Session 1 - Harnessing our collective will to rebuild health care
Dr. Katharine Smart
Good evening, everybody. It's great to see people joining us and joining our room. We've got an exciting evening ahead for you. I'm really excited to be your host tonight for the first session of the CMA health Summit Series. I'm the CMA president, Dr. Katharine smart, and I will be moderating this Twitter space is discussion. In a moment, we will hear from a panel of physicians and patient advocates about how to do health differently in Canada during COVID and beyond. We also want you to be part of the conversation and since there's no chat function in Twitter spaces, we'd encourage listeners to tweet using the hashtag hashtag CMA health summit. Since we're all participating in this virtual meeting for many parts of the country, I would like to acknowledge that we are all situated on many different treaty lands and traditional ancestral and unseeded territories. As such, we pay our respects to the traditional caretakers of these lands, and the firmer commitment to reconciliation, our shared stewardship of the land and our relationships with one another. Tonight, I think we have a very exciting and needed conversation ahead of us. The focus of tonight's discussion is saying our collective will to rebuild health care. We all know that Canada's Health Care System is in a crisis, that primary care is imploding, surgical and diagnostic back are overwhelming. And it may take years and billions of dollars to resolve and that in the meantime, patients and patient care is suffering as a result. At the same time, the pandemic has presented us with a once in a generation opportunity to build a more responsive, innovative, equitable and patient partnered health system. So how do we take advantage of it? Where do we start? And how do we make it a reality? I think these are the big ones in front of us. They don't have simple answers. But I'm confident that the panel we have tonight is going to help us get closer to those answers. So I'd like to introduce our panelists today. We have Dr. Tara Kieran. She is the fidelity Endowed Chair of improvement in innovation and family medicine and Vice Chair quality and innovation in the Department of Family and Community Medicine at the University of Toronto. Through her work as a team based family doctor, Tara Tara seeks to improve the healthcare system to better meet the needs of patients. And I know I have certainly enjoyed following her on Twitter and learning from her so I'm excited to hear what she has to say. Sue Robbins is an amazing healthcare activist, speaker and author, which is amazing. I'm always amazed by people who can box her new book ducks in a row. Healthcare reimagined explores the need to shift from a corporate monitor to a re humanizing of the health system. So it's going to be fantastic to have her insights on tonight. Dr. David Urbach is the head of the department of surgery and interim lead medical executive at Women's College Hospital in Toronto. David also focuses on developing new and better ways of providing surgical services that inform health policy decisions and address the issues of access to care patient safety and health system costs. So it's going to be great to have his his insight since surgical backlogs are one of the credibly pressing needs in our system. Dr. Nell Wyman is president of the indigenous physicians Association of Canada and Deputy Chief Medical Health Officer for the First Nations Health Authority in British Columbia. She's Canada's first female indigenous psychiatrist, and has more than 20 years of clinical experience working with indigenous peoples in both rural reserve and urban settings. And I've had the pleasure of getting to know Dr. Wyman in my work was CMA this year, and I'm very excited to hear her insights tonight. So I'd like to welcome everybody to this space. And I hope that you enjoy our conversation. So I'm going to lead off with a general question to each of our panelists. Tonight, we're here and our topic is time differently about healthcare in Canada. And I'd like to ask each of you, what does differently mean to you? So perhaps I'll start with now, why don't you tell us? What does differently mean to you?
Dr. Nel Weiman
Thanks, Katharine. And it really is a pleasure to be here this evening, and hello to everyone who's listening in? Do you know, I think from my point of view, you know, I can't help but reflect kind of, you know, on what has happened during the pandemic, what has happened to people accessing the healthcare system and what has happened to the providers. So, in order to be brief, and have my other panelists have a chance to speak as well, I think I'll speak to, you know, the the burnout amongst exhaustion amongst physicians that, you know, was confirmed and discussed a lot over the last week or so, with the results of the national physician survey that, you know, we have all been asked to do more with increasingly dwindling resources ourselves in terms of energy and capacity. And so I think we're really going to have to address that. And for indigenous physicians, for example, we're engaged in some work right now developing a framework for physician wellness, and joy and work. And I think just quickly the other thing that has risen to the forefront or at least, we're having more discussions about it is how COVID Unmasked A lot of the inequities in our Healthcare System particularly for people trying to access it. And access doesn't necessarily just mean having health services everywhere you turn, even if you live in a rural or remote place, access also has to do with people being willing to seek services when they are in distress. And we did see during COVID that indigenous First Nations Matey Inuit people were very reluctant to seek care in some instances, because of the fear that of how they would be treated in there. I'm speaking about racism and discrimination. So I've got lots more to say on that. But I think for now, I'll stop and hand over to some of my other panelists.
Dr. Katharine Smart
Thanks. Now, that's a great note to get us started off on in terms of some of the things we really need to be thinking about. Tara, can I go to you next.
Dr. Tara Kiran
Yeah. So thanks, again, for having me. And with an amazing panel I built want to build on those comments. Because I would definitely say that differently would mean to me equitable. And that includes really acting on the social determinants of health and having a healthcare system that acts upstream to prevent downstream problems. We we saw during the pandemic that issues like homelessness or precarious housing, Carius, employment, income, race, all of those impacted how well someone was how likely they were to get COVID, how likely they were to get really sick. And although we can address some of those through our healthcare organizations doing a better job at understanding bias and addressing bias, ultimately, I think some of those solutions really do need to be upstream in being able to tackle the social determinants of health and even the structural determinants that determine the social determinants. And by that, I mean racism, capitalism, sexism, etc. I also think a different to me different would mean, integrated health system that's integrated and community based. We saw, you know, in COVID-19, that there, the hospitals were actually pretty well positioned to deal with the crisis that came their way. They have AIPAC professionals working there, who deal with infection prevention and control as their job. They had the resources to redeploy staff as needed, where I think the strain was greater and whether there was less capacity to respond quickly and effectively were in the community based sectors. And those are sectors that have been relatively speaking, underfunded, but are also not integrated with the hospital sector. So you know, can we imagine a future forward where the AIPAC professional, the infectious disease professional at the hospital actually supports the the primary care centers, the home care centers, the long term care centers in being able to enhance their own infection prevention control, and that were working together in a network way? And that were community based, because I think another really tremendous, tremendous innovation and the pandemic or I should say, innovation, because I think we we known this for some time, but something we did, right was, you know, in many areas, was partnering with communities to get vaccinations to where they were needed. That took some time, but ultimately, when it when that was done in cities like Toronto, where I live, but also in First Nations communities. So there's tremendous success in the First Nation communities up in northern Ontario, because they took a community driven community based approach and being able to deliver those health care services. So to me, a better health care system is equitable, integrated, community base. And I'd also add patient centered and creative, but we can get to those in later on in the conversation.
Dr. Katharine Smart
Awesome, thanks for those thoughts. And I love what both of you have said so far. And I particularly love your comments about the importance of looking upstream. Because certainly as a pediatrician, that really resonates with me the need to really be supporting Canadians differently than we often do. Su or T would love to hear your perspective as a patient advocate. What does different look like to you?
Sue Robins
Well, thanks, Katharine. Um, yeah, so I'll be giving a patient and caregiver perspective. And doing healthcare differently to me, I think means looking at the reasons why we do health care to begin with. And I believe that health care at its core is about caring for each other as human beings, and it's about relationships between the caregiver and the care receiver. And I'm just gonna throw this in there, dare I say, I think it's also about love. And we've drifted very far away from what I consider our why. From my patient perspective, we've had a lot of incremental change, but to me, it feels like you're putting a bandaid on in the ICU, and is really not working. There's too much emphasis on what we do programs and services and not enough on the why we are here to begin with. And like I said, I believe that's about caring for each other. And right now, I feel as a patient, that healthcare is really built around the altar of efficiency. You know, I had 12 minutes for my cancer radiation appointment. That's what the radiation tech told me. That's it 12 minutes, nothing more. To get my breast cancer radiation, I had three minutes with my OB, when I when I was pregnant with my last child. You know, we had a cardiac cardiologist sort of dictating or notes when we were still in the room with our little baby with Down syndrome when my son was born 19 years ago, you know, I've had specialists who've had their hand on the door the entire time, they were talking to me, because I knew that they were rushed. And I believe that efficiency causes harm to both the patients and physicians and other clinicians. And that's because patients are not cars to be turned through a car factory, and that physicians are not caught are not factory works. And I'll just close with saying, you know, I have had the good fortune to speak at Grand Rounds, before the pandemic, even all over the world, I was actually in Tasmania, and in Toronto. And the same thing happened to me at these grand rounds in 2019, was that I was talking about kindness and healthcare and things like knocking on the door and introducing yourself and describing what you're going to do before you come in and all these small touches, which are actually a really big deal to patients. But every time I talk, I speak at Grand Rounds, I can see there's somebody agitated in the back, and they're just waiting to ask me a question. And so at the very end of my talk, we open up for questions, and somebody stands up and says, What we don't have time for all these kindnesses. That's what I get told. And if that's the case, and I've heard it over and over and over again, I really feel as if we've lost the plot here with health care in Canada.
Dr. Katharine Smart
Thanks for sharing that too. And I couldn't agree more. And what really struck me as you were talking was, I think, the root cause of so much burnout for the providers in the system, too, is that loss of connection with patients, which is why all of us chose this work to begin with. So I think thank you for reminding us that this is about people. It's about this. It's about connection. And it's not only patients that need that it's also the provider. So I appreciate that perspective. David, what are your thoughts? When we talk about doing healthcare differently in Canada? What does that mean to you?
Dr. David Urbach
It means a few things. And I think what it really means right now is using the this opportunity to address some systemic structural problems in the health system, that have really, really been problematic in Canada for many years, with respect to, you know, provision of surgical procedures, addressing things like access and wait times, and having a system that's really equitable for the population, and accessible to everybody and provides equal opportunities, also to the to the healthcare workforce. There's a lot of discussion now about the surgical backlog about the crisis with people waiting for surgery, the federal government has made a recent announcement of increases to the Canada Health Transfer to try and address this. And I think it's important to remember, when we're talking about a backlog, it's really just an extreme case of a an endemic and systemic problem that we've been grappling with for many years now. I think what's been unmasked to us is the nature of some of these problems, and how much inequity there is built into the system right now, as it exists, we do know that there are some tools available to us that can be really helpful in rebuilding a system that's more sustainable, that's more responsive to the needs of the population, and is more equitable for the population as well as for for the healthcare workforce. So to me, it means not squandering an opportunity to make much needed reforms that will really give us a better and more resilient system as we move forward.
Dr. Katharine Smart
Thank you, David. And I think that's so true. We're sort of at this juncture in time where we need to really capitalize on this moment and make sure that we can move forward with a system that's actually going to be there and able to medians. So we've heard lots of great opening thoughts from our panelists. And I'm not going to move into the next question to sort of explore those issues a bit deeper, I'd love to hear from each of you, you know, you've described sort of what you see your bit of the future, some of the fundamental ideas and values that underlie it. What do you see are the building blocks to create a more responsive, innovative and patient centered and patient partnered health system? I'm going to start with you this time, Sue.
Sue Robins
Sure, okay. The building blocks. Okay. So I just want to build on about what David said about system change. And, you know, I really believe there's two levels of change, there's system change. And there's also what we can do as individuals to make things better in our everyday lives. And, in fact, the ducks in a row is about that about what we can do what is in within within our power within our serenity prayer, but what's in our control and what's not as far as changing healthcare. So I have some very practical suggestions about what I believe from my perspective. I worked in patient engagement for many years, as well as being a breast cancer patient and also the mum of the child with Down syndrome, as I said, and my very practical sister Questions are these there's three of them. The first one is thinking of healthcare environments as healing spaces, not spaces that cause trauma to people. And, you know, you'd mentioned about creativity, I think leaning on the arts and the humanities is a really great way to start that, you know, I think about things like very practical, again, soft music in the waiting rooms turn off CNN and the TV, you know, leaning on the visual arts, and having spaces for storytelling. In fact, the last Children's Hospital I worked in, we started a book club, and we met with families together with staff to discuss the book that we were reading about health care. So really thinking about healthcare as being healing, I think that would be a reframing as opposed to traumatic, which I believe that it is, or it has been for me, right now. The second thing is, is to create safe spaces for feedback. And this to me, I get really stuck on this as a thorn. In my side, I don't think that those folks higher up in administration are open to honest feedback from either patients, or people, clinicians, people who work for patients. And I think if we opened ourselves up to the experience of health care, and what it's like to work in health care, and also to be cared for in health care, and that includes the good, the bad and the ugly, then I think that's where change would actually happen. And that hasn't happened so far. Like I, you know, anytime I've had some constructive feedback, I get shut down as being, you know, minimized or I get called hysterical or, you know, people just really want me to go away. But one point I really want to make is that patients have lots of really great ideas, especially for those of us who are invested in the healthcare system. And what's interesting about creating safe spaces for feedback, and for people to share their stories. There's an organization called care opinion in the UK, and they're also in Australia. And what that is, is a online system where people can share stories about their experiences of healthcare. And they've told me that 60 to 70% of those stories that are shared are actually good positive stories, which I think I wish there was a mechanism for us patients to be able to say thank you, especially now during COVID, to the healthcare professionals that look after us. And then the 40 to 30 to 40% of stories that might more negative or what I like to say is constructive feedback. I think that that's how we get quality improvement is when things go wrong. So, you know, that's my second point. And my third point is, you know, I hope we get to talk about patient engagement, because we talked about patient centered care, I know is in the title. But really, engagement is about outreach. And it means going out to the people and doing things together. I think and beyond the boardroom. And like Tara had mentioned, going out to communities defining what's important to them, is something that I think would really rechange reframe healthcare as we see it today and enough of the ivory tower stuff about people making decisions for us. So far removed with what real life is like both a point of care in the hospital and our communities.
Dr. Katharine Smart
Love all those ideas. So you thank you so much. And I think your point is well taken that we have to when we say we want feedback, we have to mean it. And we have to be open to what people have to say. And we have to think of real authentic ways to partner with patients and hear their voices, not just pay lip service to it. Tara, you have lots of ideas. I know, tell us what do you see as the building blocks?
Dr. Tara Kiran
Thanks, Katharine. I mean, I think I'd like to focus on two building blocks. And, and the first is really building off what Steve said. And that building block is patient partnership, and patient partnership, not just in a clinical encounter, but patient partnership to help us redesign the system. Because I totally agree with what Sue said. And I will say that working with patients has really helped me transform how I look at things, and has revealed to me my own blind spots, and often has led to new and creative ideas that I would never have come up with on my own. Sometimes they're actually obvious ideas that I'm like, Why didn't I come up with that on my own. But in any case, they're ideas that we hadn't come up with, and we weren't planning on executing, but that sometimes are simple, sometimes are complex and make make a difference. And, and so I'm speaking here from you know, when we started back in 2014, to doing a patient experience survey at our family health team to then lots of experiences I've had working with patients around focus groups or patient engagement days or even doing a province wide consultation around with patients. And I've learned so much from that. And I honestly feel that there's one thing I would go back and do differently around this pandemic that I felt I would have control over it would be to really fight to actually have built a Citizens Council during COVID where we could actually ask ordinary people who live in Ontario or Canada, what they thought at various stages and how they would value the trade offs. Because I don't think ordinary people really have that opportunity to engage in dialogue with decision makers to help inform those policies. And so that's just so that I think is a very key building block and thank you super articulating it so clearly. The second thing block is going to be no surprise coming from me. And that is, of course, I think a strong primary care system. So we know that health systems that have strong primary care systems have better outcomes, they have more equitable outcomes. And they actually also have lower costs. And and, and so you know, my dream is that every patient in Canada, every person living in Canada should have a family doctor or other primary care provider. And I don't think this is just a pipe dream, I don't think this is something that is unattainable. I really think we could make it happen if we if we focus on it. And also if we compromise, because I think there are trade offs that that we might need to make to make it a reality, I do think it would take some investment. So I think we, we need to make Family Medicine continue to be attractive to family doctors, and, and, and other primary care professionals. And that means, for example, changing the way we pay doctors, so it's not paper service. So we're not tied to time and the way that's to describe and to expanding team based care. Studies have shown that team based care produces better outcomes. We've just published a study that showed that, you know, teams, patients that will take take care from a team, they seem to help lower emergency department use and then those that weren't. So we know that that we also know that those things, changing the way we're paid as doctors and introducing teams is something that new doctors really want in order to be able to enter the profession. And it's something that doctors who are currently in the profession want to alleviate and address some of that burnout that we've been talking about as well. I do think that ideally, though, you know, those investments come with some trade offs, perhaps with physicians from an accountability perspective. So we need to be more accountable, I think to our communities, and the geographic neighborhoods in which our practices are based, and start to make more of a commitment that we're going to take on unattached patients, for example. And you know, to start, we probably have to be really mindful taking an equitable approach so that we're not just taking any unattached patient or the first comes through the door. But perhaps there's, you know, while we still don't have the capacity, we would desire when the capacity is more limited. Let's start by taking those who are most at need, you know, let's prioritize attachment for, for example, indigenous populations and black populations, population, people who are struggling with opioid addiction, people who we know, have, have a high need for healthcare potentially, or are at greater risk for health, worse health outcomes. So how can we prioritize those people to have access to a family doctor, I think we can do it and there creative ways. And some of my colleagues have already started to do that. So that those are the two things that I would focus on to start patient partnership and redesigning our healthcare system, and strong primary care.
Dr. Katharine Smart
Love it totally agree. So important, and certainly something that we have been trying to talk about a lot, as well as that need to really reimagine that primary care system in this country so that Canadians have access to the front door of the health care system. It's so critical and concerning where we're headed. And I think we're going to hear more from you on that topic shortly. But David, I'd like to go over to you now, what do you see are the building blocks that you'd like to see?
Dr. David Urbach
So I think I'd like to build a little bit on what Tara was just describing, with respect to working in teams and abroad are integration across the system, because I think that really applies to the way that we deliver surgical services as well. One of the problems right now is the the lack of coordination and the the siloed, and highly independent nature of how it of surgeons work and Canadian hospitals and how surgeries organized and I think there's tremendous opportunity for greater participation within the health system of surgical care providers. So that, you know, for example, we could be more coordinated into teams, you know, sharing the care of patients, we could have single entry models where pay, there's a central intake, or as a single queue for patients who enter a system so that wait times for surgery are more equitable, without as much variation as we see from region to region and hospital to hospital. Overall, these have a lot of benefits to the population and improved satisfaction with care as well as confidence in the health system. So I see that as a huge opportunity for system innovation, when it comes to how we organize surgical care. The other area that people often talk about is greater investment in the system, you know, greater funding or ability to increase the supply. It's important to realize right now, although, obviously, we need to provide as much surgical care as possible to address the issue of backlog. We do have some limits, primarily right now. We're really stressed with respect to Health Human Resources, skilled nurses and hospitals, and nice to test surgeons. Well, we really don't have that much capacity to really To increase the amount of services, we provide eight points. And I think, right now we really have to focus on what we can do to better coordinate and streamline the movement of patients across the system to be able to enhance access with the resources that we have.
Dr. Katharine Smart
Thanks, David, I'm hearing some definite themes emerge, I think from everyone a lot working as teams be more efficient with what we have looking for those potentially easy wins just by reorganizing how we do things and that importance of, of patient ideas and centering some of this on what they see. Because sometimes the solutions might be more obvious than them than they are to us. Now, I'd love to hear your perspective, what I think are some of the critical building blocks that we need to be thinking about as we reimagine the health system.
Dr. Nel Weiman
Yes, thanks, Katharine. I think my comments actually, I think, are very much aligned with what people have already mentioned. Here in British Columbia, which is where I'm situated, and I do work for the First Nations Health Authority, you know, even prior to the pandemic, there was a lot of effort that went into using cultural the, the ideas and actions associated with cultural safety and cultural humility, hardwiring those into the health system, this leads to health transformation. And and people have mentioned, you know, the, the concepts related to cultural safety already. But, you know, it is an outcome that's based on respectful engagement that recognizes and strives to address power imbalances inherent in the health system. So we hear that, you know, when people have mentioned patient centered care, for example, and cultural humility of the providers is, you know, that we all undergo a process of self reflection to understand personal and systemic biases, and to develop and maintain respectful processes and relationships based on mutual trust. So those concepts, I think, as lay a foundation for First of all, providing better care, increasing access, but in the benefit that everyone is it's it's a better system overall. And it manages to reach out to some of those communities and populations that have been underserved to date the some of the communities that Tara mentioned. So I'm using this in the in the, in the context, because of the work I do with First Nations, but it's really applicable to all and you know, here in British Columbia, for example, we are working on the finishing touches to developing a provincial standard, a partnership between the organization I work for and health standards organization that lays out the different domains that are required to increase cultural safety as part of different health organizations and health systems. And their you know, people I'm sure have heard of the different reports that have come out of BC during the pandemic as well, including the in plain sight report, which found that racism is widespread in the health system here in BC. So the other thing that I would mention, when we're talking about team based care and expanding different models of care, I would, I would say, from, you know, a First Nations lens from an indigenous lens, being able to work in what we call a too wide using a too wide seeing approach. So recognizing the value of Western medical systems and ways of being recognising the importance and value of indigenous knowledge and ways of being and, and that's not to say that every indigenous patient is going to want to see traditional healing or ceremony as part of their health care. But up until now, it has been really difficult for indigenous patients to access that in many instances, and that I think, you know, being able to provide work in those two systems in different settings, I know this is happening in other places across the country, not just in British Columbia CAMH, for example, in downtown Toronto, that provides better patient care, in this instance, to indigenous patients, but for other intersectionalities other groups, there are similar models that could be that could be used. So I think cultural safety in the system, cultural humility of healthcare providers prevent provides a really good background or foundation for moving transforming healthcare in Canada.
Dr. Katharine Smart
Thank you know, for highlighting that it's so important. And again, I think something that we just keep learning more about it and how critical it is to create a safe space for patients. And as you touched on an opening, actually having them want to access the health care system and having it be a place where they they feel safe is so important. We've been talking I think quite a bit about primary care. And I'd like to dive a little bit deeper into that issue, because it's such a critical problem right now, you know, as people have outlined tonight, we know that primary care forms the foundation are the backbone of our health care system. It's the front door into the health care system. You know, as Tara said, a high functioning primary care system is better for patients. improves people's lives makes people's lives longer higher quality and cuts called health care system. Yet we also know we're facing this huge crisis in primary care, I think a huge variety of reasons. But the reality of that is that all, you know, over 5 million Canadians don't have access to a family doctor. And we're expecting that to get worse, not better if something doesn't change. Also, our recent national health survey showed that almost half of doctors are planning on cutting back their clinical hours in the next two years. So it's it's concerning? You know, Tara, I know that your research really focuses on quality improvement and innovation in family medicine. And you you've already alluded to some ideas you have around the fact that we should have that goal of getting every Canadian, a family doctor, do you think it's achievable? So tell us more about that. What are you doing to innovate in this space? How do we get doctors practicing longitudinal Family Medicine, what can we do to get things back on track?
Dr. Tara Kiran
Yeah, such important questions. And, you know, I want to start just by building on what you said Katharine, about that the problem is just going to get worse right now. So I think, fortunately, some of the research that we've done ourselves here in Ontario has shown that the proportion of family doctors who stopped working was much higher in the first six months of a pandemic than it was for the 10 years prior to that. So that data to me suggests that, you know, many doctors went into early retirement. At the same time with then surveys of family doctors in Toronto and found that nearly one in five physicians, family doctors in Toronto have an active practice, are thinking that they may close their practice in the next five years. So yeah, really concerning that, we already have a workforce shortage and things may be getting tighter. So I do think that we need to place pieces to stabilize our workshop force and make Family Medicine attractive to the people who are in it now and to new graduates. And the noticing, as I was saying earlier, I think that that involves payment reform. And it's great to see that advancing, for example, here in Ontario, and as well, in British Columbia, there are some pilots that seem like they need to be expanded. There are other pilots elsewhere as well. But we really need to move away from fee for service more towards blended payments and payments that encourage also care of people with complex who have medical complexity, because that's been a weakness in Ontario for some time. And then, you know, working in teams, so I work with a pharmacist, a social worker, a dietitian, nurses, these are all part of the my amazing team, in my practice, which is a family health team. And I feel lucky to do so every day. And so that's, that really transforms how I can deliver care. You know, I'm many, many years from medical school, but I can still keep some of the latest new medications, including new medications to treat COVID, because I have a pharmacist who is in the office beside me who I can consult and who can give me advice around starting these kinds of new medications. When a patient is struggling with depression, I have a social worker who I can turn to to ask, you know, what are some, you know, resources that might support them? Or can you see them for a short time for a limited amount of time to kind of get them stabilized? So So, and then, you know, the nurses are absolutely indispensable. So for, for example, when people we were managing a lot of people with COVID, as vocations our nurses ran a whole COVID care at home program, where they would check in with with, with folks and I know many of my colleagues practice it practice in settings that don't have those resources. And that's not fair to them. And it's certainly not fair to their patients, we need to expand this kind of team based model, which works which provides joint work and better patient outcomes across the country. I also think that there's ways in which we can really lean into creativity and collaboration and learning from what's worked right in different settings. And so I'm most familiar with the innovations occurring in Ontario, but I want to just draw attention to a couple of colleagues who have been doing amazing work. So Jonathan Fitzsimons, and Renfrew County, for example, has been doing incredible work collaborating with paramedics to deliver primary care in an underserved rural area and then trialing Virtual Family Health Team as a way to deliver care to unattached patients as well. So using creative solutions, to try and meet a very challenging problem. Another person whose work I'd like to highlight is TFM, Doctor TFM, a close colleague of mine who that se trata family health team. She's worked with colleagues in the East End to join to put together a family practice network. And these, this family practice network was really instrumental in COVID. And being able to deliver vaccinations and in long term care in their area. They were one of the first to be able to, to actually complete all the vaccinations and long term care in their neighborhood to take care of patients in retirement homes, to step up during port when it came to testing and some of the priority neighborhoods in Toronto as well. So that network of doctors was stronger than any of the single doctor practices on their own and And how can we learn from these kinds of innovations? I think we can I think we can start to move towards more network models where we support each other to care for our communities. And that's the kind of innovation I'd like to see coming out of the pandemic.
Dr. Katharine Smart
Thanks for highlighting those examples. And again, I think we're just noticing a lot of themes that we're caring for each other, you know, this idea of team, working with other like minded people feeling supported to care for patient sharing, sharing that that work, to make sure that patients are getting what they they needed. And finding that joy again, in this work, which I think takes us back to what Sue said at the beginning, which is that medicine should be about connection and kindness and finding the finding that with each other.
Sue Robins
I Katharine, Can I just jump in really quick. I'm just thinking about primary care. You know, when we're talking about team, I always have this hope I was saying about the reimagine healthcare world, but that we're not only talking about professionals that we think about patients being on that team, too. I think that that's really, really important. And I was just thinking when Nell was speaking, you know, she was talking about choice and giving people choice as far as what type of medicine they want to access. And a lot of people ask me about patients, they say, though I don't represent patients, I only represent myself, but they say what do patients want? And my answer is always It depends. And how do you find out what patients want? And the answer to that is ask them. So when terror terrorist talking about all the different team models, and I came from Alberta, which had, I don't know if it still does, but it did have, at the time, a very strong primary care network model. And I think having that choice, when you enter primary care to go to a social worker, or an NP or a pharmacist, I think that's something that patients would embrace as well. And also have, you know, choices of urgent care centers and places are open a bit later. So we don't always end up in emergency. And, and no, the choice I think works both for you as the professionals and for us patients, because we're not alike. None of us are alike. So there is no one answer for everybody.
Dr. Katharine Smart
Yeah, so true. Totally agree with that. And I think that's a great perspective. And you're absolutely right, I think we need when we think about what we mean by team, we need to be thinking about patients and their plays on the teams with us collaborating 100%. So, Tara, I know you work in Toronto, and you're talking about colleagues, Ontario, I live in in the north in the Yukon. And we know that there's, you know, other challenges for sure, reaching remote and rural communities. And I know that one of the really exciting things I think we've seen out of British Columbia, and the First Nations Health Authority is their work with some more remote and rural First Nations communities. And we've saw, again, a ton of innovation and important models of care that were created there to make sure that patients, First Nations patients in BC were able to access care. So now, I was hoping you could tell us a bit about your experience working at the First Nations Health Authority during the pandemic, when what the rest of the country can learn from your health authority, and the way it was able to guard and champion the health and wellness of indigenous people in British Columbia.
Dr. Nel Weiman
Yeah, thanks, Katharine. I think you know, one of the one of the things that happened at the very beginning of the pandemic was we realized that people would need to, you know, would need to be in touch with health services and access them, even while many communities are located in rural remote and very isolated settings, in some cases, some communities or only fly in. And so very quickly, a virtual service was set up, which was the virtual doctor of the day program. And for the first time, some people had access to primary care that they didn't before. And of course, the the service was grounded in cultural safety and cultural humility. And we found that people you know, who hadn't access for the variety of reasons that I've talked about, and others have talked about earlier, was you know, there was really good uptake. And then almost quickly after that, we realized, the other thing to remember is that British Columbia has actually been living through two public health emergencies. One is the COVID pandemic, and one is the toxic drug poisoning crisis. And in many ways, First Nations communities have been disproportionately impacted by both. So there was another virtual service that was set up the virtual psychiatry and substance use service where people could see either psychiatrists and or addiction medicine specialist. And the two of those two virtual services worked together in a complementary fashion. So if you are unattached, for example, to a primary care provider and wanted to be seen during the psychiatry service as an example, you could quickly be seen by the doctor of the day and then referred on to see the specialist so that was something that will that was stood up, it quickly reached capacity. But and we're looking to expand and it will be one of our legacy pieces as the you know, as the pandemic sort of, hopefully at some point starts to wind down. And then I guess the other thing you know, that was I mentioned, I think it was Tara mentioned, it was just creativity, you know, being able, even in the midst of being very stressed, and everybody working very long hours, like the vaccination rollout, for example was, you know, extremely successful here in British Columbia because people used creativity as a way to deliver vaccines and one creativity, one creative way was, we took a whole of community approach, whereas the rest of the province was allocating the nation by age group, we strongly advocates for a whole of community. So communities were 18 and older to start with were vaccinated. So those are just some quick examples. But I think what I really want to stress, I think, for us, as physicians is that need to, you know, even though we're kind of overworked, and we're feeling we're feeling stressed out, we're feeling overwhelmed. But there's always been that space, that motivation, that drive to continue to advocate for our patients and, and be creative in doing so and looking for the solutions. And that will differ, of course, across the different provinces and territories from coast to coast to coast.
