From HEALTH CARE to
systems for HEALTH:
Family Practice Nurses are key ……
Ontario Family Practice
Nurses Conference
Carolyn Bennett M.D.,M.P.
Ottawa
What’s a Doc Like Me Doing in a Place Like
Parliament Hill? –
the evolution of an MD/MP
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Fight for Women’s College Hospital
1995 – candidate provincial election
“Doctor on Call”
1997 M.P.
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Empowered
patients
Effective
advocates
Engaged citizens
Women’s health movement
= Social determinants of health
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Poverty
Environment
Violence
Equity
Education
Shelter
Women’s College
Hospital
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Patient as Partner
Doctor
Multidisciplinary
Hospital
Community
Same job !!
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Ask people what’s wrong & listen
Opening a chart and helping people
through a system
Very few issues of public policy that
haven’t been through our office
Patient as Partner
Citizens and Elected
Representative
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Patient knows body best
I knew the system best…together we
could navigate a path
Citizens know ‘what’s working and
what’s not’
My role as an MP … “bottom up”
Sir Michael Marmot
Chair, WHO Commission on Social Determinants of Health
“The worst thing for a physician is to
help someone get well and then send
them straight back into the situation
that made them sick in the first
place”
Health OR Health CARE
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Health is a state of complete physical,
mental and social well-being and not
merely the absence of disease or infirmity.
(WHO 1948)
Health Care - The prevention,
treatment, and management of illness and
the preservation of mental and physical
well-being through the services offered by
the medical and allied health professions.
“Reorienting health systems”
FROM
a health CARE system
TO
a true system for HEALTH
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 reality
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The health of our population cannot
be the sole responsibility of the
Ministry of Health and the health
care sector.
Canadian legacy
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Tommy Douglas… Father of Medicare
Lalonde Report 1974
Ottawa Charter 1986
SARS, Naylor Report 2003
WHO Commission SDOH 2005
Health Goals for Canada 2005
Goal of Medicare…
Tommy Douglas
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Sharing risk
• getting people the health care they need
when they need it
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Keeping people well not just
patching them up once they get
sick
Lalonde Report (1974)
The Government of Canada, in cooperation
with others, will pursue two broad
objectives:
 1. To reduce mental and physical health
hazards for those parts of the Canadian
population whose risks are high, and
 2. To improve the accessibility of good
mental and physical health care for those
whose present access is unsatisfactory.
In pursuit of these two objectives,
five strategies are proposed:
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1.
2.
3.
4.
5.
A
A
A
A
A
Health Promotion Strategy
Regulatory Strategy
Research Strategy
Health Care Efficiency Strategy
Goal-Setting Strategy
Ottawa Charter for Health
Promotion (1986)
The participants in this Conference
pledge:
1. to move into the arena of healthy
public policy, and to advocate a clear
political commitment to health and
equity in all sectors;
Ottawa Charter for Health
Promotion (1986)
2. to counteract the pressures
towards harmful products, resource
depletion, unhealthy living conditions
and environments, and bad nutrition;
and to focus attention on public
health issues such as pollution,
occupational hazards, housing and
settlements;
Ottawa Charter for Health
Promotion (1986)
3. to respond to the health gap within
and between societies, and to tackle
the inequities in health produced by
the rules and practices of these
societies;
Ottawa Charter for Health
Promotion (1986)
4. to acknowledge people as the main
health resource; to support and
enable them to keep themselves,
their families and friends healthy
through financial and other means,
and to accept the community as the
essential voice in matters of its
health, living conditions and wellbeing;
Ottawa Charter for Health
Promotion (1986)
5. to reorient health services and their
resources towards the promotion of
health; and to share power with
other sectors, other disciplines and,
most importantly, with people
themselves;
Ottawa Charter for Health
Promotion (1986)
6. to recognize health and its
maintenance as a major social
investment and challenge; and to
address the overall ecological issue
of our ways of living.
Fantasy
The Em PHA sis
is on the wrong
syl LAB le
Fleeing the Medical Model,
Embracing the Medicine Wheel
Blame Hippocrates?
Affirm Hygeia
HYGEIA:
Goddess of Health
Learnings…..
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Cuba
Chile … President Lagos
Vietnam…. VSF
Thailand… the Xray system..
From
Health CARE
to
Systems for HEALTH
Health CARE
Magnetic North Pole
We need a strong opposing force for
HEALTH
We need
Empowered
Citizens
Health CARE
Empowered
Citizens
HEALTH
Empowered
Citizens
HEALTH
Romanow Report
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Discussion paper # 8
• Zimmerman & Glouberman
• Complex Adaptive Systems
• HIV/Aids Brazil vs Africa
Complexity Theory
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Simple
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Complicated
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Complex
The solutions are complex
For every complex human problem,
there is a neat simple solution, it’s
just that it’s wrong…
HL Mencken
Complex doesn’t fit
into a 7 second sound bite…..
or on a bumper sticker
We must fiercely defend the complex
solutions for the complex problems ..
BUT……we need simpler messages
Citizens have to ‘get it’
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More health …less health care
Service contract ??????
Or longer warranty ????
The Tyranny of the Acute
As long as citizens think of the
sickness care system whenever
they hear the word ‘health’ we are
not going to be able to reorient
health systems.
“Health
is Politics”
“ If you want to move healthy public
policies forward, you have to have
political dynamite ”
Dr. Halfan Mahler
HOWEVER……
Public policy usually follows public
opinion….
