This document summarizes discussions from a 2002 conference on building consensus for healthcare reform in Canada. It includes summaries of two presentations:
1. Marie-Dominique Beaulieu's presentation on the role and value of primary care. She defines primary care and argues for strengthening it in Canada. She calls for changes like developing primary care teams with nurses and better information systems.
2. Howard Bergman's presentation in which he argues for strengthening and transforming primary care as the foundation of the healthcare system. He calls for an evidence-based approach and investing in primary care to improve health outcomes. Both agree comprehensive reform is needed, not just changes to primary care itself.
What your organisation needs to know about personal health budgets, communica...CharityComms
Jaimee Lewis, Think Local, Act Personal
Changing the game: positioning your charity to succeed in the new health service market conference
www.charitycomms.org.uk/events
What your organisation needs to know about personal health budgets, communica...CharityComms
Jaimee Lewis, Think Local, Act Personal
Changing the game: positioning your charity to succeed in the new health service market conference
www.charitycomms.org.uk/events
Final Progress Report on the Implementation of the Government‟s Response to the Special Commission of Inquiry into Acute Care Services in NSW Hospitals
October 2011
Meeting the challenge together... delivering care in the most appropriate set...NHS Improvement
Meeting the challenge together... delivering care in the most appropriate setting (October 2008). This document has been designed to support the pilot sites (now starting to test new ideas working with partners in primary care and social care) but will also be of interest to other organisations attempting to reform inpatient care (Published October 2008).
Empowering and enabling charities to become trusted partners in the commissio...CharityComms
Charlie Peel, Neurological Commissioning Support
Changing the game: positioning your charity to succeed in the new health service market conference
www.charitycomms.org.uk/events
Objectives:
1.To review the need for increased efforts to implement research evidence into bedside practice.
2.To review the need for measurement to identify gaps between best practice and actual practice.
3.To demonstrate why there is a need for increased knowledge translation efforts in critical care and how aCKTION Net proposes to fill this need.
Click the link to view the video http://bit.ly/YpJWTC
This paper articulates the function of Malaysia Healthcare Travel Council (MHTC) in developing the Health
Tourism Industry. Focus was given in identifying the challenges faced by MHTC, understanding the
competitiveness of the industry and proposing a suitable value chain framework for the industry. Total of 12
organizations have been identified, which were including private and public organizations. Conclusions of
findings have been derived and few recommendations made at the end of this article.
Keywords: Health tourism, medical tourism, competitive, leisure services and value chain
Final Progress Report on the Implementation of the Government‟s Response to the Special Commission of Inquiry into Acute Care Services in NSW Hospitals
October 2011
Meeting the challenge together... delivering care in the most appropriate set...NHS Improvement
Meeting the challenge together... delivering care in the most appropriate setting (October 2008). This document has been designed to support the pilot sites (now starting to test new ideas working with partners in primary care and social care) but will also be of interest to other organisations attempting to reform inpatient care (Published October 2008).
Empowering and enabling charities to become trusted partners in the commissio...CharityComms
Charlie Peel, Neurological Commissioning Support
Changing the game: positioning your charity to succeed in the new health service market conference
www.charitycomms.org.uk/events
Objectives:
1.To review the need for increased efforts to implement research evidence into bedside practice.
2.To review the need for measurement to identify gaps between best practice and actual practice.
3.To demonstrate why there is a need for increased knowledge translation efforts in critical care and how aCKTION Net proposes to fill this need.
Click the link to view the video http://bit.ly/YpJWTC
This paper articulates the function of Malaysia Healthcare Travel Council (MHTC) in developing the Health
Tourism Industry. Focus was given in identifying the challenges faced by MHTC, understanding the
competitiveness of the industry and proposing a suitable value chain framework for the industry. Total of 12
organizations have been identified, which were including private and public organizations. Conclusions of
findings have been derived and few recommendations made at the end of this article.
Keywords: Health tourism, medical tourism, competitive, leisure services and value chain
Le Radiology Trainee Forum (RTF) est l’organisation créée par l’ESR pour les internes de radiologie en Europe. Son objectif est de représenter les intérêts des internes dans l’ESR, tout particulièrement, concernant les programmes d’éducation, de recherche, d’échanges et de développement des carrières.
Les 41 Délégués Nationaux, représentants d’internes de chaque pays de l’ESR, constituent l’Assemblée générale du RTF. Le RTF est coordonné par son conseil d’administration, élu pour un mandat de deux ans par l’Assemblée générale pendant l’ECR. Les membres actuels du Conseil d’Administration (2013-2015) sont : Viola Koen des Pays-Bas en tant que Présidente, Nadya Pyatigorskaya de France en tant que Vice-Présidente, Costin Minoiu de Roumanie en tant que Secrétaire Générale, Marijana Basta Nikolic de République Serbe en tant que responsable des relations publiques et Pablo Rodríguez Carnero d’Espagne en tant que responsable de la recherche.
