Are these pan-Canadian health organizations “fit for purpose”?

Andrew Padmos
May 30, 2018 | Author: Dr. Andrew Padmos
4 MIN READ

Dear colleagues,

Are you aware of the new federal report that outlines options for reshaping and revitalizing our pan-Canadian health care organizations?

With combined budgets of over $350 million in 2017 — and impacts on care areas like mental health, substance use and cancer care — it’s important that our response to this report be a constructive one. While the report opens the door to improvement, we need to ensure that follow up action will support practice, increase access to care and improvements in patient health.

By way of background, last fall Federal Health Minister Ginette Petitpas Taylor launched an independent review of Canada’s eight federally funded pan-Canadian health organizations* (PCHOs):

  1. Canadian Centre on Substance Use and Addiction
  2. Canadian Agency for Drugs and Technologies in Health
  3. Canadian Institute for Health Information
  4. Canadian Foundation for Healthcare Improvement
  5. Canada Health Infoway
  6. Canadian Patient Safety Institute
  7. Canadian Partnership Against Cancer
  8. Mental Health Commission of Canada

The resultant report, which was quietly released in late March, lays out various scenarios of how our government can harness and strategically channel these organizations’ efforts towards improved health care for Canadians (ranging from minor tweaks to major overhauls).

*You can learn more about each organization in Chapter 2 of the report (pages 11-27)

The report authors, Dr. Pierre-Gerlier Forest and Dr. Danielle Martin, have done a very good job producing a well-written and thoughtful overview. Their work sparks an important opportunity to soberly evaluate how this suite of organizations function and what their future might hold.

We asked some of our Health and Public Policy Committee members what they thought of the report. While we’ve heard positive reactions, there’s an important concern I’d like to share with you: the absent discussion of specialty care.

The report recommends the need for a comprehensive and integrated primary health care system that is responsive to patient needs; however, equally important are the acute, complex and specialized health care needs of patients. These needs are met through the highly trained physicians that patients access through our primary care system. Unfortunately, the report says little about the role PCHOs could play in ensuring Canadians receive the specialized health care they need, whether it is in an emergency room or operating room, a diagnostic facility or a specialist’s office. The report misses a clear opportunity to talk about how our PCHOs might further enable a health care system that accelerates and smooths patient pathways between primary care and specialty care. As the federal government formulates its response to the PCHO review, the Royal College will work to advance this goal in future actions.

Here are some other key thoughts on the summary findings and proposed reconfiguration of Canada’s PCHOs.



PCHO EXTERNAL REVIEW – REFLECTIONS ON THE SUMMARY REPORT

Reflection 1:  The recommendations in this report could be transformative for the health care landscape.

PCHOs serve a vital function. The problem, as defined by various stakeholders*, is that they

  • are a seemingly disconnected suite of organizations,
  • do not meet health system needs (as currently configured),
  • need to take a leadership role in improving the health of Indigenous populations,
  • do not adequately involve patients and key stakeholders in their work.

*See Appendix 5, pages 127-128

The report details various future scenarios, each framed around a worthy focus and with a unique vision of how government could deliberately channel PCHO efforts towards improved health care for Canadians. These scenarios range from minor “repairs” to major overhauls; emphasizing partnerships, joint planning, measurable objectives and clarified functions. In effect, the report gives the government options. Such a toolkit could be very useful to federal leaders, but we might caution not to cherry-pick solutions. A pragmatic or opportunistic response would run the risk of getting sub-optimal and/or unexpected results that may be detrimental to patient care.

There is great work being done by the PCHOs. We need to keep this in mind as we contemplate change. It will be important to transition and evolve PCHO mandates and activities in such a way that important health care issues like substance use, cancer care and mental health care receive adequate attention and, most importantly, that patients continue to receive the high quality care they need.

The four scenarios for change that are presented each have interesting components and foundations. The way forward should include the pillars of all of them: efficiency, innovation, engagement and equity. You can’t meaningfully achieve one without the others.

