​Health Care System Governance in New Brunswick:

In July 2022, Premier Higgs, having promised reform of the health system prior to election, fired the newly appointed Horizon CEO and disbanded the boards of the two health authorities.  Two trustees have served as surrogate governing boards and an interim CEO was appointed to replaced Dr. Dornan.

So now what?  Health and long-term care cannot be run from the Premier’s office forever.  Informed observers have been calling for a more relevant governance model for the health authorities for years. 

By all accounts, the Health and Long-Term Care System in New Brunswick appears to be in the state that was forecast many years ago when Llewellyn Davies Weeks was commissioned to create a plan.  The regional plan for hospitals, created by the Department of Health and introduced in 1992, was intended to be the first phase of a systematic development of the health care system.  The plan had not spelled out, in finite detail, what it would look like but the regional hospital structure then paved the way for merging difficult files such as long-term care, mental health, even public health into a vibrant system that had 7 functioning regions, fairly close to the people.

The Department of Health and Community Services had staff at senior levels and middle management who had experience and training in directing health care services and they had a vision for a system that integrated health and long-term care.

Following the resignation of Frank McKenna, the vision did not carry on and the visionary staff in the department were dispersed to other civil service assignments, some terminated, and a succession of governments responded largely to political hot buttons as they arose. 

The dream of some who were implementing reforms was that with 7 regional corporations there would have to be one central entity that would be staffed and driven by experienced and trained health care executive personnel; the role of that body would be to do the research and planning to provide direction for centers of excellence in the province.  Saint John already had the recognition as the provincial referral center for cardiac care and other clinical subspecialties.  Government did create the provincial Health Council but stopped short of conferring a mandate beyond analysis and publishing reports.

In the regional structure, the intent was to define in detail the roles of small rural hospitals, community hospitals and regional hospitals based on good research and clinical best practices.  That has never happened and has been the cause of much of the difficulty that finds its way to headlines periodically.

In the years that have followed, the system has become one of confused accountabilities with no one nor any body seriously accountable for making tough programmatic decisions.  Two health authorities had boards with vague levels of responsibility, CEOs not accountable either to boards or the Minister of Health, in reality, and serving at the pleasure of the premier, and priorities changing at the whim of political leaders.

Leadership instability would be the best descriptor of the health authorities, and that is never healthy for organizations as complex and large as the health and long-term care system; so say the experts in large organizations such as Drucker, Peters, Demings, Collins, Welch and more.

Moving Ahead:
New Brunswick is a bilingual province in which honoring the two cultures and linguistic profiles is imperative and desirable for many reasons.  The idea of creating one single health authority would be political suicide and dreadfully costly and it is not necessary nor wise to even think in that direction. 

For many reasons, however, the nature and complexity of clinical and support services are such that consolidation and creating centers of excellence is not only a great idea but an idea that is 30 years overdue.  Short of serious governmental direction, some of the clinical services have gotten organized to the extent that some great working relationships exist and they have evolved with initiative of the people on the ground.  New Brunswick has some superb clinical personnel and all with whom I have interacted honestly want to see the system managed with Excellence as the goal.  So, establishing a clinical organization that brings people to the point of organized collaboration, while protecting linguistic and cultural issues, can and must be done.

When I am referred to a specialist for the care of a complex medical problem, I want him or her to be part of a network of specialists that collaborate, compare notes, share knowledge, and consolidate scarce and specialized skills.

Essential steps for moving forward are:

1. Government must express its vision for the kind of system it wants to see in this province; that has not happened since 1992.  This needs to be bigger and bolder than has been expressed thus far.  If it is well done, it will get little push back aside from the usual skeptics.
   
   
2. Complete the formation of skills/knowledge/experience-based boards with normal board governance principles that include hiring the CEO, assessing the performance of the CEO; effecting leadership based on service excellence.
   
   
3. Newly appointed boards need serious training by persons with advanced expertise in Board governance. 
   
   
4. As Good to Great outlines, each health authority must have a clear focus on leadership, leadership development, leadership succession.
   
   
5. Overhaul of the Health Council legislation and mandate, making it the body that is responsible for working with the two health authorities to create clinical and support Centers of Excellence. 

 
This will require overhaul of the legislation, board structure, staffing will need serious consideration and direction.  In the current structure, the council has been helpful in creating much quality information but, due to its structure, it cannot point to major impact on health and long-term care strategic decisions.
 
By using the health council as the Clinical Services focal point for Centers of Excellence, you give it a serious mandate.  Properly done, it could be the repository for keeping lots of issues in play and off desk of the politicians, most of which tend to be embarrassing.

How do you get this done?  Health and long-term care is so complex that it needs a knowledgeable, committed team of advisors to think this all through.  It is not sufficient for politicians, conventional civil servants, and legal staff who draft documents to try to develop something to put to the legislature.  Moving forward could backfire as other initiatives have backfired.  This one needs to be done carefully, forcefully, but right.
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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 [email protected] or www.kenmcgeorge.com