Health professionals can be apprehensive about publicly sharing their opinions. There are countless examples of the fallouts that can happen after doing so. The Quality Practice Manager of the College of Respiratory Therapists of Ontario (CRTO) tells members “Our personal opinions on health issues are interpreted as a professional opinion so it is important to conscientiously reflect on what we choose to say and what we choose to share publicly” in her blog post “Some Things are Better Left Unsaid”. This is certainly true for confidentiality or misinformation, but as professionals, with obligations to provide patient care in the system, shouldn’t we be the ones to speak up when we see it failing?
Yes, our opinions represent our professions, our employers, our institutions, our health networks, our provinces, and the Canadian health system. If we wish to see our patients better served and the sustainability of our health system protected, we need to have difficult conversations. This blog will discuss difficult topics: modernizing the Canadian Health System, addressing the determinants of health in public policy by exploring a multilevel model of health, accepting Canada’s poor performance in chronic illness management, and finally the return to patient-centered care after the pandemic.
Modernizing the Canada Health Act
The Canadian health care system is built on the Canada Health Act (CHA) (Image 1 Health Canada 2020)
Unfortunately, the CHA is not working. Many Canadians are frustrated with the current status of the health care system, there is a concerning trend of a federal blind eye to provincial rule-breaking and increasing tolerance for privatization, user fees, and extra billing to reduce government spending while selling the illusion that it is necessary to improve wait times (Sibbald & Stanbrook, 2016). After almost fifteen years working in the emergency room and intensive care, I have learned that wait times are not the best metric to measure system access or performance. I am constantly perplexed by where we invest resources, where we do not, and how antiquated our system has become.
Dr. Danielle Martin is a primary care physician and author of “Better Now: Six Big Ideas to Improve Health Care for All Canadians” (2017). She is best known for testifying in front of an American Senate Committee and poignantly snapping back about patients dying on wait lists over patients dying from a lack of health insurance. Watch the attached clip of her testimony below and a discussion of her book highlighting her major points:
The Canadian health care system needs to invest in organizing a robust primary health care system. 100% of Canadians should have access to a family health provider.
An evidence-based National Pharmacare program would not only improve patient outcomes but would be fiscally responsible
Reconsider medical practices that are covered but show no evidence for effectiveness or show more risk than benefit (i.e. fewer investigations, tests etc, and the Beers List), this includes end-of-life planning.
Reorganize our resources and the focus from just in-hospital care to the community, including transitional supports
Coordinate our specialist referral and consultation processes – more virtual consults
Team-based care models – especially in mental health and primary care
Guaranteed Basic Income – poverty reduction will always belong in a discussion about health
A Multilevel Approach to Health: Recognizing the Determinants of Health
It is important to not only ask how we can better provide health care to our population, but also look to address the root cause of illness, where is comes from, and how so many factors contribute to illness development. Many indicators of poor health are a result of the unequal distribution of risk and resilience.
In the new age of chronic illness, it is important to understand the complexity of risk and resilience in individuals. Allostasis is the term for physiological coping, the ability to maintain stability through changing circumstance. We may have a protective response to stress or our system may be overwhelmed (Huber, 2011). There is considerable evidence that allostatic load is related to chronic conditions, an individual’s adaptation to illness, mental and physical functioning, and all-cause mortality (Rodriquez et al., 2019). Whether we are resilient or vulnerable depends on how the determinants of health add up for us.
Image 3 (The King's Fund 2019) (below) illustrates the individual, community, socio-economic, and environmental influences on health. Health care services make up a single determinant.
Image 4 (Raphael & Mikkonen 2020) (right) reveals how life expectancy and neighborhood income are directly
correlated.
Life Expectancy is a population health indicator reported by the Organisation for Economic Cooperation and Development (OECD) as an international health standard. There are 6 measurable indicators used to measure a country’s overall health status:
1. Life Expectancy at birth
2. Life Expectancy at 65
3. Infant Mortality Rates
4. Potential Years of Life Lost
5. Deaths from Cancer
6. Suicide Rates
These indicators reflect patterns in the determinants of health: living standards, equality, lifestyle, education, and access to quality health services (OECD, 2019). The more we explore the determinants of health, the more we understand that social injustice, poverty, and inequality contribute more to chronic illness than the accessibility of health care itself.