Dr. Katharine Smart
Thank you Now for those examples. And again, I just think it's amazing to see how people were able to pivot in a crisis to leverage different tools to actually improve access to care, which is amazing, right? Because we were worried about that, how are we going to reach people, and you've actually been able to find a model that improved care beyond what communities had experience before? And then how do we keep moving that forward. So it's amazing to see, like you said, just that creativity, and that importance of seeing communities and their unique needs and listening to what they want, which has been telling us about a minute pivot a bit away from primary care now and back to something we talked about a bit at the beginning. We know in addition to the crisis in primary care, probably one of the other biggest pain points in the current system is the backlog issue. We did report at CMA last fall and estimated that we were going to need a minimum of $1.3 billion in funding to clear that backlog across only eight medical procedures. So we knew that was really the tip of the iceberg. And that was before the fourth and fifth waves of COVID that increase backlogs er, and we know that the main backlogs are imaging and surgery. And we know that these delays have had an incredible impact on people's quality of life. And there's a lot of suffering. You know, David, you're a surgeon, you're the head of the Department of Surgery at a large hospital. And you've talked a little bit about you have some ideas about what we could be doing about love to hear more from you about what are some innovative approaches to improve capacity, and reduce this growing backlog and these rarely critical, important surgical procedures.
Dr. David Urbach
So I think some of the technological innovations that we've seen over the last few years have been really helpful in addressing some of these problems. You know, in particular, use of, you know, for example, outpatient surgery for common surgical procedures. You know, total joint replacement, which historically had always been an inpatient procedure with a few days in hospital has been transformed into essentially an outpatient procedure for hip and knee replacement. A lot of surgical procedures can now be done on an outpatient basis, which really helps improve efficiency decreases dependence on hospital beds, which obviously become very, very scarce. So these types of technological innovations have been really helpful. And I think it's a trend I'd like to see continued, which is innovations that, you know, in the past, it seemed like a lot of innovation just really increased cost and complexity. But now we're seeing innovations for sustainability and for efficiency within the health system that I think is going to be really important. So those types of innovations are really helpful for improving our capacity to do surgical procedures. There's probably also some work we can do on the demand side, we do know that in addition to this huge backlog of patients who are currently waiting for diagnostic imaging, testing and procedures, surgery, you know, a lot of those are for urgent and critical procedures. But we do know that a lot of people are waiting for tests or procedures that they may not necessarily need. If we can do a better job at improving our appropriateness to make sure that the patients on the waitlist are really those patients who truly need the the tests or the procedures that they're waiting for, will obviously reduce the wait times for everybody within the health system.
Dr. Katharine Smart
That's such an important point, I think about that accountability and how we're using resources and making sure that they're being used effectively. So that there is more access to people and and I think that's, you know, one of the things we've been talking about is the need to have more of a data driven healthcare system. And I think what you're talking about would, you know, is just one more example of how data could improve the way we utilize our resources if we're able to track and monitor the appropriateness of diagnostic imaging, testings, referrals, surgeries that patients have to make sure that we're optimizing those outcomes. So I'd love to hear from Your perspective, like as a patient, what do you think we could be doing to reduce wait times when you're hearing this conversation? What springs to mind for you?
Sue Robins
Well, I'm currently waiting for a mammogram. And I've been waiting for six months. And I still haven't received my appointment from the Cancer Agency. And I did have breast cancer before. So it's a little bit distressing, in the waiting, and I wanted to talk about the data, because I'm a data person, but the stories behind that, and I used to work at a children's hospital that had an Autism Clinic, and there was a very long wait list for the families to come in with their kids to get diagnosed, to have the assessment to get diagnosed with autism. And I would talk to many, many of those families in that waiting, and how distressing it is to wait. And in fact, the time between I went to my family doctor, you know, with a lump in my breast to when I finally got my breast biopsy was three months. And I have to say that that waiting was purgatory, it was awful. It was like the worst thing, thing, you know, once you're finally off that waitlist, and they're doing something, I think mentally that's a lot better for patients. So I've always wondered about weightless, if anyone has ever talked about the experience of either being on a waitlist or waiting to get on a waitlist, which is there's this pre waitlist thing that happens to right, while we're waiting for a referral to a specialist, and how we are caring for people while they're waiting. I think, you know, in the absence, like David said, you know, there's certain capacity for Oh, ours and surgeons and and if we reached that, particularly with that staffing crisis, is there a way for us to be caring for people while they wait, so that they don't experience so much in the waiting. And I think, you know, people like peer support workers and social workers could really, you know, nursing navigators, those types of people could probably step in and make your job this positions a bit easier, because we're not quite as distraught by the time we get to you, right, within the waiting. So, you know, as we talk about these kinds of hard things, these database things, I just hope that we can always think about the experience and the story and what goes along with it and talk about those things together.
Dr. Katharine Smart
I think those are great points. And I think, you know, the other thing it touches on I think is how much we've normalized waiting in our health care system. Right? We've, we've taken waiting for all these things as you as you outlined and kind of made it an expected part of the experience rather than asking those questions about could this look different? And I absolutely agree with you. And I see that certainly with my patients. Just the stress and anxiety that people experience when they're waiting, particularly as you said, or maybe not experiencing care in that period can be really impactful.
Sue Robins
Yeah, even even the term backlog like that return that reminds me of like a sewage backup, like hope that we can remember that there's people behind the numbers, like that's one of the things I've despaired about so much with the pandemic, is that I feel like our public health officials have totally dehumanized, you know, people have gotten sick and died from COVID. And what's really important to me, as we start, you know, remembering there are people behind the numbers who have families. And, you know, always talking about both right, the numbers are important, but also the story pieces important to
Dr. Katharine Smart
know, I absolutely agree with you. And I think there is nothing more powerful than that stories. And I think they're very compelling. And they're an important part of, like you said, moving past just just the numbers to really understanding the human the very real and human impact of these issues. So we've got about six minutes left in this discussion, and was just announced today that the federal budget is going to be tabled on April 7. So we've heard today about lots of potential areas that we want to see focus on that we think need to change. So I'd like to just ask each of you to close out with what you're hoping to see in the budget, and what needs to be in there from your perspective to address the future of healthcare. So why don't we start with talk, Tara?
Dr. Tara Kiran
Katharine, there's always so much that I think we all want to see in the budget. I mean, maybe I'll just start by saying that I I am hopeful for that we will make progress on national dental care and PharmaCare program. That's been a long time coming and will really help to improve the health of so many low income Canadians. I know that the details right now are a little vague, especially on the pharma care. And so I do hope that there are more details that will see this forward in the next short while. But building on that I thought Andre Picard had a terrific op ed in the globe that I read this morning, that just really helped, you know, talked about how we need to step back and think about you know, what, what is Medicare about and what should be covered in Medicare, and for so long, it's been, you know, focused on physician and hospital services. And so it's great to see the dental care and the home care, but sorry, the dental care and the PharmaCare. But of course, what the pandemic and pre pandemic reports have highlighted is, you know, we need to also bring in long term care and home care better into our system and mental health care, mental health care. have, you know, there have been some great innovations during the pandemic just or great new services, I should say, during the pandemic, that have allowed people to access that virtually I think those kinds of things need to be expanded to have greater public access and a structured way. I think some, you know, work we've done around home, transitions from hospital to home has really shone a light for me on how patients and caregivers, they think the non priority for improving that transition would be better quality and more accessible home care. And then, of course, I don't think I need to tell anyone who's listening about why we do invest better in long term care. So I think we need to really take a look at these other sectors. And I'd like to see more of that in the budget upcoming.
Dr. Katharine Smart
Yeah, totally agree. Absolutely. And like you say, when we say universal health care, we really need to define what we need mean by Universal and and I think that list that you offered is much more comprehensive than what our system currently offers Canadians. Now, what would you like to see?
Dr. Nel Weiman
Well, I think in addition to what Tara has mentioned, I think the one thing I would like to see is an expansion of services that offer, you know, both Western medical services and for indigenous people, you know, indigenous forms of healing ceremony, cultures healing, you know, there are models of this across the country. But I would like to see funding for the expansion of those services.
Dr. Katharine Smart
Thank you. Yeah. So, so needed. And I certainly see that in my work in the Yukon and that something our communities, they're asking for, David, your surgeon, what do you want to see in the budget,
Dr. David Urbach
I'm just most worried about the degree of federal investment in, in health care, I think it's really important to make sure that it doesn't wane much more, because I do worry about the provinces, ability to be able to provide comprehensive services that address the principles of the Canada Health Act. And with the declining share of provincial expenditures that's covered through the Canada Health Transfer. I think we become at risk without continued and increased federal investment in health care. And I think that's the most important thing I would look for from the federal government.
Dr. Katharine Smart
Absolutely, that's critical. We know that dollars have stagnated, and they're sent to decline as a percentage cost. So stabilizing investments in our system will be key. So I want you the last word, what matters to you in this federal budget?
Sue Robins
Boy, I'm hardly an economist. I've got a degree in Shakespeare. But anyways, let me give you a sense, from my bias perspective, I have a son with a disability. Well, dental and PharmaCare is very important to us, I just paid his dental bill a couple of days ago, and that would be great to have help with that for disabled people. But I think what we're really missing is some sort of disability benefits that's universal for folks who are disabled across Canada. So it's not just so piecemeal, province to province species benefit amount is extremely low compared to other provinces, considering our cost of living, especially since there's going to be a lot of people with long COVID that are going to be flooding into the system fairly soon, and who are unable to work and who need that support as far as a disability benefit. And I know, it's something our organizations have been lobbying for. But I gotta tell you, you know, you talk about equity and inclusion, disability tends to come last. And so I wanted to make sure that I mentioned it, my son certainly doesn't get nearly enough money for him to be able to live on and get $400 a month for rent, which in Vancouver area is ridiculous. So there's that. And then my other two things is, if I had a magic wand, and I'm doing real blue sky thinking, and I know this is not going to show up in the but I wish nationally there was some mandate that there had to be engagement with patients, not just at the hospital level, but at all levels in health care, including community health care, including public health. I wish this was more of a mandated thing like it is in some of the Australian health regions and in the NHS in the UK. And also, I think we're counting the wrong things as far as funding, really, we count like efficiencies and acuity and length of stay and all that type of thing. And what I wish that we counted were feedback mechanisms, like the patient experience, and what the experience is like in health care. I wish that that was somehow tied to funding because I think that's the only way the patient experience is going to actually improve. So those are the three things that disability benefit, mandate engagement of patients, and also some sort of mandatory feedback mechanisms for patients.
Dr. Katharine Smart
All fantastic ideas. Well, we're out of time unfortunately, feel like we could carry on this conversation for a long time. There's so much knowledge in this group of panelists and, and so much to be done in the healthcare system. But I really want to thank each of the four of you for your time tonight and your insights and how to build a stronger, more sustainable and patient centered healthcare system. And to everyone who joined us tonight as a listener. Thank you so much for taking the time to join. It's not too late to tweet your thoughts about The session or any ideas you have or things you want to contribute to the conversation about how we should do health differently during COVID and beyond, so please use hashtag CMA health summit. We'd love to see your ideas helps us think about future events and to inform these discussions and questions for our next time. May 11. Will be that next EMA health summit session and we are going to be focusing on health care and economic prosperity. So for now, good night, and thanks for joining
Session 2 - Health care in Canada – How might it drive economic growth?
CARLY WEEKS: Good afternoon, and welcome, everyone, to this event. I'm really looking forward to having this discussion today with a range of experts on some really important topics that have impacted everybody during the last two years.
My name is Carly Weeks. I am a health reporter with The Globe and Mail. And I will be your host and moderator during this event. I would like to acknowledge first that The Globe and Mail headquarters is situated on land in the traditional territory of the Wendat, the Anishinaabe, the Haudenosaunee, and the Métis Nation, as well as the Mississaugas of the Credit First Nation.
During this broadcast, if there are any technical issues, you can click on the Help Desk icon to try and resolve those. We're also going to be looking for questions for the panelists or for the first interview guests that I'll be speaking to right off the bat. So if you do have a question, please submit that. And we will get to those in due course.
The pandemic has obviously impacted everybody's lives-- given the fact we're speaking virtually-- personally and professionally for all of us. Today we're going to be discussing what some of those impacts have been, what impacts there are for the health care system, the intersection of health and the economy, and where we go from here. I think we can all agree that there are many longstanding issues with the Canadian health care system that the pandemic has brought to light. And it's also exacerbated some of them, everything from excessive wait times for surgeries and specialist appointments, to unequal access to care in many parts of the country, as well as even trouble accessing a primary care practitioner.
We also don't often speak enough about the impacts that these problems have on the individual, families, and caregivers around the country. Because of the pandemic, many people have been forced to wait longer than even before when it comes to certain surgeries or procedures or appointments. And it's also disrupted many aspects of the economy forcing many businesses to close, many people have lost their jobs, and ongoing supply chain issues that have affected many parts of the economy. So we're going to be focusing a little bit today on where we go from here and looking at some of the solutions, hopefully, to addressing some of these longstanding crises in our health care system, and where the health care system intersects with the economy, and what we can do about that.
So to speak to me about this, first off the bat, I'm pleased to introduce Nadeem Esmail, who is a senior fellow with the Fraser Institute. Nadeem is in Calgary today. So thank you for joining us here. And right off the bat to get us started, we're speaking about health care and the economy. I want to just ask some of your reflections on what we've seen, the insights you've gained over the last two years and where we do need to go when we think about the intersection of health care and the economy.
NADEEM ESMAIL: I think what's fascinating-- and thank you so much for the opportunity to present today. I think what's fascinating is we entered this pandemic with a fairly poorly resourced health care system, in spite of the fact that it is one of the developed world's most expensive universal access health care systems. We began the pandemic with fewer hospital beds than the vast majority of our peer nations.
In spite of spending more, we have fewer physicians per 1,000 population. We have fewer medical technologies. And that really came to bear as we came through what happened. Our hospital system was overwhelmed much faster than the hospital systems in our peer nations, forcing us into lockdowns quicker, which had significant impacts on the economy.
And remember, that economy is already paying for one of the developed world's most expensive universal access health care systems. So we were spending more, we were getting less. And in part, as a result, we locked down much faster and much more aggressively than other nations may have had to, simply as a result of not having the capacity to look after people. I think that's one of the key things we have to think about as we move forward, is getting Canadians better value for money to really build that support in so that the next time this occurs, or even on the next wave, we're ready with a health care system that is reflective of the amount of money we're putting into it.
CARLY WEEKS: So what does that look like then, specifically? Talking about some of those ways of moving forward, what potential solutions are on the horizon?
NADEEM ESMAIL: Fundamentally, when we look internationally at the health care picture, the Canadian health policy model is just not working for Canadians. And it's quite different from what other nations have been doing for many years very successfully. There are developed nations out there that really don't have any waiting lists in the health care system. There are waiting times, but they're more scheduling delays and moving people around as opposed to an actual queue.
And all of those health care systems have private competition and delivery, have private alternatives in finance, have cost sharing or user fees to encourage more informed decision-making about when and where it's best to access the health care system, of course, with reasonable limits, of course with exemptions for low income populations. They have activity-based funding, paying hospitals for the care actually provided, not budgetary basis. These policies together have developed some world class health care systems in countries like Switzerland, Germany, the Netherlands, health care systems that do a far better job of delivering universal access health care without costing more than the Canadian system.
Even going partway down this road the way Sweden has in the 1990s with activity-based funding and private competition could have a dramatic impact on our value for money here in health care and the health care system's ability to better support a well-functioning economy. Let's not forget that wait times in Canada last year cost Canadians just about $4.1 billion in lost time and productivity as an estimate. That's a significant cost on those waiting. And that could be eliminated by changing the way we perceive our health care system and the way it is structured in policy terms.
CARLY WEEKS: It is interesting to compare ourselves to other developed countries and look at the fact that our outcomes are generally, in many areas, worse. And this is something that was echoed during the most recent federal budget, where Finance Minister Chrystia Freeland said that very thing herself, that we were actually peeing more but we're getting less. I think one of the arguments we often come back to when we're having this debate-- and I would love your take on this-- is that we talk about, well, if our system is not working, then we obviously have to introduce some private component because that is somehow going to magically solve the problem.
In a lot of the conversations I'm having with health policy experts around the country, what they're saying is that we're actually not treating people very well. And what I mean by that is we're waiting for people to get sick, to show up in the hospital, when they probably could have had-- if they had just had care at home, they could have stayed at home longer, and that kind of thing, so sort of a preventive care model, really investing in community care, and keeping people well at home instead of cramming everyone into hospitals because they basically have no other choice. So talk to me a little bit about that because those are a lot of the solutions that some of the-- the experts are saying we need to basically restructure how we deliver health care, instead of just introducing a new competition component to it.
NADEEM ESMAIL: That is something that's happening around the developed world. It's happening in countries across the globe, where the search is out for better ways to deliver health care, deliver health care more proactively, to really explore the boundaries of what we can do with medical technology now. And there have been some fantastic pilots, even in Canada. There's some great work being done around the developed world. And certainly, that will improve the health care system.
But at the end of the day, there will be people who fall ill, who are injured, who require access to a hospital because there is no alternative. And we need a better way to do that as well. And that's where I think it's important to look to countries, like even Australia, which is geographically and demographically not very different from Canada, but that spends less on health care and has a better universal access health care system to show for it because they've structured their health policies quite differently.
We still need a good, high-functioning, well-structured hospital sector to look after those who do need it, while also considering all of the great things that are happening around the world in health care that need to happen here as well. What we can't do is do the old Canadian thing and double back down on an already failing system, on an already failing structure. And I think the concern forward is-- governments are often wont to do that because that's the politically expedient thing to do. It's not the right thing to do for the taxpayers who are paying for the health care system or for the patients who need access to it.
CARLY WEEKS: One of the things that you touched on, obviously, is lost productivity. And there's obviously a cost, in addition to the way people are feeling and injuries and illnesses and those kinds of things. I was wondering if you could just reflect for a couple of moments on the broader impacts on the economy. So I think that's something that-- we obviously, rightly, focused first and foremost on health outcomes. Why do we need to also pay attention to those economic outcomes too?
NADEEM ESMAIL: We have to recognize that when we have delayed access to health care, limited access to the health care system, waiting and having delayed access to elective surgeries-- which are still necessary, they're just not urgent-- that's not a benign process. Waiting for health care does entail some measure of worthy, of mental anguish, of lost productivity at work and leisure, of strained personal relationships. It does entail, for many patients, a decline in their medical condition, which could mean poorer outcomes, could even mean permanent disability or death, all of which would have been avoidable if we had more timely access to health care services.
A recent estimate puts that at about $4 billion of cost on the Canadian economy in terms of the value of lost time. There are other estimates that suggest the true number might even be as much as 10 times that number, depending on how we want to consider the impact. But we know that Canadians, as they are waiting, are losing time at work because they're worried about their health care condition.
They can't go to work. They can't provide for their families. They're having strain on their personal relationships. That permanent disability will have an impact as well.
An interesting example of how this has been dealt with in the workers' compensation is in British Columbia. Expedited surgeries are sometimes more expensive than waiting for the surgery in the public system. However, the savings in terms of reduction and disability payments is far greater than any additional cost in surgery. So we know even within our own country that the workers' compensation boards have figured out that waiting for health care is really remarkably detrimental on a cost analysis.
When we look at the health care system and we think about the economy, we have to reflect not only on how much it costs us directly, but also on the impact it's imposing on those who are waiting for health care, who, when we look internationally, really don't need to be waiting anywhere near as long as they are now. Canada has some of the longest waiting lists for health care in the developed world. And that undoubtedly has a drag on economic activity.
CARLY WEEKS: There's also obviously a very important question about equity. When we talk about introducing more of a private system, introducing competition, the ability to pay will obviously determine under that kind of system how some people are able to access care or how easily they're able to access that care. Geography is already a huge stumbling block. It keeps our, quote, unquote, "universal system" out of reach for many. So what would you say to those people who have those concerns about what is going to happen to them under that kind of a model?
NADEEM ESMAIL: I think there's a misunderstanding about how the private sector can contribute to the improvement of a universal access health care system. If we look at what countries like Australia, Sweden, Switzerland, and others have done, they have involved the private sector and private competition in the public health care system or in the universal access health care system, which means we're improving access for everyone throughout the system by improving value for money, by improving the volume of services provided, by improving the quality of services provided through competition. A private parallel sector does improve access for those who pay for it, but it also has the effect of taking people out of the public health care system.
In Australia, a large number of people are cared for in that private parallel sector. But that allows the publicly-funded sector, the sector that doesn't require patient payment, to focus on those who need the health care and bring waitlists down. Let's never forget that we have one of the developed world's most expensive universal access health care systems and some of the longest waiting lists for access to health care in the developed world. By no means is the Canadian system any sort of beacon for equity and access.
CARLY WEEKS: That is a good point. And I guess, to leave it there, we've spoken a lot about European countries and how more of a hybrid model that they're using does yield better results. When you do look at countries like the US, on the other hand, we all use that as the benchmark for how not to do health care. And as we all know, they don't really have any kind of a universal health system set up. There are ultimately a lot of fears that we'll end up in that kind of a situation, where it is like The Hunger Games for health care. So how do you avoid that kind of thing?
NADEEM ESMAIL: I think the Canada-US comparison is a false dichotomy. We have a government that is focused on universal access health care. The Canadian population clearly desires it, so our policy construct allows us to have that universal access health care system. The question is not, how do we avoid a US model deliberately?
The question is, how do we have a universal access health care system that best serves the needs of Canadian patients and the taxpayers who are funding their care? And the examples around the world are very clear on how to do that better, from Sweden, Switzerland, the Netherlands, Australia, Germany, France, Japan. There are a large number of developed nations that are spending the same or less on health care than we are that have better universal access health care systems to show for it. We need to take those lessons, adopt them, and move forward to the benefit of Canadians.
CARLY WEEKS: Nadeem, thank you, that was such a nice, great wrap-up point. So I'll have to leave it there and just thank you for your time.
NADEEM ESMAIL: Thank you.
CARLY WEEKS: And I'll go right into introducing our next guest. So I am now going to be speaking with Dr. Danyaal Raza, who is a family physician at St. Michael's Hospital, which is part of Unity Health Toronto. He is also past chair of the Canadian Doctors for Medicare. So thank you so much for being here today and speaking about these issues. I think you have an obviously really interesting perspective, having been a physician during this pandemic. Speaking-- or I guess reflecting on some of the comments that we just heard from Nadeem about the devastating effect the pandemic has had on health care, on the economy, what are some of the reflections that you're having right now or insights that you've gained and where we go from here?
DANYAAL RAZA: Yeah, so I'm a family doctor. And I'm very much kind of in the middle of it and providing not only direct care but quarterbacking care for many of my patients. And that's been, of course, true before the pandemic, and it's true now.
When I look back at the lessons of the past two years, I think COVID has emphasized a few things. It's emphasized what we do well in the system, but what we definitely need to do better. So for example, if you look at our acute care outcomes, things like emergency surgery or cancer care, we actually do quite well. And when you saw the way, especially in the first two waves of COVID, our health care system created this incredible ICU capacity, worked not just between hospitals and single provinces, but across jurisdictions, I think that was quite remarkable and just shows what we're capable of.
But of course, that didn't come without a tradeoff. And we're seeing the consequences of that now, where we're having delayed care for chronic care. So not just things like elective surgeries for hips and knees or cataracts, but we're also seeing issues in primary care where I'm working. And we're seeing backup in care there.
And I think it's also highlighted-- when we think about things that are included within Medicare and outside of Medicare, I think it's also highlighted some of those differences. So for example, acute care is something that's covered by a universal health care system. But things that aren't our long-term care. And we saw some of the devastating outcomes in long-term care.
And also pharmacare associated with all of the job loss during the pandemic, I had patients who were losing their employment-linked drug coverage. And I'm writing their prescriptions for things like insulin. It's put us in these very difficult situations. And the good news is I think we actually have a number of solutions that enhance both equity and access that I'm hoping we take seriously.
CARLY WEEKS: I've heard so many people say that this is now the time to have those conversations, that if we don't talk about the changes that we need now, when are we going to? And pharmacare is a perfect example because we've been talking about that for decades at this point. And we're inching ever closer, but still so far out of reach.
You said the magic word of solutions. That's hopefully what we're here to focus on today because we've talked for two years about the problems. What are some of the things that you are thinking about or some of the things that you see from your perspective as something that we really need to bring into the system to improve it?
DANYAAL RAZA: So I'd put them in three categories. Number one is stop underfunding the system. Number two is use the funding that we have but also potential new funding to do things differently, both inside of Medicare, but services outside of Medicare. And then also take a look at what we do outside of our health care system at our economic and social policies and how we can use those to enhance the health of people in Canada.
CARLY WEEKS: What does that look specifically, like on the ground example say, whether it be improving how family care's delivered, hospital care? What are some of the examples you'd cite?
DANYAAL RAZA: Yeah, so let me start with the funding piece because that's always a hot topic. And if you look at overall health care spending, we do spend above average for sure. But when you break it down to public versus private spending, we spend about 70% of all of our health care dollars publicly. And when you compare it to peers in Europe, like the UK, the Netherlands, France, Sweden, they all-- Germany, they spent 75%, 85% publicly.
So we actually-- I think a lot of people are surprised when they hear this. We spend less on our public health care system than many countries we're used to comparing ourselves against. So one is we have to be honest about that. And if we want to have a high functioning universal health care system, then we have to be able to fund it to do those things. But also, we have to use that money in smarter ways that have caught up to the ways that practice has changed.
So for example, something that we're beginning to see more and more, but I think one of the things we always struggle with in spread and scale is how do we connect patients from my office into the offices or the surgical rooms of, for example, orthopedic surgeons who are doing hip and knee replacements? The old school system is, I had my-- I don't have Rolodex, but let's just say I had my list of orthopedic surgeons in my community. And a patient walks in and I said, OK, we've maxed out medical therapy, you need to see a surgeon. And I just pick a name off of my list.
But I have no idea what the waitlists are for the other surgeons. The patient doesn't know. We just kind of put the facts out there, which is another conversation, and we see what comes back. But what we're starting to see and what we need more of are things like single-entry referral systems so we have more transparency around what the waitlists are. Because surgeon B may have a waitlist that's half as long as surgeon, and so there's tons of efficiencies to be gained there.
But also focus on team-based care, which we talk a lot about in primary care with good reason. I'm lucky. I work with social workers, nurse practitioners, nurses, and others. But pairing folks like advanced practice physiotherapists with orthopedic surgeons, because guess what, if you don't need surgery, what's the first-line treatment? It's physiotherapy. But unfortunately, community-based physiotherapy also isn't covered by Medicare. It's one of the-- like pharmacare and long-term care, it's one of the services that fall under our two-tier system.
CARLY WEEKS: One of the things that I've heard from many experts and physicians and other health professionals dating back years is that we really-- it's too much of a hospital-based model, where the patient sort of has to navigate around the system instead of the system navigating or encircling the patient. So that's a really good example of-- you have-- none of your practitioners are talking to the other. And then you're kind of on your own to try and get care in the community. And if you're lucky enough to have maybe have insurance that is generous enough to cover that, then you're in luck. And if not, then you're out of luck.
Is that a-- we talked about introducing more of a private element to-- we already have a lot of private care. On the flip side, there's just really focusing on reorganizing or restructuring how we do things. So I think I know what you'd say, what side you'd come down on.
DANYAAL RAZA: [LAUGHS]
CARLY WEEKS: Why-- I guess what I'd be asking is, can you make the case for why just reorganizing the system can actually lead to better outcomes? It's not just about competition privately.
DANYAAL RAZA: Well, I don't need to make the case because the evidence is out there. I'm here in the grind seeing my patients. I'm also motivated by the problems that my patients are seeing to engage in policy work. That's the reason why I do this work, why I dial in over my lunchtime to have conversations with readers of The Globe on this, and I do my advocacy work.
Because we're actually-- there's a lot that we're not doing. And so we're not coordinating our systems. Our hospitals aren't talking to our family doctors. We haven't-- because we have this different funding system for community-based care, like home care, long-term care, and because oftentimes you have to follow the money, money can bring people together, we have this incredible disconnection and fragmentation of care.
I'll give you another example when it comes to prescription drugs. So I have some of my patients who are on social assistance who have access to the public drug plan, and other patients who have no coverage, and some people who have private job-linked plans. If I write a prescription, and then I get a renewal, and I'm like, oh, this renewal seems a bit early, let me go see it was last renewed, we have the system in Ontario where I can log online.
And I can actually look you see when the medication was dispensed, how much was dispensed, who dispensed it, what pharmacy. But it's only linked to medications that are publicly covered. I don't have any of that information for folks who are paying out of pocket or paying privately. And it's-- again, if we want to follow the money, if we want to bring services together, part of it is actually thinking about how we want to pay with them-- pay for them and being honest about the funding that we need to do it and the tradeoffs that we're making by not moving in that direction.
CARLY WEEKS: Mm-hmm, that's a really good way of putting it. There's a question for you from the audience. And this relates directly to that. So do you think that family practice needs to fundamentally change to be sustainable? So much of the burden on family doctors right now is related to mental health or complex social and medical issues. Could this somehow be outsourced? That's the question.
DANYAAL RAZA: I sort of alluded to this. But I wouldn't frame it as outsourcing. I'd frame it as moving towards more team-based care. So for example, the old school model of a family doctor hanging up their shingle, maybe working with a secretary and nurse, that's, unfortunately, still relatively common, whereas I'm very lucky because I work in a team-based model. I work with social workers, with nurse practitioners. We even have an income security program. We have a children's literacy program.
And so that means that the potential practice size I can have is much larger than a solo family doctor because I'm lucky to work in this team-based model, where there's other folks who can work collaboratively with each other. So I wouldn't frame it as outsourcing. I'd frame it towards team-based model. Some people call it the patient-centered medical home. And if you Google that, you can find out a bit more information about that. But it's really taking primary care seriously and empowering not just family doctors-- we're just one piece of the puzzle-- but all of the other community-based health practitioners that are critical to enhancing access to primary care.
CARLY WEEKS: There's another audience question that I'd like to get to you because I think it's an important one that was so at the forefront in the pandemic. We'll probably be coming back to this during the panel as well. And that's on hospital beds. So we heard so much, we don't have capacity and we're shutting down because we don't have enough beds. And so the camera-- sorry, the question kind of gets at this, but is really-- is it about more beds? I'm kind ad-libbing, so sorry to whoever asked this. But is the problem that we need more beds, or is it that our system relies so much on hospitals that we're not really doing anything else?
