 Dr Ayman Shenouda Patient loyalty and trust It’s hard to pinpoint precisely what inspires long-term patient loyalty. Quality of care and trust must come into it. The ability to listen, having a caring presence and reliability would also factor highly. From my own experience, I think patient loyalty is mostly about trust. And it is timely and effective communication that builds that trust. Of course, for doctors, communication also involves giving the patient bad news. Listening actively and providing comfort being core communication skills. There are very few studies that have explored those factors seen to build and maintain a patient’s loyalty towards their GP or a practice. Some recent research in France provides some specific insights while a more recent study closer to home provides a new novel way to measure both GP and practice loyalty. The loyalty equation First, let’s look at a possible loyalty equation. A 2016 French study tested aspects of patient loyalty in the general practice context. This study found that loyalty was more complex than commonly assumed and is reliant on a few factors. It involves dimensions of trust, listening, quality of care, availability, and familiarity.[1] So, the loyalty equation from this study looks like this: Trust + Listening + Quality of Care + Availability + Familiarly = Patient Loyalty This is interesting enough but I think what makes this study really interesting is that the loyalty factor was seen as important enough to formalise it in policy. The efficiency factor to loyalty In France, the Caisse d’Assurance Maladie (public health insurance fund) recognises a coherence in maintaining the doctor-patient relationship in terms of efficiency and healthcare costs.[2] This has been formalised in law since 2004 and was part of broader reforms to health insurance which requires a ‘preferred doctor declaration’. The policy requires adult patients who want optimal coverage of their care by national health insurance to choose a preferred doctor - typically a general practitioner.[3] [4] What we see in France is the use of a single lever-regulation through what it calls its ‘gatekeeping’ reform. The carrot and stick approach of this effectively means that every adult must first choose a primary doctor, or médecin traitant, or risk higher healthcare fees and being reimbursed at a lower rate. The policy aim is to control both the demand and supply side of health care provision to improve care coordination and reduce utilisation of specialists’ services. The policy operates by encouraging patients to choose one GP and imposes financial sanctions if they don’t. This gives value to the relationship and makes the patient’s loyalty official.[5] One evaluation of this reform explored effect and found that specialist visits fell slightly while self-referred visits and the number of different GPs seen also declined.[6] In other words – policy success – but does a forced scheme generate patient loyalty? What can we learn from the French experiment? Forced schemes like this are never good policy. But while this scheme is perhaps set out to control access to specialists the positives will be seen over time through continuity of care. The French patient loyalty study actually found this to be true. That, by inciting patients to always consult the same doctor, the reform of the preferred doctor scheme reinforced that bond.[7] Patient loyalty in the Australian policy context has resulted through a stronger policy framework which enables choice. So, where are we at in terms of policy success against the loyalty factor? The Australian context The richness and potential of de-identified Medicare data were shown through a recent Australian study led by the Centre for Big Data Research in Health, UNSW, and published this month in the MJA. [8] This study is said to open up a new toolbox for exploring how patients use healthcare services. It’s the innovative approach using network analysis that makes this a standout. It uses network analysis of big data analysing millions of Medicare claims to gain insights into the organisation and characteristics of Australian general practice over a 20-year period. New ways to measure loyalty Providing a novel way to measure change in Australian general practice over two decades, the study shows that while there has been a move towards bigger GP practices, patient loyalty remains high. These results were found by looking at the claims to see when patients were visiting different doctors for their GP services. By applying a network analysis approach, it showed where doctors had many patients in common that they were likely to be sharing the care for these patients in the same practice. These were grouped as a provider-practice community or PPC which also provided new insights into patient loyalty. The results showed that patients’ loyalty to their usual GP and usual GP practice is high and has been stable over the last 20 years. Policy application The loyalty result is exciting combined with the innovative approach used in this study to find that the density of patient sharing within a PPC correlated with patient loyalty. The fact that patients see multiple GPs within a practice is also significant in terms of practice design and enabling more team-based GP care models. The further link made in this study in terms of