When Small Changes Add Up to System Transformation

Just as sandy beaches are the result of uncountable individual waves crashing on a shore, fundamental shifts in the health sector often reflect the cumulative result of hundreds – perhaps thousands – of individual decisions. Each, on its own, may seem to have only local effect. But together, they represent a transformation in how care is delivered.

Take hospital services, for instance. In 1975, patients spent 43.1 million days in Canada's hospitals. Shortly thereafter, Statistics Canada analysts were interested in the effect that the baby boom generation would have on hospital use (Lefebvre et al. 1979). They asked: if the population grew and aged but healthcare utilization by age and sex stayed the same, how many hospital days would there be in 2016? Their answer: 76.7 million days. Actual use was less than a third of this amount, according to data from the Canadian Institute for Health Information (CIHI 2019).

Why the discrepancy? Was it because the original population projections were too high? No, that was not the case, and in fact, the 2016 Canadian census enumerated almost 5 million more people than the analysts projected in the 1970s (Statistics Canada 2017). Rather, the way we use hospitals has profoundly changed over the last four decades.

Adoption of new surgical techniques that enabled faster recovery and a switch to day surgery. Streamlining pre-surgical preparations or discharge planning. Supporting people with chronic conditions to manage them at home, reducing the need for hospital stays. Earlier discharge after giving birth. Due to these types of changes and many more, today's hospital care looks very different from care in the past.

It is clear that it wasn't one particular decision that changed the system, but rather a multitude of smaller ones made by local teams, hospitals, regional authorities, and provinces/territories.

Because change is often incremental and cumulative, it can be hard to perceive wider, long-term trends. As a result, it's helpful to mark milestones along the way. With this in mind, I am delighted to announce that Healthcare Policy/Politique de Santé recently received its 1,000th submission – what a great way to start the 15th year of the journal!

The articles published in this issue of the journal illustrate the diversity of papers that we have received over the years. Some focus on methodological advances in the field, as Shoemaker and colleagues do in this issue. Their paper describes development of clinical cohorts of people living with HIV in two provinces that have been linked with administrative data. Other authors use a variety of qualitative and quantitative methods to illuminate topical healthcare policy issues. In this issue, for instance, authors address issues that matter to the young and the old – from children's oral health to dementia care – as well as those that affect people of all ages, such as opioid prescribing, orphan drug pricing, and technology assessment and adoption.

Regardless of your particular health policy interests, we hope that you will find food for reflection in this issue of Healthcare Policy/Politique de Santé and that you will contribute insights of your own by submitting papers describing novel methods, relevant research, and insightful policy commentary for potential publication in future issues.