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OHA HealthAchieve 2012: Closing Remarks

THE HONOURABLE DEB MATTHEWS
MINISTER OF HEALTH AND LONG-TERM CARE
METRO TORONTO CONVENTION CENTRE

November 7, 2012

Well hello everyone. And thank you Pat [Campbell]. It’s great to be here. This is my fourth Health Achieve. Every year gets better and better.

And I know for Health Ministers, four Health Achieves is almost a record.

It’s great to be here. And great to see my old friend Peter Johnson. This is his last official duty with the OHA. And I just want to say thank you Peter for all you have done for health care in London and across the province. Thank you.

Health Achieve is a celebration of innovation.

It’s an opportunity to learn from one another…it’s an opportunity to see what great new ideas are being implemented across the province.

Every year I look forward to my speech here, as it’s my opportunity to say Thank You for doing what you do.

I know these are challenging times; this is a time of real change.  And I want to say thank you for managing that change so well.  We’re asking a lot of our partners.  I know that.

Some even say that we’re completely retooling the airplane.  While it is in the air.

So thank you.  And I want you to know that I very much appreciate your support as, together, we make the changes that, I think we all can agree, are necessary.

Health Achieve is also an opportunity to update you on what’s happening at the ministry, and what’s ahead for all of us.

We are moving forward, building on the success of the past nine years.

It’s important to remind ourselves how far we’ve come, together. None of this success happened by accident.  All of it happened because, together, we decided to make health care better for Ontarians.

Nine years ago, there were big problems in Ontario’s health care system.  We had somehow lost sight of the fact that the patients are our boss.  That the health care system belongs to them.  That they are paying for it. That we work for them.

The number 1 problem that our boss told us they were having nine years ago is simply getting access to care.  When it came to making sure people could find a family doctor, we simply weren’t meeting the needs of patients. We were failing in our performance review.

So we went to work.  We increased the number of medical students; we opened a new medical school; we doubled the number of IMGs being trained; we’ve reversed the brain drain, so now more doctors are coming to Ontario than to leave for greener pastures outside of Ontario.  We’ve brought other health care providers into primary care in a way they never were before.

So, now we have 4,000 more doctors practicing today than 9 years ago.

Two hundred Family Health Teams, serving nearly 3 million Ontarians and growing.

We’ve got 26 NPLCs, serving 26,000 patients, and growing.

Doubled the number of CHCs.

And I could go on.

The bottom line though, is that in most communities, access to primary care is no longer a problem.

We still have work to do, because there are still communities where there is a problem, but we’ve demonstrated we can solve big problems when we work together.

The second biggest problem that our boss told us about nine years ago was wait times. We needed to fix wait times.

Again, we went to work, together. We have gone from the longest wait times in Canada to the shortest wait times, and, province-wide, we’re meeting targets on most procedures.

We used to have, and still do to a certain degree, a tightly siloed system.  Organizations focused on what was happening within their organization. Hospitals looked after hospitals, primary care looked after primary care, long term care looked after long-term care, home care looked after home care.

But no one was responsible for bringing the system together, no one was responsible for making it work for patients as they worked their way through the health care system, as they transition from one part of the system to another.

As George Smitherman used to say, “I hear about something people call the Health Care System.  Well, I look around and I see lots of health care, but I can’t find the system.”

Well, now LHINs were established. They’re making important and tough decisions. They’re integrating care so it reflects the needs of patients, and they’re implementing provincial priorities at the local level, with robust community input.

Back in 2003, I don’t have to tell you, hospital budgets were out of control.  Deficits were dealt with, often with a wink and a nod, and a stern warning to do better next year. And there was simply no rationale for determining what the appropriate budget was for any given hospital.

Now, all our hospitals are in balance, or on their way to balance.  Indeed, collectively, Ontario hospitals are in a strong surplus.

And we’re catching up with the rest of the world by moving to Patient Based Funding, so the more patients a hospital cares for, the more funding they will receive.

This is a key enabler of health care transformation.

I know this has been and continues to be a challenge for many hospitals.  I want you to know that we will continue to work with you in a transparent fashion as we move forward.  This is a work in progress. 

There is no question on the “what” – we’re moving to Patient-Based Funding.  But as to the “how” – I commit to you that the partnership approach we have adopted will help change to occur at an appropriate pace and in a way that works for both providers and patients.

That’s why we’ve got upwards of 25 side tables working out the issues that are brought to our attention, so we will get through this.

You know back in 2003, our hospital infrastructure was crumbling. 
23 new hospitals, and over 100 major capital projects later, we’re providing care in much better settings.

And electronic medical records were almost unheard of.  Now we’re harnessing the potential of E-Health Ontario’s success:

And maybe my favourite: Ontario Telemedicine Network. OTN is demonstrating the power and potential of telemedicine across this province.

