Rural Health Forum - Rural Health Forum - State of Healthcare in Rural Ontario: State of Healthcare in Rural Ontario:

Setting the StageSetting the Stage

November 5, 2009November 5, 2009

Hon. Carolyn Bennett, M.D., M.P.Hon. Carolyn Bennett, M.D., M.P.

Rural Health in Rural HandsRural Health in Rural HandsStrategic Directions for Rural, Remote, Northern and Aboriginal CommunitiesStrategic Directions for Rural, Remote, Northern and Aboriginal Communities

2002 2002

Building Healthy CommunitiesBuilding Healthy Communities Infrastructure for Community Capacity-Infrastructure for Community Capacity-

buildingbuilding Intersectoral CollaborationIntersectoral Collaboration Rural Health ResearchRural Health Research Health Information TechnologyHealth Information Technology Health Human ResourcesHealth Human Resources Aboriginal HealthAboriginal Health

Canadian legacy: Canadian legacy: HEALTH trumps health CAREHEALTH trumps health CARE

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 need when they getting people the health care they need when they

need itneed it

Keeping people well not just patching them Keeping people well not just patching them up once they get sickup once they get sick

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 care system whenever they hear the word system whenever they hear the word ‘health’‘health’ we are not going to be able to reorient health we are not going to be able to reorient health systems.systems.

Canadian Institute for Advanced Research

25% health attributable to health care system 15% biology and genetics 10% physical environment 50% social and economic environments

Process ….Process ….

‘‘Health in all Policies” - FinlandHealth in all Policies” - Finland Article 54 in PQArticle 54 in PQ Health Impact AnalysisHealth Impact Analysis

All MC’s , budget, TB guidelinesAll MC’s , budget, TB guidelines Better data…. Disease registriesBetter data…. Disease registries

Real Strategies – Real Strategies – What, by when, and howWhat, by when, and how

Poverty reductionPoverty reduction HousingHousing TransportationTransportation Injury PreventionInjury Prevention Healthy Ageing – DementiaHealthy Ageing – Dementia Mental HealthMental Health others others ??????????????????????

Age-Friendly Age-Friendly Rural And Remote Communities: Rural And Remote Communities:

A GuideA Guide Outdoor Spaces and BuildingsOutdoor Spaces and Buildings TransportationTransportation HousingHousing Respect and Social InclusionRespect and Social Inclusion Social ParticipationSocial Participation Communication and InformationCommunication and Information Civic Participation and Employment OpportunitiesCivic Participation and Employment Opportunities

Community Support & Health ServicesCommunity Support & Health Services

Age-Friendly Age-Friendly Rural And Remote Communities: Rural And Remote Communities:

A GuideA Guide

Community Support & Health ServicesCommunity Support & Health Services Caring and Responsible ProfessionalsCaring and Responsible Professionals Home Health and Support ServicesHome Health and Support Services Diversity of Health Services and FacilitiesDiversity of Health Services and Facilities Availability of Equipment and AidsAvailability of Equipment and Aids Caregiver Support (including respite)Caregiver Support (including respite) InformationInformation

Age-Friendly Age-Friendly RuralRuralAnd RemoteAnd RemoteCommunitiesCommunities

Boom, Bust and EchoBoom, Bust and Echo

“ “Over the next 2 decades, as 9.8 million baby Over the next 2 decades, as 9.8 million baby boomers turn 50, we will witness a significant boomers turn 50, we will witness a significant exodus from big-city Canada to small-town exodus from big-city Canada to small-town Canada. The participants in this exodus are Canada. The participants in this exodus are going to need the same hospitals that going to need the same hospitals that provincial governments want to close in the provincial governments want to close in the mid-1990’s”mid-1990’s”

Boom, Bust and EchoBoom, Bust and Echo

““Governments should view Governments should view small-town small-town hospitalshospitals not as a burden on the health care not as a burden on the health care budget but as budget but as a powerful tool for the economic a powerful tool for the economic development of rural regionsdevelopment of rural regions. In the years to . In the years to come, the reassuring presence of a good local come, the reassuring presence of a good local hospital will act as a magnet for relatively hospital will act as a magnet for relatively prosperous new retirees, whose arrival will prosperous new retirees, whose arrival will create new demand for good and services.” create new demand for good and services.”

Boom, Bust and EchoBoom, Bust and Echo

“… “…. bring their new wealth with them. . bring their new wealth with them.

