In the seven months since doctor-turned-consultant David Peachey presented his report on health care to the Manitoba government, his ideas have been called "unconscionable," "doomed to fail," a logical step, and — more than once — "the most significant change in the health-care system in a generation."
His report, Clinical and Preventive Services Planning for Manitoba, includes recommendations such as closing three Winnipeg emergency rooms and replacing two of them with urgent care centres, as part of an overall "consolidation" effort to concentrate resources and improve the quality of health care in the province.
The suggestions have been largely embraced by the Progressive Conservative government, despite the fact the report was commissioned by the New Democrats during the party's time in government, and come alongside a variety of cost-saving measures recommended by the still-unreleased KPMG health-care report — which even Peachey says he still hasn't seen.
The implementation of his ideas — the closure of the Misericordia Urgent Care Centre, for instance, and the transformation of Victoria Hospital's ER into an urgent care centre — has dominated headlines since the government and the Winnipeg Regional Health Authority presented them in April.
Peachey himself, however, has largely avoided the spotlight. After spending 18 months in Manitoba to research the report, the Nova Scotia-based consultant returned only once after presenting it, in August, to answer questions about implementation.
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CBC News spoke to Peachey in an effort to answer the questions Manitobans were left asking: who is this guy, anyway, and why should we care what he thinks?
'A blank piece of paper and no clients'
Peachey is the director and president of Health Intelligence, a consulting firm he started with his wife, Georgia Henderson, after two decades as a practising physician.
They run the health-care consulting firm from their shared home in Halibut Bay, N.S. He wrote nearly all of the Manitoba report in an office overlooking the ocean, with the reliable company of Fred, his 4½-year-old Australian shepherd and, in Peachey's opinion, "the nicest dog in the world."
Asked to send photos of himself from his youth, Peachey instead sent an image of Fred and the sunset from his office window.
Peachey worked on the report with the help of frequent collaborators: Nicholas Tait, a software developer; William Croson, a health statistician; and Orvill Adams, former director of health service provision with the World Health Organization and of medical economics with the Canadian Medical Association.
But Peachey and his wife remain the backbone of the company, and are the only names that turn up in a company registry search.
The pair started out in 1995 with "a blank piece of paper and no clients," he said.
"There were a group of people involved in the seminal thinking and it was clear that there were opportunities," he said. That group, most of whom he still works with, included two economists, a statistician and a software developer.
They shared a vision of an evidence-based system that made use of vast reams of medical data being gathered — and, as they saw it, left to collect dust — across the country.
It's that vision that still seems to guide Peachey's work, including the Manitoba health-care report.
"One of the things that struck us was the huge data sets that were available, and still are available, in health [and] are tremendously underused," he said.
"It was the sense that there were so many decisions of policy that were being made without necessarily an evidence base that could support those policy changes, that things were happening more on the reflex basis."
Since that "frightening" time, Peachey and his team have been commissioned to do work for the governments of seven provinces and territories: Nova Scotia, Saskatchewan, Alberta, Yukon, the Northwest Territories, Nunavut and most recently, Manitoba. The province's former NDP government hired him in 2015 to conduct a broad review of Manitoba's health care.
Peachey said the Manitoba project is the "widest and deepest" mandate the firm's taken on: a total review of clinical and preventive services, for more than a million people, spread across an entire province.
"The question we were asked is to, say, analyze the system, get inside the system and realize that the mandate we're asking [you] to pursue is one of quality. So how can quality improve in Manitoba?" he said.
Peachey, a lifelong Ontarian before relocating to Nova Scotia two years ago, spent 18 months in Manitoba consulting with residents and researching his report. He said he was struck by a few things: the stronger-than-usual focus on preventive health in the province; an interest in thinking about health care on a provincial, rather than regional, scale; and, most noticeably, a willingness to embrace change.
"There was a really widespread and sincere interest, saying, 'You know, we've never had a plan in Manitoba before,' which you had not," Peachey said. "And the question is, so how do you do it and what sort of information do you need?"
Yukon report 'foundational': former deputy health minister
The most similar mandate Health Intelligence has worked on in the past was the Yukon project, he said, when the territory commissioned a clinical services review in early 2013.
An emphasis of Peachey's final product was "role optimization," building collaborative, team-based integrative care, uniting many health-care specialties in a non-hierarchical way.
That model, also called "top of licence," is a value Peachey carried through to his recommendations in Manitoba, which include decreasing the overall percentage of doctors in the system, increasing non-physician workers and boosting the ratio of nurse practitioners and physician assistants to physicians.
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Yukon's deputy minister of health at the time, Paddy Meade, said she chose Peachey for the job because of his medical background and evidence-based methodology. Meade was also the deputy minister of health in Alberta and the Northwest Territories when governments there worked with Peachey.
"His data approach was important to us," she said. "Data is how you speak to physicians and he himself is a physician, so we knew we needed that kind of background."
Meade said Peachey's report was "very well" received by Yukon's health department, some physicians and the health minister, but opposed by the premier and other cabinet ministers.
"It lacked political sustained will and some provider buy-in," she said. But new physician leaders in the province have embraced it, she added.