supporting future program design in terms of where to target incentives for encouraging quality primary care is also good news for our practices. For good policy reach, program success relies in part on the patients’ choice of practice and this fact is now more keenly linked to that loyalty factor as a result of this study. Australian success story These results provide a really positive outlook on Australian general practice and our approach to healthcare policy in enabling equity in access. In contrast to the French policy experience whereby a forced scheme has formalised patient loyalty in a way, the Australian experience shows that patient loyalty and choice of practice comes through less forced means. It will be interesting to see what more can be explored through big data analytics and the network analysis approach used in this study to better understand our health system. References [1] Gérard L, François M, de Chefdebien M, Saint-Lary O, Jami A. The patient, the doctor, and the patient’s loyalty: A qualitative study in French general practice. Br J Gen Pract 10 October 2016; bjgpnov-2016-66-652-gerard-fl-p. DOI: https://doi.org/10.3399/bjgp16X687541 Available at http://bjgp.org/content/early/2016/10/10/bjgp16X687541#ref-9 [2] Ibid. [3] Law No. 2004-810 of 13 August 2004 concerning health insurance. Article 7. Published in JORF n°190 2004–08–17: 14598. [In French]. Legifrance Paris, 2015. [4] Le Fur P, Yilmaz E. (2008) Referral to specialist consultations in France in 2006 and changes since the 2004 Health Insurance reform. 2004 and 2006 Health, Health Care and Insurance surveys. Questions d’Économie de la Santé 134:http://www.irdes.fr/EspaceAnglais/Publications/IrdesPublications/QES134.pdf [5] Gerard 2016 Op. cit. [6] Dumontet M, Buchmueller T, Dourgnon P, Jusot F, Wittwer J. Original research article. Gatekeeping and the utilization of physician services in France: Evidence on the Médecin traitant reform. ScienceDirect Health Policy Volume121,Issue6,June2017,Pages675-682.Availableat: https://www.sciencedirect.com/science/article/pii/S016885101730115X [7] Gerard 2016 Op. cit. [8] Tran B, Straka P, O Falster M, Douglas KA, Britz T, Jorm LR. Research. Overcoming the data drought: exploring general practice in Australia by network analysis of big data. MJA 209 (2) j 16 July 2018. Pages 68-73. Available at: https://www.mja.com.au/journal/2018/209/2/overcoming-data-drought-exploring-general-practice-australia-network-analysis
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 Nowhere to go: tackling homelessness for older women
Dr Ayman Shenouda A measure of our society It was Ghandi who said ‘a nation's greatness is measured by how it treats its weakest members’. I’m not sure where that places us as a society particularly with the rise of homelessness in Australia. I strongly believe that governments are there for those who need them the most. Better still, if we had their focussed investment on preventive strategies it is certain that our country would be much better off. On the issue of homelessness, we’ve seen very slow progress. This is despite a strong focus by state and territory governments. But this issue cut across departments and really requires a national focus in my view particularly to direct funds to improve healthcare management in primary care. Housing and employment are two significant social determinants of health. We know homelessness can significantly impact on health outcomes. While social and economic factors lead to increased risk exposures. The patient-centred medical home can help meet the healthcare needs of the homeless population but this is reliant on a targeted program of funding. Rising rates of homeless older women One in three older women are living in income poverty in Australia.[i] Older single women are particularly at risk of becoming homeless with significant numbers experiencing rental stress. This is a public health crisis and requires careful policy planning overtime which is difficult to do in our short-term electoral cycles. Health status must remain a priority across government and not just health to provide for integrated services and supports. Social workers have warned that Australia is facing a generational “tsunami” of this older demographic in coming years. This policy catastrophe is really not all that surprising when you consider the soft policy responses to those known drivers of poverty. Women have less super due to disparity in earnings with years of lost income due to time out for family. There are cost impacts which include high-priced housing or losing a job as well as broader factors such as the rising divorce rate or death of a spouse. There is also less capacity to earn with the casualisation of the workforce which is also marred by ageist stereotypes. Combating ageism Combating ageism in our society is something this country really needs to work on. How is it even plausible that in the modern workplace you are considered old at 45 or 50? This seems to be the case yet Australia’s future prosperity is reliant on older workers. Perhaps this factor alone will make our policymakers more focussed on solutions in future. Older women are locked out of the jobs market. Losing a job is said to be one of the most common triggers that can plunge older women into poverty.