FIT FOR PURPOSE: FINDINGS AND RECOMMENDATIONS OF THE EXTERNAL REVIEW OF THE PAN-CANADIAN HEALTH ORGANIZATIONS Dr. Pierre-Gerlier Forest and Dr. Danielle Martin SUMMARY REPORT Fit for Purpose: Findings and Recommendations of the External Review of the Pan-Canadian Health Organizations Cat. No. H22-4/11-2018E-PDF Cat. No. H22-4/11-2018E (Print) ISBN 978-0-660-25782-2 (PDF) ISBN 978-0-660-25783-9 (Print) © 2018 by the External Review of the Pan-Canadian Health Organizations Disponible en français External Review of Pan-Canadian Health Organizations March 2018 The Honourable Ginette Petitpas Taylor Minister of Health Government of Canada Ottawa, ON Dear Minister, In fulfillment of our responsibilities as your expert advisors for the External Review of Pan-Canadian Health Organizations (PCHOs), please find attached our summary report. It reflects a thorough examination of the evidence and issues – and of our deliberations on them – as well as what we learned from submissions, commissioned research, and our consultation with health-care stakeholders from across the country. Thank you for choosing us for this work. We are honoured you put your trust in us, and hope that the resulting report helps guide your decisions around an intricate set of issues. This review comes at a propitious time in the history of health care in this country. From our consultations, it is clear that there is a consensus around the health system reforms required to bring 21st century health care to Canadians. The call to get on with this work came from all corners of the country and from all participants, regardless of their roles. As your portfolio evolves, the PCHOs’ role and relevance in advancing federal health policy objectives and meeting national goals becomes more crucial. A suite of PCHOs designed to help you do that, in whatever timeline you deem appropriate, is our over-riding recommendation to you. We hope that our report will generate productive discussions and inspire policies that yield stronger health systems across the country and better health outcomes for Canadians. Sincerely, Pierre-Gerlier Forest, PhD, FCAHS Danielle Martin, MD, MPP, FCFP, CCFP Professor and Director Vice-President, Medical Affairs and Health System Solutions James S. and Barbara A. Palmer Chair in Public Policy Women’s College Hospital School of Public Policy Toronto ON University of Calgary Calgary AB iii Contents Acknowledgements ....................................................... iv About this Report ..........................................................v List of Acronyms .......................................................... vi Précis of the Summary Report ................................................vii Recommendations ........................................................xiii Chapter 1 – Objectives and Context of the Review .................................1 Chapter 2 – Pan-Canadian Health Organizations ...................................9 Chapter 3 – Indigenous Health and Reconciliation .................................29 Chapter 4 – The Federal Role in Health Policy ....................................37 Chapter 5 – The Machinery of Change .........................................45 Chapter 6 – Setting the Destination: A Vision for 21st Century Health Systems ...........53 Chapter 7 – Summary of Criteria for Meeting Canadian Health-Care Imperatives .........67 Chapter 8 – A Look at the Status Quo ..........................................71 Chapter 9 – Options for Change ..............................................81 Chapter 10 – Scenarios for Change ............................................89 Conclusion .............................................................115 Appendix 1 – External Review Terms of Reference ................................117 Appendix 2 – Reference Group ..............................................121 Appendix 3 – Key Informants and Commissioned Research .........................122 Appendix 4 – Individuals, Stakeholder Organizations, and Government Entities who Provided Written Submissions ................................124 Appendix 5 – Summary of Stakeholder Submissions ..............................126 Appendix 6 – Key Concepts and Selective References .............................129 Appendix 7 – Timeline for Key Reports and PCHOs ...............................166 iv Acknowledgements We would like to recognize and thank the many people who supported the review and contributed to the creation of this report. We begin with the invaluable guidance and expert assistance from a small and dedicated secretariat within Health Canada, most ably led by Director Peggy Ainslie, who provided unfailing leadership and superb support throughout the review. We benefited greatly from the team’s efforts and thank