Le principal objectif du RTF est que le même niveau de connaissances et de compétences radiologiques soit fourni aux internes en radiologie à travers l’Europe. Pour cela, nous participons aux discussions au sein de l’ESR concernant les sujets liés à l’éducation et donnons notre avis sur les décisions concernant la formation dans tous les domaines de la radiologie. Une attention particulière est accordée à l’homogénéisation et à l’amélioration des programmes de formation à travers l’Europe. Ceci passe par l’homogénéisation des programmes de l’internat avec le cursus européen commun, par la promotion de participation des internes dans des cours européens, tels que l’European School Of Radiology (ESOR), dans des congrès internationaux et aussi par les stages d’échanges.
reseauprosante.fr
Radiology Trainees Forum.
A l’occasion de l’ECR 2011, nous nous sommes rendus compte que peu de jeunes radiologues français connaissaient le Radiology Trainees Forum (RTF) ou le forum des radiologues en formation. Or, le RTF est actuellement en plein développement et représente l’interface principale entre la Société Européenne de Radiologie (ESR) et les jeunes radiologues européens.
Voici donc en quelques mots de quoi il s’agit.
Le RTF est une association de jeunes radiologues européens en formation. C’est un peu l’équivalent de la Société Française de Radiologie junior (SFR junior) à l’échelle européenne. C’est l’interface entre les jeunes radiologues européens et l’ESR.
Le but du RTF est donc de représenter les intérêts des radiologues juniors et de promouvoir à l’échelle européenne leur formation, les développements de carrière et la recherche. L’objectif principal du RTF est de s’assurer d’un niveau égal de connaissance et de compétence entre les radiologues en formation à travers l’Europe, et ce en étroite collaboration avec les sociétés nationales et l’ESR.
reseauprosante.fr
Regards croisés sur la souffrance psychologique et existentielle en fin de vie : de l'évaluation à l'intervention
Mélanie Vachon. Professeure au département de psychologie, Université du Québec à Montréal.
Plan de la présentation :
1. Dresser un portrait du statut socioculturel de la mort en occident
2. Situer les soins palliatifs et leur approche
3. Définir la souffrance globale et en préciser les aspects psychologiques et existentiels
4. Donner un aperçu des possibilités d’intervention, au plan médical et psychologique
5. Illustrer les concepts à l’aide d’une présentation clinique complexe et soulever la question du recours à l’euthanasie comme intervention possible
A value chain is a set of activities that a firm operating in a specific industry performs in order to deliver a valuable product and servicef for the market .
Ethical Issues Of The Healthcare Essay
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Health Care Reform (The Affordable Care Act) .docxisaachwrensch
Health Care Reform (The Affordable Care Act)
“
ANA believes that health care is a basic human right (ANA, 1989, ANA, 1998, ANA 2005). Thus, ANA reaffirms its support for a restructured health care system that assures universal access to a standard package of essential health care services for all citizens and residents.”
“ANA believes that the development and implementation of health policies that reflect the six Institute of Medicine (IOM) aims (Safe/Effective/Patient-centered/Timely/Efficient/Equitable) and are based on outcomes research will ultimately save money.”
“The system must be reshaped and redirected away from the overuse of expensive, technology-driven, acute, hospital-based services in the model we now have, to one in which a balance is struck between high-tech treatment and community-based and preventive services, with emphasis on the latter. The solution is to invert the pyramid and focus more on primary care, thus ultimately requiring less costly secondary and tertiary care.”
Activity:
Please read the attached Health Policy Brief on Basic Health Program and “Nursing’s Role in healthcare reform” from American Nurse Today.
Please go to
www.rnaction.org
, go to the Take Action tab above to access the following information regarding health care reform and the new Affordable Care Act. Scroll down the page to the heading Resources and Supreme Court Challenge to learn more about the health care reform and how it affects you as a nurse and as an individual with a family. Check out all the different information.
HealthCare.gov
Keeping health care reform healthy, patients informed
New Animation Explains Changes Coming for Americans Under Obamacare
(7/13)
Health Care Transformation: The Affordable Care Act and How it Affects Nurses
(3/12)
Health Care Reform Legislation Timeline
ANA Policy and Provisions of Health Reform Law
National Conference of State Legislatures Health Reform Site
Kaiser Family Foundation Health Reform Page
The Supreme Court Decision Matters for Registered Nurses, their Families, and their Patients
ANA Analysis: Supreme Court Arguments on the ACA
ANA to Supreme Court: ‘Individual Mandate’ Needed to Make Health Reform Work
Then proceed to the Kaiser Foundation to watch the following:
http://kff.org
““Health Care Reform Hits Main Street on the Kaiser Foundation website or Youtube. (2010)
“New Animation Explains Changes Coming to Americans under Obamacare” (2013) Youtube or Kaiser Foundation
“
Health insurance Explained: YouToons Have it Covered”
(
2014) Youtube or Kaiser Foundation
If you would like more information regarding the ACA, the Kaiser Foundation is a great source and cover many issues.
http://kff.org
Link:
http://kff.org/health-reform/press-release/new-animation-explains-changes-coming-for-americans-under-obamacar.
community health center are based on health care where Healthcare for Communities are designed to offer information on how the healthcare system is functioning in order to take care of their own health.