BECAUSE…….
Doing the right thing is very
difficult is the people aren’t onside…
• “Father knows best” not great politics
Political Will
to do the right thing
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Dramatically improves with an
educated public…… health literacy
Citizens pulling healthy public
policy…. Civic efficacy
Health Literacy Quiz
version 1
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‘surveillance’
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‘Accessibility’
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Chronic Disease management
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Primary Care … provider, setting
“What we have here is a failure to communicate”
Cool Hand Luke 1967
Health Literacy Quiz
version 2
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Empowerment
Pulling
Healthy Public Policy
Putting the Public back into Public Health
Public Health 101
1.Do you think we should have a:
A) strong fence at the top of the cliff
B) state of the art fleet of ambulances
and paramedics waiting at the
bottom ?
2. Would you prefer:
A) Clean air
B) Enough puffers and respirators
for all
3. Would you prefer that wait-times
were reduced by:
A) a falls program to reduce
preventable hip fractures
B) private orthopaedic hospitals and
more surgeons
4.Should we invest in:
A) early learning, child care,
literacy,the early identification of
learning disabilities and bullying
programmes
B) increase the budget for young
offenders’ incarceration
5.Should we:
A) assume that the 'grey tsunami'
will bankrupt our health care
system
B) include our aging population in the
planning of strategies to keep them
well
6. Is the best approach to food
security:
A) food banks and vouchers
B) Income security,affordable housing,
community gardens and community
kitchens and a national food policy
7. Pick the one that is NOT correct
Pandemic Preparedness should focus on
A)
Tamiflu for all
B)
Working with the vets to keep avian flu a
disease of birds
C)
Making sure people wash their hands
especially the doctors and nurses
D)
Research on vaccines
E)
Community care plans for our most
vulnerable
8.Governments should boast
about:
A)
B)
how much they spent on the
sickness care system
the health of their citizens, leaving
no-one behind
teachable moments
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2003
• Canada… 44 died of SARS
• France…14,000 died in the heat wave
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2005..Katrina, Kasheshewan
Beyond borders….
SARS as a teachable moment
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Beyond silos
• Departments
• Disciplines
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Beyond jurisdictional squabbling
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Germs don’t respect borders
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Neither do the social contagions
Nor the humanitarian imperatives
Social Determinants of Health
vs
Choose Health
(modifiable risks)
The Causes of the
Causes
Versus
The Causes
Evolution of the Healthy Canadians Tree
Communiqué
FMM September 2004
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“In addition, governments commit to
accelerate work on a pan-Canadian
Public Health Strategy. For the first
time, governments will set goals and
targets for improving the health
status of Canadians through a
collaborative process with experts.
Progress
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First MoS Public Health 2003-2006
Public Health Agency of Canada
Chief Public Health Officer
Public Health Network for Canada
Health Goals
National Collaborating Centres
Knowledge Networks for the SDOH
Commission
Health Goals for Canada
As a nation, we aspire to a Canada in which
every person is as healthy as they can be
– physically, mentally, emotionally and
spiritually.
Changing the way we do things..
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Measurement
Process
Structure
People
Research
Better Data
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E-Rx
Dx and Rx
Birth defects, injuries, diseases etc
Incentives for reporting
“The mobilization of shame”
Irwin 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…
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.
GIS User
*******
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 Kerr
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Health outcomes down to postal code
Letter from Family Doctor
Interventions
Already paying off
Process ….Health in all Policies
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Article 54 in PQ
HIA…. All MC’s , budget, TB
guidelines
Citizen Engagement
Structure
Gridlock
horizontal – departments
vertical - jurisdiction
Structure
Silo- busting - Horizontality
• Ministries or Ministers
• Cabinet committees
• Parliament
• Officers of Parliament - Commissioners
Structure
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Jurisdictional squabble
• SARS …. Naylor report..
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Collaboration
Cooperation
Communication
Clarity of who does, what, when
People
Need to attract ‘generalists’
 Interdisciplinary care
 Scope of Practice replaced by
Core Competencies
 Self-care
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HHR Training
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Interdisciplinary
Social Responsibility
Cultural Sensitivity
Social Determinants of Health
PUBLIC HEALTH
Family Practice role in
Public Health – Getting credit !!!
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Health promotion
Disease and injury prevention
Health literacy
Link community, hospitals
Mental Health
Addictions
Chronic Disease Mgt.
Self care
Research….Learning Culture
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Evidence-informed practice
Practice-informed evidence
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Courage to fund what works
Courage to stop funding what doesn`t
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Complex adaptive systems…
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Sir Michael Marmot
“Evidence is not enough. There has to
be the desire, the political will for
change. Given that will - a big given
but I am an optimist - the evidence
of what works will be a great help.”
No time for pessimists
Research
Practice
Policy
Research
KT
Practice
Policy
Research
KT
Practice
Policy
Political will
Applied
research
Practice
Research
KT
Policy
Political will
Engaged citizens
Applied
research
Practice
Research
KT
Policy
Political will
Health
Care
Empowered
Citizens
Systems for
Systems
for
HEALTH
HEALTH
M.D.
“We are not tinkers, who patch and
mend what is broken. We must be
watchmen, guardians of the life and
health of our generation, so that
stronger and more able generations
may come after.” Dr. Elizabeth Blackwell
first woman physician
Wanless Report UK 2003
commissisoned by Gordon Brown