A New Era of First Nations Health in BC

Trevor Kehoe is a Communications Officer with the First Nations Health Authority on Coast Salish Territory in West Vancouver.

BC First Nations are making history by undertaking a transformative process to change the way health care is delivered to their children, families and communities. The Tripartite First Nations Health process underway in BC is a case study in the power of many Nations coming together and speaking with a common voice to find a path forward to better health outcomes.

The area of what is known as BC is home to the most diverse cross-section of First Nations across this country, with 203 unique communities. The importance of health and wellness emerged as common ground upon which BC First Nations communities could unite to work toward change necessary for the health of their people. This cooperation and the vision shown by Chiefs, Leaders, Health Directors, and Health Leads was the foundation that allowed for the initiation of the current Tripartite process.

Supportive partners in Health Canada, the Province of BC, our five provincial Regional Health Authorities, and others have created the space for a meaningful collaborative process to evolve and grow with BC First Nations positioned as equal partners along this shared journey.

Through innovative engagement processes like our annual Gathering Wisdom for a Shared Journey Forums, Regional Caucus Sessions in all five areas of the province, Community Engagement HUBS, comprehensive reporting and communications, First Nations Health Council Table, and other mechanisms, space is created for each First Nations community voice to be heard. This comprehensive engagement and approvals process coupled with our principle of reciprocal accountability is a cornerstone of this health system’s transfer and transformation process, with communities leading the discussion.

A series of precedent-setting agreements between the Tripartite partners, including the 2005 Transformative Change Accord, the 2006 Transformative Change Accord: First Nations Health Plan,  the 2007 Tripartite First Nations Health Plan, and the 2011 British Columbia Tripartite Framework Agreement on First Nation Health Governance has led to the creation of the new First Nations Health Governance Structure of the First Nations Health Authority, First Nations Health Council and First Nations Health Directors Association – a first in Canada.

These agreements would not have been possible without the extensive community engagement process, engagement and approvals pathway, and leadership and unity shown by BC First Nations in electing to move forward with the historic transfer of health services from Health Canada’s First Nations Inuit Health Branch – Pacific Region to the First Nations Health Authority.
Our Seven Directives developed throughout the hundreds of provincial, regional, and sub-regional community meetings, workbooks and guiding documents describes the fundamental standards and instructions for the new health governance relationship.

Directive number one, ‘Community-Driven, Nation-Based’ captures the essence of the new First Nations Health Governance approach. With a united voice from BC First Nations leadership and through meaningful participation, willing partnerships, and a vision for better health outcomes, communities are mapping out the creation of a more effective, and innovative health system that will bring to life the vision of healthy, self-determining and vibrant BC First Nations children, families and communities.

Find us online www.fnha.ca, and through Facebook, Twitter, and YouTube.

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We Have the Communication Technology – Let’s Use It!

Dr. Wendy Graham is CEO of Mihealth Global Systems Inc. www.mihealth.com, where she strives to improve patient engagement with the health care system. During her career, she has written about health policy reform and system efficiency and has been named as an extremely influential physician in primary care reform and collaborative care models for Canada. 

The Health Council of Canada’s Progress Report 2013: Health Care Renewal in Canada is an impressive report that captures the essence of where we are and where we need to be. There is little doubt that we will require a seismic shift in policy and leadership to make the needed improvements in health care delivery, but not necessarily additional significant investment.

Despite the commitment at many levels, access to health care is delivered primarily at the local level and one’s access to their primary care provider and team remains variable and lacks economic efficiency.

Theodor Marmor, Professor, Public Policy and Management for Yale says that health care reform may occur when governments face serious fiscal deficits.

We must harness the low-cost innovation technology reforms that have high returns on investment, allowing patients to fully engage in their own health care management. The time is now to embrace the 57% of physicians who are using EMRs. Interoperability will ensure needed advances in primary care reform. We must use encrypted email and smart phones in an era of BYOD in business. Estimated savings of time and money using secure messaging or texting with your provider will ensure the accountability of the providers, allowing real time access to simple questions such as the result of a pregnancy test to prevent the unwanted complication. In Diabetes Care, July 2011 the evidence was in: “mobile coaching substantially reduced A1cs (Glycated Hemoglobin) over one year.”

In the future, the profession will embrace the patient who performed the home-monitored blood pressure reading stored on their mobile phone and discussed it with the pharmacist or nurse before seeing the family physician for targeted medication intervention.

