Collaboration and Democracy in Health Care


They go by many names and most sectors have them – joint committees, collaborative tables and other industry-specific names.  These are the places where industry groups with competing interests decide to put aside their differences and come together for a common purpose – starting with dialogue and spawning initiatives for improvement in which all parties see value for their constituencies.

Most people have never heard of these groups, but we should be paying attention because in an era where electoral democracy has become vulnerable to the vagaries of influence and deception (witness our neighbor to the south), these tables bring an incremental approach to change that makes the world better for all of us.

For example, the General Practice Services Committee ( brings together the Ministry of Health, family physicians from the Doctors of BC, and all the health authorities in the province. Together, they hammer out new ways to improve the first point of contact in the healthcare system, support physicians to have more satisfying and efficient practices, and improve access to the care for patients. 

The GPSC is well-funded and has grown to include a significant team of people at the local and provincial level who have built expertise in collaborative system change.  One unintended and positive consequence of this is that skilled people from the non-profit world who come with experience in community engagement and a hunger for system change, have transitioned into helping our healthcare system improve.  Another consequence is the movement of non-physicians across the boundaries of physician, health authority and Ministry workplaces, leaving us with a strong network of people who see the system from a variety of perspectives.  

This talented group of people have – by virtue of their occupying roles across the system – built relationships that can move challenging initiatives forward by virtue of their understanding of multiple systems. 

I see these developments as a means of building convergence from diversity and improving key systems on which healthy democracies depend.  How do you see the growth of these collaborative groups?

You can see the doctor matter where you are

Great work is underway to advance healthcare in the North where a diverse population of 300,000 lives in rural and isolated communities spread across an area the size of France! One recent project I enjoyed was working with the Tele-Kidney Care Project, drafting a report for a prototype where patients with chronic kidney disease were able to get the highest standard of care from the Northern Kidney Care team using videoconference appointments as an offered alternative to in-person visits.

I listened to a team of experts that brought perspectives from clinical, technical, administrative strategic backgrounds and helped them work through several data sets to compare what they wanted to achieve against what they had achieved. Of course, as a prototype project there were lots of learnings to share with others. At the end of the day, the results were significant and very meaningful:

  • Patients and their family doctors loved telehealth!

  • Over three years, 1030 visits saved over 10,000 hours of driving time and enough CO2 emissions to take 40 vehicles off the road for a year. 

  • More patients from farther away started getting care, and some patients living closer to the Kidney Care team switched over to telehealth visits.

  • Patients were referred to the Kidney Care team earlier in the progression of their illness, which improves length and quality of life, and ultimately reduced health care spending.  

Letting patients get care closer to home (or in their home) slows the progression of chronic kidney diseases and improves community sustainability. The effort and risk put into the project by the Kidney Care team clearly paid off for patients, and for everyone who loves health care.

Kudos to Dr. Anurag Singh, his Nephrology team and colleagues and the committee overseeing the project:  Sheri Yeast, Janice Patterson, Frank Flood and Reina Pharness. And thanks for inviting me to assist with this fantastic project!

Celebrating collaboration, part 1

My projects are generally prototypes or new innovations, and while I’m strong at unleashing my clients’ collective imagination, often I wouldn’t be able to deliver on them without the advice and technical brilliance of Scott Hughes, who operates Capacity Build Consulting.  Here are some of the challenges he has helped me and my clients to resolve:

·       Designing primary care business models from the starting point of the quality of the patient-provider relationship.

·       Annual distribution of $2 million in education resources, equitably for 1800 doctors across 102 rural communities in BC.

·       Calculating the social, economic and environmental savings from using videoconference to provide patient care for chronic kidney disease and other illnesses.

Typically, Scott and I will spend a few hours at a white board, and then shortly after, an ingenious solution will come across my desk, along with an explanation of the assumptions that drive the modelling that I can bring to my clients to help them understand (and adjust) the model.  In today’s environment where we need solid financials to ensure the sustainability of solutions, Scott’s talents are charting the course to a new set of system improvements that affect healthcare, housing and community city services.

I’m a small part of his work – Scott also helps organizations to build complicated business models to achieve a social purpose.  In addition to having a very smart, analytical and creative mind, Scott and I share similar values that make our collaborations both interesting and impactful.  Scott can be found at


When is a survey not a survey?

