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Setting Priorities

for the B.C.HealthSystem


SUPPORTING the health and well-being of B.C.citizens. | DELIVERING
asystem of responsive and effective health care services for patients across
BritishColumbia. | ENSURING value formoney.
February2014

Overview
Setting Priorities for the B.C. Health System
presentsthe strategic and operational priorities for
the delivery of health services across the province.
The plan is founded on avision of achieving
asustainable health system that supports people
tostay healthy and provides high quality publicly
funded health care services that meet their needs
when they aresick.
The plan builds upon on successes achieved
through the health sectors transformational
guiding framework, the Innovation and Change
Agenda, and is focused on delivering apatientcentred culture across all health sector services
andprograms, while incrementally improving
onthe quality of serviceoutcomes.
The strategies and priorities outlined in this
document are based on thoughtful analysis of
population health and service utilization data,
best practices from the research literature,
lessonslearned from B.C.s efforts over the last
fouryears todrive provincewide system change
and consultation with many key stakeholders.

Implementing change in acomplex system is not


only difficult, it can also be unpredictable. Strategies
and approaches that have proven effective in
one setting may not work in another.Despite the
best efforts and intentions, it is highly likely that
some parts of the strategy will be less successful
or effective than initially anticipated.This is
why ongoing monitoring of progress against
clearly defined outcomes and deliverables is
critical and will be built into the implementation
plan.Themost critical feedback will come from
patients themselves. To be considered successful,
the strategy must improve the service experience
ofpatients and their families and improve health
outcomes in thepopulation.
Building learning into the strategy through
monitoring of performance indicators and feedback
from patients and stakeholders will enable us
toadjust our direction along the way and, if
necessary, abandon and replace approaches and
strategies that prove ineffective.

...avision of achieving asustainable health system


that supports people tostay healthy and provides
HIGH QUALITY PUBLICLY FUNDED HEALTH CARE...

Setting Priorities FOR THE B.C.HEALTHSYSTEM

Setting Priorities FOR THE B.C.HEALTHSYSTEM

Contents
EXECUTIVESUMMARY. . . . . . . . . . . . . . . . . . . . . . . . . 1
INTRODUCTION: Health SystemStrategy. . . . . . . . 7
KeyConcepts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
STRATEGY IMPLEMENTATION
AND FUTURE DIRECTIONINB.C.. . . . . . . . . . . . . . 17
The Innovation and Change Agenda
(2009-2013) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Priority6: Drive evidence-informed access


toclinically effective and cost-effective
pharmaceuticals. . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Priority7: Examine the role and functioning
ofthe acute care system, focused on driving
inter-professional teams and functions
with better linkages tocommunity
healthcare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

FutureDirection . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Priority8: Increase access toan appropriate


continuum ofresidential careservices. . . . . . 32

HEALTHOUTCOMES. . . . . . . . . . . . . . . . . . . . . . . . . . 21

STRATEGY. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Population and PatientSegments . . . . . . . . . . 21

Strategy1: A Shared PlanofAction. . . . . . . . . 34

Access andWaitTimes. . . . . . . . . . . . . . . . . . . . . . 25

Strategy2: AccountabilitytoDeliver
the Three-YearPlan. . . . . . . . . . . . . . . . . . . . . . . . . 34

Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
QUALITY AND A SUSTAINABLE SERVICE
DELIVERYSYSTEM. . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Priority1: Provide patient-centredcare. . . . . 27
Priority2: Implement targeted andeffective
primary prevention andhealth promotion
through aco-ordinated deliverysystem . . . . 27
Priority3: Implement aprovincial system
ofprimary and communitycare built around
inter-professional teamsandfunctions . . . . . 28

Strategy3:Quality . . . . . . . . . . . . . . . . . . . . . . . . . 36
Strategy4: Skilled Change
Management. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Strategy5: Health Human Resource
Strategy An Engaged, Skilled, Well-Led
andHealthyWorkforce. . . . . . . . . . . . . . . . . . . . . . 37
Strategy6: Information Management
andTechnology . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Strategy7: Budget Management
andEfficiency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

Priority4: Strengthen the interface between


primary and specialist care andtreatment . . 30

CONCLUSION. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

Priority5: Provide timely access


toqualitydiagnostics. . . . . . . . . . . . . . . . . . . . . . . 30

APPENDIX A:
Minister ofHealth MandateLetter. . . . . . . . . . . . . . . 40

Setting Priorities FOR THE B.C.HEALTHSYSTEM

ExecutiveSummary
Setting Priorities for the B.C. Health System proposes
that there is much that is effective in the current
health system, while recognizing there are some
persistent challenges that have been resistant
toany substantive and successful change over the
pastdecade.
Having clarified the meaning and scope ofseveral
terms, the paper takes stock ofaction taken todate.
Four years ago, B.C. implemented asector-wide
strategy called the Innovation and Change Agenda
totry todrive meaningful change across the
healthsystem.
The Innovation and Change Agenda was structured
under four keythemes:
1. Providing effective health promotion, prevention
and self-management toimprove the health and
wellness ofBritish Columbians.
2. Meeting the majority ofhealth needs with high
quality primary and community based health
care and supportservices.
3. Ensuring high quality hospital care services are
available whenneeded.
4. Improving innovation, productivity and
efficiency in the delivery ofhealthservices.
The key strength ofthe agenda was that it
established an overarching system-wide strategic
framework for co-ordinated action something

that had not been attempted in the past. It also


laid the foundation for several large system
strategies: the launch ofHealthy Families BC as
aprovincial prevention strategy; the establishment
ofa FirstNations Health Authority toclose health
gaps for Aboriginal peoples; and the strengthening
offamily physician practice and primary care
tobetter address chronic disease management
and improve community care offrail patients.
There have also been meaningful increases in the
amount and timeliness ofmany day surgeries, as
well as significant improvement in effective flow/
bed management in hospitals. Progress has also
been made with respect topatient safety and
quality through the creation ofthe BC Patient Safety
& Quality Council and the Patient Care Quality
Review Boards. Most recently, the B.C. Government
launched an open competition torecruit B.C.s first
seniors advocate. This role will be an important part
ofan overall strategic focus onimproving care for
B.C. seniors that beganin2012.
Other successes relate torealizing cost savings and
efficiencies through the consolidation ofservices,
shared purchasing, and the management
ofpharmaceutical and laboratory medicine costs.
TheInnovation and Change Agenda was successful
in helping toslow growth in government spending.
Prior tothe agendas implementation, health care
funding was growing by about seven per cent
ayear. Budget 2013 saw a2.6 per centgrowth.

...THERE ARE SEVERAL POPULATION


SEGMENTS WHERE IT IS CRITICAL that
weachieve system-wide improvement notonly
from apopulation wellness, patienthealth and
quality oflife perspective,but also fromabudget
management perspective...

Setting Priorities FOR THE B.C.HEALTHSYSTEM

Some ofthe key challenges ofthe agenda


are related tochange management and the
implementation ofthe strategy across acomplex
sector: slowly achieving alignment and buy-in
from health authorities and other system partners;
thelimited capacity ofthe system todeliver
system-wide strategic change in atimely manner;
and persistent challenges in the accessibility,
quality and availability ofdata. There were also
several service areas that remained stubbornly
problematic and resistant tosuccessful resolution,
despite significant effort. Challenges persist with
respect toaccess tofamily physician and primary
care services in many communities; providing
access tochild and youth mental health services
and effectively treating some adult patients
with moderate tosevere mental illnesses and/or
addictions; proactively responding tothe needs
offrail elderly who may require complex medical
supports and assistance with activities ofdaily
living in order toremain living in the community;
providing emergency response and emergency
health care services in some rural and remote
areas; emergency department congestion in some
large hospitals; long wait times for some specialist,
diagnostic imaging, and elective surgeries; stress
onaccess toinpatient beds in some hospitals; and
responding tothe changing needs ofpatients in
residential care in terms ofdementia. These areas
provide an opportunity for reassessment and fresh
strategic efforts in setting priorities for the coming
threeyears.

Setting Priorities for the B.C. Health System proposes


that setting fresh priorities for ahigher performing
health system in British Columbia requires analysis
and decisions in threeareas:

The ministers mandate letter (June 2013) states


that the Minister ofHealth is tocontinue the
Innovation and Change Agenda by driving change
in the areas ofprevention, primary care, home
and community care, and hospitals. This includes
recommendations tocabinet onnew priorities
for the health system toensure maximum value
for taxpayers while providing maximum benefit
forpatients.

}} Effective community services for patients with


moderate tosevere mental illness andaddictions
toreduce hospitalizations.

1. What outcomes do we want toachieve in terms


ofthe health ofpopulations and patients?
Which populations and patients require
prioritizedattention?
2. What kind ofsustainable health service delivery
system do we need tohave in place tomeet
those outcomes, and at what level ofquality?
3. What strategy will we pursue toget results?
What enabling factors do we need toleverage
and what constraints do we need tomitigate?
In response tothe first question, the paper argues
that there are several population segments
where it is critical that we achieve system-wide
improvement not only from apopulation wellness,
patient health and quality oflife perspective, but
also fromabudget management perspective:
}} Effective chronic disease prevention through
universal and targeted population health
interventions that address all major risk
factorsacross the lifecycle.
}} Reducing hospitalization and the need for
residential care by preventing or slowing down
the onset offrailty through targeted efforts
tobetter manage the patient journey from
low tomoderate tomore complex chronic
conditions linked with aging/increasedfrailty.

}} Increasing timely access toevidence-informed


care from specialists, diagnostic imaging,
andelective surgery toreduce waittimes.
}} Providing consistent quality ofcare for
residential care patients, with astrong focus
onquality ofcare for dementiapatients.
}} Effective and compassionate care for end-oflifepatients.

Setting Priorities FOR THE B.C.HEALTHSYSTEM

Meet Population and Patient Health Needs

ENABLING
STRATEGIES

PRIORITIES

GOALS

Staying Healthy

Getting Better

Living with Illness or Disability


Delivering a System of Responsive
and Effective Health Care Services
for Patients across B.C.

Supporting the Health and


Well-being of B.C. Citizens

Provide PatientCentred Care

Prevention and
Health Promotion

Access to Quality
Diagnostic Services

Access to Clinicallyand Cost-Effective


Pharmaceuticals

Shared Plan of Action

Primary and
Community Care

Review and Improve


Acute Care Services

Clear Accountability

Health Human
Resources Strategy

Information Management
and Technology

Ensure Quality

Coping with End of Life


Ensuring Value
for Money

Improve Access to
Specialist Services

Appropriate
Residential Care

Skilled Change
Management

Budget Management
and Efficiency

This focus will improve patient care and outcomes for these populations, drive asustainable budget,
andpotentially free up funds tobetter meet other patient needs in the health caresystem.
In support ofthese improved outcomes, and in response tothe second question, eight priority
areasforservice delivery action have been identified.

PRIORITY1:

PRIORITY3:

Provide patient-centredcare

Implement aprovincial system


ofprimary and community care built
around inter-professional teams
andfunctions

Shift the culture ofhealth care from being


disease-centred and provider-focused tobeing
patientcentred.

PRIORITY2:

Implement targeted and effective


primary prevention and health
promotion through aco-ordinated
deliverysystem
Focus on the effective nudging ofbehavioural
change toachieve ameaningfulimpact
on health care system use. This will be built on
the structure ofthe current Healthy Families
BCstrategy.

Create acommunity-based system ofinterprofessional health teams with astrong focus on


populations and individuals with high health and
support needs: patients with chronic diseases, frail
elderly, people with severe mental illness and/
or substance use, and people with significant
disabilities. Areas ofaction will include practice
improvements with an integrated team using
aclinical case management approach tothe
planning and delivery ofservices.

