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On: Feb. 3, 2012 When do we talk about health? Ontario’s option paper needs to build a stronger vision of a health-enabling social assistance system

Today the Commission for the Review of Social Assistance in Ontario released it’s much anticipated options paper. The paper sets out some interesting ideas and poses some challenging questions that will help to shape the debate around social assistance in the coming months.

In our submission to the Commission, we started by arguing that the cornerstone of reform is starting from a vision of a high-performing social assistance system. We argued that such a system should be:

  • Adequate: so that people on social assistance can maintain a healthy standard of living;
  • Flexible: with a range of responsive supports to help people get out of poverty – recognizing that there are very different pathways into and out of poverty;
  • Person-centred: so services and requirements are responsive to individual and family needs and situations, are delivered in a respectful manner that does not undermine dignity, and so people can be empowered to achieve more control over their lives; and
  • Health-enabling: so that people’s opportunities for better health are enhanced, not constantly eroded.

In the options paper released today, a vision is set out of “a 21st century income security system that enables Ontarians to live with dignity, participate in their communities, and contribute to a prospering economy.”

While this is a good start, the vision is not embedded in the document. The vision does not identify the components of a high-performing social assistance system and, as a result, the Commission has not articulated a clear vision in their ideas for reform. In their introductory note, the Commissioners argue that “we need to transform the social assistance system; small fixes will not be enough.” We agree, and to do this a more comprehensive vision needs to be built into reforming the system.

A cornerstone of our advice to the Commission was that the social assistance system needs to be health-enabling. The measure of a health-enabling system is not whether people on social assistance have access to health care when they’re sick – although this is important – but rather whether the system can prevent people from getting sick to begin with. This means providing health benefits, but also ensuring that social assistance rates and supports are sufficient to cover essential items that enable good health like housing, nutritious food, and child care.

Unfortunately, the Commission’s report frames health very narrowly as a question of whether people on social assistance can get health care when they need it – they did not fully recognize that health and well being are affected by other social and economic factors. The Commission rightly identified that exiting social assistance is difficult when the employment that people move into does not offer health benefits and other essential supports like child care or housing and that this can create a situation where people are forced to remain on social assistance. But they did not make the connections between enhancing these kinds of supports and building good health. Our submission set out the nature of this problem and explained how disincentives to exiting social assistance can be reduced or eliminated by providing more flexible supports and building a system that recognizes that individual needs are different and change over time.

The Commission also did not adequately address how a broad range of wider social determinants affect health: issues like the barriers that immigrants face in entering employment, income inequality, and the lack of affordable housing are only addressed as examples of areas of intergovernmental tension, not as factors that have significant population health impacts.

Throughout their report, the Commission talks about the need for social assistance to be fair to everyone. They argue that it is unfair for a low-wage worker to not receive health benefits while a person exiting social assistance who works alongside them retains their benefits. The Commission is right – this isn’t fair. But the reason that it isn’t fair is because the low-wage worker doesn’t have benefits, not because the person exiting social assistance does. We cannot penalize people on social assistance for the labour market’s failures.

This is why we argued for a system based on equity rather than just an abstract notion of fairness. Equity is about addressing differences in outcomes that are avoidable, unfair and systematically related to social inequality and disadvantage. Equity means that people with different needs are supported in different ways. The Commission needs to avoid taking benefits away from people who need them in the interest of rigid uniformity in the name of fairness.

We’ll be digging deeper into the Commission’s report over the coming days and will continue to blog our analysis. In the meantime, we encourage you to review our recent work on social assistance, including our blogs on creating a vision of a high-performing social assistance system, building a basket of essential supports, supporting people on social assistance into training and employment, building on health promotion and primary care initiatives, and collaborative solutions to fixing social assistance.

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On: Feb. 2, 2012 As Ontario braces for Drummond report, lessons from Million Dollar Murray need to be considered

As Ontario braces for the report from economist Don Drummond on provincial public service spending, an early leak from his work raises a powerful question. In a Toronto Star column by Martin Regg Cohn, Drummond is reported to be ‘staggered by the statistic that a mere 1 per cent of the population accounts for fully half of all hospital spending, or about one-third of total health expenditures’. The facts behind the reported numbers remain to be confirmed, but the notion that a tiny portion of the population is consuming a large share of public services is not new. Malcolm Gladwell’s 2006 essay on ‘Million Dollar Murray’ – an account of a homeless man who used a huge amount of public services because of his homeless status, even as authorities failed to provide even minimal housing at a much lower cost – has prompted a powerful policy response in the US and Canada on housing and homelessness services. The lesson from Million Dollar Murray is that a relatively small amount of investment in the social determinants of health – housing, income and supports – saves huge amounts of ‘downstream’ spending to pay for the health and social consequences of precarious housing and homelessness. ‘Housing first’ has been adopted by local, state / provincial and even the US federal government as the most humane and cost-effective response – and case study research has confirmed the personal, social and financial value of the up-front investments.

