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.
Opening her presentation to the Standing Committee on Budget and Fiscal Policy on Thursday, April 20, 2023 she said: “we cannot fix health care if we don’t fix long term care first!” How true it is! This is a theme that has been the topic of these commentaries for years.
What she meant is simply this: we have, in this province, where the population has a very high proportion of seniors, a huge problem with the growth of numbers not only of frail elderly but persons with mental challenges who need long term care. As caregivers burn out or die and persons with challenges of aging get into crisis, off they go to the emergency department where they lie on a stretcher for long periods then get shunted to an acute care bed (upwards of $1600 per day) where they languish, lose mobility, experience inappropriate care, and decline physically and mentally until that day, 2-3 months hence, if they are fortunate, when they get transferred to a nursing home.
But many of these people, the majority, actually, could be cared for in a special care home at a cost that is 40% less to the public purse than nursing home! Nursing home, the most expensive option in long-term care, is not the only source of long-term care! There are many options for those requiring long-term care. Neither the public, politicians, discharge planners nor physicians have been aware of that until recently. Holding people in acute care beds for months waiting only for the most expensive care option poor public policy.
That New Brunswick tries to manage this important program with no plan is absolutely ludicrous. The Aging Council Report of 2017 was supposed to be the plan; it is not. Any private business would fail in the absence of a firm plan under these circumstances. The health council has reminded us repeatedly that something of the order of two-thirds of people over 65 live with multiple chronic health challenges, some minor, many very significant.
With the emergency departments backed up with elders in crisis and acute care beds filled with people getting inappropriate care, and with the need for those beds to be available for more acutely ill patients, how do you fix that?
This entire mess is not new! In our post-pandemic environment, in which everything in health seems to be in crisis, this issue of elders inappropriately occupying acute care beds has its roots back 50 years ago or more! In 1969, I submitted my thesis to qualify for my post-graduate degree in Hospital Administration at University of Toronto. Guess what was the topic? You guessed it: Extended Care and the General Hospital, which was a rudimentary analysis of elders who could have been cared for in a less expensive skilled nursing facility!
Similarly, in the primary care area; depending on “having a family doctor” is not, by any means, the only source of great primary care. While other provinces have developed other options and while European and Scandinavian countries have not only tried but have adopted other options, New Brunswick has been seemingly dedicated to preserving what worked 50 years ago but does not work in 2023.
John Chilibeck’s sobering story of David Clark’s experience has been repeated over and over in New Brunswick; I hear it every single day and have done for years. Behind the story is a person desperate for guidance, care, support. Each story is hard to listen to particularly when you know that there are, and have been, options. Each story is a taxpaying citizen of New Brunswick who, under the Canada Health Act, should have access to quality primary health care.
Virtual care, websites, and other strategies instituted to compensate for “lack of physicians” are interesting but not too effective with the senior population for the most part. Nothing takes the place of a primary care center, be it a doctor’s office or a comprehensive, interdisciplinary primary care clinic, where they have your file, your diagnostic test results and can speak with you eye to eye.
So why has it taken 50 years for these essential services to get to crisis level? Why have obvious options not been implemented years ago?
Fairly rapid turnover of political leadership is a partial response but not the full answer. Health and Long-Term Care contain major elements that, for politicians wanting to ever get re-elected, are like hot pokers! Touch them and you get burned. Professional representational organizations, unions, and advocacy groups who tend to protect the status quo but just more of it with a higher price tag. For the politician, the issues are complex and challenging and it is usually difficult, if not impossible, to discern which of the “hot pokers” will actually bring results.
The regulatory authorities (civil service) are another constraint. These departments are staffed with wonderful people who want to go home at night with a real sense of satisfaction. The ideal is to have the Health and Social Development Departments staffed, at least in key policy areas, by people who have worked and trained in the health and long-term care field. It is really difficult to understand whether the regulations you are recommending or legislation you are drafting will have real meaning unless you have actually had boots on the ground in a hospital or long-term care facility, hopefully at a senior level.
The Minister is on the right track with long-term care and from her opening remarks before the Committee, it seems that she seriously understands the urgency.
As a veteran of health reform of the 1990’s, I can attest: it is not easy, it is not all about numbers, compensation models need to be invented that represent value for service delivered, new relationships and models need to be invented, established processes, where broken, need to be abandoned, leaders need to be developed, and more. I commend her for introducing a major start to long-term care reform.
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 firstname.lastname@example.org or www.kenmcgeorge.com
Ken McGeorge, BS,DHA,CHE is a career health care executive based in Fredericton, NB, Canada.