Perspectives is the quarterly newsletter of the New Brunswick Health Council

In this issue...

Stéphane Robichaud
CEO of the NBHC

Message from the CEO

It’s been another productive and constructi­ve year for the New Brunswick Health Council (NBHC).  We were able to successfully complete almost all of our 2014-2015 Business Plan deliverables. Along the way, new opportunities were seized and added to our work as ways to fulfill the mandate of the NBHC.  As Council members were updated throughout the year, the discussions helped identify items for future business plans.  "Plan the work, work the plan" has formed the basis of the NBHC annual cycle.

From a public reporting perspective, three important areas of work were covered. The Population Health Snapshot report offers updated determinants of health indicators for the province and by health zone. It also has a focus section on avoidable mortality and identifies the top five causes of avoidable death for New Brunswick. The results of the primary health survey were also made public. With over 13,500 responses, the report offers a wealth of information regarding the experience of citizens at the first point of contact with health services, such as personal family doctors, nurse practitioners and community health centres. Finally, the Health System Report Card offers a letter grade, as can be found on school reports, by quality dimensions and sectors of health services. This year’s report focuses on the need to increase efforts in improving primary health services.

These reports are part of the work of the NBHC to report publicly on the performance of the provincial health system.  Although we have witnessed how these reports have had an impact on many decisions regarding the quality of health services, these are status reports rather than performance reports. The main challenge to performance reporting at a provincial level is the absence of performance management.  Status reports help us understand where we stand in comparison to other jurisdictions, as well as variations within the province. They are very helpful in identifying priority areas.  Without provincial targets regarding quality standards for New Brunswick, it is impossible to show whether we are moving toward them.  As an example, we know that 30% of citizens can get an appointment with their family doctor on the same day or next day, and that it varies between 12.0% and 63.5% within the province. There has never been a provincial standard that establishes a maximum wait time. Should it be two days, four days or more?

Council members recognize that the information that is being produced annually by the NBHC represents a valuable contribution for a stronger collective understanding of the opportunities and challenges to have a healthier engaged population, improved health service quality and a sustainable provincial health system.  The 2015-2016 Business Plan was prepared with an emphasis on improving our messaging and ways to reach various audiences.  We look forward to the challenges and opportunities 2015-2016 will bring.

New Brunswick Health System Report Card 

The NBHC is launching its fifth New Brunswick Health System Report Card as part of its commitment to providing the citizens of New Brunswick with important information about the quality of health services delivered in the province. The Report Card produces letter grades, very similar to how a school report card would, according to the six dimensions of quality the NBHC reports on: accessibility, appropriateness, effectiveness, efficiency, safety and equity. An overall grade is calculated for each dimension from a combination of relevant indicators. Our health system's performance remains at an overall C grade, which continues to place us as an average-performing province.

Areas of below-average performance are:
  • Coverage of prescription drugs
  • Wait times
  • Screening tests or appropriateness of tests and procedures
  • Readmission rates to hospitals
  • Use of emergency rooms and hospital beds for cases that could be taken care of in the community
  • Communication and transitions across the continuum of care or integration across services
The Health System Report Card makes the following observations on primary health services, based on the NBHC's quality dimensions:
  • Accessibility is defined as "the ability of patients/clients to obtain care/service at the right place and the right time, based on their respective needs, in the official language of their choice." Accessibility to primary health services does not demonstrate major improvements in 2014 as compared to the situation before 2011. This fact highlights the limited health system response to a key message from citizens regarding the need for improved accessibility to primary health services. 
  • The NBHC's definition of appropriateness states that "the care/service provided is relevant to the patients’/clients' needs and based on established standards." Appropriateness of primary health services does not appear to have witnessed significant improvements. Cervical cancer screening (pap smear test) seems to be trending in the wrong direction in New Brunswick overall; breast cancer screening rate (mammogram) has not shown a major difference, but colorectal cancer screening rate and flu shots for seniors however seem to be trending in the right direction.
  • Effectiveness means that "the care/service, intervention or action achieves the desired results." Effectiveness of primary health services as measured by the rate of avoidable hospitalizations (ambulatory care sensitive conditions) continues to trend in the right direction, and across all health zones. However, there is still significant room for improvement given that the provincial rate for avoidable hospitalizations is still 1.5 times higher the Canadian average. 
  • Efficiency means "achieving the desired results with the most cost-effective use of resources." Efficiency in the provision of primary health services (as measured by the percentage of less urgent and non-urgent cases showing up in the emergency room) does not demonstrate considerable improvement on average. The only exceptions worth noting are the decreases in zones 5 and 7 which merit further exploration in identifying the factors contributing to the improvement. 
  • The safety dimension addresses "potential risks of an intervention or the environment are avoided or minimized." Safety of primary health services seems to be slowly trending in the right direction in general, with slightly fewer people reporting community error/ harm rates, and an overall modest decrease in the rate of injury hospitalizations. 
  • The NBHC’s equity dimension  is described as "providing quality care/service to all, regardless of individual characteristics and circumstances, such as race, color, creed, national origin, ancestry, place of origin, language, age, physical disability, mental disability, marital status, family status, sexual orientation, sex, social status, belief or political activity." Geographic equity in the quality of primary health services should receive more attention from health system leaders and managers. According to the selected indicators assessed for equity in this analysis, the widest inequity gaps seem to be in the effectiveness and safety of primary health services.
More details about each dimension are available in the Report Card, along with a section dedicated to the review of program and service expenditures since 2010, focusing on costs, quality and outcomes in the primary health sector. 
Did you know?

Since 2010, New Brunswick’s health system has consistently scored a C on the NBHC report card, which means the performance of our health system is average compared to other provinces.

