Thread by @jwnickerson

My PhD thesis research focused on analyzing disrupted health systems, and I've spent most of the last decade working in humanitarian response. Here's a thread with some thoughts on what's happening in Ontario:

Health systems are not just the delivery of health services, though that's the point at which most of us interact with the health system (receiving health care). To be able to effectively deliver health services, you need a lot of other things to be in place and functioning.

That picture 👇 is the WHO's health systems framework. The things on the left are generally-agreed upon blocks that need to be in place to be able to run a health system. It's not perfect, but it's a helpful organizing framework that can guide planning and analysis fairly well.

Health systems are complex adaptive systems and each of these building blocks can tolerate a certain amount of dysfunction without the whole system collapsing: Some drugs can be substituted for each other if there's a shortage; some staff can be re-allocated somewhere else, etc.

There are obvious limits to this tolerance. At some point, the distortions and dysfunctions in the building blocks become too large and the coping mechanisms and work-arounds no longer suffice. Staff burnout, meds no longer available, etc. When this occurs, a few things happen:

Most health information systems are not suited or adapted to be able to provide the information and analysis that's required to make decisions in large-scale emergencies. They weren't designed for this and they often provide too much or too little data to make sense of.

Key point here is that analyzing disrupted health systems requires enough information to make reasonably well-informed decisions. This is not long-term health systems planning where you can spend months analyzing data. You need to make rough sense of shaky data, and move quickly.

For example: How many beds are available, what services can be provided, etc. Ontario seems to have a decent system for doing this through CCSO; making decisions about resource-sharing in other areas (e.g. health human resources, equipment, etc.) is perhaps a different story.

It's really in some of the other building blocks that we're seeing the most significant distortions that are straining our health system:
Demand for health services specifically related to COVID is increasing;
Our health workforce is strained;
Medical supplies are a mixed bag;

Each of these requires an in-depth analysis to explain what's going on, but in the simplest of terms: we don't have enough of any of these building blocks to sustain a long-term surge.
This is not the kind of surge that Canadian hospitals are experienced in managing.

This past week, there's been a lot of focus on our critical care health workforce - RNs, RTs, MDs, and others - and I agree completely that this is where our focus needs to be. People are tired. There are not enough of them in many hospitals.

It seems that the plan in many places has been to ask staff to work significant amounts of overtime, back-to-back shifts, etc. This is the kind of dysfunction that can be tolerated for a short amount of time, but not long-term. We're burning staff out, and the system will fail.

More than a year ago, @DreJoanneLiu wrote in @globeandmail "Our health-care workers are our best and last line of defence in a pandemic. For their sake and ours, we need to protect their physical and mental health." This is critical in Ontario today. theglobeandmail.com/opinion/articl…

Without a properly trained health workforce available in adequate numbers, the system will fail. It's that simple.
We're not out of the woods yet in the other building blocks, though, and I think we should be very concerned about medicine shortages, e.g.:
theglobeandmail.com/canada/article…

My message here is that what we need is an all-hands on deck approach to manage rapidly-evolving waves of disruption across Ontario's health systems. Focusing on one issue - ventilators, PPE, ICU beds - without addressing the rest won't work. That's not how health systems work.

This kind of comprehensive approach is what our healthcare leaders are calling for - you see it in calls from critical care staff and from hospital leadership. It's obvious to anyone working in the trenches what's going on and what's needed.

Yes, obviously we need more beds, we need ventilators and PPE, we need medication supply chains, and so on - but without staff, without evidence-informed decision-making at the systems level to allocate resources appropriately, etc. we can't target and deliver health services.

This is obviously a hugely complicated topic, made all the more complex by the fact that we really don't have one Ontario health system, we have multiple systems that all have their own staff, equipment, information systems, etc. which makes it all the more challenging.

But this alignment and corrections in essential building blocks needs to happen immediately - you can't start to fix problems once things have deteriorated, particularly with tired, overworked staff who don't have the tools that they need or are deployed in the wrong places.

There are some essential functions in Ontario health systems that are clearly headed for crisis - our health workforce is one of them - and we need to implement solutions before it's too late. Scale-up staffing, train non-ICU staff in ICU care before you need them, etc.

I would also add that we haven't clearly described a plan for providing non-COVID care both during the pandemic (people continue to have heart attacks and appendicitis, etc.) and after: these gaps are almost certainly huge from delayed care.

We're going to need a catch-up plan for surgeries, for outpatient visits, and for thousands of other things that have been neglected or bumped in the past year. In short: we need to think about this from a health systems perspective.