Poverty reduction strategies have great potential. A full discussion of the approaches in Ontario is beyond the scope of this blog. Please see my blog post on Changing the Way we Fight Chronic Illness and Ontario Policy Priorities for more information on socioeconomic policy, poverty reduction, and the social determinants of health. Although weak, Ontario policy had some potential. If the goal is really to address health needs and health costs, we need to double down on these policy changes to tackle the most upstream causes of poor health.
Similar to image 3 depicting the determinants of health, we can see in image 5 (Galea 2015) that determinants interact across the life course, that individual health choices and behaviors are produced by a multitude of variables.
The video clip attached (HelpAge International n.d.) describes how these various influences act on individual choices and behaviours over their entire life course – from infancy to old age – and explains how poor health and chronic illness are the result of societal failures that are better repaired early on, preventing illness before it can progress. The video nods at opportunities for health improvements: quality education, health insurance, pharmacare, pensions, anti-discrimination policy, community enrichment such as health outreach programs, community groups, and others.
Social and economic policy can reduce poverty and improve health, but community buffers also mitigate the effects of the social determinants of health (Bharmal et al., 2015). There is significant evidence that neighborhood changes affect quality of life and individual health (Settels & Leist, 2021):
The availability of libraries has been associated with delaying cognitive decline while worsening neighborhood conditions were associated with increased depression-mediated cognitive decline (Settels & Leist, 2021).
Chaix (2009) conducted a literature review of 40 published studies and found that there was an increased risk of cardiovascular disease among residents of socially-deprived areas after controlling for socioeconomic status
A natural experiment in Perth, Australia found that improving the accessibility and diversity of public transport services and recreational destinations led to a positive effect on walking and recreational behaviours (Kawachi & Subramanian, 2017).
Waddell et al., (2017) describe decolonizing initiatives in northern Inuit communities with the most lasting effects being ones that are community driven. A simple investment in a community freezer in Arviat, NU led to food-sharing behaviours and thus food security benefits for all individuals living in the community (Richards et al., 2019)
As a hospital-based clinician that has worked in several regions in Ontario, I cannot overstate the difference in outcomes between patients that have access to community supports and those that do not.
Community enrichments have far-reaching effects on the health behaviours of individuals and are excellent, targeted approaches for the most vulnerable groups. If community supports are not available, hospitals and other acute care settings become a singular option for those suffering from chronic illness, unfortunately they are not well-suited to meet these needs.
Chronic Disease Prevention and Management
As an acute care respiratory therapist, I see the outcomes of an outdated health care system, how the determinants of health contribute to poorer health, and our province’s failure to correct this. Chronic Obstructive Pulmonary Disease (COPD) is a major burden on the Canadian health care system and one that, despite increasing efforts to show a decrease in hospital readmissions, we cannot seem to show any progress. Image 7 shows that we are doing especially poorly transitioning from hospital to community (HQO n.d.)
Ontario measures the quality of care for COPD patients with the indicators listed in image 8 (HQO 2021), many are consistent with best practice standards and quality-based procedures however more meaningful targets with bigger effects should be reported: how many have a primary care provider? How many do not fill their prescriptions because of a lack of drug coverage? How many have access to community supports such as smoking cessation, pulmonary rehabilitation, or COPD clinics?
Looking to the Future: Patient-Centered Care
Just as social/economic policy and community enrichments target system-level determinants of health so should our health care system prioritize care plans that target our patients’ barriers to healthy choices and behaviours. Image 9 from Miller, (2016) is a list of health facilitators and barriers that providers and patients can use to determine their specific outcome priorities to guide decision-making. Although the pandemic has shifted our focus, the value of patient-centered care must be remembered as we work to improve health outcomes and reorganize resources accordingly (NEJM Catalyst, 2017).
Our public health care system is something we should be proud of and one that can be responsive to our changing health needs with some reorganizing. We know the answers and we have the tools:
Invest in primary care to provide high-quality, patient-centered care and lead team-based case management. This is especially true for chronic illness prevention and management if we are ever to perform better (Health Canada, 2007).
Pharmacare funding under a new Canada Health Act. Restore the federal commitment to Medicare.
Poverty reduction policy
Community enrichments and social programs can offset deprivation, remove barriers to healthy behaviours and increase resilience to environmental stress.
