Engaging citizens and doctors to improve access to healthcare

After the provincial government announced a new aim to enable everyone in B.C. to have a family doctor, the local organization interested in this found itself with a unique challenge.  Vancouver is the third-largest city in Canada and statistics available showed that its citizens were the least likely in the province to have a GP.   Furthermore, the limited pool of 800 active family doctors was inundated by over 100,000 regional commuters daily, 3 million tourists yearly and 80,000 temporary residents, such as international students.  How could they come up with a plan to increase the efficiency of primary care by between 5% and 10%?

The Vancouver Division of Family Practice, a non-profit run by and for doctors engaged think: act consulting who helped to build and implement a process that would see almost half of the city’s family doctors and several thousand residents of the city help to build a plan for improvement in which everyone would participate.  We started by grounding the work in values that would guide an inclusive public process (see the Charter here).

After getting buy-in and support from the health authority executive, (health authorities operate hospitals, acute care and public health in BC), think: act consulting built a plan to engage groups of doctors, and health administrators in a collaborative process of imagining, planning and then implementing a new approach to primary care in Vancouver.  The key was to reframe the issue to focus on relationships rather than wait times.  

When we brought 300 doctors and health authority staff together to talk about the importance of relationships with patients and with each other, they found a common language and focus, and came up with 22 strategies for increasing system efficiency and access to family doctors that included over 70 potential action steps. The theme of relationships was equally powerful in eliciting constructive responses to those strategies from citizens, over 1000 of whom filled out an online survey, while marginalized groups got involved through a dozen “kitchen table” events. 

While academics have long struggled to bridge the gap between public participation and decisions about allocating resources, we resolved the problem by assessing the extent to which citizens would change their care-seeking behaviour given the choices set out by subject matter experts.  For example, we found that people would prefer to seek care from their own family doctor instead of going to a walk-in or emergency department...if they had the choice.  So we recommended support for primary care clinics to adjust their scheduling approach which would improve patient-doctor relationships, reduce demand on acute care settings and cut down on duplicate visits to walk-in clinics.

In order to work, we knew the plan needed to be simple as well as imaginative, grounded in proven research and responsive to participants.  After assessing ideas against existing evidence for effectiveness, we eliminated those that could lead to duplication of existing work.  We were left with 11 strong, innovative ideas that were then reviewed by a committee of the board.  The next step is to seek funding to implement and evaluate the plan, and the fact that half of the local family doctors and thousands of citizens  feel that the ideas reflect their best thinking on therapeutic relationships, makes it likely that soon in Vancouver, more people will have a family doctor.

Take-aways: 

-       people can understand and give informed input into complex adaptive systems, if the framing of the issues is meaningful and personal.  By framing the issue around relationships, doctors, citizens and other health professionals were able to see each others’ challenges in a way that made empathetic and value-focused dialogue possible;

-       people are willing to make trade-offs to achieve social goals.  In our survey, both doctors and patients were interested in changing how they seek or provide care, so that people without a family doctor could have one.

-       There is a need for a tool specific that helps people visualize the impact of changes in complex adaptive systems like health care. Taking an intimate concept like a well-defined therapeutic relationship can help people to change their patterns of care-seeking and care-providing if they can see the impact of change on the system.  We have since built a company which is currently developing an interactive tool to fill that gap.

-       Big, public processes are difficult.  Our client took a courageous step to take a public and inclusive approach, but moved the final decision-making process to a small internal team rather than taking advantage of the momentum generated by the involvement of thousands in the strategy-generation phase.  The upside is quicker decision-making and access to funding, but the downside could be lower levels of uptake and reduced behavioural change among practitioners, service providers and citizens.