Abstract
The urgency for reforming our health systems to improve health outcomes and service pathways is pressing and must be championed by leaders. Coalitions of the willing must be created to lead this movement. The All Nations Health Partners in Kenora, Ontario, have formed to lead health system reform in the Kenora Health District and are doing so in the spirit of Reconciliation in Action. All nations and organizations working together to reduce health disparities and improve health outcomes for all people.
Introduction
When we look at our health systems today and gauge how successful they are, the answer is highly variable depending on who is being consulted. Providers point to strengths and achievements while acknowledging gaps that exist beyond their control. Governments lament sustainability concerns and the lack of system improvement realized, despite their investments made to achieve them. The general public, satisfied with the quality of most care they receive, will express serious concern with wait times for elective services, difficulty navigating between providers, and the lack of access to more responsive community-based services. Despite all of our hard leadership work to address quality, patient safety, and change, we remain a heavily fragmented system of disconnected providers and organizations. Do we truly have the leadership capacity to bring about adaptive change? Are we tackling change the right way? 1
History
In the 2017 Commonwealth Fund report on health system performance, Canada’s performance was mediocre, ranked 9th best out of 11 countries in overall performance, 2nd worst in access to care, and 3rd worst in equity. 2 When we question why we are not improving faster, do we look at our Canadian data which clearly demonstrate substantive deficiencies in quality, access, and health outcomes for certain groups, such as Indigenous People, relative to the overall Canadian population? 3 Do we assess the impact of that reality on our health system international performance? Addressing these disparities is becoming increasingly urgent.
What if we engaged Indigenous People and their leaders in designing new solutions? They would likely indicate they lack access to a modern health system in their home communities to meet their basic service needs and often lack the basic infrastructure investments in their communities non-Indigenous People take for granted in their lives, such as clean water, quality housing, and economic opportunities that promote health and well-being. Further, Indigenous populations have been traumatized by the practices of colonialism and racism, which has undermined their personal, family, and social health. 4 The poor population health outcomes for Indigenous People are a direct impact of these realities and the failure to invest in the solutions they value and need. Under the Truth and Reconciliation Calls to Action, we can no longer ignore the poor health outcomes for Indigenous People relative to the rest of Canada or the importance their culture and traditional healing practices are for their health and wellness balance. 5
A coalition for change
To tackle these disparities for Indigenous People, there is no better time for health leaders to align and create a coalition for change. As one study demonstrated, the power of leaders to demonstrate innovation for tackling large-scale change has been given limited profile and attention as a change force. 6 Doing so will require new thinking and an appetite for seeking solutions that offer the most promise for improving access and health outcomes. New collaboration skills and planning methods, such as the use of design thinking and patient service journey maps, will be fundamental to build a collective view of design flaws and strengths. 7 These approaches will demonstrate empathy and humility while gaining collective benefit in learning through the experiences of patients, their families, and frontline caregivers. It will take courageous leadership to champion the shift from protecting our vested interests to a focus on protecting the interests of those we serve.
For leaders in northern and rural settings, this presents a great opportunity to take advantage of our relatively flat structures and collaborative partnerships and use them to leverage creation of a change coalition. Indeed, no other group will be close enough to understand our unique challenges and the opportunities for new practices and solutions. In Northwestern Ontario, a region of Ontario that occupies half of the provincial land mass with only 2% of the population, we have formed collaborative structures we can use for taking on the change agenda. Many of these structures were established through the leadership of the North West Local Health Integration Network (NWLHIN). With the impending integration of the provincial LHINs into a new entity in Ontario called Ontario Health, local leaders must now take ownership of the call for change and become champions for supporting it. There is evidence we are prepared to take on this mandate.
Discussion
When I joined Lake of the Woods District Hospital in the fall of 2018, the hospital had a long-standing and robust Psychiatric Program serving the Kenora Health District (KHD). Within 6 months of my arrival, the entire physician team had resigned due to retirements or relocations to other countries, leaving a critical service gap for Psychiatric Service in the KHD. We did not simply resign ourselves to our fate but chose to act proactively and together with our regional partners in designing a new model of psychiatric services. A 3-day planning event using design thinking was organized, inviting the collective wisdom of all of the key psychiatric leaders, the NWLHIN, partner leaders, and physicians within Northwestern Ontario to develop a new model. The engagement model utilized the provider and patient view as the key assessment and improvement lens. Vested interest did not rear itself during the planning event. The outcome was creation of a new regional model for psychiatric services which is visionary, accessible, and evidence-based. The model has been successfully implemented and has stabilized the Kenora Psychiatric Program, which is now growing in service capacity, and the entire region is now positioned with a strategy for best meeting future psychiatric service needs. A regional leadership team has been established to oversee the implementation plan.