 

So, what can Ontario learn from Million Dollar Murray as it considers the province’s significant health spending budget? Research from the Wellesley Institute and others at the national and international level has already demonstrated the strong links between poverty, inequality, precarious housing, precarious employment and poor health. Some of the WI’s own research includes Work & Health, Poverty Is Making Us Sick, and Precarious Housing in Canada. This is just a small sample of a large amount of qualitative and quantitative research and policy work that links poor health to fundamental structural issues like employment, income and housing.

 

So, if Drummond is right that a tiny portion of Ontario’s population are sick and consuming a large portion of hospital and health spending, then the logical question is: What is making these people so sick in the first place? Is it precarious housing or employment, homelessness and inadequate income? Tackling the fundamental determinants of health – jobs, income and housing, to name three – usually requires fewer public dollars than waiting until people suffer the health consequences arising from the neglect of these critical requirements, and then rushing people into emergency wards and expensive hospital care.

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On: Jan. 31, 2012 Fixing Social Assistance is all about Collaboration

Over the last couple of months I’ve blogged about reforming Ontario’s social assistance system, setting out the nature of the problem and suggesting some solutions such as creating a vision of a high-performing social assistance system, building a basket of essential supports, supporting people on social assistance into training and employment, and building on health promotion and primary care initiatives.
While our solutions have emphasized that reform needs to come from within the Ministry of Community and Social Services, building a health-enabling system requires a more comprehensive strategy that brings together a range of partners. This blog builds on this theme by highlighting the role of communities and the need for formalized policy alignment across government.

Build Community Capacities

One crucial means of enhancing people’s opportunities for good living conditions is to build community opportunities and capacities, in other words, to build healthy communities. Extensive research shows that individuals who live in strong, vibrant, well-connected, and well-resourced communities fare better on many social indicators of health.

Within Ontario, many community-based groups are working to build strong and vibrant communities, and the social assistance system should tap into – and expand – initiatives and interventions that are already underway and proven to work.

One promising direction to address complex social problems is comprehensive community initiatives. These bring together broad-based partnerships of local residents, service providers, community organizations, businesses and governments to coordinate services, share and leverage resources to build community capacity and infrastructure, and mobilize towards policy change to address the roots of poverty or other social problems in a way that is from – and for – the community.

For example, the Vibrant Communities initiative lead by the Tamarack Institute is a community-driven effort to reduce poverty in Canada by creating partnerships that make use of people, organizations, businesses and governments. This initiative, which involves partners from coast to coast, empowers communities to identify issues that are relevant to them and supports them to identify community assets and to build their own actions and strategies to address these challenges.

To harness these community strengths, the Commission for the Review of Social Assistance in Ontario should recommend that the mandate of social assistance providers include partnering with appropriate local community initiatives from across sectors.

Breaking Down Government Silos

There is growing understanding that complex social and economic problems require integrated and comprehensive policy solutions. This means getting beyond the current disjointed structure of ministries, agencies and programs, and the rigid jurisdictional boundaries between different levels of government.

Reform of social assistance cannot effectively be pursued in isolation, but needs to be considered within the context of other changes in public policy needed to reduce poverty and inequality. Integrated policy development is crucial to addressing complex social problems such as improving social assistance and reducing systemic health inequities. For example, better skills training leads to better job opportunities, and education and child care investments can help to break the cycle of poverty.

Health in All Policies is an approach where all policy development is required to consider possible health impact and implications. A version of this approach has had promising effects in Quebec: any legislation or regulation with possible health implications must be reviewed with the Ministry of Health and signed off by the Minister.

In our submission to the Commission, we argued that they should advocate for the province to implement a Health in All Policies framework across ministries. This includes working with other levels of government to fund and develop affordable housing, increase access to child care, address labour market security and employment conditions, all of which will ultimately improve population health, reduce poverty, and decrease unemployment.

This is the final blog in the series about our submission on social assistance reform, but stay tuned for updates about our work in this area and developments from the Commission. Thank you to everyone who has engaged with these blogs via Twitter and Facebook, and by getting in touch.

By:
On: Jan. 31, 2012 Austerity is bad for your health

The Ontario government is expected to release the Drummond Commission report shortly. That report that is expected to substantially shape Ontario’s fiscal plan going forward. Don Drummond was appointed to provide the Ontario government with a plan to reduce the deficit. He has indicated that drastic cuts to budgets will be needed, and that he will recommend privatization of services to increase value for money and efficiency. The premier, in a speech last week, reiterated his commitment that he will not increase taxes to address the deficit.

