From HEALTH CAREHEALTH CARE to systems for HEALTHHEALTH:

Family Practice Nurses are key ……

Ontario Family Practice Ontario Family Practice Nurses ConferenceNurses Conference

Carolyn Bennett M.D.,M.P.Carolyn Bennett M.D.,M.P.OttawaOttawa

What’s a Doc Like Me Doing in a Place Like What’s a Doc Like Me Doing in a Place Like Parliament Hill? –Parliament Hill? –

the evolution of an MD/MPthe evolution of an MD/MP

Fight for Women’s College HospitalFight for Women’s College Hospital 1995 – candidate provincial election1995 – candidate provincial election ““Doctor on Call”Doctor on Call” 1997 M.P.1997 M.P.

Empowered Empowered patientspatients

Effective Effective advocatesadvocates

Engaged citizensEngaged citizens

Women’s health movementWomen’s health movement

= Social determinants of health= Social determinants of health

PovertyPoverty EnvironmentEnvironment ViolenceViolence EquityEquity EducationEducation ShelterShelter

Women’s College Women’s College HospitalHospital

Patient as PartnerPatient as Partner Doctor MultidisciplinaryDoctor Multidisciplinary Hospital CommunityHospital Community

Same job !!Same job !!

Ask people what’s wrong & listenAsk people what’s wrong & listen

Opening a chart and helping people Opening a chart and helping people through a systemthrough a system

Very few issues of public policy that Very few issues of public policy that haven’t been through our officehaven’t been through our office

Patient as PartnerPatient as PartnerCitizens and Elected Citizens and Elected

RepresentativeRepresentative

Patient knows body bestPatient knows body best I knew the system best…together we I knew the system best…together we

could navigate a pathcould navigate a path

Citizens know ‘what’s working and Citizens know ‘what’s working and what’s not’what’s not’

My role as an MP … “bottom up”My role as an MP … “bottom up”

Sir Michael MarmotSir Michael MarmotChair, WHO Commission on Social Determinants of HealthChair, WHO Commission on Social Determinants of Health

““The worst thing for a physician is to The worst thing for a physician is to help someone get well and then send help someone get well and then send them straight back into the situation them straight back into the situation that made them sick in the first that made them sick in the first place”place”

Health OR Health CAREHealth OR Health CARE

HealthHealth is a state of complete physical, is a state of complete physical, mental and social well-being and not mental and social well-being and not merely the absence of disease or infirmity. merely the absence of disease or infirmity. (WHO 1948)(WHO 1948)

  Health Health Care - Care - The prevention, treatment, The prevention, treatment, and management of illness and the and management of illness and the preservation of mental and physical well-preservation of mental and physical well-being through the services offered by the being through the services offered by the medical and allied health professions. medical and allied health professions.

““Reorienting health systems”Reorienting health systems”

FROMFROM

a health a health CARECARE system system

TOTO

a true system for a true system for HEALTHHEALTH

Canadian Institute for Advanced Research

• 25% health attributable to health care system

• 15% biology and genetics• 10% physical environment• 50% social and economic environments

Humbling realityHumbling reality

The health of our population cannot The health of our population cannot be the sole responsibility of the be the sole responsibility of the Ministry of Health and the health Ministry of Health and the health care sector.care sector.

Canadian legacyCanadian legacy

Tommy Douglas… Father of MedicareTommy Douglas… Father of Medicare Lalonde Report 1974Lalonde Report 1974 Ottawa Charter 1986Ottawa Charter 1986 SARS, Naylor Report 2003SARS, Naylor Report 2003 WHO Commission SDOH 2005 WHO Commission SDOH 2005 Health Goals for Canada 2005Health Goals for Canada 2005

Goal of Medicare… Goal of Medicare… Tommy DouglasTommy Douglas

Sharing riskSharing risk• getting people the health care they getting people the health care they

need when they need itneed when they need it

Keeping people well not just Keeping people well not just patching them up once they get patching them up once they get sicksick

Lalonde Report (1974)Lalonde Report (1974)

The Government of Canada, in cooperation The Government of Canada, in cooperation with others, will pursue with others, will pursue two broad two broad objectivesobjectives::

1. 1. To reduce mental and physical health To reduce mental and physical health hazards hazards for those parts of the Canadian for those parts of the Canadian population whose risks are high, andpopulation whose risks are high, and

2. 2. To improve the accessibility To improve the accessibility of good of good mental and physical health care for those mental and physical health care for those whose present access is unsatisfactory.whose present access is unsatisfactory.

