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Patients First: Action Plan for Health Care

Minister Dr. Eric Hoskins Speech

February 2, 2015

Watch Minister Dr. Eric Hoskins speak about Patients First: Action Plan for Health Care.

Check Against Delivery

Well, good afternoon everyone and Andrea it's wonderful to be here with the Empire Club. It is wonderful. I had many of my ministry staff show up here at lunch today because we were all worried quite frankly that nobody would be able to make it in because of the snow storm so, but I want to acknowledge Bob Bell, my Deputy, who is here, as well as a number of other individuals who represent the ministry so well.

I'm honored to stand before you today as I know we are working for a common cause and it is a cause that I am deeply committed to along with our Premier, Kathleen Wynne . I want to thank you for coming today and for your unwavering commitment to improving health care for Ontarians.

Ladies and gentlemen, we've come a long way together. Health care is undeniably one of the most important issues facing our government and facing all of us as Ontarians. The stakes are high. Without exaggeration, the decisions that many of us make in the course of our work have life and death consequences and it's a cause I've been championing like many of you, my entire professional career.

You might conclude that my knowledge of health care stems from medical school but to be honest, that's not really where I learned about health and about what it takes to promote and maintain healthy communities, because health care is not simply the application of anatomy and physiology and biochemistry and pharmacology. These as we know are only one piece of the puzzle and in general, and speaking from experience, the piece that is easiest to negotiate when it comes to medicine, and you can take my word on that . But of course, we all know that health isn't just about science, nor is it just about the clinical setting. It's about the convergence of policy and demographics and economics and ethics and even in some cases, politics. Not party politics; though there can be a little of that too. But about the values that we share as a society. And it's also about history and globalization and even education. B ut above all, health and health care, well, it's about people. It's about protecting and promoting the rights of people to support our wellbeing and in difficult times, to ease our pain.

So we are all in this room in a very complicated yet paradoxically simple business. We are in the business of being human. I didn't always think of health or health care or even my role as a doctor and public health practitioner in these terms but my perspective quickly changed shortly after graduating from McMaster Medical School. I moved my medical textbooks into the basement of my parents' home in Simcoe, grabbed my stethoscope and went halfway around the world to Khartoum, Sudan. I was young and seemingly invincible and probably even a little too self-assured like many new docs. I arrived in Sudan ready to save lives. Well, Sudan changed my life instead.

While I busied myself with humanitarian work and health care, my office mate in the faculty of medicine, a gentle Sudanese man named Mohammed worked diligently to train legions of young Sudanese doctors to respond to their country's ongoing health crisis: epidemics, malnutrition, a high maternal mortality rate and a life expectancy that hovered around 42 years of age which, to provide added context, is far younger than anyone serving in the Provincial legislature right now, with of course the exception of Yasir Naqvi. Mohammed and I would work side by side on two metal fold- out tables and plastic chairs, often working in the dark with no electricity and the temperature climbing to 45 degrees Celsius. We never talked politics. He was a quiet, dedicated man who often shared his breakfast with me, a Sudanese bean stew.

Doctors in Sudan weren't known for their political engagement. Very few spoke publicly. In fact, during an uprising and military coup that had preceded my arrival, doctors had actually been maligned as a group for staying silent, even as the bodies piled higher in the streets. That co up tragically turned out to be the precursor to an even more bloody and terrifying one. About a year after my arrival in Sudan, there would be more political upheaval. This time installing the government of Omar Al Basheer who, as should be noted, now stands indicted by the International Criminal Court for war crimes in connection with the more recent war in Darfur.

But this time, the doctors did not stay silent. Mohammed and his colleagues at the doctors' union spoke loudly and critically of the abuses they were witnessing, of the threats to civilian life and the misery which ensued and then one day Mohammed stopped showing up to our sweltering, concrete block with his bean stew. After a few days, I went to visit his family thinking perhaps he'd been stricken by malaria, a disease which had left me bedridden only a few months prior. But when I got there, I learned that Mohammed wasn't ill; he was missing. And a few days later his body would be delivered to his wife and young children. He was covered in burns and bruises and all of his fingernails had been pulled out.

He's not the only doctor and human rights activist I have known whose life was cut violently short simply for striving to keep people alive and safe from harm. Health and human rights are indivisible. Who we are and what we stand for as a democracy, as a society that values human life, that believes in dignity and respect for all, these are essential, not only to health, but to the health care sector as a whole. Notions of equity and access and universality; these are not just lofty ideals that make for raucous political speeches ; these are principles we're striving for and defending with every measure of our being because our lives really do depend on it.

