For years, the public has been expressing its disapproval of horrific long waits in Emergency Departments along with frustration and anger when their doctor retires or leaves the practice only to be left with either the Emergency Department or an After-Hours Clinic as their source of primary health care services. In recent years, the media has carried a seemingly endless stream of articles and commentaries on topics ranging from hospital staff absenteeism to violence in the workplace toxicity. We have heard the cries from gifted specialists in various surgical disciplines who claim to have access to no more than one day per week in the Operating Room for elective and urgent surgical cases.
The stories are endless and the public has been growing increasingly restless. The professionals, on whose work the reputation of our health care services depends, are getting increasingly restless. The Minister of Health has recently spoken about the Department of Health taking over the recruitment of doctors yet it is difficult to envision recruitment and retention success until some major shortcomings of the system are cleaned up.
Health Minister Dorothy Shepard was quoted in Savannah Awde’s article on March 23rd as suggesting perhaps a correlation between outbreaks in long term care facilities and learning curve. I expect she was suggesting that staff had to learn about proper use of PPE and other elements in mitigating spread of infection in care facilities.
She made a good point. For everyone in the health and long-term care systems, and their regulators, the Departments of Health and Social Development, the learning curve has been long, steep, and difficult. In the early days of pandemic, mid-March 2020, all that the worldwide Scientific community knew for sure was that there was a bad virus on the loose, originating in Wuhan, China where that government’s official line, as recorded in the Wuhan Diary, was: “Not contagious between people; it’s controllable and preventable.”
“Nursing education has been a key factor in the quality of health care throughout Canada’s history, and the quality of education for nurses has been a major focus for the CASN throughout its considerably shorter history. The progress in educational standards has clearly been substantial since Dr. Mack first established his training school in 1875. History suggests, however, that this progress is always tenuous and subject to erosion or subversion by external forces. The overriding goal set by the Association’s founding members for nurse educators to join together and present a strong voice in support of quality in nursing education continues to be as relevant in today’s complex environment as it was in 1942.”
This was the conclusion in a most interesting history of nursing education entitled “Ties that Bind”, published by the Canadian Association of Schools of Nursing, 2012.
And, so, it has been since the early days of the Grey Nuns and the Sisters of St. Joseph in their early work centuries ago in Quebec which preceded Dr. Mack’s first School of Nursing in St. Catherine’s, Ontario in 1874. Then other nursing schools opened in major cities, including Halifax, NS, shortly thereafter.
In those days the medical and nursing professions worked together in changing the face of health care and introducing formalized and much-improved training for nurses and physicians. The Flexner Report published in 1910 set the tone for what we now know as strong, university-based education for physicians and nurses. Up to that point, for both professions, education was really based on the apprenticeship system with hospitals relying on both medical and nursing students to provide essential care for patients.
How did we get here? “Nursing education has been a key factor in the quality of health care throughout Canada’s history, and the quality of education for nurses has been a major focus for the CASN throughout its considerably shorter history. The progress in educational standards has clearly been substantial since Dr. Mack first established his training school in 1875.” The Tie that Binds report, produced by the Canadian Association of Schools of Nursing in 2012, is a fascinating history of how we got here!
In any superb health system, there are a few key ingredients, factors that are essential for quality and public satisfaction. Nursing is one of the big ones! It has always been thus since Florence Nightingale.
In New Brunswick, government and the profession and universities have some issues to resolve if the profession is to grow and develop in a manner that will meet public need and the need of employing organizations. In recent years the public has been exposed to much publicity about violence in the workplace, overworked, stressed nurses, large numbers of impending retirements with insufficient persons being trained to fill the positions, nurses without full-time jobs, unemployed Nurse Practitioners……and more.
The first rule of politics: don’t ever waste a good crisis! In exercising the need to continue to cultivate voter support, times of crisis present a magnificent opportunity to curry favor with voters and potential voters. The longer the “crisis period”, the more opportunity for elected officials to raise the level of their political capital or spend it.
