system, but they're there the community with the private practitioners in the community skyrocketed four times higher. And her estimate was for this one specialty alone, over that period of time, I think it was 10 or 15 years, 700 million dollars worth of superfluous testing. Well, think about that. I mean, that should be a front-page newspaper story.

SPEAKER_03 51:14

Yeah, yeah.

SPEAKER_01 51:15

And yet we don't see it, right? We just don't see it. This is a question of policy incentives, organization, management, evaluation. And you can't get any of it done without the engagement and endorsement of the supply side. You have to get, for example, let's just take a classic primary care, what should nurse practitioners do, and what should MDs do? Well, the literature is blindingly obvious. We have 50 years of literature that shows that there is at a minimum 80% overlap in their capabilities, and in some, it's 100%. And when you look at the outcomes, there has never been a study that showed overall nurse practitioner care is inferior to MD care. And there are lots of studies where, at least on some components, it's better. Well, where else in the world are there two professions that overlap 80 or 90% in what they are? It just wouldn't, one wouldn't survive, especially if their cost structures and pay structures are different. Well, since it is notoriously difficult to get any data on how much it costs to train a family doctor and even a nurse practitioner, um, I can't give you exact data, but I think it's probably safe to say that it's no more than a quarter of the cost to train an NP. And then on the pay, even when they're quite well paid, as in 150,000-ish a year, uh, it's still quite a bit cheaper. But never mind what the pay is. If you can solve the primary access problem simply by turning out a couple of thousand nurse practitioners a year, and you already have a pool of 350,000 RNs, you could pay them to go to school. And they're starting to do that in some provinces, right? Yeah. Well, this is an elegant, obvious solution. Because even at a fairly modest expectation of 800 patients per NP, if you trained at 1,000 a year, well, in three years, you have 3,000 more practitioners times 800. That's two and a half million people. But you could train more than 1,000 a year. You could train 2,000 a year pretty easily, right? And of course, there the point is well, don't just replicate standalone medicine because you know the the MDs who are working with no other professions, they're the ones who are saying it we're burnt out, we can only handle 1300 patients. Well, that's sort of become this hardwired figure that that's what the ratio should be. Well, go to Costa Rica. Costa Rica, their GDP per capita is maybe a third of ours, their health system costs a quarter of ours. They had a terrible inaccessible system. Beginning in the 90s, they said we have to fix it, and how we're going to fix it. Everything like we tell ourselves, lives or dies by primary care. So they set up teams: a doc, a nurse, and then two other workers. They're basically one's a basically a sort of a community development outreach risk assessment kind of worker. And the other one's basically a data geek. Seriously. They have a very data-driven system and they collect the information, they upload it into the national spy. And they do a whole bunch. And these teams look after 5,000 people.

SPEAKER_02 55:16

Wow.

SPEAKER_01 55:17

There's one doc for 5,000 people. And you look at their big dot health indicators, they're the same as ours, pretty much. When I have these conversations with primary care docs and groups, and they sort of get a little defense. So I say, look, you have a future, but your future is doing the stuff that requires the training you have. You should be basically some combination of internal medicine, psychiatrists, and in some cases, pediatricians. So what you want so you want to expand to make it truly comprehensive. And then what do people need? Yeah, they need the intensive medical care once in a while. But a lot of it, especially with an aging population, is about mobility and activation. So you need rehab. And then you need an environment, including your home, that is adaptable for you. So why wouldn't you have some community OTs? Like I think it's far more useful to send an OT into somebody's home who's 83 years old and living alone than a public health nurse.

SPEAKER_03 56:30

Yeah.

SPEAKER_01 56:31

Because how are you living? Does this make sense? What can we do here? Where are you at risk? So if we want a needs-based system, we have to look at the division of labor and which parts that we value and which which occupations do we need more of if we're going to have a system that is fit for purpose and adaptable. I mean, the one the one concept that we need to remind ourselves of, what our system needs now more than ever before is agility. It is simply unpredictable. You can't model anything 10 years out. We keep seeing these workforce projections. They're worth nothing because we have no clue what the workforce will need to be in 10 years because of the potential of so many disruptions that may or may not occur in both need, but mostly in the technology and how we deal with things. And I'm not, I'm not, I don't think AI is going to solve all of our problems, but it's going to change our problems. Like I think radiology and pathology will be the kind of focal points of this conversation. You know, I I keep people saying, you know, the radiologists shouldn't worry. They're going to have a big role. I'm thinking, really? But where what is that role?

SPEAKER_03 57:52

Yeah.