As a consultant working to improve equity in complex environments, I often run into situations where a client feels like a survey is the best way to understand how stakeholders feel about an issue or opportunity.  Surveys have an important role, but there are situations where a different approach is useful:  surveys take a lot of time to get the language right and sometimes the response rate is disappointing.  

Recently, I’ve led projects where we decided to forego a survey, or we used a survey primarily to start conversations.  Here’s how we decided what to do…

One project was for a committee that included the Ministry of Health, Doctors of BC and all seven health authorities. They wanted to create a provincial-scale program that would distribute funds to support rural physician-led learning (Rural Continuing Medical Education or RCME).  We decided to have conversations with knowledgeable stakeholders who had a variety of (sometimes conflicting) perspectives instead of a survey that would have received a low response rate (yes, doctors do have better things to do than answer surveys). When we identified where the perspectives converged, we were able to point to the recognized experts as the first-stage designers of the eventual program.

A different project aimed at improving oral health and access to care in a small indigenous community on the west coast of BC.  There, we developed a survey, but because no one really knew about the project, we carried out the surveys in person and started up conversations based on the responses, about the bigger issues of equity in access to dental treatment.  In some cases, like with the local secondary students, we just carried on a conversation using a visual design of what it might look like to get dental treatment in the community. 

 In both cases, we got deeper and more meaningful information to understand what was important, including the values, principles and issues that are most important to young families, elders and service providers…and which we never would have captured adequately with a survey.

Patients and providers design primary care in Vancouver

What would happen if we asked 500 family doctors, 1000 citizens and 50 health system experts to redesign primary care?

In 2013 and 2014, I was privileged to lead a team that did just that in Canada’s third-largest city, where almost 20% of residents do not have a family doctor.  Over 8 months, we brought 350 GPs and health authority staff together to answer a simple question:  “what can be done to improve primary care relationships, so that more people can have a family doctor?”   What started with a simple question is leading us to a new era in health care.

Using this question as our focus, we held several dialogue sessions that included over 300 family physicians and health authority staff.  Through these, we generated 250 pages of data, from which we extracted 22 ideas for making the family doctor’s office more efficient and better connected to the wider health care system in BC.  Then we circled back to all 800 local GPs to see which of these interventions were most practical, to create a shorter list of ideas with great promise.   

Once we knew what doctors thought would be possible, we asked patients – citizens – what they thought of those ideas.  Again using the theme of relationships, over 1000 citizens filled out an online survey to assess the physician-generated ideas.  We created a separate process for vulnerable groups (urban Aboriginal families, newcomers, seniors and others) to participate through a dozen in-person kitchen table events.  

It would be unfair to promise patients the moon, so we asked them to assess the extent to which the ideas generated by health system experts – including family doctors – would address their needs, and what trade-offs people would make so that everyone could have a family doctor.  We found that people were easily able to make actionable recommendations for system change when we used the lens of therapeutic relationships.  For example, we found that patients place a high value on everyone having a family doctor, that they want both continuity and convenience, and would much prefer to see or talk with their own doctor’s office instead of going to a walk-in or emergency department.   These are all ideas that support health system sustainability.

Through the process, we uncovered clues that will form the foundation for the next era of primary care: 

·       how seniors and millenials share many preferences in the design of family practice,

·       how to best engage citizens and clinicians in co-designing primary care,

·       how a culture shift among primary care providers will form the foundation of a primary care system that can enable everyone to have a family doctor

From this work, a few of us have created a new organization to implement the vision of hundreds of family doctors and thousands of patients.   The Vancouver Citizens Health Initiative brings patients and providers together to co-create primary care settings through the lens of relationships, and an eye on convenience for citizens and work-life balance for clinicians. 

Our sights are set on developing a model of whole-person, collaborative care that is sustainable within fee for service, while doing everything we need primary care to do for patient, provider and community health.  Our preliminary business case shows that our primary care clinics can achieve twice the capacity, offer more convenient and timely access, and work upstream, supporting patients to address their social determinants of health.  You can check our progress at, or follow us at @VancouverCHI. 

It turns out that it’s easier to reimagine primary care than we thought:  all we have to do is listen to what’s important to the people at the centre of the system!

Thank You Nurses…Now, Can You Do More?

