The Canadian Medical Association helpfully launched the debate about renewing the Canada Health Accord in 2014 with its Health Care Transformation in Canada policy document, published around this time last year. It parsed health demographics to predict a shift in need from acute care in hospitals toward the care of chronic illnesses and dementia in a range of more community-based settings. To serve these burgeoning needs, it recommended a shift in focus from discrete services, such as surgeries, to “patient-centred care.” I agree, with one qualification. It should be patient-relationship-centred care. The willingness to enter and sustain a relationship with the patient is crucial in these areas.
I speak from experience. My son was diagnosed with a severe chronic mental illness 12 years ago. And my mother died of dementia seven years ago. Relationships were key to the outcomes in both cases: a good death for my mother in the care of people who knew and cared for her over time, and recovery for my son.
When he was diagnosed with schizophrenia at 18, I remember brief encounters with a range of health-care providers as he was hospitalized, then released, and spiralled downward into addiction, worsening housing situations and, finally, shelters. Eventually, he was in the same ward of the local psychiatric hospital often enough that he developed a relationship with one nurse. She had an open, listening heart. Slowly, my son let his guard down enough to share some hints on what she and others could provide so he could help himself. A social worker became involved along with the nurse and the doctor, and together they prepared the ground for when my son might begin to care about himself once more. Because that’s the key in many if not most chronic illnesses, I think – even heart disease and cancer which, after an “acute” moment, often become chronic diseases that people learn to live with.
The key is getting people to take responsibility for their recovery, and that’s hard. “Recovery” doesn’t mean going back to the way things were. Believing that recovery is still worth striving for, that complying with medications is worth the effort, these are crucial “outcomes.” And a continuum of patient-care relationships, across a range of hospital and community-based services, including in the non-profit sector and in self-help groups – is crucial to achieving that. It was for my son. When he was discharged from hospital the last time, it was to a non-profit group home and a community-based treatment team, with ongoing counselling and self-help groups even when, a year later, he moved into his own apartment. Now he’s a full-time college student and a richly contributing member of the family once again.
Ensuring that the new health accord supports this focus on relationships and relationship-building in health-care delivery will not be easy.
First, to shift funding to support it, there must be a matching shift in how outcomes are measured and accountability defined. For this, we need some good strategic research, with appropriate tools that catch the non-quantifiable stuff of relationship-building and what enabling relationships deliver.
Second, primary health-care relationships should increasingly be with nurses and a nurse practitioner, not a family doctor. I say this partly due to the chronic shortage of family doctors and declining enrolments here in medical school, and perhaps too with a nod to how much doctors’ fees for services have driven up the cost of health care lately. Mostly, though, I recommend this because empathetic relationships are central to the heritage of nursing, and in an increasingly “high-tech” health-care environment, the “high touch” of that focus on shared humanity is crucial. Yet I also see nurses playing specialized roles in these patient-care relationships, alone and within teams: from communication and coaching to co-ordinating services, making referrals and managing patient records and records systems in a way that’s appropriate for complex patient care and multiple players over time.
Third, this model of relationship-centred care requires an enabling context that allows discretionary time for relationship-building. This suggests that health-care service delivery shouldn’t be contracted out to for-profit organizations which necessarily focus on billable tasks and quantifiable service-intervention moments. Instead, it is best left with public institutions, although increasingly in partnership with not-for profit community institutions run by professionals plus volunteers – such as the Alzheimer’s Society, the Canadian Mental Health Association and Centre for Addiction and Mental Health and organizations for people with asthma and autism.
The original vision of a public health-care service in Canada was health care within reach of everyone. I think this new model can deliver on that empathetic reaching vision, cost-effectively too.
Heather Menzies is an author and adjunct professor at Carleton University. Her latest book is Enter Mourning: A Memoir on Death, Dementia and Coming Home .