Chapter 12: Emergency Medicine’s Future Role in Health Policy and Advocacy
Background
Emergency department closures and crowding, with their potential lethal consequences, are garnering media attention across the country. [2] Building on shared national goals, it makes sense to have a coordinated effort to address these issues, and that is the purpose of this report, clearly articulated in our overarching recommendations.
But it will take more than words—however well-intentioned and informed—to produce meaningful change. That is where engagement in policy, public affairs and advocacy begins.
Healthcare in Canada is largely under provincial jurisdiction. The Canada Health Act provides conditions for federal health transfers to the provinces for hospital and medical care, but each province organizes and operates its own system within the very broad parameters of the Act. [1] Despite regional differences, however, healthcare shortfalls are widespread across Canada and similar in nature from province to province.
The Role of the Emergency Department in a Dysfunctional Health System
EDs fulfill a unique but increasingly difficult role in the health system. Through the patients they see, emergency physicians are witness to a host of social and health system ills that give them unique insights into the system and its failings.
The oft-used metaphor of the ED as the canary in the coal mine [3] is unfortunate, as it paints a picture of emergency staff as passive and reactive. The EM:POWER message is that ED professionals have the agency, credibility, and experience to be proactive, because we work at a critical healthcare intersection, the junction between community, prehospital, primary, and acute care. We provide services ranging from resuscitation to public health to geriatrics. EDs are the decision point for most hospitalizations, a gateway to urgent imaging, surgery, specialty care and critical care.
We are the only open door for many complex and marginalized patients and for growing numbers of those unable to access the right care in the right place. ED providers have a unique system perspective, a view of many possible pathways, including promising future directions. In that new construct, emergency physicians can be powerful agents of change, observing, anticipating, and responding to the health issues of the day, with a voice that resonates across the entire medical system.
How Can this Report be Used to Create Health Policy?
This report invites healthcare stakeholders to recognize the importance of EDs as barometers of overall system health, and emergency physicians as repositories of health system expertise. However, for any system to be functional, there must be an ever-present focus on purpose. We believe the Quintuple Aim [4] is the best framework to guide healthcare policy, and we’ve used it to inform the development of the EM:POWER report and recommendations.
Detailed action plans that cater to population needs will be essential to ensure the report has ongoing value. These are largely the purview of provincial health authorities and Emergency Care Clinical Networks [5] which we recommend be established to lead and coordinate clinical services and HHR planning. The report itself provides the framework and flexibility to allow local autonomy and decision-making; but the federal government holds a key coordinating role to connect provincial/territorial leadership from across Canada to help address common challenges. These include crowding, closures, and Health Human Resources (HHR) as well as to facilitate the establishment of accountability frameworks and disaster preparedness.
It is important for decision-makers to realize that the journey to a more cohesive and functional system will be daunting, take time, and will not conform to political cycles and exigencies. Strategies arising from this report must be based on a clear, depoliticized, long-term vision, with short, medium, and long-term objectives. This avoids the one problem, one solution trap that ultimately fails and reverts to emergency backlogs.
The Practice of Emergency Medicine and CAEP Advocacy
Advocacy can be an important part of an emergency career, giving a sense of agency and connection to the larger problems that underlie our daily work lives. Organized emergency medicine can provide a powerful platform for addressing societal needs that manifest first or frequently in our EDs.
Beyond the current focus on crowding and closures, CAEP has also articulated positions on topics such as violence in the ED, opioid use disorder, gun control, intimate partner violence, homelessness, and care of the elderly. In addition, our organization is currently leading advocacy for national red flag laws to protect those at imminent risk of harm, such as victims of intimate partner violence, those with mental health disorders and the elderly. [8] These topics are linked by way of their prevalence in vulnerable populations or those suffering health inequities. All visit our emergency departments, often feeling they have no other recourse.
During the first year of the pandemic, nimbleness was the order of the day, and a small kitchen cabinet of CAEP executive and public affairs leadership developed 18 position statements and communiques related to COVID-19, along with hosting over 40 media events. [7] This work was essential to preserving and protecting emergency staff, and to ensuring our patients continued to have access to emergency care.