[ii] Ageism has very real mental and physical health consequences. There is less discussion on the impact that ageism has on health and we need to be louder here. These are two clear areas which require more policy development. Addressing isolation My older female patients often describe feeling invisible and that’s always heartbreaking to hear. But it seems this invisibility may have also crept into the policy space. Like so many things, we know policy inaction will be more costly over time. The UK in prioritising a Minister for Loneliness is perhaps a step in the right direction. Addressing issues of isolation will help build stronger, healthier older Australians and we really need that national policy setting. Homelessness prevention We’ve been treating the symptoms and not the know causes for too long. Securing long-term tenancy options for this vulnerable cohort has to be prioritised. The fact is that we have had enough warnings in order to evacuate safely from the impending tsunami. We need to address wealth inequality, and particularly gender and income disparity in later life. Addressing ageism and particularly employment-based age discrimination too. It is about helping women before they reach crisis point. More integration across the health and homelessness support systems would help to identify earlier those at risk. Also, understanding those pathways to homelessness among older adults and ensuring prevention and service interventions are adapted to meet different needs is another key piece to this policy puzzle. [iii] [ends] [i] O’Keefe, D. One in three older women living in income poverty in Australia: study. Australian Ageing Agenda. March 9, 2016. Available at: https://www.australianageingagenda.com.au/2016/03/09/one-in-three-older-women-living-in-income-poverty-in-australia-study/ [ii] Ibid. [iii] Brown RT, Goodman L, Guzman D, Tieu L, Ponath C, Kushel MB (2016) Pathways to Homelessness among Older Homeless Adults: Results from the HOPE HOME Study. PLoS ONE 11(5): e0155065. https://doi.org/10.1371/journal.pone.0155065  Building healthcare capacity in the Solomon Islands
Dr Ayman Shenouda Unmatched resilience A recent visit to the Solomon Islands provided some new insights into what it really means to be resilient. It is one of the least developed countries in the Pacific Region, the population languishes in poverty yet they make the most out of limited resources. The community here face significant health challenges and on multiple fronts. They lack even the basic health infrastructure, and universal access seems an almost impossible health policy goal. Despite this, I found the healthcare teams here work with courage and resolve. Health system challenges Persisting social disparities mean they face significant health challenges through what is termed the “triple burden” of disease. The community deals with communicable diseases alongside rising rates of non-communicable diseases combined with the threat of climate change which we know already hits hard too regularly. The Solomon Islands suffer from significant resource deficits and the underdevelopment of infrastructure is driving inequalities. There is no CT scanner in the country – that places new meaning on what it is to be deficient in resources here. This is a country of over 620,000 people spread across more than 900 islands and it is without essential imaging diagnostic tools. Coverage of services is very weak. This is partly because past development efforts have lacked the required multi-level coordination to support any sort of integrated health system. Almost half of all health expenditure comes from donors which is mostly put to disease management with little left for service system development. [i] The Good Samaritan My visit to the Solomon Islands was unexpected and prompted by a local MP who approach me following some donations I made to the hospital in Tetere. They were relatively small contributions in the form of blood pressure and haemoglobin machines. From this visit, I learnt that while small they were vital and are the sorts of supports that help to develop capacity and reliability. The Good Samaritan hospital is on the coast in Tetere in Guadalcanal province which is about 40km from Honiara. The caseload here is overwhelming. The hospital is basic with about 30 beds, that provides mainly chronic disease management, emergency medicine and obstetrics. There is one doctor per 60,000 population, two midwives and two nurses. But with that they perform miracles here - this team provides obstetric care averaging 170 delivers a month. This is a population facing serious health problems yet you would be amazed by how well they cope with very little. The four most common conditions leading to critical illness are malaria, diseases of the respiratory system including pneumonia and influenza, diabetes mellitus and tuberculosis.