Recently, I co-wrote an article entitled Practicing patient-centered medicine in a pandemic in which we discussed the paradigm shift family physicians are experiencing as a consequence of COVID-19: pivoting from considering unique patient factors to general community principles when making decisions for patients that weigh the global good.
In other words, a public health crisis requires the sacrifices of individuals – their preferences, their norms and some of their freedoms – to ensure a community response that benefits the larger whole. One could argue to combat a crisis we must all think beyond ourselves.
We are facing, however, many crises in medicine beyond COVID-19. In fact, social determinants of health, mental illness, racial inequities and lack of access to care for some populations were identified as public health crises before the pandemic. Existing inequities such as those experienced in racialized populations or low-income households have worsened with higher COVID-19 rates and poorer outcomes in these communities.
It is for this reason that the provincial government introduced the Ontario Health Teams (OHTs) concept in 2019, a model of healthcare organization that requires collaboration across sectors that most commonly include primary care, home and community care and hospitals to coordinate the healthcare of a defined geographic population. The teams are supposed to address health inequities and decrease hallway medicine by promoting an integrated approach focused on prevention and health promotion. OHTs will need to include partners such as public health, housing and schools since, after all, the communities and context in which we live, play and study all affect our health.
The need to be innovative and work together has become more apparent than ever before during the COVID-19 pandemic.
However, shifting norms and breaking down long-existing silos in a complex health environment is more challenging than it appears. Just as doctors are struggling with pivoting from the individual to the community, OHTs must operate not as a sector but a system. As Ontario moves from the idea of “beating” COVID-19 to “living with and learning from” the virus, we must also shift from solely command-and-control approaches to true values-based system transformation.
This will require a change in our way of thinking. At OHTs, multiple partners come to tables with varying perspectives. The challenge that exists is how to look at issues facing our communities together. Too many times, I have heard from colleagues that organizational or sector hats remain the norm and challenges exist in approaching discussions as systems thinkers. Occasionally, parallel solutions representing only one or two sectors can halt momentum and, in some cases, discourage those who traditionally have not had a seat at the table. Even the selection of patients and community representatives can have links to existing power structures, as can leadership, making meaningful change harder to achieve.
This is not an indictment and simply speaks of the aforementioned struggles individual clinicians are facing in direct patient care. The leader of an agency is of course used to representing the organization’s interests. The challenge for us all is to decide which hat we are wearing and to think of system transformation as less transactional but more akin to complex negotiations amongst partners: A “good deal” for most will mean we each, as individual partners, give something up.
Perhaps a patient in a family health team will see fewer increases to allied health access than one in a fee-for-service practice. A hospital might concede that primary care, for example, would be better positioned to imbed care coordinators within its practices than the acute sector. Schools and municipalities could see their roles in mental health promotion become more empowered and their connection to healthcare less reactive and more preventative. This can only happen if traditional providers move from a disease-focused model to one that embraces new partners as the key to healthy communities.
Recently, my daughter accused her older brother of not sharing the basketball in a family game on the driveway. He explained he needed to practice more than she does as he is trying out for high school, which is more important than Grade 6. As a parent, I was initially bemused at the familiar refrains of childhood but as a systems thinker dismayed at their argument. As COVID-19 has taught us, individual strength and perspective is not enough. To be successful leaders, we must all consider each other in our actions. After all, as I explained to my son that afternoon: There is no “I” in team.
The hope and opportunities of Ontario Health Teams lies in us all coming to this conclusion. In spite of some bumps along the way, I am optimistic that lessons learned from the pandemic have uniquely positioned many of us to stretch and think beyond ourselves as a system. We owe this to one another.