Such has been the case with the Covid-19 pandemic. In Canada we have been spared the drama that seems to play out in some jurisdictions; in some of these situations the stakes are enormous and competition for air time and influence is beyond anything we can fathom in New Brunswick.
But clearly, as the Canadian version of pandemic drama unfolds we see where “the ship is leaking” and the best that can be done now is to mitigate the risk and damage. In Canada, the eyes are clearly on Long Term Care. Covid-19 has brought deaths amongst seniors and residents of long-term care facilities to the fore. Thankfully, New Brunswick has been spared this drama in long term care.
In May 2021 we will go to the polls to elect our municipal council leaders in New Brunswick. I have great admiration for all who are putting their hats in the ring; serving in municipal leadership is not as glamorous as other highly visible appointments might seem but the issues are serious, particularly in these days of social and political change and unrest.
Following a career spanning 50 years in health care leadership in three provinces and now with the added exposure of multiple post-retirement assignments, including writing columns for Brunswick News, a few have suggested that I run for a seat on the health authority board. That was from the few who actually are aware that some health authority board members are actually elected in the Municipal election process. Some say that my columns and book help them to understand issues that otherwise are dealt with in brief news articles or video clips.
I did think about it……I actually got the nomination papers and had enough people to sign to make it legal.
Minister Shepard was quoted in Savannah Awde’s article on March 23rd as suggesting perhaps a correlation between outbreaks in long term care facilities and learning curve. By that, I expect she was suggesting that staff had to learn about proper use of PPE and other elements in mitigating spread of infection in care facilities.
She made a good point. Everyone in the health and long-term care systems and their regulators, the Departments of Health and Social Development, the learning curve has been long, steep, and difficult. Going back to the early days of pandemic, mid-March 2020, all that the world knew for sure, including WHO, Centres for Disease Control, Dr. Fauci, Dr. Tam and thousands of other “experts”, was that there was a virus on the loose, originating in Wuhan, China where the that government’s official line was: “Not contagious between people; it’s controllable and preventable.”
There is a strong body of opinion amongst fiscal conservatives in New Brunswick that the provincial budget should be balanced and the debt should be reduced if not eliminated. I have had that discussion with several strong advocates of that position and the logic is clear. The overwhelming interest on debt could build nursing homes, it could free us from fiscal bondage, it is just the prudent business strategy for government. These same advocates point out, correctly, that any business that carries debt at the level carried by the province would be in deep trouble if not bordering on insolvency.
However, Government has the responsibility for a health and long-term care system, education system, provincial infrastructure, post-secondary education and much, much more. In each of those sectors, Health and Social Services representing nearly 50% of budget expenditures, structural cost growth happens year after year at 3-4 times inflation despite the best intentions of policy makers. To slow down the growth of debt or reduce it, government needs to find a way to generate operating surpluses year over year for quite a few years! Mr. Higgs was elected on his promise to get to fiscal stability and responsibility which meant trimming the debt and interest payments.
Nursing is, along with Medicine and other health care professionals, a major part of the backbone of the healthcare system. A noble profession with roots in the image of Florence Nightingale. The profession, in modern times, has grown into huge numbers as its public image has remained high. And why not? These professionals have helped deliver your children, assisted in the Operating Room, managed the Operating Room, cared for your dying mother, and have dealt with many patients who are not always the sweetest customers in the world!
Embarrassed and shocked by the large numbers of deaths in certain long term care facilities largely in 4 provinces, the Federal government is now calling for Long-Term Care Reform or the creation of National Standards for Long-Term Care.
A bit late, don’t you think? For a half century, public policy experts have been observing the growing population of aging baby boomers and forecasting that the health and long-term care system would be distressed at unprecedented levels. But in much of that 50 years, while health care has seen a boom in expensive new services, much of the approach to caring for that small segment of the senior population deemed to be frail or compromised by multiple chronic diseases seems to have progressed little. We do have an unprecedented number of long-term care facilities, many superb, that have grown more by accident than by design. Long-term care has morphed into a significant industry in the absence of consistent regulation.