Ahead of the marcus evans National Healthcare CXO Summit 2023, Joy Figarsky discusses the link between mental health costs and medical costs, and why hospitals should adopt a whole-person care approach.
Occupational Health Nurse’s in Champagne County from the Occupational Health ...Crimsonpublisherscojnh
The Early XXIth marked the beginning sof a new era for nurses
working in Occupational Health Ward. They won’t come any more
to this service to end up their career by only doing routine analysis
or vaccinations. In France, it was as from as 20 years ago, that a
specific occupational health diploma was created for nurses. Work
evolution and nurse skills’ recognition have never stopped growing.
The permanent decline of demographics in occupational
health physicians was the subject of considerable discussion
since ten years. The best solution has been to recruit nurses in the
occupational health wards. The aim of occupational health services
is to assess and identify risks for employees at their workstation
and then, to put forward new ideas to the company so it could
improve by job adjustment. In the past, there were only medical
consultations by physicians. Nowadays, occupational health nurses’
consultations may take stock, at first, on the state of employees’
health. These nurses’ consultations identify the risks of the job
and ensure that the company can offer personal and collective
protective equipment (primary prevention). Furthermore, the
nurse’s “paramedical” skills enable to search effectively for
symptoms suggestive of disorders that are likely to be related to job
exposures (secondary prevention).
The occupational health physician must accomplish many tasks.
Then, he cannot ensure alone, in particular, all the appointments. In
fact, he needs to refocus on its main functions, with an emphasis on
the missions that require a high degree of medical expertise.
The missions entrusted to nurses have evolved as much as the
doctor-nurse duo has improved in this particular societal context.
The nurse must perform these consultations according to a protocol
established by the doctor. Therefore, occupational health physician
and nurse must share and exchange informations on employee
files. They also study together the implementation of actions in the
workplace environment.
Key Principles Of Person Centred Care
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Day Care Essay
Comfort Care Advantages
Person Centred Care Essay
Continuity Of Care Essay
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Anti ulcer drugs and their Advance pharmacology ||
Anti-ulcer drugs are medications used to prevent and treat ulcers in the stomach and upper part of the small intestine (duodenal ulcers). These ulcers are often caused by an imbalance between stomach acid and the mucosal lining, which protects the stomach lining.
||Scope: Overview of various classes of anti-ulcer drugs, their mechanisms of action, indications, side effects, and clinical considerations.
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
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- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
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1. À LA RECHERCHE D’UN CONSENSUS POUR LA
RÉFORME DES SOINS DE SANTÉ AU CANADA
BUILDING CONSENSUS FOR HEALTH CARE RE-
FORM IN CANADA
2002/02/14-16 MONTRÉAL, QUÉBEC, CANADA
The Role and Value Marie-Dominique Beaulieu
of Primary Care As requested by the organisers of the conference, I will first present what, in my
Practice view, primary care is - or should be- and raise some of the issues we are facing
as we are to develop a strong primary care sector in Canada. I will then address
some questions related to the primary care team: What significant changes to
Rôle et valuer des professional practices should occur as such an approach develops? Then, as
soins de première requested by the organisers of the Conference, and with much humility, I will
ligne make some “prescriptions for changes”.
I bear particularly on Barbara Starfield’s work on primary care as well as on
WHO definition of primary care; added to this, the richness of information we have
Chair/Président: from abroad. For, as you all know, some industrialised countries are trying to solve
Clermont Racine similar problems.
Approaches What is primary care ? What is the “plus value “ of primary care, from the
communautaires et perspective of citizens ? Primary care is “person-oriented care”. It is where 80% of
inégalites de santé, health care needs of individuals could be dealt with. Hence, it means that primary
Université de Montréal care practices and services must effectively deal with the full spectrum of care :
preventive, curative, readaptation and palliative care. Primary care is not “gate
keeping care”. It is not either “population care”.
