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3 Preparing for Health System Change: Opportunities for Public Health Leadership PHO Rounds Brent W. Moloughney MD, MSc, FRCPC Public Health Consultant Adjunct Professor, Dalla Lana School of Public Health

4 Overview Patients First Observations from Other Jurisdictions Ontario Context: Increased Linkage with LHINs - Leadership Opportunities 2

5 Patients First Proposal (Dec 2015) In order to reduce gaps and strengthen patient-centred care, More effective integration of services and greater equity Timely access to primary care and seamless links between primary care and other services More consistent and accessible home and community care Stronger links between population and public health and other health services 3

6 Transfer of provincial funding to the LHINs for allocation to Public Health Units (PHUs) LHINs would assume responsible for accountability agreements Local Boards of Health would continue to set budgets Boards of Health would continue to be managed at municipal level Formal relationship between MOHs and LHINs Note also: Expert Panel to advise on opportunities to deepen partnerships between LHINs and PHUs Concurrent review of OPHS/OS 4

7 Patients First Act 2016 Formalize equity-based service planning for LHINs LHIN and MOH engage regarding local health system planning, funding and service delivery Note: the proposed change to transfer funding and accountability agreement responsibilities to LHINs has not been included. 5

8 Taking Stock Policy intent for greater linkages But, not yet clear what it will actually look like and how will work In absence of detailed plan, opportunity to influence implementation What can we learn from linkages/integration of public health and regional healthcare organizations? What should we do for Ontario context? 6

9 Regionalization Rest of Canada Regionalized health systems (RHAs) were established in much of Canada ~ 20+ years ago Intent was to address system fragmentation and incoherence better linkages & integration; increase emphasis on prevention and promotion Implementation quite different from LHINs Individual organizations boards eliminated Global funding to RHAs Often lack of explicit public health core programs Limited public health accountability mechanisms 7

10 Public Health s Experience Elsewhere? Opportunities: Bring a population health perspective to healthcare planning more serendipity than system design Better integration of healthcare services Risks: Reduction in public health capacity to fulfill its mandate Barriers to engagement with community and municipal partners for action on social determinants of health (SDOH) Net Result: Generally left to discretion of individual RHAs General agreement that a net reduction in public health capacity with greater orientation to clinical service delivery 8

11 Implication? Maintain the strengths of Ontario s public health system core programs, boards of health, transparent funding, accountability mechanisms With Patients First policy direction, How maximize the opportunities? How minimize the risks seen elsewhere? 9

12 Why Do Anything? Patients First is here: Better to influence it for optimal implementation Argued that could achieve the benefits without transferring funding and accountability to LHINs Underlying intention is to leverage public health s expertise to influence planning of healthcare services If we re interested in influencing the determinants of health 10

13 Relative Impacts of Determinants of Health Biology and Genetics 15% Physical Environment 10% Canadian Institute for Advanced Research,

14 What Do We Do to Influence Other Use data Determinants of Health? To inform collective understanding To highlight inequities To frame problems We engage in collaborative partnerships deploying various leadership styles to seek structural (policy) change & improvements in service delivery 12

15 So What Might This Look Like? (hypothetical examples) Examine geographic distribution of services by SDOH/condition Example: distribution of diabetes-related services by neighbourhood (income, ethnicity, prevalence) Examine on LHIN (or sub-lhin basis), needs and services for a particular issue or population Example: examine sexual health services across provider groups, client groups and geography Example: examine health, social service, housing, police and other relevant services for high needs population 13

16 What Will This Take? Convening function LHIN (+/- PHU) Application of a population health lens to better understand the issue Analyze and display data Facilitate/meaningfully participate in collaborative processes Articulate public health role, approaches, and impact 14

17 Leadership Competencies* How to guide change Systems thinking skills Critical thinking skills Innovation and creativity Forward thinking Adapt to rapidly changing public health sector and health systems Garner support and momentum to a public health vision of upstream solutions to health issues Champion public health principles, actions and interventions Serve as catalysts to build partnerships, coalitions, increased capacity, shared leadership *Source: Public Health Leadership Competencies Release

18 Leadership at All Levels Organizational Role Examples Front line staff Describe public health service/activity to peers in other agencies Ability to identify and bring forward community needs Identify potential opportunities for improvement (e.g., gaps, duplications, lack of coordination) Management Program knowledge and impact explain what PH does and its impact Convenor/facilitator to involve partners to meet needs Relationships with community partners and service delivery Data and information apply population health lens to assess meeting needs of specific populations/communities Technical expert Work with multiple data sources Perform small area analysis to describe situation, inequities, etc. Senior management Apply systems thinking to frame issues from a population health perspective value-add to analysis and planning of health services Strategic partnerships and relationships Organizational culture and drivers of change or resistance Funding Mitigate participation burden risk (manage commitment of number/scope of healthcare projects; monitor adverse impacts) 16

19 Challenges Seen Elsewhere Staff/Management not necessarily able to articulate what do, why and impact Inequities in technical capacity Inconsistencies in terminology among partners (promotion, inequities, upstream) Senior management not necessarily able to apply population health lens to broader health system issues Becoming overwhelmed with involvement in healthcare system analysis and planning Resistance to change been doing that this way for 25 years 17

20 What Do We Do? Suggest.. Embrace the opportunity (but manage scope) Do what we do for other health determinants Seek to influence policy implementation (OPHS/OS modernization; expert panel; LHIN engagement) Address vagueness: What s the work/expectation? Identify what success looks like -> pursue it Don t use jargon unpack terms What resources, supports, and buy-in are needed? Build capacity 18

21 What Do We Do? Suggest.. (cont d) Recognize size of the challenge: Relationship building takes time Different cultures/vocabulary LHINs will be preoccupied with other aspects of Patients First (CCACs, primary care) Start small and tangible e.g., Particular service Particular high needs population Look at what can do now with an eye to what could do in future if had x and y in place 19

22 Conclusion Patients First is a high level proposal to leverage public health expertise for healthcare system planning Learn from RHA experience and design system to optimize opportunities and mitigate risks Require leadership from multiple organizational levels to influence healthcare as a determinant of health 20