Consulted to death? More talk? Where’s the action from the last round of consultations? The public can be forgiven for feeling skeptical because the health field has been the most “consulted” field in our society. In this province, consultant reports were presented in the 1960’s and finally acted upon in the 1990’s-but then, only in part.
Why the timidity on the part of governments? Why does common sense need more consultation? This round of consultations is taking place because government tried to implement what they thought were logical steps in healthcare reform in February 2019. The logic was clear: acute care beds occupied largely by frail elders in small hospitals should be re-classified as long-term care beds. Because small, rural emergency departments only see 2-3 patient’s over-night, why would you keep a doctor and nurse on staff to cover? Tim Hortons would not do that? Economically it does not make sense. I would guess that the cost per visit would be exorbitant relative to the cost per visit in a high-volume centre.
It is hard to focus on the important when pre-occupied by the urgent. Covid-19 is the urgent and has our collective attention: the public, our institutions, our public servants, elected officials. And while we all just want to get out of this mess, it will be over in a few months and we will be in a new normal, whatever that looks like.
But please do not forget how angry so many in the population have been prior to the pandemic about the state of our health system. Rural people were traumatized in February with talk of eliminating what they believed to be an essential service. Urban people have been very angry about access to efficient primary care services, long waits for service, over-crowded emergency departments.
As promised, Health Minister Dorothy Shepherd released her Discussion Paper on Thursday, January 21, 2021. The paper raised issues of Primary Care, System Efficiency and Safety, Access to essential surgical treatment, Mental Health and Addictions, Senior Care, and use of current technologies. The last thing in the world New Brunswick needs is more public consultation, summaries, and reports. All of these themes have been beaten to death for 20 years. What has held us back from progress is having a government with the political courage to face reality in the eye and move forward on a plan to fix what so many know is broken!
The results of this Discussion Paper consultation will inform the development of the new 5-year health plan. Apparently, New Brunswick currently has a 5-year health plan about to expire. Surprisingly front-line staff and consumers of care seem unaware of such a plan. Health care is such a politically sensitive issue that governments have to avoid issues and deal only with cosmetics or wade in without fear of losing legislative seats.
The issues that plague the system stem from lack of consistent focus and informed, consistent leadership at various levels in the health system. Here are the issues that simply require courage to do the right thing:
In all the noise made in public about health care issues, the pleas from interest groups, unions, associations, societies, almost without exception, are for “Government to do more; we need more…..”
Seldom does one hear any discussion about issues of efficiency and effectiveness of the current services and systems. Why is that? It goes against the grain of interest groups to acknowledge that there may be other ways of achieving better service. And because health care is a highly-charged political system, majority governments have only 2-3 years at most in order to make a dent in improving one of the most complex and convoluted sectors of our society. We, the people, have a love affair with our health care system and heaven forbid that any politician should do anything to offend my doctor or my daughter, the nurse, or all those other people who the public believe to be working very hard to keep services going.
On Friday, January 8, 2021 the New Brunswick Labor and Employment Board handed down its decision on the fate of LPNs working largely in the Health Care System in New Brunswick. There are 4000 LPNs in the province with 2500 working in the hospital sector. That the decision came as a shock and disappointment to the eighty five percent of Licensed Practical Nurses who launched the action would be an understatement.
For many years, as the LPN profession has matured, there has been a strong and growing unease with this professional care delivery group being represented by CUPE and 85% of the LPNs initiated an action to be moved from CUPE to another union. This involves a long and expensive process of application and hearings with the New Brunswick Labor and Employment Board.
This decision represents, as well, a set-back to the vision, expressed by many, to introduce reforms to the health care system.