… …. already happening in the Okanagan and . already happening in the Okanagan and other parts of the B.C. interiorother parts of the B.C. interior

… …..one scenario where increased population ..one scenario where increased population does lead to increased prosperity….. does lead to increased prosperity….. A Region A Region that loses its local hospital may be losing its that loses its local hospital may be losing its best chance for economic rebirth.best chance for economic rebirth.” ”

SOCIETY OF RURAL PHYSICIANS – SOCIETY OF RURAL PHYSICIANS – NATIONAL RURAL HEALTH STRATEGYNATIONAL RURAL HEALTH STRATEGY

SOCIETY OF RURAL PHYSICIANS – SOCIETY OF RURAL PHYSICIANS – NATIONAL RURAL HEALTH STRATEGYNATIONAL RURAL HEALTH STRATEGY

SOCIETY OF RURAL PHYSICIANS – SOCIETY OF RURAL PHYSICIANS – NATIONAL RURAL HEALTH STRATEGYNATIONAL RURAL HEALTH STRATEGY

SOCIETY OF RURAL PHYSICIANS – NATIONAL RURAL HEALTH STRATEGY

Reorienting Health Systemsfrom Health Care to Health

Health CARE Magnetic North Pole

We need a strong opposing force for

HEALTHHEALTH

We need

EmpoweredEmpowered CitizensCitizens

Empowered Citizens HEALTH

Health Care Health CARE

Rx: Rx: Civil society insisting on healthy Civil society insisting on healthy

public policypublic policy Health literacyHealth literacy

Civic efficacyCivic efficacy

Enlightened leadershipEnlightened leadership Change in attitude… Change in attitude… respect for respect for Bottom up Bottom up solutions “Democracy BETWEEN elections”

Health Care or a Real System for Health Care or a Real System for HealthHealth

Patchwork quilt of non- systemsPatchwork quilt of non- systems

Focus on sickness…and the repair Focus on sickness…and the repair shopsshops

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 ????

““Health is Politics”Health is Politics”

“ “ If you want to move healthy public policies If you want to move healthy public policies forward, you have to have 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 difficult is Doing the right thing is very difficult is the people aren’t onside…the people aren’t onside…

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

CYNICISMCYNICISM

Meaningful citizen engagement must cynicism not

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

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

Illiteracy for Afghan women - ‘blind’ Can’t see what’s going on

Citizens pulling healthy public policy…. Citizens pulling healthy public policy…. Civic Civic efficacyefficacy

Values... Versus public opinionValues... Versus public opinion

Public opinion ? Public opinion ? sometimes very shortsightedsometimes very shortsighted What’s in in for me ?What’s in in for me ? What we see in polling dataWhat we see in polling data

Need to drill down to Need to drill down to values…values… Deliberative dialogueDeliberative dialogue

EmpowermentEmpowerment taking the time to educate and listen taking the time to educate and listen speaking plain languagespeaking plain language 2 –way accountability2 –way accountability

Values... Versus public opinionValues... Versus public opinion

Public opinion ? Public opinion ? sometimes very shortsightedsometimes very shortsighted What’s in in for me ?What’s in in for me ? What we see in polling dataWhat we see in polling data

Need to drill down to Need to drill down to values…values… Deliberative dialogueDeliberative dialogue

EmpowermentEmpowerment taking the time to educate and listen taking the time to educate and listen speaking plain languagespeaking plain language 2 –way accountability2 –way accountability

Health Literacy QuizHealth Literacy Quizversion 1version 1

Is ‘surveillance’ ?Is ‘surveillance’ ? Pattern of diseasePattern of disease cameras in school corridorscameras in school corridors

Is ‘Accessibility’Is ‘Accessibility’ Getting the businessman to work from the suburbsGetting the businessman to work from the suburbs Ramps and closed captioningRamps and closed captioning

Chronic Disease managementChronic Disease management What or who is being managed What or who is being managed ?? Isn`t this about the health care providers too Isn`t this about the health care providers too ?? Why are we blaming the patients Why are we blaming the patients ?? How many specialty clinics should one human have to attend How many specialty clinics should one human have to attend ??

Primary Care … provider, settingPrimary Care … provider, setting Have you ever heard a real person say these words Have you ever heard a real person say these words ??

“What we have here is a failure to communicate”

Cool Hand Luke 1967

The solutions are complexThe solutions are complex

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

HL MenckenHL Mencken

Tax cutsTax cuts More copsMore cops More prisonsMore prisons another MRI machine being used 9-5another MRI machine being used 9-5

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

BUT……we need simpler messagesBUT……we need simpler messages PLAIN LANGUAGEPLAIN LANGUAGE Myth busting dataMyth busting data Paint the picture….Paint the picture…. beautiful GIS maps !!!!beautiful GIS maps !!!!

