Two health and long-term care issues have been prominent in New Brunswick Media in the last few weeks. First, we had the medical society presentation of their ideas for health reform, to which the Minister’s response, as reported in the Gleaner on February 8, 2024, was that he would negotiate with them.
The second was the on-going issue of Travel Nurses and, yes, over 300 New Brunswick nurses have joined the Travel nurse industry, and that is in addition to all those who have just thrown in the towel, retired early, or chosen other career directions. Recent stories from nurses who have moved to other provinces have been alarming. Both represent crises created by years of indecision and failure to recognize emerging trends and population forecasts. The travesty is simply this: the health system is a very complex industry in which there are no simple solutions to anything! One of the areas of complexity is the large number of skills sets and professional groups that are required to maintain the vibrant health system required by the public. In these difficult areas, change does not take place on a dime, and promises of hiring and recruiting often don’t materialize as communicated.
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Since 1966 I have worked in hospitals or nursing homes, most of those years in some key leadership roles, with a few years in civil service as well. After 48 years of full time working, I “retired” only to get caught in a series of consulting assignments that largely related to senior and long-term care. And now, at age 79, I am honored to still be working with some superb people, all of whom are trying to make the health and long-term care system more consumer-friendly, operate more effectively.
In 2016, Dr. Suzanne Dupuis-Blanchard, a noted nurse-researcher at University of Moncton and national influencer, and I were asked to co-chair the New Brunswick Council on Aging. We both accepted but only after being assured by Social Development Minister Cathy Rogers that government truly wanted to implement the changes that would make a serious improvement in the senior and long-term care system. One of the huge problems in health and long-term care services is that typically decisions get made regarding services, the organization of services, the timing of services, who delivers the service by persons occupying positions of authority. Decisions at a high regulatory level are made by government officials who may or may not, usually not, have had training and experience in the area of concern by the regulation. This phenomenon is not uncommon in governmental regulatory agencies.
At a clinical or direct service level, decisions get made by staff who are engaged, as is the case in nursing homes, to provide direction for administration, care, activity and such. Decisions are influenced by government regulations, national and provincial best-practices, and collaboration between service providers including physicians. Often equipment suppliers play a role as they introduce the best of technology at “trade shows” and communicate new technology to service providers. As noted in my commentary of January 13, 2024, the way out of the Chaos in health care, referenced by Horizon officials and the media, is not for the faint of heart. The chaos results from years of serious inattention to core issues by government at both political and civil service level. Emergency Departments, Primary Health Care and Long-Term Care, as the three areas named in the chaos over the Christmas period, are three of the elements of what is, in public policy, the most complex system known to man. Don’t take my word for it. Peter Drucker, one of the all-time most famous authors, teachers and researchers on organizations called hospitals “the most complex form of human organization we have ever attempted to manage.”
So, when political and civil service persons attempt solutions to crises as simply making cuts, changing boards, changing CEOs they miss the point. Fixing healthcare performance is not a matter for sound-bytes and photo-ops. That is why the reforms of 1992 in New Brunswick started with the organization and consolidation of hospitals with the intent of consolidating managerial and clinical program direction under regional sets of policies and regulations. But there has been so much tinkering since that time that the goals of reform have been all but missed. Did you find it odd that the most joyous season of the year had to be tainted with cries from the hospital authorities for people to stay away! In the messaging, the situation at emergency departments was described as chaotic. It was not a time that instilled confidence in what is definitely a distressed health care system. Government raised hopes during the last election that this would all be fixed. In fairness, the promises and raised expectations took place prior to the Pandemic and that was yet another tragedy for which the province was seemingly ill-prepared.
Marg Melanson, the Interim CEO of Horizon, who has given stellar leadership since the major government intervention on July 20, 2022, came out on Saturday with the promise to fix the problems. I do believe that she is sincere, committed, heartbroken about the public discomfort. But the issues causing the Christmas, and other elements of Chaos, date back long before her time, long before Dr. Dornan’s time, long before the time of Premiers Higgs, Galllant, Alward, or Graham. Melanson inherited an organization that was struggling before the pandemic for reasons cited earlier in these columns. Cyclical and unplanned leadership change and political intervention do not make for superb organizations to thrive. The Op Ed by Dr. Paula Keating, published on December 17 by Brunswick News, was refreshing. It was a delight to see the President of the NB Medical Society strongly advancing the concept of integrated, multi-disciplinary primary health care. It was refreshing because it is a concept, well developed in other areas, that has been advanced in New Brunswick for nearly 20 years yet the traction has been slow to realize. In recent years some innovation has been sparked not because of government innovation or direction but out of sheer common sense when physicians themselves take the bull by the horns to create models that better serve the public in 2023.