When we got started, quality of care was an afterthought in too many places.  Now ECFAA is focusing attention on improving care in a way that matters to patients.

And we’re bringing community care into the main stream of health care.  We are recognizing it as the vital resource it is and harnessing its potential to take pressure off other parts of the health care system.

And we are implementing our Mental Health and Addictions Strategy.  Shining a light where for too long there was darkness. 

Over and over again, we’ve demonstrated that we can achieve success when, together, we focus on a problem, understand the root of that problem, change how we do things, make targeted investments, and measure and publicly report on our progress.

Our system is far stronger now than it was a decade ago. And now, because of the strong foundation we’ve built, we have the opportunity to address the next set of challenges.

Now, you may be familiar with Maslow’s Hierarchy of Needs.  You have got to deal with one level of needs before you can move up to the next level. So this is something called Matthews’ Hierarchy of Health Care Needs.

Just like in Maslow’s hierarchy, we can’t move up to the next level of system reform until we have met the needs in the level before.

The first level was making sure that we had enough health care professionals to care for us. And that people could get access to primary care and diagnostic testing and surgical care in medically acceptable times. And making sure that we had adequate infrastructure.

Then we moved up to enhancing quality. To expanding scopes of practice so that health care providers could put all their training to work. And because we have achieved success, we can move to the next level.

So here’s where we need to go next.  We need to transform the system so we work together to get people access to the right care at the right time, and in the right place. And when I say “need”, I mean “need”, because making this kind of transformational change is essential if we are to protect universal health care for future generations.

In addition to the right care, right time, right place, we also need to focus on transitions of care. Making sure that transitions in care are smooth – that no one falls between the cracks when they, for example, are discharged from hospital back to home.

I think we need to learn a lesson from relay racers.  Now, relay racers practice two things – they practice how to run fast, and they practice how to pass the baton. And they spend just as much time practicing how to pass the baton as they do practicing running.

Well, think of health care as one big relay race, and I’d say we’re pretty good at running fast.  We provide good care in any given setting.

But we’ve got a lot of work to do practicing how to pass that baton. Ensuring a safe transition. Now remember this, in a relay race, there is a moment at which both hands are on the baton.  Both hands are on the baton. The first runner doesn’t let go until he or she knows that the next runner has a firm grip. Also remember that, when a member of the relay team drops the baton, the whole team loses. Not to mention the baton.

So, everywhere I look around Ontario today, I see fantastic examples of innovation. I think the health care system is just really beginning to demonstrate its potential when it comes to transformation, of doing things differently. People are doing things that make for far better patient care and better value for money.

All these various projects are different and too many to highlight.  But they all have something in common.  In all of these innovative projects, the starting point is “What does this patient, or this kind of patient, need?” “What is the need of the patient?”  The question is not “What can the system do for the patient?” The question is “What does this patient need?” And then we work together to make the system work for patients.  The starting point is, “What does this patient need?” It’s better care for patients and almost always better value for money.

There are many, many examples, as I said too many to mention, but I can’t help myself. I do want to highlight just a couple:

Pat [Campbell] has talked about Home First.

I just think that Home First is a totally new philosophy when it comes to providing care for patients. It’s getting fantastic demonstrative results, better care for patients, better value for money.

To the pioneers of Home First, to the brilliant adapters of Home First, thank you for what you are doing.

Let me give you another example.

St. Joe’s Health System in Hamilton is experimenting with something they call bundled care. They’re testing it for three different kinds of patients – patients with lung cancer, people with hip and knee replacements and people with COPD. 

Again, they asked the question, “If patients designed this system, what would it look like?” What are the needs of the patient, not the limitations of the system?

So what they’ve done is they’ve gone through a very extensive process. They’ve removed all the unnecessary steps, the duplication, in the whole course of care from diagnosis to recovery. They’ve removed unnecessary steps.

And I love this part – they give patients one number to call. Patients no longer have to navigate and figure out, is this when I call the surgeon or is this when I call the emergency department? They have one number to call. And that person on the other end of the phone is connected to all the other parts of the health care system.  From diagnosis to full recovery, including home care, there is a single point of contact for patients.

This is the essence of integration, where the elements of the system wrap care around the patient, instead of making the patient do the work by navigating the system.

And you know as well I do that very often, that navigation ends up in the emergency department.

So it is still early days for this project at St. Joe’s. 

But results from the first three months show that patients are being discharged earlier from hospital, they’re feeling safer at home. There has been a reduction in rehab referrals for knee replacements. And home care nurses spend far less time on paper work and far more time on care.