Reflection 2:  We need vision before action.

The authors of the report very thoughtfully encourage the federal government to establish a long-term vision for Canadian health care. Where are we headed? How could PCHOs be directed towards federal goals in an integrated and rational manner? Without a clear vision, all future efforts (including those of PCHOs) are at risk of being fragmented, inefficient and ineffective. We applaud the report’s recognition that health care no longer ends at the border. The federal government should recognize global influences and realities, and reflect them in its vision for the future. We would also venture that whatever vision is established would benefit from acknowledging the roles of patients and populations.

Reflection 3:  We applaud the report’s prominent recognition and inclusion of Indigenous populations.

We congratulate the report writers on endorsing the commencement of a federal dialogue with national Indigenous organizations to identify the role PCHOs could play in meeting Indigenous communities’ health priorities; they are wise in not presuming or prematurely proposing solutions to address the unique health needs of this population (notably, there is a role at both the provincial and federal levels in meeting these needs). As the authors suggest, achieving health equity must begin with a dialogue in which Canada’s Indigenous People are heard and have an equal voice. This is the approach we took in establishing our own Royal College Indigenous Health Advisory Committee, in developing our Indigenous Health Values and Principles Statement, and in acting upon a recent recommendation to make Indigenous health a mandatory component of postgraduate medical education. We know great progress can be achieved when working together in this manner.


It is still unclear what the government intends to do with the recommendations in this report. What is clear is that the report encourages the federal government to revisit and possibly bolster its leadership role in this country’s health care landscape, and how PCHOs can better support primary and specialty care. This summary report provides them with a solid foundation upon which to base their initial discussions.

What is one piece of advice that you would give the federal government in creating its vision for the future of Canadian health care and the role it intends to play in pursuing that future?

I’d be curious to read your thoughts.

Sincerely,

Andrew Padmos, BA, MD, FRCPC, FACP
Chief Executive Officer

Summary Report_PCHO External Review_En_Page_001

 Fit for Purpose: Findings and Recommendations of the External Review of the Pan-Canadian Health Organizations