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 and B) state of the art fleet of ambulances and paramedics waiting at the bottom ? paramedics waiting at the 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 preventable hip A) a falls program to reduce preventable hip fracturesfractures

B) private orthopaedic hospitals and more B) private orthopaedic hospitals and more surgeonssurgeons

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

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

B) increase the budget for young offenders’ B) increase the budget for young offenders’ incarcerationincarceration

5.Should we:5.Should we:

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

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

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 kitchens community gardens and community kitchens and a national food policyand 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 disease of Working with the vets to keep avian flu a disease of birdsbirds

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

D)D) Research on vaccinesResearch on vaccines

E)E) Community care plans for our most vulnerableCommunity care plans for our most vulnerable

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

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

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

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 CausesThe Causes of the Causes

VersusVersus

The CausesThe Causes

Evolution of the Healthy Canadians TreeEvolution of the Healthy Canadians Tree

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

CommuniquéCommuniquéFMM September 2004FMM September 2004

““In addition, governments commit to accelerate work on a In addition, governments commit to accelerate work on a pan-Canadian pan-Canadian Public Health StrategyPublic Health Strategy. For the first time, . For the first time, governments will set governments will set goals and targetsgoals and targets for improving the for improving the health status of Canadians through a collaborative process health status of Canadians through a collaborative process with experts. The Strategy will include efforts to address with experts. The Strategy will include efforts to address common risk factors, such as physical inactivity, and common risk factors, such as physical inactivity, and integrated disease strategies. First Ministers commit to integrated disease strategies. First Ministers commit to working across sectors through initiatives such as Healthy working across sectors through initiatives such as Healthy Schools.”Schools.”

Health Goals for CanadaHealth Goals for Canada

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

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

Next stepNext step

Indicators…for each goal ?Indicators…for each goal ?

Canadian Index of WellbeingCanadian Index of Wellbeing

Atkinson Foundation Atkinson Foundation ….very interesting….very interesting

Changing the way we do things..Changing the way we do things..Managing for results…..Managing for results…..

Whole of Government – results.Whole of Government – results. Health outcomes – NY State…. Hb A1C reportableHealth outcomes – NY State…. Hb A1C reportable Health system performance – readmission ratesHealth system performance – readmission rates The Causes (modifiable risks)The Causes (modifiable risks) The Causes of the Causes (SDOH)The Causes of the Causes (SDOH)

Transparent, comparable and understandableTransparent, comparable and understandable Newfoundland and Labrador Community AccountsNewfoundland and Labrador Community Accounts ““Measuring Quality of Life: The Use of Societal Outcomes for Measuring Quality of Life: The Use of Societal Outcomes for

Parliamentarians”Parliamentarians” 2001, Library of Parliament, Canada2001, Library of Parliament, Canada

GIS …invaluable….. GIS …invaluable….. http://www.statcan.ca/english/freepub/82-221-XIE/2007001/maps/maps.htm#dt http://www.statcan.ca/english/freepub/82-221-XIE/2007001/maps/maps.htm#dt

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.

““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”

Process ….Process ….

Article 54 in PQArticle 54 in PQ HIA…. All MC’s , budget, TB guidelinesHIA…. All MC’s , budget, TB guidelines Gender Based AnalysisGender Based Analysis Disability lensDisability lens Triple bottom line…. NWTTriple bottom line…. NWT UK…Children’s Commissioner.UK…Children’s Commissioner.

impact on children of all policiesimpact on children of all policies Bias-free framework :Mary Anne Burke, Margrit Bias-free framework :Mary Anne Burke, Margrit

Eisler; Global Forum for Health ResearchEisler; Global Forum for Health Research

Structure Structure Gridlock Gridlock

horizontal – departmentshorizontal – departments vertical - jurisdiction vertical - jurisdiction

StructureStructureSilo- busting - HorizontalitySilo- busting - Horizontality

Ministries or Ministers Ministries or Ministers ACTNOW B.C.ACTNOW B.C. Seniors, Children, WomenSeniors, Children, Women Multicultural/SettlementMulticultural/Settlement UK Minister of Joined-Up GovernmentUK Minister of Joined-Up Government

Cabinet committees Cabinet committees Paul Martin’s Aboriginal Affairs – KelownaPaul Martin’s Aboriginal Affairs – Kelowna Manitoba – Cabinet Committee on ChildrenManitoba – Cabinet Committee on Children

Parliament… Parliament… Status of WomenStatus of Women Persons with Disabilities…. Persons with Disabilities….

Population Health: Population Health: Keeping Canadians healthy….Keeping Canadians healthy….

‘‘Citizen centered’ federalism…Citizen centered’ federalism… bottom upbottom up

Strong common purpose…. Strong common purpose…. Local wisdom, local knowledge to get it doneLocal wisdom, local knowledge to get it done Aligning all levels of government and all Aligning all levels of government and all

government departments to what is determined government departments to what is determined in communities.in communities.