[ii] Screening programs are grossly underdeveloped which increases critical care demand. Most facilities are short staffed and without basic equipment. From Tetere it is one hour to Honiara for Xray or just to do bloods. Despite the many challenges, the team use their clinical skills to the highest levels to provide the best care for their patients. It is the practical supports that they need the most and I think as a community of GPs we are well placed to do more. Improving critical care It is clear that the underdevelopment of healthcare infrastructure compounds inequalities. In Pacific Island countries, including the Solomon Islands, there is a high need for basic critical care resources. Equipment such as oximeters and oxygen concentrators are needed as well as greater access to medications and blood products and laboratory services. [iii] A cross-sectional survey study examining critical care resources in the Solomon Islands found that inadequate resources from primary prevention and healthcare contribute to the high degree of critical illness. This study suggested that the solution lies in simple therapies and context-appropriate resources to mitigate the high burden of morbidity and mortality.[iv] Therefore, the emphasis should be on the development and acquisition of simple and inexpensive tools rather than complicated equipment. This helps to prevent critical care from diverting resources away from other important parts of the health system. [v] This makes perfect sense in these resource-poor contexts and certainly, the healthcare team in Tetere provide a stunning example of making it work with almost nothing at all. Enabling partnerships Empowerment is key to improving health service development in the Solomon Islands. The focus needs to be on strengthening the health system and improving access to services but bringing health care to these areas is no easy task. It needs a partnership which filters right down to the community level. The Ministry of Health and Medical Services (MHMS) is really working hard towards enabling these partnerships to ensure a more planned approach to funding health services. Australia is the largest provider of Official Development Assistance (ODA) to the Solomon Islands, providing almost two-thirds of overseas aid in 2016-17. We are the lead donor in the Solomon Islands health sector, with Australia’s main bilateral assistance provided through the Health Sector Support Program (HSSP) (equates to AUD 66m over four years to 2020). [vi] Since 2008, the MHMS, with their development partners including Australia, has led a sector-wide approach (SWAp) to the delivery of health services in the Solomon Islands. The overall program goal for HSSP3 is to improve the access and quality of universal health care in the Solomon Islands. The current funding supports the Solomon Islands National Health Strategic Plan 2016-2020 and provides direct budget support, performance-linked funding and technical assistance.[vii] What more can be done? It is clear that Australia is doing its fair share for the Solomon Islands. There is now alignment in terms of ensuring best outcomes from this funding. This will certainly help build health services for this nation. But there is always more to do and GPs, in particular, can make a significant difference. We need strategies to work through how best we can support our disadvantaged pacific neighbours from a community of GPs. Education partnerships being key and the RACGP already contributes in this way particularly in Papua New Guinea. From my recent visit to the Solomon Islands, I have seen how the community there through their own resilience can achieve so much. Those working in Aboriginal Health would be familiar with what it takes to support patients in low-resource, laboratory-free settings. It would be great to share some of these learnings and provide more support for the Solomon Island communities. [Ends] [i] World Health Organisation. Article. Health closer to home: transforming care in the Solomon Islands. March 2017. Available at: http://www.who.int/features/2017/health-solomon-islands/en/ [ii]Westcott M, Martiniuk AL, Fowler RA, Adhikari NK, Dalipanda T. Critical care resources in the Solomon Islands: a cross-sectional survey. BMCInternationalHealthandHumanRights.Mar1,2012.doi:10.1186/1472-698X-12-1.Availableat: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3307438/ [iii] ibid. [iv] ibid. [v] ibid. [vi] Commonwealth of Australia. Independent Performance Assessment. Solomon Islands – Health Sector Support Program. Specialist Health Service. May 29, 2017; revised 24 July 2017. [vii] ibid.  Dr Ayman Shenouda Shaping Australia: one GP at a time For those who attended GP17 in October, I’m sure you will agree that it was delivered to its usual high standard and there was plenty of diversity in terms of viewpoints. Some perspectives were what could only be described as poles apart. Dr Jay Parkinson and Sir Harry Burns for example. Dr Parkinson with his discussion around consulting in the cloud through to Sir Harry’s on tackling poverty. There have been some blogs and articles around the technology discussion including recent Opinion in the Medical Observer. It was Sir Harry’s discussion that moved me the most as he provided some important insights into poverty and particularly around social chaos and its flow-on effects in eroding wellness. In some ways, this discussion gave me renewed hope. That as a community we can together tackle disadvantage particularly in ensuring our children get the best start in life. Not enough wellness Sir Harry Burns from Strathclyde University and former Chief Medical Officer for Scotland provided the research keynote address. This was a spirited defence of poverty which really got to the heart of the issue. The issue, of course, being disparities in terms of health outcomes