The medical society itself, a very influential body, has advanced models in the past that seem tentative and not filling the definition that Dr. Keating articulates. The Department of Health has not been able to get serious vision cast regarding integrated and multi-disciplinary primary care. For years New Brunswick has had this public policy tug of war at the expense of patients who suffer from issues requiring sometimes even minor surgical correction. The tug of war is: lots of Operating Room Space and getting much better with new construction, specialist surgeons who could and would love to do more work but cannot get surgical hours in the Operating Room.
In the middle of the pack is the patient whose gynecological issue really needed repair or the acutely painful joints that could be fixed in a flash or the vascular challenges that would benefit from repair in a few days not a few weeks. In tugs of war, it is always the patient in the middle in health care and, for them, not only is it not pleasant but it is often unnecessary. For decades in New Brunswick, the typical discussion of surgical wait times and access to operating room time has degenerated into “shortage or nurses and shortage of anaesthetists.” That theme was carried again in Andrew Waugh’s article on November 29, 2023 dealing with Hip, Knee Surgical push… Thursday’s article by Savannah Awde presented great news for Fredericton; Urgent Care in the greater Fredericton area finally! I have been envious as I travel to visit family in the US and see that they can access Urgent Care in minutes and be in and out with treatment and prescription in an hour or less. All right, it is not a socialized system but surely the principles of innovation and meeting public need must rank somewhere in public policy priority even in socialized systems.
The saga in Fredericton has been a long story and I commend the Horizon officials for getting to it. Those who experience those long waits in Emergency Departments for an intervention that sometimes may take 10 minutes may be able to breathe a sigh of relief. But let’s give them time to work out the wrinkles that inevitably will be there. Premier Higgs is a professional engineer and engineers and accountants have one thing in common: numbers and formulae. And it is good that they do or the world would be in a bigger mess than it is.
What was eye-catching, however, was the headline on Wednesday, November 8, 2023 that said: No Politics in Hospital Decision. According to the article, he was referring to his meeting with doctors in Fredericton who had expressed frustration that the new, multi-million-dollar Surgical Suite project at DECRH would not include state of the art imaging equipment. Apparently, the equipment that makes it a hybrid Operating Room will be going to Saint John Regional instead even though the Chalmers Foundation is interested in raising the funds to purchase the equipment required to create the hybrid status. Does that sound familiar? “If you don’t know where you are going, any old road will do”, so says the oft-quoted quip from Lewis Carroll. I have attended many planning and strategy sessions in which that was used to get audience focus on clarity of vision and plans.
David Duplisea, the CEO of the Saint John Region Chamber of Commerce said it well in his Brunswick News article on Saturday, October 28, 2023. Commenting on the lack of a visible plan for critical issues in the province, of which he named health as one important one, he said: “it’s time to put the cards on the table.” His article went on to observe the great successes of fiscal prudence with surpluses and paying debt while issues of health care and others continue to dog our society and economy with no apparent plan. “NBers unhappy about health system, survey suggests”; so, said the headline in the Fredericton Daily Gleaner on Saturday, October 14, 2023. The article was based on an Angus Reid national poll that interviewed 5,010 Canadians of which 285 were New Brunswickers.
I presume statisticians may consider those numbers are “statistically significant” but I would doubt that any serious business would make expansion or re-structuring decisions based on survey samples that are a tiny fraction of 1% of the population. But where there is smoke there is fire. Even with a small sample size, those in charge of program delivery need to pay attention because the poll at least indicates a need to dig further. It did suggest, for instance, that those who responded had little confidence in government to deliver on its promise of reform. One of the dangers of polls and headlines is that the great people in the system who perform with skill and compassion get swept up in the broad assessment of the health system. The truth is that when you need emergency (life sustaining) treatment, some key elements of the system are there with great efficiency. “NBers unhappy about health system, survey suggests”; so, said the headline in the Fredericton Daily Gleaner on Saturday, October 14, 2023. The article was based on an Angus Reid national poll that interviewed 5,010 Canadians of which 285 were New Brunswickers.
