Covid-19: Who Is in Charge of the Borders?

The Telegraph Journal editorial in the June 6 edition is “bang on” in terms of issues in Health and Long-Term Care.  Recent publicity in response to the unanticipated outbreak in the Campbellton Region drives home the issues of the need for health and long-term care reform much documented and written about for a decade in New Brunswick.
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At the heart of this is leadership and communication.  New Brunswick has many stellar health and long-term care professionals; people like Jennifer Russell, Linda LeBlanc, Cindy Donovan, Chris Goodyear and thousands of others.  Each wonderful professional that I know is dedicated to utilizing the terrific training and experience that they have had over many years and decades.

​But as our late Chief of Staff at DECRH, Don Morgan, used to say: “we all see the health world from where we stand.”  That observation was made as we were in the midst of one of several major controversies during the regionalization of hospitals in 1992.

Early in this pandemic, Minister Flemming quite wisely, established a Covid-19 Task Force that was intended to be the “war room” in the province’s war on this awful virus.  It brought key and knowledgeable people together to sift out evidence, data, international and national sources of advice and to create the direction that we have been hearing through its spokesperson, Dr. Russell, each day.  This allowed incredibly important and wise consolidation of direction.

The challenge that this group has, however, is the long-standing array of groups and interests and authority structures that exist within the health and long-term care system.  Each of the hundreds of focal points of authority and influence, long before the Covid-19’s arrival, were known for operating in silo’s with large gaps in understanding!  The void of understanding between health authorities and long-term care is only one such area that has led to much inefficiency over many years.

The communication between health and its health authorities has been described by many as the classic power struggle in which the health authorities are seen as much more powerful than the department of health.  Added to that has been the conventional relationship between public health and the health and long-term care system.

These sets of relationships are not necessarily the result of ill will but are a result of the long-standing structure of government characterized by lack of understanding of the roles and responsibilities that each play.  For instance, when the fairly complex bulletins that come from each of these agencies to health care service providers, the author discharges his or her duty with a signature; then the fun begins with interpretation!

To their credit, health care providers with whom I connect regularly are fastidious and dedicated to strict adherence to written directives, however difficult.

In that milieu it should come as no surprise that there would be some difference of interpretation of regulations at the border.  Both social and conventional media have carried stories of inconsistencies in the application of the regulations dealing with who is admitted to the province and the 14-day self-isolation period.  Technically the answer to who is in charge is the Department of Public Safety, a new role thrust on them with the pandemic.  Civil servants were drawn from various occupations and given this new duty.  Presumably a brief crash course was given!

People come across the borders normally for endless numbers of reasons, of course.  And one would think that the screening process should be fairly straightforward.  But it is not, as the many anecdotes have already illustrated.  Just how do you write rules and train people for new roles to manage situations that are totally without precedent?  Unless you are going to totally shut the country down, it is impossible to write rules that apply fairly to the many combinations and permutations.

Add to that the complexity of the way in which hospitals and their emergency departments are staffed and you have now introduced a huge factor that probably was not even known let alone considered when the rules were written and training done.  As the CEO of Vitalite Health Network said, up to 25% of all the shifts for physician coverage in hospitals in the northern part of the province are filled “with Locums”.  He elaborated that most of the “locums” come from Quebec (73%).  In Caraquet, 40% of the emergency department shifts are covered by locums and mostly from Quebec.

​Locum tenens is drawn from Medieval Latin and means “holding a place”.  For generations, hospitals and doctors’ offices have relied on physicians to cover a practice during illness or incapacity and hospitals have relied on locums periodically to cover transitional times or short periods when physicians would be away for whatever reason.  In that sense, the engagement of physicians to fill temporary spots, whether covering for a specialist, family doctor, or emergency department, was traditionally an exception to the rule.  Normally hospitals have not built services and programs with high reliance on temporary physician appointments.

Presumably there are factors somewhat abnormal that require the regular engagement of temporary physicians to provide coverage.  In the old days it was expected that local doctors divided up the shifts and provided coverage, but that was many years ago.  In the meantime, the number of physicians who devote their practice to Emergency Medicine has grown. 

In many hospitals in other jurisdictions, hospitals employ Nurse Practitioners and Physician Assistants to serve as vital parts of the team providing emergency services.  In Northern parts of Canada, the use of virtual consults with regional centres also augments the quality of local emergency services in otherwise under-served areas.  This apparently is not part of the system with Vitalite.  Hence, the high reliance on temporary physicians coming from other provinces to provide coverage.

It was pointed out that the schedules are set some 6 weeks in advance so the provision of consistent coverage is reliant on physicians coming as scheduled from other jurisdictions.

Would this reliance of Vitalite facilities on a regular cross border sharing have been fully understood to Public Health and, more practically, the quickly-assembled group of border guards who would be new to the health system?  Probably not.  And would the complexity and nuances of all this be well understood, then, by Worksafe?  Probably not again. 

The practice in Horizon Health Authority is remarkably different in that there is not such a reliance on locums to staff emergency departments.  Physician assistants are engaged in the DECRH Emergency and Nurse Practitioners involved in Moncton and Saint John.  Locums are engaged primarily for intermittent periods of staff vacancy or disability but not necessarily a key to baseline medical staffing.

It all begs some questions, many of which are not new.  First is the basic organization and staffing of emergency services.  The second gets to the issue of interdepartmental communication around important issues such as health and long-term care. The third would be:  in a province that statistically has more doctors per capita than other provinces and in which the fee schedule is competitive with other provinces, why do we need such reliance on temporary physicians for coverage?
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The list of post-pandemic health and long-term care reform issues continues to grow.
 
Ken McGeorge is a retired CEO in major teaching hospitals and long-term-care facilities. He was co-chair of the New Brunswick Council on Aging and is a columnist with Brunswick News. His email address is [email protected]   and Rayma O’Donnell, RN, retired Director of Care and key leader in culture reform, York Care Centre