National Nursing Week is in full swing in Canada, and it’s crucial to recognize the tremendous contribution nurses make in all areas of health care.   I’m happy to see so many people singing their praises…and rightly so!  But, despite their great commitment and healing impact, I think nurses can play a stronger role in health care.   

I have never met a health care professional who thinks that the system can’t be improved, and nurses know that the system would be better if they could do more for patients, alongside their clinical colleagues.  In fact, if we want to provide quality health care to our children and their children, we will need nurses to play a stronger role, particularly in primary care settings like the family doctor’s office. 

A new study from the Canadian Academy of Health Sciences explores the clinical division of labour that will support a health care system that serves all Canadians.  The report is called “Optimizing Scopes of Practice:  New Models of Care for a New Health Care System.”  The upshot of their analysis is that the current, limited range of activities for nurses and other regulated health care professionals is more a result of past practices and politics than evidence or even legal rulings of clinical responsibility.   

The limits exist despite the broad training that we offer nurses.  As one of the report authors, Ivy Lynn Bourgeault says, when it comes to nurses and other professionals, “we train and then constrain.”   This means that nurses are capable of taking on a wide range of roles, but are then limited when they enter the workforce –by the expectations that have developed through decades of habit and politics. 

The report calls for us to approach the issue of “scope of practice” from the dual perspective of flexibility and accountability.   Its authors argue that we need to develop roles that are based on patient and community need, rather than habit and historical pattern.  They also suggest we see the issue through the lens of “optimal scope of practice,” so that team-based clinics can evolve the best division of labour based on clinicians’ relative competencies, and aimed at meeting the health needs of their panel and the community.

I witnessed this dynamic several years ago when BC was developing its initiative to increase the availability of Nurse Practitioners.  A group of physicians and nurse practitioners spent over an hour demystifying their clinical roles, revenue sources and range of activities to each other so that we could lose our assumptions and approach the integration of nurse practitioners from a new perspective.  My fear is that as the cost of health care systems rise, we may not have the luxury of limiting this dialogue to small group discussions.  We need a critical mass of innovation to introduce interdisciplinary team-based care if we want to bend the cost curve in a meaningful way. 

In my recent blogs, I describe how doctors doing less of what we have come to expect, can result in better and more convenient access to quality primary care treatment and prevention.  This is only possible if we reimagine clinical culture and workflow from a fresh perspective that defines “scope of practice” through the lens of patient health and safety, provider wellness and system sustainability.   I think that enabling the full range of activities that nurses can do to keep us healthy should be a priority for all of us who appreciate what nurses already do! 

In my next blog, I’ll describe governance and collaboration models that will help move these changes forward.  In the meantime and if you’re interested, you can find the Executive Summary of Optimizing Scopes of Practice here:


Why Doctors Working Less Means Healthcare Can Deliver More Part 2

In my previous blog, I described one perspective on how health care can do more with less…or more precisely, how inter-professional collaboration will improve access to family doctors, improve quality of care and create work places where many young doctors (and other clinicians) want to practice.

Dr. Kristy Williams is another BC-based family physician resident who sees a future in team-based care for a different reason:  she envisions new models that enable her to provide the kind of care that prevents people from having to visit their doctor in the first place!

Kristy realizes that there are limits to what a doctor can do – especially if we look at our health care system as means to balance both patient health and clinician self-care.  By working as part of a team with nurses, pharmacists and patient advocates, she feels well have a better system for everyone:  “We should be looking at models where patients feel better supported and have the tools to follow through on treatment plans. Research shows that up to 50% of patients dont fill their prescription.  Do we know why this is the case? We need get more patient involvement and feedback to help identify how care can be more appropriately delivered and I think that means breaking down the idea that working solo is best.  ”

Kristy feels that if we are able to do this, well be better able to assist patients to achieve health, and more importantly, to maintain health:  “If we address discrimination between types of clinicians with different training we will be able to focus on what we all bring to the care of the patient.  I’m personally inspired how we could mobilize upstream interventions, like using community gardens, art and social programs to prevent illness.”

Like many younger doctors, Kristy sees the fee for service payment model as a barrier to providing this kind of care: “Fee for service takes away from the focus on the patient, and its not sustainable because its not fulfilling for many physicians entering the profession.”  By encouraging limits like “1 problem per visit” it moves us away from providing truly comprehensive care and solutions that fit the life circumstances of people outside of the clinical setting.