Why not teach a patient about the cardiac risk or the high-risk osteoporosis patient about the ten-year Risk Assessment Tool from Osteoporosis Canada available on iPhones?
      
Some of the issues are addressed with Telemedicine, which has transformed cancer and psychiatric care, reducing travel and risk in areas of underservice.

The opportunity to value time saved by engaging the consumer has arrived.

•    The Canadian Medical Protective Association has strongly advised the encryption of data flowing electronically between patient and providers in the circle of care.
•    The provision of eCodes recognizes the need for e-consults and will tip the profession to try new mobile technology: attach lab results, diagnostic images, photographs of rashes to ask the dermatologists for the diagnosis.
•    EHRs provide the ability to access and share patient records interfacing with EMRs through the internet or to download  them onto virtually any smartphone or mobile device.
•    We can connect all the allied care providers and others to the circle of care, and facilitate the effective management of population health issues, such as chlamydia identification or cancer screening.
•    The cost is shared with the engaged consumer now motivated to avoid an unnecessary visit to the emergency room and walk-in clinics.

The future will be very exciting.

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Sustaining our momentum on pan-Canadian drug pricing

Dr. Michael Law is an assistant professor at the Centre for Health Services and Policy Research, School of Population and Public Health, University of British Columbia.

I can’t help but be struck by the relative progress on two important pharmaceutical policy files that were commitments in the original 2003 Health Accord.

First, consider the progress toward harmonizing the assessment of drugs. Since 2003, the Common Drug Review (CDR) has produced 236 recommendations on new drugs, and the reviews are widely used by provincial drug plans. Moves toward jointly assessing the evidence on new drugs have become well entrenched in Canada.

In contrast, consider the baby steps we’ve made toward the Accord commitment to collaborate on drug pricing. On the brand side, it has become increasingly common for countries to negotiate confidential deals with pharmaceutical companies through so-called product listing agreements (PLAs). These agreements provide confidential discounts to drug plans in exchange for coverage, particularly as our current system allows one province to be played off against another.

On the generic drug side, while other countries get companies to aggressively compete with one another to obtain lower prices, we’ve stuck to our old formula of pricing generics as an arbitrary percentage of the brand name price. So, in short, I think there’s a need for more pan-Canadian work on drug pricing.

After many years of being stalled, we’ve recently started to see some changes. These initiatives have been launched by individual provinces, and then brought to the national level through the Council of the Federation. First, in 2010 the premiers agreed to band together to secure better deals on brand name medicines, and subsequently in 2012 they agreed to pursue generic drugs through collective bulk purchasing.

Given the commitment to pan-Canadian movement made back in 2003, progress to date has been modest: collective purchasing strategies have been completed for seven brand name products and six generic drugs. When you consider that millions of Canadians use thousands of different prescription drugs, it’s abundantly clear that there is a slew of further opportunities for collaborative initiatives.

I think an important question at this point will be how to build on these initiatives and maintain this new momentum. As the Council pointed out in their report on the National Pharmaceuticals Strategy, as governments change, priorities shift, often leaving valuable policy initiatives unfinished.  We have already started seeing this to some degree when Quebec recently decided not to continue participating in these new initiatives.

Making sure we maintain this momentum is important, as there are still significant barriers to negotiating brand prices together, and Canadians continue to pay for generic drugs using an outdated pricing model. Following the lead of the Common Drug Review, perhaps it’s time we institutionalized these joint-purchasing initiatives through a formal body or governance structure that can build on and expand these recent successes. A more permanent body would help address these serious issues, and solidify our current momentum on pan-Canadian prescription drug pricing initiatives.

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Still Waiting After All These Years

Dr. Chris Simpson is chair of the Wait Time Alliance and
President elect nominee of the Canadian Medical Association.

Yesterday afternoon, in my capacity as Cardiac Program Medical Director at my hospital, I met with Mr. B, a 72 year old man whose wife died in hospital.

I was expecting that he would want to talk about her hospital care; perhaps he wanted to explore why she died and if anything could have been done differently. I reviewed her chart thoroughly in advance so I could be sure I had all the facts I would need to discuss her case with him in a meaningful and productive way.