Setting Priorities FOR THE B.C.HEALTHSYSTEM

Planned health system funding increases will


be targeted toknown pressure points and
servicegaps:
}} Increased aging in place and home care/
monitoring services and technologies for higher
risk patientsegments.
}} Adequate and effective home and community
care supported by provincewide quality
standards. Responsive step-up/down home and
community care services that reduce emergency
visits and hospitalization and slow down the
progress offrailty inseniors.
}} Increased 24/7 access toprimary care for higher
risk populationsegments.
}} Increased group-based care for targeted
patient populations led by diverse health
professionalteams.
}} Improved transitions between community and
residential care, with areduction in avoidable
hospitalizations.
}} Improved community-based services for
people with moderate tosevere mental illness
and substance abuse, including those with
aggressive and antisocial behaviours.
}} Improved dementia care, including support
and training for formal and informal caregivers,
development ofa service framework for different
stages ofdementia, and expansion ofhome and
residential careoptions.
}} Improved end-of-life (palliative) care, including
hospice space expansion where appropriate.

PRIORITY4:

Strengthen the interface between


primary and specialist care
andtreatment
Achieve better access tomedical and surgical
specialty consultation and direct treatment.
Majordeliverables shouldinclude:
}} Creating divisions or practices ofrelated
medical specialists at the community level
linked toDivisions ofFamily Practice and health
authorities toimprove consultation, referral and
wait time management fortreatment.
}} Creating divisions or practices ofrelated
surgical specialists at the community level
linked toDivisions ofFamily Practice and health
authorities toimprove consultation, referral and
wait time management fortreatment.
}} The wider use ofpatient-focused funding
initiatives linked tomore holistic models
ofproviding medical and surgical care, including
increased contracting ofservices outside
ofhospital settings where appropriate.

PRIORITY5:

Provide timely access


toqualitydiagnostics
Complete laboratory reform and move
on toimproved evidence-based access
toimagingservices.

PRIORITY6:

Drive evidence-informed access


toclinically effective and cost-effective
pharmaceuticals

Setting Priorities FOR THE B.C.HEALTHSYSTEM

PRIORITY7:

PRIORITY8:

Examine the role and functioning ofthe


acute care system, focused on driving
inter-professional teams and functions
with better linkages tocommunity
healthcare

Increase access toan appropriate


continuum ofresidential careservices

This is driven by the changing use ofhospitals and


the reality ofan aging capital infrastructure with real
limits on the fiscal capacity tomeet thischallenge.
There is need for fresh thinking about and
analysisof:
}} How many and what types ofhospitals
theprovinceneeds.
}} Patient pathways or services for frail seniors that
avoid hospitalization.
}} Whether outpatient clinics should be part
ofahospital infrastructure.
}} Opportunities toshift tocommunity based
delivery ofservices where appropriate
particularly for high volume, highly standardized
procedures.
}} The increased use ofcontracted acute
clinical services toencourage competition
and patient choice, with the private sector
delivery ofpublicly funded outpatient
clinical services supported by an appropriate
regulatoryframework.

KEY ACTIONS SHOULDINCLUDE:


}} Developing residential care models and
provincewide quality standards appropriate
tothe changing care needs ofresidents, with
particular attention topeople with dementia.
This will be underpinned by amore flexible
regulatory system toincrease care availability
(especially in rural settings) and health care
supports using awider range ofcongregate
housing arrangements in partnership with
private and not-for-profit housingproviders.
}} Ensuring adequate residential care services for
younger populations with special needs such as
chronic severe mentalillness.
}} In the shorter term there needs tobe action
toimprove site-based hospital management
and, where needed, build anew hospitalculture.
The third question points tothe importance
ofacoherent and effective provincial strategy.
Themost interesting question facing the health
system is not what needs tochange, but why
change has not occurred. This is acritical and
neglected element. Thepaper argues that we
needto adopt acollaborative strategic approach
tochange management based on the realities
ofthe health sector, and identifies seven strategic
enablers critical for successfulchange:

Setting Priorities FOR THE B.C.HEALTHSYSTEM

STRATEGY1:

STRATEGY5:

A Shared PlanofAction

Health Human Resource Strategy


AnEngaged, Skilled, Well-Led and
HealthyWorkforce

Deliver apatient-focused vision for the health


system driven by asingle, three-year plan
ofaction built around provincial priorities and
additional health authority priorities for operational
improvement with clear, measurable deliverables.

STRATEGY2:

AccountabilitytoDeliver
theThree-YearPlan
Establish aclear performance management
accountability framework built on public reporting.
Include role clarity and accountability mechanisms
for the Ministry ofHealth, health authorities,
physicians, nurses and allied health professional
and support staff focused on population and
patient needs. This framework will be hard wired
tohealth authority governance evaluation as well
as executive and staff performancereviews.

STRATEGY3:

Quality
Enable effective quality improvement capacity
across the health system strengthen quality
assurance toeffect meaningful improvements
inpatientoutcomes.

STRATEGY4:

Skilled ChangeManagement
Enable effective change management capacity
across the health system adequate change
management capacity is needed todrive
successfulchange.

Setting Priorities FOR THE B.C.HEALTHSYSTEM

Involve professional and support staff


todrivesuccessfulchange.

STRATEGY6:

Information Management
andTechnology
Enable access totimely and high quality data and
information. Access tosystem data and information
drives successfulchange.

STRATEGY7:

Budget Management andEfficiency


Enable effective funding, financial and corporate
service strategies. Improved cost management and
different funding strategies drive successful change.
Continue and refocus drive for efficiencies across
the health system through lean process redesign
at the program level, reducing unnecessary
administrative costs at the health authority level,
and reducing unnecessary duplication ofeffort
between health authorities.
This suite ofinterrelated priorities focuses on key
patient groups, amore integrated health system
tobetter meet their needs (supported by key
organizational change enablers), and provides
acoherent, grounded and measurable game plan
forthe coming threeyears.

Introduction:
Health SystemStrategy
The starting point for thinking about health
system priorities for the B.C. health system
is torecognize that British Columbians have
thousands ofsuccessful interactions with the health
care system every day, with multiple examples
ofexcellent results: high quality maternity care;
high quality acute, critical and trauma care services;
excellent cancer care and treatment; high quality
elective surgeries; high quality diagnostic services;
and ahighly trained health workforce. Citizens
ofB.C. enjoy some ofthe best health indicators
in the world, pointing tothe underlying strength
ofthe provinces social determinants ofhealth and
the quality ofits health caresystem.
It is also important torecognize that B.C. has made
meaningful progress across arange ofareas over
the past several years, including: putting in place
aproactive chronic disease prevention framework;
strengthening primary care and, in particular,
improving care and treatment for anumber
ofchronic conditions; improving patient flow
within and between hospitals and the community;
increasingthe use ofday surgeries; an increasing
focus on quality through strengthening clinical care
management, physician quality assurance, and the
establishment ofthe BC Patient Safety & Quality
Council and the Patient Safety Review Boards; and
improving productivity and cost management.

It is equally important torecognize that, despite


significant efforts, there continue tobe persistent
challenges and issues across anumber ofservice
areas: some populations are more vulnerable and
continue toexperience poorer health and health
outcomes; gaps in the continuum ofmental
health services for children and youth, as well as
for some adult patients with moderate tosevere
mental illnesses and/or addictions; responding
proactively and quickly tothe changing complex
health service needs ofthe frail elderly living in the
community in order toavoid or reduce the need
for hospitalization and residential care; providing
emergency response ambulance services in some
rural and remote areas; emergency department
congestion in some large hospitals; long wait
times for some specialist, diagnostic imaging,
and elective surgeries; access toinpatient beds
in some hospitals; and meeting the changing
needs ofpatients in residential care in response
todementia.
There is also the reality that, similar toother
international and Canadian jurisdictions, B.C.s
health system has seen its expenditures for health
services growing at an unsustainable rate. British
Columbia has been successful in driving down this
rate ofgrowth tomore sustainablelevels.

A health care system featuring huge bureaucracies, large institutions, formidable professional associations
andunions, well paid and educated administrators, with turnover of both ministers and senior health
ministry, and all nominally supervised by agoverning political party that has torespond tothe complex
Canadian public response toahealth system encumbered with so much national emotion and self
definition, results in asector thatis large, complex and notoriously difficulttomanage.
The conclusion is that THE HEALTH SYSTEM CANNOT BE CHANGED QUICKLY OR EASILY.
Northatlarge amounts of additional money will necessarily buy change. Notwithstanding the
difficulty ofmakingchange, there is astrong level of consensus thatthehealth system cannot
continue as delivered, administered, andfinanced.
Chronic Condition by Jeffrey Simpson(2012)

Setting Priorities FOR THE B.C.HEALTHSYSTEM

Thechallenge will be tosustain this lower growth


rate while adapting the system tomeet the growth
in demand, closing the gaps, and maintaining
or continuing toimprove quality. These issues
are common across nearly every other health
jurisdiction ofmembers ofthe Organisation for
Economic Co-operation and Development and
have proved difficult toresolve. These challenges
have become the basis for setting priorities for
the health system. They require fresh thinking and
renewed strategiceffort.

The strategic challenge at its simplestis:

Making the necessary changes has been elusive in


most jurisdictions. Challenges tomaking changes
tohealth care are numerous with often divergent,
entrenched viewpoints and established ways
ofdoing business overwhelming efforts tomake
significant transformational shifts. Attempts at
change are frequently relegated topilot projects
that are too small, too vague, too undermanaged
or too slow in implementation tobe effective as
asystem-wide approach tohealth care delivery
innovation. TheCanadian health care system
has been described as asystem plagued by pilot
projects. Thecritical strategic issue is tobe specific
in the scope ofthese challenges and thoughtful
about how toeffectively realize system-wide
improvement.

}} This paper proposes setting priorities for


ahigherperforming health system in B.C.,
basedon analysis and decisions in threeareas:

Setting Priorities FOR THE B.C.HEALTHSYSTEM

}} to maintain and continuously improve the


quality ofwhat we are doingwell;
}} to be specific in identifying, analyzing and taking
effective action toaddress critical gaps and
underperformance;and
}} to drive increased value from the significant
amount ofmoney the Province already spends,
while carefully targeting increases in the budget
toclose criticalgaps.

1. What outcomes do we want toachieve in terms


ofthe health ofpopulations and patients?
Which populations and patients require
prioritizedattention?
2. What kind ofsustainable health service delivery
system do we need tohave in place tomeet
those outcomes and at what level ofquality?
3. What strategy will we pursue toget results?
What enabling factors do we need toleverage
and what constraints do we need tomitigate?

KeyConcepts
It is important tohave ashared understanding
ofseveral keyconcepts:
}} Who are populations andpatients?
}} What makes up the range ofhealth
serviceswithin the B.C. healthsystem?

To better understand how we perform


against these broad outcomes, there is aneed
tounderstand the quality ofhealth services
provided tothe entire population or tospecific
patient populations. To this end, the ministry
divides the population into key segments according
tohealth status and serviceuse:

}} What does qualityreferto?

}} Healthynon-users;

}} Why is sustainabilityanissue?

}} Maternity and healthynewborns;

}} How understanding the link between


operations, continuous improvement, strategy,
innovation, enablers and constraints is
fundamental tosuccessful strategicexecution.

}} Healthy with minor episodic healthneeds;

Having discipline in how we use these terms is


important. Together, they will be used toshape
arobust framework through which we can
drive ashared and convergent dialogue and
acollaborative approach tomanaging change
across alarge and complexsector.

}} Major or significant time-limited healthneeds;


}} Complex mental health and substanceuseneed;
}} Disability in thecommunity;
}} Cancer;
}} Low complexity chronic conditions;
}} Medium complexity chronic conditions;
}} High complexity chronic conditions;
}} Frail incommunity;

UNDERSTANDING POPULATIONS
ANDPATIENTS

}} Frail in residentialcare;and
}} Endoflife.

To meet population and patient health needs,


the Ministry ofHealth focuses on the four areas
suggested by the BC Patient Safety and Quality
Council: staying healthy, getting better, living with
illness and disability, and coping with endoflife.

The ministry analyzes health care use by assigning


each B.C. resident toone the above population
groups based on the condition that determines
their greatest need for health care in aparticular
year. This facilitates amore detailed and useful
analysis ofservicesused.

