Blog

Most of us know that our health care system provides high quality services AND (according to patient feedback over the past few years) we know that those services are disconnected, uncoordinated and managed in silos. In other words, we have great health care providers BUT they don’t always work as a team or toward the same end goal.

Those of us who live in rural and northern communities also know that we don’t have timely access or any access at all to many services that we need. To compound the problem, our communities generally have higher percentages of people who: need health services, like seniors or people living in poverty; have higher rates of accidents that result in injuries that need ongoing health services; and/or lack the transportation or high speed Internet that is needed to improve access to these services.

But access to health services is only one part of the picture. The main drivers behind a healthy life are actually not related to health services at all. Things like a sense of belonging and social connection, knowledge to understand and interact in the world around you (education), feeling safe and secure in your family and community, having enough healthy food, heat, light, space, clean water, etc., have a much more significant impact on health status than access to health care. In the population health business, we call these the social determinants of health.

So what makes this most recent change announced by the Minister of Health so significant? A few key words in the preamble of the current legislation signals a shift in the way that the health care system does business - ‘should be centred around people, patients, their families and their caregivers’; ‘improve patient experience’ and ‘improve the overall physical health, mental health and well-being’ of Ontarians. There are also statements about ensuring better value and best outcomes for every dollar spent. In my 32 years in health care, I have not seen the aim of the health care system defined in quite this same way. 

This is a significant cultural shift for our health care system. It isn’t initially apparent on the surface. Patients will say to themselves - ‘Of course my doctor, nurse, pharmacist, etc., has my best interests at heart. They are here to help me after all.’ And that is very true. Health care providers are taught to ‘do things’ and are evaluated on how much they do those things and how well they do them. As I said at the beginning, we provide excellent health services. What is currently missing is that focus on health outcomes and wellbeing - the clearly defined ‘why’ behind the doing.

And this is key.  As W. Edward Deming, the father of quality management said, “A system must have an aim. Without an aim, there is no system.” For decades, the main focus of our health services has been undefined, but by practice, the focus was on fixing or curing. And of course, we want that to remain a key focus when it is the appropriate aim. Unfortunately, when the system is measured only on fixing or curing and the main needs of the population change, the focus of the system is out of step with the needs of the population. That is the situation that we find ourselves in now. When we first created our health care system, we mostly needed services that cured or fixed to be paid for by our taxes. People either did not live as long with their chronic diseases or they had family and friends to support them as they lived (and died) with those diseases. Now, with the increase in life expectancy of people with chronic diseases, lifelong health conditions and a generally aging population, we need services that help us to live our best life while managing those conditions. And we need those services to work together as one system, not be working at cross purposes and competing for resources.

That’s where that wonderful word ‘wellbeing’ comes into the equation. Wellbeing is a concept that is defined through a set of factors that are related to more than the idea of health as the absence of disease. Many of those factors fall outside of the realm of traditional health services. Wellbeing is influenced by access to health services and social services and supports that are traditionally provided by other parts of a community - service clubs, churches, schools, municipalities, regions, etc. At the community level, this addition of achieving wellbeing as a purpose of the health care system allows health service provider agencies the opportunity to partner with these other services to plan for the needs of the population together and focus the efforts on a single aim of community wellbeing.

Taking this opportunity means having some challenging conversations about what we stop doing (and spending money on) and what we start doing. Rural and northern communities are well positioned to take advantage of this new opportunity. We already tend to collaborate well across sectors. We have fewer different ‘players’ in our communities so we can be nimble. We tend to have already built trust between agencies. And we usually have engaged and committed governors and leaders. Rural and northern communities can take this change opportunity to create systems of support and care that are connected, coordinated, aligned, lean and nimble. We only have to agree to share resources, power and effort - and of course, agree to change.

Change is possible at the individual care level as well. In order to change the focus of health services toward achieving wellbeing, health service providers need to partner with you as an individual to determine what services you need to live your best life as you define it by what is important to you. The knowledge and skill of the health care provider is then used to balance the issues identified within the complex set of diseases, conditions, social determinants and other factors that impact on your ability to live your best life - even when that best life is winding down to final months, weeks and days. The health care provider shares their knowledge and skill with you so that you feel more capable and confident to manage your health issues independently when you are not in contact with your health care provider. This is relationship-based care at its best and it is dependent upon having enough health care providers in a community to meet the needs of the population. The higher proportion of people living in a community with complex situations, the more health providers are needed. It is a move from what I call transactional care (treat and street) toward journey-based care that is focused on incremental improvement rather than immediate improvement.

This shift also means that health care providers will need to work as a team rather than as individuals. No one health service provider can offer the breadth of support that most people need when they are living with multiple health and social determinant issues. Providing team-based care effectively and efficiently means implementing communication tools so that providers, patients and family can share information in real time across care locations (in hospital, in clinic, in home, in long term care). It means having a single management structure that ensures all providers across the system are working toward the same end - the wellbeing of individual people who need services.

The success of this legislative change depends on us all making this cultural change. I don’t know who said it, but the phrase “Culture eats strategy for lunch” comes to mind in this situation. If we think of changing the structure of the health care system as the strategy, then changing the focus of why we provide health services toward wellbeing is the culture change. And culture change is always the hardest. We all need to work on that part of the change together - patients, families, health care providers, funders, managers, leaders, politicians. Are you up for the challenge - and the opportunity?

Guest blog provided by Suzanne Trivers, Executive Director, Mount Forest Family Health Team.