Participants Although accessibility is the corner stone of primary care, primary care
cannot be reduced to accessibility. Continuity and coordination are the two other
Dr. Marie-Dominique key functions of primary care, equally important if primary care is to play its role
Beaulieu fully. Coordination and continuity within primary care, but also between primary
Centre de Recherche care and referral and hospital care. Primary care can only play its role if it is
CHUM et groupe de adequately linked to the whole system - referral and public health care. Primary
recherche interdis- care is not “revolving doors” care.
ciplinaire en sante What is the plus value of having a developed and responsible primary care
system ? I see two major gains for citizens. First, a system that functions better,
Dr. Howard Bergman more efficiently, for it is proven that the whole system works better where there is
Division of Geriatric a strong and responsible primary care system. This means : easier access to
Medicine, McGill Univer- specialty care when needed, less crowded emergency rooms, more care close to
sity and Jewish General home. Second , it means more equity in health care. This has been shown par-
Hospital ticularly by Starfield in her comparative international work. We must not forget
that the health care system is one of the determinants of health.
Where are we at with our primary care system in Canada ? What are the
stakes ? We still have a health care system driven by “secondary and tertiary”
care. This is where the money is, this is where the power is. “They call the shots”,
pardon the expression. There are no “Primary care system’s advocates” - except
in Québec, to a certain extent, because of the CLSCs network. What are the risks
Transcripts of the 7th annual conference of Conference principal partner
Actes de la 7ieme conférence annuelle du Partenaire principal de la conférence
McGill Institute for the Study of Canada
L’Institut d’études canadiennes de McGill
3463, rue Peel, Montréal, Québec, Canada, H3A 1W7
(514) 398-8346 fax: (514) 398-7336
w w w. a r t s . m c g i l l . c a / p r o g r a m s / m i s c /
2. of a primary care reform driven by the current existing forces within our system? The risks are that we will
propose “secondary care solutions” for primary care problems. Two examples : the attractiveness for “inte-
grated health care networks” which bear on the disease management model and can, at one point, jeopardise
longitudinal, person oriented care. Also, the way information technologies are developed : I am yet to see a
genuine commitment to develop information technology which will address the need of primary care practition-
ers.
We are also mesmerised by “accessibility” problems. I dare to say that we do not have an accessibility
problem. We have a problem of accessibility to personal, coordinated and longitudinal care. There are very
interesting data from Québec, where a variety of financial incentives and constraints have been included in the
physicians’ payment scheme during the last 10 years. General practitioners do cover all the points of services
(hospital, emergency, CLSCs) … in the same week, still citizens cannot find a family physician. We call this
“pratique papillonante” (“butterfly practice”). Is this what we want ?
The primary care team
In order to meet our goal, professionals must change the way they practice. Still, physicians are not the only
ones who will have to change. How will my work change ? I would work closely with a primary care nurse
practitioner. She/he, will be a “Jack of all trades” like me. We will share the care of the same patients. We will
be able to increase the services to our patients. She will be able to manage common acute problems, such as
otitis media. She will also have time to offer preventive care and education for chronic diseases. I would more
a little bit more on the phone, like her. I will assume more complex responsibilities; will do more “curative”
work. Somehow the patients will have figured out that we both care for them. They would know for what kind of
problem she is in charge, and for which one I am. For sure : we would not have an hour-a-day team meeting.
We must beware of creating professional battle fields within the primary care teams, as we have often
experienced with the CLSCs when they were created. We should not but professionals in situations where they
will have to chose between allegiance to their professional autonomy, their team and their employer. What are
the arrangements which will permit the development of a strong feeling of belonging to a team responsible of a
“clientèle” ? Can you work as an equal if you are kept in an employee-employer relationship ? What does
“being followed by a team” mean to citizens ? Is it what they want ? How do they want this to unfold ? Building
trust will be the cornerstone of the success of the team approach. Between professions. But also, within
professions. Between specialists and family physicians. Between secondary care nurses and primary care
nurses.
We were asked to consider two questions : What can be done immediately to improve the quality of
primary care ? What organisational / funding incentive changes would you make immediately to improve better
integration of care. I refuse to address those two questions separately, for I think, as Journalist Jean-Claude
Leclerc from Le Devoir said this week, that the organisation of the system is as important as professional
deontology when quality of care is concerned. I prescribe :
1. The deployment of information systems developed to meet the needs of the practitioners : without good
information you are limited in your capacity to reflect on your practice, to identify your weakness and correct
them, to organise your services in response to your clientèle’s characteristics. I see simple things that can be
done now with the information we produce delivering services : I could receive feedback on the number of my
patients aged 50 to 69 who are reached by the breast screening program, for example. I think that Public
Health can help us with this. There is the issue of confidentiality, but I think that it can be worked out.
2. The consolidation of the “core primary care team”. An interesting study published in the BMJ last year
showed that effectiveness of team functioning is a key determinant of quality in primary care.