SPEAKER_01 57:53

They are pattern recognizers. That's what they do. Well, all this is is patterns. Right. And the literature, which I sort of keep up on. I mean, every week there's another study that showed how much better it is at both the sensitivity and specificity. And you know, big study of, you know, we ran this by expert radiologists, 5,000 cases of this, and AI found nine tumors that none of the radiologists did without more false positives.

SPEAKER_03 58:28

So, like the writings on the wall.

SPEAKER_01 58:47

Because what what what really matters in these encounters? It's us in a way, right? Like what's what is my mind like, and what is my uh risk assessment? What are my preferences?

SPEAKER_03 59:07

Yeah, what am I like? What matters to you?

SPEAKER_01 59:09

What matters to me, and if the holy grail of a good primary care relationship is you coaching me to look after myself better. Well, I still think those are pretty human skills. So when we come back, you know, to where we generally start, which is fix primary care or the whole system's got a problem, the conversations we need to have about what a primary care uh system ought to do and look like, and who does what in it, and how it's organized, and what's our role in this as patients, they need to be pretty deep. I mean, even some of the things that I have repeated kind of thoughtlessly, like it's a scandal that people don't have a primary care attachment. I'm not so sure anymore. I'm not so sure that it matters if if you're a healthy middle class person and you don't get cancer, you don't have big genetic risk factors, and you don't get hit by a bus, what actually do you need from the healthcare system? Practically nothing. And if you look at utilization, it is so concentrated in small numbers of the population uh that for most people, we know the system is important, we know people who have to use it, we know that for surgery, cancer care and stuff, it's big stakes, big costs, big thing. But if you're a healthy person with all and you look after yourself reasonably well, yeah, look, if you break your ankle playing sports, they'll fix your ankle. But that's episodic, you know, you don't need a big relationship with anybody on that one. Uh, if you've got a good social milieu and food security, a whole bunch of people, it's just not an issue. Yeah, and I think that partly explains why people aren't rioting in the streets over the six and a half million people, because most of them don't eat it. Yeah, they don't care, and maybe they don't care for a pretty good reason. So we should avoid too much hubris in this, the thing, you know, you your your life is meaningless without a primary care attachment. No, it isn't.

SPEAKER_03 1:01:48

Or like in the NHS, they want a digital front door, right? Your front door is always through a digital access point first, like a telehealth or an online whatever, and then we'll figure out where we need to get you. But it doesn't, it's not talking about primary care or if GP is your front door anymore.

SPEAKER_01 1:02:05

Right. And and so again, we need to challenge our assumptions. And then conversely, look at what we're missing. I mean, if Medicare were starting up today, we said, well, what uh what would we organize the primary care system around? It would be the frail elderly, the people with two or more chronic conditions, and mental health.

SPEAKER_03 1:02:38

Yeah.

SPEAKER_01 1:02:38

And mental health being an underlying factor for a whole bunch of the other stuff. That's what you would do. You know, you look at these are the Heinese people who take it's they're complex. It takes more to figure them out. Um management of their conditions is everything, it can make an enormous difference. This is hard work, but it's the work that has the biggest potential payoff and the worst consequences if you fail. Well, if that was our challenge in primary care with a blank slate of paper, you would certainly organize it much differently. There would be no such thing as a solo practitioner or a single profession clinic. And I think if I were a policymaker, I would have conversations with the provider groups about low-value care. Say, look, even if we wanted to, and even if we thought it was legit, we can't keep increasing the proportion of provincial budgets that go to the health system.

SPEAKER_02 1:03:37

Yeah.

SPEAKER_01 1:03:37

So if we're going to save the public system, we have to find efficiencies. You know where the efficiencies are. Tell us what's in the way of achieving them. And they'll probably tell you well, the incentives are all wrong.

SPEAKER_03 1:03:48

Yeah.

SPEAKER_01 1:03:49

I'm sorry. Feed for service begets activity. You can't reconcile whatever what you want to preserve in it with not doing things you shouldn't do, then you have to get rid of it. And I think providers are fine, actually. Most surveys show very few providers want to stick with feed for service unadulterated. But you have to engage them in can we agree on what performance indicators matter to you? And we are going to insist is that it's sort of an obligation that you look at variations in care and resource utilization, and you collectively figure out what some standards are. Everyone should work at top of scope.

SPEAKER_03 1:04:32

Yeah.

SPEAKER_01 1:04:33

So I think that's doable, and the conversations have to be had. And in return, when you when you say, look, the world's going to be a fluid, disruptive place in the future, what would make people working in that system say that's fine? Well, the first thing you have to do is you have to give them security. You will have a role in this system. We can't tell you exactly it will be the same role 10 years from now. But we got your back. We're not going to throw you out the door. There's going to be lots of health workers. It's going to be a big sector. It's still going to have more money, probably. But your role may change. And you'll have opportunities to upskill. If you want to move laterally, it will be easier to move laterally. If someday a nurse says, I'm sick of being a nurse, I want to be a physio. Just take a year.

