The 1^st Annual Amyot Lecture – Medicare and Wellness: The Odd Couple

Presentation by Dr. Robert McMurtry
G.D.W. Cameron Chair
Health Canada
November 2, 1999

• Executive Summary
• Speaking Notes

Executive Summary

The 1974 Lalonde report said that health is more than a health care system. That report recognized the importance of health determinants in the overall health picture. Yet, 25 years later, despite the insights of Lalonde, some of those determinants are worsening, such as the environment and socio-economic inequalities.

The Ottawa Charter of 1986 describes health promotion as the process of "enabling people to increase control over and to improve their health". This description is based on the crucial concepts of enablement and control. The importance of broadly based programs to enhance the knowledge and understanding of health is as important for the individual as it is for the population.

Two solitudes

There are two solitudes in Canada between the perspectives of health care and population health.

The first solitude, our health care system, is characterized by some as the "repair shop" model, in which caregivers diagnose and treat disease; it is a disease-centred approach.

The second solitude, population health, is regarded by others as a mere abstraction, with little potential for practical application to Canadians' health care needs.

Neither characterization rises above stereotyping.

To respond to Canadians' health needs, integration of these two solitudes is required.

The health care system can achieve its potential by being much more than the "repair shop" model. First, it should be congruent with the five principles of public health care enumerated by the Hall report: universality, accessibility, comprehensiveness, portability and public administration. Second, it should be efficient and accountable. Third, it should be person-centred, engaging with the context of people's lives and the illness experience. All are necessary conditions.

The population health model can be strengthened by addressing the notion of healthy public policy, not just a health policy. Population health should inform all public policy, be widely disseminated (the success of Health Canada's 1999 report on the health of Canadians, Toward a Healthy Future, is a good example), and be relevant to the patient encounter.

Person-centred care

We will have difficulty bridging the gap between the health care system and the population health model unless we acknowledge the need for adopting contextualized or person-centred care. This type of care emphasizes communication and finding common ground between the person and provider in identifying a treatment option that is appropriate to the individual's life circumstances.

Contextualized and person-centred care:

• takes no longer than traditional approaches
• yields greater patient satisfaction
• improves treatment strategies
• lessens patient anxiety
• reduces demand for further medical services.

In short, bridging the perspectives of population health and health care results in a better outcome.

Case study: Integration of population health and health care in the workplace

The Canadian workplace has undergone profound changes. According to an analysis by the Institute for Work and Health and the Canadian Policy Research Network, only about 54% of Canadians have a "standard" job. A growing number are working part-time, are self-employed, or hold down more than one job. Of the one-third who take time off work in any year, 60% cite mental and emotional stress as a primary factor for their absences.

Where does this leave the caregiver? The standard diagnosis-treatment model is inadequate to the task of managing health issues of Canadians as they relate to the realities of their work. Often physicians are unable to deal with problems such as repetitive strain injury unless the workplace itself (or the interaction between the employee and the workplace) is changed on a long-term basis. Thus care at an individual level is unlikely to succeed in the absence of a strategic intervention at a broader level.

Proposals

To make the health care system more responsive and comprehensive, we must take a number of concrete steps to bridge the gap between the health care system and population health.

• First, we must reform primary care through a collaborative, multidisciplinary system that involves all health care professionals. This reform must have the goal of enabling people to increase control of their own health. An approach of person-centred or contextualized care is a necessary element.
  
• Second, we must devise ways of measuring health outcomes throughout the life cycle. To succeed, the information gathered must be at the individual level, reflect community-based encounters, and be aggregated to the to higher levels.
  
• Third, we must target health inequalities among socio-economic groups by enlisting broad support for programs that benefit all. Examples are programs that deliver information, knowledge, and understanding about health in the broadest sense.

Finally, we must undertake evaluation as a co-production of care. Evaluation will succeed only if it is methodologically sound, engages patients as partners, and directly involves health professionals in the research process. The results of the evaluation in turn should inform health care practices and policy.

Conclusion

It has been often demonstrated that a better-educated population enjoys better health, with obvious benefits to the economic viability of their society. Improved quality of life and economic development must go hand in hand.

Canada has an opportunity to integrate health care and population health for the benefit of all Canadians. Our goal should be to exercise leadership that will, in the words of the 12th-century philosopher Ibn Arabi, "create for all the conditions of their fulfillment".

