Discussions surrounding solutions to health system improvement
For years, throughout Canada, health care systems have been trying to improve their efficiency and performance. Yet all the reforms introduced seem to have little effect and local innovations that work are not implemented across the country. The Sixth Estate webcast therefore decided to invite four experts to discuss the transformations needed for the situation to change.
Mike Villeneuve, CEO of the Canadian Nurses Association (CNA), started things off by talking about the concerns of his association. He pointed out that we have been encountering the same problems for years and despite all the discussions, there hasn’t been much action. He feels that as time passes, there is a growing mismatch between the needs of the population and the services provided by the health care system. He added that the population doesn’t need just acute rescue treatment care, but increasingly more long-term care, end-of-life care and palliative care. As a result, the CNA has questions about how its members should be deployed effectively to meet those kinds of needs, while also being aware that within the nursing profession, not everything is simple. It is not easy to agree on who is in the best position, registered nurses versus practical nurses and so forth, to provide care for the chronically ill, not to mention the obstacles that nurses can encounter when they want to practise in clinics without physicians.
For Dr. Hugo Viens, president of the Québec Medical Association, the relationship between physicians and nurses is evolving and the debate about the competencies of each is becoming outdated. The younger generation of physicians is more open to collaborative models for managing patient care, in particular by and with nurses.
Appropriateness and prevention
The main issue now tends to be the cost of health care, which represents more than 50% of the budget in Québec and where we are focused primarily on services and treatment for acute care. Our health care system is not adapted to the aging of the population and chronic disease management. “We feel that we need to shift to the left a bit in the timeline of disease and work together in going more toward… educating people to prevent disease,” stated Dr. Viens.
Another major issue is overdiagnosis and overmedicalization if we want to be able to afford our health system in the future, because we already know that about 30% of interventions today are probably unnecessary. “There are a lot of tests and probably hospitalizations that could be prevented only by doing the right thing at the right moment and not overprescribing, overmedicalizing our way of life… I think we are putting a lot of emphasis on medicine today and not as much on life hygiene and preventing disease,” explained Dr. Viens. “We’re in a model where we think doing more is better, but often less is better,” he added.
For Dr. Viens, the current compensation method puts the emphasis on volume care, but it is also necessary to consider value care. “The more we have technology, the more we want to do to detect cancer at an early stage, for instance. Often we know that detecting cancer early in the stages won’t change much in the outcome.” It is sometimes easier for a physician to prescribe a test than to explain why it isn’t necessary, which is why educating patients is important as well as making people aware of initiatives such as the Choosing Wisely Canada recommendations.
Adapting efficient solutions to implement them everywhere
Maria Judd, Vice-President, Programs, Canadian Foundation for Healthcare Improvement explained that it is important for governments and stakeholders to work together if they want to successfully resolve the problem. The Foundation’s mandate is to identify proven innovations and accelerate their spread across Canada. “We know chronic diseases and managing chronic diseases is a big challenge in Canada, so we identified an INSPIRED program which is a supportive COPD [chronic obstructive pulmonary disease] program developed by Dr. Graham Rocker and team in Halifax and we’re helping to spread that.”
In the first six months, this program had a reduction in readmissions to hospital of 64% and in visits to the emergency room of 52%, “and most importantly, people with advanced COPD told us they got their life back… The big focus… is to understand and identify what’s working in other places and support people in… adapting and implementing it in their local context.” For Maria Judd, educating patients with chronic diseases is essential: “people need to understand their disease and manage it, by themselves, with their families and in their community.”
Furthermore, she thinks that it is hard in Canada to implement and spread efficient initiatives “because our health systems are overloaded and we don’t have the capacity to respond to new ways of doing things. That’s where building capacity for improvement comes in. People in health care really need to have two functions. One is to do their job to provide patient care and the second is to figure out how to do that better.”
Improving rather than trying to transform
Damien Contandriopoulos, Professor, School of Nursing at the University of Victoria, feels it is not so much about having the system change as having the system improve. “We doubled the amount of money… of constant dollars since the 90s… it has been a bit less than 30 years to double the amount of actual money we are investing in the health care system… I would be curious about who has seen an improvement during that time.” For him, it is incomprehensible that in Canada’s history there has never been so much money, and so many physicians and nurses in health care, but still the system is crumbling.
It is important to understand that the source of the problem is complex, particularly because “we are living in a society where being over 50 is a chronic disease!” Damien Contandriopoulos pointed out that a study done 10 years ago showed that currently in North America, if you follow the guidelines, almost 100% of people over 50 years old are “technically sick”. 97% of people over 50 are currently fitting the guideline for at least three of the most common chronic diseases: cholesterol, high blood pressure and diabetes.
For this researcher, another aspect of our difficulty in improving things is that no-one is steering the change within the health care system, but we have interest groups that have the capacity to prevent change every time a transformation requires money to be shifted elsewhere.
Maria Judd believes it is possible to introduce small changes that will bring about improvements. When these changes in the local system start to work and we see the benefits or the savings at a higher level, it is easier to expand them.
For Dr. Viens, while everyone agrees on the problems and solutions, health care professionals still work in silos and to improve the situation, it is necessary to review how services are organized and work on building teams in which health professionals manage patients together, rather than having several professionals trying to do the same things. In addition, he thinks we shouldn’t be surprised if people continue to crowd emergency rooms. Not just because it is not always easy to get an appointment with a family physician, but also because the system is such that patients (and sometimes physicians) are still convinced that they will be treated faster by going to the hospital than by visiting a physician.