Meet Population and Patient Health Needs


Staying Healthy

Getting Better

Living with Illness or Disability

Coping with End of Life

Setting Priorities FOR THE B.C.HEALTHSYSTEM

Understanding theRange
and Level ofHealthServices
Along with an understanding ofpopulation and patient health care needs, we also need ashared
understanding ofthe actual range ofhealth services that are provided in an attempt tomeet thoseneeds.
British Columbia provides arange ofpublicly funded services,including:

COMMUNITY

POPULATION AND PUBLICHEALTH

}} Primary health careservices

}} Healthy Living and Healthy Communities

}} Home and CommunitySupports

}} Maternal, Child and FamilyHealth

}} MaternityCare

}} Positive Mental Health and


PreventionofSubstanceHarms

}} Medical SpecialistServices

}} Communicable DiseasePrevention
DIAGNOSTIC AND PHARMACYSERVICES

}} InjuryPrevention

}} Pathology

}} EnvironmentalHealth

}} Diagnostic Imaging/Radiology

}} PublicHealth

}} Pharmaceuticals

}} EmergencyManagement

HOSPITAL

SPECIALTY POPULATIONHEALTH
ANDCARESERVICES

}} HospitalOutpatient
}} CancerCare

}} MentalHealth

}} Ambulatory Support Therapies (RenalDialysis)

}} SubstanceUse

}} Physical Medicine and Rehabilitation

}} AssistedLiving

}} Maternity

}} ResidentialCare

}} Ambulance

}} PalliativeCare

}} EmergencyDepartment
}} In Hospital MedicalCare
}} Anesthesia
}} Ambulatory ElectiveSurgical
}} In Patient ElectiveSurgical
}} TransplantSurgery
}} Trauma and EmergencySurgery

10

Setting Priorities FOR THE B.C.HEALTHSYSTEM

Generally, the range ofhealth services can be


described as falling within one offourlevels:
PREVENTION AND PUBLICHEALTH
}} Activities directed at improving the general wellbeing ofthe population while also involving
specific protection for selected diseases (e.g.,
immunization against measles), injury, and
protection from health risks (e.g., food and
watersafety).
PRIMARYCARE
}} Principal point ofconsultation and treatment for
patients in the health care system and one that
co-ordinates access toother specialists that the
patientmayneed.
}} Mainly focused on health maintenance, minor
illnesses, secondary prevention (preventive
medicine that focuses on early diagnosis,
use ofreferral services, and rapid initiation
oftreatment tostop the progress ofdisease
processes or adisability), and the treatment
oflonger term care for chronic conditions.
SECONDARYCARE
}} The provision ofa specialized consultation or
medical service by aphysician specialist or
ahospital on referral by aprimary carephysician.
}} Mainly focused on tertiary prevention
preventive medicine that deals with the
rehabilitation and return ofa patient toastatus
ofmaximum health with aminimum risk
ofrecurrence ofa physical or mentaldisorder.

TERTIARYCARE
}} Treatment given in ahealth care centre that
includes highly trained specialists and often
advanced technology. Also referred toas acute
care, it is often associated with ahospital and
includes emergency, critical and intensive care
medical services. It can also include tertiary
prevention.
These health services are distributed geographically
across the health system. Thehealth system
through which these services are delivered includes
the organization ofpeople, institutions (public/
private), and the resources needed todeliver
health care services. Thedominant structures are
five regional health authorities, one Provincial
Health Services Authority, and the recently
added provincial First Nations Health Authority.
Theregional health authorities are sub-divided
into 62 geographic service areas categorized as
metro, urban/rural, rural or remote. This provides
amap from which tobetter understand the type
and quality ofhealth services delivered across the
different geographic regions ofBritishColumbia.
These entities have acomplex relationship with
quasi-autonomous physician practices and arange
ofprivate-pay health care serviceproviders.
Underpinning this organizational system are
critical considerations related towhat governance
and financing (public/private payer) mechanisms
might best optimize effective and efficient service
delivery. With these two elements (population/
patient and health services/geographic areas),
wenow have abasic matrix with which toanalyze
services. What is missing is ameans toevaluate the
connection between the two. This is where quality
comesintoplay.

Setting Priorities FOR THE B.C.HEALTHSYSTEM

11

Understanding the ScopeofQuality


Quality is often used without aclear understanding ofwhat it refers to, which makes its measurement
problematic. In B.C., we have adopted the approach used by the BC Patient Safety and Quality Council,
who defines the dimensions ofquality as including effectiveness, appropriateness, accessibility,
safetyandacceptability.

Deliver Quality Health Services


Effectiveness

Appropriateness

Accessibility

Safety

Acceptability

Consistently Provide Patient-Centred Care

Engaged, Skilled, Informed


and Well-Led Workforce

Effectiveness: Care that is known toachieve


intendedoutcomes.
Appropriateness: Care that is provided is evidencebased and specific toindividual clinicalneeds.
Accessibility: Ease with which health services
arereached.
Safety: Avoiding harm resultingfromcare.
Acceptability: Care that is respectful topatient
andfamily preferences, needs andvalues.

Optimal Use
of Resources

Underpinning these dimensions ofquality,


wepropose toadd apriority toconsistently strive
toprovide patient-centred care. While many health
organizations assert they put patients first,there is
an overwhelming consensus that thehealth care
system in many jurisdictions (including Canada)
is built around the needs ofproviders. In any true
patient-centred care deliverymodel, the primary
driver ofpriorities is the patient as opposed
tothe setting where the care is provided or the
experience from the provider perspective.

We need ahealth care system designed todeliver chronic care toan aging population. Thejourney of care
does not last afew days anymore; it often lasts years. Technology and drugs are important, but they should not
take precedence over hands-on care and good old-fashioned caring. OVER TIME, WE HAVE FOCUSED SO
HEAVILY ON INCREASING THE QUANTITY ANDSOPHISTICATION OF CARE THAT WE HAVE LOST
SIGHT OF THE BASICS namely, that we are treating people, not just bodies harbouring acollection of disease
andconditions.
The Path toHealth Care Reform: Policy andPolitics
by Andr Picard(2013)

12

Setting Priorities FOR THE B.C.HEALTHSYSTEM

Research demonstrates that alack ofcaring results


in high health care costs. ThePlanetree organization
has been akey advocate for this issue, asserting
that patient input confirms it is often the simple
acts ofcaring that are most meaningful. Conversely,
the absence ofcaring attitudes and gestures can
leave alasting impression. Improving patientcentred care is about examining all aspects ofthe
patient experience and considering them from the
perspective ofpatients versus the convenience
ofproviders (including administrators, managers
and executives). This requires ashift in the culture
ofhealth care organizations from being diseasecentred and problem-based tobeing personcentred. It requires translating high-level patientcentred care concepts into actionable, attainable
and sustainable practices; engaging medical staff
in patient-centred care; empowering staff working
with patients and residents toindividualize the
experience ofcare; and using data todrivechange.
There is asense among asector ofthe workforce
that as the technology ofhealth care has advanced
(in the context ofrecent strong efforts across
the system todrive efficiency), the personal care
dimension ofquality is being diminished. As
the system evolves in atight fiscal environment,
findingways ofdelivering care that are efficient and
effective without conceding the compassion that
patients expect and deserve is avery realchallenge.
The achievement ofquality is inextricably linked
tothe commitment and skill sets ofthe health
workforce and the ability tooptimally use all
available resources tosupport thisquality.

Why Sustainability isanIssue


Sustainability refers toaset ofactions taken
toensure future generations experience
comparable levels ofconsumption, wealth, utility
and welfare as those ofthe present. Theterm is
most often used in reference tothe health system
tohighlight the continued growth ofthe health
budget above increases in provincial revenues,
leading toother government services suffering
and/or increasing provincial debt neither
ofwhichis sustainable in thelongterm.
Government is challenged on how tomeet the
increasing costs ofthe health care system without
raising taxes and cutting programs. This is further
complicated by the belief ofmany Canadians that
their public health care system should deliver more
without requiring them topayforit.
There is also the question ofhow efficient and costeffective Canadas health caresystemis.
Many health system analysts question why
our health care system stands near the top
ofthe international rankings for per capita
spending, buttoward the bottom for results
(CommonwealthFund survey2010).
Cost and demand pressures on health systems
come from multiple factors, including demographic
change, compensation demands, advances in
medical technology, and growing expectations
from patients and the public. Other contributors
torising health costs include changing
epidemiological patterns and relativeprices.

There are arange ofbodies that influence the


quality ofservices provided, including the BC
Patient Safety and Quality Council, Patient Care
Quality Review Boards, health professional colleges
and regulatory bodies, and the medicine and health
faculties that train health professionals.

Setting Priorities FOR THE B.C.HEALTHSYSTEM

13

In B.C., the five primary drivers ofcost in the health


system have been identifiedas:
1. Inflation(2%)
2. Health care specific inflation pressures (0.7%
driven by high compensationincreases, new
equipment, drug advancements, and increased
use ofinjectabledrugs)
3. Population (1.2% growth and 0.7%aging)
4. Utilization ofservices(0.9%)
5. Aging infrastructure maintenance and
replacement

Over the past few years, B.C. has successfully


managed some ofthese pressures. First and
foremost, with compensation representing
approximately 70 cents ofevery health care dollar
spent in the public system, the government has
been successful with physicians and unions in
collaboratively negotiating agreements tomanage
compensation growth. Secondly, there have been
significant efforts in driving efficiencies in how
we deliver, administer and purchase services and
supplies. Thegraph below shows the Ministry
ofHealth as apercentage oftotal consolidated
government revenues (yellow line) beginning
tolevel out based on areduction in the annual
percentage increase ofthe ministry budget
(blueline).

15%

10%

55%

43.5%

42.1%

44.3%

40%

3.0%

2.7%
2.3%

0%
08/09

09/10

10/11

11/12

50%
45%

2.8%

4.9%

07/08

47.1%

6.3%

5.7%

6.4%

5%

43.7%

43.1%

47.0%

46.6%

45.8%

12/13

2.4%

13/14

14/15

35%
30%

15/16

Due tothese efforts, B.C. now compares well with other provinces, with the second lowest per capita
health spendinginCanada.
PER CAPITA HEALTH CARE SPENDING BY PROVINCIAL GOVERNMENT, 2011
$6,000
$5,077
$5,000

$4,528

$4,348

$4,266

$4,058

$4,033

$4,000

$3,972
$3,645

$3,604

$3,407

ONT

BC

QUE

$3,000
$2,000
$1,000
$NL

AB

SASK

MAN

PEI

NB

NS

Data Source: National Health Expenditure Trends 1975-2011, CIHI, 2011

14

Setting Priorities FOR THE B.C.HEALTHSYSTEM

Additionally, our province compares well against other Organisation for Economic Co-operation and
Development countries for life expectancy and per capita spending. British Columbia has one ofthe
longest life expectancies and is one ofthe lowest in per capita spending. As the figure below demonstrates,
spending more does not equate tobetterhealth.
LIFE EXPECTANCY AT BIRTH TOTAL POPULATION (2009)
AND PER CAPITA SPENDING (2010)
81.4

81.3

$8,233

81.4
81

80.9

80.8
80.4

$3,670

$3,604

$3,974

$3,758

$4,445
$3,022

Australia

B.C.

Sweden

France

Canada

New
Zealand

$3,433 78.2

U.K.

United
States

Sources: Organisation for Economic Co-operation and Development health data (June 30, 2011), International Profiles ofHealth Care Systems
(2012), TheCommonwealth Fund (November 2012), Statistics Canada (Canadian Vital Statistics, Birth and Death Databases and population estimates, CANSIM table 102-0512). Note: Canadian and B.C. birth data are for the 2006 2008 period. Frances birth data is estimated. Australias
per capita spending data is 2009. B.C.s per capita spending datais2011.

The challenge for B.C. will be tosustain these efforts in the context ofa health system that cannot be
changed quickly or easily acknowledging the need for decisions tobe made that may change the
waywedeliver, administer and finance healthcare.