I presume statisticians may consider those numbers are “statistically significant” but I would doubt that any serious business would make expansion or re-structuring decisions based on survey samples that are a tiny fraction of 1% of the population. But where there is smoke there is fire. Even with a small sample size, those in charge of program delivery need to pay attention because the poll at least indicates a need to dig further. It did suggest, for instance, that those who responded had little confidence in government to deliver on its promise of reform. One of the dangers of polls and headlines is that the great people in the system who perform with skill and compassion get swept up in the broad assessment of the health system. The truth is that when you need emergency (life sustaining) treatment, some key elements of the system are there with great efficiency. Disclaimer: I am not affiliated with any political party; in my career I have tried to stay in my lane of administering hospitals and long-term care facilities. It has always been wise to maintain great working relationships with persons in all major parties, sharing with them all that I know which is health and long-term care excellence. Beyond that, who gets elected is up to the public as far as my involvement is considered.
With that in mind, and since I have been so visibly passionate about health and long-term care reform in the past several years, it goes without saying that anything that slows down what should have been a clear reform process is irritating to me. In my commentaries, in the past 4 years, I have outlined issues around long waits in Emergency, Primary Care Access (or not), workplace culture and health manpower issues and ever so much more. At age 26 I had the honor of being named Acting CEO of the IWK Hospital for Children in Halifax. It was brand new with all the bells and whistles on University Avenue. This opportunity came after the NS government had sponsored my education in Hospital Administration at the University of Toronto. I was available when IWK needed someone for 18 months after which time they were successful in recruiting a more seasoned, experienced CEO to guide this superb organization. It was a delight, at that age, to rub shoulders with the Goldbloom’s, Gillis’, Grants, Ernsts, Ross’s of the world, all who taught me so much about what it takes to make a hospital great and perform at world-class standards.
Fast-forward to Halifax Infirmary at age 30, a 418-bed teaching hospital just purchased by government from the Sisters of Charity where my job was to guide the organization thru the transition to becoming part of the public hospital system. That presented large challenges and opportunities in managing the evolution from one set of cultural norms to a Crown Corporation model. Watching the performances at the Public Accounts Committee of the legislature last week has given me cause to ponder. How does NB continue to roll with public servants refusing to disclose essential information accurately to legislators? Where did accountability ever go? Is the legislature only an inconvenience in government?
I remember it well! Impressionable university student, wanting to learn about business and organizations. Business 101: the beginning and introductory course aimed at instilling in young students the fundamentals of organizations. Accountability was drilled into us. For every person in the organization there must be clear accountability to someone; that someone on the organization chart used to teach us was the person who can hire or fire that person, as well as setting performance standards, expectations of performance and professional behavior. As the school year re-opens with all the joy and excitement that normally brings, of course the damper of more covid once again seems to be hitting the media and rumor mill.
There have been calls from a variety of sources for a serious assessment of the response to the Covid-19 pandemic in Canada. This was one of the most challenging social and health crises in the country in generations and anything that significant justifies an honest, arms-length review. Such a review should not be a forum for finger-pointing, name-calling, or nastiness to be publicized; there has already been enough of that. Canada, and each province individually, has serious lessons to be learned and hopefully corrections made before further variants throw the population back into panic. August 9, 2023 should be regarded as a major turning point for health and long-term care in New Brunswick.
For decades in most other provinces, there have been academic programs that focus on healthcare organization and leadership. Ontario was the first with University of Toronto’s prestigious graduate program followed by a superb program at University of Ottawa then York University. With University of Toronto being the pace-setter in the 1950’s with Dr. G. Harvey Agnew, other universities picked up the need for education of those who are currently working in some level of healthcare leadership or those aspiring to do so. Aided by a large Kellogg Foundation grant in the late 1970’s, other universities across the country developed such programming; in Atlantic Canada the superb program was developed at Dalhousie, initially with the leadership of legendary Dr. Peter Ruderman, and it has become a key element of health care services in that province and beyond. The composition and membership of the new health authority boards was officially released by government on June 30, 2023. In previous commentaries I have indicated nothing but support and pleasure that we finally know who will fill the roles.
According to Bill 39, the Minister is obligated to present “marching orders” to the new Board Chairs by the end of September. A mandate letter is, according to the act, supposed to contain:
In two recent commentaries I discussed what really are public policy issues relative to the formation and early days of the new Health Authority Boards whose membership was announced in Brunswick News just last week. Having fired two previous boards and a CEO in what some critics in the public referred to as an unceremonious manner, the process was put in place for the appointment of successor boards.
From the description of the appointees in the news, it looks like a very strong group of people with an interesting mix of business skill, some with some health care background, others with a healthy variety of backgrounds. With a person with strong clinical background as chair of Horizon and a strong successful business executive at Vitalite, and with the requirement in the legislation that the two boards collaborate, the future months and years could get really interesting. News reports continue to keep us up to date on the latest numbers of deaths related to Covid. The pandemic is long over so why are we still getting those reports? We did not get them when influenza was the seasonal bug that impacted so many, except for the required Public Health reports on the government website. The way in which Covid reports are portrayed seems to invoke a sense of concern as if the pandemic is still alive.
