Workforce planning, training, and regulation

This issue was particularly focused on the actions and policies of government, educational, and professional bodies. In addition to integrated forecasting models (aging of the population) for the future workforce configuration (and the data needed to serve them), difficulties were identified in training for interdisciplinary teamwork and the regulation of scopes of practice (particularly as they relate to primary healthcare and non-acute settings). The value of expectations by professional regulatory groups for increased educational preparation was questioned by many. Some also pointed to the potential relationship between the increased educational preparation time being demanded (sometimes referred to as "creeping credentialism") and the shortages in the healthcare workforce, as well as the relationship between shortages and concerns about the system's quality of care and patient access.

Healthy healthcare workplaces

This issue was particularly focused on the actions and approaches of employers, unions, and professional associations. Effective teamwork and interdisciplinary collaboration also came up in this context, but with more of a focus on the relative status of different professional groups, organizational structures, and management approaches as the barriers. In addition, attention focused on the need to nurture the next generation of professional leaders, and to provide more substantive opportunities for in-service and continuing education. Concern was expressed about the emerging generational gap in which newer members of the workforce had higher expectations for balance between home and work lives. There was some concern about the health and safety of the workplace. There was a desire to identify more effective recruitment and retention practices, especially for rural and remote communities. Finally, innovation is sought after in the skill-mix of healthcare professionals in a variety of delivery settings.

Timely access to quality care for all

This was a large and recurring theme that embodies concerns about quality (including patient safety), timely access (waiting times, waiting list management), access for those living in rural and remote regions, and access for minority groups of all kinds.

Timely access: Access to all levels of care for all and reducing the barriers for certain groups (such vulnerable and minority groups).

Quality management: A link was drawn between achieving improved quality at an affordable cost and more extensive use of performance indicators, population-based and institution-specific evaluation of patient outcomes, and technology assessment. Finally, improved methods for assessing population needs was linked to potentially improved access and quality for minority groups with many unmet needs.

Creating, managing, and assessing public expectations

Although issues raised here are clearly linked to sustainability, the area was deemed worthy of separate consideration. At one end there are concerns about demand creation, and the impact of direct-to-consumer advertising and other signs of increasing marketing and entrepreneurship in the health sector. A need was identified for support of evidence-based decision-making by patients and the public, and for greater use of public and community engagement as a communication and values assessment tool, as well as a way to get the public involved in decision-making. The role of government as a guarantor of information was raised, as was the media's role in influencing public opinion and the lack of research literacy by the media and public for interpreting research results. Finally, the provision of information to the public was linked to better understanding of the broad determinants of health and changes in individuals' self-awareness and ability to take greater control of their own health.

Sustainable funding and ethical resource allocation

Concern with this issue focused on raising adequate revenue as well as defining the services to be covered by public funding. There was interest in ethical processes with public engagement to make tough allocation choices, in particular processes that elicit public values at national, regional, and local levels to determine public coverage. There was also concern for institutional-level ethics, especially in decisions affecting the healthcare workforce or access to the system for minority groups. There was some suggestion that the key to future sustainability lay in better exploration of its links to full implementation of primary healthcare, better chronic disease management, and policies to improve the use of pharmaceuticals in the system.

Governance and accountability

The focus on performance indicators was at all levels of the system, from individual practitioners through institutions to regions, provinces, and all levels of government. The need for much-improved performance assessment outside institutional settings was highlighted, particularly for primary healthcare and other forms of community-based care, with calls for more attention to population-based assessments of health and a better balance on privacy concerns for data use. There was an overall interest in assessing on a routine basis whether we are getting value for money in the health system, and whether the size of the resources put into the system was warranted based on what we got out of the system. The increasing role of public-private partnerships was seen to need a commensurate increase in the sophistication and extent of performance assessment for monitoring and compliance purposes. This was related to better evaluation of the appropriate governance and overall value of public-private partnerships. On the governance level there was also continued interest in exploring issues of regionalization, such as the appropriate size and structure of regional health authorities, the value of regional networks, and other forms of regional system integration and co-ordination.

Managing and adapting to change

On this issue there was a demand for better tools to bring about change at the system-level, particularly in breaking down the organizational and professional silos that characterize healthcare. Also, the difficulty in adapting the system to external forces was noted, both for short-term issues such as health emergencies and long-term changes such as demographics and disease patterns. A lot of faith was placed in the development and more widespread use of the tools for evidence-based decision-making, such as information systems, technology assessment, models of risk management, sharing of information and best practices, and the development of networks and other research and knowledge translation mechanisms.

Linking care across place, time, and settings

The dominant focus in this issue was the need to significantly improve chronic disease management, and the potential value of primary healthcare as the vehicle to achieve this. There was a demand for the creation of new models of integrated service delivery that documented and balanced the relative value of public versus private delivery. There was also interest in the consequences for care-giver burden of adopting different service delivery models, and better documentation of the evolving role of informal and voluntary care. Potentially valuable roles were highlighted for home- and community-based technology, such as home health monitors, and social programs, such as care-giver support. The focus needs to be on models for rural areas, different socio-economic groups, and different cultures, not just on models for traditional urban areas. Finally, attention is needed for training and workforce development to increase the capacity for this kind of service delivery.

A final note on population and public health

The focus of the consultations was on healthcare services. Nevertheless, some participants raised the importance of population and public health, especially the interaction between these areas and eventual need for and use of healthcare services. Besides the obvious link between public health emergencies and the consequent surge capacity needed in healthcare services, issues were raised such as the reduction in pressure on healthcare resources if more effective disease prevention and health promotion services were implemented. The impact of complementary and alternative medicines on the population's health was raised as a burgeoning issue. Finally, the public health workforce was seen as being poorly integrated into the system; hence there is a need for incentives and professional alignments to increase their roles as functioning members of the healthcare team. Particular emphasis was put on improving health and reducing health disparities of minority groups.

These issues will be brought to the attention of the Institute of Population and Public Health in the Canadian Institutes of Health Research.