As we launch into 2023, the third year of the COVID-19 pandemic, the state of Canadian healthcare remains deeply concerning. Over the fall and winter months, our systems have experienced crippling levels of hospitalizations due to waves of infectious diseases, including influenza, respiratory syncytial virus infection and COVID-19. We have been particularly distressed by the impact to paediatric care, the insufficient capacity in mental health services and the continued strain on our healthcare workforce as well as on patients and families.

This past summer as our editorial team reflected on the path forward for system leaders, we acknowledged that any step taken toward recovery and renewal must be grounded in health equity and the social determinants of health. To underscore the importance of these themes, we launched a specific call for papers and were inspired by the response. Each of our upcoming editions will now include articles that address these fundamental issues at the heart of what is at stake for our society as we look beyond the COVID-19 pandemic. By shining a spotlight on examples from across the country of how different organizations and systems are supporting our most vulnerable populations and addressing pressing social issues, we are hoping to promote greater adoption of potential solutions.

Building on the themes of equity and social determinants, this edition of Healthcare Quarterly (HQ) begins with three articles on support for underserved communities. From there we move to a few topics that remain top of mind for healthcare in 2023, including cybersecurity, primary care and, of course, lessons learned from the pandemic. As usual, we include our featured columns from ICES (Rochon et al. 2023) and the Canadian Institute for Health Information (CIHI) (Costante et al. 2023), as well as our colleague Neil Seeman (Seeman 2023).

Supporting Underserved Communities

In the first article in this issue of HQ, Mulligan et al. (2023) discuss the rapid rise of social prescribing as an intervention to support individual and community well-being and to promote better integration of health and social care. By referring individuals to community-based social supports and encouraging participation in recreational, artistic and cultural activities, social prescribing enables individuals to better manage their own physical and mental health. While there are advantages for all levels of society, for underserved populations there is a particular benefit from the increased connection to social determinants of health. The authors also highlight the launch of the Canadian Institute for Social Prescribing in 2022. This new self-described collective impact network is aimed at building connections and advancing the use of social prescribing nationally. The article includes several excellent case studies from across the country.

We know that the existing vulnerabilities and gaps in our health and social systems have been exacerbated because of the COVID-19 pandemic and that the impact has been inequitably distributed across our society. One group that has been particularly affected comprises newcomers and refugees who have recently faced even greater challenges in their attempts to set up new lives in Canada. Côté-Boileau et al. (2023) describe using a co-designed journey-mapping approach and qualitative interviewing techniques to better understand the lived experience of the growing newcomer population in the Kitchener-Waterloo region and surrounding areas. The authors share common themes, policy implications and potential solutions to design a more people-centred approach to achieve more equitable population health outcomes.

The next article continues with the theme of health inequities and the disproportionate impact of the COVID-19 pandemic on specific communities. Bhatti et al. (2023) share their experiences with the TAIBU Community Health Centre as a Black-led organization during the pandemic and how they used race-based data collection to drive their pandemic response, including community outreach and vaccine distribution. Given the mounting evidence showing that Black, Indigenous and racialized communities in Canada continue to experience worse health outcomes, this article sheds light on the critical need for greater application of race-based data to inform the design of better care for marginalized populations.

Ensuring Data Security and Privacy

The prevalence and sophistication of cybersecurity attacks on healthcare organizations has increased dramatically in recent years, underlining the importance of measures to prevent and prepare for such events and to manage the losses when they occur. Cybersecurity is no longer something that can just be left to the information technology experts. Dixit et al. (2023) present a very useful principles-based approach to addressing cybersecurity risks that will be a source of guidance to those at all levels of a healthcare organization. It offers a starting point for anyone looking to improve organizational cybersecurity.

Innovations in Primary Care

Most health jurisdictions are actively pursuing agendas that promote better integrated, team-based primary care. We have also learned that these kinds of changes do not come easily. They involve many different healthcare players and can involve substantial changes in practice, professional roles and how patients access care. Price et al. (2023) share an approach for redesign and implementation of changes in primary care that emphasizes engaging a range of healthcare providers and users in the planning and implementation of sustainable changes in primary care systems. It is an approach that they initially developed and tested in British Columbia. It relies heavily on personas as a focus for planning.

Lessons from the Pandemic

The pandemic took an awful toll on patients, their families and front-line professionals, and it has continued to place intense strains on those involved and the health system itself. However, there have been a few silver linings to the experience, particularly the way in which it has served to accelerate changes we had previously seen as valuable but had been unable to bring about because of long-standing obstacles and resistance. Esser et al. (2023) describe an example of how hospitals in the Greater Toronto Area collaborated to optimize the use of in-patient resources through a period in 2021 when there was an intense shortage of adult in-patient capacity but unused paediatric capacity. The authors describe how their initiative unfolded and the lessons learned for future collaborative planning.

Quarterly Columns

In our regular column from ICES, Rochon et al. (2023) provide a brilliant analysis of “prescribing cascades,” particularly as they affect women. Prescribing cascades occur when one prescribed medicine gives rise to a side effect that is diagnosed to be a new medical condition and not a side effect, resulting in an additional treatment. ICES researchers have identified numerous common prescribing cascades and have also shown that women are at a vastly higher risk. Rochon et al. (2023) go on to discuss collaborative initiatives – some international – to address this issue. This column is essential reading for all prescribing professionals and those responsible for medication management.

CIHI also addresses issues of appropriate use of selected therapies in its column. Costante et al. (2023) describe a collaboration between CIHI and Choosing Wisely Canada (CWC) that explores the impact of CWC's recommendations on two areas of inappropriate use: (1) the use of benzodiazepines or other sedative-hypnotics in older adults as a first-choice treatment for insomnia, agitation or delirium and (2) red blood cell transfusion in hospitalized patients. They find some improvement but also note that considerable opportunities remain for further initiatives.

In his now-regular column, Neil Seeman (2023) writes about child and adolescent mental health in the pandemic and the impact of schools going virtual. As always, Seeman can be counted on to look beyond commonly accepted truths. He provides a powerful reminder that in mental health, we should not assume that all those affected will respond to changes in the same way. He makes a persuasive case for more individualized approaches to childhood mental health.

As we look ahead to the rest of this year's editions, we encourage our readers to contact us with ideas for articles or to share insights into the themes you think we should be highlighting as we consider the monumental challenges facing our health systems. We look forward to hearing your thoughts about how HQ can continue to both draw attention to critical issues and share leading practices.

– Anne Wojtak and Neil Stuart

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