SPEAKER_03 1:05:27

Yeah.

SPEAKER_01 1:05:28

Literally. That's it.

SPEAKER_03 1:05:29

Yeah.

SPEAKER_01 1:05:30

That kind of stuff, right? So, yes, let's do this. And and we're not, this is not a threat to you. This is right now, we're gridlocked, unhappy, in stasis. Your life's gonna be less predictable, but it will be more fun. Yeah, you will start to enjoy your work more because you'll have more opportunities. We won't make you go faster than human. Can go. We will double down on change management, which is everything, as you know. Anyone who's been involved in QI, it's the change management that's everything. So there's a million things to do. And I think I would expect my hope is that we can get over the finger pointing, you know, governments don't understand it, the providers are intransigent. Everybody's got stuff to own. We all we're all part of the failure.

SPEAKER_02 1:06:37

Yeah.

SPEAKER_01 1:06:38

So let's just call a truce and say, yeah, let's let's walk the talk. Let's co-design a future kept honest by people, real people, and what they need and what they expect. Pay attention to what seniors groups are telling you and don't do the same old thing. Pay more attention to them than the guys who want to build nursing homes. All that kind of stuff. And for God's sake, let's get the health information architecture right and the infrastructure. We can't evaluate anything. I'm on the board of a community health center. We know nothing. We know literally nothing about the quality of our service, the efficiency of our service. We can do financial counting, but we don't know anything about financial performance. We know that our patients aren't dying, but we don't have systematic feedback. We used to the years ago apparently. We we don't do regular patient surveys. We don't know why doctors won't commit more than two and a half days a week to practice in any primary care clinic now. You can't recruit anybody in Vancouver to a primary care practice full-time. Just they won't do it. It's almost a sociology of culture and they're the practice now. So we're trying to up our game and realize what analytics can we do on our own data, and it's very, very limited. Well, we can say how complicated it is to change the healthcare system, but every high-performing system has a great data backbone. And we don't.

SPEAKER_03 1:08:23

Yeah.

SPEAKER_01 1:08:24

So I think this is one area where the feds can make an enormous difference.

SPEAKER_03 1:08:30

Yeah.

SPEAKER_01 1:08:31

Just do it.

SPEAKER_03 1:08:32

Yeah.

SPEAKER_01 1:08:32

And instead of gingerly doing it and having a bunch of bilateral agreements about this, no, we're gonna have standards, figure out what they are, we're gonna do this like a country.

SPEAKER_03 1:08:43

Yeah.

SPEAKER_01 1:08:44

And get it right. And this is this isn't anything more than common sense, right?

SPEAKER_03 1:08:51

Yeah, and it's conversations that we aren't having and conversations that we, you know, before Zoom, I think we did try to pull people into rooms more often and have those big discussions. And now people don't want to do that. They don't have the appetite for those, the costs of bringing people together, of having real conversations. And I think someone somewhere needs to show some leadership and bring those conversations back and start having the ones that matter for the for the future of our healthcare system.

SPEAKER_01 1:09:22

Well, how do you have a learning health system when there's no time for learning?

SPEAKER_03 1:09:25

That's right. Yeah.

SPEAKER_01 1:09:26

What what advanced high intelligence industry in the world doesn't spend more on RD than healthcare in the workforce bar? Like if you we if you're gonna let the words lifelong learning and continuous improvement escape your mouth, you can't say every hour not spent on direct clinical care is a waste of time or overhead.

SPEAKER_02 1:09:53

Yeah.

SPEAKER_01 1:09:54

Honestly, I think at least 10% of everybody's time has to be spent on learning, continuous learning. Seriously. And it could be as small as a little huddle to fix a little quality problem. To we need to rethink this. We need to have the conversations you just mentioned that we don't have easily 10%. Who budgets for that?

SPEAKER_03 1:10:17

Yeah.

SPEAKER_01 1:10:18

Right? But and this is your workforce. These are the people who have to, who else is going to keep on top of the massive innovation that is coming at us and incorporate it? So, yeah, you need to rethink a ton of this. And of course, they say, well, that just gets more and more expensive. To which I would reply, if you take seriously the obligation to do less when we need less, it doesn't have to be more expensive.

unknown 1:10:45

Yeah.

SPEAKER_01 1:10:46

I think the hamster wheel makes it more expensive.

