Bazinga! A unified model of palliative care in Ontario

The 2014 film The Theory of Everything chronicles the life of physicist Stephen Hawking. His distinguished career included authoring the bestselling A Brief History of Time, which stayed on the Sunday Times bestseller list for a record 237 weeks.

One of his areas of study was unified field theory, sometimes called the Theory of Everything (ToE, for short): a single, overarching theoretical framework that would comprehensively explain and unify every feature of the universe’s architecture into a coherent whole. Some have suggested that String theory and M-theory may be Theories of Everything. Fans of the popular television series The Big Bang Theory will remember that Sheldon Cooper was an experimental physicist studying String Theory.

A unified field theory would reconcile seemingly incompatible aspects of various field theories to create a single comprehensive set of equations. Such a theory could potentially unlock all the secrets of nature and make myriad wonders possible. According to Michio Katu, a theoretical physicist at City College, City University of New York, those in pursuit of a unified field theory seek “an equation an inch long that would allow us to read the mind of God.”

What does this have to do with palliative care in Ontario?

I have previously written that palliative care in Ontario is a postal code lottery – centres of excellence amid deserts of despair. Access across the province is a threadbare patchwork of programs and pockets of funding that allows patients, families and caregivers to fall through the cracks on a regular, if not daily, basis.

To ensure access to high-quality palliative care for all Ontarians facing a progressive, life-limiting illness, we need a unified model of palliative care across Ontario. We already have many of the necessary components for a unified model:

• The 2011 Declaration of Partnership “sets out our individual and collective commitments, common priorities and appropriate actions to optimize palliative care in Ontario… The Declaration identifies the next steps to provide equitable access to safe, comprehensive and high-quality palliative care and support for individuals and their families across the province. We are committed to implementing the recommended actions – both short and long-term.”
• The 2016 Fraser Roundtable Report on Palliative Care, convened by Parliamentary Assistant to the Minister of Health and Long-Term Care, MPP John Fraser, builds on the work of the Declaration.
• The Auditor General’s Report from 2014 and Health Quality Ontario’s (HQO) Measuring Up help us to monitor how the system works. While neither paints a rosy picture of palliative care in Ontario, both give us the necessary feedback to identify gaps.
• The Ontario Palliative Care Network’s (OPCN) Palliative Care Health Services Delivery Framework describes a model for how to provide high-quality care for adults in the community facing a progressive life-limiting illness.
• The OPCN Palliative Care Competency Framework outlines the knowledge, attributes and skills providers need to deliver high-quality palliative care in Ontario.
• The OPCN Tools to Support Earlier Identification for Palliative Care provides recommended tools to support providers with identifying palliative care needs earlier in a patient’s disease trajectory.
• Canadian Society for Palliative Care Physicians’ Staffing Model helps us estimate the human resources needed to provide all of the above.

So, much like the field of physics, we seem to have a lot of tools at our disposal to implement high-quality palliative care. Yet, report after report demonstrates, clearly and unequivocally, that patients do not.

So what is holding us back?

We can break it down to four key areas: capacity, funding, opportunity and collective will to change.

First, capacity.

Primary care poses both a challenge and a solution to improving access to palliative care. The predominant model for primary care in Ontario is the family health organization (FHO). While other models like Family Health Networks, Family Health Groups and fee for service provide palliative care, a unified model of palliative care could support and promote the FHO as the most appropriate model for patients facing a progressive, life-limiting illness. However, this would require amendments to FHO contracts including fair and reasonable accountabilities as well as appropriate performance metrics.

A CMAJ article from 2012 clearly outlines the significant and inexcusable gaps in postgraduate medical education. This is not just a problem with physicians. Nurses, personal support workers and other regulated health professionals do not have the basic competencies in palliative care when they graduate. Simply put, this is unacceptable.

We need a Department of Palliative Medicine in each and every medical school in Ontario.  Not a division, not an afterthought. Much like the idea of hospices as hubs, this department could be a touchstone for all things “palliative.” Let’s imagine for a moment a university where doctors, nurses, social workers and other allied health professionals work and learn side by side in the interdisciplinary model that is the real-world gold standard into which they will eventually graduate. I’m looking at you, Western.

Next, funding.

To build primary level capacity and increase the scope and breadth of palliative care, there is need for an alternate funding plan focused not only on front-line patient care but also on coaching, mentoring and educating primary level providers, including family doctors and specialists such as oncologists, nephrologists, neurologists and pediatricians.

Perhaps the single greatest obstacle is the lack of on-call funding such as CPOC (community palliative on-call) and HOCC (hospital on-call coverage). As highlighted by HQO Quality Statement #2: People with identified palliative care needs have access to palliative care support 24 hours a day, 7 days a week.”

Some of the gaps highlighted above require dedicated funding while others can be fixed with the stroke of a pen. However, a closer look shows palliative care should not have a funding problem. A 2019 study generated by KPMG for Palliative Care Australia demonstrates the cost-effective nature of palliative care and quantifies how much palliative care can save the health-care system. These savings will more than pay for any new or additional funding required as well as fund other areas that find themselves in the same “have not” position as palliative care (I’m looking at you, mental health and addictions.)

So what is the opportunity? What is the secret sauce?

Ontario Health Teams (OHTs).

The health-care system in Ontario is undergoing a massive transformation from Local Health Integration Networks (LHINs) to Ontario Health Teams (OHTs). This transformation provides a tremendous opportunity to finally, finally, create the unified model of palliative care that has been missing in Ontario, since, well, always.

Currently, 42 OHTs have been approved in Ontario with more working toward approval; 150 OHTs expressed interest during the initial call for applications in 2019. Each OHT has been asked to identify priority areas and populations to address in their first years.

While many OHTs have named palliative care as a Year One priority, many OHTs have not. The reasons vary, mirroring the patchwork and postal code lottery I referenced earlier.

But if each OHT was given a unified model of palliative to work toward and had the funding and resources available to implement this model, then each could conduct its own gap analysis, inventory of resources and move forward toward the ideal state.

This is where the final deficiency can be addressed: collective will to change.

Bill 3, the Compassionate Care Act, is intended to identify barriers to the provision of high-quality palliative care and requires that a status report be filed with the province’s Minister of Health. With this level of scrutiny, there will be significant attention upon any future government to demonstrate that palliative care is available to all who need it, when and where they need it.

Bill 3 and OHTs represent the inflection point for palliative care in Ontario. The question is, which way are we heading? While we may be far away from a unified theory in physics, a unified model of palliative care in Ontario can be a reality, if we want it.

And that would mean everything. Bazinga!

This article reflects the views and conclusions of the author and does not necessarily reflect those of Ontario Health. No endorsement by Ontario Health is intended or should be inferred.