and ways to counter these. It’s about how societies can create wellness and also how they can destroy it. In explaining this, he brings the consequences of poverty and inequity into sharp focus. His own country’s poor health, he says, is a reflection only of the health of the poor. Studies he’d undertaken led him to believe that the problem was in fact not enough wellness (and not too much illness). Social conditions as fundamental causes of health could be seen through countless studies he shared. We’ve all seen this of course in our own communities. I know in Wagga like most regional towns there are some deeply entrenched social disparities. But in addressing these, our national policy I think is structured in a way to deal with consequences, not poverty prevention and reduction. And without significant change, these patterns will only continue. The science behind wellness Sir Harry’s work has sought to unravel the science behind wellness. And I think some of the key learnings from his research can really transform our policies here in Australia today. It was the work of a colleague, Professor Alastair Leyland, which examined his own community of Glasgow against the slope index of inequality, which began his own inquiry around what causes health inequalities. Some very specific insights were shown in terms of what happened in society to slow down growth and life expectancy in the poor. The peak in mortality shown in these studies was in the young – teenage and young working age people – and from very specific causes – drugs, alcohol, suicide, and violence. Inequality mortality was not a feature of the elderly. These were not people dying from heart disease or cancer but there was something else going on in the population. These outcomes were pyschosoically determined - society determined causes of premature death - and they needed to work out what the key drivers were. It was social chaos that intervened which came with the housing disruption more than five decades ago. Traditional communities were broken as a consequence alongside loss of employment, opportunity, and hope. This was what eroded wellness and it is clear the same social disruption occurred here and we are also dealing with these same issues. Causes of wellness Looking more to those causes of wellness. Salutogenesis and the work of an American Sociology Dr Anton Antonovsky around a Sense of Coherence which relies on a life which is structured, predictable, explainable. Having resilience or the internal resources and will to deal with challenges. In quoting Antonovsky he said: “Unless you can see the world as comprehensible, manageable and meaningful you will experience a state of chronic stress.” This provided what he was looking for. It showed the link between social circumstances and ill health. Poverty and elevated stress The research presented really showed the relationship between poverty and elevated stress and how that leads to chronic disease and ill health. Those with a difficult start are less equipped to adapt to change which often manifests in poor behaviours. Studies by Bruce McEwen of Rockefeller University has made those links as well as Sir Harry’s own associated work undertaken in Glasgow. Early-life stress and the long-lasting behavioural, mental and physical consequences. For those wanting to learn the full science behind this here is his presentation and this discussion is about 20 minutes in. And there’s something in a cuddle. The molecular biology of a cuddle was shown. Comforting and its effect on suppressing the stress response. The biochemical toll of early neglect. Stress in infancy and the fact that neglected babies don’t get enough 5-HT. The work of Michael Meaney’s and the difference in brain development for those children who experience adversity in early life was shown. Other studies were shown which have looked at different types of adverse childhood events – neglect, abuse, domestic violence, alcoholic parent – which is then linked to outcome. It showed children exposed to adverse events in early life had a higher risk of alcoholism, depression or drug abuse. Breaking the cycle Social turbulence was the description used. More specifically, he described a cycle that alienates people and impairs their ability to control their wellbeing. And that it starts with chaotic early years. The policy learnings for us include around Scotland’s approach to improving wellness. That is to focus on breaking that cycle by doing things in early life. Policy solutions There are some key learnings in the policy approach itself. It was those at the front-line who developed the policy solutions in Scotland in response to these issues. They asked front-line staff for solutions, then took their ideas and tested them and shared them across the country. The secret, he says, is in marginal gains. Go out there try lots of things see what works and then do it all consistency. I think there’s a lesson in that for our own policy development. It is through those small gains which from a range of interventions that add up to produce significant overall improvements. In early years, it was simple things like attachment is improved if kids are read bedtime stories. The solution lies in enabling that to occur. Policy approach The shift in policy approach is really about enabling policy change. That is change