So the question then is not whether the system is unsustainable or whether universal health care is unattainable, or whether two-tiered alternatives are viable. These presume that principles of universality, equity and access in health care can be measured in degrees, that such rights are relative. That's not a vision for health care that I can support nor that this government supports. Instead, we have to, instead, we have to approach the challenges facing health care from a different vantage point which is that if we believe in such rights to health and health care as we do, then the questions we really should be asking ourselves are, how do we ensure universality, how do we improve access and what does it take to deliver the highest quality of care? Every decision I have made and will make as Minister of Health is centered on such considerations.

Yes, there are economic and demographic realities and we will not hide from them. Our population is aging. Our financial resources are finite. But these are challenges that we can manage together with determination and some ingenuity. It's simply a matter of choices; choices that must be rooted in evidence and experience, choices that put patients first, because doing a better job in health care means understanding and predicting the needs of Ontarians and supporting models that best serve them. It isn't in fact about those of us in this room. It's about what we do for them and we can never forget this.

So with this in mind, some of you may be asking what are my plans for health care in this province? Well, I'd like to spend a few minutes sharing these priorities with you, our priorities as a government, because I'm not someone who believes in tinkering around the margins. I believe that we have a tremendous opportunity in this province to lead, to demonstrate a bold vision for delivering universal health care that will above all, improve patient outcomes and make the best use of our financial resources.

The first A ction Plan for Health Care by Minister Deb Matthews made a commitment to be "obsessively patient- centered". Patients First, our new action plan, builds on that commitment and recognizes that the health system belongs to patients, to Ontarians, and therefore this plan is for them. It is shaped by their experiences and seeks to empower them. So let's start where patients want to start : with access. If we want our system to serve each patient, we need fast, timely and responsive care, which also means redefining access from the patient's perspective. So what might that redefinition look like? Well for starters, we should be proud that 94% of Ontarians have a primary care provider, two million more than did a decade ago. But 6% still don't and timely access to both primary care and specialists remains a challenge.

We need a front door to our medical system that is open 24/7 and that front door should be a dynamic primary care system with team-based integrated and coordinated care, leveraging the skills of more health care providers and with fewer unattached patients. That is how we can truly put the needs of patients first. And so I welcome the work of David Price, Elizabeth Baker and the members of the Expert Advisory Panel on Primary Care who are pointing the way to primary care reform. We need to ensure that our health care workers are able to put their skills and training to good use by continuing to expand their scopes of practice and we need to look past the traditional confines through which we've provided care because the technology to do so is already out there. It reminds me of a joke, a very telling one I think that I heard during a briefing by a respected leader in hospital-based care. In the 1990's, the only people who used pagers were doctors and drug dealers. Well, the drug dealers have moved on.

We don't even have to go looking for the innovations needed to change this because we use them in every other aspect of our lives.

Imagine, a parent takes her young child with an unusual rash to her family doctor who is uncertain of the diagnosis. Instead of waiting eight weeks for a consult with all the associated discomfort and anxiety for a parent and child, the family doctor can send a digital photo to a dermatologist and know the management plan often before the family leaves the office. We can do that now. The reality is, these benefits are possible when we put patients first. And more, one of the greatest challenges right now facing our health care system, when it comes to access, concerns individuals in need of mental health and addictions services; not only acute care, but longer term care and supports that revolve around the patient. That's why we're making targeted investments like the 138 million dollars over the next three years to shift more mental health services into the community; timely, effective and responsive ongoing care; and support that treats patients as people and breaks down the barriers that those struggling with mental illness and addictions too often face.

We've already made significant progress on mental health by working together. For the first three years, our strategy is focused on mental health supports for children and youth, almost 800 additional mental health workers are now providing services for children and youth in our communities, in our schools, in our courts and our tele-mental health services are providing nearly 3,000 psychiatric consults this year alone, to benefit children and youth in rural, remote and underserved communities.

And to build on that success, we've asked Susan Pigott, a leader in the field, to chair the Province's Mental Health and Addictions Leadership Advisory Council and I look forward to working with them and with all of you to implement the next phase of this strategy.

