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2014 June Conference: Prevent More to Treat Less - DAY 3 - Plenary Sessions
CONFERENCE PROCEEDINGS: PREVENT MORE TO TREAT LESS
JOINT alPHa – AOHC CONFERENCE, JUNE 3-5 2014
PLEASE CLICK HERE FOR THE CONFERENCE PROGRAM, WHICH INCLUDES BIOGRAPHIES OF THE SPEAKERS, INFORMATION ON THE PUBLIC HEALTH & PRIMARY CARE CHAMPION AWARDS AND RECIPIENTS, AND DESCRIPTIONS OF THE LEARNING SESSIONS
THURSDAY JUNE 5
8:30 AM – 10:00 AM - Plenary III
Innovation in Public Health and Primary Health Care Award
Recipient: Tungasuvvingat Inuit Family Health Team (TIFHT)
The Innovation in Public Health and Primary Health Care Award honours a policy, program or initiative for excellence in advancing collaborative practice between public health and primary health care.
Since March 2011, The Tungasuvvingat Inuit Family Health Team (TIFHT) has provided Primary Health care services to Ottawa’s Inuit population.
Nominated by Ottawa Public Health, the team was described as providing “innovative, holistic model of culturally safe, community-based primary care with interdisciplinary services that incorporate an understanding of the determinants of health and a respect for Inuit diversity, values, culture, language, knowledge and self-determination.”
To enhance health equity, efficiency and effectiveness, TIFHT and Ottawa have developed a powerful partnership — a partnership that has ensured many more people from Ottawa’s Inuit community can access culturally appropriate services that address the community’s most pressing health needs.
TIFHT has facilitated community engagement, informed needs assessments, adapted health education resources, and influenced public health approaches to collectively identify priority health concerns. This has been accomplished through ongoing dialogue, sharing promising practices, community consultations, and Elder participation in service and program planning.
This integration of public health into primary care services has meant clients who might otherwise avoid mainstream health services get the supports they need. Both Ottawa Public Health and the Tungasuvvingat Inuit Family Health Team are focused on controlling communicable diseases. Working together they have enhanced access to testing, treatment and vaccines. They also have designated liaisons, and developed collaborative case management.
Both organizations also want to improve the oral health of the Inuit Community in Ottawa. They are working together they run a monthly dental screening clinic, located at the Family Health Team’s site. And now this dynamic partnership is in the process of developing joint activities related to smoking cessation and suicide prevention.
This is an excellent example of how working together Public Health and Primary Health Care providers can promote population health and advance health equity for a population that is vulnerable to poor health.
Accepting the award on behalf of the Tungasuvvingat Inuit Family Health Team were Dr. Indu Gambhir and Connie Siedule.
Interactive Panel Discussion: Teaming Up for Transformation
Michael Rachlis , Rosana Pellizzari (Facilitators), Jack McCarthy (Executive Director. Somerset West Community Health Centre, Ottawa), Kieran Moore (Associate Medical Officer of Health, KFL&A Public Health; professor of emergency and family medicine at Queen’s University in Kingston), Dr. Danielle Martin (Vice-President, Medical Affairs and Health System Solutions at Women’s College Hospital (WCH), a family physician in the Family Practice Health Centre at WCH, and an Assistant Professor in the Departments of Family and Community Medicine and Health Policy, Management and Evaluation at the University of Toronto, minor YouTube celebrity), Dr. Penny Sutcliffe (MOH, Sudbury & District Health Unit, alPHa President).
A common theme running through all of the sessions – and even the Public Health Champion awards – has been the idea of identifying partners, building relationships and collaborating in order to reach a goal. We’ve already heard many examples of how Public Health and Primary Care are already teaming up for transformation, and this morning’s panel was invited to zero in on some of the factors that make that possible and some of the challenges that need to be overcome.
Michael Rachlis commented that it appears that shared values and common ground are creating the conditions for teamwork where health equity is the objective. These values and common ground are not even limited to the groups represented here, but also include many individuals and organizations outside of the health care system whose goals are similar. He guessed that it is only our processes that keep us apart, and observed that society is made up of “guardians” (who are loyal to the cause & follow the rules) and “traders” (who find a way around rules that aren’t working for them). We need both in order to move forward.
Rosana Pellizzari then reported that she is co-chair of the OPHA- alPHa Health Equity Working Group, and was very pleased to learn that AOHC has an actual Health Equity Charter. This, she said, is just more evidence that we have much to learn from each other. She then issued an invitation to participants who have come up with great and novel ideas for Public Health – Primary Health care collaboration to pitch them to her and Michael over lunch. These would be shared during the closing plenary.