Speaking notes from the conference

It is a great privilege to deliver the first Amyot Lecture this evening. Dr. Amyot was a giant -- a visionary physician -- who among his achievements introduced filtration and chlorination of water and pasteurization of milk to Canada. He also was a pioneer investigator (1912-13) of pollution in the Great Lakes.

It is timely to be reflecting on and learning anew from our visionary forebears; what they teach us of the past and its meaning for the future. We are at a crossroads. The very successful health care system that has enjoyed such success and popular backing is struggling. Public confidence is at record lows following years of restructuring but the support for the health care system and its founding principles remains very high. The issue is not one of whether or not it continues but rather how it should reconfigure for the future; what changes should be made, what new directions must be taken?

We must reflect on our fundamental values both as individual citizens and collectively as people. We must strive to regain "the moral centre of a common understanding," as Dr. Nuala Kenny phrased it.

Fortunately, there is an excellent starting point. The five principles enunciated by Emmett Hall in 1964 of accessibility, comprehensiveness, universality, portability and public administration are timeless. They are as valid now as they have ever been.

There is also enduring truth to the insights lent by the justifiably renowned Lalonde Report of 1974. The central thesis that there is more to health than the health care system and that the health care system is an essential but insufficient condition for the health of the population resonates 25 years after its writing. The report stands as a foundation for building the health system of the future.

Definitions

For the purposes of our discussion, the definition of Medicare is the provision of "medically necessary acts" as identified in the Medical Services Act of 1966. It is the basis of the publicly funded health care system.

"Wellness" is a new word. It does not appear in most standard dictionaries at present. The most suitable definition is (drawing on the statement in the World Health Organization's Constitution on health) "a state of complete physical, mental and social well-being, and not merely the absence of disease and infirmity."

It applies not only to individuals but also to populations or people collectively. It therefore represents an appropriate goal for interventions at both the individual and population level whether those interventions relate to prevention of disease or to the restoration or promotion of health.

Two solitudes

What is the congruence or connectivity between these two crucial concepts regarding health? "Wellness" and "Medicare" currently exist as two solitudes (note 1) or an odd couple. Given that the goals of the two do overlap, it is indeed odd that they represent two such differing perspectives. Medicare is often characterized as a "repair shop," "the medical model" or "disease-centred model." More often than not these descriptors are used as terms of derogation, as labels to identify what is wrong with the health care system. At its worst, the health care system fulfills this stereotyping. Certainly, there are many pressures currently being experienced by hospitals, physicians, nurses and other health care professionals during, and because of, restructuring. Perhaps it is being reduced to the status of a "repair shop."

At its best, however, it is much more, justifying not only Canadians' support of, but also their sense of identity, being defined by Medicare.

For its part, wellness -- and its attendant agenda -- is certainly a worthy goal and should arm us with a sense of purpose. It is inextricably linked with the precepts and principles of population health which are essential for progress. However, it is seen by its critics as a mere abstraction, disconnected from reality, a philosophical nicety detached from the real world of patients and their needs. In the 25 years since publication of the historic Lalonde Report, can we identify concrete outcomes as a result of its recommendations in the area of healthy policy? Certainly less than any of us would hope. Whatever the perceived shortcomings of Medicare or of the intentions of the wellness agenda, stereotyping is unhelpful and perhaps harmful because it is apt to polarize the discussion.

Polarization is not what is needed. Integration is. There is a connection between wellness and the population health perspective and the care of individuals or Medicare. It is a pathway which commands our attention. Our success in mapping and understanding the pathway is the necessary trajectory for the future. Fortunately, there is a growing volume of knowledge and evidence to guide us. We can, for example, learn a great deal from the Ottawa Charter of 1986. In its few pages, the Charter contains much wisdom. Among its seminal statements were calls to action for ecosystem health, for healthy public policy and for fostering greater equity. It also spoke to the need for "enabling people to increase control over and to improve their health." On the face of this, it seems simple enough but upon reflection the implications are profound. It is a unifying vision, a metaphorical bed that both members of the odd couple can comfortably lie in.

Overcoming the solitudes

If the impoverished view of the health care system as nothing more than a repair shop is true, many ill-consequences ensue. Principal among these adverse effects is that it won't work. The model reduces people to an example of the disease from which they suffer. The focus becomes a disease-treatment coupling: if disease A is present, treatment X is warranted. The practice of medicine becomes formulaic, a mere commodity. If that were the extent of Medicare, it should not continue.