In pursuit of these two objectives, In pursuit of these two objectives, five strategies five strategies are proposed:are proposed:

1. A 1. A Health Promotion StrategyHealth Promotion Strategy 2. A 2. A Regulatory StrategyRegulatory Strategy 3. A 3. A Research StrategyResearch Strategy 4. A 4. A Health Care Efficiency StrategyHealth Care Efficiency Strategy 5. A 5. A Goal-Setting StrategyGoal-Setting Strategy

Ottawa Charter for Health Ottawa Charter for Health Promotion (1986Promotion (1986))

The participants in this Conference The participants in this Conference pledge:pledge:

1. to move into the arena of healthy 1. to move into the arena of healthy public policy, and to advocate a clear public policy, and to advocate a clear political commitment to health and political commitment to health and equity in all sectors;equity in all sectors;

Ottawa Charter for Health Ottawa Charter for Health Promotion (1986Promotion (1986))

2. to counteract the pressures 2. to counteract the pressures towards harmful products, resource towards harmful products, resource depletion, unhealthy living conditions depletion, unhealthy living conditions and environments, and bad nutrition; and environments, and bad nutrition; and to focus attention on public and to focus attention on public health issues such as pollution, health issues such as pollution, occupational hazards, housing and occupational hazards, housing and settlements;settlements;

Ottawa Charter for Health Ottawa Charter for Health Promotion (1986Promotion (1986))

3. to respond to the health gap within 3. to respond to the health gap within and between societies, and to tackle and between societies, and to tackle the inequities in health produced by the inequities in health produced by the rules and practices of these the rules and practices of these societies;societies;

Ottawa Charter for Health Ottawa Charter for Health Promotion (1986Promotion (1986))

4. to acknowledge people as the main 4. to acknowledge people as the main health resource; to support and health resource; to support and enable them to keep themselves, enable them to keep themselves, their families and friends healthy their families and friends healthy through financial and other means, through financial and other means, and to accept the community as the and to accept the community as the essential voice in matters of its essential voice in matters of its health, living conditions and well-health, living conditions and well-being;being;

Ottawa Charter for Health Ottawa Charter for Health Promotion (1986Promotion (1986))

5. to reorient health services and their 5. to reorient health services and their resources towards the promotion of resources towards the promotion of health; and to share power with health; and to share power with other sectors, other disciplines and, other sectors, other disciplines and, most importantly, with people most importantly, with people themselves;themselves;

Ottawa Charter for Health Ottawa Charter for Health Promotion (1986Promotion (1986))

6. to recognize health and its 6. to recognize health and its maintenance as a major social maintenance as a major social investment and challenge; and to investment and challenge; and to address the overall ecological issue address the overall ecological issue of our ways of living.of our ways of living.

FantasyFantasy

The Em The Em PHAPHA sis sis

is on the wrong is on the wrong

syl syl LABLAB le le

Fleeing the Medical Model,Fleeing the Medical Model,Embracing the Medicine WheelEmbracing the Medicine Wheel

Blame Hippocrates?Blame Hippocrates?

Affirm Hygeia

HYGEIA: Goddess of Health

Learnings…..Learnings…..

CubaCuba Chile … President LagosChile … President Lagos Vietnam…. VSFVietnam…. VSF Thailand… the Xray system..Thailand… the Xray system..

