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Friday, January 25, 2013

We need to break out of the bubble

Jason Nickerson is a respiratory therapist and a PhD Candidate in population health at the University of Ottawa.

Because of our need to strengthen capacity within the primary care system, it is of extreme importance that we pay attention to the perspectives of those working within it. The release of the report, How do Canadian Primary Care Physicians Rate the Health System? provides such a perspective, and should signal our need to evolve not only discussion, but innovation, on how to ensure that Canadians continue to see value for money spent on healthcare.

For decades, Canadian health policy experts and practitioners have wrestled with the question of how to improve Canadians’ access to primary health care. This debate has taken place within a fractured and fragmented health care delivery system, which by all rights can hardly be characterized as a national system at all. Rather, high quality health care is frequently delivered within confined bubbles, few of which are connected in any pragmatic way that is easily navigable for patients or caregivers. An effective health care system must have seamless linkages between community care, primary care, acute care, and continuing care, something that this report finds is lacking in Canada. We need to focus more on systems, rather than on individual problems.

Regrettably, progress has been lamentably slow. As the report notes: “Canada ranks poorly compared to other countries on many factors related to access to primary care and coordination of care between primary and specialist providers.” This is not a new problem, nor is it one that has suffered from a lack of investment. Rather, a considerable number of projects and alternative models of practice have been initiated throughout Canada, some with considerable success, and many that have lacked scalability outside of the confines of the practices where they have been initiated.

What we must acknowledge is that many of the constraints faced in accessing primary care must be addressed through considerable structural reforms to the governance and organization of Canada’s health systems (and they are a plurality, rather than one cohesive system). Far too few clinicians are able to practice to the full extent of their scopes of practice, limiting the “bang for our buck” in training and deploying them; effective referral networks and procedures are often lacking in many systems or are stymied by bureaucratic and procedural constraints that make referrals or collaboration impractical; health information systems have been deployed to collect large quantities of health information, yet frequently fail to manage information in a meaningful way across different providers and care systems.

While much has been written with regard to our need to improve healthcare in Canada, we need to move beyond simplistic solutions that have largely focused on change, rather than reform. Proposals such as interprofessional education or electronic charting have arguable potential to enact these changes, but have been poor at actually reforming the structural, regulatory, or institutional barriers that impede the optimal roll-out of these innovations. Clinicians who are not empowered (or allowed) to initiate, titrate, or discontinue treatments or refer patients to colleagues in different professions are unlikely to provide optimal interprofessional care nor see the benefits of interprofessional education. Computerized charting or imaging that offers no ability to transfer records in a useful way across health authorities or clinics offers no advantage to patients nor health systems. What’s more is that frontline clinicians identify inefficiencies and deficiencies within these systems and develop work-arounds to them, which may directly undermine investments made.

Considerable work remains if we are to see Canada’s primary health care systems ranked among the best in the world. However, this cannot be achieved in the absence of coordinated reforms to link innovations and ensure the constructive evolution of Canada’s healthcare delivery systems. We currently have pockets of innovation and excellence, and what we need is a coordinated scaling-up of modern systems geared toward prevention, treatment, and accountability.

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