In a recent post, Alex Himelfarb made an interesting distinction between fiscal prudence and austerity. He argues that fiscal prudence means spending wisely, reducing waste, collecting sufficient taxes to pay for the public goods and services we want, and keeping debt down. He contrasts that with an austerity agenda — a persistent emphasis on low taxes and cuts to services and public goods, and characterizes it as ideology masquerading as fiscal common sense.

I used that post for inspiration for a submission to the Commission on Quality Public Services and Tax Fairness, an alternative to the Drummond Commission established by the Public Services Foundation of Canada. In that submission, we argued that the government should keep Ontarians’ health in mind when it evaluates the Commission’s recommendations.

Keeping Ontarians healthy will require more than the Premier’s promise to protect the Ministry of Health and Long Term Care’s budget. There are many ways austerity programs have an impact on health. Increased unemployment, lower job quality, decreased access to or levels of social benefits, and less access to services that support social inclusion will all have negative health impacts. And, these impacts will fall disproportionately on Ontarians with lower socio-economic status.

We argued that the government needs to consider how an austerity agenda will make inequities worse in Ontario, and that it’s not too late to avoid making that mistake.

Read the submission here. Austerity Is Bad For Our Health

By:
On: Jan. 31, 2012 Building Equity Into Ontario’s New Health Care Action Plan

The Minister of Health and Long-Term Care today launched an ambitious plan to transform Ontario’s health care system. It identifies key drivers of change to improve access, quality and value; all underlain by improved system coordination and coherence, and by service and quality innovation. These are positive directions, but the opportunity must not be lost to ensure that this transformation also contributes to reducing pervasive and damaging inequities in health in the province – we need to build equity into these reforms from the outset.

The Minister emphasizes the high proportion of costs attributed to preventable illness. The Action Plan should also stress that health inequities are a major cause of avoidable illness and system costs. There is an overwhelming body of evidence demonstrating the impact of wider social determinants of health and of structured social and economic inequality on shaping population health. All of the particular challenges noted on the Action Plan – chronic conditions, emergency room use, navigation – are worse for lower income people, immigrants and others facing social exclusion.

Similarly, the solutions proposed – from increasing access to community-based services, through ensuring seniors can stay in their homes longer, through improved health promotion – can only succeed if people’s living conditions and community context and are taken into account. Children cannot be expected to exercise more if there are no safe parks in their neighbourhood or if recreation programs have user fees. What if poor housing is the real problem underlying some senior’s ill health? How can health information and support be provided in the different languages and cultures of our diverse communities?

Equity must also be built into the specific reforms identified. For example, the more comprehensive and integrated care that can be provided by Family Health Teams has great potential, but this potential may not be available equitably – existing data indicates that FHTs have tended to serve the better off and healthier. This also shows how one success condition to this Action Plan is paying attention to incentives: for FHTs and other practice models paid per patient, there is an incentive to take on the healthiest (and easiest) people to serve and to locate in wealthier and healthier neighbourhoods. Ensuring any new patient-based funding does not have such unintended and inequitable consequences, and that funding models take account of the greater burden and risk of ill health in disadvantaged populations will be crucial.

There are many levers within the Action Plan that can be used to improve health equity:
• Hospital Quality Improvement Plans can be required to include equity indicators;
• Initiatives to reduce hospital readmissions should collect data to monitor if there are differences by income, neighbourhood, or region, and should be expected to reduce any inequitable differences they find;
• As LHINs shift resources where need is greatest they must take equity into account – focussing on those neighbourhoods and populations who have the greatest burden of ill health and have traditionally had less equitable access to services;
• Every LHIN should make an explicit strategic commitment to reduce health inequities within its area; and
• The Ministry of Health and Long Term Care should apply its own very useful Health Equity Impact Assessment tool within the elaboration of its seniors’ strategy.
By building equity into the Action Plan, these reforms can help to provide quality care to all Ontarians, including the most vulnerable, and deliver better value for the health care system.

By:
On: Jan. 30, 2012 Emerging Health Professionals and Driving Health Equity From Within

The Wellesley Institute researches and analyzes the policy changes needed to address the social determinants of health that underlie pervasive and damaging health inequities. These changes will need to be driven by broad community-based innovation, social movements and political pressure. But acting to ensure equitable access to high-quality health care for all and improving resources and services for the most health disadvantaged populations can also make a huge difference. I spoke to a forum of medical and other health students at the University of Toronto on key equity levers and mechanisms within health care. It’s always a great pleasure to work with these leaders of tomorrow who will be driving action on equity within the health care system.