That Covid was deadly, particularly with seniors and persons living with immune compromises, is beyond dispute. It came as a surprise to North America although the virus was alive and active in China for at least 6 months prior to the declaration of the pandemic. Once China admitted that Covid was a large public health issue, then the politics of the international community and party politics in the US, and elsewhere, kicked in. Suddenly everyone was an expert on one side or another and those who dared to express views that even questioned the official public health doctrine were branded as strange, weird, extreme. On November 22, 2022, Bill 21 was introduced in the Provincial Legislature by Hon. Bruce Fitch, Minister of Health. Not a lot of fanfare, no parades or demonstrations; the legislation just got through the process of first, second and third readings leading to vote to approve. I don’t recall any press headlines.
Yet it was a decision with some real significance for health care reform in New Brunswick. In the history of this great province, and particularly in the past 3-4 decades, serious decisions on health care have been made amidst significant political push and pull pressures. The Regionalization of Hospitals in 1992, the creation of two health authorities in 2009, the hiring and firing of health authority boards and CEOs, the construct of the health authority boards, the follow up, or lack thereof, to the Council on Aging Report of 2017, the development of the Waterville Hospital at a final cost of well over $100 million, and the list goes on. A scan of media headlines over the years will show how important decisions that have serious impact on public service and the health of New Brunswickers get influenced, if not finalized, by virtue of the noise created in the public square. Social Development Minister Dorothy Shephard has seen health and long-term care reform from the inside out. She was the Minister of Health during the pandemic when times were crazy and she was trying to get the first steps of Health Reform initiated. Given the context with a failed first attempt at health reform, prior to her term, combined with the insanity caused by the pandemic, she gave it her best shot. She was involved in the consultations that were promised, compromised again due to the necessity to do so much virtually with Zoom technology. A poor substitute for face-to-face communication.
Now she is back in the Department of Social Development in which strong attempts are being made, with a superb team of senior civil servants, to get long-term care reformed. The issues in the failure of long-term care in this province are now legendary with hundreds of empty long term care beds, challenges in recruiting and retaining skilled staff, little political or public understanding of the real issues that prevent the long-term care system from functioning like a well-oiled machine. I remember his voice from 60 years ago when Prof. Arnold Cook lectured beginning business students, and I was one, on the principles of what makes for a good organization that grows and develops. The principles of clear accountability, shared vision, strong leadership have been my guiding principles in large and small organizations that I have directed over the last half century. The organizations that grow and survive have shown that Prof. Cook was absolutely correct, and some of them are outlined in Good to Great, the classic Jim Collins book that describes what it takes to take an organization from “good” to “great”.
Transpose that basic thinking then to health and long-term care in New Brunswick and think, for a moment, of the issues that have caused so much nasty public discussion in recent years, particularly the last three. “But oh, we suffer, right? Yes, right!” So said Yente in the classic, Fiddler on the Roof! Families dealing with the Dementia journey suffer, often desperate for support. For years the challenges of getting a correct diagnosis followed by proper and helpful mechanisms and
supports for the patient, caregivers, and families has been the huge “elephant in the room” in discussions of health care for the aging population. With the greatest proportion of elders amongst provinces in the country and a population that has forecast its aging issues for decades, it should come as no surprise that emergency departments and hospital beds are distressed with elders in crisis. Professor Richard Saillant, the noted Moncton-based economist and author of Over the Cliff, wrote a sobering article in the Brunswick News on March 4 in which he detailed the difficulty that the NB government seems to have with its fiscal projections. The current government was elected on a platform of fiscal responsibility, attacking the provincial debt and reforming health and long term care, municipal government, education and other services. Somewhat accurate fiscal projections are needed but are always elusive in the public sector.
At last count, according to Saillant’s summary, government was projecting a surplus in the current year of nearly $1 Billion. And to staunch fiscal conservatives, that is incredibly great news. This could not only stop the bleeding of expenditures but could also provide some capacity to actually reduce the public debt. But not so fast. Are you heeding what is really still happening in health and long term care? Wait times for essential diagnostics are such that private clinics have been developed with the Federal government now “clawing back” over $1 million in health transfer payments. Worse still are the continuing stories of people either not getting essential diagnostics and care on a timely basis, but still a disturbing number without access to primary care or on long wait lists for long term care. |
AuthorKen McGeorge, BS,DHA,CHE is a career health care executive based in Fredericton, NB, Canada. Archives
May 2023
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