Michael Rachlis introduced the morning’s panelists, whom he invited to talk about ideas to scale up the successes of collaborations between Public Health and Primary Care and to address some of the barriers to moving them forward.
Kieran Moore began by noting that there are lots of factors behind the kinds of relationships required to move the community health agenda forward, many of which are included in the Social Ecological Framework , which they use to define and navigate them. Individual, interpersonal, organizational, community and policy influences all need to be examined in context of understanding roles & values and establishing trust as an essential starting point. The functions of the various partners are assessed each year through an equity lens to ensure improvement in both processes and outcomes. This approach could be especially successful for programs that Public Health and Primary Care are already familiar with, such as smoking cessation and the 18-month well-baby assessment. Other opportunities will likely present themselves with the increasing organization of Primary Care, a new Public Health Agency of Canada performance management framework and the mandate of Health Quality Ontario.
Danielle Martin referred to a commentary she wrote in an issue of the Longwoods report earlier this year, in which she suggests that healthcare systems should be redesigned with public health professionals at the centre of regional planning and funding bodies. From that position, public health can lead the process of planning, tracking, evaluating and managing health system performance. She agreed that there are many areas where collaboration is possible, but worries that the focus on the organized portion of the Primary Care sector may be overstating the chances of real success. She noted that the great majority of Ontario is not served by the organized system, and this has the potential to create a significant health equity issue by not reaching sizeable vulnerable populations. She continued by suggesting that the Public Health Sector Strategic Plan, Make No Little Plans should not be the blueprint for Public Health; it should be the blueprint for health care period. She acknowledged that making Public Health the “central nervous system” would require some fundamental structural changes, but that initial steps could be taken through Health Links and by aligning the LHIN / PH Boundaries.
Jack McCarthy was asked to answer a question about difficult conversations, and how to recognize them. Using the recent reorganization of the Ottawa Board of Health as an example, he noted that the difficult conversations most often occur at the policy level, but are influenced by public attitudes (which are often mirrored in the decision makers). Specifically, he recalled that when Ottawa city council and its Board of Health were one and the same, councilors were undermining progress on innovative harm reduction programs. Thankfully the province recognized their importance and arranged to have some of them shifted to CHCs with direct Provincial funding. He guessed that Safe Injection Sites are the next frontier in this battle, a harm reduction intervention that is proven to work but remains intensely controversial. He suggested that as long as Boards of Health are autonomous and following their mandate of protecting community health, they are the most appropriate venues for such difficult conversations about healthy public policy. This is also where framing the issues need s to take place, to influence contrary and ill-informed public attitudes by making evidence and stories part of those conversations.
Responding to a question about whether or not municipalities should be in the business of governance of public health, Penny Sutcliffe stated that public health’s relationship with municipalities is actually one of its greatest strengths. It gives us an important and direct avenue of political engagement, which is usually substantive given that municipalities are ultimately responsible for paying the bill. They are essential partners in the work that needs to be done to protect communities, and can act as a venue to identify and engage with others.
She added that she will always question how much time and resources she is willing to put into partnerships with Primary Care when re-orienting the health care system requires attention to so many entities outside of the health care system, noting that relationships with local school boards are especially important. Michael Rachlis agreed, noting that the roots of health equity issues have little to do with the health care system itself. Social mobilization and dynamic community organizations are very important and the Primary Care system is not where this happens.
Penny Sutcliffe added that there needs to be intensity and deliberateness in the approaches used for this kind of work. When Sudbury became interested in health equity, the first step was to examine its own “silo” to ensure that its own processes and structures would allow it. With a clear answer, they were able to identify clear allies within the local CHCs. The next step will be an analysis of respective values, mandate, roles and responsibilities so that areas of focus and concrete collaborative actions can be developed. She then turned her attention to the much larger fee-for-service part of the Primary Care system, which is much more difficult to reach and work with. There is no single point of access and no collective mandate, which makes the development of partnerships, planning and action much more difficult and more resource-intensive. All the same, many of the people we need to reach are served here.
Kieran Moore suggested that the Ontario Medical Association might be an avenue to reach the fee-for-service sector, but also acknowledged that it does not yet have the accountability and CQI frameworks in place to serve as an impetus to team up with other partners within the system.
