In Conversation with Fred Horne
First elected on March 2008, Fred Horne was still a rookie member of the Legislative Assembly (MLA) for Edmonton-Rutherford when he became parliamentary assistant to the minister of seniors and community support. By November 2010, he moved to a similar role with the minister of health and wellness. Concurrently, he served as chair of the legislature's Standing Committee on Health, with a mandate to focus on primary care, continuing care and mental health.
Editor's Note: In October 2011, several weeks after this interview, Mr. Horne was appointed minister of health by Alberta's new Premier Alison Redford.
Horne's career has been deeply rooted in healthcare, with numerous consultancy roles in health policy and a range of clients spanning government, agencies, health authorities and the private sector. With a master's of business administration degree from Royal Roads University and post-graduate certification in dispute resolution from York University, he seems aptly qualified for the issues and challenges of healthcare, health policy and systems delivery. Horne's fingerprints are prominent on several pieces of legislation, policy and system reviews, all positioned to place Alberta at the apex of performance and outcome measures in Canada.
In June 2011, Horne showcased Alberta's progress and track record in healthcare at the Canadian College of Health Leaders National Conference in Whistler, British Columbia. Ken Tremblay caught up with Horne over the summer.
HQ: During your Whistler presentation, it became very apparent that you are both articulate and wise regarding the intricacies of the healthcare system, public policy and all the moving parts. How has that knowledge shaped your approach to leading or driving the changes you feel are needed in healthcare?
FH: I have been very fortunate to have had a number of opportunities in my professional life to work with and learn from people who have a wide range of experience and knowledge within the Canadian healthcare system. That is the biggest asset I have coming into my role as an MLA and parliamentary assistant for the Ministry of Health and Wellness.
I started out as a health planner in Ontario, working in everything from mental health to acute care to continuing care. I worked with the professionals but also talked with the people who actually use the system. Increasingly, in addition to looking at best practices, I found a real need for engagement with the public in terms of understanding their experience with the health system and their goals and aspirations. [Patient] engagement is really helping me do an effective job as an elected representative.
In the past two years, I have had the chance to do some extensive consultations with Albertans. First, the Minister's Advisory Committee on Health, which I co-chair, looked at our legislative framework for health in Alberta. The second instance related to specific consultations on the Alberta Health Act, which was passed in the legislature last fall. Having had the opportunity to work in the field for a number of years, I have a network of people whom I respect to draw from – both in Alberta and across the country.
The last piece of the puzzle is an understanding that to really get the most value out of our system, we need to actively engage our citizens in a discussion, not just about how to fix the health system but about how to make improvements on their individual experiences and to respond to their priorities: primary care, continuing care and mental health care – three very basic building blocks that concern people about their health system.
HQ: Alberta seems to be leading Canada in the successful implementation of a province-wide electronic health record (EHR) and, specifically, products such as MyHealth and the Netcare EHR portal. What benefits do you see from these investments in e-health?
FH: Alberta was fortunate to have ministers and officials who had the vision for the EHR. Automating processes that already existed – laboratory test information, information about patient prescriptions and the ability to view diagnostic imaging information – has been really helpful.
Going forward, we have to take what we have developed and connect it to primary care. We are beginning to see that in primary care networks with linkages to Alberta Netcare, professionals in team-based environments not only can review historical information but can share [current] information to help achieve specific outcomes for patients.
We have seen many effective applications of the EHR in the in-patient environment. These systems are going to be even more effective once they are connected to primary care providers because if you look at chronic disease management, for example, the ability to link early intervention, proactive intervention and assisting patients to manage their own condition over time resides at the primary care level. In this sense, the EHR is not just automation; rather, it is a true enabler of new processes and approaches that actively involve patients in their own care.
HQ: I noted the interactive symptom checker on the MyHealth website. How have Albertans responded to the ability to take more control of their healthcare and access to the system?
FH: We are still in the early days of the portal. From my constituency, I have heard some very positive reactions about the ability to log in, although we are not yet at the point where Albertans can fully access their own clinical information. We're working hard on that and hope to get there soon.
