Society is reaching a turning point, where current mindsets and approaches no longer meet the challenges. The same can be said for our Canadian health care system. The older models of systems thinking and change no longer work in an overconnected world where systems become increasingly integrated with other systems.
Despite decades of investment to transform our health care system by policy reform, recent research1,2 indicates that, “Without some sort of insurmountable disruptive force, either a major shift in medical science or technology, or a catastrophic economic or political crisis, fundamental health policy reform in Canada is unlikely.”2
Since the 17th century, when health care started in Quebec, until today in the many health regions across Canada, we have focused mainly on hospital care and physician services. Despite Saskatchewan’s introduction of medicare in 1962, the Canada Health Act becoming law in 1984, and the federal and provincial governments signing an agreement on the future of health care in 2004, all we have done is tinker with existing concepts without fundamentally changing the system. The largest obstructions are embedded in our political system at large and in the opposing interests of various stakeholders: physicians, nurses, unions, hospitals, and consumers alike.1,2 As a result, we prefer the status quo over the uncertainty of any change, even if the outcome may be better.
No business can transform without knowing what its goals or objectives are, and only after defining the what, can it determine the how. Because we have not been able to define what it is we want from our health care system in the last four or five decades, it is no surprise that we do not know how to deliver it. If we have no clear goals and defined outcomes, then how can we expect policy reform leading to transformation? Top
Have we been limited in our approach to health care transformation by applying outdated mental models of change and systems thinking? What if we think about systems using an advanced change model, a model that is more appropriate for the times? What would that mean to you and me, as physicians, as consumers, or as patients? As members of the Canadian Society of Physician Executives (CSPE)? Some of these questions are addressed here, some are intended to invite a collaborative dialogue and a solution.
When Saskatchewan introduced medicare, the framework that worked best was the technical change model. This type of framework is used when the problem is relatively clearly defined, the solutions are well known, the needed skill set can be learned, and the goal is to fix the problem so as to maintain the system in its current state. Both tactical and strategic thinking fit into this technical change model (Figure 1). In those days, the Canadian health care system was simple enough to do well under the technical model of systems thinking. The mental model of health and disease that goes with this technical framework is that of treating or curing disease (Figure 2). As physicians, we are familiar with this type of change model because we were trained as problem-solvers, and we use the model daily in our medical practice.
Although we continued to use the technical model, the complexity and the context of the health care system around us changed in the late 1980s and early 90s. At that time, the adaptive model would have been more appropriate to change the health care system. That model is used when the challenge is complex, there is little agreement on the problem or on the solution, innovation is required because the old ways no longer work, and the goal is to foster resilience and equilibrium in the system by adapting to changing conditions (Figure 1). The mental model in adaptive systems thinking is that of health promotion by preventing disease and a health care system functioning independent of other systems outside health care (Figure 2). Top
The time has come for shifting to a generative model of systems thinking, a (w)holistic meta-systemic approach. The verb “generate” means “to bring into existence, to be the cause of.” Generative change is a particular way of focusing attention on change challenges by creating possibilities of further change ensuing through time as a result of the initial change. This promotes sustainable thriving. For example, giving people one fish a day only deals with the immediate problem of hunger, but focusing on a preferred future includes teaching them how to fish, which would enable them to provide their own food, earn their living, and teach others. Similarly, generative change empowers us to become architects of a preferred future for health.
Paying attention to problems and possibilities at the same time would foster health, well-being, and healthy development now and for future generations. Whereas technical and adaptive change thinking will keep us in the world of disease treatment and disease prevention, generative thinking will empower us to become architects of health promotion for individuals, for communities, for the environment, and for the world. To nudge our health system toward a preferred future, we need to learn and practice intentional generativity and meta-systemic thinking as a society. Top
What then is that preferred future for our health system? It is one of salutogenesis, the process by which health is created. Thirty-five years ago, Antonovsky3 coined this term, describing the relation between health, stress, and coping, and he focused on factors supporting health and well-being rather than disease. He explained the “health-ease versus dis-ease continuum,” the health-ease component of which is generated by salutogenesis. Once we understand the factors that generate health, we can create more of it.