InternationalInternationalWHO NGO Advisory Group WHO NGO Advisory Group

Health PromotionHealth Promotion Clear they need to be includedClear they need to be included Clear they know it’s politicsClear they know it’s politics strengthsstrengths

Respond to needs in communityRespond to needs in community Identify policy gapsIdentify policy gaps Advocacy and consensus buildingAdvocacy and consensus building Resource mobilizationResource mobilization

MahlerMahler

All I learned was from developing countries. All I learned was from developing countries. Learned the word Empowerment Learned the word Empowerment

Community Empowerment Community Empowerment

Family EmpowermentFamily Empowerment

Individual EmpowermentIndividual Empowerment

NB dynamic centre is the family NB dynamic centre is the family

Ministries of DiseasesMinistries of Diseases

Dr. Harry JeeneDr. Harry Jeene

Mirroring the way Northern countries are Mirroring the way Northern countries are structured, developing countries also fund structured, developing countries also fund health as a set of diseases. health as a set of diseases.

Health Promotion in partnershipHealth Promotion in partnershipDr. Harry DeeneDr. Harry Deene

There is not much profit to be made in Health Promotion, There is not much profit to be made in Health Promotion, certainly not for the Pharma, fast food and entertainment certainly not for the Pharma, fast food and entertainment industries, industries,

Neither for the donors who require quick wins, direct Neither for the donors who require quick wins, direct attributions and an increasing preference for commodities. attributions and an increasing preference for commodities.

There is even little in it for the formal health care providers, There is even little in it for the formal health care providers, including those in primary health care including those in primary health care

Major shifts in thinking are required, and these can only be Major shifts in thinking are required, and these can only be driven by communities working as full and equal partners with driven by communities working as full and equal partners with the formal health system, especially at the Primary Care level. the formal health system, especially at the Primary Care level.

Dr. Harry DeeneDr. Harry Deene

We have missed our Alma AltaWe have missed our Alma Alta2000 targets 2000 targets

We are missing our 2015 MDG targets We are missing our 2015 MDG targets (and where are health promotion, chronic (and where are health promotion, chronic

conditions, mental health and trauma in these conditions, mental health and trauma in these MDG's'anyway ?) MDG's'anyway ?)

Civil SocietyCivil Society will have to exercise much more will have to exercise much more pressure to get health promotion on the pressure to get health promotion on the agenda, North and South. agenda, North and South.

The Policy MakersThe Policy Makers

As most decision makers are male, female As most decision makers are male, female health issues are particularly hard to get on the health issues are particularly hard to get on the agenda agenda

(Some female health ministers, not enough (Some female health ministers, not enough female finance ministers)female finance ministers)

Dr. Harry Dr. Harry JeeneJeene

““The art of making the necessary possible”The art of making the necessary possible”

Deciding what is necessary is political…..Deciding what is necessary is political…..

We need great people to run for public office.We need great people to run for public office.

We need great people to want to be civil servants.We need great people to want to be civil servants.

They need to be believers in ‘bottom up’They need to be believers in ‘bottom up’

Putting the ‘poli’ back into Politics (& policy !)

No time for pessimists

Sir Michael MarmotSir Michael Marmot

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

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…

HEALTHEALTHH

We need enlightened leadership too !!

Dr. John Hastings Dr. John Hastings M.O.H. Toronto…M.O.H. Toronto…

on the occasion of his Presidency of the APHA on the occasion of his Presidency of the APHA,,19181918 Every nation that permits people to remain under the Every nation that permits people to remain under the

fetters of preventable disease and permits social fetters of preventable disease and permits social conditions to exist that make it impossible for them to conditions to exist that make it impossible for them to be properly fed, clothed and housed so as to maintain be properly fed, clothed and housed so as to maintain a high degree of resistance and physical fitness; and, a high degree of resistance and physical fitness; and, who endorses a wage that does not afford sufficient who endorses a wage that does not afford sufficient revenue for the home, a revenue that will make revenue for the home, a revenue that will make possible the development of a sound mind and body, possible the development of a sound mind and body, is trampling on a primary principle of democracy. is trampling on a primary principle of democracy.

Reorienting Health Systems:Reorienting Health Systems:

+ =

EmpoweredCitizens

EnlightenedLeadership

HealthyPublicPolicy

““The care of the public health is the first duty The care of the public health is the first duty of a statesman." of a statesman."

Benjamin DisraeliBenjamin Disraeli

Aspiring to become a statesman should be the first duty Aspiring to become a statesman should be the first duty of every politician ……of every politician ……