DANYAAL RAZA: Yeah. Yes and no. That was cagey. Here's something more direct. So one of the reasons why we have a shortage of hospital beds is because there's a lot of folks in hospital who shouldn't be in hospital. There are people who are waiting for long-term care, but instead, because we don't have enough capacity in long-term care are stuck in hospital because they're safer there than they are at home, or who could even be discharged to their own homes as long as we have sufficient home care support in place. But again, we don't have access to that.
If you can pay out of pocket for home care services, then maybe you can get out of hospital a little bit sooner. But for many folks that's not the case. And so that's part of the reason why we don't have-- why we have the shortage of beds. And part of the reason is also, if you look at international data-- I cited some funding figures initially-- we just have, at baseline, fewer acute care beds than other countries. So it's not one or the other. It's rarely a single answer, a single solution. It's a both here.
CARLY WEEKS: Right, right. So if we are to change the system, if we are to see improvements, we all hear this is the time now. Well, everything's still kind of in disarray. What will it take in your just-- in your viewpoint? Is it political will? Is it just trying to figure out-- I mean, how do we even go about this? We're talking about rejigging this huge system.
DANYAAL RAZA: If we have another Parliamentary report or commission, I'm going to scream.
[LAUGHTER]
Because we've had so many of these. If you look at pharmacare-- I'm just going to use this as an example-- we have had 50 years, 50 years of reports and papers that have all said the same thing-- a universal single payer system. And if we-- and the answer is not another report. It's not another platform commitment. It's actually the political action and political will.
And the confidence supply agreement we saw federally was promising. But if we look at the provincial election in Ontario, only one of the parties has committed to working with the federal government. And even the details between the liberals and the NDP federal agreement, frankly they're lacking. We need more of them. And we need to actually see action instead of just more words on paper.
CARLY WEEKS: Mm-hmm. It's hard to believe we're having that-- I had this exact conversation like five years ago with someone else, so anyway-- with many people. I will wrap up our discussion there and just say thank you so much for joining us. And now I think the panel is just waiting to jump in on all of these hot topics we've addressed. So Danyaal, just thank you so much for being here. And I'm sure we'll be in touch again soon. Thank you so much for your time today.
DANYAAL RAZA: Thank you, Carly.
CARLY WEEKS: And now it's my pleasure to shift to our panel discussion. So we have some very exciting guests here joining us. So I'll introduce them in no particular order. So we have Dr. Katharine Smart, who is president of the Canadian Medical Association. We have Craig Conoley, who is a caregiver and advocate. We have Cheryl Prescod, who is executive director of the Black Creek Community Health Center. And we also have Dante Morra, who is chief of staff and president of THP Solutions at Trillium Health Partners.
So thank you everyone for being here today, for having this discussion. I'll kick things off by talking to Katharine. We're going to go all first names today, guys. And just-- we heard some already really good, robust discussion about all the problems in our health care system and where we need to go from here. And I know that you're thinking a lot about solutions these days and really trying to seize this moment. I wanted to know what some of your thoughts were on two years into this pandemic and what we really need to start thinking about if we're going to take health care improvements and, by and large, economic improvements related to health care seriously.
KATHARINE SMART: Thanks, Carly, for the question. As we heard from our two speakers, there's so much going on. And it can sometimes, I think, feel overwhelming. But I think if we start to really think about what is it that we're trying to achieve and what are the steps that need to happen to get to where we need to be, we can start towards the action that's needed.
So what do we know? We know Canadians value universal health care. And we see this as an important part of our national identity. And we want to continue to invest in that. And we know all Canadians are going to need the health care system at some point.
So jumping off from there, I think what we can say is, this is a key priority. But the problem is we are not getting the return on those investments. The health care system is not functioning well. And many Canadians are not accessing care.
That is just a hard truth. Almost 5 million people without access to primary care, that is not a small number. The surgical backlogs are significant. Many people are suffering. So I think we can all agree we have a problem.
I think what we need is that political will to acknowledge that problem. I think it's challenging because politicians are motivated to tell the public everything's OK. But that's clearly not the case. So I think it would go a long way, both at the federal and provincial level. Our leaders could get on board with us and say, yeah, we hear you, our current system is broken.
We need systems transformation. And let's start down the road of some of the ideas we've heard. Let's change the way care is delivered. Let's move to integrated team-based care. Let's incentivize payments to match the outcomes we want for the population.
Let's leverage data so we actually know what we're doing. We can track these interventions. And we can make sure that we have accountability in the system. And let's allow physicians to work in teams and have them embedded in leadership so that we can learn from their expertise to reimagine the system together. And I think if we could do some of those things, we could start with that action to create the change we want so that we can reinvigorate our health care system I think what's clear is, if we keep just this sort of tinkering Band-Aiding here and there without those significant structural changes, we aren't going to get where we need to be. And Canadians are going to continue to suffer.
CARLY WEEKS: That's a very blunt assessment. And I see Craig has been nodding along throughout. And Craig, I'd love for you to share a little bit of your perspective, some of your experience as a caregiver, the impacts that's had, and some of the things you're thinking about that relate to what we just talked about.
CRAIG CONOLEY: Sure. Before speaking, I would like to acknowledge that I live and work on Algonquin and Anishinaabe territory, which remains unceded and unsurrendered. I would also like to acknowledge the racialized communities that are disproportionately affected by the systemic issues we're talking about today. And I'm incredibly honored to speak on behalf of all patients and caregivers in Canada, especially millennial caregivers. I represent 10.1 million millennials currently living in Canada who will be faced with the challenge of providing care in future.
Before the first wave of COVID struck Ottawa, and almost overnight, I became the caregiver for two parents. My mother had stage four brain cancer. And my father had NASH, nonalcoholic liver disease. One month after losing my mother during the first wave, I successfully donated 61% of my liver to my father. And I would continue to offer care in community following the procedure.
I think it's important that the public knows that the experience of providing care for my parents, pre-COVID and during COVID, was really traumatic. I was not prepared, nor did I have the skills to properly balance my work-life responsibilities, maintain relationships, run my business, advocate for them, and provide around-the-clock care. Even more shocking was the realization that there are limits to the care.
So COVID exposed those limits that existed before. And due to these limits, things like backlogs of procedures, staff-to-patient ratios, burnout, poor infrastructure, as a caregiver, I have to be honest when I say that I've lost trust in our health system. And I do dread having to re-enter it.
CARLY WEEKS: It's very, very difficult, and thank you for sharing that. It sounds like it's been a really, really difficult time. And coming back to you to ask you some more of the insights and things that you've learned in the last couple of years, but I wanted to also bring Cheryl into the chat and just say that you're representing a community that has been so hard hit during the pandemic.
And I think that oftentimes, some racialized communities, marginalized groups, they can get forgotten. They often are when we have these bigger, broader discussions, especially when some of the people making the decisions don't look like them. I wanted to ask you what some of the things-- what things stand out to you during the pandemic, what things you've seen, what desperately needs to change?
CHERYL PRESCOD: So thank you so much for the invitation to participate in this really important conversation. Because this issue is not only close to my heart professionally, but personally because I am one of those racialized groups where I do feel that we have some lessons to learn in how we treat and make accessible the health care, the great health care that we do have in Canada. So for me, some related questions are, is the current system really-- where is it taking us?
Is this system built for everyone? Does it consider the equitable health outcomes for all Canadians? So what we saw over the last two years in this community is the pandemic shining a really bright spotlight on the dark and dirty corners of our health care system. It exposed inequities that act as barriers to care for many of us, especially those that are most vulnerable.
Working in this community for the past two years, I saw the glaring health inequalities inequities particularly faced by racial and social economic challenged groups. This is what characterized the pandemic here in Canada. And I think it is something that we have to acknowledge. And we have to argue that we cannot return to business as usual.
We have to find ways that we can work better together because a healthy community is one that has also built a healthy economy that we are all beneficiaries of. So I think some of the things that we did at Black Creek Community Health Center, which is in the northwest part of Toronto, comprised mostly of racialized groups, folks living in poverty, many newcomers to Canada, is we engaged with them at the ground level. We made care accessible to them, things like access to vaccines, access to testing, but also access to the care they really deserve and needed. Because it wasn't just about COVID. These cracks in the system existed pre-COVID, and they needed to be addressed. And we hope that we can come up with some solutions to address them today.
CARLY WEEKS: Before we move on, I just was wondering, Cheryl, if there is any story that stands out, just either providing someone access and how that led to a change, or how lack of access really harmed someone during the pandemic, just as an illustrated purpose, just some real stories from the community.
CHERYL PRESCOD: So I can share a story of Patrick, not his real name of course, a Black man in the community, who's a home care provider. He ended up being hospitalized with COVID. Patrick lived with his wife, two children, and in-laws, elderly grandparents to his children who provide care.
He had breathing issues. He had a fever. But he continued to work because he works in an essential job without paid sick days or health insurance and extended health benefits. So he continued to work and ended up going into the hospital without a good outcome. His elderly parents ended up passing away because he brought COVID home to them.
And what this shows to us is that, in many communities, especially communities that are racialized, those people make up the bulk of our workforce that are taking care of us. It's stocking the store shelves, taking care of our children in child care centers, our elderly folks in long-term care homes. And many of them do not have the type of income that allows them the benefits of staying home, working from home, and providing what's needed for their families. So they end up working.
Many of them do not want to even take a COVID test at the very beginning because they did not want to know that they were tested positive. So they continue to work, continue to go on public transit. And that's a story that really illustrates some of the challenges of the most vulnerable in our communities.
And unfortunately, many of those most vulnerable are segregated into certain communities that were called hotspots. And there are some solutions and some strategies that we use that I hope I'll have some time to speak about through our high priority community strategy. And I think there are some elements there that really inform where we need to go as a health care system.
CARLY WEEKS: Thank you, Cheryl. And we'll definitely have time for that for sure. Dante, this is a nice segue because, like Cheryl, you saw a lot of the communities that really faced the brunt of COVID, of this pandemic. And I just wonder if you can speak a little bit about some of the insights that you've gained over the last two years and things that you saw that you want changed, where you think the system needs to go next.
DANTE MORRA: Thanks so much, Carly. And there's a lot of great voices in the room. And I'll add one other into it, and that is as providers in large systems. So I'm an internist. So I'm one of those people when you get hospitalized with COVID or other, that you're in the hospital and I take care of you, but also have the pleasure of being an executive at Trillium Gealth Partners, which is a very large hospital system in Mississauga and West Toronto that has about 12,000 people who work there and was actually the organization that had the largest amount of COVID in the population.
So to talk about a couple of things that have already been said, number one, the capacity issue was eliminated in COVID. So if you look at the number of hospital beds per population in Canada, it's the lowest in all of the developed countries. And then if you sort of zoom in to Ontario, it's actually one of the lowest in Canada.
But if you go down to like the Mississauga and Brampton and some of the rings around some of the downtown areas, it's actually some of the lowest in the world. It's sort of like in range of capita as the Philippines. And nothing wrong with the Philippines, but it's actually not known for its hospital capacity. So what COVID did is it actually eliminated some of the stresses and fractures of the system.
And that was everything from mental health to hospital capacity to primary care issues. That's an amazing opportunity because now we have a really good understanding of what we actually need to work upon. It also eliminated some of that health resource challenges of nursing labor and actually how we organize and pay people.
And that's a really big issue that we need to talk about. Because what we know right now is we are committed to a universal model, but there are better models out there. And actually, we have a really good understanding of actually where those problems are. And now we need to move forward.
What it also did was it actually illuminated some of the issues that other panelists have talked about-- people who have to go to work. There were many essential care workers, there was no option. And you heard from Craig talking about caring for family members and that trust piece. And that's a really important issue around the social determinants of how sick days and policy that actually is a really big part of health care that we need to address.
And then there were some bright lights. So for the first time that I've seen, what we started to see is rationing and delivery of care based on need. And where this was most shown was around vaccination.
We were actually prioritizing postal codes to get access to a very important medication. And that's a really important opportunity, where you can start to see not-- it's not solving an issue, but you can start to see people starting to look at those people who don't get access and putting them at the front of the line. And that's something that we need to continue to work on.
And so there's no doubt that what the pandemic did was illuminate the fractures of the system. What you're hearing from everybody-- and it's actually-- you almost hear it in harmony. There is an important thing in Canada around caring for people. There are better models. And now is the time to actually not to say what we don't want, the US, but to say what we want.
Number two, it is not a universal system. Those people, for socioeconomic, racialization issues or other, don't get the same access. So we have to not be comforted that we have a universal system. We don't. And there are things to be built upon that are bright lights. But we actually now need to have some hard conversations.
And the final piece, which I hope we get a chance to talk about, is health care is 12% of GDP in Canada. That's $200 billion. That's US dollars. And actually, there's a tremendous opportunity to create prosperity for companies and other groups that come into it, not necessarily on a delivery side, but even technology companies. There's prosperity. Health and the economy have always been linked. And now we're at an opportunity to have an honest, real conversation about where to go. So thank you so much for bringing us all together.
CARLY WEEKS: That's really great. Dante, thank you for that. And we're going to be, I guess, going into this next round talking about some of the solutions. So everyone get your answers ready for that. And I know that there are so many-- as you say, there's a lot of harmony here, maybe some different ideas on how we do arrive at that better system.
I'll turn things back to Katharine right now and just ask some of the things that you think we really need to-- expanding, if you will, on some of what your previous answer was, on what we really need to do and focus on, sort of on that ground floor level. How do we get that change? We're talking about capacity issues and more beds.
And do we bring in private care? It's so complicated. I wonder if you can simplify this for us, boil it down. What do we really need to do to achieve a better system where people aren't waiting and aren't at the back of the line and postal codes don't determine your health care access?
KATHARINE SMART: Thanks, Carly. So a few thoughts-- it's obviously a lot there, but I'll try to break it down to some of the levels of health care, where things happen and what we could think about. So the foundation of our health care system is primary care and community access to preventative care and management of chronic disease. And that's done by family doctors and other community-based health care providers, who work throughout the country providing that care.
We need to make sure that that care is available to everybody. There's excellent evidence that good primary care prevents a lot of disease down the road. It allows us to optimize people living with chronic disease. And that saves costs downstream in the health care system, prevents people from being hospitalized, and gives people a better quality of life.
So recognizing that, we need to really understand why that system is no longer working. And I think there's many structural reasons for that. A lot of times, we think we don't have private health care in Canada. But in a lot of ways, we do. What we have as a universal insurance system.
We have care privately delivered by physicians in communities who fund the infrastructure of that through their fee-for-service billings. So I think if we start examining that and go, OK, is that then the best model, does fee-for-service medicine incentivize what we want, I think most new doctors and most physicians now entering into primary care would tell you it doesn't. It incentivizes volume.
It doesn't necessarily incentivize patient-centered care. It doesn't incentivize time for people with complex issues. And I think any patient who's been to the doctor where they've only been allowed to talk about one problem would say it's also not the best way to respect people's time when they're accessing care. So I think we need to look at that for what it is and understand that we need a different structure there.
We need more support for the infrastructure of community-based care. We need different models of payment to allow for integrated team-based care, where physicians can be focused on being more patient-centric, working with a team of health care professionals to get their patients the best quality of care, and also find the joy in their work that will keep them in primary care. Physicians are in medicine because they want to care for patients. And we need to have systems that allow for that.
And once those are well-designed, then we can be doing a better job at addressing the equity issues because we can recruit and retain health care professionals across our communities. Right now, that's not what's happening. So I think some of those structural changes to the way primary care is organized and delivered would go a long ways to solving there.
When we're talking about the secondary level of care, access to specialists, medical specialists, surgical specialists, that's where there's definitely things we could be doing differently-- centralized intake systems so that we actually are making sure people are getting to the specialist who's next available, better leveraging of virtual care so that different specialists in different areas can be providing care more broadly to the population, limiting unnecessary medical travel for Canadians living in rural and remote communities, like where I am here in the Yukon. Those things can all improve access and decrease costs, be more environmentally friendly, and make better use of patients' time.
I think in the hospital side, we need to make sure we're optimizing that very expensive resource by improving access to things like publicly-funded long-term care and home care services. Having patients staying in hospital when they could be at home in the community, what we're hearing from aging Canadians is they want to age in place. They want access to home care. That is much less expensive so there's the benefit there.
People are getting what they want. Their dignity is being respected. And we're then freeing up that very expensive resource of the hospital for people that are ill and need that type of care, and for people that need to have surgery and need to be in hospital post. So we need to look at how we are utilizing our systems. We need to use data so that we're actually tracking what this is doing, we can be sure we're getting the outcomes for our investments, and also giving feedback to the system about what's working, where is the waste, and where can we do better.
CARLY WEEKS: Thank you so much for that. Cheryl, I'll go to you next because I wanted to see if you could build on that or just reflect on how that-- some of those calls for structural change could impact your community. Are those in line with some of the things you're thinking about in terms of building on those solutions, changing the system for the better?
CHERYL PRESCOD: Absolutely. I think I really resonate with what Katharine just said. But I think-- let me start with addressing the social determinants of health, for example. Let's have some upstream interventions. Let's focus on incentivizing health care organizations that really address social determinants of poor health.
Let's go back to Patrick. Patrick, who is a Black male working in an essential job, also has type 2 diabetes but cannot afford to buy his insulin. So what could it take for us to actually address Patrick's issues, maybe in an upstream way, before he falls over the cliff and ends up in the hospital bed? There are so many things that we can do.
We can address things like food security, such as proper housing and infrastructure, so that folks can exercise and really address their needs, and also have a pharmacare system where people can afford to buy those medications that they so desperately need and many cannot afford. So it's, I think-- again, as a community health center, we do this. And we also work in a team-based model with salaried clinical providers, who are able to take the time with patients like Patrick to help counsel him and refer him to an in-house dietician and diabetes educator, to help him understand how he can manage his disease.
So I think there's just so many benefits to all of-- I think we're all on the same page-- and to help him stay at home and live well. Let's see. So again, but it has to be a model that's salaried and supported and incentivized to really address those social determinants of health. It's not only a model that incentivizes us on volumes of care. It's around, as well, our outcomes.
In the community, what is your outcome? And we also have to-- again, because social determinants of health is such a precursor of ill health, we also have to think about how we can coordinate care across systems. So the public health system, for example, that's something that we know public health initiatives have-- are known to prevent diseases and known to prevent death, initiatives such as stop smoking and wearing seat belts that really decreases the rate of deaths among individuals of populations, we know that there are strategies that collectively we can come up with that will decrease the poor health outcomes of many out there.
So again, as you said earlier, Carly, the postal code that you live in should not determine whether you're a hotspot for any infectious disease. And this is what's happening. And I think if we don't want to go down this road again, we do have to think about correcting those cracks and patching those cracks that were found through COVID. We have to.
We're still battling chronic diseases like diabetes in these communities, sexually transmitted diseases, HIV. We still haven't solved a lot of those problems in certain communities. In other communities where we're more socioeconomically advantaged, certainly, people are doing better. But in these communities, there is no excuse for what's happening in Canada, where we have these universal health care systems, which I think is arguable as well.
CARLY WEEKS: Definitely. And I think that, hopefully, this is why events like these can hopefully help shine a light on some of those issues. And because there are, I think, so many people out there who just simply don't or are not aware of the disparity and discrepancies there that do exist. Craig, I'd like to bring you into the chat and just get your perspective.
We often have so many policy discussions and things of what to do with health care, without necessarily bringing in the caregivers and the people who have that firsthand experience. So what changes from your perspective? What were the things that really made it so hard that made you lose trust? And what changes, concrete things could have been done, simple things, to make it a better experience?
CRAIG CONOLEY: I know that with my mother with stage four brain cancer, there was a lot of lack of resources around aphasia and learning how to communicate with her. A lot of it was left to our own responsibility. That was very hard. And I think, due to shortages, staff-patient ratios, and wait times, there's such a high rotation of nurses in acute care facilities that there was never a familiar face, it felt like. There was always a new nurse.
And I really feel for the nurses and the doctors. I really care for them. They need to be supported. And a lot of the problems like burnout and issues we face in the care, I think, had to do with such a high rotation of nurses in those settings. Simple things-- what happens when the buttons on the outside of these institutions, those disability buttons that open doors for people with physical mobility don't work? It's a small thing, but what does that say? There were many, many, many instances of struggle, so yeah.
CARLY WEEKS: Thank you for sharing some of those. And I think you're right. And you're not the first person who's has even brought up just the accessibility issues in conversations about the little things that really can impact-- like someone in a previous interview I did was mentioning how chairs in the waiting room didn't have arms. And it was impossible for their loved one to actually sit in a chair in the waiting room. And they ended up having to leave. So the little things are really important and do make a difference.
Dante, I was wondering if you could also share some ideas you had for solutions. And I know specifically there's initiatives that you've been working on to try and bring about some really meaningful change. I was wondering if you could talk a little bit about that and what kind of impact that is having.
DANTE MORRA: Thanks, Carly. And I'm going to-- I'll answer your question. I'll just go back a level, one level. And that is, what you're hearing universally from people is that there has to be really a big adult conversation of how we spend that 70% of spend. So you heard early on from the economic side, some groups spend 75% public, some 70% of their spend in health care. The first conversation has to be, what's the most rational way that we spend a universal system?
And how do we drive that change through organizations to care for our public in the most rational way? And where that breaks down is when the money that should go to disadvantaged individuals goes to advantaged individuals. I'll give an example of that. So if you actually look at family health teams-- I'll take an Ontario lens of this, but team-based care-- when you really look at who's rostered in those teams, they're often advantaged people. So you have rich models caring for rich people. And so that's a bad use of universal dollars. And that's not because anybody's bad. It's just that the economics describe that.
So where you start to get good models-- I'll give an example of that-- are around integrated or bundled payments. So I think-- because sometimes you get into these conversations, and it starts to become almost overwhelming. Because people say, well, what about this, what about this, what about this? Step one is, what's the most-- the best way to spend our universal dollars? Step two, let's copy somebody who's better than us. Let's just have an adult conversation and say, we're not the best, we're going to copy somebody. And then step three is we actually have to have some hard conversations about choice because choice is important.
So an example of a good solution, bundled care or integrated funding-- and I'll use our cardiac PPAC program at Trillium as an example, because I was involved in that, which won a quality medal at the provincial level. What we did is, instead of a patient getting cardiac surgery, then getting home care that was detached through some organization, we bundled the payment. We said, give us the money for the full 30 days. And so what we did is we partnered in such a way so that the money came, and the cardiac surgeon and the home care person were at the bedside.
When the patient left, it wasn't a mystery who was going to show up. It was all integrated with cost savings. So what we were able to show is the patient experience was way better. They knew who to call. And when the home care person was there, they could talk to the cardiac surgeon. They all knew each other.
The second thing, you got better outcomes. Fewer people came to the emerg, less infections. If there was an infection, it got caught earlier. That's amazing. And the funny thing is it cost a lot less. When you align the funding and the delivery in the right way, it can be done. And by the way, we copied that program after other hospitals. So you don't have to-- these aren't inventions. They just need to be scaled out.
But we also need to also have some real conversations. Like I'm a physician. Every provider does want to do right. But they're economic beings as well. You have to realize that. Should a psychiatrist get paid 1/10 an ophthalmologist? No, they shouldn't. Should we be producing more orthopedic surgeons or should we be producing more psychiatrists? So we actually do have to have an adult conversation about how we're using our HR supply and how we're funding people to do that so that they're actually directing their labor in the right way.
And on the patient side, there's a hard conversation we have to have about choice. Should somebody in a hospital bed actually be able to determine what nursing home to go to and block a patient in the emerg to get in that hospital bed? Now, you want that person to have a choice because you don't want them to go to a nursing home too far away from their loved one.
But is that the best use of that bed at that point? And does that choice get to trump the person who can't get into the bed? So at every level, what we actually have to do is be very honest about what's not working within the system. And then I'm happy to talk a little bit more about how can you direct the talent of Canada to solve some of these problems so that the jobs stay in Canada. Because again, somebody needs to pay for the system. It's actually all linked.
CARLY WEEKS: Thank you for that. And I think we'll leave some of the talking about Canadian talent toward the end. We'll end things on maybe an optimistic note before we get into some questions. And just a reminder, there are some great questions coming in. We're going to get to them. And if you do have one, please submit that.
So Dr. Smart-- or Katharine, sorry, we're on first names today. I thought I would ask your perspective on that. What you just heard, as someone who also has perspective and experience within the health care system, are these the kinds of things that can work, scaling of these kinds of models? And if so, how do we just not do that faster and quicker and get it done for everybody?
KATHARINE SMART: No, absolutely. I think what Dante was talking about is so important. It's really about tying the funding to the patient and their experience and the outcomes we're seeking for the patient, rather than these global budgets that, in a lot of ways, disincentivize care. In that context, when there's a certain amount of dollars assigned to the patient, it then motivates the facility and all the people involved in providing that care to make sure that they're using those dollars efficiently to get the outcome that they want and that the patient wants. And we're very aligned there. So I think that's, again, this concept of linking outcomes and accountability to funding.
And that's one of the big problems in our system, is we don't always do that well. So I think taking some of those ideas and scaling them make a lot of sense. And this is also why we really need to improve our data infrastructure in health care with interoperability, between electronic medical records and where this information lives, so that we can be tracking how we're doing.
Without data, it's very hard to know the quality of care that's being provided, what places are doing it well, what places aren't. And like Dante said, this isn't about new inventions. It's about scaling things we know work, and then monitoring how we're doing, making changes, and then advancing on things that are working well. But we need information to understand that and to be able to make those decisions.
CARLY WEEKS: Definitely. And Cheryl, you were mentioning how just so many people in your community, it's almost like they've been kind of forgotten by the system. It's just so much harder. And we heard Dante reflecting on how the system-- health teams, for instance, are serving the rich instead of the marginalized communities where they're needed. Do you think that these kinds of incentives, this kind of model, is this the way forward? And in addition to that, I guess I would also add how you can see community health centers playing an even greater role in making sure that care is delivered where it's needed.
CHERYL PRESCOD: Certainly, I do see community health centers, community family health teams, all of these team-based models being instrumental in helping to address these issues. Because what we do is we really look at the health of a community because we have to do population-based planning. Not all population groups are the same.
We have to really do a deep dive into using data. Because definitely, we need the evidence that, so we have to-- we cannot stop collecting data and to really inform how we deliver services. What is it that we need to do? We have a lot of work to rebuild the trust in some of these marginalized communities.
Because it's not just about going to the doctor or the hospital. There are many folks who will-- the trust in the health care system is so eroded that they will not go to the hospital before things get so catastrophic that they have to be admitted. So I think there's-- again, I'm going to go back to my upstream argument, where we have to do a lot of work with people in the prevention and trust-building, confidence-building in our system. Because once we do that, we're able to change health behaviors. That may mitigate those visits to the specialists and to the hospital.
So I have to come from it from that perspective because I saw it play out in the COVID vaccine rollouts, testing rollouts, where it's the boots on the ground. It's the people in the communities that really encouraged those healthy behaviors and really helped to stop the spread. And this is what we need to do again for transmissible diseases, number one, but also for those chronic conditions that can be managed, and to prevent visits to the hospital.
And we do know that these team-based models, where people have access to a variety of support, they're able to engage with patients, or clients as we call them in the community, and help to mitigate some of these more serious health conditions. Preventative screenings, for example, so that we're catching things like cancers a little earlier and they can be addressed earlier rather than later. And it's all-- it is-- I think, ultimately, I do know that we have to think about dollars.
But how are we managing those dollars, and how are we accounting for those dollars? Is it about the number of visits to a hospital, the number of beds that are occupied? We have to get away from that. We have to come back to, how many folks are we preventing from entering the hospitals, actually, and from the community-based models that we have?
CARLY WEEKS: Yeah, that's a great point and just that whole idea of incentivizing care around what patients need and when they need it instead of, yeah, visits and things like that. Craig, we're going to do some questions in a second. We have lots of questions, and the first one is for you. But I promised Dante.
I wanted to end the formal discussion part on an optimistic note. And so I heard things about keeping Canadian talent here and leveraging some of the great work that's going on in Canada to bring about some of those system improvements. So I was wondering if you could just talk briefly about those before we get to the growing list of audience questions.
DANTE MORRA: Thank you. And I think, actually, it's a really great optimistic time because when you get everyone framing the issues together, there's amazing hope. And I think-- I hope our audience can almost hear almost like a harmony of framing, and now there's an opportunity. On the other side, so when you look at the business of health care, and people will say, OK, there's AI coming into health care, or there's technology coming in, the delivery of health care, there's large supply chains.
There's things that we build. There's things that we operate. Canada has an amazing talent of R&D and people. And the jobs actually can stay in Canada. And these great companies can stay in Canada. And the solutions can come here.
I'll give an example. CANInmunize, great Ottawa-based company that created software for immunization. The Nova Scotia Health Authority used them during their vaccination center. And that actual technology was better than the sales force that came out of the US. And Nova Scotia had one of the best vaccination programs, even globally. That company then employs Canadians and builds more capacity to then solve other problems.
Same thing, Precision ADM out in Manitoba that created recyclable masks bought by the Manitoba shared services that scaled across Canada that improves our supply chain. The solutions, right now, if any of you listeners or people remember Blockbuster Video, you go to Blockbuster. You'd be like, I need to find a video. The video wasn't rewinded. You got late fees.
We had a certain model, and Netflix came along and changed that. Health care is changing rapidly. And the question is, who do you want to be the people who change health care? It's us. Our great Canadian companies can win. They can solve our problems. They can turn into global winners. Those jobs can stay in Canada.
And that can actually power our universal system in perpetuity. That's happening right now. It's something that we call Can Help. It's about bringing the country together and using the system to scale technology and drive prosperity. That Precision ADM has 200 jobs in Manitoba. Those are high-paying precision manufacturing jobs that now pay into the tax base for that universal system.
So I think there's a moment. Health and the economy has always been linked. COVID showed us that more than ever. And it showed how it actually can make it more disparate as well. The winners can win more. The losers or the people who are not advantaged can be more disadvantaged. But actually, there's an amazing moment by bringing the 40 million people of Canada together, by choosing what is truly universal and doing that well, by copying what is an opportunity that others do better, and spreading, as Katharine mentioned, the things that work-- no more pilots. And actually using the economic power of our talent to solve our problems, there's a great future going for us.
CARLY WEEKS: Well, that's the optimistic note we were looking for, so thank you for delivering there. But certainly, yeah, there's lots of exciting things happening in that space. We could fill a whole other panel with that.
