For three years I have written these columns. For over a decade prior to that, informed people in the health and long-term care system had been calling for reform of major elements that they believe to be broken. The pandemic has underscored what should have been obvious to policy-makers long ago: the health and long-term care systems show serious signs of weakness bordering on collapse.
For some readers, reform means doctor and nurse shortage; with others it is the dreaded 10-12 hour waits in the Emergency Department. For others, it is “why do we need two health authorities?” In rural areas, it is removing the constant threat of closing local health services. With many it is ensuring that the ambulance system is able to respond consistently within a reasonable time.
Dealing with loved ones with Dementia amidst a system that is hard to navigate is another concern frequently voiced in animated terms.
The issues vary depending on geography, age group, and more. The consultations conducted by the Minister in the winter of 2021 were limited, but certainly seemed to provide some common themes. The consultations lacked the expected table talk that some were anticipating.
Since the indicators of poor performance have been evident for so many years, and since we have had a succession of governments in office hearing these things, why has nothing changed?
Understanding the sources of the forces of resistance to change is the first step in moving forward. Professor Dick Beckard of MIT introduced us to the concept of Force Field Analysis in 1976! Here we were in Halifax, a system of major hospitals and the Dalhousie University Faculty of Medicine that was the glue that caused us all to want to work together. Add to that a progressive, new Dean of Medicine, Dr. Don Hatcher, who could see a path to improving the performance of the Faculty of Medicine and its affiliated hospitals. So, we learned together. Force Field Analysis is an engineering term that helps those who want to change systems to understand the strength of forces that support and forces that will repel change!
Apply that to New Brunswick and here is what we have.
First, we have equal opportunity as a wonderful philosophy of governing the province. Premier Robichaud had in mind that every citizen would have access to the same level of service regardless of income or place of residence. What he did not envision was that all those services would be situated in every town in New Brunswick. And it did not mean a “one size fits all” approach to the organization of services. Yet the application by the regulators in New Brunswick has discouraged innovation using the phrase “if we do that in Fredericton, every town in the province will want the same.” In my work in health and long-term care I have experienced that over and over. So rather than encourage innovation and initiative, that response alone serves to discourage those who have wonderful ideas, combined with unusual skill and ability, from initiating what could be great solutions to common problems.
Next is the fear of Pilot Projects. A “pilot project”, by definition, is intended to provide a structured environment in which to experiment with a novel idea. In a good project, there are predetermined goals and methods combined with measures of success or failure. Also, normally the discipline involves a timeline for measuring outcomes. At the conclusion of the project, all involved know whether this project should be replicated as is, replicated with modifications, or scrapped. To be fair, there have been a few pilot projects but in health and long-term care not too many with the rigor and discipline described above.
Then there is the well-known silo-effect in government structures. This simply refers to the “right hand and the left hand not working together.” While the silo effect in the NB public service has been described by speakers over the years, it still persists and incredibly so while becoming evident again during the pandemic. Good people are employed in the civil service whose operating success is based on following regulations, acceding to what you have been instructed to the letter, not interpreting or varying from the policy or regulation. That is simply the culture of government. In successful organizations that are programmed to meet targets, the mind-set and culture are dramatically different. Indeed, for the years I worked in hospitals, my colleagues and I were required to exercise wise judgement based on the best interests of patients, residents, and their families.
The public service employs some of the finest people in the province. But there is a government culture that seems antagonistic to excellent health and long-term care. Part of that culture, apart from silos, is that inability of the structures to reach out to persons with expertise beyond what may reside in the department in question. Those who draft policies and regulations and manage the regulatory functions of inspections and investigations rarely, if ever, have had work experience in the field being regulated. Those of us who have actually led and managed either acute care or long-term care facilities understand that regulations represent guardrails with interpretation being done by people with skill and training in service delivery.
Finally, Premiers and Ministers of Health come and go, particularly in the last 20 years. The health and long-term care sector is very complex and unless you have actually worked in senior management levels inside the sector in driving change, it is quite likely that the essential elements of change management may not be well understood. Yet premiers and ministers of health come to their very visible and important jobs, where every word they speak is grist for the political mill and media, and they are at the mercy of well-intentioned civil servants and loyal supporters or lobby groups trying to influence policy. Their bread and butter includes briefing books, briefing notes, summaries of reports all written for them by sometimes staff who may or may not have experience in managing in the sector.
Elected officials get to learn what their employees, the civil servants, judge is important for them to learn. That may, however, stop short of full discussion of what the real palpable issues are in the system and how best to influence the change required to change course. Consequently, a succession of governments has fallen into the trap of promising to “hire more doctors” and “hire more nurses” as the solution to public concerns of the day. That has gotten them, until recently, past the next election.
In the service delivery sector, we engage some of the brightest and best, people who rescue people from disease or from the brink of death every day. These good people, the types of people that you cannot function without, don’t think in any way the same as public servants. In the service delivery sector, the priority is on the individual, one person at a time, delivering service excellence.
Change would happen much more rapidly and much better if these two cultures could come to a point of synergy. The Service delivery folks need to understand better how government works while the public sector needs to acknowledge that they need knowledge and understanding that they do not have within the department. This is called collaboration and synergy, a set of dynamics not common in the relationship between government and service provision in New Brunswick. Other provinces are much better at this than is New Brunswick.
That is why Primary Care Reform took off in Ontario over 15 years ago and why Dementia Care has seen the development of over 200 Linda Lee Clinics in a very short time. Government cannot do innovation; they can, if they choose, foster and encourage innovation. Reform will happen when that culture is changed to reflect essential synergy.
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. His email address is firstname.lastname@example.org.
Ken McGeorge, BS,DHA,CHE is a career health care executive based in Fredericton, NB, Canada.