In the KHD, a coalition for change has formed called the All Nations Health Partners (ANHP). This group was created in February 2017 in ceremony and those represented included The Grand Council Treaty #3, The City of Kenora, The Township of Sioux Narrows–Nestor Falls, the Kenora area First Nations, and the Kenora Metis Council/Metis Nation of Ontario. The following resolution was approved, “That all parties agree to work together in partnership in the development of an All Nations Health Care System, including the construction of an All Nations Hospital and Campus, with the express purpose of improving health outcomes for all people of the region it serves.” 8 This call to action in partnership and the spirit of reconciliation was a turning point for moving forward with change.
The health issues we must address are immense and unlike those faced in urban Ontario: We have a widely distributed population over a vast geography; Twenty percent of our population live in remote areas, often with limited or poor road access; Fifty-three percent have a weak link to an urban centre; Over a third of the population is Indigenous; Seasonal residents increase the KHD’s population by 25% each summer; There is a serious lack of public transportation in the KHD, which increases the cost of travel while impacting access to services; Lack of bandwidth in many communities restricts the use of telemedicine as a service option; Lake of the Woods District Hospital is the only regional hospital in the area and the tertiary referral networks are over 2 hours away in Winnipeg and 7 hours away in Thunder Bay. Highly specialized services in Southern Ontario can be up to 2 days away by car; Travelling to access service(s) often separates patients from family and support networks, which can jeopardize decisions to seek service or may create isolation that could impact health outcomes; and There can also be ambiguity regarding which level of government is responsible for delivering and funding specific services to Indigenous People, which can restrict access to care and, in turn, will create challenges as we plan an integrated health system.
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The differences become most stark when you compare health status and health outcomes as shown in Table 1. A number of factors contribute to this, including food and income insecurity, substandard housing, scarcity of health human resources, and limited access to timely healthcare. The ANHP is a unique coalition and includes Indigenous organizations and service providers, public health, housing, mental health, primary care, acute care, community service organizations, long-term care, and municipal governments. There are also several service partnerships between the ANHP members and close collaborative relationships between the Ontario Provincial Police and Treaty #3 Police Service for coordinated service pathways. By transforming service together, we will learn from each of our perspectives, expand our knowledge, and gain a broader scope of service options. Recognizing that we will be changing the status quo and building new service models, we must be inclusive and transparent so that all providers have voice, and the challenges being faced by those being served are heard and factored into solutions. This will require new strategies for engagement, planning, and using tools such as design thinking and system mapping.
Hospitalization, health status, and mortality indicators comparing the Kenora Health District population with Ontario population
Abbreviations: ER, emergency room; KHD, Kenora Health District; MOHLTC, Ministry of Health and Long-Term Care.
The ANHP is aggressively moving this change agenda forward. We have held a visioning session to frame our strategy and values. We are entering the planning phase for the All Nations Hospital with extensive community and First Nations engagement beginning in late 2019. Planning for the All Nations Health System has begun. To add additional complexity and opportunity, the ANHP was selected by the Ministry of Health and Long-Term Care as one of 31 proponents to proceed with submitting an application to become an Ontario Health Team (OHT). 10 On December 4, 2019 the Ontario government announced the All Nations Health Partners as a new Ontario Health Team. 16 This decision recognizes the importance of our work for all people living in the KHD and most importantly demonstrates the critical importance of Reconciliation in Action.
Conclusion
The ANHP’s strategic approach has strong similarities with the intent of the OHT. Both are intended to improve the health of the population and reduce disparities. Each encourage and require providers to willingly come together and shape how local health services will be delivered and managed in a way that is informed through meaningful engagement with patients, families, and caregivers. The ANHP strategy is rooted in a Reconciliation in Action lens requiring a co-creation of solutions, and the OHT process requires engagement with Indigenous People in the planning, design, and delivery of services for their communities. 11 A major challenge for the ANHP relative to other OHTs will be the ability to design, in partnership with local physicians, the professional staff model that will support the All Nations Health System and successfully negotiate a unique, new funding agreement that will enable the model to be realized.
The ANHP work is early in its journey but has already achieved some key milestones. It started in ceremony with both Indigenous and non-Indigenous partners agreeing to partner and collaborate on improving health outcomes and creating a new health system, including a new hospital, to serve all people in a culturally sensitive way. In this way, we are starting from a position of trust and respect. We have had a visioning session and agreed on a vision for an integrated model of care. We have submitted our application to become an OHT and, for our first-year population focus, identified mental health and addictions as our key area of improvement. In the first year, we will also begin our discussion on a shared governance model. We also recognize that under the OHT approach, we will need to measure the impact of our work on the health services and health outcomes for those we serve. Lastly, we have agreed to work as partners in the spirit of reconciliation, so how we are partnering as we advance this complex change agenda will remain one of our most important actions to be successful in executing.
It is inspiring to be a part of the ANHP coalition and this is commonly felt at our partner table. We will learn considerably along this demanding planning and change journey and build collective wisdom as an enduring asset. We will need to be continually mindful that Reconciliation in Action means we go forward together, always. We can use the LEADS framework to help inform our leadership strategies as we build our coalition, demonstrate effective engagement and partnership practices, and publicly demonstrate the true impact leadership can make by choosing to champion change and orchestrate improved service delivery. The time to take this on is now and we are privileged and proud to do so.