Michael Rachlis then asked if the best answer is to bring all fee-for service physicians into the organized system is the way to go. Jack McCarthy answered “yes” without hesitation, and remarked that he was surprised to learn that family doctors had no obligation to take direction from the local MOH when flu assessment centres were being set up to manage the 2009 H1N1 outbreak. Until they are accountable one way or another, the silos will be tough to break down. He also agreed that redrawing the LHIN boundaries to align with public health units will remove a major structural obstacle to planning for community health and the resources required to serve it.
Danielle Martin then observed that fee-for-service is just a payment model and needn’t be a major obstacle to changing the service-delivery one. She gave the example of the University Health Network’s Seamless Care Optimizing the Patient Experience (SCOPE) program, which offers a basket of services to groups of geographically related doctors. This in turn creates a collaborative team of existing physicians and other service providers, which is works toward to facilitating access to community resources and specialist care for high-needs patients who are most at risk of avoidable Emergency Department visits and hospitalizations.
She continued by sharing her doubts that expansions to Family Health Teams and CHCs are in the cards, so the question is really how to do more with what we have. We need to take the existing Teams and their resources to expand their reach. The fact right now is that even if everyone in the fee-for-service system was interested in a more organized approach, there isn’t a yet a model for them to walk into. Health Links may provide a start. Kieran Moore agreed with this, reporting that KFLA is at every Health Links table in its area, and it is working really well.
A challenge was then issued to the panel from the floor to shift the focus back to Public Health and the organized part of the Primary Care system that are in the room right now, with specific questions about Public Health’s capacity and mandate to do community-based planning, and about issues that can be tackled in partnership in the near term.
Penny Sutcliffe pointed out that competencies required for community-based planning certainly reside within Public Health, but the capacity to actually do it is another matter. Opportunity costs also need to be taken into account, which is something that Public Health continually has to struggle with when making decisions about what actions are going to have the greatest community health impact within its specific mandate. Danielle Martin added that while the conversation may have strayed a bit from the theme of the conference, we need to be cognizant of the risks of such a narrow focus on improving delivery of services at the expense of those who will not actually be served by these improvements.
LEARNING SESSIONS (C) 10:30 AM – 12:15 PM
A full list and summaries of the Conference Learning Sessions Is available here.
PLENARY IV: 1:30 – 3:30 PM
Champion for Public Health and Primary Health Care Award
Recipient: Dr. Hazel Stewart Director of Dental and Oral Health Services, Toronto Public Health
The Champion for Public Health and Primary Health Care Award honours an individual for significant leadership in advancing the relationship between primary health care and public health at system, managerial and/or frontline levels.
Hazel Stewart has served as the Director of Dental and Oral Health Services at Toronto Public Health for many years. She is a strong and effective advocate for the oral health care needs of vulnerable and marginalized people. For many years she has recognized the value of Community Health Centres in delivering oral health services to populations who face barriers accessing the services they need: people living on low incomes, newcomers, people with disabilities, LGBTQ and other populations experiencing barriers to health care.
Hazel’s leadership has led to partnerships between Toronto Public Health and a number of CHCs throughout the city. As a result, thousands of people are getting the services they need. They are not living with dental pain and their health is not compromised because they couldn’t afford to see a dentist working in a traditional practice.
Hazel was nominated for this award by Toronto’s Parkdale and Stonegate Community Health Centres, both of which serve vulnerable populations who face barriers in accessing health services. They say Hazel works like a steady stream that quietly cuts through bureaucratic bedrock to make the changes that need to happen.
She is also a tireless and outspoken advocate for the thousands of low-income people in Ontario who are left out of publicly funded programs. As a result of her advocacy and wise counsel, Parkdale CHC has developed a volunteer oral health program, together with George Brown’s College School of Dental Hygiene. This provides vital services to hundreds of people who would not have access otherwise. We commend Dr. Stewart for her many years of passionate commitment to this cause.
Dr. Hazel Stewart rose to accept her award, remarking that it is on behalf of all of the members of her advocacy group for their efforts despite challenges and resistance. She has been impressed by the passion and enthusiasm of her colleagues, whom she noted are not all within the health sector. She remarked as she looked out that she does not see doctors, nurses, trustees, advocates or even individuals. She sees the components of a system. Like a watch, there are many parts, each essential. When a watch is disassembled, there are parts placed on a table, and others around, under or near it. It is not until all the parts are put together that the jeweler will know the time. The expertise, parts and design for a better and more equitable health system are all there and they just need to be put together.
