A set of forums were held by Vancouver Coastal Health to improve care for seniors with complex conditions.
Problems and Purpose
The ‘Keeping Seniors Well’ forums were held in Richmond, B.C. in early 2016 as a result of a request made but the Canadian Ministry of Health. The Ministry of Health asked Vancouver Coastal Health to find ways to improve care of seniors, especially those with difficult health conditions. This method of participatory governance was used so that VCH could better assess the specific needs of the elderly with very complex illnesses, in hope of being able to improve services for their specific, challenging needs.
Background History and Context
For the past 30 years, it has been believed that public participation and involvement has had a great impact on how Canada’s health system has improved and operated. Citizen participation is quite often used at various levels in order to get a more in depth view of the specific care needed by people, and the flaws being experienced in the system. The Health Council of Canada actually stated that “democratic renewal and public involvement have moved to the forefront of the public agenda” and that “involving the public in democratic decision-making processes in Canada are being explored by many systems”.
Richmond is in the Canadian province of British Columbia. It is very close to Vancouver, and its healthcare services are provided by Vancouver Coastal Health. The forums were held because often elderly patients with complex conditions would turn to emergency health care services as they were not receiving the standard of care required at home. The forum needed to speak directly to those who suffer with complex conditions, and their families, in order to get an accurate view of how they can improve services and care, in order to take the prevent seniors using emergency services.
Previously, VCH had run other ‘Keeping Seniors Well’ forums but in different areas. A set of forums containing the same design of participation was held in the West End and Fairview Slopes area in 2015 to discuss the same issues as these forums. The design was the same as the one produced here.
Organizing, Supporting, and Funding Entities
Vancouver Coastal Health and the government’s Ministry of Health worked together in order to fund this process. Vancouver Coastal Health designed and facilitated the forum process used, and VCH actually have their own Community Engagement Division to do this. The Community Engagement Division was established in 2001, and has only grown since.
Participant Recruitment and Selection
Vancouver Coastal Health targeted those who were currently receiving care from them and were elderly and had complex or difficult illnesses. They also aimed to get families of the patients involved, as well as their caregivers, in order to get a wider range of perspectives on the issues to be discussed. Invitations were sent out to all those who fit the criteria, so all participants had to put themselves forward voluntarily. This is the method of ‘opportunity sampling’. There was also a method of self-selection, as the forums were advertised on posters put up in Vancouver Coastal Health institutions, and these posters were also published online on the VCH website and on other Richmond news outlets 
VCH were very careful to make sure that participants knew how much they were needed and valued. The initiation stated “[the participant’s] voice and feedback is very important to [VCH]”, and they also stated what sort of information they would be looking for . Also, in order to entice more participants and make participating even easier, it was stated in the invitations that those who could not attend could share their views via email or telephone – this was most likely to cater to the type of participants they were expecting, elderly and sick
Methods and Tools Used
The method used in this case is a series of forums, which is a method of participatory governance, and a democratic innovation. This method requires a facilitator to set the questions and topics, and to then record the main issues and anecdotes that are brought up. The main tool used in this method is actual face-to-face facilitated and moderated discussion. The forums work in a way that they identify the issues, then identify solutions, then consolidate these solutions and create a plan of action.
What Went On: Process, Interaction, and Participation
A total of three community engagement forums were held in Richmond over the space of a month, and at its peak, the forums hosted about 85 participants. The first two were more about the problems and ideas on how to solve them, and the last was on agreeing and confirming what steps were to be taken, and whether they would actually be effective.
The first two forums were named ‘Identifying Needs’ and ‘Defining Better Care’. These forums focused on the seniors and their families or caregivers. The first forum was held on 26th January 2016, and this was facilitated in English, Cantonese and Mandarin. The second forum was held on 4th February 2016, and was aimed at Cantonese and Mandarin speaking elderly people who were not at that time receiving home health services from VCH. These discussions were facilitated in Cantonese and Mandarin, and aimed at the same ethnicities, because Richmond has a very dense population of citizens of Chinese ethnicity. 54% of Richmond’s citizens come from a Chinese background, so obviously with such a large proportion being of Chinese origins, it was important to make the forums accessible for them too. During the discussions of the first two forums, four significant themes appeared amongst the conversations.
The four main themes found in discussion were ‘Health Professional Care’, ‘Enhanced Homes Support Services for Seniors’, ‘Enhanced Services for Family Caregivers’, and ‘Socialisation and Awareness of Resources’.
The third and final forum was held on 9th February 2016, and was named ‘Confirming a New Approach to Care’. The discussion in this forum was shaped around the four main emerging themes, and asked for participant feedback on these topics.
HEALTH PROFESSIONAL CARE
This topic centred around how care by professionals, so clinical care, could be improved. Participants commented on issues with clinical care, access to care, and how they would like better transitions. From this, VCH worked with participants to formulate ‘next steps’ such as receiving more care outside of the hospital, having a “core health team” and providing better care and access to it for low income seniors .
ENHANCED HOME SUPPORT SERVICES
This topic mainly covered issues with actual home support of seniors. Participants identified issues with language barriers and lack of both cultural understanding and comprehension of specific needs. From this, solutions were proposed such as increasing hours and introducing ‘quality control’ measures. As well as this staff would now be pushed to focus on consistency and fulfilling needs instead of just carrying out set tasks. Education about culture and language matching would now be involved too.