Works Cited
Bharmal, N., Derose, K. P., Felician, M., Weden, M. M., & Health, R. (2015). Understanding the Upstream Social Determinants of Health. Rand Health. https://www.rand.org/content/dam/rand/pubs/working_papers/WR1000/WR1096/RAND_WR1096.pdf
Chaix, B. (2009). Geographic life environments and coronary heart disease: A literature review, theoretical contributions, methodological updates, and a research agenda. Annual Review of Public Health, 30, 81–105. https://doi.org/10.1146/annurev.publhealth.031308.100158
Galea, Sandro (2015). The Determination of Health Across the Life Course and Across Levels of Influence | SPH. Boston University School of Public Health. https://www.bu.edu/sph/news/articles/2015/the-determination-of-health-across-the-life-course-and-across-levels-of-influence-2/
Health Canada. (2007). Chronic Disease Prevention and Management—Canada.ca. https://www.canada.ca/en/health-canada/services/health-care-system/reports-publications/primary-health-care/chronic-disease-prevention-management.html
Health Canada (2020) Infographic: Canada Health Act. https://www.canada.ca/en/public-health/services/publications/science-research-data/canada-health-act-infographic.html
(HQO) Health Quality Ontario. (n.d.). Patients Readmitted to Hospital in Ontario—Health Quality Ontario (HQO). Retrieved March 6, 2021, from https://www.hqontario.ca/System-Performance/Primary-Care-Performance/Hospital-Readmission
(HQO) Health Quality Ontario (2021). EVIDENCE TO IMPROVE CARE: Chronic Obstructive Pulmonary Disease. https://hqontario.ca/Evidence-to-Improve-Care/Quality-Standards/View-all-Quality-Standards/Chronic-Obstructive-Pulmonary-Disease/About
Help Age International (n.d.). Lifecourse approach to ageing | What we do |. https://www.helpage.org/what-we-do/life-course-approach-to-ageing/#.YC21qo2dPRg.twitter
Huber, M. (2011). HEALTH: HOW SHOULD WE DEFINE IT? In British Medical Journal (Vol. 343, Issue 7817, pp. 235–237). https://www.bmj.com/content/343/bmj.d4163
Kawachi, I., & Subramanian, S. V. (2017). Social epidemiology for the 21st century. Social Science and Medicine, 196, 240–245. https://doi.org/10.1016/j.socscimed.2017.10.034
Miller, K. L. (2016). Patient centered care: A path to better health outcomes through engagement and activation. NeuroRehabilitation, 39(4), 465–470. https://doi.org/10.3233/NRE-161378
NEJM Catalyst. (2017). What Is Patient-Centered Care? NEJM Catalyst. https://catalyst.nejm.org/doi/full/10.1056/CAT.17.0559
OECD. (2019). Health At a Glance 2019: OECD INDICATORS. OECD Publishing Paris. https://doi.org/10.1787/4dd50c09-en
Raphael & Mikkonen (2020). Social Determinants of Health: The Canadian Facts. https://www.thecanadianfacts.org/The_Canadian_Facts.pdf
Richards, G., Frehs, J., Myers, E., & Van Bibber, M. (2019). The climate change and health adaptation program: Indigenous climate Leaders’ championing adaptation efforts. Health Promotion and Chronic Disease Prevention in Canada, 39(4), 127–130. https://doi.org/10.24095/hpcdp.39.4.03
Rodriquez, E. J., Kim, E. N., Sumner, A. E., Nápoles, A. M., & Pérez-Stable, E. J. (2019). Allostatic Load: Importance, Markers, and Score Determination in Minority and Disparity Populations. Journal of Urban Health, 96(Suppl 1), S3–S11. https://doi.org/10.1007/s11524-019-00345-5
Settels, J., & Leist, A. K. (2021). Changes in neighborhood-level socioeconomic disadvantage and older Americans’ cognitive functioning. Health and Place, 68, 102510. https://doi.org/10.1016/j.healthplace.2021.102510
Sibbald, B., & Stanbrook, M. B. (2016). Canada health act needs bite. CMAJ, 188(16), 1133. https://doi.org/10.1503/cmaj.161128
The King’s Fund. (2019, March 29). What does improving population health really mean? The King’s Fund. https://www.kingsfund.org.uk/publications/what-does-improving-population-health-mean
Waddell, C. M., Robinson, R., & Crawford, A. (2017). Decolonizing Approaches to Inuit Community Wellness: Conversations with Elders in a Nunavut Community. Canadian Journal of Community Mental Health, 36(1), 1–13. https://doi.org/10.7870/cjcmh-2017-001
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