1. Health Professional’s Role in Health Equity October 12, 2012 2012 CAPA Annual Conference Dr. Anna Reid, MD, CCFP-EM

2. What is Health Equity  Health equity exists when all individuals have the opportunity to achieve their full health potential.  Equity is undermined when preventable and avoidable systematic conditions limit life choices. What causes Inequity?  Differences due not to biological factors but to differences in social advantage i.e., social and economic factors known as the social determinants of health

3. Social Determinants of Health In 2002 researchers decided on the following list:  Aboriginal status  Disability  Early life  Education  Employment and working conditions  Food insecurity  Health services  Gender  Housing  Income and income distribution  Race  Social exclusion  Social safety net  Unemployment and job security

4. Health Consequences of Health Inequity  Social gradient of health: Those with higher income experience greater health status.  The steeper the gradient, the lower the overall health of the population.  Those in the lowest income group are  50% less likely to see a specialist or get care in evenings/weekends;  40% more likely to wait longer for a dr’s app’t;  3x less likely to fill prescriptions;  60% less able to get needed tests because of cost

5. Financial Cost of Health Inequity  Utilization of health services follows a reverse social gradient with those with the lowest incomes using more health services  Those living in the most disadvantaged neighborhoods experience almost 20 years less disability-free life than those in the highest income neighborhoods

6. What Needs to be Done? WHO’s 4 categories for action on the social determinants:  Reducing social stratification  Decreasing the exposure of individuals/populations to health-damaging factors  Reducing people’s vulnerability to health-damaging conditions  Intervening through health care to reduce the consequences of ill health caused by the underlying determinants.

7. Health Equity: CMA Actions to Date  CMA expert panel on health care sustainability  CMA/CNA Principles to Guide Health Care Transformation  GC 2011 – Policy discussion paper.

8. CMA Actions (Cont’d)  This paper was developed and approved by the Board for consultation in December 2011  Provides background and 4 areas for action:  CMA and National-level Initiatives  Medical Education  Leadership and Research  Clinical Practice

9. Health Equity: Opportunities in Practice  In developing the policy it became clear that there was limited published evidence on clinical interventions  CMA staff interviewed physicians identified as experts in this area.  November 2011: pilot interview  Feb - April 2012: 30 physicians in 8 provinces, 2 territories were interviewed

10. Health Equity: Opportunities in Practice  Clinical settings were primarily family practice, but ER, pediatricians, psychiatrists and public health were also interviewed  Populations included rural and urban, inner city, Aboriginal, child and youth, mental health, women’s health and northern health  Many interventions identified could be done by various members of the health care team

11. Most Common Interventions Identified 1.Linking patients with supportive community programs and services 2.Asking questions about a patient’s social and economic circumstances 3.Integrating considerations of social and economic conditions into treatment planning e.g., cost of medications

12. Most Common Interventions Identified (Cont’d) 4.Advocating for changes to support improvements in the social and economic circumstances of the community e.g., advocating for reductions in child poverty 5.Undertaking advocacy on behalf of individual patients e.g., letters about the need for safer housing

13. Most Common Interventions Identified (Cont’d) 6.Adopting equitable practice design e.g., flexible office hours, convenient practice location) 7.Providing practical support to patients to access the federal, provincial/territorial programs for which they qualify

14. Most Common Barriers 1.Payment models (100% fee-for-service in particular) 2.Attitudes that lead to stigmatized environments and prevent public action 3.Lack of clinically oriented information about programs and services available for patients

15. Most Common Barriers (Cont’d) 4.Lack of time to address these issues 5.Lack of integration between health and community-based services 6.Lack of knowledge and skills for this type of work 7.Practice design

16. Most Common Barriers (Cont’d) 8.Lack of services and supports in the community (especially in rural and remote communities) 9.Lack of evidence and research on effective interventions for health care providers 10.Personal attitudes that include powerlessness in the face of patients’ social and economic barriers

17. Most Common Facilitators Identified 1.Clinical training about how to do this type of work (e.g., service learning programs in medical school and residency training) 2.Interdisciplinary team-based practice settings 3.A relationship with community services and programs

18. Most Common Facilitators (Cont’d) 4.Clinically relevant resources about the programs and services that were available for patients 5.Supportive compensation models (i.e., salary, billing codes for complex patients) 6.Continued research that demonstrates efficacy in the clinical environment 7.Finding a like-minded community of practice

19. Possible Areas for Action Advocacy and Communications  Develop a network of health equity physicians  Develop an advocacy strategy for health equity  Develop an advocacy map/tool for clinicians  Health equity leadership & advocacy training resources for physicians Compensation  Identify effective compensation models for health equity practice in Canada CMA and National Level Initiatives

20. Possible Areas for Action (Cont’d) Education  Further integration of the social determinants and health equity in medical schools and residency training  Develop an accredited continuing medical education programs for practising physicians Research  Continued research on physician interventions  Assemble evidence base and best practices and facilitate knowledge translation

21. Possible Areas for Action (Cont’d) Clinical Practice  Health equity/social determinants of health assessment tool  Clinical practice guidelines to integrate social and economic factors into medical care  Resources for physicians on programs/services for patients  Resources for physicians on accessing provincial/territorial and federal programs  Plain language resources for patients on chronic disease management

22. General Council 2012  Health Equity a major theme at General Council in Yellowknife  There were an education session, a strategic session and a special lecture by Professor Sir Michael Marmot  Delegates were passionate and enthused about the topic

23. Next Steps  CMA staff are currently developing a work plan for health equity  CMA will be reaching out to other health care provider associations to identify areas for action within the health care sector

24. Next Steps (Cont’d) The ultimate goal is to develop:  A policy position on the impact of various social and economic conditions on health  Advocacy efforts with the government, including the development of policy recommendations  Information for the public on how social and economic factors influence health  Tools for health providers to use in clinical practice