The use of the word salutogenesis helps us reframe our thinking about health by shifting our focus from disease and health care to health creation and sustainability, not only for individuals, but also for communities, organizations, and the world.4 Despite the World Health Organization’s guiding principle “health for all,” adopted 30 years ago, the gap between the world in which we would like to live and the world we create through our actions continues to grow.
The new commitment for the 21st century has to be “health for all, health by all.” By adding these three simple words, our global commitment to “health for all” is activated by our local commitment to “health by all.” We should generate health through our daily actions and behaviours, through our relationships with others, through our local systems and services that shape our shared lives: economy, education, justice, social services, governance, transportation, production, and availability of food, water, and waste management, and the health care system.4Top
Health, then, is the concern of everybody, not just the health professionals. Because there is no single sector that can address the challenges and the opportunities facing us, everybody can and has an obligation to contribute. So far, such true collaboration has not happened in the Canadian health care system and certainly not for Canada’s health.
Considering that the overall health of a population is not determined by acute care and public health services, why have the socioeconomic determinants of health never been included in the dialogue, using the lens of generative change? Although the Canadian Medical Association’s town hall document, Health Care in Canada: What Makes Us Sick?5 clearly identified socioeconomic factors as fundamental to our health, one year later no visible action has been taken to implement its 12 recommendations because the CMA could not find a government partner. Yet, another technical advisory committee on health care innovation was formed recently, despite Lazar’s2 and Picard’s1 findings that most health care reports by advisory committees have been ignored and have rarely been a trigger for policy change without the political will to do so. Top
In today’s world, we need a diverse set of leadership capabilities depending on what systems model we are working in. What are some of the skills and tools we need for salutogenesis in a generative model of systems thinking? Whereas tactic and strategic leadership skills serve the technical model and adaptive leadership skills are appropriate for the more unpredictable adaptive change model, they limit us in dealing with generative thinking. To be successful in the five factors and their integrated combinations at the heart of generative change,6 we need emergent, generative leadership skills to apply meta-analytical generative systems thinking (Figure 1).4 The five factors for generative change toward salutogenesis are simplified in the next five paragraphs.
Shift mental models to create space for new potential and possibilities to emerge. So far, we have viewed health as the opposite of disease; as a result, the disease pole of the health continuum has captured most of our attention.7 But by letting go of the expert stance and being willing to access our ignorance, we create an environment that supports ongoing learning and a willingness to question and explore new perspectives that allow us to apply the new knowledge continuously.8 The old mental models of treating and preventing disease have to be supplemented with or replaced by health creation, by salutogenesis. Top
Add a heart-centred, appreciative mindset to the traditional head-centred, deficit-based mindset that tends to focus on overcoming limitations and fixing problems. Developing an appreciative mindset is not about looking at the world from a Pollyanna perspective; it is about being intentional about shifting the paradigm from problem-solving to focus on potential and possibility.6 Roy et al9 suggested positive analysis and positive deviance, in the context of emergent strategy and experimentation, as generative strategies in network systems.