All of us in this room know that the burden of disease is shifting profoundly from infectious disease and emergencies to more chronic conditions associated with the demographic changes taking place across this p rovince and around the world. So an effective and efficient health care system must be forward -looking. The needs of Ontarians are evolving and our sector must continue to evolve along with them to predict rather than react so that our interventions are smart and targeted and effective. And along the same lines, we need to recognize that access to health care also depends on connectivity. I've already mentioned connectivity in the context of new technologies and the opportunities we have to provide patients with faster and more holistic support but there are other ways in which connectivity may be strengthened to achieve integrated and coordinated patient care, for example, in the home and community care sector.

The current experience of our loved ones in this sector as we know from the feedback we have received from thousands of individuals and families is uneven and disjointed and I know that our caregivers feel that every single day. Let's consider in the first instance, the needs of our seniors. Understandably, more of them want to remain in their homes for as long as possible. This is not only better for them, but for the health care system as well. But to achieve this, they will need more flexible, reliable and affordable community and homecare supports. We also need rigorous standards of care to keep them safe and we need to be monitoring our progress every step of the way so that we can be confident that patients are getting the quality services that they deserve. That's why we're working closely with Gail Donner, the Chair of our Home and Community Care Task Force, to help us expand current capacity, modernize delivery and improve the patient, family and caregiver experience. Home and community care is ripe for transformation and I'm committed to seeing it through.

It is this same patient- centered approach when it comes to the management of high risk patients which laid the foundation for Health Links due to a fragmented primary care system and gaps in the continuity of care. We know that 5% of our population consumes as much as two-thirds of our health care costs. This is where Health Links has the opportunity to be a catalyst not just for cost savings, but for better quality of care and a cornerstone in our primary care system by connecting patients to community-based care. Health Links means connecting an 82 year old patient with congestive heart failure who doesn't speak any English with a CCAC care coordinator and a translator to develop a care plan that will keep him out of the emergency room. It means connecting a 33 year old patient with adequate housing and ensuring that her psychiatrist, family doctor and social worker are all in one room when she explains what's important to her.

These are the stories that cut past the numbers and help those who have been falling through the cracks in our health care system and we now have 69 Health Links across Ontario, making good inroads to bridging health care with housing and education and our justice system, so we can get at the social and economic conditions that have an enormous impact on our health and well-being: the so-called social determinants of health. And I know just how important this is from personal experience. For many years, I worked here in Toronto as a doctor providing care to refugees, immigrants and inner city patients. Their health issues were complex but so too were their circumstances. But nowhere perhaps are these challenges greater than in our Aboriginal communities where the key to success is so often found within the communities themselves, if we can only realize that and respect them as valued and equal partners.

But medicine can only go so far in addressing the health risks that Ontarians face each and every day.

As we all know, penicillin cannot cure poverty and homelessness but by connecting patients to resources, and those resources to one another, we are better able to support them. And of course, if we want more of our system to perform as a unit, we have to change the way we pay for care. That means moving away from the current piecemeal approach of fee- for -service, and instead aligning incentives around the patient's journey, rather than provider activity. And there's good evidence, and ladies and gentlemen, there's good evidence for such payment reform in health economics textbooks, but what does this look like in action, and what does it feel like for the patient? One excellent example of this evidence in action comes from St. Joseph's Health care Center in Hamilton where I once did part of my medical training. St. Joe's, thanks to the leadership of Kevin Smith and his team, has been a real leader in what's known as bundled care. Well how exactly? Well, you can ask patients like Ilene who is here with us today, who knows far better than I do, but to me, it starts with wrapping care around the patient.

Instead of having a patient actively seek out every single aspect of her care independently, we can make sure that all of the necessary providers from surgeons to nurses, physiotherapists and personal support workers are all provided together and paid together as one bundled price to be integral parts of Ilene's full care pathway, from her pre-surgical assessment to the operating room, to her homecare. A nd the results are real. For bundled procedures like hip and knee replacements, returns to the emergency department after surgery dropped by over 30%. Referrals to rehab went down by over 40% and there were marked improvements in patient satisfaction.

Real innovations in health care funding models such as the St. Joe's experience happen when we adopt an evidence-based approach to patient care, prioritizing programs and interventions that deliver the highest standards of care, and that's one of the reasons why we're working with Health Quality Ontario to be a leader on this front. We need to be better able to measure the outcomes that matter to patients. So how are we doing this and perhaps most importantly, how do patients think we are doing? Knowing the answer to these questions is the only way we can add real value to our system and make maximum use of our health care dollars. Accessible care that is connected with patients is the driver , this is how we will build a more efficient and effective health care system , a health care system that rewards value over volume, one that is capable of adapting as patients' needs change.

