As promised, Health Minister Dorothy Shepherd released her Discussion Paper on Thursday, January 21, 2021. The paper raised issues of Primary Care, System Efficiency and Safety, Access to essential surgical treatment, Mental Health and Addictions, Senior Care, and use of current technologies. The last thing in the world New Brunswick needs is more public consultation, summaries, and reports. All of these themes have been beaten to death for 20 years. What has held us back from progress is having a government with the political courage to face reality in the eye and move forward on a plan to fix what so many know is broken!
The results of this Discussion Paper consultation will inform the development of the new 5-year health plan. Apparently, New Brunswick currently has a 5-year health plan about to expire. Surprisingly front-line staff and consumers of care seem unaware of such a plan. Health care is such a politically sensitive issue that governments have to avoid issues and deal only with cosmetics or wade in without fear of losing legislative seats.
The issues that plague the system stem from lack of consistent focus and informed, consistent leadership at various levels in the health system. Here are the issues that simply require courage to do the right thing:
Shift in primary care delivery.
Expanding the implementation of Family Practice Health Teams is a good place to start. These systems should involve getting physicians, nurse practitioners, pharmacists and other health professionals working together in teams and not independently in parallel. Having nurse practitioners and pharmacists independently manage health issues without knowledge of the full scope of a patient’s medical history is fraught with risk. Ontario and Alberta are examples of provinces that have broadened the scope of practice of allied health professionals. This has led to further ‘silos’ and lack of coordinated care, medication changes without informing the primary care provider, expensive ‘medication’ reviews that have led to increased profit for pharmacies without improvement in patient outcomes. To be done effectively, the sensitive area of compensation needs to be front and centre with the conventional fee for service model replaced by one of many alternate payment systems that can be found in the Western World.
Replacement of after-hours clinics with Urgent Care Centres properly integrated with the Health Authorities.
These could be set up in hospital outpatient clinics that sit empty evenings and weekends—a patient’s health team could then access imaging, bloodwork, medical records and keep patients out of the Emergency Room. This would also decrease the duplication and patchwork approach of after-hours clinics. This is not new! Structured Urgent Care has been part of the health system elsewhere for decades!
Courageous and visionary overhaul of Addiction and Mental Health Services.
Deficiencies in the system have been discussed in New Brunswick since the early 1990s yet we still wring our hands. Government-sponsored services cannot meet the needs alone. A strategy for the future that does not seriously embrace all the mental health and addictions resources that are available (many not in the publicly-funded system) is foolhardy and short-sighted. Solutions include integrating some outstanding not-for-profit services as well as the educational system in a more meaningful way, and coordinating what is already available.
Replacing the ‘we need more doctors, nurses, physiotherapists..’ mantra with data and not hearsay.
There are two “elephants in the room” that never get discussed in public. The first is the competition between professional groups and unions that has plagued New Brunswick for decades. Associations, unions, regulatory authorities need a moment of truth here and the best place to start is with facts as opposed to emotion. How many health professionals are there actively practicing in this province and how many are needed to service a population of less than 800,000? If these numbers show we have more than enough personnel to serve our population how is the hiring of more staff the answer? The second is that great staff are attracted to and retained by organizations that make culture and the strong management of their human resources top priority. Health Care services are all about people, unlike many other industries. Health care in New Brunswick is plagued with issues of morale, internal competition for territory, high absenteeism, worksafe claims…issues that can be radically improved with change in workplace culture resulting in much better cost-effectiveness of the system.
Addressing seniors’ care deficiencies that the pandemic has laid bare
The government working paper invites discussion of Improving the Care and Service Experience of our Seniors. In 2016 government invested hundreds of thousands of dollars in creating the Council on Aging and its report, filed in January 2017, that was referred to as “An Aging Strategy for New Brunswick”. The report itemized 77 recommendations, 15 of which could be implemented in weeks with little or no cost to government. Yet there has been little to no results where it counts. One such key item, given the rapid growth in Dementia-related diseases, was the Dementia Strategy. Apparently, that still is in some stage of production in the Department of Health, nearly 5 years later. The pandemic has underscored the urgency of acting on what was recommended.
Reviewing the current structure of both health authorities
Many health care providers in New Brunswick would suggest that the current structure of the health authorities is a major contributing factor for major problems in the system. While some would simply raise the question of duplication between the Francophone and Anglophone health authorities, the real major issue is that both authorities, by their structure and governance model, are too unwieldy to offer solutions to provision of great care to the public.
Each health authority is huge with hundreds of service sites across the province, some small, some very large and complex. There are principles of franchise-management that the health authorities do not appear to embrace leaving larger service sites like major hospitals functioning without a local authority figure who can inspire staff and volunteers while resolving serious problems as they occur. The workplace violence issue would be one that could and should be dealt with forcefully locally. Another would be the over-crowded emergency department waiting rooms and long waits. And yet another would be the high rate of absenteeism amongst staff along with standards of hospital cleanliness.
Government must have the courage to subject the structure and governance of the health authorities to informed, qualified external review. This would involve people who have experience directing major health organizations known for excellence.
It would look beyond the surface issue of language and get to substantive issues: board/executive/management structure, corporate culture, standards for recruitment and retention, new digital technologies, appointment and compensation methods for physician leaders. Nothing will ever change until the structures of the system are addressed along with the implementation of accountability measures.
Please, with a majority government, don’t disappoint!
Ken McGeorge,BS,DHA,CHE 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 and author of Health Care Reform in New Brunswick. His email address is firstname.lastname@example.org.
Linda LeBlanc, MD, FRCPC is a Radiation Oncologist practicing at the Dr Léon-Richard Oncology Center in Moncton. She is a past member of the CHUDumont physician executive, is a review committee member of the NB College of Physicians and Surgeons and is an advocate for evidence-based health care organization and delivery.
Ken McGeorge, BS,DHA,CHE is a career health care executive based in Fredericton, NB, Canada.