​Health and Long-Term Care Reform: any old road will not do!

“If you don’t have a plan, any old road will get you there”.  This phrase from Lewis Carroll.  And in New Brunswick, frankly, it seems to fit so many of the public services that have drawn concerning headlines and occupied much debating volume for decades.  Our highways?  Check.  Our education system? Check.  Our Health and Long-Term Care System?  Indeed; check and check.

The publication of the New Health Plan can give us some hope, although the bookshelves are lined with such plans in New Brunswick, each one promising to guide us to the promised land.  It does present hope for those souls who have endured “no access to primary care services” and for whom the Emergency Departments and after-hours clinics have been a dreadful substitute.

With the litany of plans and the combined consulting and staff costs in addition to publication and translation, do we have a measure of success?  We do have some incredible clinical services in this province and once you get to them, your life can improve pretty quickly.  Personal experience in my own crisis has born that out; DECRH staff and the SJRH Heart Centre and Extramural  were fabulous.

You would think that with all those reports and all that we have learned about issues in health and long-term care, the gaps should be narrowing.  Forty percent of the acute care beds in the Horizon system are occupied by persons awaiting some level of long-term care.  How often have you heard that in the last few years?  Does that not anger you just a bit?  And if you are aware of the impact which includes those long and dangerous wait times in Emergency and corridors filled with sick people who need expert nursing and medical help…does that not send chills down your spine?

It sure does for me and the chill gets icy when I know that the chaos is not only unnecessary but preventable.  But prevention cannot include the insanity that has plagued previous attempts to “fix”.  Insanity is defined as doing the same things over and over and expecting a different result.  That has been the pattern of government initiatives on this file for well over a decade, yea two decades.
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This makes the importance of this plan and the leadership of those who wrote and introduced it “heart-attack serious”!  (that is Triage Level 1!).

Another quote:  Winston Churchill: “those who fail to learn from history are doomed to repeat it.”

In 1971, the NB government/Department of Health, being concerned as all provinces were, with the rapidly rising cost of health care services, commissioned an important study resulting in the Llewellyn Davies Weeks report.  That firm was a world class consulting firm who, at that time, was on the leading edge of public service organization and financing.  Their report recommended that New Brunswick begin the process of re-organizing and streamlining health care services by instituting regional hospital boards.

In 1978 the visionary engineer and father of the Stan Cassidy Rehabilitation Centre authored a report of health care in NB. 

New Brunswick elected Frank McKenna as Premier in 1987 in a landslide and, I expect, this subject would have been an important point of discussion in his cabinet.  Moving from hospitals being directed by local boards, albeit in conformance with the Public Hospitals Act of the day, to those same hospitals coming under the authority of regional boards of directors who may or may not represent all the local interests. 

In 1988, NB appointed the McKelvey/Levesque Commission to advise on health care strategy for the province and central to their conclusions was that government should follow through with the recommendations of the 1971 consultants by implementing Regional Hospital Boards.

Think of the politics of that for a minute.  Each of the rural communities took enormous pride in their local hospital, raising funds, supplying volunteers, having their friends and neighbors as members of the board.  It gave local communities a great sense of security and pride.  And knowing that their local hospital was there for them 24/7 regardless of what they presented with:  having a baby; chainsaw cut; heart attack, stroke.  They were secure in their feelings of safety and security. 

In February 1992, the strong health minister, Dr. Russell King, stood in the Legislature to announce the creation of 8 Regional Hospital Corporations to take effect on July 1, 1992.  This sent shock waves through the province!  The ensuing months were dominated by chaos, the level of chaos varying depending on the community effected.  In Fredericton there was no serious push-back on that issue; the public did not seem too concerned that the local hospital would not have its own board.  However, the CUPE and Nurses Strikes raised the temperature a great deal and created lots of problems for the local administration that now did not have a board.  The Minister of Health was effectively the hospital board for all facilities during a three-month transition.  During that interim period, the Minister and his advisors were engaged in selecting board members (12 for each board), the board chair, then the CEO.

For me, having moved home from Ontario just 18 months earlier, it was not a pleasant time of wondering.  On July 1 will I have employment in any capacity?  Do we pack up and return to Ontario?

Late in July it became clear that those who were CEOs of the regional hospitals would be appointed CEO of the new regional hospital corporations…but for a three year term!  So much for employment contract!  Welcome home!

But each regional corporation and CEO took these rare jobs seriously; we soon came to understand more than we had ever understood about rural health care, professional political issues at the provincial level, implementing huge change that had never been done in Canada.  We were all inventing change and each region had its own unique characteristics.

Talk about culture shock!  But we all got through the initial stages.  The overall intent was that the regional hospital boards, once matured, would become involved with the long-term care services.  That had no definition but was the topic of many discussions between the regulators and some of us “on the ground”.
There has been so much change with the hospital sector since that time, lots of which was not part of the original plan. But the establishment of the regional boards was the enabler for all that took place later.  But somehow long-term care got dropped along the way.

What are the lessons to be learned for reference to the new plan?  the reforms of 1992 represent a process, certainly not neat and tidy, that worked:  Legislators, cabinet minister, premier were engaged, knowledgeable and committed; they seemed to really grasp the strategic significance of what was happening.  From the day of announcement through the following years they were supportive as we worked together to respond to the trauma that local communities were feeling.  Some of it became very lively (I still have some newspaper clippings!)

The civil servants were incredibly knowledgeable.  Not only were they very informed of the history and the succession of reports that had preceded this initiative but many of them had long experience themselves in the health field prior to their civil service work.  They did a great job of making sure that we had as much as was available in terms of background, documentation, and other information that we would need.
But neither the politicians nor the civil servants could do what we were called to do on the ground.  In Region three there were many facilities, some clinics, some busy hospitals, some very small hospitals.  There was no “cookie-cutter” approach that could anticipate or deal with the issues of implementation that we dealt with.  But suddenly, all the issues in Minto, Chipman, Plaster Rock, Bath, Woodstock, Oromocto, Fredericton Junction, Forest Hill Rehab, DECH that normally would go to a CEO and/or Board were coming to our regional team.

Thankfully we had a strong team with a Chief of Medical Staff who also was very strong.  But it was rough.  We had lots of important, sometimes very delicate, issues to deal with in each of those facilities ranging from bed reductions to staff layoffs, local volunteer challenges.  It was like “drinking from a fire hydrant”.  But persevere we did.

Of course, in the election of 1995 and the associated activity took on importance across the province, some regions more than others.  Those of us who were not involved in any political party had to become very sensitive to activity on the ground.

The point is that with this round of essential change in health and long-term care and mental health, there is a lot of work to be done on a lot of issues that are not necessarily understood widely; but those issues, many of which have been on the table for a decade or more, need some robust attention and fixing.  People “on the ground” usually have a stronger grasp of the issues and some potential corrections that do not seem to get done.

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