3. About financial incentives for physicians : we have to pay for “responsibility”, that is to pay not only for
services given or time spent on site, but for assuming the basic functions of primary care : longitudinality and
coordination. Capitation and inscription of clientèles can be means of doing this. But they can only be if the
primary care system is given the means of assuming its responsibilities.
4. We need to create a primary care organisation which can relate efficiently to the rest of the system and
make it accountable to the primary care needs. I do not see how this would be possible without decentralisa-
tion of the “bargaining power” to local authorities who will have not only the money to give primary care serv-
ices but also to “sub-contract” for referral care services. I am in a “Groupe de médecine familiale”. We are
told that we have to develop “corridors of services” with referral care for our registered patients. Can anybody
in there right mind think that we will be able to do such a thing the way the system is organised and funded
now ? I often wonder if the worst think Michel Clair did was to say that “If there was only one recommendation
to apply, it should be the one on the “Groupe de médecine familiale”
2- The Role and Value of Primary Care Practice
3. I will conclude with one question : can we change primary care without changing the health care system as a
whole ? If your answer is “No,” then it means that all the goodwill of the individuals and organisations involved
will not be able to overcome the huge barriers on our way if the politicians do not have the courage to do their
part in order to change some of the rules. And when we say the politicians, we mean the population. Indeed, if
politicians do not “feel” that the population want that kind of health care, they will not do it. When I see the pile
of reports that have accumulated on shelves for the last 25 years, saying basically the same things, I must say
that my prognosis is reserved.
Howard Bergman
(French in beginning to come)
Primary care is the foundation of our healthcare system and I think that means that we need to both
strengthen and transform primary care. I think also we need an evidence-based approach to health prevention
and disease management and I think there again primary care is the key to an integrated system and a coher-
ent system of care. I just want to give the example of diabetes, because it will come back and I can give the
example for congestive heart failure as well. We know that in diabetes, we know that if we invest in primary
care, in terms of population and patient education, in detection of diabetes, in treatment and ensuring compli-
ance in diabetes, we know from many studies that we are going to have more positive health outcomes. We
also know that there are going to be less complications as the result of diabetes and there are going to be less
utilization of secondary and even tertiary care at some point. We can say the same about congestive heart
failure, where by the way we have had a tremendous explosion of excellent medication in the past 15 years,
but if you look at the statistics for readmission rates for people with congestive heart failure, over 65 years old,
in the past 15 years, they haven’t changed. So for one reason or another, this medication is not getting to the
patients in an appropriate way. And again primary care is the key. We’ll come back to what this means to the
health care system, because it means that you have to invest in one part of the health care system but you’re
not going to get the returns right away, the returns might come back only in 5 or 10 or 15 years.
As I worked on the Clair Commission I was surprised that there’s actually quite a large consensus in the
medical and non-medical community around what are the problems and the directions for change in the health
care system. And what we put forward in the Clair commission wasn’t an invention, it was based on what was
being put forward by many organizations in Quebec and Canada, including organizations of primary care
physicians. And so, the problem of accessibility, meeting the needs, the problems of the vulnerable population,
and I’ll just point out for my constituency that the frail or the elderly with disabilities comprise approximately 15-
20% of all the elderly population, which means 3% of the total population. Well, that 3% of the total population
consumes 30% of all the health and social services resources in our health care system. So, sure I’m worried
about how we’re going to pay for dialysis for the well elderly, as senator Morin pointed out, but I am particularly
concerned with how we are going to organize efficient care meeting the needs for this part of the population. I
think here primary care again is essential.
The other thing is that we have to realize that nobody can do it alone anymore. The problems are
complex, the treatments are complex and our system is terribly complex. So the old concept of the Dr. Welby
going out in his car and visiting his patients is not possible, both from having doctors getting together and
different professionals getting together and different parts of the health care system getting together. Here is
what I think are the key elements of primary care, based on what I have seen here and in other countries. I
think that the issue of population and clinical responsibility is an essential issue. I think that a primary care
group has to know what population it is dealing with. And that is where the issue of rostering comes into effect,
because if you know what population you are dealing with then you can study the population, you can develop
programs that are aimed at that particular population. And if you are working with a population, if your practice
is in downtown Montreal, or the Cote des Neiges district of Montreal, or the west Island of Montreal, you are
going to have quite different populations that are going to be coming to see you, and you have to adjust your
intervention in a different way. The notion of clinical responsibility is also essential: what happens to your
patient or your groups of patients beyond the moment when they leave the door of your practice or your
institution. Our system of care is based on taking good care of people when they are within the four walls of
your institution and hoping for the best when they get out.