As discussed in previous commentaries, the entire culture of care needs major overhaul. While there are many moving parts in creating a true culture of Patient-Centred Care, one major element is the creation of a clinical workforce that truly works together in complementary, not competitive, roles. The roles of PSW’s, LPNs, and RNs need to be clearly identified so that they function in true complementary fashion with all functioning at full scope of practice and collaboratively with all health care professionals. The workplace in which those dynamics come together under informed leadership is a true delight!
In the lead up to Christmas during the legislative session of the Province of New Brunswick, the Minister of Health re-affirmed her commitment to consultation with the public relative to health care reform. She is an honorable person who will always do as she says; I know that.
The challenge will be to engage in consultations that are truly meaningful to the population being served and who pay taxes. They are the customers and, in the end, the customer is always right! The customer knows when a great product is being delivered but most often the customer is not sufficiently aware of all that it takes to get a quality product to market, a product that can be sustained in quality and price in changing times.
On the other hand, government officials working in offices with desks and computer screens in Fredericton, Bathurst, or Miramichi, or elsewhere, often have their thought processes directed by their own set of experiences, their own educational background, the experiences and backgrounds of those around them and the very culture of government and the civil service itself.
According to Christian tradition and teaching, two thousand and twenty years ago a shepherd and his pregnant wife were faced with sleeping on the street. An Innkeeper was merciful and allowed them to use the stable where, later in the night, the wife delivered her firstborn son. By modern standards, delivering in a stable with hay, animals and their smells, no hot water, and dim lighting would be thought of as reckless, substandard.
The celebration of Christmas typically brings memories from childhood and for persons of faith it brings strong and important reflection on the meaning of Christmas as expressed in the Holy Bible. Along with reflection comes a towering sense of charity amongst people as reflected in year end giving to charities, the Salvation Army, Feed the Family and food banks and others who do great work with thousands of families. Some specifically target people “living on the street”.
In his TED talk in 2015, Bill Gates warned the world: there will be another pandemic soon. He warned governments to get prepared by developing good plans and doing “Germ Games, not War Games”. He said no need to panic but we need to get going to be ready for the next epidemic. Using the problems with combating the Ebola outbreak in 2014 he showed that the world is not ready, that the WHO is not the body to mobilize resources and systems, that there is a need for an overall global health system to respond to outbreaks.
As our Emergency Measures Leaders will attest, proper planning is a tough discipline and it is often difficult to get busy people to take emergency preparedness seriously. It is difficult to mobilize political support because it has little electoral appeal. For those of us in the health professions, it is much more satisfying to look after sick people, frail elders, accident victims and those with terminal illness than to invest hours in planning for the unimaginable.
How much relevant pandemic planning has taken place since 2015? None that would be recognized.
At this point, we are all experiencing Pandemic Fatigue, tired of hearing it as the main news item as if nothing else is happening except the US election! Tired of being locked down! Tired of following arrows and being so anxious in the grocery store! Tired of not being able to see family without someone making you feel guilty. Is the upper limit 5 or 10 or 20 this week? The prospect of Christmas being so very different from the way it has been forever is depressing to many!
As some have suggested, much that once was wholesome and fun in normal living has been stolen. One hopes the departure is temporary, but some may suspect otherwise.
We have had many serious outbreaks in our history and several just within the last two decades, namely SARS, H1N1, Ebola, Influenza, Measles, Cholera and more. Each has been serious and each has been deadly. Remember just two years ago in New Brunswick we were a bit panic-stricken with the detection of a few Measles cases that somehow got into the schools.
In the view of many, the Auditor General’s Report was revealing, welcome, and finally placed some issues in public view. All those news stories about long waits and ambulance no-shows seem to have firm foundation.
For decades the local ambulance service across the province was a mix of hospital-operated vehicles, Saint John Ambulance services, and systems in rural communities of volunteer-based services and services run by local businessmen or funeral directors! With this hybrid, there was a variety of levels of service from highly professional and efficient to fairly rough. There were some concerns with standards of service brought to government’s attention that in the mid-1990’s staff in the department of health commenced working on a plan that would provide standardization across the province.