From

Health CARECARE to

Systems for HEALTHHEALTH

Health CARE Magnetic North Pole

We need a strong opposing force for

HEALTHHEALTH

We need

EmpoweredEmpowered CitizensCitizens

Empowered Citizens

HEALTH

Health Care Health CARE

Empowered Citizens

HEALTH

Romanow ReportRomanow Report

Discussion paper # 8 Discussion paper # 8 • Zimmerman & GloubermanZimmerman & Glouberman• Complex Adaptive SystemsComplex Adaptive Systems• HIV/Aids Brazil vs AfricaHIV/Aids Brazil vs Africa

Complexity TheoryComplexity Theory

SimpleSimple

ComplicatedComplicated

ComplexComplex

The solutions are complexThe solutions are complex

For every complex human problem, For every complex human problem, there is a neat simple solution, it’s there is a neat simple solution, it’s just that it’s wrong… just that it’s wrong…

HL MenckenHL Mencken

Complex doesn’t fit Complex doesn’t fit into a 7 second sound bite…..into a 7 second sound bite…..

or on a bumper stickeror on a bumper sticker

We must fiercely defend the complex We must fiercely defend the complex solutions for the complex problems ..solutions for the complex problems ..

BUT……we need simpler messagesBUT……we need simpler messages

Citizens have to ‘get it’Citizens have to ‘get it’

More health …less health careMore health …less health care

Service contract ??????Service contract ?????? Or longer warranty ????Or longer warranty ????

The Tyranny of the AcuteThe Tyranny of the Acute

As long as citizens think of the As long as citizens think of the sicknesssickness care system whenever care system whenever they hear the word they hear the word ‘health’‘health’ we are we are not going to be able to reorient not going to be able to reorient health systems.health systems.

““Health is Politics”Health is Politics”

“ “ If you want to move healthy public If you want to move healthy public policies forward, you have to have policies forward, you have to have political dynamite ”

Dr. Halfan MahlerDr. Halfan Mahler

HOWEVER……HOWEVER……

Public policy usually follows public Public policy usually follows public opinion….opinion….

BECAUSE…….BECAUSE…….

Doing the right thing is very Doing the right thing is very difficult is the people aren’t onside…difficult is the people aren’t onside…

• ““Father knows best” not great politicsFather knows best” not great politics

Political Will Political Will to do the right thingto do the right thing

Dramatically improves with an Dramatically improves with an educated public…… educated public…… health literacyhealth literacy

Citizens pulling healthy public Citizens pulling healthy public policy…. policy…. Civic efficacyCivic efficacy

Health Literacy QuizHealth Literacy Quizversion 1version 1

‘ ‘surveillance’ surveillance’

‘ ‘Accessibility’Accessibility’

Chronic Disease managementChronic Disease management

Primary Care … provider, settingPrimary Care … provider, setting

“What we have here is a failure to communicate”

Cool Hand Luke 1967

Health Literacy QuizHealth Literacy Quizversion 2version 2

Empowerment Pulling Healthy Public Policy

Putting the Public back into Public Health

Public Health 101 Public Health 101

1.Do you think we should have a:1.Do you think we should have a:

A) strong fence at the top of the cliffA) strong fence at the top of the cliff

B) state of the art fleet of ambulances B) state of the art fleet of ambulances and paramedics waiting at the and paramedics waiting at the bottom ? bottom ?

2. Would you prefer:2. Would you prefer:

A) Clean airA) Clean air

B) Enough puffers and respirators B) Enough puffers and respirators

for all for all

3. Would you prefer that wait-times 3. Would you prefer that wait-times were reduced by:were reduced by:

A) a falls program to reduce A) a falls program to reduce preventable hip fracturespreventable hip fractures

B) private orthopaedic hospitals and B) private orthopaedic hospitals and more surgeonsmore surgeons

4.Should we invest in:4.Should we invest in:

A) early learning, child care, A) early learning, child care, literacy,the early identification of literacy,the early identification of learning disabilities and bullying learning disabilities and bullying programmesprogrammes

B) increase the budget for young B) increase the budget for young offenders’ incarcerationoffenders’ incarceration