as opposed to full reform. It is in enabling those incremental shifts to existing structures, or the adoption of new and innovative approaches that can facilitate that change. The risk in full reform is that it stifles innovation which can limit participation and if it’s not realised quickly then all is lost including those approaches that proved to work. Politicians turn to the next new thing which may not be as effective. In Scotland, they’ve had 1500 small tests of change carried out in child health with 60 or 70 of them now implemented. Similar community strengthening type approaches which can facilitate incremental gains are what we need here to shift disparities. Conclusion The key message from the discussion is that it is those experiences in early life which can set off a life course of adversity. Those clear links in social circumstances and the beginnings of chronic ill health. We need much more focus here in Australia on what causes wellness. It’s not that we haven’t had a focus here on concepts which include community resilience. Those social capital discussions were full of it in the early 2000s. There seems less focus now and perhaps its due to governments not realising fully how investments now pay health dividends later on. There also may not be that political will to invest in wellness knowing the results will not be seen in the space of an electoral term. Sustainable healthcare: A shift to a proactive, preventive approach with increased engagement2/11/2017  30 October 2017 Dr Ayman Shenouda Investing in health A greater investment in health requires a strong focus on patient-centred care prioritising both prevention and primary care. In progressing these shifts we’re currently locked within the constraints of our reactive healthcare system. Despite significant levels of funding, we’re just feeding a sick system here. This is less about payment reform or performance-based models but more one of prioritising and getting that focus right. In making that shift towards a healthier population and sustainable healthcare system it comes down to priorities, not just savings. Removing waste including through the removal of obsolete, redundant or unsafe treatments from the MBS item numbers is important. But so is ensuring we transition from our episodic, acute care or reactive model towards a more proactive one. Preventive care solutions To shift health outcomes then we need to address those causal factors. It’s not just medical care alone that influences health with social factors known powerful determinants of health.[1] Those causal factors affecting health status must be also be tackled. Socioeconomic factors – income, wealth and education – all impact. Those “upstream” factors which include social disadvantage, risk exposure and social inequities that play a fundamental causal role in poor health outcomes and must be addressed.[2] These are issues which play out over long periods and much longer than electoral cycles. But stopping the onset of illness is the only way to contain our rising disease burden.[3] Therefore, it is those emerging preventive care solutions, which fall as either proactive or predictive care, where we now need to focus.[4] A prescription for health This prescription for health is very different to the one we currently have and involves a Proactive, Preventive Approach with Increased Engagement. The shift is something we’ve been trying to do in primary care for some time but barriers from without our framework are limiting a full transition. The policy response involves a mix of proactive and predictive care solutions. For proactive care solutions, this involves improving treatment outcomes through stratifying at-risk individuals based on known algorithms ensuring preventive action is taken well before the onset of symptoms. [5] We know that certain behavioural risk factors - tobacco use, alcohol consumption, physical inactivity and unhealthy eating - are most amenable to change. We can do more to modify these behaviours as part of proactive care through stratifying individuals based on key risk factors for chronic disease.[6] While predictive care is about leveraging emerging technologies and using big data to not only stratify risk but predict risk and intervene even further upstream.[7] More predictive care, through improved analytics, genetic risk testing and technological developments build an even clearer picture. These early insights will help us anticipate issues pinpointing those behaviours to avoid and actions to take much earlier than before and before risk factors arise. [8] Risk and protective factors In transforming our health system, it is a focus on those risk and protective factors over time that really holds the answers. The Life Course Health Development (LCHD) framework offers a new approach to health measurement, health system design, and long-term investment in health development.[9] It takes into account those risk and protective factors and early-life experiences in determining long-term health and disease outcomes. [10] More understanding of how these health trajectories develop over a lifetime helps us influence change for optimal health development through more effective preventive strategies and interventions. [11]