There is a lot of questions for you guys so I wanted to jump right in and get to some of them. And the first one is for Craig. And I think it's one that a lot of people have been thinking about during the pandemic. So from your perspective, how could home care be improved? Just reflecting on your experiences as a caregiver and just things that you've witnessed, what do we need to do?
CRAIG CONOLEY: Well, I think that during the last two years, we've seen that unpaid caregivers continue to play a crucial role for adults living in Canada and others needing instrumental help with activities of daily living. I do think that we're-- my generation is the hidden backbone of the health care economy, in fact. And if we're not supported to thrive versus solely survive or merely exist, the resulting systemic backlog could bring the system to its knees.
And because we're talking today about strategic partnerships, I do want to note that the partnerships between unpaid caregivers and the health care teams were severed due to COVID visitation restrictions. So I think that caregivers need to be invited into the team dynamic in an authentic way in order to learn about hands-on care alongside staff in hospitals. Because we are the ones who are going to be delivering this care in community.
And I also think that this will impact hospital readmission rates, especially if we do it right the first time. And then on a positive note in thinking about solutions, which will inevitably help home care, I think the media has an important role to play in spotlighting caregiving stories. We need to see the experiences.
We need to feel them, hear them. We need to know what's coming. And so if it's CBC or if it's investigative reporting or if it's documentary work, millennials really respond to this kind of content. I also think that education has a role to play.
I had this wonderful idea where-- co-op placements in high school were a thing. What if we had care placements? What if we started thinking along those lines? Those are just two ideas that I have.
But yeah, I think also really important and lastly is we live in a culture where we regard death in a certain way. We speak about death in a certain way. I think that we need to think about quality of death in our system, in our health system, and try to create a context where a patient can actually have a good death, which is something that I know my mother, unfortunately, I don't think had. So those are just some thoughts.
CARLY WEEKS: Thank you, Craig. And I think those reflections really resonate. And to your point about death, it's very true. And it's something that survey after survey shows can Canadians want to die one way, and at home, maybe with loved ones. That doesn't happen in many cases. So there's a lot of things that can be done in that space.
And anyway, just thank you for your advocacy work in this area. We'll come back. We have more questions. And one of them I wanted to get, probably Katharine and Dante will have the most to say about this.
But basically, looking at what we talked about earlier about the private model and the idea of opening up our system to competition, to really embracing more of the public-private split, we did address this already by saying we do have a lot more private care than people realize. But I wanted to just to get your thoughts on-- maybe Katharine can start us off in this, and then if Dante wants to chime in and anyone else. Does the private sector have a greater role to play? What can they help with? What areas would be a natural fit if we were to go down that road?
KATHARINE SMART: I think what we think about when we talk about private care in Canada is often an American style health care system, which we know is not an example of a health care system we want to emulate. But we do have examples in Canada, where there are private delivery of publicly-funded services that work well. And that would be-- an example of that would be your family doctor's clinic. That is a publicly-funded clinic, but it's privately delivered by the physician who's running that infrastructure.
So I think, first of all, we need to understand what we're already doing, what goes well there. Physicians are generally quite efficient at running offices and have a lot of experience in creating that community infrastructure. But they could likely use more support from governments to be able to move that, shift that more to the community care models that we've been hearing about, more of the integrated team models.
So I think there are opportunities there. We've also seen some ability to create more capacity by moving surgeries, for example, out of hospitals into other facilities, surgeries that are day procedures that don't need all the resources of a hospital, where patients can receive that care. And that can help to lessen that load. But again, what we're talking about there is publicly-funded procedures happening in different environments, versus that two-tiered system that has really significant equity concerns.
So I think we have to be careful that we don't let that conversation derail by assuming what we're talking about is creating sort of a market for health care, which I don't think is really what we're meaning. But really what we're thinking about is what things can we leverage, where can we partner, where can we find efficiencies, where can we deliver better value for Canadians, while keeping equity as a key driver. And in that way, it means that those things do need to be publicly funded so that we're not creating a two-tier health care system. But I think we need to be having the right conversations and not be afraid to talk about what's needed to create the change.
[AUDIO OUT]
DANTE MORRA: And so we continue to perpetuate the current status quo. And I think this conversation is illuminated-- look, there's things that we can do. And we have to actually call the baby ugly a little bit and move on. So I think that's risk number one.
The second biggest risk-- because it's actually not hard to know who to copy, right? Just, let's copy Australia. OK, done. Like it's-- you're not going to copy Denmark because it's not the same type of population. Or Sweden, it's 5 million people. But there are groups that we can copy. And copying and fast following is always a good idea.
The biggest issue right now is labor and the ability to have the labor to actually do the work. Because if you start to create parallel models of surgical delivery, as well, you can start to take nurses out of the OR of hospitals, where they're actually having difficulty. And that actually can make the system worse. So what we actually need to agree-- and the nursing shortage that happened during the pandemic is like all the cracks.
Everybody knew it was coming. It's just now everybody can see it. So the reality is we actually have to decide, how many nurses do we want do we need, and produce enough in Canada, not to steal them from other countries that probably need them even more, but actually produce enough of the light labor source for the market. As an example, don't leave it up to a university to decide what type of doctors they're going to produce. Because they'll create a certain number of orthopedic surgeons, a certain number of general surgeons.
Actually say, this is what we need. Let's produce enough nurses. Let's produce enough social workers. Let's-- we control the admissions processes of these spots. We pay for it. So we can match supply to demand. It's not going to be perfect. It's a market.
But the reality is that that's going to help us four years from now. And there are ways of recruiting and retaining Canadians and bringing new Canadians in. But there's a certain ethical lens of that as well. But the human resource supply, let's figure out what we need. We fund it. We already fund those spots. Let's allocate the right amount.
And that allows us the ability then to transform into new models. It's actually not as complicated as people make it out to be. You've got to be willing to take some of the power away from decision-makers who are satisfied with the current status quo. Often around health care, there's an industrial complex between physicians, labor, and the people who run the system. Patients are often outside of that. That industrial complex maintains the status quo. And so you just have to understand the politics of that.
CARLY WEEKS: That's actually a really great explanation. You took a huge issue and you were-- thank you for simplifying that because I think that's-- a lot of the questions that are coming in are kind of going about that in various ways, the idea that we spend so much and our capacity is so terrible. And how do we fix that?
This is one thing that perhaps Craig can reflect on, and then others want to jump in. We're having some technical issues with Cheryl. We think she might still be here. So we'll just-- if Cheryl wants to chime in after-- I think-- OK, I think she is there.
CHERYL PRESCOD: I am.
CARLY WEEKS: So Cheryl, I'll get you maybe to jump in too. OK, great. So Craig, when we talk about coordinating care-- and that's one of the things that has emerged. We need a system that's going to follow patients around. Just your perspective, how could that have made the difference for you?
You said that you've lost trust in the system. You dread going back to it. That's obviously terrible. It's tragic when that happens. And it happens all the time. So what are the kinds of things that could help with better coordination of care? And then Cheryl, perhaps when he's done, you can jump in on that as well.
CRAIG CONOLEY: Yeah, I think that Ontario health teams and caregivers really have an opportunity to team up. And I think that during COVID, there were moments where I was providing care in community and couldn't have access, couldn't have people come into the home. So I think that if these pandemic realities, they continue, we need to really find a way to get care in the home and supported.
Mobility, transportation, administration of medicine, these are all things that I had to do. And they were very difficult, especially when it comes to physical mobility support and hygiene care. Unfortunately, some of these things are pretty-- these resources are thin and unreliable. So I do think we need to bolster the Ontario health teams and really strengthen that relationship with caregivers.
CARLY WEEKS: Cheryl, your thoughts on that as well.
CHERYL PRESCOD: Hi, there, so sorry about the camera. I'm trying to figure that out. But I did want to go back a bit to the previous question because I also wanted to bring up the point about scope of practice within our health care system. When we talk about the system, we very much talk about physicians.
And I really want to acknowledge the work of nurses and nurse practitioners and RPNs within our system, especially throughout the COVID pandemic. They played such an integral role. And I do think that part of our health care planning needs to really ensure that we think of how best to utilize and maximize the scope of practice of these professional groups because they do-- they can do so much.
So I just wanted to-- as well as, again, coming from the community sector, the work of community health workers, who are so integral to connecting with our communities, building trust in the communities, and really helping patients navigate our very, at times, complicated systems. And I do think of folks that are newcomers to the country that don't understand the health care system and get caught up. And they get stuck, and they fall through the cracks, or folks that do not speak English as a first language. We really have to think of all of these elements of our system that contributes to good health and getting them to the right place at the right time and get them the care that they truly deserve.
And to going back to from a patient perspective, we hear so many stories of folks who just don't understand the system, don't have supports at home. Even though home care may be available, it's just never enough. It's never appropriate at times. The cultural elements are not there that are needed for really good comprehensive care. So I do think that language, education, navigation, all of these things are integral. We just can't talk about health care without thinking of those other social determinants as well.
CARLY WEEKS: Yeah, that's so important, Cheryl. And just to that--
[AUDIO OUT]
--advocacy. And how well you can advocate for yourself will often determine your health and your access to the health care system, so obviously, not a very good situation. Just to build on that point that you had just raised-- a question did come in, as someone just noting the panel discussing the disconnect between frontline health care workers and the people who are making decisions about the health care system. So what can be done to bridge that gap, to really drive home that point about why we need to start caring more about social determinants of health and paying attention to the needs of communities, all throughout our geographic areas?
KATHARINE SMART: Can I make some comments on that, Carly?
CARLY WEEKS: Oh, yes. Yeah, please, go ahead.
KATHARINE SMART: Thanks. I think what Cheryl's been saying is so important. The social determinants of health are so critical. And in my clinical work, I'm a pediatrician. And we're learning more and more about how adverse childhood experiences impact the health of adults. It's a major driver of both physical illness and mental illness.
So we need to have better policies that are supporting families and young children to optimize development. We need to be addressing things like poverty that lead to bad health outcomes so that we are keeping people healthy. I often say, again, what we have is an illness system, not really a health system. So we do need to be thinking about what creates health.
And I think another big theme you've been hearing today is just the lack of integration. And to Dante's point, we do not have a human health resource strategy in this country. And a human health resource strategy absolutely needs to look at not just doctors and nurses, but about all the health people we've been talking about today-- community health workers, families as caregivers, as we've been hearing from Craig, home care.
We need to really look at-- if we have it our ideal model, who do we need as those human health resources within that model. And then we need to make sure that we're integrating across the system, including our educational institutions, to be providing the supply there. But right now, those things are not connected.
We don't talk to each other. We don't make those plans collaboratively. So we end up with this sort of random assortment of people, not always in the right areas, not always in the right locations. And that doesn't allow us to sort of have that integration right from that social determinants upstream lens of prevention.
And how do we create health right through into the health care system, and who do we need where, and at what numbers to make sure that people are getting the access that they need? So I think if we can start to really move towards that collaboration, that integration, with that overarching model of what it is we're trying to achieve, I think we can get a lot further to where we need to be.
CARLY WEEKS: Thank you for that. And Cheryl, I'd ask you to jump in, as well, just any thoughts you have on that, just about the-- because I feel like that's something that is a question that must come up for you time and time again.
CHERYL PRESCOD: Again, I think in order to really address population health, we really have to get to know our population. And we have to, again, rely on data and evidence. So I know that during the pandemic, we really emphasized the need to do that in Canada. A lot of what we learned early was from the UK or the US.
And I do think that we do not do it very well. And we have to figure out, how can we plan better by getting the evidence, the data that we need? Data, in a way, that's segregated in such a way that we understand what's happening in certain communities and population groups.
Let's not-- I think someone said it earlier. We have to have some tough conversations, courageous conversations where we talk about race. We have to talk about people living in poverty and realize that we are amongst-- these are Canadians. They're fellow Canadians. And for us, for one of us to be well and this country to be well, we all have to be well. We cannot leave anyone behind. We have to take care of everybody that's here across our country.
CARLY WEEKS: Thank you for that, Cheryl. We're just a couple of minutes from wrapping up. And just thank you everyone so much for contributing. I wanted to do one last go-around. And I'll start with Craig, and ask everyone the same question. And feel free to take it in whatever direction you see fit. But it kind of riffs off what someone had submitted. And this is basically-- are we at a moment in time where politicians and bureaucrats, are they motivated to make those changes that we need? And what would be your message to them about why this is so urgent, actual change, actual reform? Craig, you're up.
CRAIG CONOLEY: Yeah, that's a big question. But I like it. I like it a lot. Well, I've taken some time to read the letters of appointment from the PM to our health ministers. I've-- from my experience, I feel like some of these things have not been followed through on. And for me, I think having that transparency and being able to document, potentially, care, suboptimal care, it's important that we are able to do that for our family members who can't advocate for themselves, especially those with aphasia.
And it's not about pointing out specific people or institutions, but calling out systemic problems and barriers to quality of care. And I think this data, being able to document subpar care in the context of your mother or father, I think that kind of data will really help physicians who are also advocating for better quality of care conditions in the workplace. And that's just one final thought that I had.
CARLY WEEKS: Thank you. Thank you so much, Craig. Dante, your turn, huge question, and you have like 30 seconds to answer.
DANTE MORRA: Yeah, I think first of all, politics and politicians, it's a tough job because there's many different voices that you're trying to manage. But they follow the people. And I think the reality is that we're at a special moment, where I believe that you won't get a singular voice like you do with the Olympics, where everyone is cheering. But there are moments where people can come together and agree.
And I do believe we're at a moment where we can agree on what's not working, and we can agree on some things that work better elsewhere. And I think that's a great place to start. And then also, there can be an agreement on what's the right amount of public dollars and how to spend that the best way.
Community health workers may be the best dollar per dollar use of health care dollars and the best use of a primary care model. Let's actually have that conversation. But let's actually agree on how much we're going to spend.
Competition is really important. So you could go often to get your teeth cleaned at a dentist's office, but you couldn't get into your doctor's office. It's actually-- that's interesting. So there's-- competition in models, actually, can be helpful. And they can lean out processes. And they can bring capital in new ways.
And so I think we are at a really important moment. And we have to actually decide some tough things. Are we-- has Canada decided to pay for a long-term care? Is that part of the Canada Health Act?
And so there's-- but we actually have to put these issues in the storefront and not bundle them all up as a private and public system, and take them one by one by one in a rational way. And I do think we're at a really unique moment. Canada is a great country. It's taken care of its people in the best way that it could.
And there's a lot of positives that happened in COVID. And there's a lot of realizations. And what Cheryl said is, what COVID did teach us is you can't hide. The public health is-- we're all together. And so let's take that energy and unify it and come up with some really tangible next steps and solutions. And I do think the political environment will follow the people as we move forward.
CARLY WEEKS: Thank you for that, very, very nice summary. Cheryl, I'll turn it to you.
CHERYL PRESCOD: I think, again, lessons from COVID, terrible, terrible time for everyone, but also the lessons learned. And I'd really like us to move forward with those lessons. And I think the public, in general, have-- they're more in tune with their health. They're more in-- everyone is now a scientist and understands about vaccines.
So I do think that we have to grasp that opportunity and help ensure that the voice that people now have, especially in marginalized communities, is amplified. So to the previous point around advocacy, how do we connect the decision-makers with what's actually playing out on the ground with health care is we have to start listening. We have to start listening I know that in our community, we have really engaged with folks who have previously been disengaged around their health.
And they now want the care they deserve. And I hope and pray that we can do that as a collective. We can't do it alone. We have to work with our partners in public health. We have to work with our physicians and hospitals. We have to work with each other, as well as those caregivers.
We have to remember what's happening in our homes and ensure that we support everyone. So I do think that I'm hopeful that, in partnership with everyone that we serve-- we are all patients. I'm a patient at times. And I'm a caregiver as well. And we have to ensure that we just-- we have that empathy that we all should have in health care.
CARLY WEEKS: Thank you, Cheryl, very nicely put. Katharine, I'll give you the last word.
KATHARINE SMART: Thank you. So I think right now we're at a pivotal moment where we need to own this problem collectively, with our leaders in politics, with our leaders in health care across health care professions, and with our patients who we're here ultimately to serve, and community. I think we're at a point where we all agree what we have is broken. More of the same, the status quo is not working.
So let's own that together, and let's start moving towards those solutions. And let's make sure as we engage in those solutions we have the right people at the table, the people that deliver the health care, the people that are impacted by how the health care is delivered, creating these solutions. Let's leverage the things we know work in other places. Let's get towards that action.
Let's not be blocked by our commitment to the sort of status quo or our fantasies about what we think our health care system is. Let's get serious. Let's move towards systems transformation. And let's do it so that all Canadians have that chance to be healthy. We can really be serious when we talk about equity. We can recognize that we need to create health and prosperity and have a health care system that's ready to deliver. And I think we can get there. I think it just needs us to get there together.
CARLY WEEKS: That's a great message. Thank you so much for that. Thank you, everyone, for being part of this today, to everyone watching and submitting questions. Lots of interesting-- we didn't get to all of them, but we do appreciate the interest. And thank you to The Globe and Mail and to the Canadian Medical Association for partnering with us on this event.
For those of you who are here, we're going to be sending a link to the webcast. So you can share that, watch it again. And I just wanted to say thank you all for being here and taking part of this really important discussion.
KATHARINE SMART: Thank you.
[MUSIC PLAYING]
Session 3 - Rethinking the health care system to create value
Moderator: Bonsoir à tous. Merci d’être avec nous ce soir. Mon nom est Alexandre Bacon, Innu de la communauté de Mashteuiatsh. Alors je tiens à vous souhaiter la bienvenue à ce troisième webinaire sur la santé organisé par l’Association médicale canadienne. Un webinaire ce soir organisé en collaboration avec le H-pod de l’École de santé publique de l’Université de Montréal.
Alors, ce soir nous allons parler de création de valeur. Nous verrons plus avant avec nos panélistes ce soir de quoi nous parlons plus au juste lorsqu’il est question de création de valeur, c’est-à-dire de quelle façon peut-on faire différemment, faire mieux sans pour autant investir davantage de ressources financières et humaines dans un système de santé dont nous avons tant besoin.
Alors, ce soir nous avons l’honneur de recevoir quatre panélistes de haut niveau. Nous sommes très heureux de vous les présenter. Je vais d’ailleurs vous inviter tout du long de la prochaine heure et demie à formuler vos questions à travers cet ongle dans le bas de votre écran qui s’intitule donc Questions et réponses, Q et R. Alors, n’hésitez pas, si vous le souhaitez tout au long de la présentation à formuler vos questions.
Alors, idéalement, je vais pouvoir toutes les adresser à nos panélistes et nous aurons en toute fin de présentation le professeur Jean-Louis Denis de l’École de santé publique de l’Université de Montréal qui aura le défi de faire une synthèse de tous les propos tenus ce soir. Donc, avant bien sûr de nous lancer dans la présentation des différents panélistes présents avec nous ce soir, j’aimerais quand même rappeler le contexte dans lequel nous tenons ce webinaire. Contexte, bien sûr, où nous avons tous en tête les deux dernières années qui ont constitué un défi majeur, non seulement pour le système de santé mais également pour l’ensemble de l’économie pour de nombreuses dimensions de nos sociétés.
Alors, nous avons pu voir à quel point nous avons dû interrompre beaucoup de nos activités non seulement économiques mais que ç’a impacté l’ensemble de notre fonctionnement sociétal. Déjà fragile, notre système de santé dont nous sommes si fiers s’est quasiment écroulé à certains moments, du moins les gens l’ont porté à bout de bras comme ils le faisaient déjà auparavant. Donc ç’a été vraiment, bien sûr, une épreuve pour l’ensemble du système.
La pandémie a donc exposé au grand jour des problématiques qui existaient d’ores et déjà tout en les exacerbant. Alors nos décideurs, toute la population, ont alors compris le lien intime qui existe entre bien sûr, d’une part, une économie qui est dynamique mais par ailleurs aussi un système de santé stable, robuste et accessible pour l’ensemble de la population.
Donc, il s’agit là d’une fondation pour une société bien sûr en santé, épanouie tout en permettant une économie à l’ensemble de la population de prospérer. Notre système de santé a exposé des failles importantes et des limites, bien sûr, et il devient difficile, voire illusoire de penser que nous pouvons continuer de fonctionner de la même façon en espérant que les choses changent. Donc, c’est bien sûr ce soir on va se poser cette question à savoir de quelle façon peut-on innover, changer nos façons de faire de sorte que nous ne connaissions pas lors d’une éventuelle nouvelle crise une pareille situation.
Et par ailleurs, l’usager, contribuable, patient et bien sûr dans le droit de se demander de quelle façon nous allons apporter ces améliorations nécessaires. Donc, nous vous proposons d’utiliser l’occasion de cette sortie de pandémie pour chercher des solutions, des approches innovantes afin d’améliorer l’ensemble du système. Bref, on va vous inviter à réfléchir de quelle façon nous pouvons apporter des changements de ce qu’on appelle de paradigme, donc de quel modèle de fonctionnement pourrions-nous envisager et potentiellement adopter pour faire en sorte que nous puissions disposer des meilleurs systèmes de soins possible. Et donc créer cette valeur que nous recherchons à l’intérieur de notre système de santé.
Donc système de santé qui bien sûr est une composante essentielle de la société, de l’économie et de la vie quotidienne de chacun. Et pour avoir une société donc en santé, il faut un système qui arrive à répondre à l’ensemble des besoins. Donc ce soir à l’occasion de ce sommet, nous verrons comment il est proposé de repenser ce système et d’envisager de nouvelles pistes de solutions.
Sans plus attendre, je vous propose de vous présenter nos quatre panélistes de ce soir, à commencer par Mme Joanne Castonguay, Commissaire à la santé, au bien-être. Elle informe les autorités gouvernementales et la population sur le contexte, les enjeux et la performance du système de santé et des services sociaux du Québec. Elle conseille aussi les choix qui s’imposent à adapter – pour adapter ce système afin de mieux répondre aux besoins de la population.
Économiste, Mme Castonguay étudie les systèmes de santé depuis de nombreuses années et est l’auteure de plusieurs publications, notamment sur la gouvernance des systèmes de santé et sur le transfert des innovations. Madame Castonguay, merci d’être avec nous ce soir.
Joanne Castonguay: Bonsoir.
Moderator: Notre seconde panéliste, Dre Lucie Opatrny. Elle est sous-ministre adjointe au ministère de la Santé et des Services sociaux et, ce, depuis février 2018 où elle gère la Direction des affaires universitaires, médicales, infirmières et pharmaceutiques. Ses champs d’intérêt sont particulièrement axés sur l’accessibilité aux services de santé et la qualité des soins. Spécialiste en médecine interne, Dre Opatrny détient une maîtrise en gestion de la santé, un diplôme en négociations avancées de l’Université de Harvard, ainsi qu’une maîtrise en épidémiologie et biostatistique de l’Université McGill. Docteure Opatrny, merci également d’être avec nous ce soir.
Lucie Opatrny: Merci.
Moderator: Notre troisième invitée et panéliste ce soir, Mme Édith Lambert, a bien connu le système de santé sous plusieurs angles, que ce soit à titre d’infirmière, mais également comme proche aidante, comme patiente à la suite également d’un accident vasculaire cérébral et d’un accident de voiture traumatique. Elle nous en adressera peut-être quelques mots tout à l’heure. Elle a récupéré une grande partie de son fonctionnement malgré le manque de ressources de réadaptation dans sa région, et utilise son histoire pour aider les autres.
Donc à l’heure actuelle, Édit s’occupe de ses deux parents septuagénaires ainsi que de ses enfants dont l’un présente des symptômes neurologiques atypiques et présentement en investigation. Merci, Madame Lambert, d’être avec nous ce soir. C’est vraiment un grand plaisir de vous accueillir.
Édith Lambert: Je vous remercie.
Moderator: Et enfin quatrième et non le moindre panéliste ce soir, urgentologue, innovateur et spécialiste de la santé publique, Dr Abdo Shabah, a participé à de nombreuses missions humanitaires. Il mène des recherches sur l’utilisation des technologies de l’information dans les situations de catastrophe.
Il détient un doctorat en médecine de l’Université de Montréal, une maîtrise en administration des affaires à McGill, une maîtrise en administration des services de santé, et un certificat en études humanitaires, spécialisé en gestion, crise d’urgence et de catastrophe de l’École de santé publique de l’Université Harvard. Docteur Shabah, merci également infiniment d’être avec nous ce soir pour ces échanges qui se promettent d’être fort intéressants.
Alors, écoutez, pour nous permettre d’avoir un maximum de temps avec nos invités, je vais d’ores et déjà inviter Mme Joanne Castonguay à briser la glace et a lancé les discussions avec une présentation. Madame Castonguay, à vous la parole.
Joanne Castonguay: Merci, Alexandre. Merci beaucoup à l’AMC et merci à H-pod de m’avoir invitée pour faire cette présentation. Je vais vous entretenir ou vous présenter comment le Commissaire à la santé et au bien-être peut contribuer à la création de la valeur, mais en information sur qu’est-ce qu’est la valeur mais surtout en évaluation de la performance du système de santé dans cette création de valeur.
Alors, je vais d’abord vous présenter c’est quoi notre mandat au CSBE, malgré que vous avez déjà dit un mot sur cette question, mais le Commissaire à la santé et au bien-être a comme mission, comme rôle d’analyser la performance du système de santé et d’informer la population et le gouvernement sur les meilleurs moyens d’améliorer cette performance. On a aussi dans notre Loi le mandat d’encourager la participation citoyenne, c’est-à-dire d’informer le gouvernement sur l’opinion citoyenne, si on veut, sur des questions spécifiques.
Donc quand on fait des recommandations s’il peut y avoir des enjeux éthiques, on va faire participer la citoyenne – un forum de citoyens à la conversation. Enfin, on a décidé étant donné justement le fait que ça fait, en fait, longtemps que notre système a besoin de changer la façon dont on fait les choses et qu’il y a eu beaucoup de rapports qui ont été – qui ont fait des rapports d’experts, qui ont fait des recommandations sur les meilleurs moyens d’améliorer la performance du système et puis qu’il y a eu beaucoup de – en fait, pas assez d’action, si on veut, pis il y a beaucoup – c’était généralement lorsqu’on faisait des recommandations qui affectaient ou concernaient les institutions, à ce moment-là ça devenait – ça devenait excessivement difficile.
Donc, on a décidé de contribuer à débloquer les barrières systémiques à l’innovation, au changement, finalement. Et donc d’accroître finalement notre – nos interventions par rapport à la mission première qui nous est confiée. Donc comment on va faire ça? D’abord, tout d’abord en commençant notre mandat, on a remis en question les façons traditionnelles d’évaluer la performance des systèmes de santé. Alors, si vous voyez – ça, c’est la représentation graphique du cadre d’analyse qu’on propose pour analyser la performance des systèmes de santé.
Traditionnellement ce qu’on examine c’est surtout les deux – bon, on va regarder c’est quoi le contexte. On va regarder c’est quoi les éléments qui sont dans la structure et les ressources. Donc, on est censé regarder la gouvernance et la direction. On regarde énormément quels sont les intrants, donc les ressources au système de santé. Quelle est la capacité ou la viabilité du système? Notre capacité à continuer à allouer des ressources au système.
On regarde beaucoup quels sont les quantités, les services qui sont produits. On regarde la qualité, pis quand je dis « regarde », c’est parce qu’on va plutôt regarder si on adopte les meilleures pratiques sur la qualité plutôt que de regarder les résultats liés à la qualité. Et quand on parle de résultats, généralement on va regarder si on a eu un impact sur l’efficacité. Encore là, nos indicateurs d’efficacité sont très limités. On va regarder la réactivité du système. Est-ce qu’il y a eu une réponse à la demande? Est-ce que les gens ont accès au système?
On a le besoin de regarder l’équité et les coûts. Mais on est très critique par rapport aux indicateurs de résultats que nous avons, parce que ce sont tous des indicateurs, ou en grande majorité, qui vont poser un regard sur qu’est-ce qui est fait et non quels sont les résultats. Alors, on se pose pas la question, est-ce qu’on fait la bonne chose, au bon moment, à la bonne personne qui produit les meilleurs résultats escomptés?
Donc on propose de faire évoluer cette façon d’analyser le système de santé, mais d’abord je dois dire que c’est excessivement difficile parce qu’on a très peu de données qui nous permettent de le faire. Donc, on compte influencer pour le faire. Maintenant, qu’est-ce qu’est la valeur? Alors, pourquoi on parle de valeur? C’est-à-dire, quand on regarde la performance d’un système de santé, quand – ou en analyse organisationnelle, performance dit est-ce que vous atteignez les résultats pour laquelle votre organisation existe?
Donc, quand on parle d’un système de santé, on devrait regarder si on améliore la santé de la population. Et puisque c’est un système public, on a un devoir d’utiliser les ressources de la meilleure façon possible. Et c’est exactement ce que la valeur cherche à faire, évaluer est-ce qu’on optimise les résultats atteints par le système de santé compte tenu des ressources dont on dispose? Et pour faire ça, on doit absolument bien comprendre la demande, les besoins et de sorte qu’on puisse arrimer les besoins avec la demande – avec l’offre des services, pardon, pour avoir une offre qui correspond aux besoins de la population.
Maintenant, ça, c’est encore dans le rêve mais disons on est en train de mettre les choses en place pour arriver à cet élément-là. Maintenant, j’ai parlé de gouvernance plus tôt. Je vais vous réexpliquer un peu plus tard comment on veut travailler cette question-là parce qu’à la fois la valeur et la gouvernance ne sont pas des caractéristiques qui sont examinées traditionnellement dans les cadres d’analyse des systèmes. Alors, je vais revenir sur les définitions et pourquoi c’est important. Ben, en fait, ce sont des facteurs excessivement importants si on veut atteindre les résultats souhaités.
Donc, la valeur, qu’est-ce que la valeur? Alors, la façon traditionnelle – les systèmes de santé regardent traditionnellement – ou en fait, il y a deux grandes écoles de pensée. Il y a l’école de pensée de l’Institute of Health Improvement qui est, là, on le connaît davantage sur les quadruple aims et essentiellement on parle d’améliorer l’état de santé, améliorer la réactivité du système, l’utilisation des ressources, et d’améliorer la satisfaction des prestataires.
Il y a une autre définition qui est celle qui sont plus des tenants de l’École – de Michael Porter qui est essentiellement – pas nécessairement à la source ou le fondateur de la valeur, mais disons que c’est lui qui l’a rendue plus communément connue ou utilisée dans le secteur de la santé. Mais essentiellement, c’est deux façons d’exprimer la même chose, bien que les deux écoles puissent penser qu’ils sont deux écoles différentes. Essentiellement, la première va regarder différents facteurs ou stratégies, c’est-à-dire que la réactivité du système et la satisfaction des prestataires sont des stratégies pour améliorer la valeur. Donc, à notre sens au CSBE, ça veut dire exactement la même affaire.