In a post-pandemic world, access block, and the resulting negative impact on patient health and mortality will dominate the discussion for the foreseeable future. [8] While ED crowding has become an international problem, as we emerge from the pandemic this has been particularly chronic and intractable in Canada. The problem is covered extensively elsewhere in this report, but the necessary changes will only come about if we have effective emergency medicine champions to engage with planners and decision- makers, within and beyond medicine.
Training Future Leaders in Public Affairs
As the EM:POWER Task Force formulated this report, we were frequently asked, “Who is this report’s target audience? Those providing care in the ED or those outside it?” While our proximate audience is within healthcare, the ultimate drivers of change are those who consume it, the citizens of Canada, our patients. They will demand system improvement through their publicly- elected officials. The importance of public affairs to emergency care thus becomes self-evident.
Succession planning is important in any political sphere, and this is no different. There are notable emergency physician public affairs thought leaders, who for decades have increased emergency medicine’s profile and advanced its priorities. However, there is little to no formal education in public affairs within EM training programs, even though those in the ED are inextricably linked to, and impacted by, health policy. EM training programs would therefore do well to include such training within a larger Health System Sciences curriculum [9] to nurture the next generation of public affairs leaders.
Recommendations for Emergency Medicine’s Future Role in Health Policy and Public Affairs
CAEP should actively engage with federal /provincial/territorial ministries, health policy experts and medical organizations to promote the report and its recommendations.
Provincial ministries of health should fund and enable Emergency Care Clinical Networks (ECCN) and integrate them with the broader Healthcare system governance structure.
The Provincial/Territorial Council of Deputy Ministers of Health should establish and fund a National Emergency Care Council to provide expert advice to each provincial ECCN; connect/coordinate provincial leadership from across Canada to help address key challenges (e.g., crowding/closures/human health resources); and assist in the development of accountability networks and disaster preparedness.
CAEP should continue alliances with organizations who share their goals and objectives such as CMA (Canadian Medical Association), NENA (the National Emergency Nurses Association), IFEM (the International Federation for Emergency Medicine), the Society of Rural Physicians of Canada (SRPC), and the Coalition for Gun Control.
EM:POWER’s framework recommendations should be presented to provincial and regional ECCNs as a basis for system redesign at a more granular level, based on local population health needs and resources.
EM training programs should include public affairs as part of a Health Systems Science curriculum, to educate residents and nurture the next generation of public affairs leaders.
References
The Canada Health Act: An Overview [Internet]. [cited 2023 Sep 20]. Available from: https://lop.parl.ca/sites/PublicWebsite/default/en_CA/ResearchPublications/201954E
Contact AFCNNMCF|. CTV News. 2023 [cited 2023 Sep 20]. Three stabbed teens were driven from a party to a nearby hospital, only to find that the ER was closed. Their story is one of many. Available from: https://www.ctvnews.ca/health/three-stabbed-teens-were-driven-from-a-party-to-a-nearby-hospital-only-to-find-that-the-er-was-closed-their-story-is-one-of-many-1.6545043
Kelen GD, Wolfe R, D’Onofrio G, Mills AM, Diercks D, Stern SA, et al. Emergency department crowding: the canary in the health care system. NEJM Catalyst Innovations in Care Delivery. 2021;2(5).
Nundy S, Cooper LA, Mate KS. The Quintuple Aim for Health Care Improvement: A New Imperative to Advance Health Equity. JAMA. 2022 Feb 8;327(6):521–2.
Abu-Laban RB, Christenson J, Lindstrom RR, Lang E. Emergency care clinical networks. CJEM. 2022;24(6):574–7.
Position Statements [Internet]. CAEP. [cited 2023 Sep 6]. Available from: https://caep.ca/advocacy/position-statements/
Breaking News [Internet]. CAEP. [cited 2023 Sep 20]. Available from: https://caep.ca/breaking-news/
Varner C. Emergency departments are in crisis now and for the foreseeable future. 2023 Jun 19;195(24):E851–2.
Gonzalo JD, Chang A, Dekhtyar M, Starr SR, Holmboe E, Wolpaw DR. Health Systems Science in Medical Education: Unifying the Components to Catalyze Transformation. Acad Med. 2020 Sep;95(9):1362–72.