Thinking About Health Equity/ Acting on Health Equity

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On: Jan. 24, 2012 Drawing Out Links: Health Equity, Social Determinants of Health, and Social Policy

The Wellesley Institute engages in policy development and advocacy to advance population health. Our work also sees us working with researchers and community groups to help develop policy capacity, and we often speak on how to maximize the policy influence of research and knowledge exchange.

Earlier this week, we spoke to a graduate-level social work class at the University of Toronto about why policy matters to the social problems they address. We highlighted parallels between the kinds of policy changes needed to address social determinants of health and health equity and those needed to address the structural foundations of social inequality and exclusion. We set out some key ways to develop effective policy recommendations. The slides from Bob’s presentation are below.

We also often speak on knowledge exchange with policy impact: including recently to a major national KE conference and a CIHR research conference (here is the audio of that speech).

Social policy grad class jan 2012

 

By:
On: Jan. 24, 2012 TCHC Update: Executive Committee has voted to delay sell-off of affordable homes

Toronto City Council’s Executive Committee has voted to delay consideration of the proposal to sell-off of 675 single-family homes from the Toronto Community Housing Corporation stock until February 13th. Media reports suggest that Mayor Rob Ford was worried he would lose the vote on this matter at City Council due to strong and principled opposition. More info will be posted as the news develops.

Read Wellesley Institute’s submissions to the Executive committee here and recommendations, here.

By:
On: Jan. 24, 2012 Should social assistance ensure access to health care services, or keep people from getting sick? Both, actually.

The social assistance system causes poor health. The low levels of income supports combined with inadequate supplementary supports like affordable child care and transportation mean that people on social assistance do not have a fair chance at good health. I’ve blogged about this, and have set out some solutions such as building a basket of essential supports and supporting people on social assistance into training and employment.

This blog talks about how the social assistance system can build upon existing infrastructure to reduce health inequities by facilitating access to primary care and health promotion initiatives.

Primary Care

Extensive health research has found that one of the most effective ways to reduce health inequities is to enhance access to primary care for disadvantaged populations. Effective primary care can stop people from getting sick and can catch and treat illnesses before they become critical. This means greater system efficiency and improved quality of life for patients.

There is, however, more than one way to deliver primary care. In recent years Ontario has focused on family health teams: interdisciplinary teams that work out of a shared location. Depending on your needs, this can be an effective health care option. But the funding incentives have not been well aligned, and family health teams have tended to serve more advantaged and healthier populations.

For disadvantaged populations in particular, community health centres (CHCs) are a proven model. CHCs provide multidisciplinary and person-centred care to disadvantaged populations, connect clients into further services and emphasize health promotion activities to keep people well. This comprehensive model of care means that CHCs deal with issues that reach far beyond health care into individual and family social supports, and community capacity-building and development.

Although direct health care is outside of the scope of the social assistance system, the Commission for the Review of Social Assistance in Ontario should advocate for improved access to primary care and CHCs should be empowered to provide a greater role through their unique grass-roots level infrastructure and specialized knowledge of the community that social services could link into.

Health Promotion

Leading health policy experts and researchers consistently emphasize the importance of health promotion strategies to delay or prevent illness. This is especially important for lower income and more vulnerable populations. Conditions such as asthma, hypertension, diabetes, depression and other chronic conditions are particularly sensitive to social circumstances (for example, one key to preventing and managing diabetes is good diet). Poorer people are at greater risk, yet also tend to have less access to health promotion services.

Social assistance should positively facilitate access to health promoting activities and support. This may include subsidizing user fees and removing other barriers that may prevent people on social assistance from being able to participate in health-promoting activities.

For this to happen, social assistance reform needs to be linked to other spheres; for example, ensuring there are adequate parks and activity opportunities in poorer neighbourhoods, and working with healthy community partnerships to ensure the needs of the poorest and most marginalized are met – more on this in my next blog.

By:
On: Jan. 23, 2012 Use new fed/ON housing dollars to invest in permanent, affordable homes: WI submission to Exec

The Wellesley Institute, in its formal submission to Toronto City Council’s Executive Committee on Jan. 24, 2012, commends the City of Toronto as it considers the allocation of $108 million in federal and provincial affordable housing dollars. The Wellesley Institute supports the overall approach proposed by city staff, which is to divide the housing funds among four of the major priorities set out in the City of Toronto’s long-term affordable housing plan, Housing Opportunities Toronto. However, we recommend adjusting the percentages to ensure that more funding goes into long-term and permanent affordable rental housing, and proportionately less into housing allowances paid to tenants who then hand the money over to private landlords.

Read it here: Housing Investment Allocations

UPDATE: http://www.wellesleyinstitute.com/news/tchc-update-executive-committee-has-voted-to-delay-sell-off-of-affordable-homes/

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