Donc quand on est en train de regarder la valeur, on est en train de regarder les résultats qui sont importants, des résultats de santé et de bien-être qui sont importants pour la population compte tenu des coûts totaux, tous les coûts, toutes les ressources qu’on alloue. Et on doit également s’assurer qu’on préserve les valeurs de la société, c’est-à-dire que si on fait – on atteint nos objectifs, mais qu’on le fait à l’encontre des valeurs de la société, on n’est pas un système de santé publique qui répond aux besoins de la population. Alors, on perd de la valeur à quelque part. Même chose si on le fait sans tenir compte de la valeur nécessaire ou importante pour les prestataires. Et les prestataires étant les travailleurs et les organisations.
La gouvernance. Pourquoi la gouvernance est importante? Là, je viens de sauter. Je m’excuse. Alors, la gouvernance, lorsqu’on a fait une évaluation de ce que voulait dire la gouvernance, on s’est rendu compte d’abord qu’il y avait autant de définitions qu’il y avait de personnes qui s’y intéressaient. Ensuite, les cadres d’analyse de la gouvernance étaient très peu fréquents. Donc on s’en est donné un. On en a proposé un et c’est ce qu’on a utilisé dans notre premier grand mandat.
Donc, si on regarde – on a adopté une définition aussi pis, en fait, la gouvernance ça réfère à l’ensemble des institutions qu’elles soient formelles ou informelles. Donc tous les mécanismes qu’on met en place pour favoriser l’atteinte de nos objectifs. Et puisqu’il s’agit ici d’un système public, ça inclut la réglementation, les lois, etc. Et le rôle de la gouvernance, c’est de traduire la volonté de la société en objectif, d’établir les politiques, les orientations et les stratégies afin d’atteindre les résultats, et de mieux soutenir. En fait, on est en train ici d’exprimer quel est le rôle du Ministère dans l’atteinte des objectifs du système de santé? Ou en tout cas, un des rôles importants.
Comment on va apprécier la gouvernance? Alors, on s’est donné un cadre d’analyse, la gouvernance, pour apprécier l’alignement de l’ensemble des politiques, des stratégies, des mécanismes incitatifs, etc. Est-ce qu’ils sont bien alignés avec l’objectif d’atteindre les meilleurs résultats de santé compte tenu des ressources?
Alors, on a analysé chacun de ces éléments-là dans le contexte de notre mandat, donc la façon dont on finance les CHSLD, la façon dont on donne les objectifs, la façon dont on mesure l’atteinte des résultats qu’on évalue la qualité. Est-ce que c’est en lien avec la valeur ou non? Est-ce qu’on donne des directives qui sont conséquentes ou non? Et donc, on s’est donné un cadre d’analyse qui nous permettait finalement de faire le contour des leviers et donc les différents leviers sont le plan stratégique et sa mise en œuvre.
Donc ça inclut les orientations ou comment – quelles sortes d’évaluations qu’on fait de l’environnement et comme compréhension des enjeux, les stratégies qu’on met en place, le type de leadership qui est exercé. Est-ce que ces moyens-là mis en place sont conséquents ou cohérents avec l’objectif d’amélioration de la valeur? Même chose pour les mécanismes de contrôle qui sont l’évaluation de la qualité, par exemple. Les mécanismes d’incitation, toute la rémunération, comment on compense les hôpitaux pour les offres – les services qu’ils offrent. Est-ce que c’est en lien avec la valeur? Ou c’est en lien avec la multiplication des activités?
On peut se poser la question. La mesure des résultats à la gestion des risques, est-ce qu’elle est faite? Est-ce qu’on le suit? Est-ce que l’évaluation, les processus d’évaluation, les données dont on dispose, est-ce qu’elles nous permettent de porter un regard sur la performance ou la valeur, et soutiennent la prise de décisions?
Donc, on a obtenu un premier mandat et je vais pas passer à travers ça parce que je dispose pas le temps, mais je veux juste montrer les différentes – excusez-moi, là, je vais passer plus vite. Mais essentiellement pour mentionner que ce qu’on a observé c’était les causes fondamentales de notre échec pendant la première vague, ou à gérer ou à bien gérer, étaient essentiellement dues au fait que le Ministère ne valorise pas son rôle de la gouvernance qui est pourtant essentiel.
En fait, l’attention du Ministère est portée sur les opérations du système et donc il ne mobilise pas les leviers et les ressources de façon à aller chercher, maximiser la gouvernance. Maintenant, on a proposé des orientations plutôt que de proposer des recommandations. Un ensemble d’orientations qui permettraient de favoriser la valeur, mais ça exige des changements institutionnels qui sont excessivement importants.
Alors comment on souhaite au Québec – excusez-moi, au CSBE soutenir cette amélioration-là, ça va être en trouvant les blocages et les freins qui nuisent à l’adoption des innovations, qui nuisent au changement, en identifiant les accélérateurs. Alors, allons voir comment les autres on réussi à débloquer, mais surtout en soutenant la collaboration, en permettant aux différents acteurs de codévelopper des solutions, en tenant compte des enjeux de tous, mais en travaillant vers notre objectif qui est commun qui est d’améliorer la valeur qu’on obtient en temps de population à partir de notre système de santé.
Et donc les questions auxquelles on répond. Trois catégories de capacité à développer pour y arriver. Alors à la fois au sein du CSBE mais aussi au sein de l’ensemble du système, la gouvernance en santé, l’innovation dans les politiques publiques et surtout la mesure de la valeur. Comme je disais, on n’a pas les bonnes données. On doit s’entendre sur les données et comment les cumuler. Alors, je vous remercie beaucoup.
Moderator: Merci à vous. C’était tout un défi que de faire un tour aussi rapide des enjeux. Et ben, j’en profiterais, si vous permettez, pour inviter immédiatement Dre Opatrny à prendre la parole pour la seconde présentation. Après quoi, je vais inviter nos deux autres panélistes à formuler un peu à brûle-pourpoint leurs impressions de manière synthétique sur ce qui aura été avancé jusqu’ici. Docteure Opatrny, à vous la parole.
Lucie Opatrny: Merci beaucoup. Et merci beaucoup à AMC de l’invitation ce soir. Alors, je vais continuer, je pense, à vrai dire sur pas mal le même sujet, de vous présenter quelques prismes et angles sous lesquels, moi, je regarde la valeur en santé, et de partager avec vous ce soir quelques exemples québécois que je trouve regarde et démontre la création de valeur.
Alors, comme Mme Castonguay a aussi dit, pour moi ça c’est en termes graphiques le modèle de IHI (sic), de quadruple aims où on regarde comment une création de valeur doit toucher plus ou moins, mais vraiment regarder tous ces éléments-là. Alors, de regarder les résultats patients, de regarder comment ceci peut améliorer l’expérience patient, de regarder comment on peut diminuer les coûts. Et finalement, le quatrième qui a été rajouté plus récemment, c’est dans un contexte de bien-être du clinicien aussi auquel ç’a rajouté des fois un cinquième qui est l’équité. Mais ça, c’est quelque chose que pour nous ç’a toujours été pas mal intégré.
Et l’autre en lien avec ça, en termes de création de valeur, c’est d’avoir un concept qu’on devrait jamais être statique. On devrait toujours se demander n’importe où où on est, comment est-ce qu’on peut s’améliorer dans un processus d’amélioration continu? Alors d’observer où est-ce qu’on est, de mettre un plan, de le mettre en application, de regarder par la suite est-ce que le plan de mesurer – pis ça, c’est clé vraiment – de mesurer est-ce que ce qu’on a mis en application a donné les résultats? Si oui, mais parfait. Continuez sur le même angle ou le prochain. Et sinon, pourquoi non. Alors, reculons pis peut-être essayons d’autre chose. Mais de toujours avancer vers une amélioration qui nécessite vraiment une mesure et une réflexion.
L’autre, c’est pour moi la standardisation. Et là, j’utilise l’exemple d’un repas de McDonald pis on peut ou peut pas dire que c’est la qualité, OK, mais on peut dire que peu importe si on est à Montréal, à Mumbai ou à Madrid, là, ça va goûter pareil. Et si on pense que c’est bon ou non, on sait que la qualité va être pareille parce que leurs processus sont hyper standardisés. Et ceci dit, mes enfants me disent, il y a quand même une variation du menu local. En France, c’est des macarons. En Angleterre, il y a des scones. Mais à la base, c’est standard.
Pis je pense en médecine, il faudrait voir comment la base 80-20 standardiser ce qui peut être standardisé pour par la suite la variation qu’il faut amener, laisser nos cerveaux, laisser le temps à faire cette personnalisation-là pour ceux qui ont besoin d’être personnalisés.
Alors là, si on regarde les soins, pour moi il y a un continuum. Il y a la vaccination que pour moi est quelque chose qui est à un extrême, qui est quelque chose une procédure simple qu’on fait à très haut volume pis c’est assez facile de standardiser. Et parce que c’est facile à standardiser et c’est à haut volume, on peut vraiment l’administrer pis l’avoir partout. À l’autre extrême, il y a peut-être d’autres exemples aussi, mais pour moi c’est la neurochirurgie où c’est une procédure qui est très complexe et ça prend une équipe hautement spécialisée et il y a très peu de volume.
Et c’est pour ça qu’il faut le concentrer dans quelques sites au Québec, parce que la chirurgienne il faut qu’elle voie un certain nombre de cas pis entourée par l’équipe spécialisée pour être sûre que la qualité est là. Les complications sont bons (sic). Entre ça, ben, c’est entre la vaccination et la neurochirurgie, et on peut penser à l’obstétrique, à la cancérologie, à la cardiologie interventionnelle où c’est – il faut regarder et balancer à quel point ça peut être standardisé tout en gardant un certain volume pour s’assurer qu’on a accès à une qualité de l’aide qui nous amène toujours à un équilibre.
Parce qu’il y a toujours un équilibre à aller chercher entre un accès en proximité parce qu’on veut aller chercher nos soins près de chez nous, mais de s’assurer qu’il y a une certaine qualité et de diminution de complications. Il faut quand même avoir un certain volume de procédures pour avoir un seuil et pour atteindre cette qualité et sécurité. Alors, c’est pour ça que par exemple il y a certains cancers qui sont traités aussi juste à quelques endroits pour être sûr que ce qui – les résultats qui sont obtenus sont de haute qualité et il y a une certaine standardisation avec le volume.
Et ça, ça joue beaucoup aussi sur notre territoire qui est très vaste et des fois il faut toujours regarder la balance entre un accès de proximité avec l’assurance de qualité. Alors maintenant, je me tourne – alors ça, c’est quelques exemples de prisme. Mais là, les exemples québécois, en particulier, et j’ai choisi quelques-uns que pour moi va chercher différents éléments du modèle de quadruple aims.
Le premier que j’utilise, c’est celui des médicaments biosimilaires sur lequel on a travaillé. Alors ici, je vous montre – ça, c’est les coûts pour les médicaments, pas juste les biosimilaires, le coût total des médicaments au Québec. Et on voit que ça monte en flèche depuis quelques années. Alors, c’était pas mal stable. Ça monte en flèche. Et ça, c’est dû à l’arrivée des médicaments biologiques qui sont excellents, qui marchent très bien en cancérologie puis immunomodulation, par exemple, en gastroentérologie ou chromatologie. Mais c’est pas soutenable d’avoir cette montée-là.
Alors, qu’est-ce qu’on peut faire? On a suivi les autres pays. Il y a d’autres pays européens. Il y a d’autres provinces qui sont allées avant nous de voir est-ce qu’on peut réduire le coût? Et est-ce qu’on peut le faire de façon qui est efficace et sécurité? Et la réponse est oui qu’on peut remplacer quelques médicaments originaux par des médicaments biosimilaires qui ont fait preuve des études pour l’efficacité et de sécurité. Et qui sont beaucoup moins dispendieux.
Alors nous avons travaillé depuis un an avec plusieurs parties prenantes, des patients partenaires, l’INESSS, les compagnies pharmaceutiques, les médecins, les soignants pour – avec un objectif d’aller de 5 % d’utilisation des médicaments biosimilaires à 50 % en trois ans. Et ceci pourquoi? Parce que comme ça, on peut traiter le même nombre de patients pour beaucoup moins d’argent qui dégage des sommes pour faire quoi? Pour aller chercher d’autres médicaments novateurs qui sortent sur le marché pour être capables de traiter plus de patients pour la même somme.
Alors pour moi, ça, c’est un exemple de création de valeur. Et je vais sauter ça juste pour dire que ça fonctionne. L’année passée, c’est vraiment à l’automne que ç’a été mis en place avec 14 millions qui ont été une diminution de 14 millions. Mais cette année, une projection de 100 millions de diminution de coûts avec le transfert vers les médicaments biosimilaires.
Alors, un deuxième pis c’était finalement fait main dans la main avec les soignants pis avec les patients. Et évidemment, il y a des exceptions pour ceux qui ne peuvent pas faire le transfert de façon sécuritaire.
Deuxième exemple. J’utilise complètement autre chose. C’est une intervention coronarienne percutanée pis je pense que beaucoup de demandes à AMC sont des médecins, mais juste au cas où pour les autres qui le sont pas. Alors je rappelle que quand on a une artère qui est bloquée, mais une procédure percutanée pour aller ouvrir soit avec un stent ou non l’artère. Mais ça, c’est encore une chose qui est hautement spécialisée. Et est-ce que c’est comme le McDonald? Est-ce que peu importe où on va, les résultats sont pareils?
Et la réponse à ça c’est non. C’est pas le cas. Alors, il faut regarder et mesurer. Alors, ce qu’on voit ici, c’est un graphique de montrer pancanadien de façon brute quels sont les résultats en termes de mortalité suite à un choc cardiovasculaire – choc cardiaque et on voit qu’en brut, Canada en rouge, et la mortalité est moins qu’au Québec en bleu. Et en bleu foncé, on voit qu’il y a une mortalité qui est plus élevée. Mais ça, c’est brut. Alors notre population est pas pareille parce qu’on est plus vieux, plus âgés, avec plus de comorbidité. Alors, on voit l’importance qu’on peut pas se fier sur des chiffres bruts. Il faut faire des ajustements pour être sûr qu’on compare les mêmes populations.
Alors il faut comparer les mêmes âges avec les mêmes comorbidités. Alors quand on fait ça, mais les écarts sont beaucoup moindres, mais les écarts continuent. Alors maintenant, c’est que les résultats québécois qu’on voit. Alors après qu’on ajuste pour toutes sortes comorbidités et âges, etc., ce qu’on voit c’est qu’il y avait des outlyers. Il y avait quelques endroits au Québec qui avaient des résultats qui étaient pas aussi bons que les autres.
Alors – des différences sont pas si grandes que ça. C’est pas des différences qui seraient – qui frappent l’œil sans mesurer de façon standard. Alors, on les a rencontrées pis c’était très intéressant de voir l’approche. Alors il y a quelques centres qui sont venus pis ils disent, oui. Alors, on a vu ça pis on a commencé à analyser nos données puis on a réfléchi pis on a vu telle, telle affaire, pis on a décidé de faire tel, tel, tel ajustement. Et c’est exactement le cycle de réflexion de mettre en application et de voir comment on améliore.
Et il y a d’autres qui ont dit, ben, vous avez les mauvaises données. C’est pas vrai. C’est pas – alors, il y a une résistance des fois à accepter les données qu’on démontre. Et ça, c’est tout à fait naturel. C’est tout à fait normal qu’au début on se dit, mais ça se peut pas. Je fais tout bien. Je suis expert. Pourquoi? Alors, c’est vraiment un changement de pensée qu’il faut accompagner de façon de dire mais – et de réaliser et mettre en place des éléments pour par la suite s’améliorer et venir dans les moyennes.
Alors ça, c’est un autre exemple pour moi où de mesurer des fois ça nous soulève des éléments de qualité auxquels on n’était pas au courant qui nous laissent par la suite faire des changements pour s’améliorer. Mais ça veut pas dire que ceux qui sont en dessous de la moyenne peuvent pas non plus continuer à s’améliorer quand on regarde nos données.
Alors ça, encore une fois, c’est dans la vision d’amélioration continue. Alors pour moi, quels sont les différents éléments qui sont importants? C’est de se mesurer et de comparer les clés (sic), parce que ça nous permet d’identifier et de travailler et suivre les écarts. Mais c’est vraiment un changement de paradigme parce que c’est pas des données vraiment qu’au Québec en ce moment on partage nécessairement comme fait d’autres, par exemple Ontario, comme font d’autres pays, mais on s’en vient.
Je pense qu’il me reste pas beaucoup de temps alors je vais sauter le coût par parcours de soins où vraiment on va changer la façon qu’on finance le système d’un budget historique vers un parcours – un coût par parcours de soins. On peut peut-être regarder ça à un autre temps pour encore une fois mettre la valeur pour – au système pour peut-être dire que pour moi le plan santé qui a été récemment déposé va chercher ces éléments-là. Il y a vraiment un changement de paradigme que, moi, je vois.
Vous avez vu récemment qu’on commence à publier des tableaux de bord qui ont pas été publiés avant pour partager ces éléments-là pour vraiment de mesurer et agir sur ce qu’on voit comme indicateurs. Et je trouve que c’est un rattrapage qui est important à faire. Je pense qu’on devrait dans le futur le pousser encore plus loin pour, comme a dit Mme Castonguay, aussi regarder pas que les processus mais des résultats de qualité. Et tranquillement ça va prendre un changement de culture dans le milieu de santé parce que c’est pas quelque chose auquel on est habitué mais je suis certaine qu’on y arrivera.
Moderator: Merci infiniment. Alors des enjeux de fond que vous avez soulevés sur la nécessité d’aller vraiment inciter le système à entrer dans une sorte d’adaptation de transformation à plusieurs égards dans plein de dimensions. Mais avant d’aller plus loin, là, dans ces questions que je voulais mentionner tout à l’heure, j’aimerais inviter nos deux autres panélistes à prononcer un peu à brûle-pourpoint, à chaud comme on dit, vos impressions ou des réflexions que vous soulèvent les différentes – les deux interventions qui vous ont précédées. À commencer par Mme Lambert en deux minutes.
Édith Lambert: Parfait. Ben, en fait, je suis contente de voir qu’on va regarder les résultats ou même les objectifs de façon différente. Bon, ayant été dans le milieu de soins pendant 15 ans, on a souvent pas été écoutées, nous, en tant qu’infirmières. On faisant des demandes. On mentionnait des situations pis c’était juste comme balayé. Je pense qu’avec la nouvelle vision, ça pourra plus être balayé pis les intervenants vont pouvoir être mieux entendus.
Pis je pense que c’est la base. C’est eux qui savent ce qui fonctionne pas pis qu’est-ce que justement quand vous dites que, ah, j’ai fait tel changement pis il y a une réussite. Ben, c’est les intervenants qui ont fait ces changements-là. Donc c’est eux qui sont en mesure de dire, oui, ça fonctionne, non, ça fonctionne pas. Évidemment, il faut faire tomber la résistance. Ça aussi c’est pas facile mais je pense que justement en travaillant en équipe pis en étant plus transparents, ça aussi je suis contente de voir.
T’sais, en publiant vos résultats et tout, ben, ça donne de l’éducation pis les gens aussi vont mieux comprendre un peu pourquoi mettons les délais sont longs ou telle chose se fait pas parce qu’on voit, ben, on a tenté ça. On a eu tels résultats mais on va amener des changements pis on va pouvoir suivre le changement. Pis ça, je pense que ça va calmer aussi la population au niveau de toute la colère qu’ils ont parce qu’on a l’impression que le système est brisé pis qu’on n’a pas – on n’a pas de soins, là, comme on devrait avoir. Donc, je suis contente de ce que j’entends, là.
Moderator: Merci. Merci beaucoup, Madame Lambert. Docteur Shabah.
Abdo Shabah: Je trouve que c’est extrêmement intéressant la présentation d’une perspective un peu systémique et systématique de l’approche un peu de l’analyse dans le système de santé à différents niveaux. Je pense qu’il y a des défis qui sont là par rapport à comment est-ce qu’on – la prestation de soins au niveau local, au niveau régional et au niveau, on va dire provincial, et quand on compare au niveau national et ailleurs.
On n’a pas les mêmes chiffres qu’ailleurs. On a un territoire très vaste. On a aussi une prestation de soins qui est variable entre les régions. Demeunier (sic) en Gaspésie ne se traite pas de la même manière même si on donne les mêmes antibiotiques, mais l’épisode de soins ou la durée des fois la réalité régionale vient nous rattraper pour dire, ben, il y a certaines interventions qui sont données différemment. Et c’est de la personnalisation. C’est vraiment de l’adaptation en fonction de la communauté ou des besoins des patients localement.
Donc, je trouve ça très intéressant d’amener de la standardisation et de la personnalisation en même temps par rapport aux soins et de regarder ça dans une perspective très large, systémique et d’une manière beaucoup plus locale également.
Moderator: Merci beaucoup, docteur Shaba. Je prends également soin de vous rappeler que si vous avez des questions à formuler afin de les adresser donc à nos panélistes, n’hésitez surtout pas à les écrire. Comme je vous le mentionnais tout à l’heure dans la section Q et R, Q&A pour formuler ces questions. Alors nous en avons d’ores et déjà une, alors.
Et la question est la suivante. « Le système de santé est fondé sur l’assurance-maladie. Dans le requestionnement de ce système, doit-on à ce niveau changer de paradigme, soit assurer la santé à proprement dit? » Alors je sais pas si l’un ou l’autre d’entre vous a des idées à formuler par rapport à cet enjeu de fond qui revient de manière régulière depuis plusieurs années sur l’assurance. Je suppose que ça soulève aussi l’enjeu de la privatisation des soins, bien sûr. Est-ce que – Madame Castonguay.
Joanne Castonguay: Oui. En fait – ben, en fait, moi, ça m’interpelle à deux niveaux. Je dirais que – ben, en fait, je dirais oui on est – le système est fondé sur l’assurance-maladie, mais en fait il est fondé sur les soins et les services de santé. Alors, que si on regardait de façon différente pis qu’on mettait davantage – et c’est une de nos recommandations dans le cas de notre mandat spécial qui est de donner davantage de place à la santé publique, davantage prévenir la maladie.
Et donc de partir avec ce paradigme-là. Et quand on parle de parcours de soins, Dre Opatrny parlait de coûts par parcours de soins. Ben, le parcours devrait aller aussi loin que de considérer la prévention. On n’est pas rendu là dans la façon de faire, dans les moyens de financer. En fait, je crois – je l’ai jamais vu même dans les systèmes de santé en les observant, mais on peut toujours prendre le concept et investir et placer la santé publique au cœur des stratégies pour améliorer la performance du système.
Moderator: Merci. Et si je me souviens bien et si ma mémoire est bonne, dans la mise en place du système d’assurance-maladie, la carte d’assurance-maladie est également un M. Castonguay qui était là. On parlait de la castonguette au sujet de cette carte d’assurance-maladie que l’on passait dans les systèmes de soins. Très bien. Alors, je vous remercie. On aurait une question qui s’adresse cette fois-ci au Dre Lucie Opatrny.
Elle se formule comme suit : « Comment pouvons-nous changer les paradigmes et rendre plus fluide et agile la présente gouvernance pour accroître l’accès aux services de première ligne de qualité en mettant à contribution le bon professionnel au bon moment pour répondre aux besoins du patient. Donc agir là où ça compte. Par exemple, les physiothérapeutes occupent un champ vaste d’exercice en neuromusculosquelettique et cardiorespiratoire et ont accès direct depuis maintenant 30 ans – et ont un accès direct depuis maintenant 30 ans. Alors comment voyez-vous les prochaines étapes pour nous permettre de vous aider tant en organisation du travail optimisée qu’en valorisation de cette profession qu’est la physiothérapie au bénéfice des patients, des listes d’attente postopératoire, du désengorgement des urgences? » Alors Madame Opatrny, tout un menu.
Lucie Opatrny: Je pense qu’on est tous d’accord qu’il faut vraiment changer le modèle de la première ligne d’aller à j’ai besoin d’un médecin de famille qui par la suite qui est le goulot d’étranglement qui va par la suite nous diriger vers un service plus approprié si c’est physiothérapeute comme mentionné dans la question ou si c’est un pharmacien ou un travail social. Plus de dire, quel est le problème que j’ai qui doit être adressé par le bon professionnel? Alors vraiment de changer le paradigme et voir comment aiguiller l’individu avec le professionnel qui est plus apte à adresser la problématique dans le temps opportun.
Et c’est vraiment ça qu’on est en train de travailler avec, par exemple, le guichet d’accès en première ligne qui est vraiment une transition vers un système plus de capitation de voir comment est-ce que – et on parle aux États-Unis par exemple d’un patient home, de voir comment quelqu’un peut être entouré par des services auxquels il a besoin. Alors ceci, c’est sûr que ça prend une réorganisation mais c’est exactement vers ça qu’on est en train de travailler.
Alors maintenant, il y a beaucoup de sommes qui ont été données pour essayer de structurer ça. On regarde aussi des éléments de TI pour nous aider. On est en train de travailler avec plein de différents professionnels de santé pour faire exactement ça, de voir plus comment arrimer les besoins avec le bon professionnel. C’est vraiment là-dessus pis c’est vraiment là-dessus qu’on veut travailler d’ici activement les trois prochaines années.
Moderator: Merci beaucoup, Docteure Opartny. J’ai vu brièvement une question tout à l’heure qui m’interpellait aussi qui est le défi de la mise en œuvre. Alors, vous avez soulevé, si on veut, cette réalité pis elle est organisationnelle. Elle est pas propre à ici mais il y a toujours une certaine résistance au changement. On a parlé du changement de culture dans les organisations. Et il y a une notion qui a été soulevée tout à l’heure qui m’a interpellé qui est celle des accélérateurs d’innovation. Alors, comment fait-on pour amener les gens à sortir de cette stagnation, de cette force d’inertie des fois.
Vous avez parlé tout à l’heure des – justement. Comment fait-on pour rester en mouvement pour être dans cet esprit du changement, d’adaptabilité. Alors, ce serait ma question qui va reprendre – qui reprend une des questions qui avait été posée. Alors, dans le défi de la mise en œuvre de l’amélioration du système, où sont ces pistes d’accélération qui nous permettent d’adapter davantage le système?
Lucie Opatrny: C’est pour moi aussi, j’imagine. Pour moi, ça serait un mariage entre – que le Ministère fasse des objectifs clairs, mais qu’il donne des outils pour que le réseau le mette en place. Et alors quand on a des objectifs et que le réseau a des moyens. Quand je dis des moyens en ressources humaines, des moyens en termes d’outils technologiques, en termes de stratégies, de partage des meilleures pratiques parce que c’est vraiment le terrain qui aussi va faire en sorte – c’est là où les solutions se trouvent.
Alors, c’est ce mariage-là que pour moi est important, d’avoir les orientations qui sont données mais par la suite c’est vraiment le terrain avec tous les outils qui sont disponibles de le mettre en application. C’est assez simpliste mais en même temps je pense que ça revient un petit peu à ce que vous avez dit aussi.
Joanne Castonguay: Oui, tout à fait. Et quand je parlais du rôle du Ministère. Mais j’ajouterais à ça que souvent on va avoir des projets de démonstration qui vont dire on va essayer de voir si ça marche en organisant les choses autrement. Et qu’à partir du moment où on retire, t’sais, que c’est plus un projet de démonstration pis qu’il y a moins de soutien, souvent les projets tombent.
Et la raison pour laquelle ces projets-là vont tomber, c’est que les institutions donc les mécanismes de rémunération, la façon de suivre les données, ça peut – ben, les mécanismes de rémunération surtout dans l’exemple que vous donniez qui concerne la première ligne pis l’intégration des nouveaux membres d’une équipe, ben, c’est exactement ce que vous faites ou ce que le Ministère fait quand il est en négociation pour orienter le financement de la première ligne vers une équipe de soins plutôt que vers le médecin.
Et par contre, ça confronte la culture. Ça confronte les institutions parce que les médecins n’ont jamais été financés comme ça. Les infirmières n’ont pas été financées comme ça. Les infirmières travaillent pour le réseau. Alors, il y a toutes sortes de résistances qui sont pas nécessairement identifiées ou connues à l’avance. Et l’idée de faire travailler – alors quand je parlais de codévelopper les solutions pour développer des institutions plus agiles, c’est exactement de ça que je parlais.
Et quand on regarde les mécanismes d’innovation pour des innovations technologiques en ingénierie, etc., eux, ils sont habitués de faire du codéveloppement. Ils appellent ça – bon, il y a toutes sortes de termes, le design thinking, les living lams. Essentiellement ce qu’ils font c’est du codéveloppement. Et il y a des connaissances qui commencent à se développer sur le codéveloppement pour les politiques publiques.
C’est pas encore quelque chose qui est répandu ou qu’on attend, mais il y a une littérature qui commence à se développer et ça fait partie, là, des choses que, nous, on veut investiguer pour informer davantage sur faire des recommandations sur comment améliorer la valeur.
Moderator: Hé bien justement, ça me permet peut-être de faire le pont vers notre deuxième volet de la soirée, parce qu’il apparaît évident que dans l’approche d’intelligence collective qu’on soulève, sans la nommer depuis tout à l’heure, c’est-à-dire en interpellant dans l’identification des problèmes et des solutions à mettre en place l’ensemble des acteurs qui sont partie prenante de nos sociétés à la fois donc les décideurs dans toutes les étapes de gouvernance, mais aussi les prestataires, les usagers.
Et c’est dans cette logique que nous avons l’honneur ce soir de recevoir Mme Édit Lambert qui elle a été à la fois donc du côté – dans le système à titre d’infirmière. Mais c’est ce soir non pas à titre d’infirmière qu’elle est invitée, mais pour son expérience dans le système de santé. Et je l’inviterais pour les prochaines minutes justement à nous partager brièvement quel a été votre parcours au cours des dernières années avec le système de santé. Madame Lambert, merci d’être avec nous.
Édith Lambert: Ben, merci à vous. Donc, dans le fond, ben c’est ça. J’ai été infirmière pendant 15 ans. Donc j’étais – je me suis promenée beaucoup. J’étais équipe volante. J’ai quand même vu bien des choses. Ensuite de ça, j’ai eu un accident de voiture qui m’a causé un AVC et suite à ça malheureusement j’ai dû faire le deuil de ma profession et me réorienter. J’ai quand même eu des enjeux suite à mon AVC, bon, au retour à la maison. Je vais vous en parler un petit peu plus tard.
