We can’t just build a more equitable system. Healthcare in Canada has a healthy history of mobilizing funds for pilot projects with an aim to find new and implementable improvements to service. The aim is collectively shared and has best intentions from policy makers to service providers to researchers and leaders alike.My experience with Frayme has exposed me to different ways of doing, sharing and learning from across our network of over 400 partners. While it’s clear everyone is working towards the best outcomes for clients there's a similar sentiment we have heard from across the country: Something in the way Canada is approaching system transformation isn't working for the most systemically marginalized clients and their families.

I’ve heard this over and over again for many years and the frustration is only growing as global mental health becomes more complex with large-scale, wicked problems like the economic crisis, climate crisis, pandemic impact, systemic oppressions and housing instability compounding mental health and well being. So I’ve been thinking: Why is the system not having the collective impact we've hoped for? There are two factors that I think are critical to highlight here that impede our best implementation intentions:

1. We design solutions and/or service improvements based on dated research (we know that 17 year knowledge to practice gap still exists) that highlights the needs of the traditional research participants. This demographic is rarely representative of those made most marginalized by systemic injustices. Therefore we implement models and programs that serve the same groups (those that are already the most supported) and try to adapt these for equity seeking groups. There is no equity in adaptation. We must develop equity-first approaches to research, model conceptualisation, implementation and evaluation. What does this mean to folks and do we have any collective wisdom to share about this?
    
2. We are terrible at de-implementing. We will never have the space for equitable service improvements to flourish when we are only adding on new programs and services without removing, decommissioning and (in some cases) demolishing those that do not work. Now arguably, this is a significant change management process with the challenge of not having something shiny and new to highlight upon completion; which is part of the rationale for not investing funding dollars into de-implémentation. However, our less effective and sometimes harmful models and services are a major barrier to enhancing equity in our system. It’s highlighted clearly here in one scoping review:

"Low-value care also has implications for health equity. Helfrich and colleagues highlight several examples of racial and ethnic disparities in both overuse and underuse [18]. For instance, Black and Hispanic patients receive a higher rate of low value care than white patients for several services, such as inappropriate feeding tube use among dementia patients [19]. Furthermore, patients of color with low socioeconomic status subsidize low-value care among more affluent white patients [20]. When overprescribing or overuse occurs, this leaves fewer resources that can go to patients in need
[21]. McKay and colleagues suggest it is unethical to leave harmful, ineffective, or unnecessary interventions in place when removal and/or replacement is warranted, and at the same time caution researchers to carefully consider the contextual factors surrounding these interventions and potential remedies as to not further disempower marginalized stakeholders [22], "The authors continue:"These findings and others have helped bolster the importance of de-implementation research to develop approaches to promote the reduction of unnecessary interventions. De-implementation is defined as discontinuing or abandoning practices that are not proven to be effective, are less effective or less cost-effective than an alternative practice, or are potentially harmful [22, 23]."

With these two points at the forefront of my mind as a system leader who works in the area of evidence and implementation I’m curious as to what others think about this topic. How can we shift the collective approach in our country to value de-implementation as a driving force for equity? And when we implement, how do we ensure we have an equity-first approach from the outset?

https://implementationscience.biomedcentral.com/articles/10.1186/s13012-021-01173-5