Health care reform and reform for health: creating a health system for communities in the 21st century

Futures 31 (1999) 417–436

Health care reform and reform for health:creating a health system for communities in the

21st century

Trevor Hancock*

28 Napier Street, Kleinburg, Ontario, Canada

Abstract

If we are to improve the health of the population and reduce the inequalities in health thatplague our communities and our planet, we will have to give greater attention to the determi-nants of health. The reform of the health care system, necessary though it is, will never besufficient; we need to reform our whole society and in particular to focus on human ratherthan economic development. At the community level we need to create healthy communitiesthat are “health-creating systems” of environmental, social and human development, as wellas health care systems that focus first on improving and maintaining health. Such a “bottom-down” health care system would see the hospital become once again the place of last resort(but still a potentially important partner in creating healthier communities) and would focusinstead on how to provide health promotion and health care from the household level up.1999 Trevor Hancock. Published by Elsevier Science Ltd. All rights reserved.

Futurists are in the business of helping people to think more creatively and effec-tively about the future they prefer and how to achieve it. The noted American futuristRoy Amara, in a series of articles on “the futures field” inThe Futurist(1981), hasidentified two purposes for the futures field:

O to create alternative visions of the future,O to involve people in choosing their future [1].

* Tel.: 1 1-905-893-2808; fax:1 1-905-893-2107; e-mail: [email protected]

0016-3287/99/$ - see front matter 1999 Trevor Hancock. Published by Elsevier Science Ltd. All rights reserved.PII: S0016 -3287(99)00003-8

418 T. Hancock / Futures 31 (1999) 417–436

Moreover, if futures thinking is to be relevant, it must be related to actions under-taken today: as the British futurist James Robertson has noted,

Thinking about the future is only useful and interesting if it affects what we doand how we live today.

In my view, good futures thinking is about both creating a vision of a preferablefuture and involving society as a whole in the process of creating that vision andmaking it happen. I am thus interested in helping people create visions of futuresfor health and the health care system that are both plausible and preferable. That isthe approach that I have taken in this article, combining elements from a variety ofsources that, when taken together, create a vision of how we might choose to organiseour society and our health care systems in the future if our aim was both to createhealth at the community level and to provide an effective and efficient health caresystem. It is not intended as a ‘prescription’ so much as a source of ideas and abasis for discussion. The process of creating your own vision together with the com-munity that you serve is a much more important process than simply taking someoneelse’s vision and implementing it.

1. A vision of health

In creating a vision of health, we have to begin by asking what is it we seek toachieve, what is our purpose as a society or a community? This is the simplest, butalso the most profound question that our society has to confront, in the face ofgrowing evidence that our way of life is environmentally and socially unsustainable[2–4]. As part of that society, and one that utilizes a significant proportion of ourhuman, social and economic capital, the health care system will be profoundly affec-ted by the answer to that question. If society’s fundamental values change, the healthcare system will also change because, it should be clear, the health care systemreflects the society of which it is a part.

In my view, the simple answer to my question is that the central purpose of societymust be to improve the health, wellbeing and quality of life of individuals and thepopulation as a whole—and, I would add, to improve the health, wellbeing andquality of life of those for whom it is lowest. If that is accepted—and the recentlyreleased US draft on report objectives for 2010 [5] proposes just such a pair of healthgoals for the US—then the issue for the health care system becomes one of figuringout how and in what ways health care systems can contribute to the health, wellbeingand quality of life of their communities and to society as a whole.

My focus is on the creation of a vision of a healthier future that incorporates bothhealth care reform—changing the health care system so that it functions moreefficiently and produces better outcomes in the shape of better health—and reformfor health—changing our society and our communities so that we are all healthier.The implications of my approach for hospitals and health systems is that they mustmove beyond the narrow confines of health care reform to participate with their

419T. Hancock / Futures 31 (1999) 417–436

communities in creating a vision of a healthier future which incorporates both abetter health care system and a healthier community. They must then participate inthe process of creating that healthier future through the actions they undertake inthe present. Working with the community is essential; it is not enough simply tohave a vision and impose it on others, co-creation and co-ownership are needed.

In the sections that follow, I will first discuss (briefly) the determinants of healthand then ‘reform for health’ and what this means for hospitals if they take seriouslythe concept of health promotion and commit themselves to playing a role in creatinghealthier communities. I will then discuss the topic of health care reform beforeending with a description—a vision—of what a health system in a healthy com-munity could look like in the 21st century.

2. The determinants of health

What is it that determines the health, wellbeing and quality of life of individualsand populations? I will present only a brief synopsis here of the topic. Readersare referred to the more extensive treatment of the topic in a previous edition ofFutures [6].