She concluded by observing that she has never met an individual whose lifelong ambition is to be sick. We all want individual and collective health, and until our parts are assembled and synchronized, we will never know the time. But the time is now: we know the system is not sustainable, and we know that we cannot pay more to treat more. We need to be objective and understanding, and maintain a desire to change with deliberate action and focus. We all know our roles. Our expertise and abilities say that we can do it. Our commitment says we must do it. .
Where Do We Go From Here?
Dr. Paul Roumeliotis reappeared to set the stage for the final discussions of the conference by offering his observations on themes and points of interest that have emerged over the past day-and-a- half.
First off, he noted that costs and resources have been a recurring theme in many of the discussions. He referred to a video that was created by his health unit for the Canadian Public Health Association entitled Public Health: a Return on Investment , which is designed to answer questions about what it costs to do something by asking what it would cost to not do something. The specific example of a proposed Guaranteed Annual Income was given, with the observation that its projected $12-13B cost should be more than justified when we know that we are spending twice that on the social supports required in its absence.
He continued with a reiteration of the value of outreach to the unorganized portion of the health care system. We need to start with identifying gaps, analyzing our resources and capacity, and see what we can reach. The importance of this comes from the concern that the primary focus of the Health System is on the 5% of people who use 70% of the resources. Our collective mission is to prevent the 95% from becoming the 5%, and we need to work with the whole system in order to achieve this.
Finally, he turned to the importance of persuasion and relationship-building. We do need to pay attention to economic arguments, evidence, personal stories and various other factors that speak to potential allies’ and decision makers’ values and roles. We also need to be aware of the various ways that roles, responsibilities and mandates create artificial boundaries that become perceived obstacles to meaningful partnerships and effective action.
With that, he initiated another DOTS survey, whose aim was to assess the extent to which delegates learned something new that they will be able to apply in practice and to tease out some priorities for next steps. 95% of participants answered the first question in the affirmative, and collectively identified a map of who’s doing what (30%), collection and sharing of data (23%) and developing a , shared mission statement (20%) as the top three contenders for near-term action.
Paul then invited Michael Rachlis and Rosana Pellizzari back to the stage to introduce the ideas that were pitched to them during lunch, and the people who proposed them:
1) Carol Timmings and Nicole Nitti, who are the Chronic Disease leads for Toronto Public Health and Toronto Central LHIN respectively, submitted the idea that leaders in Public Health and Primary Care should join together at tables to discuss various issues related to prevention and healthy living in our communities. The idea will be to propose actions with an ongoing focus on primary prevention, which is often not prominent enough in existing discussions. For a start, Carol and Nicole will co-lead a table to generate more specific ideas, and they will spend some time outside the room following this session to sign up interested volunteers.
2) Suzanne Schwenger from Health Nexus proposed to use its unique position as leaders in innovation, connection and collaboration for health promotion in Ontario to take snapshots of what’s already working – they have new technologies to take those snapshots – GIS mapping, social media mapping etc. Health Nexus be a valuable a bridge organization linking public health and primary care and as a vehicle to take key messages to new audiences and decision-makers. She invited participation far and wide.
3) Leah Stephenson from AOHC shared the high points of what she learned at the conference, through its impressive array of topics, hearing from distinct populations, and learning more about the determinants of the health. She was particularly struck by the KFLA research partnership that demonstrated that Primary Care is so inaccessible in the areas of highest deprivation, which forces the use of ERs to manage health issues at much higher cost. Still, she observed that even in these areas, there are geographic and cultural assets, sub-communities, and gathering places. These are the entry points for community engagement and gathering the data & stories required to assess health needs and then address them.
4) Vera Etches from Ottawa Public Health referred to the Collaborative Relations between Public Health Units and the Aboriginal Community session she attended, in which she noted the varying levels of success in elevating such efforts into strategic plans. There was great interest in building relationships with other stakeholders, including some from outside of the health system, to reinforce the commitment to doing so. By bringing interested voices to the table, we will be better able to identify gaps and develop effective actions.
5) Andrew Pinto from St. Michael’s Hospital described an initiative there that is meant to bring an income security lens to acute care. A full-time income security health promoter has been hired to focus on interventions to assist low income clients of the St. Michael’s Family Health Team to improve their income and reduce the health impacts of living at low income. He remarked that this is a small step forward on the issue of poverty, which requires interventions from the individual to the provincial level and points between. His idea is that as a start, this model could be replicated elsewhere and serve as the source of the powerful stories about people who have material needs.