The end, however, is not near. It will not be, so long as the five founding principles of Hall are respected. If, in addition, there is accountability and transparency in the practices within the health care system as well as the use of the method of Patient-Centred Medicine (PCM) (note 2), there is cause for optimism. There will always be support for a system that delivers on these principles.

As for wellness and, particularly, the crucial insights and lessons of the population health perspective, they must become part of the daily bread of the health care system and related policy. It is not the case at present. Despite countless calls for "healthy policy" -- public policy that is sensitive to its health impacts -- it remains an elusive goal. Inequalities in health and degradation of the life support systems of the planet, air, water and soil, are worsening not improving. Not only does the notion of healthy public policy demand our attention, but the insights of what contributes to the wellness of populations and individuals should be widely and comprehensively disseminated. Furthermore, it can and must inform individual patient encounters.

There is a significant gap between what we are doing and what could be done. Our central task is to explore, define and understand the connection between the health of an individual and of a population. What are the mechanisms, or the biological pathways of the determinants of health? (note 3) How do the determinants exert their influence? Can we mitigate the ill-effects and enhance the positive? These questions, and related ones, have been posed before. The time has come to seek the answers. Fortunately, progress is being made. The movement of PCM has demonstrated the value and perhaps the necessity of integrating the determinants into the individual patient encounter.

Patient-centred medicine

The above concept is not new. A quote from Sherwood Nuland's book Doctors, the Biography of Medicine reveals why: "However, by concentrating their treatment not on the actual diagnosis but on the patient and his environment, and by making him a member of his own therapeutic team, they achieved successes that eluded their rivals." The passage refers to practices of the Coan School (of which Hippocrates was a member) and dates back some 2500 years.

Over the past 30 years, McWhinney and others have studied and researched extensively on the method of Patient-Centred Medicine. It is the antithesis of the "repair shop" characterizations. As a method, it focuses on the person, the nature of their lives within their social, physical and economic environment and the meaning of a health compromise in that context. It distinguishes between the disease, (an objective, demonstrable departure from normal) and the illness experience. The illness experience is defined as the individual's response to the disease and is unique to each person.

At minimum, the goals of care are to empathize, communicate and find common ground between patient and physician. A full engagement with the individual's perspectives, values and needs are essential for finding the common ground. Once there is agreement or a shared understanding, the treatment plan, based on the best available evidence, can be developed. The development of the treatment plan includes the patient as partner to the full extent that the person is able.

The engagement is not episodic; rather it is continuing (ideally primary care and PCM should be maintained throughout the life cycle).

While this is a very sketchy portrayal, it is worth emphasizing several key points about PCM.

1. It brings the determinants of health to the individual patient encounter.
2. It is successful as measured by higher patient satisfaction, fewer diagnostic tests, fewer referrals, higher adherence to treatment plans and better physiological outcomes (e.g. blood pressure readings, blood sugar).
3. It takes no longer than traditional approaches.
4. It is an excellent foundation for pursuing the goals of disease prevention, health promotion and evidence-based care.

The contrast to disease-centred medicine is obvious. In the disease-centred approach, the considerations are much narrower. There is a disease-treatment coupling and, not surprisingly, patient satisfaction is less with the attendant demands for further tests, referrals, etcetera, becoming more probable.

In short, PCM is a success story and though not a panacea, it does achieve some integration of the aspirations of the wellness agenda and the goals of population health, as well as the effective care for the individual.

A. Case study - The changing workplace

While PCM can result in more positive outcomes, it also reveals emerging problems and failings. The linkages between the determinants of health and their impact on the wellness of people (collectively and individually) is seldom more apparent than in the workplace. At an individual level, it is clear to me as a practicing physician that my ability to manage work-related ailments is far more limited than I would like. This is, of course, anecdotal as is the sense I have that the situation is becoming worse.

It leads to the question of what is happening at the macro level in regards to the Canadian labour force. What is there to learn from an analysis of the overarching forces operating in the workplace and how might that help an individual patient and practitioner? It is an enquiry where macro meets micro.