From my conversation with Kristy and other younger doctors, we have an opportunity to shift our primary care system towards more and better care, with doctors working as part of a team and sharing responsibilities.  This reduces the burden of care solely on physicians…in other words enabling more to be done with less. In my next article, Ill be speaking with a young pharmacist who sees his future as part of a team with doctors and nurses.   I will also describe a new initiative that will develop models of care to increase physician and practice capacity by involving citizens in their design and operation. 

What do you think about a future where health care delivers more with less?

Why Doctors Working Less Will Mean Healthcare Delivers More, Part 1

It sounds like a contradiction to say that someone working “less” will do more, but in primary care that may be the case.   Currently there is a culture shift happening among family doctors – many younger doctors don’t want what the previous generation had: responsibility for opening and operating their own family practice clinics where the doctors are supported by a receptionist, but otherwise do everything from soup to nuts.

I sat down with Dr. Daniel Heffner, a pharmacist and now family practice resident in Vancouver.   Dr. Heffner is currently working in one of VCH’s Community Health Clinics, and looking forward to his career as a family doctor. Beyond his talents as a clinician, Daniel is also a virtuoso flamenco-fusion guitarist.

Daniel identifies himself as part of a new breed of family physician who loves being a generalist but doesn’t feel like it’s possible to do everything perfectly for every patient on his own.   Daniel says: “providing care is so complex now.  For example, prescribing used to include detailed knowledge of only a few categories of drugs, but now the number of new medications, complex indications and the circumstances of every patient make it challenging even for specialists to make the best decision within their area of expertise.” 

Another issue we discussed is a culture change among many young doctors.  Younger doctors want to have a healthy work-life balance and time to raise their children, something that is difficult when doctors have responsibility for operating a health care business business and providing comprehensive care for their patients, with little or no support.   

So how will it be possible for family doctors to provide the best care as a generalist in an age of great and increasing complexity?    And how can we have a system that provides more care to more people with more complex conditions, when many in the next generation of GPs wants to do less of what we have come to expect of family doctors?

A new way of providing care can help us achieve more with less, according to Daniel. Working as part of a team that includes physicians, nurses, pharmacists and other care providers will bring a range of expertise to the diagnosis and treatment of illness, so fewer errors will be made.  We discussed primary care settings where nurses will be a core part of continuous care, by being an initial contact and supporting the patient’s treatment plan.  Pharmacists will use their specialized expertise to determine the right medicine for each person’s personal and health circumstances. 

In this situation, doctors can focus on what’s important – the continuous care of the patient, the diagnosis of disease, and the best course of action to treat the patient and their illness.     With a team of providers available, patients can get easier access to the care of their family doctor, avoiding trips to a walk-in clinic or emergency department.

It’s not just about adding more clinicians to the mix – doctors will always be the lead in diagnosing and prescribing treatment.  The change requires working in a different way so that doctors can be freed up to focus what’s important.   Daniel thinks that’s good for him, that it’s the way that many clinicians want to work, and it will ensure quality of care and access for patients.

Daniel points out that “the new generation of doctors are still Type A:  we want to be all things to all people.   But now we realize that better care for patients results from involving the patient and other care providers.”  Working in this way strengthens the doctor-patient relationship because “the doctor is able to focus on what’s most important to the patient.” 

Daniel also wants you to help figure out the solution.  He says: “Society needs to decide what kind of care they want, and then help make it happen.  Do people want access, shared care, community health centres?  Do they want a situation where doctors operate as a business?  There is an opening for citizens to get involved in shaping the health care system.”   

The time is right for new primary care models that will improve access and be functional for the younger generation of clinicians.  In my next article, I’ll discuss how new models can expand the range of preventive services provided by a new generation of team-based clinics to improve wellness.

Incidentally, Daniel is also a virtuoso flamenco guitar player – you can check out his videos at or catch him live in Vancouver or Calgary.



Why Social Enterprise will Help Save Healthcare in BC

A woman in my neighbourhood was diagnosed with late stage colon cancer by a doctor a walk-in clinic.   She was given two years to live, and recently passed away after three years.  The reason she was diagnosed too late for medical intervention?  She couldn’t find a family doctor. 

In Vancouver where I live, over 120,000 people don’t have a family doctor, and another 25,000 arrivals are expected each year.  That means the problem will get compounded, as new arrivals to Vancouver are the least likely to have a doctor – even after being here for 10 years.  