How the Linkages LeadtoSuccess


Understanding the Link between Operations,
Continuous Improvement, Strategy, Innovation,
Enablers and Constraints is Fundamental
toSuccessful StrategicExecution
Understanding the complexities involved in system
change is key toits success. Thefirst and most
important lesson about health care is that simple
one-off solutions tocomplicated problems are
invariably wrong or deeply suspect changing
the health system presents awicked problem.
Itcan be argued that the change agenda is often
significantly undermanaged, moves too slowly
anddoes not result in system-wide transformation.

Operational management is the basic day-today processes by which the health care system
produces its services and delivers them topatients.
These are both direct (service delivery) and indirect
(human resources, information technology, budget
and cost management). Continued efforts tolean
these processes reducing waste and improving
efficiencies can result in cost savings, deliver
short-term quality improvements, and are critical
underpinnings ofa sustainable health system in
BritishColumbia.
Strategy points tothe overarching efforts
tosuccessfully position the health system
toprovide both quality services and sustainability.
It can be described as the approach used by the
provincial health system tocreate value for its
population and patients. Strategy is often assumed

Setting Priorities FOR THE B.C.HEALTHSYSTEM

15

tobe synonymous with aplan. A plan supposes


asequence ofevents that allows one tomove
with confidence from one situation toanother. A
strategy implies the involvement and dependence
on others with different and possibly opposing
interests and concerns. This is critical tochange
management in ahealth system populated by
multiple professional, administrative, and political
interests. A successful strategy has tosuccessfully
navigate the differences in these interests
toastatedendpoint.
Innovation is often an important element ofa
successful strategy. Innovation refers togenerating
anew solution toaproblem. It can involve new
services, products and processes, or involve ideas
based on cutting-edge discoveries, technologies
and practices. Innovation involves doing something
differently rather than doing the same thing and
expecting differentresults.

Also critical toasuccessful strategy is accurately


assessing the factors that enable or constrain
thestrategy:
}} The range ofideas, values and beliefs about
the vision for health care how it should be
organized and how it should be evaluated.
These are expressed in the prescribed and
emergent structures and systems that drive
the organization. In health care, the role
ofthe hospital has been akey, and potentially
dysfunctional, driver ofthe way health care
hasdeveloped.
}} The impact ofthe organizational context
(political, cultural, financial). Thefiscal constraint
highlighted above is an important constraint on
any chosenstrategy.
}} Power dependencies in the health care
sector are also critical. Power is dispersed
and distributed across arange ofcompeting
professional groups, health administrators,
civil servants, politicians, interest groups
andsuppliers.
}} The capacity (e.g., leadership, management,
commitment, knowledge/skills, and information
management) todeliver astrategy.
Each ofthese elements requires careful assessment
in crafting asuccessfulstrategy.

16

Setting Priorities FOR THE B.C.HEALTHSYSTEM

Strategy Implementation
and Future DirectioninB.C.
The Innovation and Change Agenda
(2009-2013)
Setting new priorities starts with understanding
where we are. Four years ago, B.C. implemented
asector-wide strategy called the Innovation
and Change Agenda totry todrive meaningful
change across the health system. TheInnovation
and Change Agenda is structured under four key
themes. Thefirst three are linked tomajor health
services delivery areas, and are underpinned by the
fourth strategic imperative:
1. Providing effective health promotion, prevention
and self-management toimprove the health and
wellness ofBritish Columbians.
2. Meeting the majority ofhealth needs with high
quality primary and community based health
care and supportservices.
3. Ensuring high quality hospital care services are
available whenneeded.

carried out amulti-pronged approach aimed at


avoiding or delaying the onset ofchronic disease
through population based healthpromotion.
The Healthy Families BC strategy targets
investments and efforts into programs with
measurable outcomes that address physical
inactivity, unhealthy eating, and obesity by focusing
on four key areas: proper nutrition, healthy lifestyles,
resources for parents and fostering healthy
communities. For example, the groundbreaking
partnership with ParticipACTION has enabled
increases in physical activity levels throughout the
province and has strengthened British Columbias
reputation as aleader in healthyliving.
A Parliamentary Secretary for Healthy Living was
appointed with amandate towork with medical
professionals and make recommendations tothe
minister on how government can support healthy
living and preventative healthmeasures.

4. Improving innovation, productivity and


efficiency in the delivery ofhealthservices.

INTEGRATIONOFPRIMARY
AND COMMUNITYCARE

HEALTH PROMOTIONAND
PREVENTION OFCHRONICDISEASE

Integrated primary and community care strategies


are aimed at shifting the way health care is
managed and delivered toprovide the coordination and continuity ofcare required tomeet
the needs oftargeted populations: those with
complex chronic conditions, people with moderate

In partnership with health authorities and other


sectors (e.g., local governments, schools, nongovernmental organizations), the ministry has

If left unrestrained, health spending could soon exceed realistic limits beyond what governments, social security
or family budgets can afford. The need torein in large fiscal deficits offers AN OPPORTUNITY TORETHINK THE
FINANCING AND DELIVERY MODELS OF HEALTH SYSTEMS. Long-term trends are equally challenging, with
changes in disease patterns forcing countries todeal with the rapidly changing structure of sicknesses, especially the
growing burden of non-communicable and ageing-related diseases. This will require investing inpreventing chronic
illnesses related tolifestyles as well as promoting integrated care and further innovation inhealthservices.
Angel Gurria, secretary general, Organisation for Economic Co-operation and Development

Setting Priorities FOR THE B.C.HEALTHSYSTEM

17

tosevere mental illness and/or substance use,


thefrail elderly, and individuals with dementia
oratendoflife.
Structural elements have been put in place
tofacilitate increased capacity for care in the
community, in addition tothe implementation
ofa wide range ofprograms toimprove care
for targeted populations and efforts toimprove
access through ongoing programs such as GP4Me.
Currently, 32 Divisions ofFamily Practice (groups
ofphysicians working toaddress common health
care goals within their region) cover 53 ofthe 62
geographic service areas. These divisions are linked
tothe use ofcollaborative services committees
bringing physicians, the B.C. Medical Association,
the ministry, health authorities and communities
together tomake decisions about localservices.
A more recent development has been the tripartite
agreement between the federal government,
provincial government and First Nations toestablish
the First Nations Health Authority, which focuses
onawellness approach tostrengthening the health
ofB.C. First Nations peoples and communities.
HIGH QUALITY HOSPITALSERVICES
Hospital-related strategies include standardizing
anumber ofevidence-based care protocols,
increasing access toappropriate diagnostic imaging
services, increasing surgical capacity toreduce
wait times, improving flow though emergency
departments and improving medical inpatient bed
management. These actions have been supported
by the establishmentofthe
BC Patient Safety and Quality Council and improved
systems torespond topatient complaints and
concerns through the use ofPatient Care Quality
ReviewBoards.

INNOVATION, PRODUCTIVITY
ANDEFFICIENCY
The ministry has pursued assertive expenditure
management through the use ofinnovative
strategies toincrease productivity and improve
efficiencies. Specific actionsinclude:
}} Lean process improvements toreducewaste.
}} Active management ofpharmaceutical and
laboratorycosts.
}} Consolidation ofback-office functions and
shared businessservices.
}} Activity-based financial incentives and patient
focusedfunding.
}} Information management/technology
solutions,including:
Implementation ofe-Health, developing
systems tomake health care information
accessible, supporting personal health and
health care decision-making, and health
system sustainability.
Development ofthe BC ServicesCard.

Strengths oftheInnovation
and ChangeAgenda
With the establishment ofthe Innovation and
Change Agenda, the provincial health system has
had aconsistent, overarching system-wide strategic
framework over four years something that had
not been attempted inthepast.
The Innovation and Change Agenda has laid down
the foundational elements ofseveral large system
strategies:
}} Healthy Families BC provides the foundation for
aprovincial chronic disease preventionstrategy;
}} The First Nations Health Authority is an
important foundation in closing the health gaps
between Aboriginal and non-Aboriginal British
Columbians;

18

Setting Priorities FOR THE B.C.HEALTHSYSTEM

}} The integration ofprimary and community care,


including the development ofDivisions ofFamily
Practice, is better meeting the secondary
prevention and continuity ofcare needs for
chronic illness management and improved
community care offrailpatients;
}} Meaningful increases in the amount and
timeliness ofmany day surgeries, and
significant improvement in effective flow/bed
management in hospitals;and
}} The eHealth program has established arobust
information technology infrastructure, creating
and enhancing information repositories and
building secure information exchange services
that enable the exchange ofhealth information
(e.g., drug profiles, laboratory tests, medical
imaging information).
The Innovation and Change Agenda also focused
on cost savings and efficiency. Theleading
actions were consolidating back-office functions
and implementing shared purchasing across
health authorities, and strong management
ofpharmaceutical and laboratory medicine costs.
This has resulted in helping toslow growth in
government spending. Prior tothe agendas
implementation, health care funding was growing
by about seven per cent ayear. Budget 2013 saw
a2.6 per centgrowth.
In 2008, the provincial government created the BC
Patient Safety & Quality Council toenhance patient
safety, reduce errors, promote transparency and
identify best practices toimprove patient care.
Its mission is toprovide system-wide leadership
through collaboration with patients, the public and
those working within the health system. Progress
has been achieved on quality care improvement
through the implementation and use ofclinical
care guidelines in asmall number ofselected
areas. Government also introduced the Patient
Care Quality Review Board Act toestablish aclear,
consistent, timely and transparent approach
tomanaging patient care quality complaints in
British Columbia. This process provides patients

with the opportunity tobetter resolve concerns


and further improve the quality ofthe provinces
health caresystem.
Most recently, the B.C. Government launched
an open competition torecruit B.C.s first seniors
advocate. This role will be an important part ofan
overall strategic focus on improving care for B.C.
seniors that beganin2012.

Challenges oftheInnovation
and ChangeAgenda
Some ofthe key challenges for the agenda
were related tochange management and
the implementation ofthe strategy across
acomplex sector. Alignment and buy-in from
health authorities and other system partners
tothe provincial strategy has been partial and
incremental (highlighting the challenge ofbuilding
commitment toashared agenda across diffuse
interests and power dependencies) due tothe
limited capacity in the system todeliver systemwide strategic change in atimely manner. There
have also been persistent challenges in the
accessibility, quality, and availability ofdata for
performance management, monitoring and
outcomes measurement across the system. There is
still work todo before the benefitsofthe e-Health
strategy is fully realized in particular with regards
tothe use ofthe electronic medical/ health record
and health informationexchange.
As noted at the beginning ofthis paper, several
service areas remain stubbornly problematic and
resistant tosuccessful resolution despite significant
effort and some key populations continue tobe
more vulnerable and experience poorer health
and health outcomes. These challenges and gaps
provide an opportunity for reassessment and
fresh strategic efforts in setting ofpriorities for the
coming threeyears.

Setting Priorities FOR THE B.C.HEALTHSYSTEM

19

FutureDirection
The ministers mandate letter (June 2013)
states that the Minister ofHealth is responsible
for protecting and enhancing the health care
system while ensuring the best possible value for
taxpayers in the context ofsignificant demand
pressure. Itincludes two instructions regarding
the overall direction for the health system. One is
tocontinue the Innovation and Change Agenda by
driving change in the areas ofprimary care, home
and community care, hospitals, and prevention
(mandate letter, no. 4). Theother mandate direction
is torecommend tocabinet the new priorities
forthe health system toensure maximum value
for taxpayers while providing maximum benefit
forpatients (mandate letter,no.3).
Additional mandate deliverables focus on key
service areas prevention, utilization ofnurse
practitioners, mental health service improvement,
laboratory reform, addiction service expansion,
expanded end-of-life care services, and successful
labour negotiations.

20

Setting Priorities FOR THE B.C.HEALTHSYSTEM

Finally, the minister must ensure services are


delivered within health authority and overall
ministrybudgets.
Having set out the context and starting point,
let us now turn toanswering the following three
keyquestions:
1. What outcomes do we want toachieve in terms
ofthe health ofpopulations and patients?
Which populations and patients require
prioritizedattention?
2. What kind ofsustainable health service delivery
system do we need tohave in place tomeet
those outcomes and at what level ofquality?
3. What strategy will we pursue toget results?
What enabling factors do we need toleverage
and what constraints do we need tomitigate?