The second thing that we’ve talked about is an interdisciplinary, systemic approach. Marie-Dominique
mentioned the question of information technology and I’d like to add general infrastructure as well. She said it
very well. You know that we are managing in Quebec a $17 billion enterprise not knowing what happens. Most
organizations will not know their financial situation until three or four months later, will have no idea of the
utilization of services that their population is using. We need infrastructure because we cannot do it alone. I
met a physician who said that he works alone and he doesn’t even have a secretary and it’s a terrific system.
Diagnostics & Solutions -3
4. But it is very limited what he can do.
We need accountability and incentives for excellence and performance. In other words, we can no
longer in the health care system distribute money for primary care, physicians, specialists, CLSCs or hospitals,
without having some sort of indication of what the performance is, and having indicators in that performance,
giving incentives for people doing an excellent job. And finally, we can’t do things in terms of the fee-for-service
for primary care physicians or global budgets for CLSCs because I am including that in remuneration funding
mechanisms of primary care we need remuneration that will be able to support these different elements of
primary care.
What we put forward in the Clair commission was that primary care is the basis of the health and social
service system and we said that the two components of primary care are family medicine units and the
CLSCs. But we also said that primary care needs to be supported by integrated service networks. There is a
whole area of complex and vulnerable populations, the frail elderly, and mental health populations, very com-
plex populations that even a well-organized family medicine unit will need to work with others in order to deliver
a complex combination of health and social services. We also have complex diseases like congestive heart
failure, pulmonary disease, alzheimer’s disease, that need the integrated support of secondary and even
tertiary care. Integrated service networks supporting and working together with primary care: this is what things
should look like. It’s not rocket science. A lot of other people have been saying it, nursing groups, practitioners.
Voluntary rostering makes sense. You want to be allowed to change physicians if you want to, but that can be
worked into a voluntary rostering type of system. There is very interesting work in Britain around development
of primary care trusts and also community trusts, bringing together primary medical care and community care
into trusts that are working together.
Change is very difficult to accept and very difficult to understand, because we’ve been doing things this
way for many years and how could any other way be possible? I would like to finish by giving some elements
of what I consider the vision and strategy for change. Number one, the whole area of governance and man-
agement. Unfortunately, our health care system is driven by very short-term objectives and we are plagued by
the fact that the chairman of the board of this industry changes about every two years, and the CEO, the
deputy minister changes about every year and a half or so. We calculated that Quebec has had 11 or 12 sous-
ministres de sante in the past 15 years. So how can you develop a strategy for change and carry it out? We
suggested that there may be ways to think of governance in a different way.
Number two, I think that we have to work very hard on consensus building. I strongly believe that we can
get more done by confidence and incentives than by using the big stick. I think that we can build on leadership
as well. The third thing that Marie-Dominique brought as well as other people is that this change towards
strengthening primary care as Walter Lutz brought out when he was talking about integrated care, saying it
costs before it pays. We have trouble understanding that in our health care system so we are always talking
about the run-away costs but we never talk about investing in order to make the changes necessary to control
these costs. Also, we need a change in the methods of allocating the resources. To allow for shift in resources
from one level to another based on performance. So, in the case of diabetes, if we invest in primary care and
there is reduction in utilization of secondary and tertiary care, we need to have a mechanism for that money to
come back into the primary care. Otherwise, this investment in primary care is seen as just an additional
expense. We are seeing that response to the SIPA project. In other words, something might make sense over
overall utilization and the costs of the health care system, but if there is no way of transferring the resources, it
just looks like an add-on and people say that it is too expensive. We see the same thing with information
technology.
My last point is that we need to open up two corridors in the way we govern our health care system. One
is the corridor to look after the daily crises, the daily management of the health care system, the over-run ER,
the accessability, the crises in a nursing home, etc. But we need another corridor which is separate from that
which is going to look at the strategic changes that need to be made in the health care system. And I am
concerned that, in terms of our efforts to get a family medicine group going, that if we don’t have those two
corridors, we are going to fail because it is going to be the immediate crises which are going to over-run any of
the strategic changes.
Questions
Audience #1: With respect to the idea of performance of different aspects of the health care system, particu-
larly hospitals and thinking about what Mr. Legault said recently. How do we look at performance of, for exam-
ple a hospital , when so much of it depends on other aspects of the health care system, such as good
4 - The Role and Value of Primary Care Practice
5. primeary care system, home care, a place to discharge patients, because i think that’s really where the difficul-
ties in the emergency arise, is that they can’t get their patients bed for acute care and long term care. Also,
people arrive at the emergency for primary care which could be received elsewhere.
Howard Bergman: I completely agree. As the ER crisis emerged, there are more and more headlines and we
say we need to invest more in the ER room, so we pour more money into the Er and then lo and behold, we
wonder why 6 months leter people go to the ER Rooms. You go there because that is where all the resources
are, that’s where your needs will be responded to very quickly, and it’s an example of where we just look at
performance in a very isolated way. We need performance indicators for different types of institutions and we
talked a lot about performance indicators for hospitals but we don’t talk about performance indicators for
CLSCs, for nursing homes, etc. But the idea of developing integrated performance indicators is fascinating.