Kajan Ratneswaran, Tara Finlay, Gregory Huyer, Brennan Graham, Michel LeClerc, and Mélodie Vaillant for all their hard work. We are grateful for the wise counsel and attentive input we received from the knowledgeable and thoughtful members of our reference group, who provided regional and international perspectives as well as diverse views and areas of expertise. We thank them for being so generous with their time and talent, for their careful feedback, and for engaging so vigorously in the issues. To the readers who reviewed drafts of the report and laboured to improve it, we thank you. We were fortunate to have spoken with so many leaders and health sector stakeholders from coast to coast to coast, including the leadership and senior management of the PCHOs and deputy ministers of health from federal, provincial and territorial governments. We would like to recognize and thank them for their reflective input, insight, and forthcoming views. Our discussions with, and input from, representatives of the Assembly of First Nations, the Métis National Council, and Inuit Tapiriit Kanatami were revelatory and essential and we greatly appreciated their participation. All these views have helped shape ours; but if there are criticisms of the report, the responsibility lies with us. We would like to share our deep appreciation of, and thanks to, Sine MacKinnon of SMK Strategic Communications and Public Policy for her expert contributions to the report. Thanks also to Michel Amar for his strategic advice. Finally, we would like to thank the institutions for which we work, the University of Calgary and Women’s College Hospital, for giving us the time and space to perform this important work, as well as Ian McMillan and Stacey Wallin for their invaluable help. v About this Report This summary report presents the analysis and recommendations of the External Review of Pan-Canadian Health Organizations, launched October 3, 2017 by federal Health Minister Ginette Petitpas Taylor. The independent review was conducted by expert external advisors Drs. Pierre-Gerlier Forest and Danielle Martin who presented their advice to the minister in March 2018. The review’s terms of reference appear in Appendix 1 of the report. This is not an academic report; it is evidence-informed and the sources for the key concepts discussed across the chapters are outlined and referenced in Appendix 6, which was prepared by Dr. Renee Misfeldt. Questions about quotes and citations may be directed to the Review Secretariat. The report builds on input elicited during the advisors’ consultation with the PCHOs, National Indigenous Organization (NIO) representatives, industry leaders, academic experts, other stakeholders, and senior government officials from all parts of the country. It also reflects findings from the latest literature related to the review’s subject matter and the results of commissioned research. The views expressed in written submissions from organizations and individuals across Canada are also taken into account in the report and summarized in Appendix 5. A list of those who were consulted and the names of the review’s advisory reference group also appear in Appendices 2 to 4. The report begins with a précis of the summary report and the advisors’ recommendations. It then lays out the facts and arguments in three sections. Chapters 1 through 6 include the review’s mandate and context; PCHO profiles; the need to address Indigenous health and reconciliation; the federal role in health policy; the machinery of change at the federal level; and a vision for 21st century health systems. The next section, Chapters 7 and 8, describes the needs of Canada’s health systems, sets out the criteria for meeting those needs, and assesses the current configuration of PCHOs against those criteria. Finally, Chapters 9 and 10 make the case for change and lay out four possible future scenarios for a PCHO suite, followed by the report’s conclusion. vi List of Acronyms AFN Assembly of First Nations APHI Advisory Panel on Healthcare Innovation CADTH Canadian Agency for Drugs and Technologies in Health CCOHTA Canadian Coordinating Office for Health Technology Assessment CCSA Canadian Centre on Substance Use and Addiction CFHI Canadian Foundation for Healthcare Improvement CHSRF Canadian Health Services Research Foundation CIHI Canadian Institute for Health Information CIHR Canadian Institutes of Health Research CPAC Canadian Partnership Against Cancer CPSI Canadian Patient Safety Institute CRISM Canadian Research Initiative in Substance Misuse EHR electronic health record EMR electronic medical record FNIHB First Nations and Inuit Health Branch FPT federal, provincial and territorial HTA health technology assessment ITK Inuit Tapiriit Kanatami MHCC Mental Health