Eleven preliminary research themes emerged as priorities from the nine consultations that took place across Canada from February to April 2007. For each theme identified below, we outline the scope and meaning of the theme as discussed during the workshops. These themes are not in rank order; no attempt was made to prioritize them.

1) Workforce and the Work Environment

The workforce and the work environment continue to top decision makers' concerns, as in previous Listening for Direction consultations. Participants thought it imperative to find strategies to address staffing shortages. Yet overall they felt the solution was not necessarily to train more of the same kinds of providers to do the same kinds of things. Research and strategies are needed to better employ existing providers, to develop new models for staffing (such as new team mixes, including non-traditional health system workers) and to develop new models of practice (such as collaborative models of care and self-care). To support this, we need innovative education and training programs to help healthcare providers adapt to these new models and train staff for the future.

The issue of workforce migration, particularly for recruitment and retention, was raised in several regions: out-flow (in the East); influx (Alberta); and permanent flux (in the North). Other issues identified included the impact of the aging population on the healthcare workforce (staff aging, the type of workforce/care needed to address the aging population), succession planning, a healthy workplace and safety issues. Finally, participants acknowledged the need to continue to invest in strategies to create and sustain healthy workforces and work environments in light of the implications for the healthcare system (such as retention and productivity) and patient outcomes (for example, experience of care, mortality and morbidity).

2) Change Management for Improved Practice and Improved Health

Change management was raised throughout the workshops. Participants expressed frustration with having enough evidence to drive policy change but insufficient evidence regarding strategies of how to implement change. Participants wanted better evidence on how to make change happen. Several called for uncovering best practices, intervention/implementation studies, demonstration projects, impact analyses and evaluations. They also identified a need to understand how to engage providers (particularly physicians) and other stakeholders in renewal and redesign and how to embed evidence into decision-making.

3) Data, Information and Knowledge Management

An important new theme raised by decision makers in 2007 was the need to strengthen current information/data management and infrastructure. There was a concern that decision makers (and researchers) lack the right, comparable data, and there is a need to better manage existing data - assess, collect, access and use them - and to find ways to integrate them across silos (across organizations, across sectors, across jurisdictions, etc.). Participants highlighted the importance of having data presented in useable and meaningful forms, from a decision-maker perspective, that lend themselves to interpretation and application in particular management, clinical and/or policy contexts. Furthermore, some investment is required in determining effective strategies to enable the translation of existing data and databases for use by decision makers. There needs to be an information system in place that can feed back to clinical practice in a bottom-up process. In addition, issues were also raised around creating, implementing and evaluating electronic health records; ensuring the appropriate use of data within electronic health records by decision makers and researchers; ethics; and privacy issues.

4) Values-Based Decision-Making and Public Engagement

Values-based decision-making and engagement were raised as issues in many of the nine workshops. In the eastern workshop (held in Halifax), they were identified as the most important issues. The focus was on the need for ethical decision-making frameworks, involving the public in decision-making and, in particular, strategies for engaging the public in priority-setting (or at least ensuring they understand the difficult trade-offs necessary). This theme area was linked closely to concerns about sustainability and resource allocation and the need to make trade-offs relative to system design, the medicare basket and access.

5) Patient-Centred Care

Closely linked to the previous theme, but not mentioned as frequently, was the call for patient-centred care and consumer participation. Patient-centred care is seen as a collaboration between informed, respected patients and their families and a co-ordinated healthcare team to achieve quality healthcare. The focus is on the participation and engagement of the patient, as opposed to engagement of the public at large. There are two sides to this: what is the patient doing to be more engaged; and what are providers doing to help patients be more engaged? Discussions at workshops related to collaborative care: having patients participate in their own care and in decisions about their care, as well as having providers be more responsive and designing systems around patients' needs. Key is the need to implement and improve continuity and co-ordination of care from a patient-centred perspective with a philosophy of care where the relationship between provider and patient/family is a core value. The impact of increasing patient demand was also of concern.