I actually spoke to a home care nurse who’s in this project, we connected over Skype. She was in the home of a patient. I asked what difference it made to her. She said, “Well, I used to come for a half an hour and spend 27 minutes filling out paperwork, and three minutes on patient care. Now it’s completely the reverse: 27 minutes on patient care, three minutes on paperwork.”

I want to see more of this in the system, and patients do too.

Let me get to another example, who is here from London? Other than Peter. Great to see you all. So, here’s another great idea from my hometown of London: somebody thought about people who are ventilator dependent. Who are living their life, if you can imagine this, living their life in an ICU. Imagine living your life in an ICU because you were on a ventilator. And then somebody said, is this the best way? Is this the best we can do for this patient?

Well, they thought about it, and the hospital and the community and community care, an organization called Participation House in the community that provides housing, worked together.

And now, patients who need long-term ventilation can get the care they need in the community, in a home, rather than in the ICU. So supportive housing, day programing, transportation and full-time nursing care are all provided in the community.  

There is no question that the quality of care for patients in home is better than the ICU.  And getting just one patient out of the ICU and into the community means savings of almost $625,000 a year for one patient - and it frees up ICU beds for somebody who really needs it.

So, great things are happening across the province.  But these innovations are still very much the exception, not the rule

We can do better, we will do better.

You know as Canadians, we pride ourselves on Canada’s health care system. When Canadians are asked who the greatest Canadian ever in the history of Canada was, they answer Tommy Douglas. That tells you how much pride we have in our health care system. And I can tell you that no one is prouder of our health care system than I am.

But there are real opportunities to make it so much better.

And I think we make a mistake if we just compare our system to the United States.

If we look at other jurisdictions, you really do see opportunities to do better. International studies demonstrate that our per capita spending is high relative to other jurisdictions, but our outcomes are not so good.

Indeed, it’s pretty clear to me that the problem is not that we’re not spending enough; it’s that we’re spending it on the wrong things.

Let me give you a few examples:

When it comes to same day/next day appointments, only half of Ontarians can get the care they need when they’re sick on the same day or next day. In Switzerland and the UK, it’s 80 per cent.

Twenty-three per cent of us wait for six or more days.  To see a doctor.  When we’re sick.  In the UK it’s 2 per cent; it’s 4 per cent in Switzerland.

And perhaps related, Canada leads the pack when it comes to ER visits: 58 per cent of us have visited an ER in the past two years, compared to less than one-third in Germany, the Netherlands and France

While we’ve come a long way in reducing wait times – measured from the time of the consult to the time of the procedure - we’re just about the worst of the countries surveyed when it comes to how long it takes to see the specialist.

Half of the Canadian patients report that they don’t get complete instructions and planning for follow-up care when they were discharged from hospital.  That’s twice as many as in the U.S. and in the UK.

These are system problems.

We have the best health care professionals anywhere in the world.

The problem is the system, not the people working in the system.  These problems are fixable.  And they’re up to us to fix.  So let’s fix them. Together.

That’s why we’re at the table with the OMA, not only working to find an agreement on physician compensation, but how to partner together to improve quality and access for patients.

It’s also why we plan to expand not-for-profit specialized clinics for routine procedures, moving more procedures into the community where it makes sense for patients. I look forward to having more to say on this in the weeks to come.

I have to tell you that I am increasingly focusing on the needs of patients who have high health care needs.  ICES data shows us that the top 1 per cent of patients use 33 per cent of our health care dollars.  The top 5 per cent, about 2/3 of our health care dollars. And 50 per cent of us, the healthiest 50 per cent of us, use only 1 per cent of health care dollars. 

So rather than looking at how we’re going to meet our fiscal challenges the traditional way, by looking line by line – what we spend on hospitals, on drugs, on long-term care, for example – we need to shift our focus on what we spend on patients.  I think we can go a long way to meeting our goal of providing better care, and getting significantly better value for our health care dollars.

That’s why I’ve appointed Dr. Samir Sinha to be our expert lead on our Seniors Care Strategy.

He’s building on the work of others, including Dr. David Walker and Dr. Ross Baker.

Dr. Sinha has been travelling the province, listening carefully, for the past few months.  Soon, he’ll be reporting back on what we need to do to change our system so that it meets the needs of our growing seniors population. To provide the finest possible care, and the greatest possible independence.

I have a feeling that Dr. Sinha’s recommendations are going to be bold.  And transformational.

You should know that Dr. Sinha has been tasked not just to develop the strategy but also to implement it.

He’s going to help us provide better care for people like Bernice. I want to tell you a story about Bernice. This is a true story.  And I say thank you to the HNHB LHIN for this story. This is one patient’s story, Bernice. Only the name has been changed.