2. Then an equal focus on protective factors –These are those protective or health-promoting factors which are of course broader than health but have a positive influence on our lives and are health affirming. From the best start through breastfeeding, positive educational influences or being more physically active throughout through to access to quality healthcare and strong social capital are just some examples. 3. Finally, increased engagement in striving for our own good health –Population health management really offers the collaborative approach required to empower patients and patient centred care. Informed and involved patients who are active participants in setting their own goals for wellness are central.[15] Those social factors and the government’s part in that to ensure we all have the best start and life possible is really key. Strategies for intervention It is these focus areas which hold promising strategies for intervention. Still, we see very few health dollars being prioritised for prevention. To fully support a stronger focus on prevention we need to pursue new data on risk and protective factors, investigating how and when they develop across the life course.[16] Through these key learnings, new proactive and predictive care solutions will need to be developed and prioritised in our healthcare system. This is not a new concept; many general practices already do this – identify and stratify patients according to risk – but it our current payment system really restricts us here in limiting to diagnoses. It is really just the difference between disease focus care and actually enabling more patient centred care. More incentives around prevention and in reducing risk are required to make this work particularly in general practice for an optimal business model. More broadly, this requires a whole of government shift, not just from within the health budget but towards a Health in All Policies (HiAP) approach. This will help redress inequities and give everyone a fair chance for health. The policy remit extends well beyond health and also beyond any discussions occurring right now around fee-for-service and performance-based models. If the government is really serious about shifting health outcomes then we need to think less about a system which drives episodic care and more about those broader factors that influence health outcomes. [1] Braveman P, Gottlieb L. The Social Determinants of Health: It’s Time to Consider the Causes of the Causes. Public Health Reports. 2014;129(Suppl 2):19-31. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3863696/ [2] Bharmal N, Pitkin Derose K, Felician M, and Weden, M. Working Paper: Understanding the Upstream Social Determinants of Health. RAND Health. Prepared for the RAND Social Determinants of Health Interest Group. WR-1096-RCMay 2015. Available at: https://www.rand.org/content/dam/rand/pubs/working_papers/WR1000/WR1096/RAND_WR1096.pdf [3] MacIntosh E, Rajakulendran N, Khayat Z, Wise A. Transforming health: Shifting from reactive to proactive and predictive care. MaRS. 29 Mar 16. Part of the Transforming Health Market Insights Series. Available at: https://www.marsdd.com/news-and-insights/transforming-health-shifting-from-reactive-to-proactive-and-predictive-care/ [4] Ibid. https://www.marsdd.com/news-and-insights/transforming-health-shifting-from-reactive-to-proactive-and-predictive-care/ [5] Ibid. https://www.marsdd.com/news-and-insights/transforming-health-shifting-from-reactive-to-proactive-and-predictive-care/ [6] Ibid. https://www.marsdd.com/news-and-insights/transforming-health-shifting-from-reactive-to-proactive-and-predictive-care/ [7] Ibid. https://www.marsdd.com/news-and-insights/transforming-health-shifting-from-reactive-to-proactive-and-predictive-care/ [8] Ibid. https://www.marsdd.com/news-and-insights/transforming-health-shifting-from-reactive-to-proactive-and-predictive-care/ [9] Halfon N, Hochstein M. Life Course Health Development: An Integrated Framework for Developing Health, Policy, and Research. The MilbankQuarterly.2002;80(3):433-479. doi:10.1111/1468-0009.00019. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2690118/ [10] Ibid. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2690118/ [11] Ibid. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2690118/ [12] Halfon N, Larson K, Russ S. Theories And Consequences. Why Social Determinants? Healthcare Quarterly, 14(Sp) October 2010: 8-20.doi:10.12927/hcq.2010.21979. Available at: http://www.longwoods.com/content/21979 [13] Tasmanian Government. Determinants of Health. Department of Health and Human Services. Available at: http://www.dhhs.tas.gov.au/wihpw/principles/determinants_of_health [14] Op. cit. Halfon et al. Available at: . http://www.longwoods.com/content/21979 [15] Ernst & Young. Population Health Management. EY Health Industry Post. News and analysis of current issues affecting health care providersandpayers.2014.Availableat: http://www.ey.com/Publication/vwLUAssets/Health_Industry_Post_population_health_management/$FILE/Health_Industry_post.pdf [16] Public Health Agency of Canada. Strategic Plan 2016-19. Improving Health Outcomes. A Paradigm Shift. Publication date: December 2015. Cat.: HP35-39/2015E-PDF ISBN: 978-0-660-03990-9 Pub.: 150173. Available at: http://www.phac-aspc.gc.ca/cd-mc/assets/pdf/ccdp-strategic-plan-2016-2019-plan-strategique-cpmc-eng.pdf |
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