Should Health Reform in New Brunswick embrace any of the elements of U.S. healthcare?
It is Friday, 4 p.m., the chest infection that you have nursed for a week is not getting better and has you weak and sick. You call your family doctor’s office; a recorded message says “call telecare, go to an afterhour’s clinic, or go to the Emergency Department.”
None of those is a good option that will lead to optimum care. A common outcome from a call to Telecare is that at the end of the call there is encouragement to go to the Emergency Department. When that advice has been heeded, what could take 10 minutes of professional time has always taken many, many hours. Sitting in a waiting room when I should be home in bed with prescribed medical therapy is not an attractive option.
Presentation at an After Hours clinic will possibly get you medical care, but each operates differently, some with a “wait and take your chances”, others where you call to make an appointment, while still others require you to go to the clinic in person to get your name on the list after which you may be seen a few hours later. And in no case does the after-hours clinic have access to any of your records, particularly of medications you may be on or to which you may be allergic, or, better still, what antibiotic worked for you the last time!
In writing this column, I am working from an office in Augusta, Georgia where I see Prompt Care, Primary Care, and Urgent Care usually within a 5 minute drive of my office! And when you go to Urgent Care with flu-like symptoms or other symptoms, the receptionist calls up our records from the hospital on the computer and can tell right away what hospital and emergency visits you have had, what clinical interventions you have had, results of diagnostic tests. You can get routine lab testing on the spot along with some imaging scans. You can be out and back home with any essential medications within an hour!
Each of these facilities, including Emergency Departments, advertises time to wait and Time to Care, the latter being the measure of efficiency. Each facility seems to take great pride in the lowest possible “Time to Care”. Why is that?
Unlike the New Brunswick urban system, the method of payment to physicians and clinics is dependent on customer (patient) satisfaction; as with buying cars or fast food, there is a doctor and patient financial relationship that recognizes that while the service provider has time pressures, so do I as the patient. I need to get home to heal; I need to get back to work as quickly as possible.
This is a sharp contrast with the semi-socialized system that seems to direct primary care in New Brunswick. In our system, we have the blessing of not having to worry about whether there is a co-pay charge or whether our insurance has somehow lapsed or whether the treatment is covered. Most of what we need for life sustaining care is available with the presentation of the Medicare care.
In our system, we are patients but there is no buyer-seller relationship; strictly doctor-patient, professional, mysterious, wonderful in many ways. But the waiting times, the delays, the inability to see our records, the inability to check diagnostic test results. This is 2020 and New Brunswick is supposed to be an IT leader……but not in health.
My friends in Augusta have access to a portal at which they can obtain on the internet their full hospital medical record, results of diagnostic tests including lab results. And a new resident in the area can find a family doctor pretty much the same day. And the discovery of a bad gall bladder can be fixed on the same day as its discovery!
That all costs money, my critics will say. That undoubtedly is true but more importantly it requires understanding that service providers have their first duty to their customer, the patient. Jim Sinegal, founder of Costco, makes the point that organizational success in dealing with customers is all about culture. That is why employees happily remain with Costco for years when other retailers experience turnover.
Then it requires vision of a system that places the interests of the patient at the centre and builds services and systems that ensure efficient and effective care. It also requires a commitment to putting the people with the best training, experience and skill in charge of essential programs.
We could build these patient-centred systems in New Brunswick. It will never happen as long as we keep violating the key principles that make the system patient-centric. When all is said and done, what makes this system so much more efficient is customer focus whereas in New Brunswick, until now, our system has largely been driven by the convenience of service providers. This relates to office hours, access to care, weekend care both in the community and in the hospital. Every service provider needs to start their work day by asking one simple question: if I were treating my parents today, how would my service be different?
In using the American health system analogy, we get immediately to the issue of cost and certainly when we hear tales of six figure invoices for what we deem to be routine surgery that is sobering. And when we hear about the large number of “charity cases” and persons without coverage that too is sobering. Just adopt the principles and apply them to New Brunswick.
For instance, the first thing that I learned many years ago studying some excellent centres is that the physician community plays a huge role in governance! By having physician and nursing leaders embedded in the governance structure, or even leading it, there is a better than average chance that policies and strategic directions of the organization will go down better with the professional community.
Another key element is reliance on efficient information systems, driven in the US by the critical billing system. Being able to get access to records and test results on line is huge.
The focus on getting patients processed efficiently with a minimum of delay is another feature that requires physicians and administrators to work very closely together. Both benefit because of the way the system is financed whereas in Canada the compensation and reimbursement models tend to present a wedge between physician practice and hospitals.
Another stunning feature is that staff functions at full scope of practice: LPNs, RNs, Nurse Practitioners, Nurse Anaesthetists, Family Practice Nurses and more. This stands as a serious contrast with New Brunswick where rivalries, inter-professional angst still is strong. This feature alone is a great roadblock to patient-centred care.