When I started my career, healthcare was very much a program where individuals, families and communities were, for the most part, passive players. "Healthcare" was something we received, but we didn't really get involved in terms of making decisions about our own health. There is an increasing demand for access to information, enabling individuals and families to take an active role in managing their own health and health outcomes. When I talk to constituents caring for young children, their aging parents and their own health, [I hear that] these tools offer access to information and support people, particularly those with chronic diseases or at the threshold of developing, let's say, diabetes. It's those people who want to pull themselves back from the brink who are going to really benefit from the portal. It's not just a case of pushing information out to people; it's allowing them to pull information to use to make decisions.
HQ: Creating the best-performing, publicly funded health system in Canada by 2015 is the endgame contemplated by your province's five-year health action plan. In it are performance targets such as scheduled primary care visits within two days, and 100% of patients discharged from the emergency department within four hours. Tell us how you found the resolve to make such standards-based direction statements within your province's reform agenda.
FH: The credit goes to our minister [of health and wellness] and our premier, in particular, and my colleagues in caucus for making the decision to focus on performance. In the years during which I've been involved in [healthcare], the country has been fixated on the total cost of healthcare – sometimes expressed as a percentage of GDP [gross domestic product], sometimes as a percentage of the provincial budget. It's important that we are mindful of those metrics as some provinces are approaching 50% of their expenditures on healthcare. But limiting the discussion to what we're spending versus engaging people in a conversation about how well we're spending the money seems to be a missed opportunity.
While Albertans are mindful of costs, they're [more] interested in how well we're doing, not just against the best in the OECD [Organisation for Economic Co-operation and Development] but benchmarking against our own performance. It's an incremental approach to system improvement versus trying to find the one big fix. I don't believe there is a single big fix for healthcare; I do believe we are not getting the most value out of the public dollars that are spent.
Our citizens want us to be focused on performance, specifically in the basics such as access to primary care and a culture of continuous quality improvement. And not just on how many people have a family doctor, but also how many people have access to other professionals such as nurses, pharmacists and mental health workers. How are we doing in continuing care? Are we offering home care services that meet people's needs? Are we offering a full range of facility-based services that support heavy care, assistance with daily living or supportive housing?
HQ: I noted the deployment of da Vinci robotic systems for minimally invasive surgery in both Calgary and Edmonton, some two years ago. Is this commitment to leading-edge technology an indicator of how well your system is performing?
FH: We are fortunate in Alberta to have funds to invest in research and technology. There are a lot of questions about technology deployment, such as the issue of diffusion of new technology, because it's coming out all the time.
Using magnetic resonance imaging [MRI] as an example, as you bring more MRI units into the system, utilization rates go up. While we need to continue to invest and make the most of technology, these decisions have to be tied to specific health outcomes for our population. If a particular technology can increase throughput in a high-demand procedure and it is an objective established for our health system, we need to look at how we can make the most of it. If, on the other hand, we're replacing a technology that is not necessarily obsolete, we need to take a look at that as well. Alberta is always looking to health technology assessment as we make these decisions.
HQ: Alberta has come full circle in its evolution of districts, to regional health authorities, to the current Alberta Health Services. What would you say are the lessons learned that can be used by other provinces?
FH: There are probably a number. One is the engagement of your citizenry, health professions and the people who work in the system as key to the success of making this kind of change. Alberta Health Services has about 96,000 employees at the moment; there are a lot people who have been affected by the change.
One of our major goals was simply to maximize efficiency. I believe we had over seven separate payroll systems. But, if you also look at [the system] from a policy perspective and seek to improve the health status and outcomes of your population, you really need to deploy a best practices approach across the board. Alberta Health Services is going to allow us to do that. With that said, one of the lessons is that you don't want a remote head office to take away opportunities for local input on decisions best made on a site basis. It's a balance, and we're still learning.
Another important lesson is the approach that form should follow function. We spent a lot of time looking at the functions we want performed by the health system and then selected the structures that enable those outcomes to be achieved. The new chief executive officer [CEO] of Alberta Health Services has focused on that.
HQ: Notwithstanding forms of engagement, change remains difficult in the healthcare policy field. Have you any sense why changing the system is such a juggernaut when it comes to provinces or these large health systems?
FH: I have been around healthcare for over 25 years now; it's always been a difficult issue. At a base level, Canadians do not want to live with the idea that [the system] won't be there when we need it. We have done a really good job in this country, regardless of what some people might say, of making sure that this is a system that people can count on when they need it.