In many ways, our current interest in the determinants of health was spawned bythe work of McKeown and his colleagues [7]. Their work was important because itdestroyed the myth that the improvements in health that we experienced in the 19thand 20th century were the result of clinical medicine. Instead, they demonstratedthat the major improvements in health in the 19th and 20th century resulted fromimproved nutrition (itself the result of economic and technological development),reduced family size, improved hygiene and sanitation and (mostly after 1935) vac-cines and antibiotics. It is not surprising, then, to find the Director General of theWorld Health Organization (WHO) writing that “...health for all is a holistic conceptcalling for efforts in agriculture, industry, education, housing and communicationsjust as much as in medicine and public health” [8].

In 1986 WHO’s Ottawa Charter for Health Promotion listed a set of prerequisitesfor health; peace, food, shelter, education, income, a stable ecosystem, sustainableresources, social justice and equity [9]. Of particular importance is the inclusion inthis list of the ecosystem and resources, anticipating the report on sustainable devel-opment that was in the process of being developed by the World Commission onEnvironment and Development [2]; this was the first time that WHO had acknowl-edged these items as important determinants of health. (It is also noteworthy thatthis list of prerequisites does not include health care!)

In Canada in the 1990s there has been a growing interest in what has been called“population health”, as popularized by the Canadian Institute for Advanced Research[10,11]. The work of the CIAR is important in part because it draws attention tothe importance of both absolute material deprivation and relative deprivation as deter-minants of health.

The determinants of health identified in the Ottawa Charter, when taken togetherwith the work of the CIAR suggests a list of determinants of health such as that


shown in Table 1. If the determinants of health are this broad, then clearly reformof health care is of only peripheral interest—the most important determinants ofhealth lie beyond health care, in the realm of “reform for health”.

3. Reform for health: health promotion in the 21st century

In general, health status has improved overall for most people for most of the20th century [13]. However, a number of fundamental challenges to health at theglobal and national level must be faced as we enter the 21st century. These includethe challenges of meeting basic needs for all (such as food, shelter, education, cleanwater, income, safe work, etc.); ensuring social equity both within and betweennations; promoting economic development while preventing its adverse environmen-tal, social and health effects; achieving ecological sustainability in the face of popu-lation growth and growth in expectations and material consumption; building strongsocial networks, a civic society and community capacity; creating a culture of peaceand nonviolence; establishing democratic governance; and stabilizing population[6,14,15]. Many of these challenges are also applicable at the local level, wherecommunities will have to grapple with issues of equity, sustainability and democracy.Health promotion provides a framework for this approach, which amounts to a majorreform, indeed a transformation, in the way we organize our societies and our com-

Table 1Key determinants of health

I living and working conditions– a thriving and sustainable economy, with meaningful work for all– an adequate income for all Canadians– reduction in the number of families living in poverty– achieving an equitable distribution of income– ensuring healthy working conditions– encouraging lifelong learning– fostering friendship and social support networks, in families and communities

I physical environment– foster a healthy and sustainable environment for all– ensure suitable, adequate and affordable housing– create safe and well designed communities

I personal health practices and coping skills– foster healthy child development– encourage healthy life-choice decisions

I health services– ensure appropriate and affordable health services, accessible to all– reduce preventable illness, injury and death

I biology and genetic endowment– heredity– gender– development and aging

Source: Report on the Health of Canadians [12].


munities. The basis for this reform is a shift in our societal values to a focus onhuman rather than simply economic development.

3.1. From economic to human development

For many years now, the economic performance of society has been seen as themost important indicator of human progress. But, in recent years, there has been agrowing recognition that not all economic activity is beneficial, indeed that suchactivity can deplete human, social and ecological capital [16]. The Brundtland Reportdrew attention to the need for economic development to be environmentally sus-tainable [2]. The Human Development Index ranks countries by many other factorsthan mere economic growth [17]. Even the World Bank recognizes that a nation’swealth includes social, ecological and human capital and not merely economic capital[18]. The Genuine Progress Indicator provides an alternative to GDP that deductsthe ecological, social and human costs of economic activity (and adds in some of thenon-monetized community-building, child-rearing, home-making and food-growingcontributions people make) to arrive at a measure that more accurately reflects ourprogress. Or to be more precise, our lack of progress: the GPI has declined in theUSA since the mid-1970s, while the GDP has grown [19].

This broad approach to human rather than economic development underlies theview taken by a Canadian Public Health Association Taskforce on the global impli-cations of the ecological crisis in its report “Human and Ecosystem Health” in whichit stated:

Human development and the achievement of human potential requires a form ofeconomic activity that is environmentally and socially sustainable in this andfuture generations [20].

Indeed at all levels from the global to the local there is a growing interest in andrecognition of the need for an integration of the environmental, social and economicsectors if human development is to be enhanced. One way of expressing this isshown in Fig. 1, which defines three spheres of interest: social wellbeing, ecosystemhealth and economic activity; their interaction determines the level of human devel-opment [14]). The overlap between economic activity and social wellbeing identifiesthe need for social equity, while the overlap between economic activity and ecosys-tem health identifies the need for sustainability; the overlap between ecosystem healthand social wellbeing takes us into the realm of community livability. Health, wellbe-ing, quality of life—in short, human development—require a balance that optimizessocial wellbeing and ecosystem health. Economic activity is quite deliberately sub-servient in this model, supporting social wellbeing and ecosystem health; only if itdoes so is economic activity health-enhancing.