That comes back to the issue that we can do it if we do it from a patient-centered point of view, or a popula-
tion-centered point of view.
Marie-Dominique Beaulieu: The question shows the importance of making silos, because you can really see
both sides, primary care is not doing what should be done, that’s why there are problems with the hospitals. To
have access to the hospital as a primary care practitioner for referral care is to send people to the hospitals.
There is a problem there. Referral care has no incentive to collaborate with the primary care sector because
their budget is not looked at that way. We are in a vicious circle. Yes, the primary care sector could be more
efficient, but also part of it is that with better collaboration with referrals, we could have a better system. But the
hospital has no incentive to do this. You question shows how important it is to change the way the money
flows.
Audience #2: There is a question of money but also I feel, coming from the hospital setting, the question of la
lourdeur du system. There are a lot of people who are very creative, who can do things, change things, but
there is and inertia in the system, there are so many levels of administration to get through, that people give
up. We need to develop a system that would foster creative solutions from the ground up. (FRENCH TO
COME) A lot of people feel they have no power in their own hospital to change things.
Audience #3: I have a question of curiosity about the funding mechanism that would be used for these inter-
disciplinary teams under the Canada health act, since it does stipulate that its physician and hospital services.
I am particularly intrigued, since the primary health care model abdicates the appropriate care by the appropri-
ate provider, how this would work for a vulnerable population. I’ll take the example of the aboriginal population.
Would a salary mechanism for doctors allow in the interdisciplinary tem, them to hire, for instance, a traditional
healer, to work with the team. Do you think that this fits under the Canada Health provisions?
Marie-Dominique Beaulieu: I am a practitioner and not a politician so I am not a policy maker. But obviously
when we are talking about different levels of governments having to make some decisions, I think that you are
giving a good example. I think that one of the things that has to be rethought is what part can be paid and so
on, so that you can really, at the level of the field, make that kind of decision. If you make the practionners
locked in something they cannot do, like not being able to pay for nurses, under the Canadian Health Act, or
things like that, it’s like you are building people who want to change and placing them in situations that they
cannot effect change. And I think that’s the same thing for some of the money flow. There needs some political
courage to change the money flow because the interest there won’t permit that. I wish that there would be
changes that permit us to redefine the services that we give.
Howard Bergman: One of our icons is the Canada Health Act. When you say that we have to relook at the
Canada Health act, it does mean that the Canada Health Act, which was developed
in the late 60s and early 70s, things have changed since then, the whole issue of chronic disease, vulnerable
population, the demography has changed. What you raise is an interesting point. Th Canada Health Act was
focused on physicians and hospitals. Her is an example of how you could think of funding in a different way. If
you had a primary care structure that was funded on a per capita basis, and you said now you are responsible
for organizing services, here are the types you have to organize, which leaves that community-based group
some leeway as to whether they need 6 nurses, 4 or 10? How many doctors? Do they want traditional healers,
etc., based on again a contractual agreement in terms of the services they have to give and the type of per-
formance indicators. So one could think of that type of building in more flexibility, and perhaps linked to what
somebody was saying of the lourdeur de la systeme, where all decisions have to come from the top.
Diagnostics & Solutions -5
6. Audience #4: Now in Ontario, we are reinventing primary care reform or family health networks, which my
section feels is a redundancy and I find it kind of unwieldy, whilst the HSO has had some very innovative ones.
The one which I think is the best in line with what you’ve just been talking about is in Sault St. Marie, which has
a third of the population and once you’ve got big population-based groups you can really do interesting things.
It has a non-profit board so you can indeed bring in alternative practitioners. This model got frozen in the 90s
by the ministry. I think that rostering should be universal; perhaps we should make it universal registration.
Once you’ve registered the population, then rostering is the thing to do next. It is interesting to hear about
Denmark where you have the option of derostering yourself. This fulfills everyone’s ideas about choice. I hope
that Romanow is going to listen to that. Denmark is a wonderful example. It’s cheaper and it throws in dentistry
as well. In Toronto there are lots of people who don’t have insurance, the mentally-ill and the homeless, and
unless you have some default mechanism to automatically get people into these settings, you are going to
miss many of the sickest, most problematic cases.
Dr. Beaulieu: I personally agree with rostering, it is something important, but you have to have the right
system. Obviously, the medical profession in Canada is not very agreeable. Rostering by itself is not a solution.
It is agreeable when you have the rest to support it. And then we have to walk the Canadian population
through it. How will people react. Some people feel that it is an impingement on freedoms. You cannot have
engagement where you don’t deliver what you promise.
