Leading Change: Why Not Physiotherapy?

Fred Horne, former Alberta Minister of Health and Member, CPA Board of Directors

As Canada approaches its 150th birthday, we will quite rightly celebrate our proud history of providing universal access to critical health care services since the 1960s.

However, many will also be reflecting on the challenges of delivering health care in the 21st century and wondering about whether the system we all value so highly can effectively meet the increasingly complex needs of Canadians and be sustainable in the long-term. As a former health minister, health policy analyst, and more recently a member of CPA’s Board of Directors, Physiotherapy Practice asked me to reflect on the key challenges ahead and the contribution physiotherapy might make to meet them.

Canada’s Performance and the Case for Change

While our health care providers offer excellent care and our governments spend more on health per capita than most countries, our overall performance on international benchmarks can best be described as “middle of the pack”. The fact that more money does not buy better health care is well-documented and has been the subject of considerable discussion in the last few years. Many provinces have reported that as few of 5% of the population are utilizing 60-65% of health care resources. At the same time, the proportion of health costs as a percentage of provincial budgets continues to increase and may soon reach 50% in some provinces.

Where to Focus

We know change is needed. The question is where do we focus and how do we get the job done? Traditional approaches to health policy and program development often involve identifying factors in the external environment and developing targeted strategies to address them, often in the form of new programs at an additional cost. Demographic changes, such as our growing and ageing population and the emergence of new technologies are two examples. These are significant factors, to be sure, and health systems must respond. But much of the answer, in my view, will come from looking inwardly at how basic care is delivered, and being willing to confront and address what’s simply not working for patients. There is no shortage of stories about fragmented care, poor or failed transitions between hospital and community, unnecessary repeated tests, lack of access to after-hours care and community-based support services that keep people out of hospital, and most of all, missed opportunities to prevent illness and injury before it happens. Whether you are a front-line health provider, an administrator, or the health minister these are the issues that are front and centre now. And from a sustainability perspective these are costly problems. Every decision we make in health care carries an opportunity cost decision – by choosing to do something, including what is unnecessary or avoidable, we forego the opportunity to do something of greater value.

The Value Proposition for Physiotherapy

Physiotherapy offers an impressive and unique value proposition. As a profession, physiotherapy is present with patients through virtually the entire continuum of care —from primary care and rehabilitation through to the subspecialties. Physiotherapists rarely work in isolation; they must be effective managers and coordinators of care to deliver high value outcomes to patients, including working with providers outside the formal health care sector. Physiotherapists work in both public and private health care delivery environments; in the latter, dealing with a wide range of issues that simply aren’t sufficiently or satisfactorily addressed in public health care settings. They contribute new knowledge and valuable data through research. Moreover, physiotherapists are investors in health care, providing facilities, equipment and staff needed to support improved population health and workforce productivity. With a clear value proposition, the question then turns to where the profession can best focus efforts to have greatest effect, and with whom to partner.

Integration

One of the greatest challenges Canada faces is to become successful in the integration of care delivery. While the term itself is not well defined at the system level, talk to patients and they will tell you clearly what integration “looks” like:

  • I tell my story only once.
  • I receive care from a community-based team of providers and am involved in all decisions about my care.
  • My health information goes where I go. The health providers I see communicate regularly with one another and have immediate access to relevant health information about me, whether or not they work in the same location.
  • I am not asked to repeat the same tests when I see a new or different provider.
  • I am provided with information about what I can realistically expect from my health providers and the contribution I can make to improving and maintaining my health.
  • If I need to see a specialist or require hospital care, my primary care providers coordinate this for me before I go and arrange for and coordinate any follow-up services required.
  • My health care team provides access to non-emergency, after-hours care.

Physiotherapists, for the reasons cited above, are in an excellent position to support efforts to better integrate care. At a program level, we can see many examples of how the profession is contributing not only to improving the “lived experience” of patients, but in designing programming and research to support better use of resources and improve patient outcomes.

The Alberta Hip and Knee Clinic in Edmonton, a collaboration between Primary Care Networks, family physicians, allied health providers and the Alberta Bone and Joint Health Strategic Clinical Network, is an example of a program supported by physiotherapy and a program often cited for its success in supporting better integration.

Situated in a primary care setting, the clinic has developed a special screening process for patients referred for orthopaedic surgery. The results are impressive: approximately 80% of patients seen are found not to require surgery and offered alternative, more appropriate intervention, including physiotherapy. The other 20% receive pre and post-operative surgical care, coordinated at the primary care level rather than the hospital.

In addition to improved patient experience and better outcomes, the system gains are impressive. Eight of ten people who would normally wait to see an orthopaedic surgeon unnecessarily are taken out of the queue. The patients who remain can be seen earlier, and more can be accommodated. Unnecessary diagnostic procedures such as magnetic resonance imaging tests are avoided. Patients tell their story once and the information is consistently and accurately shared with all involved in the continuum of care. And at a population health level, health professionals collaborate to evaluate patient outcomes and key performance indicators. This includes feedback to individual surgeons and institutions where arthroplasty care is provided.

The result is that a key population health risk and expensive health resources are managed effectively, and outcomes and the patient experience are optimized.

Implementation

When I was first appointed health minister, someone who had served in the role previously said to me, “Everyone will want you to fix health care until you try and change something.”

Despite successes like the Bone and Joint Clinic described above, the difficulty of making things actually happen in health care is considerable. In my experience, this has nothing to do with the commitment of everyone in all parts of the system to do better for patients—of that there is no doubt. But the pressure to simply “keep up” with the day to day delivery of care leaves little room for providers to even think about, let alone plan and implement, changes that will support better care. Change fatigue is a growing problem.

One thing I have observed in the last 30 years is that “top-down” driven change is rarely effective. The most effective and lasting change comes when decision-makers and administrators create the time, space and tools to support front-line providers in leading change that will benefit their patients, and then only when patients are directly involved in the discussions. We must find a way for the lived experience of both patients and providers to be the most highly valued commodity in health system improvement. Physiotherapists may well prove to be our best kept secret in addressing the challenges of 21st century medicare.

About Fred:
Fred Horne is a health policy consultant and served as Alberta’s Minister of Health from 2011-2014. A frequent speaker and panelist on health system issues in Canada, he is Principal of Horne and Associates, Public Policy Consultants, and Adjunct Professor at the School of Public Health, University of Alberta. As Minister of Health, Fred was responsible for the province’s $18 billion health budget, the Ministry of Health and Alberta Health Services, the province’s health delivery organization and the fifth largest employer in Canada. Fred holds an MBA from Royal Roads University and the Certificate in Dispute Resolution from York University. He currently serves as Chair of Med buy Corporation, and on the boards of the Canadian Physiotherapy Association and the Canadian Frailty Network.