6) Lynn Beath, Director of Oxford County’s Public Health & Emergency Services recounted her experience at last year’s AOHC conference, during which she observed a similar passion for health and wellbeing to that of Public Health. She also learned about the application of the Canadian Index of Health and Wellbeing in Guelph as a guiding framework for its broader Community Wellbeing Initiative, which prompted her to explore replicating it in Woodstock and the County. She and Cate Melito continue to build on the success of this over the past year, which has seen a significant growth in local partnerships that will formulate specific actions. She urged others to do likewise, characterizing the CIW as a great model that uses language that resonates with health care and non-health care partners alike.
7) Jacquie Maund, AOHC’s Policy & Government Relations Lead raised the issues of access to pharmaceuticals and dental care. With 23% of Ontarians facing barriers to the former and 25% to the latter, we have already identified two areas of health where converted advocacy efforts could have a huge impact. She encouraged delegates to take what they have learned about building partnerships and effective advocacy strategies and return to their communities to engage health & social services providers, as well as community members themselves on these issues. We need to gather data, present the evidence and tell the stories of the people who are directly affected. Put together, this could be a very effective way of bringing two important health issues into the public eye through media, and in turn into the consciousness of the decision-makers.
8) Ruta Valaitis from McMaster University referred to her research on Strengthening Primary Health Care through Primary Care and Public Health Collaboration, which includes the Ecological Framework that was referred to above. She remarked that it is critical to have front-line people on research teams as well, many of whom occupy seats in this room. She noted lots of alignment of themes from this conference with those of the framework, and suggested that more clarity about this could be achieved through focused and mandatory introductory courses on Public Health and Primary Care next time around. This will augment mutual understanding and trust, clarify roles, responsibilities and mandates, and lay the foundations for action.
9) Bill Bisset from the Gateway CHC suggested that there would be great value in building bridges between local Boards of Health and those of CHCs to have discussions about how collaborating might serve their respective missions. He added his voice to those who have identified the CIW as an excellent foundation for what we’re trying to accomplish.
In closing, Rosana Pellizzari noted that what resonated with her throughout this event was the history that we share, indicating that Public Health was instrumental in the development of Community Health Centres, and has also been active in the creation of Family Health Teams in some areas. In some ways, she saw the conference as a celebration of that history and a reminder that CHCs and Public Health Units have the same aptitudes for health promotion and addressing the social determinants of health.
Michael Rachlis’ closing observations included the following:
1) Using the example of how Indigenous peoples are too often not represented on the boards and agencies that represent them or make decisions about them, he encouraged delegates to use their privilege to make the invisible visible.
2) He referred to several reports – The Health Planning Task Force Report by Dr. Fraser Mustard (1974), the Lalonde Report (also 1974) and Tommy Douglas’s original vision for our public health care system – to illustrate that the ideas that are being generated by the participants in this event are not new. He pointed out that Tommy Douglas’s idea was not simply to introduce the single-payer model, but also to orient the system’s focus on wellbeing. He remarked that fee-for-service physicians don’t see it that way, so population-based, upstream health needs don’t get addressed. He agreed that these providers need to be brought into the organized system and subject to some form of accountability. In addition, the Ontario Medical Association wields enormous influence on setting Ontario’s health policy, which leaves little room for those focused on population health and wellbeing at the table.
3) The concept of Better Together: reinforcing the importance of the existing links with municipalities, health sector partners, education, community-based organizations and so on is essential. Public health cannot achieve its goals on its own, will be aided by complementary and collaborative actions from like-minded organizations.
Rosana agreed with this, and reiterated that we are all on the same team despite our differences. We share a vision and it is up to us to fuel a wider understanding of that vision. We have a responsibility to be advocates from the place our feet are firmly planted, and we know we can succeed. She referred to the the 25 in 5 poverty reduction campaign as an example of this success, where a huge mobilization of partners and a consistent and powerful set of messages got one of our key issues onto the political agenda.
She concluded by referring to the 2012 Institute of Medicine report, Primary Care and Public Health: Exploring Integration to Improve Population Health, which outlines five principles to help primary care and public health groups work together. These include:
· A shared goal of population health
· Aligned leadership
· Community engagement
· Sharing and collaborative use of data and analysis
These principles will allow us to navigate the complex systems in which we do our work, and to seize opportunities when they arise. In closing, she remarked that nothing great was ever achieved without enthusiasm.