Develop a shared vision
Picard1 repeatedly asserts that a vision with specific goals and outcomes was and remains missing from the Canadian health care system. Roy et al9 identify a clear vision of the desired outcome as one of the factors to handle increasingly complex systems. A shared vision is an idea for the future that inspires people to work together, cooperatively and collaboratively. For example, when Walmart developed the vision of a zero-waste business using 100% renewable energy and offered customers more environmentally preferable products, the company ended up creating its sustainability program through collaboration with the David Suzuki Foundation.6 When have we ever seen the food industry sit down with health professionals, scientists, shareholders, governments, and consumers in a collaborative fashion to develop a shared vision of salutogenesis? Top
Engage in narrative, active listening, and dialogue
The art of dialogue and active listening is interwoven throughout the generative change model, to develop vision, deal with today’s problems, and create potential for the future. It means suspending preconceived mental models and being curious and open to possibilities. Narrative is the framework through which we comprehend life10 and it helps us understand others and ourselves by creating a collective framework. This would encourage participation, which matters because contribution in itself generates higher levels of health. Len Duhl, a cofounder of the International Healthy Cities Foundation wrote about health causality, “We have learned that active participation, in itself, leads to health.”11 In other words, contribution creates ownership, and it is salutogenic because it generates higher levels of health. How does each Canadian participate in generating health for him- or herself, for the community and for the environment we live in? Top
Develop a systems perspective, a conceptual framework for understanding complex patterns and interrelations that exist among individuals, organizations, and across sectors. Such a viewpoint helps us understand that everyone shares responsibility for what is happening within a given system, rather than responsibility or blame falling on one individual or agency.12 It can take the form of “the kind of relationships, social experiences, social environment and patterns of interaction known to both promote health and over which a community has considerable control.”13 By reconnecting the seemingly separate parts into a more inclusive and integrative whole, our change efforts will generate more resilience (the ability of an individual or system to cope and adapt in the face of adversity) and more response-ability (the intentionally creative capacity to respond positively and proactively to present problems and future potential).4 “Integration might be the principle underlying health at all levels of our experience, from the microcosm of our inner world to our interpersonal relationships and life in our communities.”14
The meta-system approach to interconnected systems moves us closer to the goal of healthy people, healthy communities, and a healthy world where we pay as much attention to generating health as we do to socioeconomics, public health, and preventing or curing disease. The evidence is growing,1,2,5 the proof is staring us in the face. A successful health system cannot care for disease sustainably without being connected with and integrated into the food system, the environment, the economy, and the education system. Top
As a Canadian society, we have claimed that health care is part of our identity. We are about to give that identity away by focusing solely on acute care and disease, while ignoring the health of the community, its members, and the environment within which these communities evolve. As members of our great Canadian community, each and every one of us has to claim back ownership of our health. We have a choice: either we stay in the present condition, which makes the Canadian health care system look discouraging, or we truly transform ourselves into a society that embraces salutogenesis.
What would that mean for you and me, as physician, as patient, as a consumer of either health care services or of unhealthy and addictive foods, as a voter, as a leader? What role can the CSPE and each of its members play in salutogenesis? Top
1.Picard A. The path to health care reform: policy and politics. Ottawa: Conference Board of Canada; 2013.
2.Lazar H, Lavis J, Forest PG, Church J. Paradigm freeze: why it is so hard to reform health-care policy in Canada. Montréal: McGill-Queen’s University Press; 2014.
3.Antonowsky A. Health, stress and coping. San Francisco: Jossey-Bass Publishers; 1979.
4.Lundy T. Generative change: a practical primer. Albany, CA: Communities that can! Institute; 2014.
5.CMA (Canadian Medical Association). Health care in Canada: what makes us sick? (Town hall report). Ottawa: CMA; 2013.
6.VanQuickenborne T. Exploring generative change. MSc thesis. Malibu, CA: George L. Graziadio School of Business and Management, Pepperdine University; 2010.
7.Antonowsky A. Unraveling the mystery of health: how people manage stress and stay well. San Francisco: Jossey-Bass Publishers; 1987.
8.Schein EH. Process consultation revisited: building the helping relationship. Boston: Addison-Wesley; 1999.
9.Roy D, Litvak E, Paccaud F. Population-accountable health networks: rethinking health governance and management. Mascouche, QC: The Point Publishing; 2013.
10.Ball A. Toward a theory of generative change in culturally and linguistically complex classrooms. American Educational Research Journal 2009;46(1):45-72.
12.Senge P. The fifth discipline: the art and practice of the learning organization. New York: Doubleday; 2006.
13.Lerner R, Benson P. Developmental assets and asset-building communities. New York: Kluwer Academic/Plenum Publishers; 2003.
14.Siegel DJ. Pocket guide to interpersonal neurobiology. New York: W.W. Norton; 2012.
Johny Van Aerde is president of the Canadian Society of Physician
Executives. He is clinical professor of pediatrics at the Universities of British Columbia and Alberta, an associate faculty member at the School for Leadership Studies at Royal Roads University in Victoria, and a member of the faculty of the Physician Management Institute.