This letter is part of series of Open Letters from Canadian leaders in Healthcare. To see the complete series please click here 

The challenges to healthcare in Canada are well known: non-sustainable increases in expenditures¹ which are eroding our capacity to address other pressing societal needs and a growing burden of chronic disease² creating ever more expenses.

In response to these realities, the Triple Aim has been widely adopted: improving population health; improving the patient care experience; and reducing healthcare expenditures.³

Improvements in the quality and efficiency of medical care have been made, but expenditures continue to rise. This is because our priorities have been wrong: an over-emphasis on medical care to the neglect of population health interventions.

Of the modifiable determinants of population health, medical care accounts for about 20%, and the social determinants of health (SDOH) account for 80%. Within the SDOH, health behaviours (smoking, diet, exercise, alcohol and drug use and unsafe sex) about 30%, physical environment about 10%   and socioeconomic factors (early childhood development, food, housing, income, education/training, social supports and social justice) about 40%. ^4,5 The field of genetics, while important, is considered relatively unmodifiable at this time and so is not included in this analysis. Those who are deprived of the SDOH are stressed, have poorer health and often an early death.

But healthcare systems are spending about 90% on medical care and less than 10% on the SDOH.¹ While the healthcare system should have a prominent role in addressing these issues, this can’t be done in isolation. To address the SDOH, innovations are needed both ‘within the walls’ of healthcare in clinical settings and ‘outside the walls' by cooperating with other agencies across the community and all levels of government and society.

Innovation is happening more quickly in the US, driven by healthcare expenditures that are much more out of control than in Canada. Under the Accountable Care Act there are financial incentives to improve population health through Accountable Care Organizations and Accountable Health Communities.⁶ They are investing healthcare dollars in progressive programs such as subsidized housing for low income patients, ‘food pharmacies’ within hospitals and farmers’ markets and nutritious food outlets in poorer communities.⁷ Similar initiatives are beginning in Canada.³ These experiences suggest the following innovations for healthcare systems across Canada⁶:

1. Geographically define the population being served. Usually this will be a city, town or cluster of smaller communities and can include special populations (e.g. the frail elderly or the homeless).
2. Create a strong local healthcare governance body that includes health professionals as well as patient and citizen representation. This governance body provides leadership, oversight and a mechanism for planning, data analysis and reporting, communication and accountbility.⁷
3. Financial allocation should urgently move away from fee-for-service (volume-based) payments to more global budgets (value-based payment) with incentives for improved clinical and population health outcomes.
4. In addition to comprehensive clinical services, interventions on the SDOH should be included (such as identifying patients in need of food, housing, employment, skills training or income supports) and linking them to appropriate services directly or through programs such as Health Leads⁸ or Basics for Health.⁹
5. Integrated, interprofessional healthcare teams should include community development experts along with physicians, specialists, nurses, pharmacists, physiotherapists, mental health professionals, public health experts and others.
6. Clinical information must be included in an interoperable electronic health record (EHR) and be enhanced by patients’ SDOH data. These data should be made available to patients and professional caregivers as needed, with appropriate privacy and security measures in place.
7. These health data need to be linked and analysed to track health outcomes and expenditures for the patient and the population (‘Big Data’) and made available in regular reports to support a ‘learning culture’ within healthcare and to be accountable for expenditures and outcomes.
8. A ‘Collective Impact’ approach with sectors in the community ‘outside the walls’ of healthcare is required to tackle some of the more challenging SDOH such as poverty, homelessness and hunger. The key elements of this are¹⁰: a common agenda, governance by a strong intersectoral ‘backbone’ organization (healthcare playing an important role), common metrics of performance, mutually supportive activities, constant communication and trusting relationships.¹¹

Addressing the SDOH will reduce the burden of chronic disease and lower healthcare expenditures. This can¹² and should be done¹¹ but there are barriers to overcome.

Entrenched attitudes (both public and professional) and vested interests encourage the ongoing over-emphasis on clinical care as the chief means to better health. To change this will require effective leadership.

Good leadership requires clear vision, values and goals and the ability to change mindsets and attitudes and to bring together the right people to make the necessary changes. The federal and provincial governments have an opportunity to provide both the necessary leadership and incentives to encourage innovative change. Provinces and health authorities should be made accountable for spending transfer payments on a balance of population health policies (as above) and medical care improvements.

There has been much talk about innovation – it is time for our governments to take the lead in working with local communities to transform Canadian healthcare. 

References

1. National Health Expenditure Trends, 1975 to 2016.  Canadian Institute for Health Information. 2016.
2. "Seniors and the Health Care System. What is the Impact of Multiple Chronic Conditions?" Canadian Institute for Health Information, 2011.
3. "Triple Aim in Canada: developing capacity to lead to better health, care and cost." Farmanova, E. at al. International Journal for Quality in Health Care. 2016.
4. "The Case for More Active Policy Attention to Health Promotion." McGinnis, M. et al. Health Affairs 21(2), 2002.
5. "Different Perspectives for Assigning Weights to Determinants of Health." Booske, BC, Athens, JK, Kindig, DA et al. February, 2010. County Health Rankings Working Paper, Population Health Institute, University of Wisconsin.
6. Kindig, D. and Stoddard, G.  "What is Population Health?" American Journal of Public Health; 2003, 93(3):380-383
7. "Accountable Health Communities. Getting There from Here." Fisher, E. and Corrigan, J.  Journal of the American Medical Association. 2014, 312(20) 2093-2094.
8. "The Community Cure for Health Care." Hussein, T and Collins, M. Stanford Social Innovation Review. 2016.
9. Health Leads: https://healthleadsusa.org/
10. Basics for Health: www.basicsforhealthsociety.ca/
11. "Collective Impact." Kania, J. and Kramer, M. Stanford Social Innovation Review, Winter 2011.
12. "Beyond Markets and States: Polycentric Governance of Complex Economic Systems." Ostrom, E. American Economic Review. 2010 100: 641-672.

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