5.Should we:5.Should we:

A) assume that the 'grey tsunami' will A) assume that the 'grey tsunami' will bankrupt our health care system bankrupt our health care system

B) include our aging population in the B) include our aging population in the planning of strategies to keep them planning of strategies to keep them wellwell

6. Is the best approach to food 6. Is the best approach to food security:security:

A) food banks and vouchersA) food banks and vouchers

B) Income security,affordable housing, B) Income security,affordable housing, community gardens and community community gardens and community kitchens and a national food policykitchens and a national food policy

7. Pick the one that is NOT correct7. Pick the one that is NOT correct

Pandemic Preparedness should focus onPandemic Preparedness should focus on

A)A) Tamiflu for allTamiflu for all

B)B) Working with the vets to keep avian flu a Working with the vets to keep avian flu a disease of birdsdisease of birds

C)C) Making sure people wash their hands Making sure people wash their hands especially the doctors and nursesespecially the doctors and nurses

D)D) Research on vaccinesResearch on vaccines

E)E) Community care plans for our most Community care plans for our most vulnerablevulnerable

8.Governments should boast about:8.Governments should boast about:

A)A) how much they spent on the how much they spent on the sickness care system sickness care system

B)B) the health of their citizens, leaving the health of their citizens, leaving no-one behindno-one behind

teachable momentsteachable moments

20032003• Canada… 44 died of SARSCanada… 44 died of SARS• France…14,000 died in the heat waveFrance…14,000 died in the heat wave

2005..2005..Katrina, KasheshewanKatrina, Kasheshewan

Beyond borders…. Beyond borders…. SARS as a teachable momentSARS as a teachable moment

Beyond silos Beyond silos • DepartmentsDepartments• DisciplinesDisciplines

Beyond jurisdictional squabblingBeyond jurisdictional squabbling

Germs don’t respect bordersGerms don’t respect borders

Neither do the social contagionsNeither do the social contagions Nor the humanitarian imperativesNor the humanitarian imperatives

Social Determinants of HealthSocial Determinants of Health

vs vs

Choose HealthChoose Health(modifiable risks)(modifiable risks)

The Causes of the The Causes of the CausesCauses

VersusVersus

The CausesThe Causes

Evolution of the Healthy Canadians TreeEvolution of the Healthy Canadians Tree

CommuniquéCommuniquéFMM September 2004FMM September 2004

““In addition, governments commit to In addition, governments commit to accelerate work on a pan-Canadian accelerate work on a pan-Canadian Public Health StrategyPublic Health Strategy. For the first . For the first time, governments will set time, governments will set goals and goals and targetstargets for improving the health for improving the health status of Canadians through a status of Canadians through a collaborative process with experts. collaborative process with experts.

ProgressProgress

First MoS Public Health 2003-2006First MoS Public Health 2003-2006 Public Health Agency of CanadaPublic Health Agency of Canada Chief Public Health OfficerChief Public Health Officer Public Health Network for CanadaPublic Health Network for Canada Health GoalsHealth Goals National Collaborating CentresNational Collaborating Centres Knowledge Networks for the SDOH Knowledge Networks for the SDOH

CommissionCommission

Health Goals for CanadaHealth Goals for Canada

As a nation, we aspire to a Canada in which As a nation, we aspire to a Canada in which

every person is as healthy as they can be every person is as healthy as they can be – physically, mentally, emotionally and – physically, mentally, emotionally and spiritually.spiritually.

Changing the way we do things..Changing the way we do things..

MeasurementMeasurement ProcessProcess StructureStructure PeoplePeople ResearchResearch

Better DataBetter Data

E-RxE-Rx Dx and RxDx and Rx Birth defects, injuries, diseases etcBirth defects, injuries, diseases etc Incentives for reportingIncentives for reporting

““The mobilization of shame”The mobilization of shame”Irwin CotlerIrwin Cotler

Management 101

“If it’s measured it gets noticed, if it’s noticed it gets done”

With the Public Health Map Generator, you can produce high quality, detailed maps of your own health data, in combination with extensive geography from our spatial data warehouse…

GIS User

*******

The Public Health Map Generator is a secure, web-based mapping application, accessible only to clients registered with the GIS Infrastructure at the Public Health Agency of Canada. All of the Infrastructure’s

services, including the Public Health Map Generator, are available at no cost to all public health professionals in Canada.

