By now, only the tone-deaf fail to understand that health and long-term care services are in need of reform. Not change, but reform. Traditional, conventional thinking and organization has gotten us to the point of serious inequity in access to effective primary care services, access to timely specialist services, access to urgent and emergency care, timely and effective mental health services, timely and efficient access to long-term care. The good news is, and it is really sad good news, that all provinces are struggling with these issues, some more than others, some at different levels than others.
In each of the regions of this province the practical manifestations of challenges with these issues varies. For instance, the worst of access to urgent and emergency care, as well as routine primary care, is apparently in urban areas, according to observations made by those directing Health Reform. There are many good reasons for the disparity.
Health and Long-Term Care services are totally reliant on the ability of any particular jurisdiction to recruit and retain an adequate supply of nursing personnel in all classifications, physicians of all levels of certification, and the many other incredible health care professional groups that make up the essential core of great service. In business terms, the rule of thumb has always been that up to 80% of the cost of health and long-term care is human resources.
The common core issue right now that is plaguing health and long-term care services is the ability to recruit and retain great people in all classifications. Vacancies abound at all levels that are pressing paying agencies to embark on perquisites heretofore unheard of. Overtime in hospitals and nursing homes, for instance, is now compensated for nurses at a level that had to be introduced in order to maintain the attraction to work and continue working. Retirement at the earliest possible age is the mantra of many employees while it distresses pension plans, as the current CUPE/NBANH discussions illustrate.
It should be pointed out that staff recruitment and retention is not an issue only in the health and long-term care system. Retail, food and beverage, tourism, and others are experiencing difficulties of an unprecedented nature. Some food and beverage businesses have actually been forced to curtail hours simply as a reflection of staff recruitment issues.
If nursing home beds are empty due to staffing, hospital services curtailed due to short staffing, other areas of long term-care expressing challenges with meeting staff ratios, and there is a consensus that health manpower is the major issue requiring resolution, the first step must be to fully understand where we are and how we got here. In New Brunswick, too often in the past, these discussions start with the blame game: salaries are poor? Workplace environment is poor? Union contracts are to blame? Supervision is toxic? And on the list of finger-pointing assertions go………to no productive end.
The analysis has to start with an honest, cerebral look at the factors, the environment, the historic policies and regulations that have driven current practice, and more. But get to the facts in a no-blame environment. For instance, earlier in my career I remember vividly the assertion that we “are training too many physicians” so medical school enrollments were reduced. In retrospect, probably not a great decision; but at the time it gained favor with those desiring cost containment above all.
Over 40 years ago, population trend analysis experts forecast that by now we would be where we are. That is, a significantly lower birth rate producing fewer children ultimately destined for the workforce while the population grows seriously older. I remember the charts and graphs and we, in the audience, listened in shock hoping it would not happen. But it did. So, Universities are scrambling for students, career options have multiplied in geometric proportions, many great career options do not require a university degree as the ticket to success.
Now we start with a proportionately smaller pool of potential employees to begin with. And if, early in their lives, kids are not programmed to think of Health and Eldercare as serious career options, then the need for serious marketing is clear. Appearing at high school career fairs has been a staple over the years but the current situation would dictate a more imaginative approach.
Years ago, one could learn much of what is required in the care disciplines through apprenticeship models (that was my story!). But over the years, there has been systematic credential creep that started with the declaration of the Baccalaureate degree as the basic entry requirement for nursing. For many years, indeed, decades, this closed the door to many great employees who had started literally in apprenticeship roles as aides then moving to an LPN level. Over time, as the credentialling and training has improved, the 2-year community college diploma became the gold standard for LPNs and the Baccalaureate, and for some, advanced nursing degrees, became the norm.
Each discipline in health and long-term care has a similar pattern of credential creep. And all with the best of intentions of improving the standards of service. But all that has ignored, really, the population forecasts that have proven to be correct. With the level of crisis that the system is facing and which does not serve the public exceptionally well, do we just proceed with some worn out old recruitment tools to be able to say we are doing all we can? Or do we start with facts, as cold as they are, and re-think our model of service provision?
It was gratifying to hear the new President of the Nova Scotia Medical Society, Dr. Leisha Hawker, on Tuesday’s newscast as she explained how expanding models such as the North End Health Clinic in Halifax the 93,000 people in NS who are not registered with a primary care practitioner could soon find themselves enjoying good primary care. I remember that clinic because I had a peripheral relationship with it 40 years ago when it was just starting. Today it is staffed with doctors, nurses, Nurse Practitioners, social workers and more. Her paraphrased comment was telling: “by engaging all the professions in the clinic, I am able to focus on applying my training to those who need me the most.”
There are some models in New Brunswick, one on King Street with Dr. Sara Davidson, in Fredericton, which could and should be used as models for establishing consistent primary care across the province.
And while we are at it, we need to apply new thought process to all of nursing, physio, lab technology and more. Many repetitive skills such as patient mobilization, managing wounds and dressings, bowel care and ever so much more, can be taught to intelligent people so that those professionally trained can use their training and invest their professional time in large-payoff activities.
The founders of the core health professions could not have foreseen the distress the system is now under and they clearly did not foresee codifying repetitive care functions into scope of practice to be restricted to those with advanced training. But somehow that is where we have gotten. This current crisis affords the opportunity if not the necessity now to inject pragmatism and reason into the analysis and problem-solving.
Do we want great health and long-term care accessible to all in need? Or will we avoid the obvious and seek the easy way out? I vote for solving real problems.
Ken McGeorge,BS,DHA,CHE is a retired career health care CEO, part time consultant, and columnist with Brunswick News; he is the author of Health Care Reform in New Brunswick and may be reached at firstname.lastname@example.org or www.kenmcgeorge.com