Doreen M. Rabi, MD, Clinical Researcher
Fobete Dingha, Community Advocate
On behalf of the Canadian Collaboration for Complex Care
There is an ancient, Eastern parable about blind men encountering an elephant. Having no knowledge or concept of this creature, the men each approached the animal from a different angle, using their sense of touch to try to understand the elephant. The first man touched the trunk and thought an elephant must be like a large snake. Another touched the tusk and thought this may not be a living creature at all, but a smooth sculpture of a great beast. The third touched a leg and thought an elephant must be an odd tree-like animal. The last man touched the ears and thought an elephant was a large, winged creature with leather instead of feathers. The morale of the parable is that individual perceptions are always limited and not always the same. We need to respect that differing accounts are valid and that the truth is often something much bigger and more complex than we can imagine.
In discussions about health care reform, we need to keep this parable in mind as position and perspective shape our understanding of the health care crisis. While we can all agree health care has its challenges, the cause of the crisis varies depending on positionality and diverse perception of individuals within our society. In Alberta for example, Premier Smith blames Alberta Health Services leadership and structures for long wait times and rising care costs. Alberta physicians and nurses blame the government for not supporting evidence-based policy and their health care workforce leading to preventable illness and a massive workforce exodus respectively. The government thinks we have an efficiency problem and care providers see significant issues in capacity across the continuum of care. Both perspectives have some truth. But is it the whole truth? Whose perspectives are we missing and what is the impact of creating solutions based on partial truths?
The government of Alberta has moved to restructure health care in Alberta so that there are four different health care organizations to support care design and delivery within primary care, acute care, continuing care and mental health and addictions care. This restructuring is in response to some indisputable truths: 1) As many as 80000 Albertans do not have access to a primary care provider; 2) There are record wait times in emergency rooms and for common surgical procedures due to hospital over-crowding; 3) There is a critical shortage of appropriate continuing care beds for older adults with complex care needs; 4) We have inaccessible and under-supported mental health care programs and are losing far too many Albertans to drug poisonings. Primary care, wait times, elder and mental health care are all very reasonable areas of focus that have had significant media attention. Breaking the system into four silos that address four priority areas could reasonably be criticized for being reactive and responses to the most visible challenges but perhaps not the central issues that make people ill or prevent them from being well.
Health care is not a democracy, and citizens do not generally get invited to the conversation on how to improve the status quo. Decisions about health care are made at the top of organizations or at a ministerial level. Politicians, health system administrators, health information analysts, physicians and health care professionals all come to the health care discussion from a specific position, but at the end of the day, they provide a perspective from the top of the hierarchy. They see health care narrowly from their vantage point and design solutions based on their respective expertise and the tools they have at their disposal. This approach will always lead to incomplete and unsuccessful solutions. System transformation requires deep system knowledge. It demands an understanding of the complex journey from well citizen to a patient needing investigations, consultations, procedures, rehabilitation, community health programs, health benefits, medications, medical devices for one or several conditions. Patients and their families are the only ones that really know where the cracks are in our system as they are the ones that deal with the consequences of falling through them.
System transformation requires deep system knowledge. It demands an understanding of the complex journey from well citizen to a patient needing investigations, consultations, procedures, rehabilitation, community health programs, health benefits, medications, medical devices for one or several conditions.
Patients and the public have very different ideas about why our health care system is struggling. Dr. Tara Kiran, a family physician and health services researcher at the University of Toronto, has asked Canadians what they think needs to be done to improve health care. Dr. Kiran’s team convened panels of citizens in five provinces (Ontario, British Columbia, Manitoba, Quebec, and Nova Scotia) to determine priority recommendations for their respective ministries of health. While each panel had distinct recommendations, there was significant thematic overlap across the provincial panels. Canadians want to see more attention to social and structural determinants of health; more attention on disease prevention and health promotion; emphasis on holistic and culturally sensitive approaches to care; expanded team-based health care and training pathways for primary care; and ensure interoperable digital health records and that all citizens have access to their health information. While this study did not have representation from Alberta, it is unlikely that participants from Alberta would have provided significantly different responses.
Governments rightfully see themselves as stewards of taxpayer’s money and want to deliver value on money invested. Health care budgets are large and health system performance is of great interest to all citizens. As Alberta reorganizes care to focus on care access and reduced wait times, it cannot lose sight of what its people need to be healthy and well and we must think more broadly on what it means to have an effective system. It also needs to consider that the most important parts of the system may lie outside of hospitals and that overcrowding in ERs might reflect failures to invest in strong social and health policy (low barrier access to contraception or universal basic income for example) that have proven economic and public health benefits.
Bottomline, we cannot talk about health care reform in Alberta, without talking to Albertans.
For instance, we need to speak with new Albertans. Alberta’s population grew by 183,000 people (an increase of 4.1%) in 2023 with most newcomers coming from abroad (62% from the Asian and 16% from the African continents). Currently, there are no systems in place to “onboard” newcomers to our health system, so they are left to access and navigate our challenging system on their own.
We need to speak with young Albertans and their families. Alberta’s population is younger than other provinces with a higher-than-average fertility rate. Young people having children in Alberta creates an ongoing need for pregnancy care and resources to support healthy child development, especially in rural areas of the province.
We need to speak with Albertans living with chronic disease. Nearly a third of adults over the age of 18 live with two or more chronic conditions. We are seeing a rising number of patients admitted to hospital with complex care needs due to chronic disease. As people have more conditions, they have more symptoms, health concerns, and take more medications. They also have an increased risk for mental health concerns and may have a lower quality of life. Chronic diseases are largely managed by patients with guidance from the health care teams that have the medical, pharmacy, nursing, and mental health support to keep people out of hospital and support them to continue their education, raise their families, and go to work (or all the above).
So, as we look at Alberta’s care reorganization, will it address all the health needs of Albertans, or will it just address the limited areas identified by the (metaphorically) blinded few that typically inform health care design? How will the four new health organizations address the unique needs of newcomers, young families or those with complex needs- examples of people that have needs that span the four new organizations?
Being able to see all the complexity of health care demands that we attend to all the information that is available about how our system works. We must listen to citizens and patients and engage them intentionally as we move forward in health care transformation efforts. Health care is an enormous, intricate, dynamic entity, it is absurd to think that that it can be fully understood by just a select few. There are nearly 4.4 million sets of (metaphorical) hands that can provide insight into what is wrong and possible solutions. There simply needs to be a will to listen.
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