Modify primary care clinical practice guidelines and payment incentives to encourage integration of food into primary care
Improve population-level food-health and health care data collection
The data connecting food interventions and improved population health outcomes remains underdeveloped and this affects negatively policy, clinical practice and training. The Canadian Institute for Health Information and the Public Health Agency of Canada have published state of the situation reviews on some high profile relationships, such as obesity (PHAC and CIHI, 2011). Several research teams have tried to make the most of the Canadian Community Health Survey data, including Statistics Canada and PROOF at the University of Toronto. NGOs with a specific disease / condition focus have put out state of the evidence reports. CIHR does have an institute on Nutrition, Metabolism and Diabetes, but in the past decade it has only funded a small number of research projects. It functions somewhat independently from the sibling Institute on Population and Public Health (IPPH), meaning that not many of its funded initiatives are tied to these larger population health considerations. Equally significant, the IPPH likely does not see food population health questions as central to its ambit.
Certainly what has been done the last few decades has brought more attention to the population food - health connection and helped engage decision makers, but the data gaps remain significant and as a result health care practice and policy related to food as health promotion remain suboptimal in the primary care sector. Good data alone will not overcome all barriers to better implementation, but it certainly helps.
Although there are many gaps, perhaps the most glaring relate to the effectiveness of community and population interventions. As discussed under Financing the Transition, there's a Catch - 22 that needs to be overcome. Many health care practitioners will not entertain creative and progressive interventions because they feel there's insufficient evidence to support their implementation. But if new things aren't tried, the evidence will never develop. I propose then that a specific fund be created, through PHAC and CIHR that explicitly attracts new intervention designs to be tested. The fund would likely need to be a minimum of $20 million over 5 years to encompass s sufficient range of multidisciplinary projects and teams that would include researchers, NGOs and practitioners.
Revise Provincial Mandatory Public Health Programs
Provinces are responsible for health and many have assigned regional and local municipalities the responsibility of delivering certain public health services. In Alberta, NS and PEI, public health is now delivered at the provincial level, following reforms to local/regional service delivery, though sometimes through paragovernmental agencies (AB, PEI). Territorial public health services are a mixed structure of territorial, regional and local delivery. Ontario is the most reliant on local municipalities for service delivery (Institut national de sante publique Quebec), although the current government has proposed, and since delayed, amalgamation into more regional units.
Certain programs are considered core or mandatory to be offered and the provinces pay for them or co-share funding with the regional and local municipalities. Provinces have core or mandatory program frameworks and guides that explain provincial priorities. So, essentially, municipal and regional public health units where they exist across the country, receive their instructions and some of their funding from provincial health ministries.
The problem is the mandatory / core functions. Most (BC and Quebec can be considered exceptions) still focus on traditional ideas of food safety and diet modification. While these are important, they represent a very limited interpretation of the food - health relationship. The incidence of provincial food insecurity is frequently described in public health reports, but interventions are often weak or non-existent beyond monitoring the situation. BC, Quebec and some municipalities in Ontario have encouraged public health staff to support and sometimes fund community organizations delivering food as health promotion (see Scale up and out community based programs), and to advocate for a food system analysis of health problems and associated solutions. Often, however, this work is funded directly by the region or municipality, rather than by the province, as these are considered non-core functions. In 2013, Canada had at least 64 food policy organizations addressing food system and health issues, with roughly 25% having significant connections to regional or local government (MacRae and Donahue, 2013). However, provincial funding of these bodies was very limited, with most of the money and in-kind support coming from NGOs and municipal governments. A consequence of such narrow framing of mandatory activities is that they are reduced when municipal finances are in difficulty. When the newly elected (2018) government of Ontario announced that public health funding would be reduced but mandatory programming would have to be retained, the City of Toronto had to develop plans to curtail it's food system work.
The language of BC's core program functions (see particularly section 8.2) should be adopted in mandatory programs across all provinces. Because of this framework and related work, BC has the most active food system work within public health units, although funding has been somewhat irregular and unevenly applied. The next challenge is to make sure that budgets align with the framework.
Bring food as health promotion to workplace cafeterias
Some public sector employers have made changes to the quality of their food offerings, based on instructions from government units responsible for procurement (see Goal 3, Food in Public Institutions and Spaces). Voluntarily, many private firms have also changed the menus and pricing in their workplace cafeterias as part of their employee health and performance program, and to save expenses on their health care plans. To move this from voluntary to mandatory undertakings, government intervention is required.
At this stage in the transition, a possible instrument to require workplaces to create healthier menus is the federal and provincial Labour, Employment Standards, or Occupation Health and Safety Codes and Regulations (e.g. Canada OHS regulations), Typically, the regulations specify sanitation, food waste and lunch room requirements for food service operations. Canada's Food Guide recommends workplace eating behaviours so these can be used to ensure that workplaces provide the options that the Food Guide recommends. Regulations would have to be added to require that:
- all workplace cafeterias provide the options recommended for workplace eating behaviours in the Canada Food Guide, and nutrition education instruments to help employees with the transition to new menus;
- inspectors have training to assure compliance with the regulations, or other provincial staff with nutrition / dietetic training are authorized to perform such inspections, including municipal staff that carry out inspections related to municipal requirements;
- workplaces have differential pricing, whereby healthy options are sold at cost, while the less healthy options not named in the Food Guide are sold at a minimum 20% above normal markups. This provision is more challenging to implement and might have to occur more at the Substitution stage once the other measures have been introduced. Given that labour codes and regulations require firms to spend money on health and safety processes, the price setting function would likely have to be framed as part of company requirements to assure the health of employees, using price signals to help shift purchasing behaviour. Legislative and regulatory language could be adapted from the Telecommunications Act regarding tariffs.
