Renewing emphasis on health systems integrations
BY DALE SMITH
Across Canada, health care systems are testing innovations to improve care and more importantly, find improvements in both cost savings and health outcomes. Before the Bell spoke with a panel of experts and stakeholders to discuss what it will take for some of these innovations to get widespread adoption, and what is holding us back from our successes.
Mike Villeneuve, CEO of the Canadian Nurses Association, said that his association has some specific concerns about health care system transformation and how health human resources are used as part of that transformation.
“We are encouraged by all of the health accords of the last few years, but also a little bit frustrated by the constant agreement in what’s in them without a move to a lot of action,” said Villeneuve. “There seems to be a bit of a bit of a mismatch between the system we have, and our population health at large.”
Villeneuve said that the world is clamouring for more than just acute care, but also long-term care, chronic disease management, end-of-life care, palliative care, and hospice care. As an association, the CNA has concerns about how people can be deployed to meet those needs, while they are aware that there are problems around turf within the nursing community.
For Dr. Hugo Viens, president of the Quebec Medical Association, the debate over the competency between doctors and nurses is starting
to fall aside as younger doctors enter the system. With as much as 50 percent of the provincial budget in Quebec being devoted to healthcare, Viens said that there needs to be a greater focus on population health and prevention.
“We feel there needs to be a shift in the timeline of disease, and work together in going toward preventing disease and advocating for a better health system that would reach people, educating them, to prevent disease,” said Viens. “This is something we need to focus on if we want to be able to afford our health system for many years to come.
Viens said that over-diagnosis is an issue for doctors, given that as much as 30 percent of what doctors do is probably unnecessary, including tests and hospitalization, which could be avoided.
“We are in a model that thinks that doing more is better, but often less is better,” said Viens. “There is new science that is becoming more acknowledged that value care is not necessarily volume care, and fee-for-service is probably something that needs to be addressed.”
Viens said that while technology is helping to some address problems, it can exacerbate the problem of unnecessary testing especially when it comes to early detections of some cancers, given that it may not change the outcomes.
Maria Judd, vice president of programs at Canadian Foundation for Healthcare Improvement, said that governments and stakeholders need to come together to address problems. She said that CFHI’s mandate is to look for innovations with the system and trying to make them more widespread.
“We identified an INSPIRED program, which is a supportive COPD [chronic obstructive pulmonary disease] program, developed by Dr. Graham Rocker and team in Halifax,” said Judd. “We’re helping to spread that and its scaling, increasing and expanding in every province in this country.”
INSPIRED stands for “Implementing a Novel and Supportive Program of Individualized Care for patients and families living with REspiratory Disease,” where the first six months of implementation saw patients’ emergency room visits fall by 60 percent, hospitalizations fall by 63 percent, and days in hospital fall by 62 percent by comparison with their previous experience. CFHI’s website notes that the reduction in hospitalizations translates into an estimated $977,000 in savings, which is more than three times the annual operating costs of the program.
With innovations like this, why aren’t they getting greater adoption?
“Our health systems are overloaded,” said Judd. “We don’t have the capacity to respond to new ways of doing things, and that’s where building capacity for improvement comes in.”
Dr. Damien Contandriopoulos, professor at the school of nursing at the University of Victoria, said that healthcare spending has doubled over the past thirty years, but there has not been any sense of improvement in the system.
“There never have been as many physicians in Canada [as there are now] – same for nurses,” said Contandriopoulos. “And still the system is crumbling.”
Contandriopoulos said that nobody is leading the change within the healthcare system, and that nobody has the capacity to steer the system. What there is, however, are interest groups who resist change when it means that money gets moved around.
“Powerful interest groups have the capacity to slow down change,” said Contandriopoulos.
Judd said that small changes can have dividends when they are proven effective at the local level and start bumping up against levels above, which can spread those changes more broadly.
Viens said that while everyone agrees on problems and solutions, they need to work on building teams rather than siloing the kinds of care that doctors, nurses and other professionals can provide. He added that the current system is responding to the kinds of rewards that are built into it, such as the assumption that an emergency room visit will treat them faster than a clinic visit.
Contandriopoulos said that another problem is that the training system of learning-by-doing helps to entrench current practices. “You learn to behave as a doctor by seeing [how] other, more experienced doctors behave, and this reproduces the system, so it’s not easy to disrupt.
Sixth Estate Host Susan Delacourt with Mike Villeneuve. Photograph courtesy of Twitter.