Thus in the next century, at all levels from the local to the global, we need toaddress all of the other sectors that are the real determinants of health and we needto put health on the social and political agenda of those sectors and of society as awhole (this is what is meant by “healthy public policy” [21,22]. In short, we need


Fig. 1. Human development model.

to assert that the central purpose of our society should be to improve the health,wellbeing and quality of life of the population. And we need to bring together thebroad range of sectors in society whose activities affect health in a comprehensiveand collaborative approach to promoting health and enhancing human development.This is the task of health promotion.

3.2. Health promotion in the 21st century

Health promotion is defined in the Ottawa Charter for Health Promotion as “theprocess of enabling people to increase control over and improve their health” [9].Where health promotion differs from health care is in the priority it places on thedeterminants of health and disease, recognizing that we need not simply to reformthe health care system but to reform our whole society if we are to create healthier


communities and thus a healthier nation. Thus health promotion is concerned withcreating the conditions for good health through transformation of our communitiesand of society as a whole. Health promotion takes a settings approach, working withpeople where they live, work, play and shop and where they experience the physical,social, economic and political environments as a whole. These settings includehomes, schools, workplaces, stores and malls, streets, hospitals, neighbourhoods,communities and cities.

In health promotion, we need to think about who the creators of health are insociety: clearly, it is not primarily physicians, nor is it even the health care system.The creators of health are the people who produce our food, manage our wastes,keep our air and water clean, build our housing, create jobs and wealth, educate ourchildren and so on. These are the people who should be our partners in creatinghealth. Thus it becomes clear that the investments that will create the largest healthgain are not likely to be investments in health care services. On a global level forexample, in its report “Investing in Health” [23], the World Bank has pointed to theimportance of women’s education and respect for their rights and their wider involve-ment in society as fundamental determinants of health. Focusing on women’s edu-cation and respect for their rights also serves to reduce inequity and respecthuman rights.

Strategies for improving health in the 21st century will have to move beyonddisease prevention to address the broad environmental, social, economic, politicaland cultural determinants of health. The strategies outlined in the Ottawa Charterfor Health Promotion will remain relevant:

O build healthy public policy, investing in health and narrowing the health gapbetween rich and poor, while putting health on the social and political agenda;

O create environments supportive of health, including sustainable natural environ-ments, liveable built environments and in particular, supportive environmentsfor children;

O strengthen community action for healthby building community capacity, enhanc-ing local democracy and encouraging mutual support and self-help;

O develop personal skills for health, including basic education (especially ofwomen), the development of medical and health self-care skills and the broadcitizenship skills that allow people to effectively participate in health promotion;

O reorient health services, redesigning those services from the bottom down;

At the local level, healthy community strategies will go beyond disease preventionstrategies: for example addressing food security rather than simply seeking to changediet; creating car-free cities rather than preventing motor vehicle accidents; promot-ing active living rather than emphasizing physical fitness; creating safe cities ratherthan simply preventing violence. These strategies call for the coordinated effort ofall sectors of society, lying well beyond the normal jurisdiction of health care servicesand public health.


4. Health care reform—as if health mattered

If the purpose of health care reform is to actually improve health, rather than makemedical care more cost-efficient, simply tinkering with and attempting to reform thecurrent health care system is not enough. We need to completely reinvent or trans-form the system, perhaps using a process that I call “zero-based health planning”.This is in essence a very simple concept: if the health care system were to completelydisappear tomorrow and we had to start again, what sort of system would we putin place? What would a 21st century health system look like? [24]

I believe that we would turn the existing system on its head, so that the “bottom”(health promotion) becomes the top and we would then work down the system fromthere [25]. Thus instead of the hospital being at the apex of the system it becomes,in a literal sense, the place of last resort. In this “bottom-down” health system (Fig.2), which would be responsible for the health and health care of a defined populationand would be managed at the local level, we would begin with health promotion,which works to create the conditons for health—environmental, social, economic,political, cultural—operating through healthy community coalitions. Next we wouldemphasize environmental, occupational and consumer protection as well as lifestyle-oriented wellness and health maintenance programs. In Vickery’s terms, peoplewould be supported in both “health self-care” (to maintain their own health) and in“medical self-care” (so they can diagnose and treat their own minor ailments andtake more control over their medical care) [26]. Mutual support and self-help net-works would provide a means of enabling people to both seek and provide the socialsupport and to acquire the self-help skills that are needed, assisted by the health caresystem where necessary.

Fig. 2. Bottom-down health system.