Audience #5 Paul Moreau, Sante Canada, premieres nations: (FRENCH TO COME)
Howard Bergman : (FRENCH TO COME)
Marie-Dominique Beaulieu: (FRENCH TO COME)
Audience #6 France Legare, medecin de famille: (FRENCH TO COME) How do you produce evidence,
what are the questions that you are asking, which type of design? Most of the evidence that we are working
with now has been done in tertiary care.
Marie-Dominique Beaulieu: (FRENCH TO COME)
Howard Bergman : (FRENCH TO COME)
Clermont Racine: (FRENCH TO COME)
Audience #7 Isabelle Arsenault, CLSC, du région de Sherbrooke:(FRENCH TO COME)
Howard Bergman: (FRENCH TO COME)
Marie-Dominique Beaulieu: (FRENCH TO COME)
Audience #8 Sonia Samonic, PhD student in nursing at McGill University: I would like to thank Mme.
Beaulieu for recognizing the absence of nursing at this table. I am interested in hearing more about the pro-
posed role of nurses in the family medicine group. I think there is a lot of concern in nursing that nurses are not
used as physician replacements, and that nurses are actually used in recognition of their role in families cope
with transitions and health education. I am also interested in how we see family medicine groups interfacing
with the CLSC, particularly in my area of expertise, perinatal health, where a large percentage of the primary
care is provided by nurses at the CLSCs.
Howard Bergman: Just in terms of numbers, what we proposed was 2-3 nurse clinicians or practionners to 6
attendants. I agree with you. We have to carve out s specific role for nurses, which is distinctive but collabora-
tive with the physicians. This is going to take time. The same principal from the standpoint of perinatal care
applies to the frail and elderly. A nurse practitioner in a family medicine group is probably going to be a
generalist, depending on the group. Linked up with the family medicine group are the CLSCs, with their home
care program, their professional program and with their nurse practitioner clinicians. This is an example of an
integrated group working with the generalists of the family medicine unit.
6 - The Role and Value of Primary Care Practice
7. Dr. Beaulieu: I realize that the word group de médecins de famille carries a message which removes it from
nursing. There is a lot of work to do and we don’t have a model in Canada. To create a primary care team,
people need to feel that they belong to a team. We as professionals are accountable to our profession, we are
accountable to the people who pay for us, and we are accountable to our team. If there is still a division, where
nurses are in one organization and doctors in another, we won’t accomplish the team building.
Audience #9: I am a family physician and am fortunate to work in a very positive team environment, at St.
Michaela’s hospital in downtown Toronto. I am part of a group where about half of our patient population is HIV
positive, and this is a practise that has evloved over the recent past. We were formerly of the Welsley hospital,
got swallowed by St. Michael’s hospital and so on. The team itself is composed of not only physicians and
nurses, but we have pharmacists, physiotherapists, and nutritionists and social workers. And on that team we
actually have some of those that are specifically dedicated to a HIV population, and then we have a whole
other contingent that are for the rest of our patients. That team meets every week with the residents and the
students and we discuss problematic cases and we go through some efforts to try to address not just medical
problems but also psyco-social issues and nutritional issues, and so on. There is on-going negotiation in terms
of what each member of the team does. It does work. I trained in Ottawa, in an environment where one of my
main teachers was a nurse. If I have to think back to the things that made this work is, first, the leadership in
the hospital and in the family medicine department. Philip Burger, who is now our chief of family medicine, has
been very proactive in making that happen. The other big component has been the community itself. It is not
by chance that a lot of that came about because we were dealing with HIV positive patients who are very
complicated patients. We need to listen to the communities and let them tell us what they need and from there
we’ll be able to develop the system we need.
Audience #10: Carl Guttman, Family Medicine College of Canada: Integration amongst all of the players
providing primary care and all parts of the system is essential. We are facing major challenges in the renewal
of primary care because the rest of the system is not coordinated with this. The role of the family physician in
hospitals remains a critical piece of this. Across Canada, the role of the family doctor has been diminishing in
hospitals, whether it is active provision of care at the bedside or supportive care, it has dropped to nothing in
many instances, particularly in urban and academic hospital settings. This is the link between the hospital and
the community at large. The other aspect of integration is the role-modeling and philosophy that has to hap-
pen in terms of educating our future health care providers. We are always going to be fighting an uphill battle
in terms of trying to change those who have been in practise for years and years.
Audience #11: Fernand Montchenie. J (FRENCH TO COME)
Howard Bergman (FRENCH TO COME)
Marie-Dominique Beaulieu: (FRENCH TO COME)
Clermont Racine: (FRENCH TO COME)
Audience #12:(FRENCH TO COME)
Audience #13: (FRENCH TO COME)
Clermont Racine: (FRENCH TO COME)
Diagnostics & Solutions -7