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Avatar Dr. Alison Fox-Robichaud | June 16, 2018
Dear Dr. Padmos, I have read the report and like you find the direction lacking in some detail. While I agree that a focus on equity and public health are important for the sustainability of the Canadian Health system, it is apparent that the report is missing some important links to acute and specialist care. As mentioned in the report I also do not see any accounting for Canadian responsibilities to the WHO who also sets a health care agenda and to which Canada is a signatory. There are examples where there has been impact to specialist care. I have been supported by the CPSI through grants and I believe this agency has successfully worked with specialists in a number of areas. The recent refresh of their plan and their broad engagement supports hospitals and specialists in key areas such as critical care, anesthesiology and emergency medicine, I am also aware of funding of some great work in COPD management supported by CFHI and initiated by Dr. Graeme Rocker from Dalhousie University. I have also seen the impact the work of Canadian Health Infoway has had on integrating our patient data and care. In my opinion there is significant room for improvement within CIHI which potentially has the biggest impact on specialist care. The fragmented interactions and incomplete responsiveness to our concerns has come short on a national information systems for intensive care units. However suggestions to align the data collection with our current clinical practice and needs was incomplete. We are left with inaccurate data that is not useful to our practice. In my own field of sepsis we know the data reported is likely a significant underestimate of the burden of this disease on the health system. While this is not entirely a CIHI problem (most specialists need to significantly improve our documentation of both acute and chronic diseases during hospital admissions), strategies are needed to improve the collaboration between specialists, the coders who report what we document in the medical record and CIHI. Until recently I was not aware of the work of CADTH. My contact with this group suggests that they are taking on some new investigations. I am hoping there be an opportunity to collaborate with this group and help meet our WHO obligation with respect to a national sepsis plan. I think this statement from the report is the most telling "For the most part, PCHO leadership and teams are not sufficiently intergenerational, diverse, or multi-disciplinary. There is often a revolving door of leadership in which people work in more than one or several PCHOs over the course of their careers. This is not always a bad thing, but there is a perception that it has created a class of individuals who migrate from one PCHO office in Ottawa to another, which if true, may contribute to disconnection from the health systems of the country." Chapter 8 Section 5 While I think this report is a comprehensive overview of the current status of the PCHO systems, I agree that the authors missed on the important role specialists and the acute care system still play in the health of all who live in or visit Canada. I believe our recommendation back to the authors, the chairs of the PCHO and Minister Pettipas-Taylor should be that any restructuring should a greater focus on collaboration with all sectors of health care and broad engagement and accountability to the residents of Canada and those who provide day to day care within our system.
Avatar Dr. Andrew Padmos | June 20, 2018
Hi Alison, thank you for your thoughtful comment. I agree with your assessment. More and more I believe that collaboration will be central to long-term efficiencies and effectiveness. Our responsibility to serve patients and populations in Canada is, I believe, a hallmark of the health care profession. – Andrew
Avatar Laura | June 12, 2018
Are there other pan-Canadian health organizations? If yes, why were these eight selected?
Avatar Dr. Andrew Padmos | June 20, 2018
Hi Laura, the 8 PCHOs in the report are those funded by Health Canada; however, there are many other health care organizations that consider themselves to be pan-Canadian. - Andrew
Avatar Dr. Andrew Padmos | June 8, 2018
Thank you for your replies; we’ll take your views into account as we consider the Royal College’s future advocacy work and what form that may take, specifically with regards to this report. We are all in agreement that changes to the current structure would be beneficial, and could be transformative, but must be done in a thoughtful manner that safeguards patient care. We will be closely monitoring the federal response to this report, and awaiting news of their proposed vision for the future of Canadian health care and role in bringing it to fruition. -Andrew
Avatar Paula Gordon | June 3, 2018
I was pleased to see the email asking for input pan-Canadian health organizations. I firmly agree these organizations are disconnected from stakeholders and those impacted by their decisions. For example, the Canadian Partnership Against Cancer (CPAC) was tasked by the Public Health Agency of Canada (PHAC) before the Senate in 2013, to provide breast density awareness to the Canadian public and has failed to act on this initiative even till now. They have not been held accountable for this in action by PHAC based on their arms-length arrangement. CPAC cites the Canadian Task Force on Preventive Health Care’s (CTFPHC) 2011 Guidelines on Breast Cancer Screening for their inaction. It is clear that there are accountability issues with these arms-length pan-Canadian health organizations created under the Health Portfolio. I strongly recommend that the Royal College of Physicians and Surgeons highlight the accountability failings of these organizations and include commentary on the Canadian Task Force, as this panel deliberately excludes clinical experts despite the weight their recommendations carry across Canada in health authorities. The Task Force is largely comprised of family practitioners and other non-specialists who create cancer screening guidelines. They have instructed evidence centres to limit studied literature to randomized clinical trials (RCTs) when evaluating benefits of screening, but consider non-randomized trial to evaluate harms of screening. As a result, as it applies to breast cancer screening, they choose to prioritize trials that are 30-50 years old, that used technology that is now obsolete, and ignore large bodies of contemporary evidence that supports screening. Their policy allows for comprehensive research when appropriate RCTs are not available, but to date, the Task Force has ignored its own policy. One result is that women with dense breasts are considered to be at average risk women when, in fact, their risk of breast cancer is higher than average (equivalent to having a 1st degree family history). And they have completely ignored the issue of mammography being less sensitive for women with dense breasts because of masking. I strongly recommend that the College raise awareness of the failings of the Canadian Task Force’s recommendations, and the need to hold them accountable for the consequences of their recommendations.
Avatar Tom Lesiuk | June 1, 2018
Agree totally. Just a frivolous administrative structure to make some administrator feel they are serving a useful role. Where I ask is rational dialogue left in healthcare, followed by rational control and distribution of healthcare resources.
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