To this point, the system has required very little in the way of professional support,with the professional involvement beginning to become apparent as we move intothe more clinically-oriented realm of disease prevention and then on into primarycare. Primary care drives the health care system in this model; it is provided by ateam of professionals, some of whom are physicians. The primary care team wouldplay a pivotal role in its community, on the one hand supporting self-care, wellnessand health promotion activities and on the other working closely with the home andcommunity care systems, coordinating patient care and purchasing secondary andtertiary care when necessary. See for example the model of a ‘primary care led’system proposed for London by The King’s Fund [27] and the ‘abolition’ of hospitalsin New Zealand [28]. The vast majority of specialty care (including investigation,diagnosis and surgical and medical treatment) would be provided on anambulatory/day-care basis, while institutional care would begin with communityfacilities such as birth centres, low-intensity-care centres, respite care and communityhospices. Only those patients whose problems were impossible to manage in theother elements of the system would require hospitalization, either in a communityhospital or, if necessary, in a specialty/referral hospital.

Many of these changes are already underway in various parts of the system inmany different countries, or have been called for in a variety of reports. They aresupported by technological developments, particularly information technology, whichmake many of the suggested changes feasible now or in the near future. (A moredetailed description of such a health system, designed to operate from the householdlevel up, can be found at the end of this article).

But while the process of health care reform is important and will continue,healthcare reform alone will never be enough. Thus it is important for peopleinvolved in health care not only to be concerned with the topic of health care reformbut to move beyond that debate to discuss what it is that truly creates health andwhat their role is in supporting the changes in society and in our communities thatwill result in improved health for the population. In particular, it is important tothink about the role that hospitals might play in creating healthier communities.

4.1. The role of hospitals in creating healthier communities [29]

No longer the pinnacle of the health care system, operating in splendid isolation,hospitals will nonetheless remain significant and high profile institutions in the com-munity and could play a significant role in creating a healthy community. They coulduse their prestige and their resources as leaders in the community-wide effort topromote health, in addition to their primary role of providing high quality diagnosis,treatment and care for sick people.

One possible approach is that they will apply the set of strategies identified in theOttawa Charter for Health Promotion. But first, it is important to stress that they canonly do so if they are successful in moving from a position of loyalty to their owninstitutions to one of putting the community first; from a concern with health carereform to a concern with reform for health.


Some of the ways that hospitals can apply those strategies to create healthiercommunities in the 21st century are discussed below.

O Build healthy public policy: Hospitals need to have a clear idea of which publicpolicies could best impact upon the health status of the community and need todevelop expertise in providing a health input to policy making in areas such asurban planning, economic development, environmental protection, transportation,housing, education, parks and recreation, social services and, last of all healthservices. Hospital’s have to be seen to be using the political process not merelyto advance their own institutional agenda but to advance the interests of the com-munity as a whole. For this reason, hospitals should become members of coalitionsseeking to affect public policy in areas of significance for health status, and shouldavoid seeking to dominate or take over such coalitions.

O Reduce inequalities in health: One particularly important aspect of healthy publicpolicy is to seek to reduce inequalities in health. Hospitals have considerablestatus within their community, and have the potential to be effective and respectedadvocates for health. But it is my experience that hospitals are rarely if ever heardtalking about the health consequences of poverty, poor working conditions, unsafeand unhealthy environments, bad housing or the many other conditions that deter-mine health status in their community. This in spite of the fact that people suffer-ing from the consequences of such disease determinants daily walk or are carriedthrough their doors. If hospitals are serious about health promotion they willbecome strong and effective advocates on issues related to poverty.

O Create environments supportive of health: Hospitals interested in creating environ-ments supportive of health should start at home. How many hospitals providephysical and social environments that are truly supportive of the health and well-being—and the healing and recovery—of their patients and staff? There is grow-ing evidence that the physical environment of the hospital can help support healingand recovery. Patients seem to do better when they can see out through a windowand/or are connected with nature. More home-like settings, particularly at times ofbirth and death, are supportive of both the patient and the patient’s family [30–33].Beyond the confines of their own walls, hospital’s have yet further responsibilitiesfor creating environments supportive of health. If any facility in a communityshould be environmentally friendly and environmentally responsible, surely it isthe hospital? However, too often in the past hospitals have been at best environ-mentally oblivious, and at worse environmentally harmful. The design construc-tion and operation of hospitals should meet the highest standards of environmentalresponsibility [34–36].Finally, hospitals should also play a vital role within their community in helpingto identify and address environmental threats to health and in ensuring that allaspects of community life contribute to the creation of physical and social environ-ments supportive of health.

O Strengthen Community Action: If community action is to be strengthened by hos-pitals, it has to be in collaboration with the community and its members, andhospitals have to become community-oriented in their work. An important part


of strengthening the community is to give the community a greater say in themanagement and organization of their own health care services, including theservices—and for that matter the education and research—provided by hospitals.It is particularly important that hospitals identify and work with disadvantagedgroups within their community, since these groups are likely to have both theworst health status and the least control over their health and their health careservices.Ultimately, hospitals can only strengthen community action if they are willing togive up some of their power and to join with communities in a genuine partnershipto improve the health of the community.