Fortunately, robust enquiry and scholarship have been brought to bear on the workplace and health. The Institute of Work and Health (IWH) and the Canadian Policy Research Network (CPRN) with other partners have done an analysis which is quite revealing. Over the past 10 years, major shifts have come to pass. The workplace has been redefined as profoundly as that which occurred during the industrial revolution according to Dr. Terry Sullivan, Executive Director of the IWH. Of employed Canadians, only 54.2 percent are doing standard work. Their analysis demonstrates the following facts about the workforce.

What is demonstrated in the following table is a large variation in job patterns. When one takes into account those among the employed who are self-employed, temporarily employed, part-time and other short-term workers, it leaves slightly more than half in a traditional or standard job.

Overview of Canadian Labour Force (based on total labour force of 15,631,500)

Employment status

• Total = 14,326,400 employed -- 100 % of employed labour force
• Paid employees (17.6% self-employed) = 11,801,200 -- 82.4 % of employed labour force
• Permanent employees (9.8% temporary) = 10,406,400 -- 72.6 % of employed labour force
• Full-time employees (10.9% Part-time) = 8,835,300 -- 61.7 % of employed labour force
• Job tenure more than 6 months (5.5% less than 6 months tenure) = 8,044,400 -- 56.2 % of employed labour force
• Note multiple job holder (2.0% multiple jobs) = 7,766,900 -- 54.2 % of employed labour force

Clearly the concept of job security is a diminished reality. For those still in standard work, there are emerging trends of interest. Internationally, there is a shift from blue collar to white collar work. That the work place is less dangerous represents a clear gain, but what of stress and pace?

According to the IWH and CPRN, in 1997 the number of workdays lost in Canada was 66 million or 6.2 days per employee. What is most revealing, however, is that among the one-third who had work-related health conditions, 20 percent were ill, 20 percent were injured and 60 percent suffered from mental and/or emotional stress. The most common cause was related to pace and insufficient control over their job.

As one contemplates these findings, it is not hard to imagine the explanation for the relative inability of medical treatment to provide definitive relief. As much insight as a practitioner may have in regard to the work-related problems of stress or of tenosynovitis or carpal tunnel syndrome, the prospects of therapeutic success are dim in the absence of a change in the circumstances of work.

The integration of the micro and macro levels certainly enriches an understanding of the problem. Progress, however, will depend upon more widespread dissemination of the information and, certainly, upon job modification for the vulnerable worker.

The case study of the workplace is clearly an example of the need for integration of the two solitudes. The changes identified at the level of the population of workers informs the individual encounter. In addition, the phenomenon of determinants of health being adversely influenced and its negative impact on health care delivery is important information. It is of value to the development of labour and health policy as well as being of interest to employers, unions and others.

Proposals

In contemplating the "odd couple" and the resulting isolation of the Medicare and the wellness agenda, some strategies to create integration of the two are in order. The potential rewards and gains are substantial. The following is a starting point and not an exhaustive list of proposals. The choices however may reflect a personal bias regarding priorities.

Primary care reform

Approximately 50 percent of physicians are family practitioners. Of the population of physicians, they are most likely

• to have a community perspective of care
• to engage in collaborative practice
• to consider alternative payment schemes
• to engage with people and thus populations longitudinally.

The foregoing is a formidable list of assets when contemplating change in delivery models. Indeed, there are in existence a number of practice settings, across Canada, that are characterized by collaborative, multi-disciplinary care and alternative payment approaches. If there were policy initiatives that supported further development and the principles of Patient-Centred Medicine, significant progress is possible. Cooperation with the provinces should be achievable given the directions that are already occurring, for example, in Ontario.

Measurement of outcomes

The Minister of Health, Allan Rock, has recurrently indicated his commitment to the notion of a report card on the health care system. Indeed, his statements have been backed by a $95,000,000 investment being coordinated by the Canadian Institutes of Health Information (CIHI) to create the report card. Measures relating to issues such as access, waiting lists, patient satisfaction, etcetera, will be used among others to develop the report card. What is missing, however, is a reliable data source of individual patient encounters, gathered longitudinally and reflecting out-patient and community settings. The Hospital Medical Record is an insufficient source of information inasmuch as it reflects a subset of information, is episodic (in-patient) in nature and the quality of data is problematic.