HealthOutcomes
WHAT HEALTH OUTCOMES DO
WEWANTTOACHIEVE FORTHE
POPULATION ANDPATIENTS?

Population and PatientSegments


British Columbia has apopulation of4.64 million
people, made up of50.5 per cent women
and 49.5per cent men. Almost athird ofB.C.s
population is over the age of50, while the
proportion ofchildren under 15 is lower than ever.
Within the next 15 years there will be fewer schoolage children than people over 65 and more people
retiring than entering the workforce. It is expected
that by 2022, one in five British Columbians will be
over 65yearsold.
B.C. generally has the healthiest population in
Canada and experiences among the highest life
expectancy (82 years) in Canada (81 years) and
the world (70 years). Weare continuing tosee
decreasing premature mortality rates. However,
there are still over 550,000 British Columbians who
smoke and over one million who are overweight
or obese.Additionally, adecrease in premature
mortality is not consistent across the province,
andin particular the gap between the North and
other health authorities is growing. There continue
tobe significant differences in health outcomes
between Aboriginal and non-Aboriginal people in
the province, notably in terms ofhealth indicators
such as life expectancy and mortality. These
elements point tothe importance ofthe social
determinants ofpopulation health as opposed
tothe role the health care systemplays.

The key tounderstanding how best todeliver care


toBritish Columbians is an in-depth understanding
ofthe care requirements ofthe patients themselves.
For the purposes ofthis analysis, health service use
is used torepresentneed.
As noted earlier, the Ministry ofHealth analyzes
health care use using aframework that assigns
each B.C. resident toapopulation group based
on the condition that determines their greatest
need for health care in aparticular year. Within
this framework, the health care needs ofthe
population can be divided into the following
keypopulationsegments:
}} Healthynon-users
}} Maternity and healthynewborns
}} Healthy with minor episodic healthneeds
}} Major or significant time-limited healthneeds
}} Complex mental health and substanceuseneed
}} Disability in thecommunity
}} Cancer
}} Low complexity chronicconditions
}} Medium complexity chronicconditions
}} High complexity chronicconditions
}} Frail incommunity
}} Frail in residentialcare
}} EndofLife

...B.C. generally has the healthiest population


in Canada and experiences among the
HIGHEST LIFE EXPECTANCY...

Setting Priorities FOR THE B.C.HEALTHSYSTEM

21

Underpinning an understanding ofthese


population segments is the need tounderstand
population differences across diverse geographic
and socio-economic status, and their impact on
health status. As noted earlier, this is facilitated by
the regional health authorities being sub-divided
into 62 geographic service areas categorized as
metro, urban/rural, rural or remote. This allows us
tobetter understand the type and quality ofhealth
services delivered across the different geographic
regions ofBritishColumbia.

The following table lists each population segment,


their number and percentage ofthe overall
population, and the number and percentage
ofoverall health spending they required in 2011/12.
It covers approximately two-thirds ofactivity across
akey number ofthe health services1. While the
data is incomplete, it is still agood representation
ofhealthcareuse.

Healthy Non-Users
Maternity and Healthy Newborns
Healthy with minor episodic health needs
Major or Significant time limited health needs: Adults
Major or Significant time limited health needs: <18 yrs
Mental Health and Substance Use needs
Population with Cancer
Low Complex Chronic Conditions
Medium Complex Chronic Conditions
High Complex Chronic Conditions
Frail Population, living in the Community
Frail Population, living in Residential Care
Palliative Needs
All Population Segments

662
111
1,613
119
45
83
54
1,332
383
208
13
38
16
4,675

14%
2%
35%
3%
1%
2%
1%
28%
8%
4%
0%
1%
0%
100%

$
$
$
$
$
$
$
$
$
$
$
$
$

29
150
26
9
19
26
235
145
156
16
27
31
868
9%

$ 148
$ 199
$ 122
$
47
$ 100
$ 107
$ 520
$ 315
$ 311
$
17
$
50
$
41
$ 1,977
20%

$
$
$
$
$
$
$
$
$
$
$
$
$

5
11
51
8
94
28
221
207
251
24
44
27
970
10%

$
$
$
$
$
$
$
$
$
$
$
$
$

188
203
180
225
284
404
418
958
82
381
271
3,595
36%

$
$
$
$
$

Residential Care

Supports for Daily Living

Population Segments Assigned to their


highest health care need in the year

Hospital Care (Inpatient & Day


Surgery, not including
Physicians)

People
(Thousands)

PharmaCare

Estimate of the distribution of $9.9 Billion


of Selected Publicly Funded Health Services
used by BC Residents in 2011/12

Primary Care (GP and


Professional Home Nursing)

Health System Matrix 5.0

Specialists, Surgeons, Labs and


Diagnostics

Millions of Dollars

12 $

236
158
48
32
486
5%

Total Cost
(Millions)

$
17
$
7
$ 1,912
$
57
$ 1,994
20%

$
369
$
359
$
401
$
244
$
438
$
459
$ 1,380
$ 1,086
$ 1,928
$
305
$ 2,462
$
458
$ 9,889
100%

0%
4%
4%
4%
2%
4%
5%
14%
11%
19%
3%
25%
5%
100%

Selected publicly funded Health Care Services are based on Physician encounter billings, PharmaCare paid prescriptions, Hospitalizations, HCCcommununity
services (Home Support, Assisted Living, Adult Day Services, Home Care Professional Services), and Residential Care. Peopleare assigned to their highest health
care need in the year, and all their health care services in the year are counted in that final population segment, even if they occurred earlier in theyear.

The population and patient needs analysis results


in some key findings about the populations and
services most in need ofattention. Four populations
in particular are relatively low in number but use
high percentages ofhealthservices1:
1This analysis includes publicly funded health services that are
reported to the ministry on a person specific basis. It represents
approximately $9.9 billion in publicly funded services, though
some services are not included (e.g., salaried physician services,
community mental health expenditures, BC Cancer Agency
activities). PEOPLE 34 Population Data, BCSTATS.

22

Setting Priorities FOR THE B.C.HEALTHSYSTEM

1. people receiving cancertreatment;


2. the frail senior population living in
residentialcare;
3. people with medium or high complex chronic
condition;and
4. patients with severe mental illness and/or
substanceuse.

People receiving cancer treatment are large


users ofresources in generally atwo year period
the year ofdiagnosis and the following year
as treatment continues. This use ofservices is
understandable and largely unavoidable, and
British Columbia is seen tohave ahigh functioning
cancer care system that generates some ofthe best
patient outcomes in the world. As such, this is not
seen as an area requiring priority action beyond the
regular focus ofcontinuous improvement by the BC
CancerAgency.

The next two population segments on the list are


dominated by older adults (65+) and use 55 per
cent ofall services. As demonstrated in the chart
below, these two populations also have some
ofthe highest projected growth rates in population
and service demand between 2011and2036.
These three populations also play akey role in
many ofthe service challenges identifiedearlier.

GROWTH IN DEMAND FOR HEALTH CARE BY POPULATION SEGMENT


IMPACT OF PROJECTED GROWTH IN B.C. POPULATION
Growth 2011 to 2016

Next 10 Years to 2026

Next 10 Years to 2036


120%

Frail in Care (In Residential Care)


98%

High Complex Chronic Conditions

96%

Frail in the Community

93%

End of Life
76%

Medium Complex Chronic Conditions

69%

Cancer
45%

Low Complex Chronic Conditions

45%

Sever Disability
32%

Mental Health and Substance Use

31%

Adult Major Condition, OTHER

25%

Healthy and Low Users


Child and Youth < 18 years

19%

Maternity and Healthy Newborns

18%

Total

120%
0%

20%

FRAILSENIORS
British Columbias population is growing and
aging, with the fastest growing seniors population
in Canada. Thepopulation over 65 is expected
toincrease from about 14 per cent to24 per
cent ofthe total provincial population between
2006and2036.
Theaging ofthe population is important as the
likelihood that aperson will have at least one

40%

60%

80%

100%

120%

chronic condition or life-limiting illness increases


significantly with age. As aresult, so does their need
for healthservices.
While seniors use more health services than other
populations, they are not ahomogenous group and
only asubset ofseniors requires high cost services.
Those using residential care represent one per cent
ofthe population and only nine per cent ofthe
total population over 75, but use 25 per cent ofall
health systemresources.

Setting Priorities FOR THE B.C.HEALTHSYSTEM

23

Once people enter residential care, the majority


oftheir publicly funded health care is provided by
the residential care facility (91%). However, alarge
driver oftotal cost occurs in the year prior to, and
the year of, entry into residential care - with high
rates ofhospitalization via emergency departments
en route toresidential care. For example, more than
seven out ofevery 10 new entrants toresidential
care have at least one inpatient hospitalization
intheyear.
The health status ofseniors prior toentering
residential care is an important factor in the analysis
ofpopulation and patient needs. More than 60
per cent ofpeople entering residential care have
been identified as having ahigh complexity
chronic condition in the previous year, and it is
likely that many will also have fallen into the frail
in community category as well. These seniors
require arange ofhealth supports tomanage
the challenges ofincreasing frailty, which is often
combined with chronic diseases such as dementia
that can profoundly impact their ability tomaintain
independence.
It is estimated that frail seniors in the community
may be under-served by existing community
and support services, which may only hasten the
need for high-intensity residential care. Once in
residential care, there are challenges as tohow
we provide dignified and compassionate care
given the increasing number ofpatients suffering
with moderate toadvanced dementia and the
associated care and behavioural challenges
thispresents.
The data confirms the continued need for
astrategic and operational focus on improving
health care interventions and services for asubset
ofseniors using atargeted population approach
tobetter manage chronic conditions, avoid
unnecessary emergency department visits and
hospitalizations, and better plan for the impact
offrailty on aseniors ability tocontinue tolive
safely in the community. Improving the quality
ofgeriatric care across the entire health care

24

Setting Priorities FOR THE B.C.HEALTHSYSTEM

systemcontinuum is critical toensuring that seniors


receive the most appropriate care topromote the
best outcomes and quality oflife, including the
need for palliative care as they approach end oflife.
Thecosts ofinappropriate hospitalization versus
expanded and more effective care options in the
community must be akey consideration in any
strategy goingforward.
Preventative services for seniors are also
vitally important. Prolonged inactivity during
hospitalization can lead toaloss offunction
and mobility. Seniors who are admitted toacute
care often get discharged with areduced level
offunctional ability and never recover their
previous level ofindependence.
CHRONICCONDITIONS
Frailty is linked in part tocomplex chronic
conditions. People with medium or high complexity
chronic conditions represent 12 per cent ofB.C.s
population and use 30 per cent ofhealth
systemresources.
With an aging demographic, the prevalence
ofchronic illnesses is on the rise. Chronic illnesses
have multiple causes that vary over time, including:
hereditary factors, social and economic status,
lifestyle (e.g., poor diet, lack ofexercise, smoking
and/or alcohol consumption, stress), exposure
toenvironmental factors and physiological factors.
There are awide range ofchronic illnesses (e.g.,
arthritis, asthma, lung disease, chronic pain,
congestive heart failure, diabetes, high blood
pressure, stroke) that require sustained and coordinated medical and non-medical management.
People with high complex chronic conditions
use the most hospital, PharmaCare, and home
and community care services, and are high users
ofgeneral practitioner and specialist services.
Thirty-five per cent ofpeople in this population
were hospitalized at least once duringtheyear.