O Develop Personal Skills: Traditionally, health education has focused on preven-tive, protective and health promotive behaviours related to lifestyles and to self-care. But in the lexicon of health promotion, personal skills for health are muchmore than traditional behavioural modification strategies; they include educationabout how to use the health care system effectively, how to care for one’s self,and even broader “citizenship” skills.The vast majority of illness that people experience does not require medical care,but the community’s capacity for self-care has been severely eroded by pro-fessional care. Hospitals could assist communities to develop and strengthen theircapacity for self-care and mutual aid. They could thus help communities build aspirit of self-reliance, coping and capability which would help the community toaddress other issues important to health and well-being.But most important of all, people need to develop the skills that will enable themto increase control over and improve their health. At their most basic, these skillsinclude literacy and numeracy. It is a shocking fact that some 25% of adult NorthAmericans are functionally illiterate; their illiteracy is a threat to their health ina number of ways [37]. At the very least, hospitals should be identifying andassisting members of their own staff who are illiterate and educating their staffabout how to deal with functionally illiterate patients. More positively, they couldwork with literacy groups within their community to combine health educationand literacy programs, since the desire to know more about health is one incentiveto learn to read and write.

O Reorient Health Services: This is the final health promotion strategy because inmany ways it is the least important, from the point of view of promoting popu-lation health status. If we accept the argument that health care services are notthe major determinant of health, if follows that health care services are not theprimary focus of strategies to promote health. Nonetheless, it is vital that healthservices be reoriented in a number of ways, and hospitals can play a crucial rolein that reorientation. The reorientations required of health services are to providea better balance between promotion/prevention and treatment/care; between insti-tutional care and community care; between cure and care; and between conven-tional allopathic medicine and alternative caring and healing approaches. All ofthese re-orientations are consistent with and can fit within the reformed “bottom-down” health system described earlier, which in turn can fit with the healthycommunity described in the next section.


5. A health system in a healthy community: a vision for the 21st century

The idea of starting with health promotion—keeping people healthy rather thanfixing them once they are ill—needs to be combined with the idea that we need tostart with the household as the basic building block of a community and a societyand to imagine all the ways in which our “bottom-down” aproach could be appliedfirst at this level, then building up through the block, the neighbourhood, the “vil-lage”, the town and the city or region. This approach has the added benefit that itcan be applied both in rural and remote settings and in large urban areas. Some ideasabout what a transformed health care system would look like are described below,based on the human development strategy designed for Seaton, a proposed new com-munity of some 50 000 people northeast of Toronto [38]. It combines reform of thehealth care system with a number of the elements of the broader “reform for health”approach. (It also bears some parallels with a much older description of an ideal,healthy community—Sir Benjamin Ward Richardson’s 1875 description ofHygeia—A City of Health[39].

5.1. The household

Health begins at the household level, and promoting health at the household levelbegins with the need to meet basic human needs. Housing must be available, afford-able, of high quality, situated away from dangerous environmental conditions, builtwith non-toxic materials, well ventilated and with built-in safety features, especiallyfor young children, seniors and people with disabilities. Specific safety features mightinclude hard-wiring the house for fire, smoke and burglar alarms and for alarms thatcould be triggered by seniors and others requiring medical assistance. Adequate foodpreparation and storage areas are essential, and preferably there should be the opport-unity for the household to grow its own food.

In the information age, a variety of health education and information resourceswill be available to members of the household through their terminals and interactiveTVs, linked to the community’s information network with fibre optic cables. Theseresources include interactive health education programs and other electronic learningopportunities; links to mutual support and self-help networks; information on thecommunity’s programs and services; on-line health encyclopedias and self-care pro-tocols; on-line access to local primary care facilities and hook-ups to facilitate in-home diagnosis and treatment.

Homes need to be flexible and adaptable to meet the changing needs of aginghousehold members, including their needs for home care and support. A wide varietyof health care services are provided at the household level. In addition to primarycare services, these include a complete range of acute, chronic and palliative homecare services, thus providing some secondary and even tertiary care in the homesuch as dialysis, chemotherapy and parenteral nutrition.


5.2. The block

As with the household, the block must first provide an environment which pro-motes health and wellbeing. This means safe play areas for children, traffic-freepedestrian areas, linkages to pedestrian and bike paths, greenspace and food-growingareas such as community gardens. The block also needs to be designed to fostercommunity interaction and support; this might be accomplished by having commonrecreational and play spaces such as playgrounds, gardens, hobby rooms, laundries,etc. Some blocks might be set up as co-housing units in which a number of familieslive in their own homes, grouped around a central car-free area with shared openspace, community facilities and a common dining area, thus meeting more of theirneeds for social interaction and a sense of community [40]. For those with specialneeds, group homes and other forms of supported housing will be needed.

It should be possible to identify and train volunteer health aides who would be aresource for self-care and would foster the development of mutual aid and self-helpnetworks. In blocks with large numbers of multiple dwelling units, it may be possibleto have community service rooms which can be used, among others, by visitingpublic health and primary care nurses, community health workers and the like.

