June 28 2012

I’m delighted to have been invited to join the panel at this event organized by the Canadian Federation of Nurses Unions. As the Premiers gather down the street here in Halifax at their Council of the Federation meeting on the general topic of health and the specific topic of health innovation, it is certainly timely for your Federation to discuss and make your important voice heard on these same issues.

Let me begin by saying that in my view, families, schools and communities stand or fall on the shoulders of seven professions: child care workers, social workers, teachers, police officers, general practitioners, correctional service officers and, of course, nurses. Members of these seven professions are generalists serving exceptionally large and diverse populations. Parents, principals, mayors and the population at large rely and depend upon their collective experience and intuition to step in and step up when problems arise. When any one of these professional groups ceases to function coherently and professionally, there is breakdown.

I want to take nothing away from the value of specialists, the technicians, the managers and the executive leadership in terms of human problem solving. However, it is at the front lines where the “Big Seven” professions work that, by far, the largest number and greatest variety of human problems are dealt with.

We’re lucky in Canada to have such a remarkable corps of quality, competent and ethical professionals serving our communities. Unfortunately, too often these groups are asked by the systems within which they work to focus exclusively on urgent human needs. For example, how many nurses get to work on promoting the health of their patients or even intervening meaningfully with families to work on why there are so many child visits to the ER?

How many police officers get to play some basketball with the Grade 9 kids in the inner city school where there’s repeated gang and drug issues?

How many correctional officers get to mentor young offenders and create the meaningful relationships and role models they so often lack outside the institution?

How many teachers are given the latitude during school hours to work with a student on his or her behavioural issues together with the child’s parents, social worker and community health worker?

Madame Michèle Rouleau was invested a few weeks ago with the Order of Canada for her work with First Nation Peoples. In an interview regarding the award, she said that although she was honoured to be made a member of the Order, “It’s not a happy time. We can’t pretend everything is alright.” As an example, she cited the Northern Ontario community of Attawapiskat. She said that the federal government’s recent announcement of funding to improve housing on the reserve was a “stopgap” measure that “does nothing to solve the underlying economic and social problems in communities across the country.”

My point’s the same. Though our professionals are quite capable of dealing with urgent issues through stopgap measures, our systems to a large extent don’t allow or organize them to focus on getting to what’s underlying the emergency. Our professionals are like ambulances at the bottom of the cliff when, to a much larger extent, they must be at the top of it. Another way to say this is that we have an excellent system of illness care and a poor system of health care.
I wrote an article recently on these matters using the language of the Fram oil filter company. In the early ’80s, the company came out with an ad that said “You can pay me now for a Fram oil filter, or you can pay my mechanic later to fix your car (at a much greater expense)”.
The same is true in our health and social services. We can pay now for early intervention services or we can pay later for “last resort” expensive emergency services.

Please don’t misunderstand me. Of course we’ll always need ER nurses, SWAT teams and special needs teachers. However, in a “pay now” world, these services would be the exception, not the rule.
Who benefits from a “pay now” approach to health and social services? Everyone.

Research is making increasingly clear that vulnerable children, teenagers with early onset psychosis, adults with disabilities, a person with signs of dementia all have better lifetime outcomes if our professionals, using appropriate risk assessment tools, intervene early in an evidence-based way to provide support and guidance. And, it’s never too late to intervene early. For example, we know that effective intervention with young offenders decreases the risk of re-offending and therefore decreases government spending over the life course of the youth.
Families benefit by not having to devote the same time and effort to caring for a family member in trouble.

Communities benefit by having more volunteer resources and less conflict and crime.

And, of course, governments benefit as “pay now” services are less expensive over the citizen’s life course than “pay later” services.

Are these just daydreams? No. Let me give you four examples of these ideas being put into action, two from New Brunswick, one from Quebec and one from here in Nova Scotia.

Firstly, New Brunswick’s child welfare system was overhauled over the last five years to implement a “pay now” approach. The reform, entitled “New Directions,” funded the hiring and training of new social workers, to intervene to support families with early signs of distress. Instead of waiting until the family has completely broken down and the child has to be removed through judicial proceedings, these new social workers are able to work with families to stay together and avoid further stress.

These family enhancement services combined with family group conference, child mediation and kinship care are starting to pay off. The number of children coming into care is falling like a stone. Foster care costs are falling dramatically as are legal costs. These savings are being funneled into further early intervention services which should themselves produce further savings. Last resort, panic type interventions will soon become the exception to the rule. “Paying now” is paying off.

Secondly, under New Brunswick’s ground breaking bi-partisan poverty reduction plan, entitled “Overcoming Poverty Together,” important investments continue to increase both economic and social inclusion in the province. The most recent such investment was just announced last month, when almost $5 million was set aside to fund a vision and dental program for low-income children. Working families with limited family income will now be able to access preventative dental and vision care for their kids without having to turn to the social assistance system for help. Parents can continue to work and their kids, now that they can read the blackboard and get their fillings, have a reduced lifetime risk of themselves having to turn to social assistance when they become adults.

Thirdly, Quebec’s remarkable universal early learning program, known as “$7.00/day daycare,” is strongly associated with better child health outcomes and school readiness. As important, it pays for itself. The income tax revenue generated by a combination of new child-care workers and parents who choose to work totally covers the approximately $2.5 billion cost of the program.

Finally, Dr. Stan Kutcher’s work here in Nova Scotia in training teachers to identify, intervene and refer high school students demonstrating signs of early onset depression or psychosis is seminal in terms of preventing lifelong episodes of personal and system stress. In light of the fact that at least 70 per cent of mental health problems and illnesses begin during childhood or adolescence, it’s clear that school-based early detection, referral and treatment can save the system uncounted millions of taxpayer dollars if such programs become part of the wider health-care system.

These are only a few of many examples of the new social safety net we need to build, one that is not so low that vulnerable Canadians can’t climb back up onto the wire of their life and live their dreams, not their nightmares.
Creating a high social safety net across the health and social services is possible. The Premiers meeting down the road are in the most powerful position in the country to begin making a meaningful transition to a new and better 21st century welfare state.

In 2014, the federal and the provincial governments will be renewing many transfer agreements including the Canadian Health Transfer, Canadian Social Transfer and the Affordable Housing Agreement. I think it’s important to include the language of and commitment to early intervention in these long-term agreements, in the same way wait times were focused upon in the last health transfer agreement. As nurses are the primary caregivers not just of patients but of the health care system itself, who better to make a big push for systemic change that improves patient outcomes and saves money.

Good luck to you and good luck to all of us.

James Hughes is the President of the Graham Boeckh Foundation in Montreal and former Deputy Minister of Social Development for the Province of New Brunswick.

New Brunswick Telegraph-Journal