Pis présentement, dans le fond, c’est ça, je suis dans une situation difficile avec mon garçon qui a des symptômes neuroatypiques et qui sont soudains. Il s’est levé comme ça un matin et j’ai beaucoup de difficultés à avoir des soins pis des suivis pour lui. Donc, au niveau des premières lignes justement quand je vous écoute, je suis comme, OK, super, parce que justement d’avoir quelqu’un présentement autre qu’un médecin, ce serait très apprécié.
On a l’impression d’être en chute libre présentement pis on se croise les doigts que le parachute va s’ouvrir. Et c’est très désagréable comme sensation. C’est pas le parcours que j’ai eu. Dans le fond, t’sais, la difficulté d’avoir des soins c’est pas basé sur une seule personne ou un seul intervenant. Ç’a vraiment été au niveau du système. Je vous donne un exemple. Avec mon AVC quand je suis retournée à la maison, j’ai été six semaines en réadaptation interne. Ça allait bien. C’est l’fun. T’es entouré. C’est magique. Tu vas chez vous une fin de semaine, tu reviens, yé! Quand t’es rendu chez vous 24 heures sur 24 dans la routine avec des enfants toute seule, pas de ressources, c’est autre chose.
J’avais dans le fond – ben c’est une perte d’autonomie. J’ai paralysé du côté gauche au complet. Donc oui j’ai récupéré pis ils nous retournent pas à la maison quand on n’est pas prêt. Mais ça reste qu’on n’est pas à 100 % quand on revient à la maison. Et bon, il y a des programmes d’aide pour les personnes âgées en perte d’autonomie et ç’a l’air qu’il y a des programmes d’aide pour la petite enfance quand il y a de la perte d’autonomie.
Entre cinq ans et 65 ans, il y a rien. Moi, j’ai eu mon AVC à 34 ans. Donc je rentrais dans aucun programme. Donc si je voulais avoir de l’aide à la maison justement pour que ce soit le ménage, que ce soit pour la routine avec les enfants, que ce soit d’aller faire l’épicerie. Tout ça, je devais payer pour avoir de l’aide, mais évidemment je suis en arrêt de travail. Oui, il y a des différents programmes pour nous aider dans ça. Malheureusement, moi, ma condition, bon, il y a eu des enjeux avec la SAQ (sic), là. Donc j’ai fini par aller sur l’aide sociale.
Donc on s’entendra qu’avec l’aide sociale j’avais pas les moyens de payer pour avoir de l’aide à la maison. C’était temporaire heureusement. Mais c’est quand même une réalité que j’ai eue. J’avais aucune ressource pour m’aider comme ça. Donc, il faut voir, t’sais, on parle de standardiser, oui, mais justement à cause de critères précis, moi, j’ai pas eu d’aide quand je suis revenue à la maison, parce qu’il fallait que j’aille 65 ans et plus. Il fallait tel, tel, tel critère.
Pis ça, je trouve que c’est – je me suis sentie un peu comme abandonnée pis pas importante, t’sais, parce que je veux dire dans le fond ma perte d’autonomie était comme banalisée par rapport à une personne âgée. Pis ça, ça devrait pas parce qu’on devrait tous avoir, on va dire, la même qualité de vie. Ce serait merveilleux. C’est un peu utopique mais une base du moins, pis avoir de l’aide pour justement regagner notre autonomie, ben, ça devrait pas devoir être une dépense personnelle.
Pis encore plus quand les autres en ont droit pis que toi tu l’as pas. Au niveau plus récemment parce que ça, bon, ça fait quand même huit ans pour l’AVC, là. Il y a des choses qui ont changé, du moins j’espère.
Plus récemment avec mon garçon, ben, l’accès aux soins est difficile. On se présente à l’urgence. C’est long. On comprend le processus pis, bon, les médecins sont débordés. J’ai vu – j’ai dû consulter trois fois parce que mon garçon se détériorait. J’ai toujours la même réponse, je peux pas rien faire parce que j’ai pas de neurologue qui peut le voir. Dans cette situation-là, c’est pas tant les délais d’attente qui sont angoissants ou qui nous perturbent. C’est vraiment, c’est l’incertitude, je vais-tu avoir des soins? Je vais-tu avoir quelqu’un? Pis moi, je suis là pis je regarde mon fils se détériorer, pis je peux pas rien faire.
C’est l’impuissance aussi qui est là. Pis quand on est un proche aidant et qu’on parle, ben, il faut être écouté. Moi, je suis avec 24 heures sur 24. Donc je vais amener des données, des faits que vous voyez pas quand on est avec vous dans une évaluation quelconque ou peu importe l’intervenant. Donc, c’est important que – c’est pas parce que c’est pas mon fils qui parle que c’est pas vrai. Pis ça, c’est un sentiment qu’on a vécu tous les deux de ne pas être écoutés, entendus.
Mikael (ph) a de la difficulté à s’exprimer présentement. Il cherche ses mots. Il dit pas les bons mots. Il y a une lenteur au niveau de l’assimilation de l’information. Donc, expliquer au médecin ce qui se passe quand il regarde pis dis-moi ce qui se passe pis qui enchaîne question après question après question, il est incapable de le faire. Et on lui laisse pas le temps parce qu’il n’a même pas fini sa première phrase qu’on lui pose une autre question.
Donc dans ce contexte-là, on respire, et on se dit, OK, on va aller voir ailleurs pis on essaie. T’sais, j’ai peut-être abusé mais j’ai consulté dans trois hôpitaux différents pour essayer d’avoir de l’aide. On vient désemparé pis quand le dernier médecin que j’ai vu à l’urgence, il était lui-même désemparé quand il m’a dit, je vous remets le papier de consultation pour un neurologue. Vous devez vous trouver un neurologue parce qu’on peut pas le voir avant un an, mais il doit être évalué rapidement.
Donc, je fais quoi, moi, avec ça? Donc, j’ai dû par moi-même – évidemment, maman m’a aidée. Une chance que je l’avais, mais j’ai dû appeler dans 25 hôpitaux sans jamais être capable de parler à qui que ce soit, parce que c’est le message vocal qui dit « envoyez votre requête à tel numéro de fax ». En 2022, on peut-tu envoyer nos requêtes en courriel? Déjà trouver un fax ç’a été un défi en soi. J’ai faxé des requêtes mais est-ce qu’elle a été reçue?
Est-ce qu’il y a quelqu’un qui va prendre la requête, qui va la lire pour vrai pis qui va voir c’est coché urgent pis qui va vraiment nous traiter de façon urgente ou pas? C’est quoi urgent? C’est vaste. Ma version d’urgence c’est tout de suite. La version du système semble être autre chose, parce que c’est depuis le 16 mars que mon garçon va pas bien pis j’ai toujours pas de piste de solution.
Donc, c’est tout ça mis ensemble qui fait que – justement c’est ça, on est désemparés. On devient, ben, en colère pis c’est pas toujours dirigé vers les bonnes personnes. On essaie de faire attention mais, bon. J’ai dû demander l’aide de mon député pour qu’on arrête de canceller mes rendez-vous qu’on me donnait pour une évaluation. Pis quand j’ai réussi à avoir un neurologue, elle a focussé sur des choses qui étaient pas dans la condition existante.
Donc elle a focussé sur – son poids sur ses difficultés à l’école, sur son TDH non médicamenté. Je consulte pas pour ça, loin de là. Donc pour la suite, j’ai encore aucune idée où je m’en vais. Je sais plus à quelle porte cogner, pis c’est pas normal que le proche aidant doive faire ça. Le système devrait m’orienter vers la bonne ressource et devrait – on devrait pouvoir justement parler à quelqu’un, là, entre – OK, le neurologue m’a dit, bon ben, va là, fais ça. OK. Mais entre-temps si j’ai une question, qui répond à mes questions.
Google, c’est pas notre bon ami. C’est pas un bon ami. Donc je pense que c’est là beaucoup. On a parlé d’éducation, là, de prévention. Oui, ça fait partie de la solution mais justement il faut avoir les ressources pour pouvoir aller là.
Moderator: Vous avez, pis sincèrement, je souhaite que les choses s’arrangent le plus vite possible. Je pense personne ne devrait se retrouver dans une situation comme celle-là qui est difficile. Vous avez quand même identifié des pistes de solutions, c’est-à-dire des choses qui auraient pu changer votre itinéraire dans le système. Vous avez parlé de l’accès aux soins, de la flexibilité du système, de la flexibilité de l’accès, par exemple, aux ressources pour la perte d’autonomie.
Mais également la valorisation, là, du rôle des proches aidants. Alors je pense que c’est – ça reste, comme je vous disais, à mon avis, justement le rôle des patients, les rôles des usagers est important pis c’est – pour identifier des pistes de solutions comme celles-là, parce que vous y êtes confrontée. En tout cas, merci beaucoup pour votre témoignage, Madame Lambert, en espérant que les choses se règlent le plus rapidement possible pour votre garçon.
Édith Lambert: Merci.
Moderator: Alors, je vous proposerais qu’on enchaîne avec monsieur, Dr Abso Shabah. J’ai fait tout à l’heure la présentation de Dr Shabah qui lui a le défi de parler de justement de transition vers l’innovation, de quelle façon est-ce qu’on peut parler d’innovation, améliorer les choses. Docteur Shabah, je crois que vous avez aussi une présentation. À vous maintenant la parole.
Abdo Shabah: Merci infiniment pour cette opportunité et merci pour cette expérience très touchante que vous avez partagée. Ça nous rend toujours humbles de voir jusqu’à quel point qu’il peut y avoir des défis malgré tout ce qu’on aspire pour notre système de santé. Je suis urgentologue donc j’en vois des patients de cette sorte-là. Je suis également porte-parole de l’Association médicale canadienne et j’ai eu la chance de travailler au sein du Commissaire de la santé au bien-être, de même de gérer quelques institutions, notamment sous le leadership de Dre Opatrny brièvement il y a quelques années.
Et votre expérience au niveau des soins de neurologie, la performance du système de santé, les différentes perspectives d’amélioration qu’on peut amener au niveau organisationnel, c’est quelque chose qui est extrêmement important et je vais essayer d’illustrer très humblement, brièvement tout le sens à travers. C’est une courte présentation sur les différents aspects de diffusion de l’innovation. On a parlé d’innovation comment est-ce qu’on peut intégrer ça et on a été chanceux de pouvoir intégrer une innovation dans une période très difficile qui était post-pandémie après la première vague.
Donc, de mon côté, bon, mon intérêt pour l’innovation a commencé il y a plus d’une dizaine d’années. Voici une photo de 2010 lorsque j’étais déployé avec la Croix-Rouge canadienne pour monter un hôpital de campagne. On l’a monté en 36 heures. Voici notre première patiente qu’on a reçue avec sa proche aidante, sa maman qui était là et qu’on a pu traiter.
Et malgré que ce sont des innovations, on va dire, organisationnelles qui arrivent, qui ont été déployées dans les pays en voie de développement mais que ça soit dans les chaleurs du sud, on a eu malheureusement, nous, notre expérience ici au Canada après-pandémie des déploiements de ces hôpitaux, des installations temporaires. Donc, ces innovations organisationnelles nous suivent et peuvent être inspirées de n’importe quelles circonstances.
Et aujourd’hui ce qu’on a après plusieurs vagues de pandémie, notre système est encore affecté et les délais associés par le délestage aujourd’hui rendent ça tellement difficile pour les utilisateurs et les professionnels qui y travaillent. L’accès aux soins est plus critique que jamais et l’expérience patient dont vous avez fait part, Madame Lambert, est de plus en plus difficile. Et avec les temps d’attente qui se prolongent et ça prend de plus en plus d’importance.
Et si par ces moments difficiles on se dit, on donne des soins de qualité, la confiance des patients dans le système de santé je vois de plus en plus certains patients exprimer comment que leur confiance est un peu ébranlée surtout quand ils rencontrent des situations dans lesquelles les soins ne sont pas nécessairement très adaptés par rapport à leur expérience. Ils réclament de plus en plus des services très personnalisés et adaptés à leurs besoins, à leur contexte.
Et on sait que la médecine, ben, ça devient – la médecine est complexe, très spécialisée, et le personnel de son côté a cette lourde tâche de livrer la meilleure qualité de soins, la meilleure expérience patient optimale avec des ressources qui sont de plus en plus limitées avec des équipes malheureusement de plus en plus épuisées. Et lorsqu’on sait que la médecine a évolué au fil du temps, comment est-ce qu’on donne un peu les soins au début. On était sur un peu l’artisanat, donc c’est un art la médecine. On la donne. C’est du un à un. Donc on se disait, ben, la qualité et le temps ou le coût qu’on y consacre ça aide ça.
Pis quand on a organisé ça en système, on se dit, ben, est-ce qu’on peut produire des soins de masse. Donc donner vraiment ça à un plus grand nombre et a même introduit l’amélioration donc le lien (sic) au sein qui provient un peu de différents secteurs. Pis aller chercher, est-ce qu’on peut avoir une bonne qualité, un meilleur coût pour ce qu’on offre comme soins? Et aussi donner ça en temps opportun. Et au fil du temps, ben, il y a eu une évolution. On se dit, est-ce qu’on peut amener la personnalisation de masse?
Donc là, on amène le concept de flexibilité au niveau des soins. Ça va un peu à l’encontre de la standardisation parce que c’est un peu dans l’aspect quand on standardise énormément ou qu’on fait quelque chose qui est de l’artisanat, la personnalisation de masse, c’est un peu entre les deux. Et de plus en plus, on parle de la production personnalisée, donc on donne vraiment des soins qui seront au-delà de la flexibilité. On rajoute l’adaptabilité de ces soins-là et l’innovation qui doit être ajoutée dans certaines circonstances qui ne sont pas – ce ne sont pas des innovations qui peuvent être généralisées dans l’ensemble du système.
Et comment l’innovation peut nous aider à croître l’accès, améliorer la qualité des soins, à offrir un environnement de travail stimulant et réduire le coût de votre santé. Je vais vous donner – je vais vous présenter une aventure qu’on a eue au niveau de l’innovation. On prendra la pandémie et c’est la preuve qu’on peut innover et s’améliorer même en temps de crise.
Et en fait, c’était une innovation, un projet qui avait été – que j’avais débuté et qui avait été soutenu par Grand Challenge Canada pour – il y a plusieurs années dans le domaine humanitaire et qui a repris forme dans notre système ici au Québec après la seconde vague. Et c’est un vidéo un peu qui illustre ce qui a été développé. En fait, c’est de prendre certains modules, de les installer dans une salle d’urgence, de pouvoir connecter, de créer comme un environnement complètement connecté, de pouvoir amener ces dispositifs-là à géolocaliser différents soit outils, soit les intervenants, soit les patients.
De leur envoyer des messages, des informations très ciblées et de monitoriser à distance l’ensemble des opérations sur le terrain et de donner des informations clés en temps opportun pour le bon patient avec le bon clinicien au bon moment et au bon endroit. Et ç’a été, bon, une innovation. Ce qu’il fallait, c’est avoir de la simplicité, de la flexibilité. Il fallait que ça soit adaptatif donc c’était du plug and play. On l’insère dans une prise murale et normalement ça devrait fonctionner.
Et ce projet a permis une installation en quelques heures dans un hôpital sur la rive sud de Montréal. Et c’est un projet qui s’est nommé, on l’a baptisé Kronos (sic). Donc en outillant les patients. On a commencé avec les patients avec un bracelet géolocalisé. On avait la possibilité de monitoriser tous leurs déplacements et d’assurer que le bon patient reçoit au bon moment avec le bon intervenant le bon soin, donc dans un parcours vraiment bien ciblé.
Et ça, ce qu’on voit ici c’est ce qu’on avait commencé avec la COVID. Donc, ici vous voyez c’est la géolocalisation de deux, de l’intervenant et du patient. Bon évidemment, c’est un mannequin qui est simulé à l’intérieur de l’établissement de l’amener de la salle d’urgence vers les soins intensifs pour les patients COVID. En même temps vous allez voir, il y a certaines lumières qui s’allument pour dire qu’on a un trajet actuellement qui devrait être protégé.
Donc c’est la lumière rouge pis la lumière peut devenir verte par la suite. Donc c’est vraiment dans cette continuité de donner un peu des soins en temps réel et avec des notifications qui sont ciblées. Et on a choisi quelque chose, une trajectoire qui était extrêmement pertinente pour nous. Au-delà de la COVID, on s’est dit, on va cibler une trajectoire qui est bien définie. C’est la trajectoire ACV. On sait qu’au niveau ACV, c’est une maladie extrêmement importante.
En fait, au Canada on a un patient à toutes les neuf minutes qui est atteint d’ACV. Et aux États-Unis, c’est toutes les 40 secondes. Et c’est la troisième cause de mortalité. C’est la première cause d’invalidité et si on peut sauver 15 minutes dans une trajectoire de soins avant de donner par exemple la thrombolyse à un patient, on peut rajouter un mois de vie en bonne qualité de vie pour ce patient-là. Donc, chaque minute compte.
On a été vraiment vers la chronodépendance et le Ministère l’avait bien reconnu. Donc la trajectoire ACV, il y a des indicateurs de performance mais c’est différemment, on va dire traduit dans chacune des organisations. Et ce qui était important, c’est d’avoir un peu le feedback en temps réel. Est-ce qu’on est en retard de quelques minutes ou on peut – on a encore le temps? Est-ce qu’on peut accélérer le processus? Et on a pu rapidement déployer ça sur l’ensemble des étages et d’aller regarder de la salle d’urgence au moment où les paramédics l’amènent jusqu’aux soins intensifs ou à l’unité de neurologie.
Donc on a pu le déployer rapidement. On a créé un comité de gouvernance, en fait, qui implique l’ensemble des acteurs pour l’ensemble des perspectives en fonction de chacun des intérêts qui sont là en place. Et évidemment, on a utilisé les nouvelles technologies, une interface numérique, qu’on a amené la numérisation du parcours de soins. Et l’ensemble des éléments qui devaient être captés lors de ce parcours de soins là. Donc on a amené des tableaux de bord vraiment en temps réel au niveau clinique avec les indicateurs, avec l’éducation ciblée, la carte qui définit où est-ce que le patient il est.
Pis en même temps, ben, les gestionnaires, eux, de leur côté au-delà du temps réel, ils veulent avoir des données cumulées et de savoir comment est-ce que ça s’est passé au courant des derniers jours, des dernières semaines et/ou des derniers mois. Évidemment, on a inclus des patients partenaires pour valider le projet, les informer, les impliquer, et également leurs proches aidants.
Et la communication, c’est clé. Donc on a vraiment amené la communication plus informelle, donc vraiment diffuser ça au sein de l’organisation, la communication plus formelle en informant l’ensemble des gens. Et ici le projet a été couronné quand la découverte est venue pis ils ont pu capter un peu l’innovation.
Donc, comment ça se traduit? Bon, ici, très brièvement, bon, les ambulanciers vont venir. Et vous avez bien compris le message au niveau de on installe une balise et en même temps de l’autre côté, ben, les intervenants avec un appareil mobile sont capables de capter les données. Et aussitôt que le patient arrive dans une certaine zone, l’information la plus adaptée au niveau du patient est amenée et l’intervenant est capable de consulter. Et des notifications clés sont envoyées aux différents intervenants qui eux sont à distance, mais qui suivent de près ce parcours-là.
Donc en tant que médecin, si je peux me permettre une prescription pour notre système de santé en transformation, c’est vraiment de cultiver un peu l’innovation, de l’inclure comme remède pour accroître à la fois l’équité, réduire un peu les coûts et d’améliorer la performance au niveau des soins et mobiliser les équipes de travail. Et surtout d’améliorer l’expérience patient qui doit demeurer au centre de nos préoccupations.
Donc je voulais simplement partager une expérience qui est arrivée pendant la pandémie. Des innovations clés arrivent tout près de chez vous et ce qui est important c’est de pouvoir un peu les généraliser, les amener, pis essayer de créer de la valeur au niveau du système. Chaque minute compte. Chaque minute dans une salle d’urgence rajoute un peu plus d’accès pour d’autres patients qui peuvent venir consulter. Donc voilà. Merci.
Moderator: Ah ben, merci beaucoup Dr Shabah. Alors plein de belles pistes de mise en œuvre pour optimiser le fonctionnement pis améliorer le cheminement que l’on traverse quand on entre dans le système de santé. Optimiser nos ressources sans qu’il n’en coûte vraiment beaucoup plus cher. Vous avez parlé de justement de l’efficacité au niveau des coûts parce que c’est une des préoccupations bien sûr dans l’esprit de beaucoup de gens, alors que les systèmes de santé dépassent souvent la moitié des budgets des gouvernements.
Alors, il s’agit bien sûr de ressources énormes. On cherche à optimiser l’utilisation des fonds. Je vous remercie beaucoup pour vos deux interventions. Comme je vous le mentionnais d’emblée, on va avoir maintenant une période d’échange. J’ai vu qu’il y avait eu quand même de nombreuses questions qui avaient été adressées, plusieurs questions. Et nous en avions une qui était particulièrement destinée à Mme Lambert. Si vous permettez, je vais vous la lire.
Et elle évoque justement la volonté du ministre Dubé de mesurer la performance du réseau avec différents indicateurs et dont un qu’elle dit saluer qui parle de mesurer l’expérience patient ou l’expérience client. Alors un indicateur qui mesurerait l’expérience patient. « Comment, selon vous, doit-on s’y prendre pour que cet indicateur fasse sens justement pour le patient, l’usager avec votre expérience patient partenaire et proche aidante? De quelle façon devrions-nous mesurer et suivre l’expérience client pour que ça signifie quelque chose pour que ça fasse sens pour l’usager lui-même? Alors de quelle façon doit-on mesurer cet indicateur? »
Édith Lambert: Ben, je pense qu’on peut partir du principe un peu comme quand on achète quelque chose ben souvent il y a un service après-vente. On pourrait aller un peu avec un service après-soins. Donc, ça de l’air un peu absurde mais ça reste que comment savoir si ç’a bien été, si ç’a fonctionné, si le patient on va dire satisfait des soins reçus. Ou qu’est-ce – quelles embûches ils ont eues? Je pense qu’il y a pas d’autre moyen que de poser la question aux personnes concernées.
J’ai entendu un petit peu plus tôt, je pense que c’est Mme Opatrny qui disait que depuis qu’elle est en poste, il y a des gens comme moi dans tous ses comités pour entendre justement les patients, les aidants et tout. Pis que ç’a fait un gros – une grosse différence. Si je ne me trompe pas, c’est ce que vous aviez dit tantôt, là. Donc, je suis contente d’entendre ça parce que les proches aidants ils peuvent aider, ben, grandement.
On peut pas remplacer un intervenant chose que des fois on voit pis qui est triste parce que c’est pas parce qu’il y a un proche aidant ça implique qu’on peut retirer quelqu’un, un intervenant pour aller le mettre ailleurs après. Parce que le proche aidant a besoin de soutien, a besoin d’éducation lui aussi et il a besoin de répit également. Et sans le proche aidant, ben le système s’écroule encore plus.
Je parle pas juste de ma situation, là. Tantôt, j’ai vraiment focussé sur la situation qu’on vit présentement mais ça s’applique à tout le monde. Quelqu’un qui a une perte d’autonomie suite à de la chimio ou que sa famille l’encadre, il va avoir rendez-vous avec eux. Bon, pour revenir à comment je pense qu’on doit évaluer ça, vraiment je pense que c’est – que ce soit par la technologie justement, en envoyant un courriel avec un sondage avec des questions prédéterminées avec peut-être un espace où on peut nous-mêmes écrire quelque chose, de verbaliser la frustration ou le bonheur qu’on a eu.
Parce qu’il y a des endroits où j’ai juste des bons commentaires à dire dans tout ce que je vous ai raconté. Ç’avait de l’air négatif, mais il y a certains endroits que c’était positif. Donc c’est important d’avoir les deux. On cherche l’équilibre donc il faut avoir du positif, du négatif. Pis après ça, je pense que basé là-dessus on va pouvoir aller vers des objectifs qui sont réalistes et dans les attentes de la population. Pis après ça, ben, de mieux justement quantifier.
On a changé telles choses, est-ce que ça fonctionne? Ben, on va le voir avec les prochaines réponses des prochains patients qui auront eu droit à la nouvelle version de soins à ce moment-là.
Moderator: Oui, c’est ---
Lucie Opatrny: C’est loin d’absurde de ce que vous dites de post-expérience ou post-vente. C’est parce que je pense qu’on part d’assez de loin que ç’a pas été intégré à date. Puis il y a des sondages qui existent qui sont appliqués par exemple dans d’autres juridictions qui vont aller chercher ça pour voir. OK, mais en général où et comment s’améliorer. Alors, loin d’absurde je pense qu’il faut vraiment aller vers ça pour l’inclure dans nos pensées et réflexions.
Édith Lambert: Super. Je suis contente d’entendre ça.
Moderator: D’aller chercher donc une sorte de rétroaction systématique de tous les usagers qui entrent d’une manière ou d’une autre.
Édith Lambert: Mais pas juste le patient, t’sais. Justement si le proche aidant a été impliqué, ben lui aussi devrait répondre à ce sondage-là, parce que la perception va être différente.
Joanne Castonguay: Il faut souligner la richesse que ces données-là aurait si on le faisait de façon systématique. Ce serait fantastique.
Édith Lambert: Là, vous seriez en mesure de vraiment voir. T’sais, on sait qu’on manque de données. Ben, là, vous les auriez. Je pense que c’est quand même quelque chose – je m’excuse. Je croyais que c’était dans mon fil. Je pense que c’est quelque chose qui est quand même facilement applicable parce qu’on a déjà les technologies pis je veux dire un courriel – je travaille présentement au marketing par courriel. On fait ça à la journée longue. Les entreprises envoient des courriels à leurs clients. Donc je pense qu’on peut faire la même chose facilement, là, avec les soins.
Abdo Shabah: (off microphone) que le système a en région.
Édith Lambert: Oui, c’est ça, sur Google.
Moderator: En tout cas, excellente piste de réflexion. Merci beaucoup Madame Lambert. Nous aurions ici une question pour Dr Shabah. Alors, une question qui se formule comme suit. « Quelles stratégies ont été utilisées pour s’assurer de la perpétuité des nouvelles façons de faire à la fin du projet? » Alors, comment assure-t-on la pérennité d’initiatives comme celle-ci?
Abdo Shabah: Oui. C’est une excellente question. En fait, plusieurs initiatives initialement peuvent être coûteuses, mais élargies à plus grande échelle peuvent faire du sens. Et c’est là où on peut avoir des économies d’échelle. De mettre un système en place pour une seule organisation, ben, ça peut être coûteux pour l’organisation et c’est pas l’ensemble de tout le système de santé qui va en bénéficier. Mais quand on fait un peu cette expansion, c’est vraiment ce bénéfice-là se traduit de plus en plus.
Et des fois, ça se traduit autrement que par simplement des gains financiers. C’est un gain comme de satisfaction. C’est des gains en termes d’efficacité et de satisfaction au niveau du personnel. Donc il faut le mesurer de différentes façons. Mais pour la pérennisation, il faut regarder les indicateurs clés et il faut aussi s’assurer que si on arrive à ce que c’est quelque chose qui peut s’élargir à plus grande échelle pour amener un plus grand bénéfice.
Moderator: Si vous permettez, je vais vers Mme Castonguay.
Joanne Castonguay: Ben, en fait, ça m’amène à poser une question parce que pour moi, je regarde cette solution-là pis je peux pas m’empêcher de penser que pour d’autres types de soins, des soins à domicile, par exemple. Si on était capable de localiser les patients, de les monitorer et même chose avec les ressources à leur disposition, ce serait fantastique. Il me semble que ce type de technologie là serait pertinente. Est-ce que vous avez déjà été appelé à regarder si c’était pertinent ou utile ou l’utiliser dans d’autres?
Abdo Shabah: Définitivement qu’on a regardé pour des – où est-ce que ça peut s’appliquer. Il y a deux échelles de temps, soit qu’on regarde au niveau des aigus où chaque minute compte. Vous savez, si on sauve cinq minutes aux deux heures dans une salle d’urgence de 75 civières, on donne trois civières par jour de plus pour de l’accès à des patients. À la fin de l’année, c’est à peu près 1 000 civières-jour qu’on peut avoir.
Et ça, c’est au niveau hospitalier où c’est le plus coûteux. Mais quand regarde ce qui se passe au niveau de la première ligne, au niveau des soins à domicile, il y a plein d’exemples qui existent dans d’autres industries, mais aussi dans le secteur de la santé pour faire du monitoring à distance, pour faire le suivi des interventions. Il y a même des innovations qui émergent ici au Québec par rapport à ça et qui pourraient, si déployées à grande échelle, servir au moins au niveau de la satisfaction mais sinon pour la réduction des coûts.
Moderator: Le temps que nous avions pour le webinaire s’écoule plus vite que je pensais. Et il ne nous reste que 10-12 minutes et pour cette toute, toute dernière étape, tronçon avant la fin de notre webinaire, nous avons un petit défi pour vous qui est d’essayer de formuler en une ou deux phrases les idées clés les plus marquantes, selon vous, qui devraient être retenues de tous nos échanges de ce soir. Alors, évidemment dans cet esprit de créer de la valeur, s’il y avait des messages clés qui devaient être retenus au cœur des prochaines démarches à entreprendre, lesquels messages clés devraient-ils être?
Alors c’est un bon défi. Je vais vous laisser peut-être décider qui veut se lancer en premier. Alors que retenez-vous de plus important de ce que nous avons mentionné ce soir? Docteur Shabah.
Abdo Shabah: Je vais commencer. Je veux dire l’innovation c’est pas une invention. On peut innover. On peut amener des changements, des petits changements et ça peut amener un grand impact au niveau des organisations. Il faut regarder les facteurs de diffusion de ces innovations-là, de les prendre en considération. Une fois qu’on a ça, on peut par la suite les pérenniser et en bénéficier à grande échelle.
Moderator: Merci, félicitations. Madame Castonguay.
Joanne Castonguay: Moi, je dirais l’information, la circulation et la transparence sur la bonne information qui permet d’informer sur les résultats, parce qu’on voit – on a parlé, Mme Lambert nous parlait de ce qui était important pour elle. On doit absolument monitorer ces éléments-là pour nous permettre de prendre les bonnes décisions. Ça arrivait exactement avec qu’est-ce que vous disiez aussi. C’est-à-dire que si on a cette information-là que ça soit du point de vue du prestataire ou du point de vue du patient ou de son proche aidant, on arrive à prendre les meilleures décisions. Et c’est vrai aussi pour le système.