The government has gone forward with his recommendations to a certain extent, "with a lot more stealth," Meade said. She maintains his ideas were excellent and fact-based.
"It was quite foundational for where Yukon will continue to go," she said.
A spokesperson for the government of Yukon told CBC News she couldn't specifically pin down which of Peachey's recommendations had been implemented.
"We have had a change in senior management, as well as a change in government, so the focus has shifted slightly," she wrote.
"I think it is fair to say that we continue to use the Peachey report in helping to guide our decisions program-wise."
A spokesperson for the government of Saskatchewan — which commissioned a report on physician resource planning from Peachey, presented in January 2016 — said the same was true for that province.
"His recommendations serve as a tool as we continue with our physician resource planning," the spokesperson wrote.
'Art and science' of medicine
Peachey's own career in medicine began decades earlier, when he started med school at the University of Western Ontario at age 18.
The only child of an accountant and stay-at-home mom in London, Ont., Peachey skipped a few grades in school — he can't remember which ones — and started university at 16 before deciding to become a doctor, drawn in by the "art and science" of medicine.
Now nearly 70, he said he's never questioned his decision.
"The interesting thing was you never, ever lose the sense of privilege that it is to be a doctor," he said. "The privilege for people to talk to you, to tell you the most important details of their lives."
The university's medical students' journal at the time — on which he worked as an editor — is peppered with references to a young Peachey, a member of his graduating class's executive and the modest leader of the Meds hockey team, which the paper reported was unofficially called "Peachey's Panthers."
"I was a goalie. They called me The Gazelle, because the puck stopped here, you know?" Peachey said, laughing. "I haven't played for a long time."
When he graduated in 1971, he was just 23 years old, he said, and among the youngest members of his class.
An interest in data, statistics
From school, Peachey did a general internship at St. Michael's Hospital in Toronto and spent four years in an underserved area of Ontario before starting as a family physician at the Royal Victoria Hospital in Barrie, Ont., in 1975.
In the decade he was at the hospital, he became the chief of general and family practice, chief of obstetrics and neonatology, and president of medical staff.
"It was during that time that I developed a series of things: one is an interest in general in economics and statistics, and then an awareness that there were huge data sets in care that were not being used, or not used very well," Peachey said.
"Policies were often being decided in the 'system' — 'system' in quotation marks — without necessarily the evidence that would underpin it in a proper way."
As those interests grew, the Ontario Medical Association invited Peachey to sit on its committee of economics — which he did, for roughly four years.
"Then a series of things happened very rapidly," he said.
He became a negotiator for the association, and was asked to join its permanent staff to help establish and direct a new wing of the association, the department of professional affairs.
Peachey stayed with the association for 10 years, seeing patients on the weekends to keep himself involved in practice. It's where he met Georgia Henderson, a negotiator for the OMA with a background in clinical psychology and business. They later got married, he said, brought together by common beliefs about how health-care systems could work.
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"Those were interesting times," Peachey said. He was with the association when it led a 25-day physicians' strike in 1986 — at the time, the longest doctors' strike in Canadian history — in unsuccessful and largely unpopular protest of the province's proposed legislation to ban extra billing.
"When that got settled and we got back into a normal way of life, it became evident that the face of medicine had to change," he said.
"It struck a lot of us as not appropriate, that rather than the medical model, it should be a health model because of the range of providers out there that do really good work. To ever believe that a physician should necessarily be sitting at the top of that hierarchy didn't make any sense," he said.
'Wall of silence' following firing in 1995
Nine years after the strike, Peachey, Henderson and the director of public affairs and corporate affairs, Gary Cooper, were fired from the organization.
On the same day, another staff member resigned, and Peachey says roughly a dozen more people were forced out of the association due to differing ideology, as officials retreated behind what the Toronto Star described at the time as a "wall of silence."
Dr. Michael Wyman, the president of the association at the time, told CBC in October the firing had nothing to do with Peachey's competence or ability to perform his job. In fact, Wyman said, Peachey was an "excellent employee."
"Good guy," Wyman said. "Certainly respect the work that he did. His ability to assess situations and come up with solutions was always wise in its approach."
But at the time, Wyman said, the medical association had recently brought on a new CEO: David Pattenden, the former chief executive officer of Ontario's now-defunct Urban Transportation Development Corp., a Crown company which specialized in the development and production of transit machinery.
"There were a number of positions that changed at that time in the top echelons of the OMA staff. Dr. Peachey was just part of that process," Wyman said.
He called it a "change in approach" more than a clash of philosophies.
It was after his exit from the OMA that Peachey formed Health Intelligence — and the rest is Manitoba health-care history.
'Nothing's going to stop this'
Since Peachey completed and presented his final report for Manitoba, he says he's often been asked if changes should be moving more slowly.
"The truth is, I don't think they should," he said. "I think that things are happening rapidly but the benefits will be worth it."
He said he's loved watching the beginning stages of his vision take shape, and he understands the resistance to change the first phase has encountered.
But he stands behind each of his ideas.
"It's going to take time to realize this is the best thing that's happened to health care in Manitoba," he said.
"I find it exciting just to think that [the province is] going to take this idea and they're going to translate it into action, and I could see it before my eyes. It's starting to happen and nothing's going to stop this."