5.3. The neighbourhood

As for the household and the block, the neighbourhood should provide a healthpromotive environment. This would include neighbourhood parks, bicycle paths, apedestrian-friendly environment in which basic services and facilities are withinwalking distance of most homes, the safe separation of traffic from pedestrians andcyclists, and neighbourhood facilities for recreation, including both indoor and out-door exercise facilities.

The neighbourhood would also have a range of supportive housing and grouphomes for seniors, people with disabilities (physical, mental or developmental) andso on. One or more clusters of supportive housing for seniors should allow for acontinuum of living arrangements, from independent apartments and cottages withshared dining to live-in wardens and group living arrangements and perhaps low-level-care facilities. Preferably, these facilities will be located in proximity to theneighbourhood service centre and/or the seniors centre.

A number of neighbourhood services will support people in leading healthier lives.A neighbourhood library could provide a health information resource centre and/oron-line access to such a centre for those lacking access in their own homes. A neigh-bourhood elementary school would provide a health-promoting environment for chil-dren in which education about health and the development of skills for health wouldbe an integral part of the curriculum. Schools might also be sites for communityrecreation and fitness programs and community health education programs.

A multi-purpose neighbourhood services centre (perhaps combined with theelementary school and library) would provide meeting space for neighbourhood self-help and mutual aid groups, community health events, daycare for children andseniors, a seniors centre and facilities for visiting health promotion, primary care


and community care staff. A neighbourhood health worker could be permanentlylocated in the neighbourhood service centre to work with community members onneighbourhood health promotion and to develop and support mutual aid and self-help networks. One or more health services rooms in the centre would be the basefor visiting health promotion, primary care and community care staff includingnutritionists, public health nurses, midwives, mental health nurses, psychologists,rehabilitation staff and so on. Screening clinics and other primary care services mightalso be organized in these centres on some occasions.

5.4. The “village”

In addition to villages in rural areas, we can expect to see more “urban villages”as a result of the influence of the “New Urbanism” [41,42]. As at the other levels,the village should provide a health promotive environment. Environmental qualityshould be enhanced through neighbourhood and village recycling programs, designfeatures that reduce automobile use and thus emissions (i.e., local stores and serviceswithin walking distance, opportunities to work at home, telecommute or live nearto work and services, good public transportation, etc.), district heating systems thatincorporate co-generation so as to reduce emissions from heating, and similarenvironmentally friendly features. A village square would provide commercial, rec-reational and social opportunities. Pedestrian walkways and bike paths would connectto “greenways” that would link the community to the wider bioregion and the naturalenvironment of which it is a part.

A village high school and recreational centre can provide higher-order fitness andsports facilities, cultural facilities, meeting spaces and access to information andresources. The village would have some form of village services committee thatwould ensure that people were involved in planning and directing their local servicesand facilities so as to meet their needs.

The chief health feature of the village, however, is the village health centre, locatedat the village square. It serves as a health information and resource centre, providingaudio and videotapes, books and other written materials, and maintaining an elec-tronic health bulletin board for the village. Needless to say, it is designed to be ahealthy building, with lots of light and greenery, non-toxic materials and furnishingsand a home-like atmosphere.

This primary care centre provides a comprehensive range of health promotion,disease prevention and primary care services and is the home-base for communitycare and support staff in the village. A team of nurse practitioners, midwives, familyphysicians and other primary care workers is located here, together with servicessuch as lab, x-ray, pharmacy, optician, chiropractic, rehabilitation services and soon, as well as practitioners of alternative (or complementary) medicine. Space isavailable for visiting specialists if necessary and the centre is linked electronicallywith individual households, the town’s community health campus and to regional,national or international specialty centres, thus allowing for real time, on-line consul-tation with specialists and with the many other medical services that the informationage makes possible.


Outreach services are provided from the village health centre to neighbourhoodservice centres, schools, workplaces and other settings in the village. Communitycare and support workers providing acute, chronic and palliative home care in thevillage are based at the health centre, ensuring a close coordination between primarycare and community care. Mental health services are provided at the village healthcentre, including counselling, assessment and referral. The village also has a numberof community health facilities, including group homes for people with physical, men-tal or developmental disabilities, supportive housing for seniors and a small nurs-ing home.

5.5. The town

The town, being composed of healthy neighbourhoods and urban villages, is ofcourse itself a healthy place to live. This is enhanced by features designed to reducethe town’s impact on its ecosystem and on the planet as a whole, thus ensuring itis more environmentally sustainable. Such features might include renewable energysystems, “living machine” sewage treatment facilities [43] and a comprehensive,flexible public transport system.