When workplace cafeterias are self-operated by the firm, this model can be internally financed if it does not break even. Some firms report that the savings on drug and health plans more than make up for any losses in the cafeteria (Roberts et al., 1999). More challenging is when a company has contracted the cafeteria out to a food service operation. Such contracts are usually let on a competitive bid basis, so the parameters of cafeteria operations, pricing and profit levels would have to be well specified in the tender. A contract might also have to allow for compensatory payments should the cafeteria run at a loss.
Integrate food health promoters into primary care teams
For many years, primary care organizations have not typically focused on social determinants of health (Pinto and Bloch, 2017), but now many provinces are moving away from fee-for-service arrangements provided by individual doctors to a range of team approaches, often combined with a capitation model, creating opportunities to bring SDOH expertise to team organization and operations. Interdisciplinary teams are known to be important for effective chronic disease care (Ramond-Roquin et al., 2019). As part of this effort, provincial and national medical bodies have published SDOH guidances for physicians. CHCs have been engaging health promoters as part of a social determinants focus for many years, but now family practices in some hospitals (Toronto St. Mike's), clinics and teams have been adopting the approach when they focus on marginalized populations (Pinto and Bloch, 2017).
Although this work isn't specifically about food, it creates that possibility of food - related interventions since food is a core social determinant of health. Kiran and Pinto (2016), from their work on two urban adult family practices, found that about 15% of patients had an unmet resource need, usually low income and associated food insecurity or difficulties obtaining health insurance and medication. These patients were less healthy with more emergency department visits. From the medical literature, it is established that such patients generally have higher prevalence of diabetes and associated side effects, cholesterol, blood pressure and more difficulty with glycaemic control. But, unfortunately, most practices do not address the upstream factors that are significant contributors to these health conditions.
Although the evidence remains weak because such approaches have yet to be scaled up and out, making these efforts effective requires (Pinto and Block, 2017):
- clear frameworks for SDOH, operations, participation, and interdisciplinary practice
- data to identify upstream causes of downstream problems
- the ability to translate that data into family health practice, using well designed screening and assessment tools
- listening to patient and community experiences
- appropriate structures and funding (including incentives, see below)
- evaluative data to inform practice
- advocacy based on patterns of problems and health improvements
Ideally, then, teams are created in which the medical professionals recognize when SDOH dimensions are pertinent to improving health outcomes and can refer the patient to a health promoter within the group.
Modify primary care clinical practice guidelines and payment incentives to encourage integration of food into primary care
For diseases and conditions where food / diet is a significant risk factor, clinical practice guidelines do identify desirable dietary changes as part of a prevention and treatment regime (see, for example, 2016 Hypertension Guidelines). However, compared to other aspects of the treatment plan, the dietary elements are typically rather broad, lacking details on the strategies to be employed to bring them to reality with patients. Having teams with nutrition expertise obviously helps with implementation, but relying on patients to implement dietary changes without significant support, especially in the absence of specific clinical practice guidelines, is not likely to be successful.
To address this deficiency, several changes are needed. First, the clinical practice guidelines need to be more specific regarding strategies to help patients meet dietary recommendations. In some cases, that will mean engaging health promoters to address SDOH issues. In other cases, detailed work with dietitians will be necessary. Their recommendations on best approaches should be part of the guidelines, since not all patients will be seen by teams having such expertise. Better training for physicians will help (see Substitution) and those not feeling adequately knowledgeable can refer patients to other clinics and specialists, though the health care system is trying to reduce this practice because of discontinuities of care and additional administrative and communication inefficiencies (these difficulties explain, in part, the drive for electronic patient records that are readily accessible across multiple care providers).
Second,incentives are needed to bring food expertise into teams, and to reward teams for employing food-related interventions to improve treatment, where applicable. Provinces have been experimenting with incentive payments to encourage better health outcomes and reduce health care system utilization related to the consequences of ill health. Financial incentives for primary care providers exist in Ontario for patient rostering, patient retention within the group, cancer screening, immunizations, type II diabetes care, and limited other chronic disease management (CHF, smoking cessation). Some of these existing incentives are applied to diseases/conditions that have food as a significant risk factor, though the incentives are not specific to the food-related interventions. There is debate about the merits of this approach and it is not yet clear that bonuses have had a positive impact on health outcomes. There are questions about incentive design and whether they can surmount other structural problems in health care delivery. When the incentive rests largely within teams and is relatively "neat and tidy", there are more likely to be short-term benefits (Lavergne, 2017). It would appear that, as with so many other change processes, incentives have to be carefully designed and bundled with other adjustments to be effective. Since incentives have not yet been used in the way proposed here, there would likely need to be some pilots to test the design, as has frequently been done with other new initiatives.
Strengthen system targets for improved food-related health
The health care system has numerous performance targets. Those most relevant to this site are related to access to, and timing and continuity of care (whether prevention, primary or acute), and preventable deaths (see for example, Health Quality Ontario, 2015; .CIHI Performance reporting). CIHI should collaborate with provincial health quality organizations and external experts on the development of sub-targets within these categories, on themes for which the data are relatively definitive. The system targets should be designed at this stage and then executed (with adjustments) for the substitution stage.