There is aclear progression over arelatively short


time period (five years) where people move from
healthy or low complexity chronic conditions
tohigh complexity chronic conditions. For people
newly diagnosed with one or more chronic
conditions, their hospital and specialist costs are
much higher than for people who already are in
the high complexity chronic conditions category.
This can be explained by the significant medical
intervention needed in the initial acute onset ofthe
illness, as opposed tothe the disease management
stage thatfollows.
Patients with chronic disease require increased
time, planning and care co-ordination as they age.
Inadequate or ineffective community care also
results in increased demand for acute care services.
This is clearly less than optimal for the patient
and unnecessarily more expensive. Thechallenge
is tobetter understand this reality and change
the trajectory through earlier, more effective
interventions.
SEVERE MENTALILLNESS
AND/OR SUBSTANCEUSE
While being asmaller driver ofoverall health care
costs, mental health and substance use conditions
represent ahigh burden ofdisease in the
population due tothe early age ofonset for severe
mental illness (typically before age 24) and need for
ongoing treatment and support across thelifespan.
The majority ofchildren, youth and adults with
mild tomoderate mental health and/or substance
use problems can be effectively supported or
treated through low-intensity community-based
services. However, this statement is dependent
upon the timely access toeffective evidencebasedtreatment.
A small proportion ofpeople experience severe
and complex problems that require more intensive
service approaches. According tothe ministrys
patient and population needs analysis, people
with severe mental illness and/or substance use
problems represent about two per cent ofthe
population. However, they are significant users

ofhospital services, which are linked in part toan


imbalance between hospital use and effective
community resources. While patients presenting
with mental illness or substance use needs
represent only six per cent ofemergency visits,
29 per cent ofthose visits result in admission
toan inpatient bed, using close to3.5 per cent
ofinpatient bed days at acost of$390million.
In this context, there is agrowing level ofconcern
regarding the capacity ofthe health system
toeffectively meet the needs ofindividuals with
severe addictions and/or mental health illness. In
particular, asubset ofthese individuals suffers from
chronic, disabling poly-substance use and often
severe mentalillness.
The costs ofuntreated or under-treated mental
illness and addictions go well beyond the health
care system and impact the ministries ofSocial
Development and Social Innovation, Housing
andJustice.
ACCESS ANDWAITTIMES
The three populations described above are an
important contributing factor toageneral issue
that is often portrayed as widespread across
Canadas health system access and wait times.
As noted at the beginning ofthis paper, the
starting point for thinking about access and wait
times is torecognize that British Columbians have
thousands ofsuccessful interactions with the health
care system every day, with multiple examples
ofexcellentresults.
Many large emergency departments remain
congested. Thetotal number ofemergency visits
continues toincrease each year (an 8.6 per cent
increase from 2009 to2013), and the per capita
number ofvisits has also increased (by three per
cent from 2009 to2013). There are now over two
million emergency department visits per year.
Thepercentage ofemergency patients admitted
within 10 hours ofdecision toadmit remains at 67
per cent, while the percentage admitted within two
hours has declined from 39 per cent to38 per cent
(2009and2013).

Setting Priorities FOR THE B.C.HEALTHSYSTEM

25

Most medium and large hospitals operate


consistently at capacity levels close toand over
the nominally funded 100 per cent bed level.
This is predominantly driven by demand for
medical inpatient beds from the populations
identifiedabove.
Overall, Canadian elective surgical waitlist reduction
strategies have been expensive, narrow in focus
and only partially successful. A negotiated 2003/04
agreement committed funding of$5.5-billion
over 10 years tothe Wait Time Reduction Fund
in order toreduce wait times for five procedures:
cataract removal, hip and knee replacements,
diagnostic imaging, cardiac bypass surgery and
cancer radiation therapy. In 2011, the Canadian
Institute for Health Information showed that there
were reported improvements for three years, but
also noted the very generous timelines being
used by the health sector tomeasure the success
ofthestrategy.
Despite the attention paid tosurgical waitlists and
increases in volumes ofelective surgeries, B.C.s
wait times for many procedures have not declined
and performance is either stagnant or slipping.
For example, the average wait time for the top 20
surgical procedures declined slightly from 2009
to2010, but has remained mostly the same since
then. Thepercentage ofnon-emergency surgeries
completed within the benchmark wait time in
B.C. currently stands at 66 per cent (Q2 2013/14),
down from 82 per cent in 2010/11. In 2002/03,
90 per cent ofpatients received their procedure
within 23 weeks. Ten years later (2012/13), 90 per
cent ofpatients received their procedure within
26 weeks. Over the same time period, the number
ofprocedures increased from 206,000 to218,000
per year, pointing toincreased use based on
procedural improvements.
Finally, in the area ofdiagnostic imaging, and
despite the needed debate on appropriateness,
B.C.has one ofthe lowest rates ofMRI and CT
exams in Canada and has only recently begun
measuring wait times for diagnostic procedures.

26

Setting Priorities FOR THE B.C.HEALTHSYSTEM

OUTCOMES
Based on this population and patient analysis, what
outcomes might B.C. want toachieve? This can be
framed in three propositions:
}} To improve health outcomes, as well as
patient and workforce satisfaction, we need
todrive apatient-centred culture across the
healthsector.
}} Any strategy going forward needs torequire that
we maintain and incrementally improve on what
is workingwell.
}} There are several population segments where
it is critical that we achieve system-wide
improvement both from apopulation wellness,
patient health and quality oflife perspective and
from abudget management perspective.
Six desired outcome areasstandout:
}} Effective chronic disease prevention through
universal and targeted population health
interventions that address all major risk factors
across the lifecycle.
}} Reducing hospitalization and the need for
residential care by preventing or slowing down
the onset offrailty. This can be achieved through
targeted secondary prevention, with aparticular
focus on better managing the development
from low tomoderate tocomplex chronic
conditions linked toaging/increased frailty
thatappear tohappen over afive-yearperiod.
}} Reducing hospitalizations through effective
secondary and tertiary prevention for mental
illness and addictions.
}} Increasing timely access toevidence-informed
care from specialists, diagnostic imaging,
andelectivesurgery.
}} Providing consistent quality ofcare for
residential care patients, with astrong focus
onquality ofcare for dementiapatients.
}} Effective and compassionate care for end-oflifepatients.

Quality and a Sustainable


Service DeliverySystem
WHAT KIND OFSUSTAINABLE HEALTH
SERVICE DELIVERY SYSTEM DO WE
NEEDTOHAVE IN PLACE TOMEET THESE
POPULATION AND PATIENT NEEDS,
ANDATWHAT LEVEL OFQUALITY?
This section ofthe paper identifies eight linked
areas that will require prioritized and sustained
focus toachieve meaningful improvements in
thepopulation and patient outcomes identified
inthe previoussection.

PRIORITY1:

Provide patient-centredcare
Patient-centred care will be the foundational driver
in the planning and implementation ofall strategic
actions in the health system strategy. Theprovince
will strive todeliver health care as aservice built
around the individual, not the provider and
administration. Wewill do this in collaboration with
our health workforce and with patients. This is not
an overnight change, but apromise ofa sustained
focus that will drive policy, service design, training,
service delivery, and service accountability systems
over the coming threeyears.
A first key action will be tostart toshift the culture
ofpublicly funded health care organizations in B.C.,
where required, from being provider/administratorcentred and/or overly disease-centred tobeing

person-centred. It will require translating high-level


patient-centred care concepts into actionable,
attainable and sustainable practices across all
sectors ofthe health system, including: engaging
medical, nursing, allied health and support staff;
empowering staff working closest with patients
andresidents toindividualize the experience
ofcare; and using feedback from patients
toevaluate and drive change. This approach
willbe built into governance evaluation, as well
asexecutive and staff performancereviews.
A key deliverable will be the development
ofaframework for patient centred care, which
setsout key principles, practices anddeliverables.

PRIORITY2:

Implement targeted andeffective


primary prevention andhealth
promotion through aco-ordinated
deliverysystem
Chronic disease and injury prevention is essential
for improving overall population health and
reducing the growth ofhealth care costs. British
Columbia has built astrong prevention foundation
and is seeing results. However, sustained efforts
are required, and amore focused approach can be
taken toprevent and reduce avoidable illness and
injury and the associated care and treatmentcosts.

The Informed Dining program provides consumers with nutrition information


upon request before or at the point of ordering in the restaurant so that they can
MAKE INFORMED MENUCHOICEs.
Now implemented in 37 restaurants, with 1,523 OUTLETS INB.C.
(and 6,035 outlets acrossCanada).
Setting Priorities FOR THE B.C.HEALTHSYSTEM

27

The first key focus ofthe prevention strategy will


be towork with partners in health authorities and
the wider health sector (e.g., non-government
organizations) tobuild on Healthy Families
BC, withasuite ofevidence-informed actions
organizedacross seven interventionstreams:
}} Healthyeating
}} Physicalactivity
}} Tobaccocontrol
}} Healthy early childhood development
}} Positive mental healthpromotion
}} Building aculture ofmoderation for alcoholuse
}} Injuryprevention
Activity in these areas will focus on the life course
and key settings, designing interventions that
take into account health inequities and using
multiple tools ofinfluence. A second key focus
will be tomore explicitly apply the behavioural
sciences toshift (nudge) modifiable behaviour at
the individual level for enough ofthe population
tohave ameaningful impact on overall health
inthelongterm.
The prevention strategy will implement four ofthe
goals in B.C.s Guiding Framework for Public Health,
and will drive action tohelp meet these goals and
the 10-year performance measures outlined in that
directionaldocument.

PRIORITY3:

Implement aprovincial system


ofprimary and communitycare
built around inter-professional
teamsandfunctions
Critical tomaking progress in reducing
hospitalizations and the need for residential care
is toprevent or slow down the onset offrailty or
the need for hospitalization through effective
and proactive secondary and tertiary prevention
for frailty, chronic diseases, mental illness and
addictions. Therole offamily physicians, primary
and community care professionals and support
staff are central tothis effort. To the extent possible,
patients and families will be encouraged tobe
active partners in theirowncare.
Efforts todate todevelop asystem ofprimary and
community care have focused on establishing
foundational elements linked toimproved care
for patients with chronic diseases and structures
such as the Divisions ofFamily Practice across the
province (linking family physicians around quality
care at acommunity level) and their associated
collaborative services committees (linking family
physicians with health authorities). British Columbia
is now well positioned tofurther leverage this
collaborative infrastructure with meaningful service
shifts in chronic disease management and care
improvements ofthe frail elderly in the community.
This will include astrong focus on inter-professional
teams andfunctions.
Key tothis approach is facilitating ahealthy
partnership between community physicians and
health authorities, as well as ensuring progress
on the GP4ME and NP4BC programs. Further, the
ombudspersons report, TheBest Care: Getting It
Right for Seniors in British Columbia, the subsequent
Improving Care for B.C. Seniors: An Action Plan, and
the Healthy Minds, Healthy People mental health
plan (mandate letter, no. 5) all provide important
reference points for driving improvements tohome

28

Setting Priorities FOR THE B.C.HEALTHSYSTEM

A GP 4ME
2,100 family physicians have
registered for theprogram.

4,200 previously

unattached complex patients


now have afamilyphysician.

and community care, home support and assisted


living (as well as residential care) and mental health
and addictionservices.
A key action for this priority is tofully implement
access tofamily physicians and primary health care
teams across all 62 geographic service areas (metro,
urban/rural, rural or remote) based on asystem
ofinter-professional health teams. Thesystem
has astrong focus on populations and individuals
with high health and support needs: patients with
chronic diseases, the frail elderly, people with severe
mental illness and/or substance use problems, and
people with significant disabilities.
In particular, this action will enable amore
consistent approach toworking with rural
communities by ensuring that residents in rural
and remote areas ofthe province, including First
Nations, have reasonable but consistent access
toservices,including:
}} Defining what access looks like for primary,
community and ambulance care in rural and
remote communities.
}} Facilitating partnerships with communities in
shaping health servicedelivery.
}} Establishing clear patient pathways for how rural
and remote communities are linked tospecialist
and acute care services (e.g., information
management and technology, telehealth,
transportation).