Moderator: Merci beaucoup. Donc innovation, information. Madame Opatrny.
Lucie Opatrny: Je dirais de mesurer et être transparent avec ce qu’on mesure. Pis quand je dis mesure, ça peut être des expériences patient comme ça peut être des données médicales comme autres, parce que c’est juste en sachant où nous sommes qu’on peut mettre des actions et aussi mesurer l’amélioration qu’on met en place.
Moderator: Et de dresser un portrait juste d’où on en est c’est vrai que ça nous permet de – ça va où on doit faire le prochain pas. Merci beaucoup. Madame Lambert.
Édith Lambert: Je vais répéter un peu ce qu’ils ont mentionné. Effectivement, la transparence, la flexibilité dans la standardisation justement pour dire, ben OK, on veut des critères fixes, oui, mais selon certaines situations on pourrait bifurquer pour assurer des soins de qualité pis de l’aide à tous les niveaux, à tous les âges. Et en même temps, valoriser plus le rôle des proches aidants et – ben, les mesures comme ils disent, là, à tout point que ce soit au niveau de la clientèle, des données ou – pis de mettre ça, ça va permettre de se comparer à des systèmes qui fonctionnent pis de justement aller voir. Ben eux, ça fonctionne. On va pouvoir se partager tout ça pis améliorer le système.
Lucie Opatrny: Je voulais juste clarifier que quand je dis « standardisé », je veux pas dire qu’on fait tout copie conforme. Je veux dire que les bases égales sont standardisées pour laisser le temps pour l’innovation et l’ajustement. Parce que ce volet-là est essentiel pour personnaliser et pour l’innovation. Alors, je voulais juste quand même dire que je veux pas que tout est – soit standardisé.
Joanne Castonguay: C’est important ce que vous venez de dire là.
Moderator: Pis écoutez, on vous aurait écouté encore des heures. On le sait que le sujet et les sujets que nous soulevons ce soir sont d’une haute complexité. C’est un défi de les vulgariser. Merci infiniment d’avoir été avec nous ce soir. Et c’est maintenant au professeur Jean-Louis Denis de relever le défi de faire la synthèse des synthèses et en quelques minutes de s’adresser à nous. Mais, Monsieur Denis, bienvenue.
Jean-Louis Denis: Merci. C’est bon? Oui. Tout d’abord, j’aimerais remercier pour la richesse des interventions et la diversité aussi des points de vue. Même s’ils sont à la fois complémentaires mais ils proviennent d’une expérience différente du système ou d’un point de vue différent sur le système. Je commencerais par deux considérations générales. On n’aurait pas un tel panel si on n’avait pas appris de l’expérience des systèmes publics de santé et les systèmes publics de santé nous disent, en fait, nous a appris, en fait, deux choses.
Ils ont une limite pour améliorer la santé de la population. On sait qu’il faut regarder aussi ailleurs et c’est moins le sujet de ce soir mais avec ce que Joanne appelait la santé publique avec des politiques qui nous permettent de produire de la santé et pas juste des soins. Et presque paradoxalement ces systèmes-là nous ont appris qu’ils deviennent de plus en plus importants pour les trajectoires de vie des individus qui font face à des conditions complexes ou de longue durée. Et Mme Lambert nous a donné un exemple très éloquent.
Une autre chose aussi qu’on a appris c’est qu’on a tout le temps un décalage entre ce qu’on pourrait appeler les innovations technologiques sans délimiter à ce point-là, et la capacité de renouveler nos institutions pour capitaliser sur le potentiel de ces innovations. Fait que ça, c’est le contexte dans lequel on a discuté la question de la création de valeur. Et là, ça va m’amener à faire dans les quatre prochaines minutes et demie neuf points.
Le premier point, c’était notre point de départ. C’est-à-dire il faut prendre acte de la pandémie et de se dire, oui, la pandémie nous oblige à répondre à des impératifs à court terme, mais surtout elle nous a révélé de façon encore plus dramatique les conséquences des failles ou vulnérabilités persistantes dans notre système. Il nous incite donc à amener des réponses et les panélistes nous faisaient part de différentes hypothèques et options.
La notion de valeur, on pourrait la résumer à trois peut-être qui ont été évoquées plus ou moins explicitement. La question de l’efficience et de l’efficacité souvent traduites en termes de résultats, la question de l’équité et la question de l’innovation voulant dire aussi un système de santé qui s’adapte, mais sans jamais oublier à l’arrière une équation, je dirais, à la fois fondamentale et qui nous contraint le rapport entre les coûts et les résultats. Et ça, ça me semblait animer beaucoup certaines des interventions.
Maintenant, on se dit, comment ça peut se passer tout ça. Donc une question, je dirais, de changement institutionnel. Comment on passe de la situation actuelle à un système qu’on jugerait producteur de valeur ou générateur de valeur au sens large. Là, je retiens quatre éléments des discussions.
C’est 1) pour produire de la valeur, il faut changer la façon dont on voit les choses, c’est-à-dire cette idée par exemple d’assez simple mais difficile à exécuter à grande échelle qui est de dire ce qu’on produit a une finalité. C’est une expérience patient, par exemple, positive. C’est beaucoup plus facile à dire qu’à faire mais c’est un changement, je dirais, dans notre tête de viser ça comme premier point où le service j’ai beaucoup aimé post-vente, post-expérience.
Un autre aspect, c’est développer les outils dont la standardisation avec les nuances qui ont été faites qui nous permettent de garantir de façon systématique une qualité, une sécurité des soins ou une pertinence des interventions. Le troisième, c’est des nouvelles relations. On en a parlé beaucoup. Il faut qu’il y ait des nouveaux acteurs autour de la table. Il faut mettre ensemble des nouveaux secteurs. Il faut que les gens puissent exprimer des nouvelles attentes et là que les groupes ou les personnes plus marginalisés habituellement aient voix au chapitre.
Et je dirais le quatrième c’est aussi peut-être jouer différemment avec l’autorité. Et ça, ça va m’amener à mon dernier point, c’est-à-dire on ne change pas un système sans ébranler un petit peu comment on utilise le pouvoir et l’influence qu’ont les acteurs. Et là, je terminerais là-dessus. Je dirais, on a parlé d’accélérateur mais je dirais nos accélérations ont besoin de terrains d’atterrissage. C’est toujours gênant en avion si on avait juste de l’accélération pis pas de piste d’atterrissage le moment venu.
En tout cas, moi, quand je voyage j’aime bien qu’il y en ait une. Et je dirais, il y a peut-être trois hypothèses en ce moment autour de la table et je terminerai là-dessus. Elles ont été évoquées. Un premier terrain d’atterrissage, c’est prendre enfin au sérieux qu’on ne va pas faire des progrès substantiels tant qu’on n’a pas des soins de proximité organisés. En anglais, ils disent des teams-based care qui sont réactifs, accessibles 24 heures, qui sont un point de contact, qui peuvent filtrer la demande.
Mais non seulement la filtrer mais aussi la retenir et y répondre au mieux. Donc ça, c’est extrêmement important. Et ces structures-là doivent être imputables aussi et être équipées, avoir les capacités, première chose. Deuxième chose, je vais le dire vite. Je pense qu’un partenariat renouvelé avec la profession médicale, ça s’adresse pas à l’engagement au commitment des individus médecins, mais un partenariat renouvelé avec la profession médicale qui dépasse sur le plan institutionnel ce qui se discute à la table de négociation. Ce serait une de nos grandes innovations institutionnelles.
Et un troisième point pour l’équité. Je vous promets que j’arrête. Je sais que le temps n’est pas infini. Un troisième point sur l’équité. C’est on doit penser à des partenariats ambitieux avec les groupes dits plus marginalisés. Il y a des exemples dont au Canada l’Alliance canadienne pour terminer l’itinérance est un exemple. Et on doit avoir des partenariats avec ces groupes-là où à la fois les financeurs et à la fois les groupes visés sont mutuellement imputables d’objectifs de résultats et des fonds qu’ils vont recevoir.
Mais tant qu’on ne va pas sur des projets plus ambitieux à ce niveau-là, la question d’agir auprès des iniquités va être plus un vœu qu’une réalisation. Je terminerais là. Il y aurait beaucoup de choses à dire. Ressources humaines, c’est un chantier qu’on ne peut aborder mais qui est à considérer entièrement mais ce que je dirais en conclusion c’est on sait qu’on a des pénuries de main-d’œuvre clairement et de la pression excessive sur ceux qui travaillent dans le système.
On ne sait peut-être pas encore la teneur de ça tant qu’on n’a pas fait un travail pour renouveler la manière dont on fait, on s’organise et c’était le message de Dr Shabah aussi. Je vous remercie.
Moderator: Merci à vous, professeur Jean-Louis Denis. Pas facile de faire cette synthèse sur justement les différentes dimensions des enjeux. Pis je me sens particulièrement interpellé sur la question de justement l’intégration des groupes marginalisés à titre, évidemment, spécialiste des questions autochtones au Canada. Je suis tout particulièrement touché par ces enjeux-là. Et je pense sincèrement que les groupes marginalisés ont aussi des réponses innovantes à apporter si on les interpelle.
Alors, dans cette idée d’intelligence collective, faisons en sorte que tout le monde participe aux pistes de solutions. Merci à l’ensemble de nos panélistes, Mme Joanne Castonguay, Dre Lucie Opatrny, Mme Édith Lambert et Abdo, Dr Abdo Shabah. Merci d’avoir été avec nous. Merci également au H-pod pour l’organisation du webinaire de ce soir. Je tiens aussi à vous souligner que si jamais vous souhaitez écouter à nouveau le webinaire, il sera disponible en ligne sur le site du H-pod, mais également un rapport synthèse normalement s’en vient.
Bonne chance aux rédacteurs pour résumer les propos qui auront été tenus ce soir. Et à mon tour maintenant de vous remercier d’avoir été avec nous, d’avoir participé, d’avoir été nombreux à poser vos questions, à formuler des commentaires dans la fenêtre de conversation. Mon nom est Alexandre Bacon. Ç’a été un plaisir de partager cette heure et demie avec vous. Portez-vous bien et à la prochaine. Merci.
Session 4 - Facing the health workforce challenge
KATHARINE SMART: Welcome, everyone, to the CMA's fourth and final Health Summit session for the year. I'm CMA president, Dr. Katherine Smart, and I'll be your host and moderator for this event.
Thank you for being here today and for contributing to this important conversation on solving the health workforce crisis. Before we get started, I'd like to acknowledge that I'm coming to you from the traditional territories of the Kwanlin Dün First nation and the Ta'an Kwach'an Council in Whitehorse Yukon. And since we have people joining from all across Canada, I'd like to acknowledge that we are on many treaty lands and unceded territories. I make this land acknowledgment with the recognition it must come with action towards real change that honors Indigenous peoples as the caretakers of this land we now call Canada.
The 2022 CMA Health Summit series has been a virtual forum for bold conversations about how to do health differently in Canada during COVID and beyond. Our first Health Summit session in March explored ways to reform primary care, reduce wait times, and develop new models of care. In May, our second and third sessions, held in English and French respectively, focused on transforming the health system to a thriving and responsive one given the societal and economic consequences of the status quo.
We are bearing witness today to a collapsing health workforce, patients left without care, and the economic fallout of prolonged closures to protect capacity in our health care system. Change is needed. Today's session is about Canada's health workforce crisis heightened by 2 plus years of the pandemic. Burnout, increased workload, staff shortages, and harassment are just a few of the issues health workers now face.
Results from the CMA's 2021 national physician health survey were quite disturbing. They showed that 53% of physicians and medical learners are reporting high levels of burnout, up 30% from 2017. The survey also found that 46% of respondents were considering reducing their clinical hours in the coming months. Another recent survey conducted by the Canadian Federation of nurses unions found that severe burnout in the profession had jumped from 45% compared to 29% just two years ago.
As more health care professionals retire or leave their profession due to exhaustion, burnout, or dissatisfaction, the foundation of our health care system is at risk of collapse. So the question becomes, where do we go from here? This event is all about exchanging ideas, and we have several experts here with us tonight to help in that conversation.
But there are also several ways that you can take part in the discussion. The chat is there for you to share your thoughts and to connect with other participants. We'll have a question and answer period where you'll be able to submit and upvote questions for our panelists.
And we'll be hosting Zoom breakout sessions, safe spaces for you to unmute, share your stories about the health workforce shortage and crisis, and work together to come up with some potential solutions. As with any online forum, we ask you to please be polite and professional. Any appropriate conduct or language will not be tolerated. Finally, if you encounter any technical difficulties at any time, please click the tech support button on the lower left corner of the screen.
With that, I'd like to now introduce you to our keynote speaker, Dr. Verna Yiu, someone who certainly understands the magnitude and the urgency of the situation facing our health workforce. For more than six years, Dr. Yiu was president and CEO of Alberta Health Services, or AHS, Canada's largest province-wide fully integrated health system.
Under her guidance, AHS saw improved efficiencies in patient care, and launched a province-wide clinical information system. Verna also led AHS and its more than 100,000 employees through the pandemic response. She is here to share her insights. Welcome, Verna.
VERNA YIU: Thanks very much, Katharine, and thanks to the CMA for this invitation to speak really on one of the biggest challenges that we are all facing in health care as we continue to combat COVID-19. The health workforce shortage is not just a Canadian issue, it's a global issue.
There were notable challenges even before the pandemic, but COVID has really highlighted the growing gap of the most important health care resource, which is health human resource, or lack thereof. According to stats, Canada between the third quarter of 2019 and 2021, job vacancies in health care and social assistance increased by 80%, or more than 52,000 spots.
With the exception of Nova Scotia, all provinces saw an increase in vacancies, with Quebec, BC, and Saskatchewan leading the pack. Occupations with the largest two year increases in job vacancies were nursing aides, orderlies, patient service associates, RNs, and registered psychiatric nurses.
On an international level-- because this is a global issue-- the WHO says that by 2030, the world would need an additional nine million nurses and midwives to reach a sustainable state. For physicians in Canada, although there have been some moderate growth in the number of doctors from 2016 to 2020, there remains a maldistribution of where they're practice. And you've just heard from Dr. Smart the burnout stats that's going to further impact on physicians and workload.
About 8% of physicians working and only 2% of specialists work in a rural setting compared to 19% of Canadians who live in rural areas. For those that are in training, there are about 3,000 medical students enrolled in first year, with another comparable number in medical schools outside of Canada.
How many do we need to train each year? What about IMGs who are Canadian but not working as physicians? These are really, really difficult questions to answer since there's never been a physician workforce strategy at either the provincial level or the federal level.
Regardless of what or where the shortages there, are some common principles that must be applied when looking at health human workforce strategies. The first is that any strategy developed must be integrated and go beyond the silos of individual professions.
Health care is a team sport. And working in health care has moved from individual practitioners to team-based care. Understanding how one influences the other and how each compliments holistic care for the patient is absolutely critical in determining the future demands on the workforce.
COVID proved the value of team-based care. And in fact, without augmenting team functions and ensuring that everyone worked to their maximum scope of practice, we would not have fared as well in caring for Canadians. Second, solutions have to be multi-pronged, involve multiple stakeholders, and address the entire pipeline and career continuum of a health care professional. Partnerships are absolutely critical to create to creative solutions, especially between regulatory colleges, educational institutions, local municipalities, and governments to list a few.
Third, we have to think outside the box. Traditional solutions have been tried and will continue to be tried, but do we have the time to wait? Can we afford to wait? Going forward, we need to consider solutions we would have never thought of before.
For example, outside of Canada in one remote rural jurisdiction, retired teachers are the first point of patient contact. Armed with very simple point of care tools, they screen local residents, and if required, they then refer them onto further care. Are we ready to consider these atypical solutions?
So whatever strategies we consider, they need to be integrated, partnered, and innovative. In terms of developing solutions going forward, we need to consider how to not only increase the supply of health care workers, how to improve and maintain retention, how to optimize scopes of practice and models of care, and last, but not least, how to improve the wellness of health professionals. They serve the basis for the integrated workforce plan that AHS has developed back in 2021.
And I just want to share with you some examples of the work that AHS has done in each of these areas. In terms of increasing supply, at least for the short-term, AHS actually started hiring fourth year nursing students in partnership with regulatory colleges and 9 post-secondary institutions.
This enables students to get paid work experiences, receive academic credit while filling critical positions within the health care system, and then allow for seamless transition to the workplace upon graduation when they were hired as full-time employees. Another short-term strategy is for AHS to grow its own workforce through the creation of an in-house health care aide or a health care aide training program to support acute care and long-term care areas.
Many uncertified health care areas were unable to fully fund their additional requirements, so AHS created a bursary program to support an additional 600 health care aides per year. For retention, one of the really critical determinants of whether people stayed in the health workforce was that the amount of support that they received. Supports can be financial, they can be educational, and social.
So for example, enhancing education. Specialty orientation training and student nursing graduate engagement were amongst the top reasons that people stayed practicing in rural areas. Local communities and municipalities are also essential partners in supporting recruits and making them feel welcomed and part of the community. And without that local support, even though you may get young health professionals through the door, they will leave shortly thereafter for more urban areas.
For optimization, one needs to consider what job is being done and is it being done by the right person? Optimizing scopes of practice not only improves efficiencies, but also improves work satisfaction and builds a team-based model of care. COVID has shown us how essential team-based care was in dealing with the pandemic. Going forward, we cannot lose sight of this important enabler to ensure that we have the right people doing the right type of job at the right time.
And finally, wellness. Wellness is critical to supporting a tired and burnt out workforce. We need to invest in programs that support both physical and psychological well-being through multi-pronged approaches. And the use of additional resources, tools, and training.
Examples would include peer-to-peer local support, 24/7 support lines, online texting tools and resiliency building programs, as well as supports to ensure a safe, quality work environment. We know that the health human resource challenge facing us. What we need to do now is to find common solutions.
It doesn't matter where you live in Canada. This is a borderless problem, so we need to find borderless solutions, like national licensure. COVID has brought a level of nimbleness, creativity, and innovation to our health systems. Let's not lose sight of what we've been able to achieve over the past two plus years of the pandemic.
Let's learn from it. We can overcome the workforce shortage. And we'll do what we do best-- focus and find solutions so that Canadians can have quality health care and better outcomes. And Katherine, back over to you.
KATHARINE SMART: Thank you, Verna, for your optimistic outlook and for sharing some unique workforce strategies from Alberta. I have a few questions for you now. I often notice that we hear authorities reassuring the public that the health care system is OK or that people will still get care when they need it when we know that's not always the case. How can we work with policymakers, health care providers, patients, and all stakeholders so that we can encourage people to take the actual action that is needed to transform the system to make those statements true?
VERNA YIU: Yeah, I totally get where you're coming from, Katherine, with that question. But I think even before I get to answering the question, I think we actually need to define what we mean by transformation. Because everybody talks about transformation, but the definition is different for each group of stakeholders.
From the health care system perspective, transformation is a word that actually scares many of us because we're very cautious. What exactly does it mean? Are you speaking about financial transformation, are you speaking about clinical transformation, workforce transformation?
So first, I think we need to define what we mean by transformation. And until we do that with public and key stakeholders in a very clear and transparent way, we're going to continue to run around circles avoiding the conversation. So it's a very, very important discussion to have, because as I said before, the system belongs to all of us.
From my perspective, as you can tell from my initial five minutes, I'm an optimist. And I think that any of us who lead in health care, we have to be optimists. Otherwise, it'd be very depressing because it is very stressful.
And there seems to be a disconnect, for sure, from the front line struggles to what I would say others are trying to say in the public. But after saying that, at least within Alberta and Alberta Health Services, there are a lot of difficult things that have been happening recently-- long wait times, EMS struggles. But when you think about the whole province and the whole system, the bulk of people are actually getting good care, and I think we can't lose sight of that.
From my perspective, I'm actually really proud of all that we've done over the past two-plus years. The pandemic is still with us. It's really stretched us all. I think we've found ways to work together to ensure that Canadians get the best health care possible. And I think we've come a long way since the Canada Health Act, but we have a ways to go.
And we know what we need to do. I mean, there are no magic bullets. Anything that's been easy has been done. I think that's the first comment I would make.
The second thing I think is really important is that I think health care providers have to really feel valued, and they're not being valued right now. The type of, I would say, difficult situations they've had to encounter-- I think some difficult interactions with patients and the public has really been demoralizing. And it's been very, very difficult, especially for the frontline clinicians.
But when we think about our health system in Canada, we know what we need to do, Katharine. You can list it all off. It's about really trying to find a strong primary care system. That is the foundation of any health care system.
We need better integration between our different sectors. We need better support-- we need to better support Canadians in their home setting. We need data to help inform our decision making.
We need social prescribing, because so many aspects of health care are really social care. But we really need Canadians to support the notion of a publicly funded health care system. We need the health care system-- because we in the health care system what we need to do.
We just need to have the time, the support, and the will, and we will get there. And we need to support our teams. And at the end of the day, we need to tell our story, we need to make sure that the public knows what's happening, because we're experienced today. If you're not on the front lines and you haven't experienced it, I don't know what you can really say. So I think the personal experience is really, really important.
KATHARINE SMART: So much of what you said, Verna, really resonates with me. First of all, I'm reassured that your list of things that you would like to see for transformation are the same as mine, so that's good news.
But I also totally agree with you-- it's incredible what health care workers have been able to do for their communities over the last two years. It's really absolutely incredible how people have pulled together. And I agree-- we have to maintain optimism that we can make things better.
So that links kind of into my next question. I think when we look at what's happened over the last two years, and the system in general, we know that medicine and other aspects of the system have really relied on the altruism of health care providers for a long time to keep the system going.
And whether that's working 36 hours shifts as physicians-- and this is really true in rural settings where, often, resources are limited. And even some of our bigger hospitals where there are small numbers of specialists and they do huge amounts of call. Or expectations for family doctors to be available 24/7 to patients.
But I think what we're learning is that these expectations on our workforce are not sustainable. And frankly, they can be unfair and really prevent work-life integration. How do we account for are these changes in terms of what we expect from professionals in the health workforce in our workforce planning?
VERNA YIU: Yeah. So I think all of us, health care, as a career choice, is a calling and not a job. And I think one of the benefits for myself and leading-- before Alberta Health Services was that there fundamentally, at the forefront, is a level of altruism that you don't see in any other business or in any other organizations.
So right off the bat, when you lead this type of organization, you know the types of people that are going to be in there are the ones that are going to put themselves out beyond the call of duty. They're going to care for others before they care for themselves, and that's just what has incented them to go into health care.
So that's not a criticism by any means. That's, if anything, inspiring and admirable, but it leads to burnout. And so let me just start a bit by saying that unless we understand that we need to care for ourselves first, we can't really care for others.
And so we need to build our own resiliency. We need to-- what does that mean? It means that all of the health care organizations, each of us as individuals, we need to actually look at how we look after ourselves.
And we know resiliency encompasses four dimensions. It's not just the mental resiliency. It's physical, spiritual, and emotional. And we need to work on all of those aspects to ensure that we can remain strong to keep on going.
And if any of those areas are neglected, then we're more likely to succumb to burnout and fatigue. But no question, the system is pushing everyone. I know many people who won't answer their phones anymore because they don't want to be called in for a shift.
Or if you're working in the hospital, you can't get out when you're supposed to because there are so many other patients waiting. So it is a really stressful time. And all I can say is that we have to share the burden together, which is why some of the workforce strategies around really ensuring that team-based model of care is so important. Because it's not just on one individual. This is on all of us to be able to share and use our skill sets to be able to complement each other going forward.
And in terms of what we need to do in terms of workforce planning going forward, well, Katharine, I bet you that it's not going to be just one person that's going to be replacing you. If anything, it's going to be maybe two or even three. In my generation, the role models that I saw worked 24/7 in the hospital, had no life outside of the hospital.
Those are the people that we saw. They were incredible clinicians. Everybody wanted to emulate them, but there was a price to be paid. And we're now seeing a generation of medical students and residents where they're saying, you know what, I'm not going to be doing that. And they're so right.
And we need to learn from that. So it's not going to be a straightforward 1-to-1 ratio. And going forward, when we look at workforce planning, we will always underestimate the number of people required if we don't consider some of these changes in demographics and changes within society.
KATHARINE SMART: I totally agree. Thank you so much, Verna. We'll reconnect with you in about 30 minutes after our panel discussion to take part in the Q&A.
So for those of you listening, if you have a question for Verna or for any of our upcoming speakers, you can add them to the Q&A tab at the main menu. To enter your question, you just go there, enter it, and then click Send. It'll come through to you, and then people can upvote their favorites.
So before I introduce our panel, I'm proud to let you all know that this Health Summit session is a patient-included event, which means people with lived experience participated in the design and the planning of the session, including the selection of themes, topics, and speakers.
As we all know, patients have a very essential perspective to bring to health human resources as the quality and timeliness of their care depends on a robust workforce. We extend a warm welcome tonight to Jake Starratt-Farr a member of CMA's patient voice committee and one of today's panelists as well to all patients and caregivers in the audience.
So now, let's move on to getting to know our prestigious panel. First, we have Amie Archibald-Varley who is a registered nurse and a quality and patient safety specialist for Niagara Health. She's a graduate of the master's of nursing program at the University of Toronto.
Amy is a thought leader in advancing health equity and political health activism, including anti-black racism. She also co-hosts the Gritty Nurse Podcast. Dr. Dax Bourcier is a first year pediatrics resident at Dalhousie University. Yay, pediatrics-- I'm also a pediatrician.
As a board member at the Canadian Federation of Medical Students, he founded and chaired their health human resources task force. Dax is currently a co-investigator on a project to develop a minimum data standard for health workforce data in Canada funded by the Canadian Institutes of Health Research.
Doctor Lynette Powell has been practicing family medicine in Grand Falls Windsor Newfoundland Labrador since 2004. She's a passionate advocate for strong primary care, and recently closed her practice to tackle the family doctor shortage in the province's central region.
Lynette is past president of the Newfoundland and Labrador Medical Association. And last, but certainly not least, is Jake Starratt-Farr. He's a social worker and a counselor who works with an interprofessional primary care team in Durham Ontario.
As a trans person, he's dedicated to supporting trans and gender expansive individuals, and is passionate about helping health care providers better understand the unique health needs of the 2SLGBTQI community. So welcome to all of you. Lynette, I'm going to get started with you. We've all been hearing about how the shortage of family doctors is reaching a crisis level across the country, but particularly in rural communities across Canada. Can you describe the impact it's having on patient care where you work?
LYNETTE POWELL: Sure, Katharine. Thanks for having me this evening, and it's a real pleasure to be able to talk about this. It's a very heavy topic.
I wanted to maybe tell a little bit of story about where I work and where I live. So I'm in the middle of Newfoundland and Labrador, and I work on what we call a hub site. So it's a community that services a lot of our rural communities.
We have an emergency room in my community, but it supports about nine small rural emergency rooms. And there's about 177 communities in Central Health that are all kind of within the umbrella of our hub sites. So over the past few years, our hub sites have hollowed out.
There's no there's no positions in a lot of these rural emergency rooms. Of the nine, I think there's two that are still fully staffed. And interestingly enough, those are actually rural teaching sites for our family medicine program. So it's an interesting kind of thought about how we work on keeping people in rural areas.
But through the course of the pandemic, with the hollowing out of these sites, what's happened is primary care has really been fragile on these sites for a long time. As physicians come and go-- and long before the pandemic, that was happening-- emergency care would often take precedence to family medicine and primary care.
So a lot of these patients have had a long legacy of not really having great primary care. Now, they have no primary care, and they also have lost their access to emergency services. So through the pandemic, I'm very proud of what we have been able to do.
We've been able to implement virtual emergency rooms in our hub site. And that's actually taken a lot of our physicians away from their family practices. We've also been able to implement a health hub that provides both virtual and in-person care to the orphan patients from across the region. So you know it's quite an innovative and rapidly implemented step that happened at the beginning of the pandemic, which is probably something that should have happened long before.
But I think what we're seeing now is our hub sites are now very affected by this primary care shortage as well, because physicians are now providing urgent and emergent care, and taking care of a lot of orphan patients. And what's happening now, of course, is people are just leaving their family practices because the demands elsewhere in the system are so robust.
So it's been a little bit tragic to see that patient care and longitudinal family medicine has really taken a beating in the last couple of years. And that has a tremendous impact on patient care. We're seeing more late stage cancers, more complications from diabetes. Newfoundland and Labrador has some of the highest rates of diabetes in the country, and you can imagine, if they have no primary care, the kind of complications we're seeing.
So that's been very heartbreaking for sure. It's something a lot of us take home at night when we work when we see these patients. So it's certainly contributed to burnout in a lot of the physicians who are trying to step up and support this kind of failing peripheral system.
KATHARINE SMART: Thanks for sharing those experiences. It really resonates with what I'm seeing where I work as well. I know that things became so dire in the central region of Newfoundland that after nearly 20 years, you recently closed your own family practice to help with these critical staffing shortages. Can you tell me a bit about that decision?
LYNETTE POWELL: Ah. So that's still very raw, and it's a bit disingenuous to say that I did it to help. I think it's-- I think the picture really of what's happened to primary care across the country-- as other parts of the system fail, family doctors who have a broad scope of practice and a lot of skills, are often getting pulled in 100 different directions.
So you end up in a situation where you really can't maintain your practice. You really want to help in all the different places that the system needs you, but at the end of the day, community family medicine, I think, is an example really of failure of policy around primary care.
Community-based family physicians really don't have the support or the infrastructure to really be able to continue in the system in the way they need to the way it is currently. So I think for me, I struggle with this decision. I had tremendous guilt about it. I still do.
These are people I've taken care of for 16, 17 years. They need me. And what the best place for me as a family doctor and where I do the best work is sitting in front of patients in my family practice. So being pulled into other parts of the system to kind of help lift things up and support the other areas is necessary right now, but at the same time, it's not where we need to be focusing our efforts, I think, across the country.
We need to be figuring out how to keep family physicians in their longitudinal practices, supporting them with teams, and helping with their infrastructure. I think that's going to really be-- in the future, if we can do that, and if we can build our primary care infrastructure around our family physicians and our nurse practitioners, then we're going to succeed in providing better care. But we have to move out of this urgent/emergent quadrant of management. We need to start looking at what's really important, but maybe not absolutely urgent right now. Because if we don't focus on that, there's going to be lots more in the urgent and emergent category.