Scotland – Honourable Andy KerrScotland – Honourable Andy Kerr

Health outcomes down to postal codeHealth outcomes down to postal code Letter from Family DoctorLetter from Family Doctor InterventionsInterventions Already paying offAlready paying off

Process ….Health in all PoliciesProcess ….Health in all Policies

Article 54 in PQArticle 54 in PQ HIA…. All MC’s , budget, TB HIA…. All MC’s , budget, TB

guidelinesguidelines Citizen EngagementCitizen Engagement

Structure Structure Gridlock Gridlock

horizontal – departmentshorizontal – departments vertical - jurisdiction vertical - jurisdiction

StructureStructureSilo- busting - HorizontalitySilo- busting - Horizontality

• Ministries or Ministers Ministries or Ministers

• Cabinet committees Cabinet committees

• ParliamentParliament

• Officers of Parliament - Commissioners Officers of Parliament - Commissioners

StructureStructure

Jurisdictional squabbleJurisdictional squabble

• SARS …. Naylor report..SARS …. Naylor report.. CollaborationCollaboration CooperationCooperation CommunicationCommunication Clarity of who does, what, whenClarity of who does, what, when

PeoplePeople

Need to attract ‘generalists’Need to attract ‘generalists’ Interdisciplinary careInterdisciplinary care Scope of Practice replaced by Scope of Practice replaced by

Core CompetenciesCore Competencies Self-careSelf-care

HHR TrainingHHR Training

InterdisciplinaryInterdisciplinary Social ResponsibilitySocial Responsibility Cultural SensitivityCultural Sensitivity Social Determinants of HealthSocial Determinants of Health PUBLIC HEALTHPUBLIC HEALTH

Family Practice role in Family Practice role in Public Health – Getting credit !!!Public Health – Getting credit !!!

Health promotionHealth promotion Disease and injury preventionDisease and injury prevention Health literacyHealth literacy Link community, hospitalsLink community, hospitals Mental HealthMental Health AddictionsAddictions Chronic Disease Mgt.Chronic Disease Mgt. Self careSelf care

Research….Learning CultureResearch….Learning Culture

Evidence-informed practiceEvidence-informed practice Practice-informed evidencePractice-informed evidence

Courage to fund what worksCourage to fund what works Courage to stop funding what doesn`tCourage to stop funding what doesn`t

Complex adaptive systems…Complex adaptive systems…

Sir Michael MarmotSir Michael Marmot

““Evidence is not enough. There has to Evidence is not enough. There has to be the desire, the political will for be the desire, the political will for change. Given that will - a big given change. Given that will - a big given but I am an optimist - the evidence of but I am an optimist - the evidence of what works will be a great help.”what works will be a great help.”

No time for pessimists

Research

Practice Policy

Research

Practice Policy

KT

Research

Practice Policy

KT

Political will

Research

Practice Policy

KT

Political will

Appliedresearch

Research

Practice Policy

Engaged citizens

KT

Political will

Appliedresearch

Empowered Citizens

Systems for Systems for HEALTHHEALTH

HealthCare

Systems for

HEALTH

M.D.M.D.

“ “We are not tinkers, who patch and We are not tinkers, who patch and mend what is broken. We must be mend what is broken. We must be watchmen, guardians of the life and watchmen, guardians of the life and health of our generation, so that health of our generation, so that stronger and more able generations stronger and more able generations may come after.”may come after.” Dr. Elizabeth Blackwell Dr. Elizabeth Blackwell

first woman physician first woman physician

Wanless Report UK 2003Wanless Report UK 2003commissisoned bycommissisoned by Gordon Brown Gordon Brown