An integrated and team-based clinical case


management approach will focus on delivering
services topatients moving toward frailty or
chronicdisease.
Planned health system funding increases will be
targeted tosupport this action,including:
}} Increasing aging in place and home care/
monitoring services and technologies for higher
risk patient populationsegments.
}} Ensuring adequate and cost-effective home and
community care, supported by quality standards.
There will be astrong focus on providing
responsive step-up/down home and community
care services that reduce emergency visits and
hospitalization and slow down the progress
offrailty inseniors.
}} Increasing 24/7 access toprimary care for higher
risk patient populations.
}} Increasing group-based care for targeted
patient populations led by diverse health
professionalteams.
}} Improving planning for transitions between
community and residential care toreduce
avoidable hospitalizations.
}} Improving community-based services for
children and youth with mental illness and
adults with moderate tosevere mental illness
and substance use problems, including those
with aggressive and antisocial behaviours
and additional addiction spaces (mandate
letter,no.9)
}} Improving dementia care, including support and
training for formal and informal caregivers and
developing amore adequate service framework
for different stages ofdementia linked tothe
expansion ofhome and residential careoptions.
}} Improving end-of-life (palliative) care, including
hospice space expansion where appropriate
(mandate letter,no.10).

}} Creating asustainable and effective rural health


human resourcesstrategy.

Setting Priorities FOR THE B.C.HEALTHSYSTEM

29

PRIORITY4:

Strengthen the interface between


primary and specialist care
andtreatment
In ahigh functioning health system, patients with
conditions requiring specialist services experience
seamless and timely access tothe services they
need. A priority area for further improvement
is the ability offamily physicians, primary and
community care practitioners tofacilitate timely
access tospecialist levels ofcare for their patients
whenneeded.
A key action for this priority is toensure timely
access tomedical and surgical specialty
consultation and treatment across all 62 geographic
service areas (metro, urban/rural, rural or remote).
In support ofthis action, major deliverables
willinclude:
}} Collaborating with physicians tocreate divisions
or practices ofrelated medical specialists at
the community level, with links toDivisions
ofFamily Practice and health authorities
toimprove consultation, referral, and wait time
management fortreatment.
}} Collaborating with physicians tocreate divisions
or practices ofrelated surgical specialists at the
community level, with links toDivisions ofFamily
Practice toimprove consultation, referral, and
wait time management fortreatment.
}} Improving patient-centred choice and timeliness
ofaccess totreatment through the wider use
ofpatient-focused funding programs that may
also support different models ofproviding
medical and surgical care, including increased
contracting ofservices out ofhospital settings
where appropriate.

30

Setting Priorities FOR THE B.C.HEALTHSYSTEM

REBALANCEMD
PROVIDES complete care from initial
assessment and diagnosis topostoperative therapy andfollow-up.
PATIENT wait times tosee aspecialist
have been reduced from 6-20 months
tofiveweeks.

PRIORITY5:

Provide timely access


toqualitydiagnostics
Timely access toevidence-informed diagnostic
services is critical tothe previous two priorities.
Demand for diagnostic imaging and laboratory
testing is rising, driven by anumber offactors,
including: an aging population; increased reliance
on testing tofacilitate evidence-based medicine;
rapidly advancing technology and availability
oftesting; and amore informed patient population.
Continuous improvement in both quality and cost
are important elements ofa sustainable strategy
going forward for the healthsystem.
Government is already committed tolaboratory
reform that will establish laboratory medicine
services as an integrated provincial system
(mandate letter, no. 7). This system will drive quality,
co-ordinate investment in new technologies and
optimize valueformoney.
Similar efforts are required toimprove wait times,
develop and implement ordering guidelines for
CT, MRI, and PET based on patient safety and
appropriateness, and eliminate unnecessary and
duplicative testing using evidence-basedpractices.

PRIORITY6:

Drive evidence-informed access


toclinically effective and cost-effective
pharmaceuticals
Access toclinically effective and cost-effective
pharmaceuticals is akey service area for any health
system. Two overarching aims will be achieved
through the followingactions:
}} Achieve the best therapeutic value and price for
publically funded products andservices.
}} Continue participation in the Council
ofFederations Pan-Canadian Pricing Alliance for
brand and genericdrugs.
Continue toleverage the BC Pharmaceutical
Servicesregulations on the Lowest Cost
Alternative and Reference Drug program
toachieve best drugpricing.
Set generic drug prices at 20 per cent
ofbrandprices.
}} Deliver an accessible, responsive, evidenceinformed, and sustainable drugprogram.
}} Lean the drug review process and establish an
annual plan for more therapeutic reviews and
drug policy strategies.
Produce an implementation plan that
outlines practice support strategies
(prescribing) for doctors and pharmacists
toimprove the optimal use ofdrugs linked
tothe six priority patient outcomeareas.
Improve drug formulary alignment and drug
review collaboration between the ministry
and health authorities tosupport patient care
and transitions back tothecommunity.
Develop new regulations toensure arobust
PharmaCare program, including provider
enrollment, information management and
audit enforcementpolicies.
Develop aprogram for pharmacists and
doctors tohelp them work together

toachieve the best patient health outcomes


linked tothe six patient outcome areas
through Divisions ofFamily Practice and
medical specialists. This will be linked tothe
proactive team clinical case management
approach toplanning and delivering
services topatients at risk ofhospitalization,
on atrajectory toward frailty, or from
low tomedium tohigh complex chronic
conditions.
Explore innovative coverage policies
toimprove adherence for selected high
user populations. This will be linked tothe
proactive team clinical case management
approach toplanning and delivering
services topatients at risk ofhospitalization,
on atrajectory toward frailty, or from
low tomedium tohigh complex chronic
conditions.

PRIORITY7:

Examine the role and functioning ofthe


acute care system, focused on driving
inter-professional teams and functions
with better linkages tocommunity
healthcare
Acute care is the largest and most expensive sector
within the health care system, and within this
sector, hospitalization is the most expensive. There
is considerable variation between hospitals and
between health authorities in planning approaches,
service models, service levels, and the best use
ofclinical, staffing, operational and management
practices. Traditional socio-organizational structures
in hospitals have been subject tosignificant change
without the emergence ofa new dominant socioorganizational model. This change has been driven
by significant efforts toincrease efficiency, improve
bed-management/flow, and introduce new skill
mixes toservice delivery while maintaining or
improving quality. These efforts continue toplace
stress on individual managers, physicians, nurses,
and other allied health carestaff.

Setting Priorities FOR THE B.C.HEALTHSYSTEM

31

The use ofhospitals has also changed. Theuse


ofinpatient beds for surgical recovery has
diminished significantly, replaced by an expanding
day surgery service. Medical inpatient beds for frail
seniors now make up amajority ofthe bed capacity
in many hospitals. A frail seniors route intoan
inpatient medical bed through the emergency
department, with abattery oftesting and the
subsequent impact on their overall functioning
andresiliency, can affect healthoutcomes.
Notwithstanding efforts tochange, there is still
agap between hospital and community care in
many parts ofthe province. There is aneed and
opportunity tobetter link the acute care system
tothe regional and community systems, improve
provincial planning, and ultimately improve
the quality ofacute care services delivered
toB.C.patients.
An urgent key action will be torevisit and rethink
the role and scope ofhospitals in the regional
health care continuum. This is underscored by the
reality ofan aging capital infrastructure and the real
limits on fiscal capacity tomeet thischallenge.
There is need for fresh thinking about and
analysisof:
}} How many and what types ofhospitals the
provinceneeds.
}} Patient pathways or services for frail seniors
thatavoid hospitalization.
}} Whether outpatient clinics should be part
ofahospital infrastructure.
}} Opportunities toshift tocommunity based
delivery ofservices where appropriate
particularly for high volume, highly standardized
procedures.
}} The increased use ofcontracted acute
clinical services toencourage competition
and patient choice, with the private sector
delivery ofpublicly funded outpatient
clinical services supported by an appropriate
regulatoryframework.

32

Setting Priorities FOR THE B.C.HEALTHSYSTEM

In the shorter term there needs tobe


acomplementary key action toimprove hospital
management and, where needed, rebuild apositive
hospital culturethat:
}} Addresses and strengthens on-site management
and closes leadership gaps inhospitals.
}} Strengthens relationships and co-ordination
between health administration, physicians,
nurses, allied health and support staff. There is
aneed toactively think through, support and
enable new effective team-based approaches
that maintain quality while providing
ameasurable benefit toimproved patient care
and/or cost-effectiveness.
}} Increases the capacity toprovide crossdisciplinary Mayo Clinic-type comprehensive
assessment, treatment planning, and treatment
for complex patientneeds.

PRIORITY8:

Increase access toan appropriate


continuum ofresidential careservices
A key goal ofthe health care system is ensuring
the right mix ofservices for frail seniors requiring
residential care. Thecapacity ofthe existing
residential care system is limited and does not fully
meet the needs ofpatients.
Key actions will include developing residential
care models and provincewide quality standards
appropriate tothe changing care needs
ofresidents, with particular attention topeople
with dementia and younger populations with
special needs such as chronic severe mental
illness. Thiswillbe underpinned by amore flexible
regulatory system toincrease care availability
(especially in rural settings) and health care
supports using awider range ofcongregate
housing arrangements in partnership with private
and not-for-profit housingproviders.

Strategy
WHAT STRATEGY WILL WE PURSUE TOGET
RESULTS? WHAT ENABLING FACTORS
DO WE NEED TOLEVERAGE AND WHAT
CONSTRAINTS DO WE NEED TOMITIGATE?
The most interesting question facing any
contemporary health system is not what needs
tochange, but why change has not occurred.
Crafting an effective strategy is acritical and
neglected element ofhealth system change efforts.
In practice, there are anumber ofkey elements
that, depending on how they are managed or
not managed, will either enable or constrain
changeefforts.
As noted earlier, it is often assumed that
astrategy is synonymous with aplan. A plan
supposes asequence ofevents that allows one
tomove with confidence from one situation
toanother. Astrategy implies the involvement and
dependence on others with different and possibly
opposing interests and concerns. Successfulchange
in the health system will require astrategy that
accounts for the diverse political, administrative

and professional power structures and interests


that make up the sector, and acompetent change
management strategy suited tosuch acomplex
organizationalsetting.
A clear strategy ofhow government intends
tointeract with the different governance systems
(e.g., health authorities, health professionals,
educational institutions, unions, suppliers) is critical.
No single organization in the health sector has
enough power tocompel the others. Therefore,
agrounded strategy built on collaboration,
consensus building and practical accommodation
is the key requirement for significant systemwidechange.
Adequate change management capacity is
also necessary toeffect system-wide change.
Thesuccess ofsystem-wide and timely change will
be directly related tothe ability tolead and manage
change among the diverse, competinginterests.
This section identifies seven strategic enablers
critical tothe how component ofthe health system
changes identified in the previoussection.

...agrounded strategy built on COLLABORATION,


consensus building and practical accommodation
is the key requirement for significant systemwidechange.

Setting Priorities FOR THE B.C.HEALTHSYSTEM

33

STRATEGY1:

A Shared PlanofAction
A critical enabler for successful health system
change is the development ofa compelling vision
and an inclusive and credible planofaction.
This paper proposes athree part focus for
thevision:
1. Supporting the health and well-being
ofB.C.citizens.
2. Delivering asystem ofresponsive and effective
health care services for patients acrossB.C.
3. Ensuring valueformoney.
Realizing this vision will require disciplined
engagement and collaboration between
government, communities, health authority
governance and administration, health
professionals, support staff, professional
associations and unions. This must be linked
tocascading operational and strategic plans at the
provincial and regional levels that are comprised
ofclearly aligned objectives, meaningful and
measurable deliverables, meaningful timelines,
change management processes, balanced
budget plans (mandate letter, nos. 1 & 2), and
accountabilities driven by population and patient
outcomes and identified service priorities.
Theaction plans must be grounded in regional
realities and provide adequate detail detailing how
we are responding tothe health needs ofthe 62
geographic service areas categorized as metro,
urban/rural, ruralorremote.

