But on this afternoon, away from the cameras and the rhetoric, during a break from patient consults at Vancouver's Cambie Surgery Centre, what emerges above all is his deep, abiding hatred of patient waiting lists and the suffering they cause, the dollars they waste: "At UBC hospital, we could really use another three orthopaedic surgeons, but we can't provide them with OR time. We all know that the root of the problem is this system of rationing access to surgical procedures." Day firmly believes orthopaedic surgeons have a legitimate leadership role to play in arguing for change, "because we've seen the deterioration over the last 10 to 15 years as much as or more than anyone else, because we have the longest waiting lists and are subjected to the greatest pressures as a result. Everyone agrees the status quo is unacceptable."

Day doesn't think much of the governments' quick-fix promise of selected wait time guarantees: "If we treat everyone, it's going to cost a lot of money to treat the 700-800,000 people currently on wait lists." Nor is he keen on concentrating solely on the five priority areas, which obscure and deprive other urgent priorities: "A recent BC study showed that an estimated 65% of children were waiting for a medically unacceptable period of time for treatment. So I think wait time guarantees applied to the five priorities are no solution at all."

In Day's opinion, the UK's National Health Service is a good place to look for new models and ideas, if only because the ratio of doctors to population is about the same in the United Kingdom as in Canada and because the NHS has almost eliminated its wait times. The crucial difference between the two public health systems, he says, is in how hospitals receive their funding from the regional health authority.

It wasn't always so. Not so long ago, the UK and Canada were the only two OECD countries to provide block funding to their hospitals, a model that essentially leaves it to hospital managers' discretion on how to best spend the money. Both countries had long wait lists for services. In recent years, the NHS abandoned block funding in favour of a model called "Payment by Results", where the local health authority retains control of the budget and allocates resources to the hospital that meets a given patient's needs and preferences. By the end of 2005, NHS patients referred for hospital care were often offered a choice among four hospitals (one of which was usually privately funded) and were able to pick a time for the procedure that was convenient for them. Whether delivered in a public or private clinical setting, no fee for service or co-payment was required of patients.

"Instantly you reverse the mindset," says Day. "Managers have to make their hospital systems work so that patients don't wait. They need patients and they need doctors to treat those patients, because that's where the revenue comes from." Not only is the NHS patient-centered, but it's also transparent. The NHS web site provides visitors with a host of information, including nearby hospitals and a complete list of fees for service, all calculated down to the last variable. It's a business model based on "internal markets" and introduces private funding methodology into the public system. Patients are empowered because they can choose among hospitals for service, which sets off an element of competition among institutions.

"Activity-based funding alone won't help aboriginal health or rural family practice or mental health or child health or any of those important priorities," acknowledges  Day, "but I think we have to recognize that the biggest expenditures in health care are related to hospital treatment - $40 billion a year in Canada. If we can deal with that problem, then we have moved ahead substantially. We don't need to re-invent the wheel. The only other country that had block funding like ours has given it up, and the results have been fairly dramatic."

There's little doubt that under such a funding regime, orthopaedics would benefit. It's where all the big wait lists are and where the demand is. And since orthopaedics deals mostly with reversible disease, the resulting patient outcomes and quality-of-life measures are hard to beat. The final irony, if the NHS experience is anything to go by, is that when patient wait times go down, so does patient demand for privately funded health services.

During his tenure as CMA president, Day says, "if there's one thing I want to push it's activity-based funding." With the support of the BC Medical Association, he believes that the province may soon become the first Canadian jurisdiction to try the activity-based funding model.

Day is also hoping for the same the kind of support from the COA that saw the association and the CMA intervene in the Chaoulli case: "Bob Hollinshead's leadership was crucial in recognizing that the COA must make a stand - that it was just unacceptable an orthopaedic patient should be forced to wait a year or more for treatment. What I'm doing is really an extension of that."