In those days, local ambulance services operated on one-year contracts and could easily have been cancelled if performance was a problem. One seasoned operator, who served on a government advisory committee, observed that there were regulations in place but no regulatory capacity; nothing happened to those operators whose standards were problematic.
“Those who fail to learn from history are destined to repeat it.”
Let’s get the lessons straight, well documented, and get prepared for the next one, as Bill Gates said prophetically in 2016! Despite the fact that outbreaks seem to come as a big surprise to the population and health officials, they are cyclical! This is the reality of modern times.
After months of media clips showing China dealing with this virus, the World Health Organization declared a pandemic on March 11, 2020, this announcement being based on very early experience and forecasts employing statistical models done by experts. This was after major US media outlets had down-played the seriousness and the U.S. administration was admonished for curtailing air traffic from China.
Within the health and public policy community, there was very little knowledge of the virus and its characteristics.
Sue Rickards, in her commentary on Friday, September 18, 2020, advocated the attack on chronic social and economic problems at their roots. It was a good piece that illustrated the shallowness of much conventional public policy decision-making.
Such has been the case with health care for generations until 1992 when true reform was initiated by the NB government. Taking the first steps to consolidate control and direction of acute care by merging hospitals into regional structures was an important first step. While that was a very difficult, highly-politically-charged step, it was only the beginning. What was to come later would and should make a serious difference for citizens of New Brunswick.
In 1970, as a fledgling Acting CEO at the IWK Hospital in Halifax, I was approached by some persons from upper and western Canada who were Icons in the field of health services organization and management. Dr. Len Bradley, then Medical Director at the great Winnipeg Health Sciences Complex, and Dr. John Phin, formerly professor in the field of health administration in Minnesota. I had graduated just one year earlier from what was the Blue-Ribbon program in Hospital Administration at the University of Toronto. This was a small program available only to 18 persons per year who had had some previous experience in the health field.
My class included physicians, nurses, pharmacists, accountants….all having had just enough experience in the management positions in the health field to understand that they really needed a deeper, more rounded education in health administration. So, with superb professors such as Dr. Burns Roth, Eugenie Stuart, Dr. Peter Ruderman and many others we worked through courses in medical science, economics, human resources, health law, hospital organization and management, public health and much more.
Brunswick News publications carried a lead article on Saturday, August 8, 2020 posing the question: Are We Beginning to Tune Out of Covid-19? The previous day, the Chief Medical Officer of Health, Dr. Russell, posed a similar question in commenting on the latest large gathering of people in celebration at a boating event.
From the beginning, back in late 2019, the risk, scope, etiology, contagion, control, treatment and much else surrounding this virus has been the subject of so much more controversy on the international stage than any other in history. The public can be forgiven for feeling more than a little antsy a full 9 months in!
With previous outbreaks, particularly the worst ones in recent memory (e.g., SARS, H1N1), there was a huge spike, much publicity, much discomfort, and so little controversy because the science seemed less vague. Since the 1970’s we, as citizens, have become accustomed to the promotion of the annual “flu vaccine” which has been helpful but never forced on people. Indeed, the vaccines apparently get adjusted regularly and we typically are at the mercy of the pharmacist or doctor to ensure we are getting the latest vaccine.
So, we are going to the polls! Last week had drama leading to the fact that the parties will not agree to the plan placed before them by the Premier. There are two vacant seats and, according to reports, at least three that want to be vacant!
Those who are seriously interested in seeing the health system get fixed should now start to memorize some lines so that when candidates contact you, you can respond with good questions that will force some response. In just how many elections have you heard the same promises? No more cuts! We will keep your emergency departments intact! No, we will not close rural hospitals. Yes, we will hire more doctors and nurses. We will add more nursing home beds; why we will even put some in your riding.
One of the greatest that comes up in every campaign is: We will place new resources into Health Promotion and Disease Prevention. And sometimes that happens, yet the basic issues of the health system remain.
Ken McGeorge, BS,DHA,CHE is a career health care executive based in Fredericton, NB, Canada.