Opinion

We need substantial health system improvements to be prepared for future pandemics

The pandemic required Canadian health and social service professionals – many of whom were already burned out – to stretch themselves further. In the height of COVID-19, these heroes ran to battle, sometimes without adequate personal protective equipment or systemic support to enable their efforts. Some developed new skills, some took on new leadership roles, and some developed new partnerships to try to get the job done. Most did not do this work for extra money or ‘credit’ and in most cases no special attention or media requests came their way. These people demonstrated the Canadian values we all want to imbue in our children.

When the next crisis comes along – will we again rely on the sheer grit of heroic individuals to craft ‘work-arounds’ with patchwork solutions? Or will we invest in the supportive infrastructure that would make it easier not just to respond to the next pandemic but to actually improve the lives of Canadians in the interim?

To improve our response to COVID-19 and set our entire health system up for a better future, we need to substantially improve both data and oversight.

Consider that in Ontario, a software system (from an American company) was purchased to record and track COVID-19 vaccine inventory, distribution, and injections. Ask the average Ontarian and they would assume – wrongly – that this program could easily be expanded to use for other types of vaccines and that it readily populates the electronic health records held by their health providers. Instead, a limited set of clinicians get a password to access a clunky system, and some (but not all) get a feed of unstructured data to their electronic records that they cannot search or track.

Ask the average Ontarian, and they would likely assume – wrongly – that the databases could easily be used by health providers to identify who is eligible but not-yet-vaccinated. Instead, a limited set of family physicians (but not hospitals or nurse practitioners or pharmacists) get partial lists of their patients who are already vaccinated and are asked to compare that to searches of their own electronic medical records. This extra administrative work, including checking charts and calling patients, sometimes leads only to find that a patient was vaccinated but not captured properly in the available data.

Ask the average Ontarian, and they would assume – wrongly – that when public health professionals conduct COVID contact tracing, they would easily see vaccination data because that affects how they do case management. They might also assume that the case management systems for COVID would connect to those used for other contagious illnesses, including influenza. Or that when our public health professionals go ahead to do vaccinations in schools for children, COVID vaccine data would be accessible alongside other routine vaccinations to facilitate implementation.

But they would be wrong because we purchased (expensive) patchwork COVID “solutions” instead of truly investing in our provincial health system.

Wouldn’t it be nice if public health professionals, family doctors and community pharmacists who have been working so hard to fill the gaps in the system didn’t also have to double-enter vaccine data or check multiple systems? What if we used this crisis as an opportunity to upgrade this woefully inadequate eHealth infrastructure?

This isn’t a technical challenge – it’s a political one.

Better systems with better data will enable better oversight too. Over the course of the past year, Canadians became used to seeing maps showing differences in infection and vaccination rates by region and by setting. The term “hot spot” became part of the COVID-vernacular. In many regions, the response included hospital-based experts offering their time to help in nursing homes. In some regions, novel partnerships between public health authorities, hospitals, and community-based health and social care professionals sought to incorporate views from the frontlines to coordinate efforts.

These successes should be celebrated, but we must recognize that this involved mostly-burned-out people going “above and beyond” to do necessary work. Fires were put out in “whack-a-mole” fashion – no system for systematically spreading successes or avoiding failures of others, nor for thinking ahead to prevent the next fire. Not surprisingly, this ad-hoc, extra work does not seem sustainable even in areas where it was successful.

For example, in Ontario, implementation of the COVID response was decentralized to the point where local solutions could not be scaled or spread. This was exacerbated by the pre-pandemic de-funding of regional infection prevention and control hubs that had been run by Public Health Ontario. We can contrast this with the brave approach taken in B.C. to provincialize nursing homes, allowing for implementation and oversight of measures needed for infection prevention and control, with centralized resources that could be redirected as needed. Enabling local solutions while providing regional supports allowed a systematic approach for development and implementation of best practices, instead of a band-aid strategy that might fall off, allowing the wound to fester. The pandemic represents the opportunity for regional groups that can ensure accountability to best practices.

While it is true that each region understands the needs of its population and the capacity of its professionals and should tailor its response accordingly, there was (and remains) a chance, during this pandemic, to provide the oversight needed to guide strategies and implement them effectively.

A pandemic, like a health system, cannot be managed by allowing fiefdoms, siloes, or a laissez faire “let a thousand flowers bloom” approach. Inadequate oversight aggravates professional burnout as people rightly wonder who is in charge and question if their voices are heard. We have an opportunity now for integrated regional approaches, supported by centralized resources, that work to achieve the quadruple aim. For example, Ontario Health Teams could bring together local public health, with clinical and social care providers as full partners for the pandemic response and beyond.

Imagine if each region had the capacity and authority to re-allocate services where they are needed; imagine if high-risk settings like nursing homes truly had the support needed to keep people safe; and imagine if primary care clinicians could readily “prescribe” social services to their vulnerable patients.

There will be time later for extensive post-mortems. The recommendations after this pandemic will likely look similar to those that came before. But COVID is not over, and a fourth wave could be imminent. We’re getting by on a combination of grit and patchwork solutions. Let’s take this opportunity to honour those who have worked so hard by investing in the infrastructure we need to be prepared for our next fight against a pandemic.

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Author

Noah Ivers

Contributor

Noah Ivers is a family physician at Women’s College Hospital and the University of Toronto and holds a Canada Research Chair in Implementation of Evidence-Based Practice.

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