One of the reasons change is difficult, especially big change, is that it leads people to believe that healthcare won't be there in the same way. As our population ages, people see change from their perspective, their parents, their children, their community. What makes it harder is to talk about one big fix – usually about the cost and how to spend less. We're not asking the right questions: we need to shift the conversation to what individuals, families and communities can do to improve health with the resources available. It's about engaging and enabling people. It's a lot easier to talk about how to benefit a community with a new primary care team or a continuing care facility enabling people to age in place than it is to take on the question of the cost of healthcare.
HQ: What keeps the parliamentary assistant to the Alberta minister of health and wellness up at night? What issues are top of mind?
FH: My personal belief is that if we truly want to talk about a patient-centred or a person-centred healthcare system in Canada, we need to think differently at a system level. How are we going to get there? Engagement is a big part of the answer, but where are the data coming from in order to make better decisions? How are the provinces and territories going to work together more effectively to ensure that we are leveraging the best of what each has to offer?
Alberta has done a lot, but there have been some tremendous lessons learned in other provinces. I worry about the question how: how, if we want a patient-centred system, are we going to give people a home within that system? One of the recommendations in the report [of the Minister's Advisory Committee on Health] was that every Albertan should have the opportunity to be a member of a team-based primary care structure in his or her local community. We now have over 40 primary care networks, so the issue becomes one of attachment. How do well citizens become attached enough to the system and its resources and data to take an active role in managing their own health? If we don't [tackle this], we're going to have a real problem with the current system down the road. How do we connect and support people in a meaningful way as they plan for their own health and that of their family and their community?
HQ: In its report of the Minister's Advisory Committee on Health, your committee provided new perspectives on the legislative and policy frameworks underpinning a high-performance healthcare system, including person- and family-centred care. What elements of that report hold the greatest promise, and which will be the most challenging?
FH: I'll start with the challenges side. Alberta has over 30 acts and more than 100 regulations that govern the healthcare system, many dating back to the 1960s or earlier and largely focused on institutional providers and money. Where we're trying to head is toward a system that is focused on individuals, families and communities.
But any time governments start to talk about changes to legislation, people worry that they're going to lose programs and services as a result of that change. One of the approaches to making people feel more comfortable with legislative change is a more flexible framework that allows us to be responsive, rather than prescriptive. In terms of the report and the [revised] Alberta Health Act, the focus was performance and patient-centredness. The Alberta Health Act is principles-based legislation, perhaps the first of its kind in Canada, where we set out specific principles to guide decision-making. They include things like people taking an active part in decisions about their health and a commitment to the principles in the Canada Health Act. It is not about institutions and money; rather, it's about individuals, families and communities and their respective roles.
There is a provision in the act for a Health Charter for Alberta. It would set out what citizens can expect from their healthcare system as well as what role the individual might be expected to assume. The majority of people I talk to support the notion of individual responsibility [for health]. While not everybody can fully participate, many want to take a greater role in using resources wisely in the community, being informed about their particular condition or following a prescribed course of treatment to the best of their ability.
The act also made provision for the Office of the Health Advocate, designed to help people navigating through the system, supporting them when and where disputes may arise and making sure that the charter, when finalized, lives up to expectations. The act looks to the future, from healthcare to health system, as a tool to improve the health of our people over time and for future generations.
Albertans are becoming focused on wellness, recognizing that health is not a "one-ministry function"; rather, the legislation mentions the social determinants of health and contemplates mechanisms for ministries to work together – from acute care, to housing, to mental health and all of the other things that improve the health of the individual.
HQ: What else do you want the readers of Healthcare Quarterly to know about Fred Horne?
FH: It's a real privilege for someone like me to be able to serve in the role I now have. I started out as a health planner, and I'm grateful for the opportunities that Premier Stelmach has given me to capitalize on that experience and my perspectives. The future of healthcare in Canada is bright, and I know there are other people who think the same. If we can work together, if we can look at more opportunities to collaborate nationally and, most importantly, if people in elected positions can put a little more focus on engaging local communities, I think we'll get there. Our performance will continue to improve and our costs can be sustained. It's important that people not believe that it's too difficult a challenge; it is within our grasp. We have people and ideas and a population willing to work with us. We should get moving.
HQ: Thank you.
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