Don't Tinker, Transform: Launching a Primary Healthcare Revolution
For years, efforts to reform primary healthcare in Canada have focused on fixing bits and pieces, rather than on a wholesale transformation of how care is delivered. Exciting, effective changes flourish in pockets but rarely manage to spread.
"So much innovation, so little change," laments Dr. Brian Hutchison, co-chair of Picking up the Pace – How to Accelerate Change in Primary Healthcare, a conference hosted by the Canadian Health Services Research Foundation (CHSRF) in Montreal on November 1–2, 2010. Canada, Dr. Hutchison says, is "the reigning champion of pilot projects." But, he adds, the conference offered proof that primary healthcare innovation in Canada is gaining speed and force.
Picking Up the Pace brought together more than 300 clinical leaders, health system managers and policy makers to hear about 47 innovative solutions to primary healthcare challenges and to share their own experiences and strategies for reforming primary care. Over two days, participants communicated ideas on ways to create an effective, sustainable primary care system flexible enough to serve the varied needs and realities of communities and people across Canada.
The conference opened with an inspiring presentation by keynote speaker Doug Eby, vice-president of medical services at Alaska's Southcentral Foundation. Southcentral's revolution began 12 years ago when control of the organization passed to the Alaska Native People it served. It was, says Dr. Eby, the beginning of an extraordinary adventure, moving from giving care to recognizing that healthcare's role is to support individuals, who ultimately control their own health outcomes.
Southcentral's goal was no less than "transforming this thing called medical care to a lifetime journey through health." That message – that primary care reform demands a shift away from the medical model and an accompanying ascendance of teamwork – resonated throughout the conference as speakers challenged each other to stop thinking in terms of medical care.
Although Southcentral has up to 75 quality improvement projects going at any one time, and a staff of 20 supporting them, these projects are no longer how Southcentral judges the work it does. There are always technical improvements that can and should be made. But success depends on creating a system based on relationships with individuals, recognizing them as the leaders of their own care. "We went from project-based fixes to whole-system transformation. That's the part to take home," Dr. Eby asserts.
How to take innovations from the project level to system transformation was a recurring theme of the 23 breakout sessions at Picking Up the Pace, which covered topics including unattached patients, province-wide quality improvement, patient self-management, hard-to-reach populations and payment reform. (A casebook describing the 47 innovations, as well as four videos and a full report on the conference are available at www.chsrf.ca.) Innovations included a variety of models for community clinics, rostering and governance as well as the following:
- A public-private partnership in Jocoeur, Quebec, that puts health professionals in the workplace to help employees address issues such as smoking, obesity and chronic diseases
- Programs in British Columbia and Ontario to help family physicians provide better support for patients with mental health issues
- A converted recreational vehicle that serves as a clinic on wheels to get healthcare to low-income neighbourhoods in Saskatoon
- "Virtual wards" to reduce emergency room visits and hospital readmissions among seniors.
Some of the innovations were local efforts, while others were supported by provincial programs to improve care. In many of the sessions, participants were hearing for the first time about innovations that are having remarkable impact in other parts of the country.
That kind of opportunity to share information and experience first hand was one of CHSRF's main goals in holding Picking Up the Pace. "We wanted to organize a different type of conference," CHSRF president Maureen O'Neil explains. "Our aim was to offer peer-to-peer learning and a chance for people to build relationships that would help them improve the delivery of primary healthcare across Canada. From talking to participants and panellists, I sensed a real thirst for this type of exchange and for ongoing opportunities to learn about successful practices from across the country."
The breakout sessions were followed by a panel examining policies and actions necessary for transforming primary care. Conference co-chair Denis Roy (vice-president of scientific affairs at the Institut national de santé publique du Québec) told the audience that primary care, which is vital for Canadians' health, is "swimming in paradoxes." It ought to be the most important part of the system, he said, but it's the poor cousin. Information is essential for making it work, but the data we have is fragmented and useless.
Nothing short of a "new deal" can bring about the revolution in care that Dr. Roy envisions: collaboration among health systems, providers and patients; flexibility on rules that constrain change; and far-reaching data gathering to measure progress and improve quality. He also proposed an innovation network that would showcase local and regional breakthrough approaches to primary care.
Jeffrey Turnbull, president of the Canadian Medical Association, advocated for greater use of multidisciplinary teams and also suggested that health services realignment should be a major focus in future federal-provincial negotiations on health financing – including $300 million to establish some sort of national institute for quality that would promote innovation and the exchange of best practices across jurisdictions.
Susan Fitzpatrick, assistant deputy minister of the Negotiations and Accountability Management Division at the Ontario Ministry of Health and Long-Term Care, spoke of the important linkages between evidence, quality improvement, accountability and the ability to manage healthcare costs. She argued that primary care needs to demonstrate the contribution it makes to the rest of the system.
Panellist Brian Goldman, an emergency physician and journalist, said it might be time to turn the debate over which professionals do what on its head by determining the scope of care needed at different tiers in the healthcare system and then figuring out "who gets to play" in that scope, based on what patients need and the competencies required to meet those needs.
But ideas for reform will not go far until those interested in the issue learn to work together and speak with one voice to win society and governments over to the idea of transformation, according to Antonia Maioni, keynote speaker on day two of the conference. "What's missing in primary care reform? Support, commitments and endorsements. Strong alliances," said Dr. Maioni, who is director of the McGill Institute for the Study of Canada. She said primary care reform must find a collective voice, get on the map and get a grip on public interest if it's to win support from governments and the public.
To help CHSRF accelerate action on primary healthcare reform, a group of healthcare leaders met after Picking Up the Pace to discuss what they had heard and distill it into actions and policies for driving faster transformation. Here are some of their ideas:
- Have all stakeholders work together to define objectives and develop plans before starting.
- Set measurable goals, and use data for understanding, planning and quality improvement.
- Base all change on evidence and make sure data are timely, relevant and complete.
- Create an institute ("The Tommy Douglas Foundation") to fund research and act as a clearing house for primary care innovations.
- Collaborate, pool resources and have regular meetings to share innovations.
- Be adaptable and flexible – on rules, funding, professional roles and where services are offered.
- Try different approaches to governance, suited to the culture and needs of each organization.
- Focus on developing teams and client-centred care, starting during the training of care providers.
About the Author
Jane Coutts is a healthcare writer based in Ottawa, Ontario.
Erin Morrison is the senior advisor in regional capacity development at the Canadian Health Services Research Foundation, in Ottawa, Ontario.
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