SPEAKER_03 1:10:49

Yeah, yeah. What's the cost of not doing it?

SPEAKER_01 1:10:52

Yes, exactly.

SPEAKER_03 1:10:53

Yeah.

SPEAKER_01 1:10:54

So there needs to be a mindset change. Um, but also you need a belief that it can actually be different. And I think that's the most that's the daunting challenge. I think that Canada's kind of numbed. I I think there's a bit of a defeatism that we could actually change this thing around because we've had so many false starts. How many Royal Commissions do we have to have? How many provincial reports do we have to have? How many quality councils do we have to establish? And then when you see that the dial doesn't move, I mean, that you know, the sad thing from last fall, I guess, you know, after the famous Baker Norton study that showed how many people were dying in hospitals avoidably uh 20 years ago. Well, the update from Canadian Institute for Health Information, it didn't talk about deaths, but it did talk about safety and adverse events, and it said the dial hasn't moved. And this is after 20 years of taking it kind of seriously, and that's a head scratcher, right? So there's a reason why we're tempted to fatalism about this, but we also know there are places that do it better. There is no magic wand, but there are things that we have to quit doing, which is you cannot keep signing the same collective agreements with especially the medical associations. They're just not fit for purpose anymore. Yeah, all the wrong incentives, there's a whole bunch of inequities built in, a whole bunch of cost drivers built in, and not enough obligations built in. You just can't do that anymore. Secondly, you have to have some serious conversations about workforce training. Uh, and as a heretical view, I think it's an iron law that once a program gets absorbed by the university, you've got trouble because there's all sorts of conflicting goals. Research is a big one, prestige is a big one, credentialism is a big one. We can't do this anymore. And I think we need to do a lot more training in the colleges, especially at the front end of the system. The care aides are the future. If we don't have a well-trained, decently paid cohort of care aids, then we got trouble. I almost think we need a Royal Commission on the future of the health workforce.

unknown 1:13:25

Yeah.

SPEAKER_01 1:13:25

I know it's a terrible sounding thing, but how else are we going to do it? We have 30-some professions. We have a like a zillion regulators if you count accreditation. Well, all these people have a piece of the pie and they build in requirements that may or may not be fit for purpose. And then we have this workforce challenge. The longer and longer the training programs get and the entry to practice, like you have masters for physio and OT. They only take two years of physio and OT, but they have to have a degree.

SPEAKER_03 1:13:58

Yeah.

SPEAKER_01 1:13:58

Well, that has an impact on who will go into these professions. And if it takes six years to produce one, that's not fast enough for the need. Well, all this stuff has to be sorted out. And it has to be sorted out systematically. And it can't be done province by province. What's PEI gonna do? Or what's Saskatchewan gonna do? You can't on your own sort this stuff out, right? But this has to be national, integrated. We want worker mobility, right? All of these barriers to getting a license in another province with the same like this is absurdity. And the regulators will tell you it's absurd. Australia managed to nationalize regulation. How did they do it? Why can't we do it? So let's get the craziness out.

SPEAKER_03 1:14:49

Yeah. Well, that was such an interesting conversation. You are the right person to have had this conversation with because you put out so many ideas that I haven't even considered, I haven't thought of. I think, you know, the general theme of what I heard is that we need to start having these conversations. It's that cartoon of who wants change and everybody puts up their hand, who wants to change and everybody keeps their hands down. And that's not an option anymore for I think the the direction that we're going. And I'm looking for the leaders and the organizations that are going to start leading those conversations. And I hope they start having them soon.

SPEAKER_01 1:15:28

You know, I think we all struggle with how do you start? And where would you apply the WD 40 first? Like honestly, I don't have one idea in my head that isn't common sense. Yeah, like it's not rocket science. And I don't think people have are malicious and that they're, I think everybody actually wants, most people want to actually start fixing this. So it's all about strategy and where you begin and where, and it's importantly, there's a there's a zillion hills, but there's only four or five that you need to die on. But you must know what those are. And I think figuring that out is important.

SPEAKER_03 1:16:13

Thank you so much for joining me today, and thank you to my guest, Stephen Lewis. So many learnings in that episode, right? I told you it'd be worth it. I don't know about you, but I know I will be thinking about what he said for a long time to come. What are your thoughts about Steven's views? Do you agree, disagree? What ideas are starting to shift the system where you are? As always, you can engage with me on Facebook, Instagram, and now YouTube at Shift Podcast Canada. And you can also reach out to me at shiftpodcastcanada at gmail.com with any feedback or show ideas. And remember, systems don't change unless we do. This is shift. See you next time.