In the same way as we evolve to become more accountable to patients, and that must include involving patients at every point in the decision-making process at every level, we also need to take the necessary steps to be more transparent so that patients can make informed choices about their health care. Ontarians have a right to know and control for example, what they are putting into their bodies. By preserving and creating healthier choices for all Ontarians my colleague, Associate Minister Dipika Damerla, will continue to implement S moke-F ree Ontario and our Healthy Kids Strategy. We will also work to ensure that calorie postings are front and center on menus in Ontario restaurants.

But in addition to having more control over what they are eating and the air that they are breathing, Ontarians also have a right to make the best possible decisions when it comes to their own care. That means creating a culture of openness alongside an unwavering commitment to patient privacy because transparency, when used appropriately and responsibly, is one of the greatest tools at our disposal for enhancing performance and patient safety. Today, Ontario hospitals are publicly reporting on more quality indicators than ever before. Patients deserve to have access to this information . Quite simply, patients ought to know how their hospital or provider is performing when it comes to their care. We routinely access this kind of information when we make decisions about which car to buy or where to eat. How is it rated? What were other people's experience? Health care should be no different, especially because the stakes are so much higher.

Putting patients first means ensuring that they have access to the information they need to make decisions around their care. No one should be left in the dark about whether a clinic they are using has been cited for infection control violations or has a higher than average complication rate. The default in our health system should be disclosure, not discretion. We need to keep asking ourselves, if we were to redesign our health system, what are the things a patient should absolutely know? How can we harness data to better protect our patients so that patients not only drive performance, but so that all patients are benefitting from the medical advances in our health care system. This should be every patient's right and I am working to ensure that our policies here in Ontario bring us closer to this goal.

(Now, you'll love hearing this line.) As I begin to wrap up, (because I'm sure you're all getting hungry), I want to take a moment to reflect on one of my most important responsibilities as Health Minister, which is protecting our universal health care system for generations to come because it is a system worth upholding and worth defending. Good health is the bedrock on which social progress is built. That was the opening line to Minister Marc Lalonde's trailblazing report, "A New Perspective on the Health of Canadians," over 40 years ago. We've come a long way, but there is still more work to be done because in the same way that no one should ever lose their home to pay for time spent in an ICU, Ontarians should never be forced to choose between buying food or paying for medication.

Ladies and gentlemen, national pharma care is a missing link in our universal health care system especially for Ontario's working poor. A nd so that's why we're working with other provinces and territories to build on the Pan Canadian Pharmaceutical Alliance and working with the f ederal government. A nd I'm encouraged as Ontario will be taking a leading role in hosting this initiative. [Applause] I wasn't aware how much you guys wanted to talk about drugs.

So the economic rationale is that by strategically leveraging our combined purchasing power, we can help deliver better health outcomes and generate savings right across our system. The evidence is clear and it's by coming together as one purchaser, like many of our peer countries do, we stand to save billions of dollars while also ensuring that Ontarians who need essential drugs have them.

We are the only country in the western industrialized world that has universal health care but has no national pharma care program.

We don't have to choose between bending our cost curve and putting patients first, both are possible. But it means being willing to challenge the status quo to find ways to better serve patients, by strengthening community-based care, improving transparency and accountability and developing evidence-based models that will tell us whether what we are doing is working. A nd we cannot be afraid to try new things and diverge from old ways if what we are doing isn't working or isn't in the patients' best interests.

Now, I know that all of you here today share this passion for making health care better and I'm grateful to all of you in this room for the job that you do each and every day. I know it isn't easy. Mine too isn't without its complications. Some days world peace seems like a more achievable goal. But it's a privilege that I refuse to lose sight of because we have an opportunity here together, to revolutionize health care in this p rovince in ways that will better serve Ontarians in the months and years ahead.

And so, I want to conclude as I started : with a personal note.

I often think about Mohammed and the many other health care workers and humanitarians I've had the privilege of knowing over the years who were killed while striving to keep their communities safe from violence and harm. It's what drove me to enter politics, to actively contribute to our democracy, to help build a just and fair society. But these experiences have also perhaps given me a different perspective on the challenges facing our health care sector : none are insurmountable. We all know what's at stake, but this vision won't succeed unless all of you too are on board. So let's begin this new Action Plan – " Patient s First," together. It begins today. I sincerely hope you will join me in this effort and I thank you for being here this afternoon. Thank you.


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