In 2014, important areas that can be improved are: wait times, coverage of prescription drugs, and readmission rates to hospitals.

Population Health Snapshot

In January, the NBHC released its latest Population Health Snapshot. The snapshot for the province and each of the seven zones have been updated with the most recent indicators available and can be viewed on an interactive map here:

The snapshot features summary tables of 43 indicators, with each indicator categorized under either Population health outcomes or Health determinants (itself subdivided into health care, health behaviours, socioeconomic factors and physical environment). Also, for each zone, the snapshot highlights zone characteristics, which paints a demographic profile and lists the 10 most common chronic conditions and the 10 most frequent causes of hospital admissions.

Overall, provincial trends may mask a wide variability across the health regions/zones with some zones exhibiting trends that are opposite to those of the province. Understanding the geographic variability in health determinants and health outcomes is essential to better understand the possible underlying inequities in population health and quality of health care services, thus to effectively plan health programs and initiatives based on the needs of a given community.

The NBHC’s 2014-2015 analysis highlights several key points, including:
  • The focus on prevention has allowed some improvements when it comes to some health services such as increase in access to a doctor, to pap tests and mammograms.
  • Some health behaviours or risk factors (known to be factors contributing to chronic diseases) such as healthy eating, obesity, and smoking are starting to trend in the right direction. Other risk factors such as physical activity and alcohol consumption remain a challenge.
  • The sense of community belonging demonstrates an improving trend.
  • Physical environment factors related to air quality (second-hand smoke at home and in vehicles and public places, and self-rating of indoor air quality) are showing a slow trend in the right direction.
  • When it comes to self-rating their general health as being very good or excellent, New Brunswickers rank in last place out of the provinces for the fifth year in a row.
  • The report also includes a "Focus" section providing a detailed analysis of the causes of New Brunswick’s avoidable mortality. Measuring the rates of premature mortality (death before age 75) and the causes of premature mortality can provide insights about how healthy the population is, and what are the challenges it is facing that could shorten a person’s life. This concept is clearly explained in a clip available on the NBHC website:
Did you know?

Health service quality in New Brunswick varies greatly from one part of the province to the other. This reflects the challenge that the province faces in better distributing its health resources based on the local needs of citizens.

Understanding local needs, such as demographics and the social economic status of citizens, can greatly contribute to discussions on better allocating resources.

Home care survey 

A few days ago, the NBHC launched its second survey about the quality of home care provided to New Brunswickers.  The survey targets citizens who have recently received home care services for which costs are entirely or partially covered by public funds. This survey by mail looks at accessing and navigating services, meeting the needs of clients and their families, provider/client communication, safety, equity based on preferred language of service, and overall satisfaction with services. 

Home care includes health services that can be provided by a nurse, social worker, physiotherapist, occupational therapist, speech language pathologist, respiratory therapist, dietitian, or rehabilitation assistant; they are most often provided by the Extra-Mural Program.

Home care also includes personal care services provided by a home support worker to help with bathing, dressing, grooming, feeding, transferring, home cleaning, laundry, meal preparation, or respite/relief care; they are most often provided by home support agencies. In New Brunswick, the Department of Health funds the Extra-Mural Program and the Department of Social Development funds home support services, entirely or partially, based on eligibility.

The overall results of this second survey will be made public in the fall as a follow-up to the 2012 edition of this survey. Repeating this survey will allow for comparison with the previous results and will allow the NBHC to observe if improvements have been made when it comes to home care services in the province. In the meantime, if you receive this survey in the mail, please take the time to answer it. Your opinion matters, please share it!
Did you know?

One out of four New Brunswickers die on average 16 years early from causes that can be prevented or better treated. In other words, out of 6,400 New Brunswickers who die each year, about 1,700 could live longer.

This avoidable mortality is caused primarily by lung cancer, heart disease, suicide, chronic obstructive pulmonary diseases and transport accidents: five causes of deaths that can be prevented.

Primary care survey

A total of 13 500 people answered the phone survey that we conducted between the months of May and September 2014.  Just like in 2011, calls were made across the province. The goal of 2014: to understand and report on New Brunswickers’ experiences with primary health services, and - more specifically - at the community level.

Primary health is defined as the first place people go when they have health concerns, often to a family physician, a nurse practitioner or other health professional. It typically includes routine care, care for urgent but minor or common health problems, mental health care, maternity and child care, liaison with home care, health promotion and disease prevention, nutrition counseling, and end-of-life care.

The survey looked closely at key elements of primary health services, such as accessibility, use of service, satisfaction with the services, communication with the doctor, including barriers to health services, among others. 

Here are the main observations that can be drawn from the comparisons between survey results from 2011 and 2014. From an overall perspective, we can see that little has improved. Large geographic variations continue to exist in the quality of services throughout the province. This can lead to geographic inequities and affect health outcomes.

The lack of timely access to a primary care provider leads to an increased use of emergency services and after-hours clinic. Even if communication with family doctors and satisfaction with their services have improved, we must note that there has been no improvement in access to family doctors in the past three years.

"Being able to see trends when repeating large-scale surveys like this one is very important for improving the quality of health services," said Stéphane Robichaud, CEO of the NBHC.  "Given that 90% of New Brunswickers use primary health services in a year, the information we now have can help guide how we can achieve improved health outcomes for the population, while being fiscally responsible and citizen-centered."

The complete report is available here :
Did you know?

The allocation of the health budget to the three health sectors are as follows: Approximately 56% goes to the acute (hospital-based) care sector, 23% to the supportive/specialty sector, and 17% to the primary health sector.

These proportions have largely remained the same since 2010.
The NBHC has been established as an independent organization that measures, monitors and evaluates New Brunswick’s health care system performance and population health, and that engages citizens in the improvement of health service quality.
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