The main feature of the health care system at the level of the town, with itspopulation of some 50 000 people, is a community health campus. The campusincludes a medical mall; an ambulatory care centre for specialty services and daysurgery; a community care centre for post-surgical care, respite care and other short-stay, low-intensity care purposes (see for example the Lambeth Community CareCentre in London [44]; a birth centre staffed primarily by midwives with familyphysician and obstetrical backup for the majority of the births in the community thatare normal; and a hospice. All aspects of the campus are designed and operatedaccording to the principles of the Planetree Foundation, thus ensuring they are trulyhealing environments [45,46].

A vision of the design and operation of such a campus follows. It is based onvisioning work done with a community hospital in Toronto in the early 1990s; itis also influenced by the vision of Del Mar, CA based health care architect DonMcKahan [47].

5.6. The community health campus

The Community Health Campus is the central site for a network of onsite andoffsite facilities managed by the Community Health Board. Some of these facilitiesare leased, some are freestanding collaborative centres and some are shared facilities.The Community Health Board also manages a range of programs that are offeredboth through the campus’ facilities and at other sites in the community. The Board,through its social contract with the community, is responsible primarily for secondarycare services emphasizing birth and child health as well as old age and death andfor managing the continuum of care for its clients to ensure effective coordinationwith primary and community care services in the community and tertiary care ser-vices at other facilities. The Community Health Board is also a respected advocate


for the health and health care service needs of its community, supporting healtheducation and health promotion programs and drawing attention to the basic healthneeds of the most disadvantaged groups in the community, including the homeless,street youth and others living in poverty.

In addition to its emphasis on health services at the beginning and end of life,the Community Health Board has managed the development of special expertise inambulatory and community care alternatives to inpatient care and in the developmentof software and technologies that promote such a system of care, including infor-mation and communication technologies for use by health professionals in the com-munity and by community members in their own homes. The Community HealthCampus provides culturally appropriate and accessible services for the diverse com-munities in its area, ranging from aboriginal and multicultural communities to themiddle class community, as well as disadvantaged communities of street youth andthe homeless.

The development of high quality services in such innovative areas as ambulatorycare and surgery, community-based services, free-standing birth centres and hospices,and in the areas of software/information and communications technology means thatthe Community Health Campus is a centre for the training and continuing educationof a wide range of health practitioners involved in such services.

5.7. The Campus in the community

The Campus is well integrated in its community. It has good community relationsthanks to an open and accessible approach to planning, and to its welcoming attitudetowards patients and families. Through the resource centre attached to the publiclibrary branch, health education and information is provided to the communitythrough audiovisual, written and computer systems. Volunteers and Campus staffprovide outreach health promotion and counselling programs to schools, seniorsclubs and other community groups; these programs are integrated with services inthe community. The Campus provides information through community radio and TVprograms and through community newsletters.

The Campus is clearly wanted by its community and plays a valuable role in thecommunity. This is seen in part by the extensive use of volunteers in the Campus’programs and the annual innovations that are made in ways of working with thecommunity. Volunteers help with mutual-aid and self-help groups, work as patientcounsellors, and even as patient assistants once they have been suitably trained, andfamilies play a large role in patient support and in some forms of care.

There is also significant community involvement—and municipal involvement—in the Campus’ governance. Board membership remains voluntary and the Boardmeets both community and organizational needs through its “Social Contract” withthe community, which defines the Board’s responsibilities and accountability to thecommunity. Most programs have advisory committees. The board, administration,physicians and staff work harmoniously as a team, sharing a common vision of therole of the Campus in the community. Senior managers are visible and accessible.

The Campus is a popular place to work, there is a waiting list for employment.


Staff work largely in self-managed work units with an emphasis on TQI/TQM. Theyare well trained, supported and nurtured, have a good working environment, are moreautonomous, committed to high quality care and to a focus on the relationship withindividual patients. Staff have more choice and diversity in their work, are moreflexible and less categorized. In turn, patients have more choice, are more self-directed and have a greater degree of autonomy.

As part of its commitment to quality, the Campus has recognized that it is software,not hardware, that is the basis for technological excellence and leadership and hasemphasized the use of sophisticated information and communications technologiesas a means of improving service both on the Campus and in the community.

Finally, the Campus is involved in community issues that affect health such asunemployment, homelessness and hunger. It contributes to community developmentand works as an advocate for the community, recognized as a visible voice and forcefor health, a vital partner (but not necessarily the leader) in the community’s health.

5.8. Health care programs and services

The Campus provides an integrated birth and reproductive health program fromfamily planning through to parenting. A free-standing, self-contained, family-centredbirth centre is linked to the Campus and provides a range of choice including culturalbirthing practices, involvement of the father and siblings and home births. The centreis staffed primarily by midwives and family physicians. The program is comp-lemented by a child health program.

As it is for birth, so it is for death. There is a free-standing, self-contained, family-centred hospice linked to the Campus where death can be a private, intimate familyaffair. However, in many cases death occurs at home, with Campus and communitysupport through a home-based community hospice service. This includes a palliativecare program and is related to the long term care program, both of which providesupport for care in different settings in the community through outreach teams inte-grated with community agencies. Like many other programs, this is a partnershipbetween the Campus and other community agencies; sometimes the Campus playsthe leadership role, sometimes it plays the supportive role.