KATHARINE SMART: Thanks for sharing your story, Lynette. I can only imagine how tough this has been when you're, just as you said, pulled in so many directions. So thank you for what you're doing.
Amie, I'm going to move to you. During the pandemic, I think we have all heard so much, and so importantly, about how nurses have been under incredible pressure, faced with increased workload, staff shortages, and a lack of resources. What effect is that having on their mental health?
AMIE ARCHIBALD-VARLEY: Yeah, Thank you so much for that question. I mean, in terms of how nurses are feeling-- and I think it can speak broadly for nurses across Canada-- is that we are suffering the ill effects of moral injury as well, which is that distressing psychological, behavioral, and social-- sometimes, almost spiritual-- aftermath of the exposure of the various events that we've been dealing with over the pandemic.
And this is actually kind of a long-standing problem. Nurses have been working short for several years now. This is actually something that I learned about when I was in nursing school over 10 plus years ago, and the problem hasn't changed. It's actually been really exacerbated by COVID-19 and the pandemic.
And really, a lot of us are feeling overwhelmed, overburdened. Again, nurses are expected to do more and more with less and less. And the strained system-- we're seeing this ripple effect trickling down to patients, and that's where that moral injury and moral stress is really coming from from our standpoint.
So we understand that patient safety is an integral part of nursing. And many nurses are looking actively to leave the profession and move away from bedside nursing because of this moral injury and this moral strain. Because at the end of the day, what we want to do is care for our patients and families. We want to see best health care outcomes.
But one of the things that we're concerned about is we're not seeing that quality of care that we would like to see. And I've been hearing this countless times, that we're just not being listened to. So that stress, and that moral injury, and that strain, it's beyond burnout at this stage. And it's sad to hear that there are many nurses looking at leaving the profession and then moving into non-traditional nursing types of roles.
KATHARINE SMART: Thank you for sharing that, Amie. It is so heartbreaking. I so value the relationship I have with the nurses and the skills that they bring. And to hear those people that are in this work to care for others aren't being cared for by the system to the point it's breaking them is really heartbreaking, and I think a testament to just how challenging our environments are right now.
AMIE ARCHIBALD-VARLEY: Absolutely.
KATHARINE SMART: Jake, I'm going to move to you now. I know it's really challenging for transgendered people to get the health care they need, to find people skilled in delivering the care and having access to the care. So how is that being impacted right now by the shortage of health professionals, and what are you hearing from your communities?
JAKE STARRATT-FARR: Oh, yeah. Thank you very much for asking me that question. As a person of lived experience and also a professional that does provide services for the trans community, I think the things that we notice nowadays is that we are seeing a vast increase in folks who are becoming who they are and identifying under the trans umbrella.
And so the services that were already short in gaps-- and have large gaps have increased, especially during this shortage. But even before this pandemic and this shortage, affirming care for trans folks has been really referred to specialists. And we kind of need to bring this forward-- that trans care is not something that always has to go to a specialist.
This is something that a general practitioner or nurse practitioner can absolutely care for trans people. And I think it's around us taking a look at how do we make those changes that can help sustain our physicians, our nurse practitioners in supporting the community away from going to specialists, which then makes long lineups, it puts harder care on the mental health system because people aren't accessing care equitably.
And so when we look at it currently, it takes someone to diagnose a trans person with gender dysphoria to access care. It's the same DSM book that we're also accessing information about if someone is depressed or someone has anxiety, and then we could offer them treatment.
And again, we've come away from that sort of like referring people to psychiatrists. Many general practitioners are doing this work now. And it just seems that there's still this kind of space around trans health care that we look at it like it's much bigger than what it is.
And there's a fear of do no harm, and what if I'm wrong, and misunderstandings around the effects of cross hormones, those type of things. And I think-- how do we fix that and how do we make that sustainable? I think there's a space in there that, one, we really have to go back to reinventing our education a little bit around trans health care in all medical academics.
I heard earlier someone speaking about we can't just keep doing the same thing over and over again. And I think that's the real key here, is that we need to take a step back and be like, hey, let's get folks the information, let's get these providers the information in their education so when they have a patient that comes to them, they can support them.
It's not something like, oh, my gosh, what am I going to do here? In a trans pulse survey, they had 1 in 3 non-binary people said their doctors or nurse practitioner had no idea anything about trans health care. So I think that's something where we're-- I think we have a big gap in is education.
I think it's really great to start seeking out how do we promote specialists that can be mentors, or like mentorship phone calls like rainbow health Ontario offers. For practitioners to call in and say like, I have a patient-- this is what I need help with.
I think we need to look at funding around supporting the expansions of interprofessional care teams. So including like a cross-country team. So it doesn't have to be just this town or that province, but where practitioners can help providers-- can call in and be like, so I've got a trans person-- I need some support and helping them move along in their journey if they choose to.
And I think that's the things that we can really look at. When we look at our statistics around this, most trans people actually report through Trans PULSE Canada again that they have about the same amount of primary care space as general population. Around 80% have primary care.
However, when we look at their unmet needs in health care, it's 45% versus 4% for the general population. So I think that that's what the difference is. And we look at an IPC team to help-- one out here in Durham, quickly, they had 153 patients in one year since its inception.
And out of that, like 32, or 20%, have already returned back to their primary care providers with support of this team. And during this time, they have supported 60 different individual practitioners to keep patients in place. So that's how we're going to stop the-- we're talking about shortage of care.
By really developing these teams, but developing them for those practitioners who are on their own so they don't have to be on their own. And I think debunking the myth that trans health care is just complicated and breaking down those systemic barriers. And understanding that when a provider refuses to care for a patient because they don't know about trans care, or they choose not to maybe learn about it or look it up, it really has a long-lasting and negative effect.
And as a patient who has had that happen to them-- as a person with lived experience-- that I had a practitioner that I had I worked with for 20 years. And when I was finally able to get up the-- ha, I guess the courage to tell them who I was and what I needed, I mean, they looked at me and they said, oh, I'm sorry I don't do that sort of work.
And they just had me walk away. So I think that's stayed with me for a very long time, and I think that we can do better. And I think it also puts less pressure when we start looking at teams approach for the practitioners to help with trans health care.
KATHARINE SMART: Thank you so much, Jake, for sharing your experience, and challenging all of us to do better. And I love your vision and just the call to action that we can do better, and we can collaborate, and learn, and that certainly resonates with me.
As a pediatrician, this is an area of health care for my patients I've been actively learning about. And I couldn't agree with you more with your vision of what that experience should look like for people when they're in our offices and in our care. So thank you for that work, and that advocacy, and also for challenging all of us to do better.
Dax, I'm going to move to you. You are at the very beginning of this journey as a first-year medical resident. Well, I guess you're part way through. You completed medical school, so that's one hurdle.
So you must be really looking at what's happening in the health workforce and wondering what that means for your future. How do you think this shortage and this challenge with burnout amongst health care professionals affecting the future generation of doctors?
DAX BOURCIER: Yeah. Thank you for having me on this panel. And really, the answer probably depends on who you talk to. And in general, medical trainees are probably either scared or in hopeful denial that this won't affect them.
And so scared are the ones who have lived experiences. Dr. Powell talked about rural students in Newfoundland going to emerge there and seeing firsthand what the shortage feels like. And disproportionately so, this is affecting primary care.
And so people or students-- trainees who have worked with primary care physicians and have seen them burn out and even perhaps retire during their time working under them is having a big impact on these future trainees. And what happens is once they live these experiences, they're scared, and they either want to choose a different discipline, they either want to move to bigger urban areas, they might look to work in teams, or they might even leave home and look for different provinces and try to look for work elsewhere.
And then you have another group who's in hopeful denial. This is never going to affect me, or I hope it doesn't. And it's really important to note that the majority of trainees in Canada are being taught in big urban cities and fully staffed academic centers, and so there's little vacancies there. And this probably skews their perspective as to what medicine really looks like across Canada.
And it skews their perspective, but also it affects their desire to-- what they want to become in the future is. What they see and what they breathe every day is what they're going to develop an interest in wanting to do that in the future. And so with everything else that's unknown, why would they want to risk going there? What's the incentive of going out to do that work afterwards?
And so overall, we have trainees who are either scared or in hopeful denial-- this isn't going to happen to me. And really, this kind of leads a relentless drive to want to find a job that's desirable and one that's sustainable in the long run for them and also for their families. And so currently, one could argue that most of these jobs are in urban cities in large academic centers. And so this sort of creates this bottleneck around big cities and big academic centers, leaving huge gaps in rural Canada. And ultimately, it really is the patients who suffer the most, because this perpetuates poor access to health care.
KATHARINE SMART: Thank you, Dax, for sharing that perspective. I totally agree, and that's why I'm a big proponent of electives outside of big centers. And I welcome you to come to an elective with us here in Whitehorse so you can see what rural pediatrics is like.
So now we're going to bring everyone back to the stage together to share some ideas. So we've heard a bit about different strategies for addressing these concerns, and I'm curious if each of you might want to share what you see as some short-term solutions.
So Lynette, I'm going to start with you. We've talked a bit about expanding the idea of team-based care. How do you think that would help solve the workforce shortage, especially in primary care?
LYNETTE POWELL: So I guess I really had some lived experience with this through the pandemic. I told you earlier about the fact that our local hub had-- or a local community had really kind of-- position group had banded together to establish an orphan patient clinic, which serviced the entire orphan patients from across the region.
And our health authority had the foresight to put a nurse in that clinic and give us an LPN as well. And we've grown as a team over the pandemic. And the work I can do in that clinic now far surpasses the work I'm able to do by myself in my family practice.
I think we'd all agree through the pandemic, the system's gotten very sluggish. It's very hard to navigate for patients, but it's also very hard to navigate for providers now. I spent a good deal of my day triaging people who've been waiting for things, figuring out why they got lost or where they are in waitlists.
It's been invaluable to have a team around me in the orphan patient clinic. And I mean, I think we've serviced three to four times the number of patients with like two doctors a day that it would've taken five family physicians in their own clinics without a team around them.
So it's-- we really-- we've been very far behind in Newfoundland and Labrador on team-based care. Very few primary care practitioners have nurses, our allied health professionals in their practices. I can only imagine the value that would come with having other people-- therapy, social work.
It just excites me because I've seen how well it can work. And I just think if we can move towards that more quickly, and particularly focus it on longitudinal family medicine so we can support the practitioners who are doing that very important work. The most important work in the system is the longitudinal care. So we need to support those people to keep doing it, and help them to continue to navigate the system that's kind of not really supporting them at present.
KATHARINE SMART: Thank you so much, Lynette. Jake, I'm going to go to you. You're a social worker. You work on an interprofessional professional team. What do you see are the benefits for your patients and for the other team members?
JAKE STARRATT-FARR: Sorry about that. Yeah, you know what? I see a great advantage on these. I've been on many interprofessional teams. And what we see is that it takes that weight off, or that heaviness off of the practitioner to be everything.
And I think oftentimes, as whatever the practitioner is doing, they often get sidelined and are in need to help with those secondary supports. That really could be done by folks like me who are a social worker, or maybe a counselor. And so when we have those interprofessional teams within maybe even a health care setting itself, then we can really take care of the patient.
The patient gets involved, they have a voice. And as we discussed in our patient voice meetings, that yeah, oftentimes, the providers end up doing secondary supports that could be well-managed by others, and which takes away from their time then to see other patients, or to have time to research or how to get things done.
So I think by having those interprofessional teams, they are very important. And they're very important to I think the patients as well, because it helps them be a full part of the process, because when there's things going on that a medical provider sometimes is supporting them in one area. But where do they go to get that blood work done?
In my case, for around folks who are under the trans umbrella, where's a safe place to go get your lab work done, where do we go get an ultrasound that's safe? And if we're looking to our health care provider to tell us those things and they're trying to find resources, it really takes away from their time. So I think these interprofessional teams really adds to and fulsomely takes care of clients much better than when we just do everything on our own.
KATHARINE SMART: I think that's so true, Jake. Absolutely. We're going to move on now to take questions from the audience. And I want to invite back Dr. Verna Yiu to join our panel for the question and answer session.
So welcome back, Verna. And if you haven't posted a question already in English or French, now is the time. Click on Q&A in the main menu, enter your question, and then click Send. And then you can also upvote your favorites.
For the next 15 minutes, our speakers are going to try to answer as many of your questions as is possible. So that's just great. We already have our first question. How much of our health human resources problem can be attributed to the federal provincial territorial system?
How can we overcome this rather than using it as an excuse for inaction? Great question. Any takers?
DAX BOURCIER: Sure, I'm happy to tackle this one. This is a great question, Maggie. And I think there's one thing that, in Canada, is missing, and that's a national health human resource governance.
So in many countries, this exists where there's a national body that is in charge of health human resource planning and strategy, and we don't have this in Canada. And so creating such a body would help for accountability.
So it would help four provinces and it would help for local problems to-- so Dr. Smart, do you still hear me? I have a message--
KATHARINE SMART: I do.
DAX BOURCIER: --that says that they've lost sound? Good.
KATHARINE SMART: I'm hearing you.
DAX BOURCIER: Great. And so this would ensure that there's accountability in reporting [? box ?] specific indicators as to performance not only at the provincial level or territorial level, but also in health jurisdictions. And so again, having a national governance health human resource committee or body would be a very important step into answering this question.
KATHARINE SMART: Yeah, absolutely. In the interest of answering the most questions possible, let's move to the next one. I think this is-- that first question, we could all talk about for a long time.
So the next question is from Diane. How do we involve young emerging physicians at the problem-solving table, and encourage thinking outside the box, breaking the old guard hierarchical rigid structures? How do we make it psychologically safe for young doctors and residents to make health system change suggestions? Great question. Anyone want to weigh in on that?
VERNA YIU: Katharine, maybe--
KATHARINE SMART: Verna-- perfect.
VERNA YIU: --I'll try to help with this one. I think one of our big challenges in health care in Canada is that-- at least within Alberta, but I'm assuming in every single province-- physicians don't necessarily see themselves as being part of the system.
They're funded outside of the system. If you think about it, the majority of their work is outside of health care system, and they're small business models, small business practices. And so it's a very different, I would say, environment for physicians.
And in fact, that was one of the reasons why I actually joined Alberta Health Services, was that as a physician, I actually wanted to have-- or to make some changes-- impact the health system, but I could not do that actually from a University setting. I could not do that as a private practitioner.
I actually had to be within the health system to be actually able to help provide some input into how we can make our system better. So I would say that one of the most important things for physicians who are listening to this session is that you can do more by being part of the solution than being outside of the box.
And when I first started-- I joined AHS in 2012-- I can tell you that everybody was saying to me, Verna, what the heck? Why are you going into the health system? It's like going into the Death Star.
You know what I mean? The negativity that I heard was unbelievable. And I'm sure, Katherine, you've heard that from a lot of physicians who decide to go into medical leadership. It's actually very hard for them to actually get that.
But I see I see a shift in the trend in how physicians see themselves as leaders within the system. And it's very important for physicians to actually be heard in the system as medical leaders. And it's through that process that we can actually bring the younger generation to the table to actually have all of the diverse voices heard.
KATHARINE SMART: Absolutely. Amie, I'm curious if you have any insights to share from the lens of a nurse? How do we do this for young nurses that are so important as well?
AMIE ARCHIBALD-VARLEY: Yeah, I was actually going to add on. Thank you so much for calling on me, because one of the things that I pride myself on is actually advocacy.
I think if there's one thing that we can all-- and we have all learned is health care is political. Like, I think COVID-19 has shown how political health care can be. And I think one of the biggest things that we all have to involve ourselves in is understanding health care politics.
And I am not a physician, but I think all of us as health care providers have that field of advocacy within our role. So like, I know CanMEDS there's a pillar of advocacy. And as well as in nursing, there's also a pillar of advocacy.
And we have to think about how can we use our voices, how can we use our platforms, how can we use our tables, or whatever shared power mechanisms that we have to continue to encourage these dialogues, especially when it comes to politics? Because we can see that huge intersection in terms of who might be voted in politically, who might not be, how health care is discussed, or the financial aspects, or these various different elements.
And I think it's super important for all of us to be involved in some way, shape, or form, whether that's advocating for at the bedside or advocating at a decision-making table in politics, whatever. And I think that that is one of the most important things that we all need to do-- is who are our MPs, who are our [? MBPs, ?] who are our political leaders?
Making sure that we know them, making sure that we know what the agendas are, what they're running on in terms of their platforms in health care, and actually be involved in those different channels and aspects as well. I think it's a very powerful place for us all to be in. And I think we definitely should be involved in that political aspect in health care.
KATHARINE SMART: Thanks for sharing that, Amie. And certainly, I know for myself, I think the general approach to advocacy and working in that space is absolutely one of the things I enjoy most in my own work.
So we're going to move to the next questions. And I think we'll direct this one at Lynette. Lynette, do you have sound? Can you hear again?
OK, perfect. Why are IMGs not included in the plan to face this health crisis? IMGs are well-prepared and already assessed. IMGs are a fast and reliable solution.
So Lynette, you're in a rural part of the country. What do you think? Why aren't we doing better on that front?
LYNETTE POWELL: Oh, absolutely. I mean, it's a great question. I don't know that I know the answer. I would like to shout out to all the wonderful IMGs that have for many years been the backbone of the health care system in rural Newfoundland and Labrador.
I think there's been some things over the years that I have seen since I've been in practice that have been a little bit upsetting and possibly we need to change going forward. We need to make sure that IMGs coming into our system are empowered in the system and they feel like they have a voice.
I felt often that that was not the case, and some of our IMGs were sometimes put in places where they might not have had the comfort level to maybe work. And that really led to them probably not being there as long-term as they might have been. We need to look at just making sure that they are integrated into our communities.
I think one of the big things in Newfoundland and Labrador that happened recently was a change in licensure, which made it harder as an International Medical Graduate to get a license. So that's actually been a large driving force why a lot of our rural sites now are in such desperate shape. So I agree with Teresa's question. I think it's a question we do need to be asking across the board, across all provinces and territories.
KATHARINE SMART: And Verna, you've been a leader in a health system. What do you think is happening here?
VERNA YIU: Yeah, we actually absolutely do include IMGs in the plan, but it's not actually a fast solution contrary to popular belief. There are many different types of IMGs.
They come from different parts of the world. The training is different. And so it's actually not a quick solution. But one of the things I would really strongly advocate for is that I actually think we should be opening [? Harms-- ?] the first round [? Harms ?] to all IMGs.
I think it's been a limitation. I think that we need more positions in residency training programs. And I think going forward, this is something that government definitely can support and fund. And I think that IMGs should be eligible for first-round [? Harms. ?]
KATHARINE SMART: Thanks for sharing that, Verna. And, again, I think it links to that problem where we don't have a pan-Canadian workforce strategy. If we did, we could then be thinking about the numbers we need at medical school, the CaRMS entry-level, and then the output.
So I agree. We need to start thinking more broadly and eliminating these silos. The next question is from Suzanne. We've been talking about integration for at least a decade, but we don't even have the basic IT infrastructure available to allow for this in most provinces.
How can we have any meaningful integration without dealing with this up front? I might throw that back to you Verna since you are part of an organization that did actually implement a province-wide EMR-- is in the process of doing so.
Tell us, what is holding us back there? This always fascinates me as well-- how Instagram is better than EMRs. What's happening?
VERNA YIU: You know what, Suzanne? It was very difficult to actually get the support from government to embark on a provincial EMR.
People are very scared of any EMR rollout. There's been some notable rollouts that have been less than optimal, I would say, in Canada. But the way we actually sold it to the Alberta government back in 2016 was really talk about what the 10-year vision is for health care.
And I think one of the challenges that we have in Canada is that we actually don't think of health care in the long enough time frame. It's two years, four years at the most. We really need to think about it 10 years out.
What do we need as a sustainable health care system? We need data. We need data to connect the clinical with the financial, with the outcomes piece. We need to be able to know what we're doing. We need clinical decision support tools, appropriateness of care, reduced variation of care.
All of that is better for Canadians. Ultimately, it's better for financial budgets, for health systems if you do that. So it really requires this conversation with the government to actually say we need this-- this is a long-term strategy. This is something that we need to be prepared for, and you can do it.
Alberta is well on its way-- Connect Care is about 50% rolled out. We're on time, on budget, if not for COVID. And it's working really, really well, and there have been significant demonstrations of improved outcomes as a result of that.
KATHARINE SMART: Absolutely couldn't agree more. We've got to have a data-driven system for accountability and quality. There's just no other way to do it. Dax, I know you work in this area as well. What are some of your thoughts?
DAX BOURCIER: Yeah, thank you. Doctor Yiu, I totally agree with what you've brought up. And there's two things I'd like to bring up in terms of data in Canada, and that are kind of missing right now, and that could really at the core, help fix this issue of interconnectivity in terms of data infrastructure.
So one is the fact that we have old data. So we use old data to base our current workforce planning. So we need either real-time or near real time data processing to be able to power, a system where data can be useful for planning and health human resources strategy.
And the second is that we need a minimum data standard. What this means-- and this is actually-- Dr. Smart mentioned that we're working on a project with the Canadian Institute of Health Research. And we are currently developing this minimum data standard, not only for physician data, but for all allied health professionals in terms of what and how should we be recording data in terms of very specific criteria so that it can all be interconnectable.
And so what this brings forward afterwards is that you can have machine learning and automated processes into using this data, and processing it and reporting it in near real-time so that it can be used right away to make decisions.
KATHARINE SMART: Fantastic. Thank you for sharing that. So one final question. I'm going to send this to Jake, and I think it's a really critical question coming from Maya. How can we incorporate the patient voice to be part of the discussion to help transform and innovate the health care system?
JAKE STARRATT-FARR: Yeah, that is a fabulous question, and I appreciate that. So yes, as someone who is on the patient voice with CMA, one is I know accessing that diversity of that team within-- when we're making policies or standards. Or we're looking for how do we connect to the community, because each one of us on there comes from a different community.
And then again looking-- I heard in here we're using old data. So when I think of old data that's around research, when we're using research from 10 years ago and we're saying that's the voice of the patient or that's what needs to be done, we're really missing that space.
And so we need to start to look at current data and also data from the appropriate places. So Statistics Canada is not really a great place to get some information. We really need to go to the people that are doing the right research for the right communities.
And I think that's part of it. And then also to really develop this team approach to health care. That the health care providers are not the only ones who are in charge of the health care. That it is an absolute responsibility and right for the patient to have part of that care, and to not just be looking at their providers as fix me-- that they're part of the solution.
And they're part of also being able to say, yeah, I'm not sure if I agree with that. And being able to start to help-- and I think what I've heard is breaking down the barriers-- maybe that systemic hierarchy that's been put in place over the years so that patients can feel they can come forward and say things. And also start doing the, I guess, funding of proper and good research to be able to bring forth patients with lived experience voices.
KATHARINE SMART: Thank you so much, Jake, for sharing that perspective. And totally agree, and that's why I love this idea of patient partner that you people at the CMA voice have come up with.
It really, I think, is that right lens of we're partners in the care, and patients need to be partners at the table and not an afterthought. So thank you for that. We're now going to take a break. It was going to be a 10 minute health break, but now it's going to be a 7-minute health break before we transition to our breakout rooms.
So before we do that, I just want to thank you, Dr. Verna, for kicking off our conversation today, and for her incredible leadership in health care and being a mentor to so many of us in this very difficult time. For the rest of our panelists, they are going to be sticking around to join the breakout sessions, so you'll get a chance to speak to them a bit more in-depth. So let's all come back at 10 minutes past the hour, and we will go into our breakout rooms and continue the conversation.
Welcome back, everybody. I hope that you enjoyed your breakout rooms. And while everyone's getting back, I'm going to encourage our panelists to share some key takeaways from in the chat.
So all of you, please jump in. Say what you thought-- panelists as well. And we're also welcoming back our panelists now. Each of them also attended a breakout session, tackling four of the main questions related to the health workforce challenges.
So I'm going to go around and ask each person to give us a 2-minute summary of what they heard. Lynette, I'm going to start with you. Your session focused on team-based care.
Is it an effective model for health professionals and patients? And if, so how do we scale it? What did you hear?
LYNETTE POWELL: So it was a very interesting session, actually. The diversity of opinion there, hearing about some of the lived experiences is actually quite relevant when we're looking at team-based care and how we move forward with it.
I think the prevailing thought is that patients have to be part of that team, and we have to make sure that happens at every junction along the way. I think there's a general consensus amongst our group that team-based care should be our future, and it is probably likely effective.
Patient navigation, seamless transitions through care. That's important when you're a patient, and that's important to care providers as well. There was a-- a lot of people talked about team based experiences that had worked for them.
You'll be happy to hear, Dr. Smart, that pediatrics seems to be one of everybody's favorites. The pediatrics teams tend to be very effective at being patient-centered and wrapping around patients and families. And it's been noted that that often gets lost as people age out of that system. Mental health care in particular was identified as a need for better wraparound team-based care.
In terms of scaling, I think there were ideas that came from across the country. There's been things in Alberta, for an example, of pre-emergency care by advanced care paramedics, and how that's enhance the team in the emergency department.
We, again, talked about Tee models that had worked. And looked at the fact that we haven't really invested those resources into primary care teams. And primary care providers work in every community, but have not been effectively integrated into any team-based models.
But we've done it for other specialty services that have been short like cardiology, things like that. They often have team-based approaches within larger centers. So we just need to start looking at models from across the country that work. And those are going to be our blueprint for moving forward, particularly with primary care based teams as primary care gets more and more stretched.
KATHARINE SMART: Excellent. Thank you so much, Lynette. Dax, I'm going to move to you. Your group explored the huge gaps in patient care left by the workforce shortage. How do we ensure an adequate supply of health workers in the future? What were some of the suggestions?
DAX BOURCIER: Yeah, so there's some great talk about different suggestions as to how to tackle the future supply. And the conversation started in the fact that there's supply that's there, but then there's a comment that having more people will cost more money, and that this is not effective.
Whereas really, if we have more people in there, it will save money in the future just by the system being more effective. And so from that standpoint, we then went on to talk about how the way that the system is set up currently doesn't focus as much on the needs of the population, but more so on the supply and how to fill the gaps.
And so to look at what the actual needs are of our population, and then to design the system following that. And then the two other parts of the design the system that were brought up were pay models being one, whereas fee for service in some regions of the country don't seem to be effective in doing their intended purpose.
And so looking at alternative pay models might be a way to entice people to go into where the need is. And the other part is that we lack data. We lack the data to tell us what the needs are, and where needs are in the country.
And if we have a better visualization of what health care looks like in Canada, what the needs are not only now, but in the future, this will help retain and it will help attract the future workforce to fulfill these needs in the society.
KATHARINE SMART: Fantastic. Thank you, Dax. Amie, I'm going to move to you. Your breakout room tackled retention, especially in rural communities. What strategies are needed to better support health workers as well as attract new ones?
AMIE ARCHIBALD-VARLEY: Yeah, it was a great session, and there was a lot of really great pearls that came from that. And one of the things that was talked about a lot was about culture. So creating a culture that was really important that-- making people feel welcome in the space, and supporting that collaboration, and cross-practices to support how other people who might be coming into these rural areas can feel comfortable and stay within the communities.
It also dovetailed into not feeling isolated, and how do we support individuals who are out there working in these areas as well. There was also some discussions about medical school. So for example, like the northern school of Ontario, and how do we attract people who want to stay in these communities to continue to practice medicine within that region.
And thinking about recruiting campaigns for rural areas for medicine, health care just in general as well. So not even just physicians, but how do we retain nurses, social workers, and other people in those areas, and making it more attractive for them to stay.
And also talking about the way that people think about rural communities. There's this sense that urban centers are better centers to work in, but how do we change the conversation from talking about whether it's better or not? I think there was a lot in terms of talking about how we can talk about the importance of the care that's needed in these rural areas.
There was also discussion about advocating for the importance of teams and that team model. So that was definitely a theme that has run through all of the different questions that were discussed tonight. And also the importance of knowing how to reach out to other community and other team organizations.
There was a lot of conversations on concerns around perpetual understaffing. And then really challenges surrounding obstetrical and maternal care. How do we support these particular areas in these rural communities?
And then also looking at various different other models of care. So places like in Australia, and looking at how can those care models be integrated here? And then just also making sure that we address these concerns adequately and effectively, because we have to have that important focus on rural care as well.
KATHARINE SMART: Thank you so much, Amie. And finally, you Jake. Your group looked at how to shift more care from hospitals to community-based care. What would need to change to support patients and their caregivers, particularly those living in under-resourced marginalized communities before they need acute or complex care?
JAKE STARRATT-FARR: Yeah. So thank you. Our group-- was a very fulsome conversation. So some of the things that came out of that was definitely establishing what outcomes are valued for the area, and then connect funding to those, and don't keep refunding things that aren't working.
Develop comprehensive plans. Provide team-based preventative care. So working to align that population needs with the workforce service capacity not only just now, But. As we've talked in this whole thing tonight about it's about the future as well.
When we keep just looking at one or two years out, we're going to kind of miss that long-term care. About fun preventative care activities, which would include mental health care. And then how do we bridge the gaps from youth into adulthood? Because sometimes, that's a big part of what happens in the community.
We have a lot of youth programs, and then once they hit a certain age, there isn't anything else. So more trauma-informed care, and have community partners more engaged with the community before they arrive into the health care system.
And then also recognizing that sometimes, some of our systemic places like around policing and all that-- that sometimes, we have to make sure that we are listening to those engaged with those types of services. And that as people are getting formed into mental health and things like that, that we are really listening to what's happening for them and not just taking that one authority to another authority is the right answer.
And that health care is not and cannot be a singular person process. That this has to be a community thing in order for us to continue to engage in promoting and moving forward from where we know it isn't working into what can work. So accessing that team-based care is going to be essential.
But part of that in the group-- we were talking about is that everybody has to know what's being offered and what they can actually have available to them. Sometimes, we have these team-based approaches, but kind of nobody knows what's there and who's doing what. And so to really promote that sort of space.
KATHARINE SMART: Excellent. Thank you so much, Jake, and to all our panelists, and again, to Dr. Verna Yiu for taking part in this Health Summit session, and for sharing your passion and commitment to building a stronger workforce. Thank you also to all our participants tonight for taking this time from your evening and your busy schedules to engage with us, and to share your ideas about how we can do health care differently.
The insights shared tonight are extremely valuable, and will help inform the CMA's advocacy work on health human resource strategies and planning, and our overall work to build a better future of health for everyone in Canada. Thank you again for helping to lead that change.
[SPEAKING FRENCH]
Goodnight, everyone.
Scaling up team-based care
© Canadian Medical Association2023