In examining other health systems, the Organization for Economic Cooperation and Development ranks the US and Canadian systems as the lowest amongst 10 western world countries. So we would not want to blindly parachute elements of one system over another. We should, however, have the courage to acknowledge that for all of our excellence in New Brunswick we can be so much better for our patients by doing some things that other systems have already shown to be effective. That starts with putting the patient at the centre and building programs around them, not around the convenience of service providers.
Ken McGeorge,BS,DHA,CHE is a retired veteran health care CEO, part time consultant and columnist with Brunswick News.
True to their promise from last fall, the Higgs government has succeeded in capturing the attention of New Brunswickers around health reform. The announcement of what is referred to as a plan that includes major changes to small, rural hospitals was the second step. The actual first step was the announcement of the expansion of Nurse Practitioner appointments within the health authorities on January 27.
Anyone involved in the health reforms of 1992 knows that a frontal attack on rural hospitals is a formula for certain push-back, speaking mildly. My friends and I remember well the fact that despite the logic, people on the ground were interested in only one thing: will my doctor be able to look after me and my children when we are sick particularly at night or on the weekends.
It was difficult enough in 1992 when 55 hospital boards were dissolved in favor of creating 8 regional hospital boards. But now you have a population for whom that is forgotten and the power of social media. Social media can win and lose elections!
The aftermath has been predictable with local MLAs taking real heat at a time when election talk is in the air and rural seats are critical. Dwight Eisenhower said: “Farming looks easy when your plough is a pencil and the cornfields are a thousand miles away.” And so it is with those who would initiate health care reform. From Fredericton the world looks vastly different than it does at 2 a.m. in Plaster Rock!
It is clear by now that the provincial government is intent on shaking things up in New Brunswick and most New Brunswickers think it is about time! Many issues face the Premier and his government that have been the topics of angst in the electorate for decades including municipal reform, the performance of the education system, infrastructure, extremes in labor relations, economic and jobs development.
So where do you start? It is a challenge for government hanging onto minority status. A strong majority status is to be preferred when wading into major reform for many of the reasons already mentioned in previous commentaries. The commencement of major reform in 1992, difficult as it was, was made much easier with Mr. McKenna’s huge majority and lack of social media!
But make no mistake; the public is looking for leadership on this very complex and challenging file and the Premier and the Minister of Health have both made it clear that they have some great plans in mind.
So just where do you start?
In last week’s column we outlined steps to set the stage for major change in large organizations. Having dealt with determining priority and forces of support and opposition, we concluded that with such a complex, highly political system, it is imperative that government “strike while the iron is hot.” In other words, there are times when the electorate is just ready to support change in its cherished programs and reading the mood and readiness is critical.
The electorate has been calling for change in health care in New Brunswick for over a decade but the messages have not been clear. Government response and public desire have often been on opposite sides of the street. While the public has wanted an improvement in the Ambulance system and its life-saving services, governments snarled it up with issues of which is not where the mood of the public was. They want their loved ones attended to as quickly as possible.
The modern hospital has become the centre of much attention here and across the world. These are not facilities to be treated as yet another office building nor retail outlet. Lots of things happen in hospitals that can, and often do, attract some unsavory characters to the premises!
I remember calling one of my colleagues several years ago and in mid-conversation, he said: “gotta let you go; terrorists are in our ICU”! This was not North America but could be.
I remember getting an urgent call from our Post Partum unit one day when the nurse said a husband was there brandishing a revolver! I also remember countless stories of persons coming while intoxicated to our emergency department, sometimes for treatment of injuries, sometimes to sleep it off.
My staff often had to deal with persons with major psychiatric problems that manifest in belligerence and serious aggression. There have been cases reported of babies abducted from post partum and nursery areas in some cities.
On Tuesday, the New Brunswick Health Authorities issued a document that is mostly aspirational in terms of future directions for health care services. The document did, however, get specific as it relates to rural “hospitals” and noted the conversion of beds to “chronic care” and announced changes to the way emergency health services will be offered in small, rural facilities. Understandably, those living in rural communities are expressing visible concern if not anger.
And why not? They, for the most part, enjoy a level of primary care services that exceeds the expectations of those of us living in urban New Brunswick. The family doctors who provide care in many of these local communities offer their patients a totally personal level of care without the significant delays that are typical in urban health care. With access already to a level of superb primary health care services, the thought of losing some elements of that service is too much for them.
If I were driving health care reform, this would not be the hill on which I would want to die because the actual cost savings, relatively speaking, are not significant.
Ken McGeorge, BS,DHA,CHE is a career health care executive based in Fredericton, NB, Canada.