As it turned out, he didn’t want to talk about that at all. Instead, he wanted to talk to me about his wife’s experience leading up to her surgery. He told me her story chronologically. She’d had a series of encounters, each characterized by a wait. She had waited in the ER. She waited for diagnostic tests. She waited for consultations, she waited for decisions and she waited for her surgery.

“All of the doctors and staff were great”, he repeatedly told me, almost as if he were trying to protect those of us who work on the front line from critique, “but the system let her down.”

He went on to explain how all of these constituent waits in her health care journey left this very thoughtful, seemingly-empowered and articulate man and his wife feeling afraid, vulnerable, disconnected, anxious, demoralized and uncertain.

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Canadians understand that when they require non-urgent health care, they will usually have to wait. When waits are appropriately brief and when patients feel connected and in control, they feel confident and satisfied. When waits are too long, however, and when people are left “in limbo” between encounters, patients and their families experience anxiety, economic hardship, needless pain and suffering, and perhaps even more serious adverse events, including death. Also important is the societal cost of excess waiting. The Canadian Medical Association has estimated that waits exceeding medically acceptable benchmarks for just four key procedures cost the Canadian economy $14.8 billion dollars in a single year (http://www.cma.ca/multimedia/CMA/Content_Images/Inside_cma/Media_Release/pdf/2008/EconomicReport.pdf).

As I reflect on the nearly ten years that have passed since the 2004 health accord was signed by the federal government and the provinces and territories, I find little reason to cheer. Despite all the goodwill, hard work and cooperation; despite the money committed to reducing wait times and the intense pressure from the public to improve, we have seen only modest progress. Over the past year or two, most discouragingly, we are now seeing the reversal of that modest progress. CIHI (http://www.cihi.ca/cihi-ext-portal/pdf/internet/HCIC2012_SUMMARY_EN), the Health Council of Canada, and the Wait Time Alliance (www.waittimealliance.ca) all agree that wait times have worsened again. Essentially, we’re regressing right back to where we started.

How is it that all this work and all these resources have not led to sustained improvements in wait times?

The reasons are many but they essentially boil down to one indisputable truth: the money that was invested didn’t buy change. All we did was to make the numbers look a little better for a short time. Our “success” was fleeting. The Senate Committee on Social Affairs, Science and Technology, in its review of the progress made since the 2004 Accord (http://www.parl.gc.ca/Content/SEN/Committee/411/soci/rep/rep07mar12-e.pdf) echoed this sentiment, recommending that investments must be used to buy change, not to maintain the status quo.

What would real, transformational change look like?

Well, it would start with the assembly of clear and timely information on outcomes and performance, the tools to measure these, and the establishment of a national body that is resourced and empowered to collect, analyze and present these data. We can’t change what we don’t measure.

Transformational change would also see more accountability to deliver the change that is purchased by the investment. We won’t change if the payers don’t hold us all accountable to deliver the change that the resources provided are intended to buy.

Transformational change means far less “siloism” in the system. It’s often said that we are a nation of health care pilot projects. Our jurisdictional and cultural silos impede the sharing of successes and best practices. We are forever “re-inventing the wheel” because we have diminishing national focus, standards, and goals.

And finally, transformational change means that all stakeholders in the system have to step up to do their part. Physician groups and other health care professional organizations must continue to advocate for individual patients but we also must embrace our civic professionalism – to help our system find better value for money and to help lead our collective responsibility to find a path to sustainability.

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Putting my doctor hat back on, though, I see this as being about how to fundamentally change our approach to the provision of care from one that is provider-centric to one that is patient-centered. Mr. and Mrs. B wanted us to accompany them on their journey. Instead, we invited them to join us on ours.
 
Mr. and Mrs. B recognized the excellence embedded in the silos, but felt abandoned at the transition points in her care pathway. The transition points between each component are the wait times; it is at these bottlenecks where negative perceptions, inequities, and suboptimal outcomes are born. It is also where inefficiency and waste are generated.

They deserved better. All Canadians deserve better. And we can do better. Together, we can build a health care system that is truly worthy of Canadians’ confidence and trust. 

Health Human Resources (HHR) in Canada Part 2: Where to next?

John G. Abbott, CEO, Health Council of Canada

In my previous blog post I outlined some of the pressing challenges our health care systems face when addressing the management of our health human resources and underlined the need for a strategic approach.

So, what steps should Canada take to get to the high-performing health care system all Canadians want? From the Health Council’s perspective, there are several basic elements we need to work on.