Bernice lives at home.  CCAC visits once a week and her kids are regular visitors.  One day, she falls and gashes her arm. She calls the ambulance, goes to the hospital by ambulance.  They fix her up, send her on her way.  Her family doctor isn’t notified and there’s no follow up care.  When the CCAC next comes, they’re surprised to see that she’s been injured.

A year later, Bernice falls again and breaks her hip.  Another ambulance trip to the hospital.  She waits three days in the ER, then gets transferred to another hospital where she has surgery. She spends six months recovering in the hospital and gets MRSA.  She sells her house and moves to long-term care.

So you look at five years of care for Bernice, we spent close to half a million dollars.

Now, we have to ask ourselves, did it have to be that way? Were we doing our collective best for Bernice?

So let’s imagine what that journey could have looked like.

Bernice lives at home.  CCAC comes once a week and her kids are regular visitors.  One day, she falls and gashes her arm. EMS comes, fixes her up right on the spot, notifies her GP on the spot and makes a geriatric assessment referral.  Her children go with her to the appointment and learn how they can improve Bernice’s functional ability.  Bernice is enrolled in a falls prevention program, where she makes new friends and starts going to Bingo. 

One day, leaving Bingo, she slips and falls on the ice and breaks her leg.  She is taken to her local community hospital.  Staff there call the designated referral hospital. Bernice is transferred there, has her surgery right away, then is transferred back to the community hospital where she recovers. A week later, she is discharged to a transitional care program for a month.  Then she goes back home, with on-going support to maintain her functional ability.

Now that care would cost about $100,000 for five years. So when you look at the needs of real people and ask ourselves, are we doing our collective best? I think we all have to agree that we can do better.

So Bernice’s case as you know is not an exception. You know people like Bernice, you see them every day.

So how do we get from here to where we’re going to be?

We need to work to link all the health care providers in a given geographic area who are providing care to individuals in that top 1 per cent or top 5 per cent. So that primary care docs know when their patients are getting care elsewhere – in the hospital, from a specialist, from home care.  So that all the providers have the same information about a patient:  what medications they are on, what tests they have had, and what those results are.

Then we need that network of linked health care providers to work as a team to collectively manage the needs of those patients with the greatest needs, in partnership with family and community, so they move smoothly through the system, always confident that they’re being looked after. That they don’t fall through the “gaps” in the system.

These health link networks will work to ensure that there is one “most responsible provider” for each patient.  Someone responsible for making sure that that patient is getting the right care, at the right time, in the right place.

That the patient is getting proactive, preventative care to stay out of hospital, out of long-term care.

We need that network to create strong links between providers to ensure that referrals to specialists are faster and more appropriate.

Now, there are some parts of the province where that kind of cooperation and partnering is starting to happen.  We want to accelerate it.  That’s why I’m very happy to announce to you that in the coming weeks, you’ll be hearing about a competition for early-adopters of this new way of caring for people. 

Working with the LHINs, we will be asking partners to work together on their proposals and describe how they would reach our common goals, like better care for high needs patients, and lower re-admission rates.  We know that Ontario is a wonderfully diverse province. And we recognize that the proposals from rural and northern communities will look different from those in the cities.  But start talking now. The potential here is unlimited.

I see a time, somewhere in the not too distant future, I hope, where this model will exist right across the province.  But the time is now, we need to start learning about how best to provide co-ordinated, pro-active care, and I don’t think there’s a better way to do that then to put out a call to Ontario’s most innovative health care leaders.

Our job, as the ministry is to enable this kind of transformation.

Our new motto at the Ministry of Health is: If it’s better for patients, and it’s better value for money, then YES, WE CAN!

And to demonstrate how serious we are about this Deputy Minister Saäd Rafi has even appointed a new Associate Deputy Minister, Helen Angus  - I know many of you know Helen - to drive this kind of transformation.  I call her the “silo-buster”. Her job is to remove barriers to innovation, so we can provide better care for patients and get better value for money.

I am very excited about the changes that we’re driving to provide better care for Ontarians. I am very optimistic. 

I believe that we’re on the cusp of transformational change that will ensure the viability of universal health care for the next generation. 

It’s not going to be easy, and there will be bumps along the road.  There always are.  But if we continue to work together, never losing sight of the only two questions that matter – is it better for patients? Is it best value for money? – then together we will transform our precious health care system into one that works for Bernice, and for all the people of this province.

We know what we have to do, and we have started down that path of transformation. And we are now accelerating the pace of change. It’s a very exciting – and yes, a very challenging – time in health care in Ontario.

But I know we can do it.  Because we’ve done it before. By working together. It won’t be easy.  It will require steely determination and a steady hand on the wheel.   

Patients are counting on us. Patients know we can do better. I know we can do better. You know we can do better. This is no time to slow down. So let’s roll up our sleeves and get to work.

Thank you.

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