ENHANCED SERVICES FOR FAMILY CAREGIVERS
This theme emerged mainly looking at those providing care who weren’t hospital staff. Solutions to problems arose such as including family and caregivers at the centre of care, and providing a lot more support to caregivers, for example, ‘relief’ days and access to support networks.
SOCIALISATION AND AWARENESS OF RESOURCES
Finally, this last theme focused on making sure that seniors have access to be able to socialise and do recreational activities. It also provided solutions to issues by making people aware of what resources were out there and how to access them.
Influence, Outcomes, and Effects
Each of the four themes discussed had produced practical ‘next steps’ and solutions. These next steps were a product of collaboration between VCH and the participants in the forum, as they solved the participant’s issues, but were also within the organisation’s scope of action. The input received from participants was passed on to the “Richmond Seniors Prototype Working Group”, which processed the data and material in order to form a developed model for what action they would take. The forums appeared to be successful, as more were carried out in 2017 in British Colombia. Also, a “Keeping Seniors Well Reference Group” was set to be established and would receive participation from all of those who attended the forums, and this group would continue giving feedback and help out during the implementation of the proposed care model. This was expected to be carried out in Spring 2016 .
Analysis and Lessons Learned
The idea of using forums to help accurately make beneficial change to a specific section of society is a good one. There is no better way to learn people’s needs and how best to help them than to actually hear from them themselves. This plays largely on the concept of considered judgement. This is the idea that the citizens will know more about the issue than, say, an elected official, and will also be able to understand and take account of other citizen’s perspectives . This is well demonstrated in the forums, as solutions covered a whole range of different types of patients, from those who only speak Cantonese or Mandarin, to those who are living on a low income. Also, the information gathered by the forums covers areas that elected officials may not have even realised are an issue.
The other main principles of participatory politics are inclusiveness, popular control, transparency, efficiency and transferability . This case was definitely inclusive, as the forums were accessible to anyone who could have valuable input on the decisions, and measures were taken to make sure it was accessible to all, such as phone access and facilitation in different languages. Popular control was hugely important in this system, as the participants, although guided by VCH to fit their abilities, were able to formulate problems and effective solutions to help them personally. The case was transparent, with discussion being published online, and participants being able to join the groups to help with building a model and implementation. Finally, the case was definitely efficient, as within the space of less than a month, valid solutions had been formed, and the case is transferable – this method could be used at different levels to talk about different issues. Overall, the format of this case fits the principles of participatory governance very well.
The benefits of this system is that issues are heard right from where they are experienced. Also, by taking a collaborative approach, VCH have not worked together with those in the system to improve its so changes will be effective and therefore the process was efficient. On the downside, although the process worked well, there was still a relatively low level of participation with only about 85 people maximum taking part. Despite still having good input from those who attended, it is impossible to know whether outcomes would differ is more participation was in place. This could be improved maybe by offering incentives, or by making it clear how much of a role participants actually played in changes made.
Although there was not an official evaluation posted online, it could be suggested that the process was relatively successful, as the format stayed the same as the one see in 2015, and continued in to 2017. However, this could possibly just be that it was only fair to cover all areas of the district, so although promising, it is not proof of success. The process was not largely reported in the media, probably as it applies to such a niche section of society. However, more reporting in the media could improve participation levels, and make other kinds of citizens aware that this sort of participatory governance is possible.
Public involvement has a promising future in the Canadian Health System. Increasingly, structures are being put in to place to allow public participation in decisions at a multitude of different levels. Recent polls show that Canadians want to participate more actively in making healthcare decisions for the nation, and this only suggests that this case is one of many to happen over the next few years.
 Vancouver Coastal Health. (2016). Keeping Seniors Well Forum Richmond 2016 Summary Report. Available: http://mpap.vch.ca/wp-content/uploads/sites/26/2016/11/Keeping-Seniors-Well-Forum-Richmond-Summary-Report-Feb-92016.FINAL_.pdf. Last accessed 7th Dec 2018.
 Vancouver Coastal Health. (2016). Community Engagement Framework.Available: http://www.vch.ca/Documents/CE-Framework.pdf. Last accessed 8th Dec 2018.
 Health Council of Canada. (2016). Primer on Public Involvement.Available: https://healthcouncilcanada.ca/files/2.31-PublicInvolvementPrimer_EN.pdf. Last accessed 7th Dec 2018.
 Vancouver Coastal Health. (2018). Keeping Seniors Well Community Forums. Available: https://www2.gov.bc.ca/assets/gov/health/about-bc-s-health-care-system/heath-care-partners/patients-as-partners/keeping-seniors-well-engagement.pdf. Last accessed 7th Dec 2018.
 Personal Correspondence with Belinda Boyd, Engagement Lead on ‘Keeping Seniors Well’ Forums, Richmond, 2016. Correspondence held via email in October/November 2018.
 Vancouver Coastal Health. (2015). Keeping Seniors Well Forum 2015 Summary Report. Available: http://dtes.vch.ca/wp-content/uploads/sites/26/2016/11/Keeping-Seniors-Well-Forum-Vancouver-Summary-Report-Aug-26-2015.pdf. Last accessed 7th Dec 2018.
 Smith, G (2011). Democratic Innovations. 2nd ed. United Kingdom: Cambridge University Press. Chapter 2.
 City of Richmond Hot Facts. (2017). Ethnicity Hot Facts. Available: https://www.richmond.ca/__shared/assets/2006_Ethnicity20987.pdf. Last accessed 7th Dec 2018.