While the efforts of CIHI represent important progress, the goal should be to meet the above standard of longitudinal, individual-based health system encounters. Furthermore, the standard of congruence to PCM could be measured. A simple nine-item questionnaire has been developed for the purpose and has been employed on a large scale in Australia. Patient confidentiality is of paramount importance and if assured, the above approach would create a data base that could be aggregated for analysis at the meso (community, hospital, region) level as well as the macro level. Success in this endeavour would be another mechanism to bridge the two solitudes.

Program priorities

This lecture has endeavoured to make a case for the enormous importance of the workplace and health and the need for a richer understanding by all: employers, employees, policy-makers and health professionals. Another priority is an investment in the first years of life -- including intra-uterine existence -- to ensure optimal growth and development of children. The case for this second priority has been made elsewhere, recently and compellingly by members of the Canadian Institute of Advanced Research, among others, and by Dr. Fraser Mustard, in particular.

The third priority relates to education and literacy. Canada invests very heavily in the formal education system. About 7 percent of our Gross Domestic Product is committed to the purpose, which in terms of expenditures, places Canada at the forefront internationally. What requires more focus is the informal educational processes of the acquisition of information, knowledge, skills and understanding throughout life.

There is emerging evidence that large numbers of the Canadian population are disadvantaged by compromised literacy. For example, in the International Adult Literacy Survey it was demonstrated that only 22 percent of Canadian adults were in the top two levels of the five-step scale. Furthermore, over 50 percent of seniors (over 65 years old) were in the lowest level. In short, there is a gradient of literacy achievement. In addition, a correlation can be seen between education (an input, while literacy is an output) and health status. It is as robust a relationship as socio-economic status. Indeed, the two are difficult to tease apart. It is of interest that it has been shown, in both the American and Canadian context, that the well-educated poor are more likely to report good health than the well-to-do with low educational achievement. The findings go well beyond academic interest and have important policy implications. Literacy is as important in the context of health and health care as it is in the workplace and indeed for virtually all coping skills and a meaningful life itself. There's never an age at which literacy is unimportant. Certainly, the best window of opportunity is the first two years, but it is not the only one. Strategically, it demands the attention and collaboration of Health Canada, Industry Canada and Human Resources Development Canada. Promoting literacy could and should be part of any initiative of primary care reform. In the future, we must focus more on health literacy and less on therapeutics.

Evaluation

In keeping with the needs of accountability and transparency in the health care system, evaluation is clearly part of the equation. Ideally, it should:

• be an integral part of patient care
• engage patients fully as partners
• include human as well as financial coordinates
• be supported by, and include the participation of, health care professionals be a replacement for existing documentation practices and, as such, represent no further work burden.

If the above conditions are met, feasibility will exist. Of equal or greater importance is that uptake of research findings by practitioners is more likely to occur. To quote Lomas, "the best predictor of uptake of research is involvement in the research process."

Conclusion

Progress is possible if it is based on the evergreen principles of Emmett Hall. Enactment of the other requirements in the health care system of the future involves an integration of PCM, issues of literacy and effective evaluation. All can be woven into a coherent whole of primary care reform.

The whole would be characterized by a connectivity that would join the two solitudes, enriching both. The outcome would be a more robust health care system for the future and, more significantly, an improved health status of Canadians.

The task is daunting. It will require the efforts of, at minimum, the political and governmental sector, the health professions and, certainly, the public.

The evolving opportunity deriving from the historical federal investment in research with the Canadian Institutes of Health Research must not be missed. The integration of research themes envisioned by the CIHR mandate is entirely congruent with these proposals and the bringing together of the odd couple.

The rewards are potentially great. There is a lot at stake including not only the future of Medicare, but of Canada itself. It is a time when wise choices are imperative. Making such choices is not always easy, but if we are guided by the words, " to create for all the conditions of their fulfillment," success is likely to follow.

Notes

1. The concept of two solitudes was contained in the title of a novel by Hugh McLennan published in 1946. The book poignantly portrayed the gap between the English and French cultures in Canada.
2. Patient Centred Medicine (PCM) or Contextualized Care is described in detail in the next section. For a comprehensive review the book Patient Centered Medicine by Moira Stewart et al (1966) is recommended.
3. The determinants of health are those factors occurring in the environment (e.g., social, economic and physical) and in the individual (e.g., genetic environment, biology and behavior) that impact on health status/outcomes.
4. Doctors, the Biography of Medicine, p.10, Vintage Books, 1998.