Mental health services are provided by a mobile assessment team, a multidisciplin-ary team combining hospital and community resources. The team’s objective is toavoid admission by developing an effective management plan and to support andtrain other care providers. There is greater role for the Campus in addressing prob-lems of addiction, and the provision of psychological support to Campus staff.

The urgent care/walk-in centre provides 24 hour coverage for minor trauma, medi-cal emergencies, psychosocial urgencies and minor surgery but it is not a “screamingER” for multiple trauma. The multidisciplinary team provides rapid response andurgent care with a particular emphasis on street health needs, medical detox andother urgent health problems of concern to social agencies and the police. The centreis open, friendly and accessible but provides privacy and respect for the individual.The centre is linked with community agencies and provides good links to transitional


housing, after care, etc. As a result, there is not much admission directly from thecentre, except for assessment; the vast majority of people are referred or discharged.

The diagnostic and assessment centre provides appropriate high tech, minimally-invasive assessment and diagnosis on one floor. It is busy and bustling, well managedand with little or no delays. In many ways it is the hub of the Campus, with highvolumes of use. Results are provided on-line to family physicians and to patients,who are involved in decisions about their own care.

The medical daycare centre provides services that used to be provided on an inpa-tient basis (e.g., oncology, diabetes stabilization, etc.) and coordinates a variety ofcommunity outreach programs. This includes pre and post-admission andreadmission services to hostels, seniors centres and other community facilities. Thefamily practice department networks and links together the Campus with family prac-titioners in the community in support of ambulatory and community care. Severalambulatory services are provided in community facilities and family physician healthcentres with support from the Campus.

Eighty-five percent of surgery is now performed on an ambulatory basis, usingminimally invasive surgery, laser surgery and other modern techniques using epiduraland acupuncture anesthesia rather than general anesthesia. The ORs are all on onefloor, warm and friendly, efficient and harmonious. Lounges for post surgical recov-ery are warm and comfortable and allow privacy. The ambulatory surgery program issupported by pre-operative education and assessment, post-operative care by surgicalassistants and routine post-op check-ups and phone contacts with discharged patients.Some patients spend a brief stay in the transitional care facility.

The innovations in ambulatory surgery, ambulatory care and community care aresupported by research programs and by education and training programs for prac-titioners, all with a focus on practical applications of knowledge.

5.9. The building

The Campus buildings are low-rise and have a human scale appearance, blendingwell into the neighbourhood. Outside the Campus there are trees, gardens and seats(all low maintenance), water and a pond (which is used for skating in the winter),bicycle racks and vehicles for the disabled. We can see evidence of roof gardensand occasionally we can catch a glimpse of the interior courtyards that serve to linkthe building’s interior to its exterior. The environment-friendly quality of the hospitalowes much to a new budgeting approach that the Campus insisted upon, allowinga longer pay-back period for cost saving design innovations.

It is also obvious that the Campus is a community space, a community resource.There are storefronts, a public library and children’s play spaces, while a sign at theentrance points to the community centre where there are meeting rooms, educationalfacilities, a resource centre, a daycare for seniors, a daycare for children and a fitnesscentre. It is clear that community people use this facility a lot.

The campus has only a few beds, those needed to support ambulatory care and asmall ICU to support surgery. Most care is ambulatory or community-based, whichexplains why there are so many empty offices—staff are out working in the com-


munity a lot, using their laptops, modems and cellular phones to stay in touch. Thereis a lot of space for ambulatory programs as well as a walk-in/urgent care centre.

As we enter the Campus we are struck by its openness, warmth and friendliness.This results from the use of lots of wood and glass, warm, bright, soothing colours,lots of light, plants and water, brightly coloured fish in tanks, and a multitexturedfeel. The entrances are welcoming, and computer information terminals provide easyaccess to information. In some respects it feels more like a hotel—good quality butnot the Ritz! The entrance lobby has seating spaces and is a social space, there isa small retail mall and a sense of activity; even the patients seem to be active.Soothing, meditative music is played in the public spaces, no speaker calls are made(everyone has pagers) and there is a piano in the entrance lobby. One part of thecampus is a hostel/hotel pod providing transitional care for patients with minimalcare needs.

The patient rooms and clinics have a home-like feeling to them, with furnishingsof wood and wicker, colourful fabrics and couches. The colours everywhere are softand warm, and although not carpetted, the floors are also soft and warm. There arelots of opening windows, no fluorescent lights and no long corridors. Patient spacesprovide a lot of privacy and quiet space, either in single rooms or in mini-wardswith effective sound and privacy dividers, while the ward units have dining andlounge spaces and small self-serve kitchenettes. Patients have access either at bedsideor in the lounge to entertainment and education centres including healing tapes andmusic, videos and computer information and education terminals. Patients are wear-ing gowns that preserve their dignity!

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Documents

Health care reform and reform for health: creating a health system for communities in the 21st century