34

Setting Priorities FOR THE B.C.HEALTHSYSTEM

This classification will provide amore accurate


picture on what improvement is being achieved
across the province, including enabling specific
patient access pathways toacute, residential, and
tertiary services at the regional and provincial levels.
It will facilitate amore standardized approach
topolicy and program development that takes
into account the different population sizes and
geographies that are linked tothe criteria set out
earlier for aprovincial system ofregionally delivered
care (see priority1).
This will be undertaken in collaboration with
the community-based strategy being used by
the First Nations Health Authority as it supports
the development ofcommunity and regional
healthplans.

STRATEGY2:

AccountabilitytoDeliver
the Three-YearPlan
The successful implementation ofa three-year
plan requires aclear performance management
accountability framework built on public reporting.
Key actions focus on refreshing role clarity and
accountability mechanisms for the ministry,
health authorities, physicians, nurses, allied health
professionals, and support staff focused on
population and patientneeds:
MINISTRYOFHEALTH
}} Align the role, core functions and structure
ofthe ministry tostrengthen capacity tolead
effective policy development, quality assurance,
and co-ordination ofeffective strategic action
across the healthsector.

}} Re-position ministry interaction with health


authority boards, health authority executives
and management. Focus on supporting
stronger governance through board member
selection and orientation, and through routine
performance reporting toboards in relation
togovernments health system priorities.
}} As required, modernize and refresh health
services legislation toreflect current and future
directions for health servicedelivery.
}} Annual reporting on performance against
provincial priorities and continuous
improvement across all core functions
linked toministry executive 10 per cent
holdbackmeasures.
HEALTH AUTHORITIES
}} Require explicit alignment, comprehensive
action, and reporting on provincial priorities and
key actions at both the regional and local health
service delivery arealevels.
}} Reduce unnecessary duplication and overlap
and continue tofind the right balance
between asingle-system approach tohealth
service delivery while allowing useful regional
variation in terms ofpatient outcomes and
budgetefficiency.
}} Comprehensive and timely reporting on
performance across the continuum ofservices.
}} Annual provincial board evaluations and
the introduction ofa 10 per cent executive
performance holdback for all CEOs and vice
presidents (voluntary or 18-month formal notice)
linked toprovincial objectives and continuous
improvement across all deliveredservices.

PHYSICIANS
}} Ensure physicians have aconstructive voice and
accountability in the provision ofhealth care in
each community and health care facility in B.C.
based on acommitment topopulation health,
the experience ofquality care for patients,
and aconcern for per capita cost (Triple Aim,
Institute for Healthcare Improvement).
}} Negotiate asystem with mutual and increased
accountability between physicians and health
authority administrators. Ensure physicians
are able toexert meaningful influence on
decisions in the regional health authority
system that affects patient care, while also
ensuring professional accountability tothe
healthauthority.
}} Collaborate with physicians towork more
effectively with other health care providers
as part ofhealth care teams through mutual
accountability.
}} Ensure effective engagement with government
and professional accountability on the
development and implementation ofpolicies
that promote positive change in population
and patient health and the best standard ofcare
forpatients.
}} Make alternative contractual arrangements with
family and specialist physicians apriority, linked
toimproved health care topatients.
NURSING AND ALLIED HEALTHSTAFF
}} Ensure nurses and allied health professionals
have aconstructive voice and accountability
in the provision ofhealth care in each
community and health care facility in B.C.
based on acommitment topopulation health,
the experience ofquality care for patients,
and aconcern for per capita cost (Triple Aim,
Institute for Healthcare Improvement).

Setting Priorities FOR THE B.C.HEALTHSYSTEM

35

}} Ensure effective engagement with government


and professional accountability on the
development and implementation ofpolicies
that promote positive change in population
and patient health and the best standard
ofcareforpatients.
HEALTH SUPPORTSTAFF
}} Ensure health support staff have aconstructive
voice and accountability in the provision
ofhealth care in each community and health
care facility in B.C. based on acommitment
topopulation health, the experience ofquality
care for patients, and aconcern for per capita
cost (Triple Aim, Institute for Healthcare
Improvement).
}} Ensure effective engagement with government
and professional accountability on the
development and implementation ofpolicies
that promote positive change in population
and patient health and the best standard
ofcareforpatients.

STRATEGY3: Quality
To realize effective clinical quality improvement,
we must leverage the BC Patient Safety and Quality
Council todrive clinical quality improvement across
thesystem:
}} Establish aguideline driven clinical care
management system toimprove the quality,
safety and consistency ofkey clinical services
and toimprove patient experience ofcare,
building on the work undertaken todate
inthisarea.
}} Identify 15 high-priority areas for system
improvement and implement five per year
forthe next threeyears.
}} Require each health authority tohave
aformalized and adequate clinical quality
improvement capacity linked tothe BC
Patient Safety and Quality Council that is
inclusive ofphysicians, nurses and allied
healthprofessionals.

36

Setting Priorities FOR THE B.C.HEALTHSYSTEM

The second key action focuses on improving quality


information systems for decision-makers across the
healthsector.
}} Harmonize and standardize clinical data sets for
improved, evidence based decision support in
clinical information systems at the point ofcare.
Advance and standardize implementation and
adoption ofclinical information systems at the
pointofcare.
The third key action establishes an academic health
science network in B.C. todrive effective teaching,
placements, and applied health research that will
promote and encourage improved quality and
innovation linked toidentified health care and
serviceneeds.

STRATEGY4:

Skilled ChangeManagement
The ministry will work with and require each
health authority todemonstrate effective change
management capacity across its system - ensuring
managers are adequately skilled in change
management and are putting adequate time into
change management action todrive successful,
timely and efficient change. Managementwill:
}} Develop shared change management
approaches and expertise across thesector;
}} Ensure timely, open communication and
engagement with the health workforce during
the change management process;and
}} Provide accurate information on change
management performance todecision-makers.
}} Evaluate each health authority on the adequacy
ofits change management in moving forward
on the system wide priorities and time frames
established by the government.

STRATEGY5:

Health Human Resource Strategy


An Engaged, Skilled, Well-Led and
HealthyWorkforce
In asector driven by the commitment and skills
ofits professional and support staff workforce,
anengaged, skilled, well-led and healthy workforce
is acritical strategic asset. A number ofkey actions
willbetaken:
}} Develop and implement an integrated provincial
workforce strategy linked toregional and local
health service area health work force plans and
built on supporting both individual and teambased practice, including scope ofpractice
for nurse practitioners (mandate letter, no. 8),
asappropriate tobest meeting patientneeds.
}} Ensure the development and implementation
ofa leadership and management development
framework for the healthsystem.
}} Continue todevelop and strengthen
professional development and quality assurance
mechanisms.
}} Negotiate anew Physician Master Agreement
with the BCMA tosupport anew relationship
with physicians that builds on the significant
progress ofthe last decade and drives afresh
contractual and partnership relationship with
the health authorities.
}} Develop aprovincial engagement, influence
and accountability framework in collaboration
with health authorities and unions tosupport
the creation ofinclusive, vibrant and healthy
workplaces across the healthsector:
Ensure rigorous discussion with physicians,
nurses, allied health workers, and health
support workforce staff about health care
practices andchange.
Improve provincial-level analytics tobetter
assess where teamwork and what skill mix is
best for both quality patient care and costeffectiveness.

Develop clearly articulated, specific, and


measurable healthy workplace objectives in
each health authority linked tothe provincial
framework that are monitored, measured,
and reported tothe board and ministry on
aquarterlybasis.
}} Ensure effective labour relations and health
sector negotiations (mandate letter,no.6).

STRATEGY6:

Information Management
andTechnology
The information management and information
technology (IM/IT) strategy for the health sector
outlines aplan ofaction torealize more accessible
information, toensure knowledgeable people, and
todrive better health outcomes. It will leverage
technology such as the eHealth infrastructure built
over the pastdecade.
Theplanwill:
}} Increase information flow and personal
access tohealth data toempower patients
tobe full partners in actively managing their
healthconcerns.
}} Ensure the provision oftimely access todata
anduse oftechnology tosupport actions
related tothe six priority patient outcome areas.
Thiswillinclude:
Expanding the capability for cooperation,
enabling referrals, improved wait time
management and improved exchange
ofpatient information across service areas
tosupport inter-professional care teams in
the delivery ofhigh quality patientcare.
Expanding telehealth tosupport: patients
with chronic diseases, mental illness and
substance abuse; access tospecialists; and
acute care services in remote serviceareas.

Setting Priorities FOR THE B.C.HEALTHSYSTEM

37

Enabling electronic prescribing across the


health care system continuum tosupport
greater efficiency, safety and closed loop
medication management.
}} Address access, quality, standardization and
timeliness ofadministrative and clinical care
data for health system planners, policy makers,
managers and researchers.
}} Build informatics capacity touse data
toenhance decision-making and improve
outcomes at all levels ofthe system, while
meeting privacy and security requirements.
}} Review the current patchwork oflegislation
governing the use ofhealth data with aview
toimproving its utilization while respecting
patientprivacy.

STRATEGY7:

Budget Management andEfficiency


Funding and corporate services are both key
enablers and constraints on any organization. Seven
areas have been identified as requiring continued
focus over the coming threeyears:
1. Complete apopulation needs based funding
model (a method ofdetermining how todivide
apredetermined pool offunds fairly and
equitably) review and any recommended
changes tobe implemented over the three-year
timeframe.
2. Implement arefreshed funding strategy,
incorporating global, patient-focused and
activity-based funding strategies toachieve
patient outcome and service objectives.
3. Strengthen cost management systems and
reportingcapacity.
4. In consultation with health authorities and the
BCMA, re-energize effective alternative funding
mechanisms for physicians.
5. Continued consolidation ofback-office
functions and shared business services through
arenewed approach for provincial health
shared service delivery and the expansion
ofthe Lower Mainland consolidation project
toaprovincialmodel.
6. Continue todrive Lean as ameans toincrease
flow and reduce waste across the healthsystem.
7. Apply key findings from the Fraser Health
Strategic and Operational Review tofuture
budget management approaches.

38

Setting Priorities FOR THE B.C.HEALTHSYSTEM

Conclusion

1. What outcomes do we want toachieve in terms


ofthe health ofpopulations and patients?
Which populations and patients require
prioritizedattention?

}} Reducing hospitalization and the need for


residential care by preventing or slowing
downthe onset offrailty by targeted secondary
prevention, with aparticular focus on better
managing the development from low
tomoderate tocomplex chronic conditions
linked toaging/increased frailty that appear
tohappen over afive-yearperiod.

2. What kind ofsustainable health service delivery


system do we need tohave in place tomeet
those outcomes, and at what level ofquality?

}} Reducing hospitalizations through effective


secondary and tertiary prevention for mental
illness and addictions.

3. What strategy will we pursue toget results?


What enabling factors do we need toleverage
and what constraints do we need tomitigate?

}} Increasing timely access toevidence-informed


care from specialists, diagnostic imaging, and
electivesurgery.

It has set out acase that while maintaining and


incrementally improving on what is working
well, there is aneed todrive apopulation-and
patient-centred culture across the health sector
while paying particular attention tothe outcomes
achieved for six specific populations:

}} Providing consistent quality ofcare for


residential care patients with astrong focus
onquality ofcare for dementiapatients.

}} Effective chronic disease prevention through


universal and targeted population health
interventions that address all major risk factors
across the lifecycle.

This suite ofinterrelated priorities, which is focused


on key populations by working toward amore
integrated health system tobetter meet their
needs, and is supported by key organizational
change enablers, provides acoherent, grounded
and measurable game plan for the coming
threeyears.

This paper has proposed that setting priorities for


ahigher performing health system in B.C. requires
analysis and decisions in threeareas:

}} Effective and compassionate care for


end-of-lifepatients.

...focused on KEY POPULATIONS


by working toward amore integrated
health system...

Setting Priorities FOR THE B.C.HEALTHSYSTEM

39

Appendix A: Minister ofHealth MandateLetter

40

Setting Priorities FOR THE B.C.HEALTHSYSTEM

Setting Priorities FOR THE B.C.HEALTHSYSTEM

41

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Setting Priorities FOR THE B.C.HEALTHSYSTEM

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Setting Priorities FOR THE B.C.HEALTHSYSTEM