6) Patient Flow and System Integration

The issue of waiting times was raised in a number of sessions. Concerns were raised that addressing waiting times by way of disease silos has failed to recognize the common determinants of many conditions (co-morbidities) and also has failed to acknowledge other pressing health priorities, such as mental health. Participants spoke of the need for more of a systems approach to waiting time issues. Themes that emerged in this regard included the need to consider the system as a continuum and as a whole; for navigational aids for patients and families; to move away from an acute-care focus to primary healthcare models (and take up lessons learned from work undertaken through funds made available from the national Primary Health Care Transition Fund); to consider both public and private elements of the health system; for related governance and accountability structures; and to ensure the needs of vulnerable populations are not lost in a systems approach.

7) Chronic Disease Prevention and Management

Participants said there was a need for new approaches to the management of chronic diseases such as mental health, diabetes, arthritis, stroke and obesity. Such approaches must incorporate consideration of strategies for prevention, which extend beyond healthcare to include the contributions of other sectors and relevant non-healthcare professionals. Concerns included the rising complexity and burden of chronic illness, its impact on funding and the need for new ways to deliver care. Discussions were related to the need to move away from acute-care models and to avoid current silos. Chronic disease management and interventions need to be function-based rather than disease-based. Models of care should be flexible and contextualized, taking into account co-morbidities and paying particular attention to vulnerable, at-risk populations. Also of concern is the aging population at increased risk of chronic illness. Participants agreed that innovative models of care are needed to address this complex area spanning prevention and management; questions were raised about the effectiveness of different models/approaches and various combinations of interventions and the implications for quality of care and providers' roles. It was stated during the consultation sessions that we have "islands of good practice related to chronic disease management in a sea of disinterest."

8) Health System Financing and Sustainability

Financing and the sustainability of the healthcare system continue to be an issue for decision makers. Concerns include the balance and interplay between public and private financing and balancing the issues of accessibility, quality, choice, innovation and cost-control. Other concerns include the impact of different funding and remuneration/incentive models on the supply and price of human resources, the quality and cost of care provided and the economy. With respect to sustainability, it was commonly thought that an even greater shift from the current hospital-centric model to a community- and preventive-based approach will come with time. Several worried about rising costs related to pharmaceuticals and an aging population. Also, there is a need for new decision-making structures to provide more appropriate resource and service allocations. (This is closely linked to the values-based decision-making and public engagement theme.)

9) Emerging Technologies and Drugs

Decision makers are concerned about the impact on the health system of new technologies such as genetics, genomics, nanotechnology and reproductive technologies, and they articulated the need not only for modelling and forecasting, but also for developing practice standards and ethical frameworks. The focus was also on the need to adapt to new technologies, such as electronic health records, to develop standards and to assess their real value. A lot of interest was also expressed in the management of and ethical decision-making about pharmaceuticals and adoption of new drugs. These concerns were linked to issues of sustainability, financing, safety, access and appropriateness. Also, there was an expressed need to develop capital and technological infrastructure to its full potential.

10) Quality and Patient Safety

Concerns focused on the quality of care and the need for a cultural change to better involve providers upfront in the quality strategy through different mechanisms such as making quality a key component of their tasks, using the right incentives and having a system that can integrate innovation. There was also concern around quality within chronic disease management, focused at the intersection of disease groups. Also mentioned was patient safety related to adverse event management, long-term and homecare, and post-marketing surveillance of pharmaceuticals. Questions were also raised about performance indicators - their use and misuse, the need to focus on clinical results, the need to understand data gaps, and the need for shared standards allowing for comparative analyses.

11) Linking Population and Public Health to Health Services

This is an area that was also considered a priority in the previous Listening for Direction II report. During the Listening for Direction III consultation, participants continued to acknowledge that the healthcare system cannot possibly cope with demands if greater attention is not paid to prevention. Emphasis was placed on system-level interventions aimed at improving health and at addressing health status disparity. Questions were raised on the influence of the political/governance structure on health outcomes. Also of concern were issues related to the environment - the impact of global warming and other environmental changes on health and healthcare - and to globalization, such as medical tourism, migration of healthcare professionals and pandemic management.