1. Set a vision and measurable goals 

 

We need to set specific targets nationally and provincially that are aligned for each of our professions. These have to be based on our population health needs, the interprofessional collaboration model of care and the capacity of our education and training system to meet them. For example, we should aim to be self-sufficient and set a timeframe to reduce our reliance on international recruitment across all professions. In addition, we could set explicit targets for training the workforce we know we’re going to need to care for the growing number of complex patients living in the community and at home.

2. Address our human resources challenges in workforce planning 

 

Canada has shown that, given time, it can implement innovative ways of delivering better quality care more efficiently at the “micro level”. But, when it comes to achieving a high-performing health care system, time is not on our side. We need governments and professional bodies to better collaborate to create supportive “macro level” policies that accelerate the implementation and spread of innovative practices. This includes regulatory frameworks that support professionals to work in teams and a post-secondary education system that is more responsive to training professionals that meet projected population health needs.

3. Central body of evidence 

 

Traditionally, knowledge translation on health human resources has been a one-way street where researchers produce evidence which they communicate to decision-makers. It is, therefore, not surprising that we don’t yet have a shared information base.

Seeing this, a number of Canadian health care stakeholders are calling for the establishment of a health human resources observatory. An observatory would be a forum where researchers, governments, employers, health professionals and unions can come together to share their views and gradually develop an evidence base that has “buy-in” from all sectors.

An observatory could also be a forum for coordinating research on health workforce issues, strengthening data collection and sharing approaches across provinces and territories. In this role it would build on the current trend towards increased interprovincial collaboration.

In 2010, the House of Commons Standing Committee on Health recommended the creation of a national observatory. The Health Council has endorsed this recommendation. Among peer nations, Australia has established an observatory whose work is highly regarded by experts in the field. Known as Health Workforce Australia, the observatory states as its goal: to build a sustainable health workforce for Australia.

In fact, the building blocks of an observatory are already up and running in the form of the Canadian HHR Network. The Pan-Canadian Health Human Resources Network (CHHRN) was established with federal funds and is made up of renowned researchers and policy makers. The Network has over 75 users from across Canada, and their Advisory Committee includes health ministry representatives.

The Network is already a valued source of best practice information on issues like health human resource retention and productivity.

To conclude, I believe that Canada is in a strong position to enact policy changes that would improve the productivity of our health workforce and improve the performance of our health care systems. Today’s governments and health care managers are well-versed in the language of quality improvement in health care. They also realize that there are cost-savings to be made by reorganizing our health systems to produce more effective care that is responsive to the needs and wishes of patients.

Just as Canada is proud of having one of the world’s strongest financial systems, shouldn’t we also want to have one of the best health care systems in the world? Canada has the knowledge and resources required to plan for our future health care needs, and this is more than true for our health workforce.

In the end, we want not only to be self-sufficient nationally, but to have the highly-skilled people to meet our health care demand needs in each region of the country. That will require a strategic approach built on continued collaboration amongst governments, professional bodies, their regulators and the education and training community.

The Health Innovation Breakfast

The Health Council celebrated the winners of our 4th annual Health Innovation Challenge this morning at a Health Innovation themed breakfast held at the Toronto Reference Library.

Winning students came from the University of Alberta, Dalhousie University, McMaster University, the University of Northern British Columbia and the University of Toronto to collect their awards in front of Health Council staff and health system stakeholders.

Will Falk provided an inspiring keynote address about the future of health care where patients and providers will connect virtually.   He discussed his interest in the innovative practices taking place in developing countries and stated that Canadians need to get rid of old ways of doing things i.e. doctors reliance on fax machines.

The Health Council demonstrated the Health Innovation Portal and informed winning students that the innovative practices that they identified as part of the Challenge will be posted on the Health Innovation Portal with acknowledgement.  Their work will contribute to sharing good ideas across jurisdictions and hopefully help to build national leading practices that allow for better health care for all Canadians.

You’re all invited to join the health innovation dialogue and share health care innovative practices on the Health Innovation Portal.   Our searchable database makes it easy to find practices, programs, services and policies that are of interest to you.  If you would like to contribute an innovative practice, please email innovation@healthcouncilcanada.ca. Your contributions will make this tool of value to the Canadian health care system.

Congratulations again to all the winners!