Who will solve the problem?  Getting family doctors to take up the slack is unrealistic for two reasons.  First, they are already working at or over capacity.  Second, even if each doctor in Vancouver took on another 150 people as patients, their patients would have to wait longer for an appointment.   We could recruit and retain more doctors, but those efforts would only solve the problem for a short time.

What we need is innovation in the way that primary care is provided, to multiply the impact of the doctors we have now.  Most system experts believe that involving nurses and pharmacists as part of a team of care, is the best way to increase access to family doctors without increasing costs to the system.  After all, it is comparatively expensive and time-consuming to train doctors, so increasing their efficiency through team-based care is a good long-term investment.

However, consider that changing to team-based care requires a different business model, and we can’t expect family doctors – who are at the same time business owners – to absorb the risk of changing their model of care in BC…If a family doctor hires a nurse to help provide care, they have to pay their salary and risk reducing their main source of income.  Some are ready to take on this challenge, but many are not.

Enter the social enterprise: non-profits that embody a hybrid of business and community values that have the ability to change the game.  Social enterprises can absorb the risk of exploring new models of care.  Good ones can imagine, build and operate family practice clinics in new ways, so that doctors can focus on doctoring and more people can have a family doctor.  If done well, we could find a model that ensures that our children will have a strong health care system as well.  

Examples are already out there.  REACH and Mid-Main are non-profits that have operated interdisciplinary care models for decades.  There are community dental clinics that have found a way to remove the barrier of cost for low-income individuals and families using a business model that reinvests any profits into free treatment.   In White Rock / South Surrey, a non-profit clinic operated by a group of family doctors and Fraser Health, has helped to make a primary care provider available for everyone…without family doctors having to shoulder the entire burden themselves.

BC’s healthcare system is being pressed from all sides.  We need enterprising non-profits to help us find new ways of making a continuous relationship with a primary care provider accessible for everyone.

In my next blog, I’ll describe how the next generation of primary care providers have the right stuff for saving universal healthcare in Canada, partly because they will work shorter hours than previous generations of family doctors.




Playing with our future

Canadians repeatedly and proudly say that our health care system is the most treasured piece of our cultural identity.  Some say it’s our highest expression of how we care for each other.  But what role are we really playing in maintaining the health of the health care system?  Like most aspects of democracy, our role is in transition, and I’d think we can find better ways to put citizens at the centre of health care.

Great efforts are being made to involve people in maintaining their own heath care, improve the planning of health care initiatives and the processes that patients are given so that they can have better health.   But the complexity of the system is a big barrier to getting a wide range of perspectives.  It's complicated, filled with political and professional tension, and very expensive.   Because of this, we often feel that people who have specialized knowledge about how the system works are the only ones who can provide informed input into changing the system.  At the same time, many doctors I work with want to get input from people who have no specialized knowledge of the sector, or the workings “behind the curtain.”   They want to understand how the impact of changes that make the system work better for providers will affect their therapeutic relationship with patients and their patients’ families / caregivers.

Many are looking to expand the range of ways we engage people in improving the health car system.  New apps engage people in playing games that inform them about ways to improve their health, and connect people with others facing the same chronic conditions.   There is evidence now that millions of people use a health app on a regular basis, and while they might not increase diagnostic abilities, they play a role in raising awareness of habits that improve our wellness

Improving the system so that it is sustainable requires that we close the loop on citizen engagement even more profoundly than we do now through surveys, public health announcements and engagement programs.  After all, we’re not just the beneficiaries of and believers in the system.  We’re also ultimately the funders.

I’ve been looking at ways we can involve people in designing a system that works for us and for care providers, without requiring specialized skills.   As much as the health care system is complex, there are patterns in the behaviour of system elements that can be understood and interrupted.   People can understand complexity if it’s presented to them in a way that is meaningful.  Gamification shows us that we need to think outside the box for ways to connect, engage and improve our collective responsibility for a system upon which we all rely.

In the next month, I’ll be offering an opportunity for people who know the system well – patients, professionals and policy-makers – to create a shared pool of knowledge about how we all respond to changes in the system.  Then I’ll be asking game designers and coders to build a tool that helps us to play, explore and discover new potential in our health care system…stay tuned!