Many thanks to co-author Dr. Jeffrey Turnbull for his contributions to this post.
Equity is now firmly integrated into our understanding of quality. The landmark Institute of Medicine Report Crossing the Quality Chasm, included equity as one of the six dimensions of quality. Health Quality Ontario has included equity as one of the key elements of the Quality Matters framework. And Ontario has a history of reporting on aspects of equity like women’s health through hospital report cards or broader efforts contrasting health system performance by sex and other factors like the POWER Study. More recently, Health Quality Ontario has reported on equity for the first time, focusing on the impact of income on health and has developed an equity plan. And around the world we can see efforts to improve equity that have had positive impact on health. And there are examples of improvements in equity with meaningful impacts on health and healthcare use at the national such as Brazil’s Bolsa Familia.
However, much of our discussion around if and how we can improve health equity gets stuck on statements like “it’s complicated,” “most of it is beyond the health system,” or “it will take a very long time.” These sorts of responses can be demotivating (complicated), require levels of authority beyond any single health system leader’s scope (beyond the health system), or perseverance beyond their typical lifespan (takes a long time). And despite our best intentions to focus on equity, new themes are dominating policy discussions. Patient-centred care and population health are important foci of health system reforms across Canada. Although equity is on everyone’s radar, it can appear hard to see how we can work towards its improvement.
So what can we do about equity? The first thing to do is to sweep away some of these sticky statements starting with the notion that patient-centred care and population health are distinct from equity. Patient-centred care means providing the right care at the right time in partnership with the patient. It is impossible to meet this test without paying attention to the same factors that affect equity in health and health care. Likewise, population health addresses the full continuum of the determinants of health from the social and environmental determinants, to biology and genetics through to health care. When we address the social and environmental determinants we are addressing those factors that are most closely correlated with and contribute to inequities in health and health care. So we cannot move towards patient-centred care and population health management without addressing equity.
Now it is true that equity in health and healthcare is complicated, but so are so most things in health and healthcare. Ontario (and Canada) have several relatively simple – although not always easy – examples of where we have been able to improve equity, often by paying attention to both the health care and social needs of patients. A report from the Canadian Population Health Initiative described 11 case examples from hospitals, health regions, and community and social care organizations where efforts to improve care directly addressed equity. So there are elegant ways to improve equity in health and healthcare now that myth-bust the typical arguments against addressing equity.
These 11 examples and more from across Canada and around the world suggest three fundamental approaches to improving equity that can include anyone working in our health system.
- First, we can make equity the target of quality improvement projects. We know that the gaps and mishaps in healthcare disproportionately affect people whose ability to navigate our system is the weakest. By addressing issues related to equity like language, cultural safety, and health literacy as part of QI, we can promote improvements in equity and potentially crate scalable and spreadable innovations with wider relevance. Clinicians, front-line administrators and even patients can lead in this approach. We know that the gaps and mishaps in healthcare disproportionately affect people whose ability to navigate our system is the weakest. By addressing issues related to equity like language, cultural safety, and health literacy as part of QI, we can promote improvements in equity and potentially crate scalable and spreadable innovations with wider relevance. Clinicians, front-line administrators and even patients can lead in this approach.
- Second, we can create vehicles for joined-up action on equity and broader determinants of health. The lessons of Health Links for Ontario are clear. High-users of healthcare are high users for many reasons. Municipalities and other organizations have joined or even led Health Links in Ontario because these other resources are a critical part of any solution – and usually function as the safety valve for health care – for these high users. Likewise, work by Laura Rosella and colleagues showed that the biggest predictor of being a high user was food insecurity. Organizational leaders whether they be in the social or health sectors can lead by creating these sorts of joined-up approaches to improvement. Thankfully, there is already evidence from around Ontario of communities where these organizations have shown leadership in creating such coalitions.
- Third, we can support operational and strategic policy decisions that organize resources around promoting equity. Operational policies like the collection of information on ethnicity as part of the healthcare record provide a vital resource to measuring, monitoring and improving equity. Public reporting on equity and health can provide a critical spur to action, particularly when it is done at a level of detail that captures the attention of decision-makers. Strategic policy experiments like basic income can provide some buttress against inequity. Policy-makers and senior decision-makers in the public sector can help lead these types of initiatives that both enhance equity as well as provide critical enablers for the first two approaches.
Although equity is now clearly part of quality, the danger is to look at it as aspirational rather than practical. As we have argued above, there are simple enough ways we can improve equity at the team, organizational and system level than can start now and have real benefits now and in the near future. However, there will be challenges. Improving equity in health and health care will require us to develop new settings, new partnerships, new sources of data, and new models of care. Thankfully, there are signs already of these changes at the grassroots of our health system. Inner City Health in Ottawa that brings health and social care into homeless shelters is one model of new settings and new partnerships, the recent efforts in Toronto to collect data on ethnicity represent an important step forward in new data, and Health Links brought together municipalities, social service agencies and health care providers into combined delivery models to help high users. All of these changes may be hard, but they are remarkable simple solutions that can have remarkably early and important impacts.