​Health Authority Boards: chapter 3

The composition and membership of the new health authority boards was officially released by government on June 30, 2023.  In previous commentaries I have indicated nothing but support and pleasure that we finally know who will fill the roles.

According to Bill 39, the Minister is obligated to present “marching orders” to the new Board Chairs by the end of September.  A mandate letter is, according to the act, supposed to contain:

1. The strategic and operational direction of the regional health authority, and
2. The performance expectations for the regional health authority.
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In “man on the street language”, that translates into:  are these boards simply an extension of the Department of Health or are they expected to seriously take over the health reform mandate that the Premier and the Trustees commenced or will they simply be executing on behalf of the Department of Health.  It is a very important distinction in a province that has placed, in the past, a high value on local input.

We saw, in early 2020, for instance, how a “made in Fredericton” solution for emergency and urgent care in non-urban areas went down!  Not well and was one catalyst for the Premier to withdraw the plan and promise consultation.  That particular misfire illustrated the serious problem that New Brunswick has had in its health and social policy in differentiating between policies relevant to urban areas as opposed to policies relevant to rural areas.  Hopefully by now, those in leadership have figured out why “one size does not fit all” in New Brunswick.  And why Ontario, nearly 30 years ago, constructed the Rural and Northern Health Strategy because Toronto health policies just do not work in northern Ontario.

While the public may never see these mandate letters, my hope would be that the direction would enable the Health Authority Boards to be the strong voices of strategic direction that the structure and turnover in leadership of the previous health authority boards did not seem to allow.  At various times they had great people but not supported by political resolve.  All the issues summarized in the current plan for reforms, resulting from the consultations of 2000/21 are issues that have been simmering for years looking for leadership.

Take Primary Care, for instance.  The world of primary health care has radically changed in the last 20 years, witnessed by the impact of recruiting newly graduated physicians to fill practices currently managed by some superb veteran physicians.  Many years ago, the pattern was becoming clear.  Newly graduating physicians, bright, intelligent and highly motivated, have no intention of being “married to the practice”.  In many cases, it required two or three physicians to cover a practice previously managed by one senior physician.

Then as Dr. Ian Macdonald explained to Rotary Club nearly a year ago, a large percentage of physicians who complete family medicine residency have little desire to own a practice but find meaningful practice opportunities in Palliative Care, After Hours Clinics, Emergency Medicine, and serving in temporary roles as Locum tenens appointments.

Watching that evolution, and speaking with some prospective physicians and a few recent graduates, the trend has been very clear as has been the message.  Other provinces have moved to and encouraged other care and compensation models.  New Brunswick has been routinely exposed to other successful inter-disciplinary, integrated models for over 15 years yet the pace of change has been glacial and apparently government locked into salary or fee for service compensation models for family doctors.

As has been demonstrated elsewhere, other models encourage new approaches to primary care without providing a great economic threat to physicians, nurse practitioners, and others.
New Brunswick has worked with the Medical Society in creating the concept of Family Health Teams.  On paper they seem to have some of the characteristics of comprehensive clinics.  The Emergency Departments still overflow and the numbers of persons waiting for “a family doctor” do not seem to have changed appreciably yet.

To government’s credit they have approved some virtual care initiatives with the establishment of Health Link.  While possibly helpful in some circumstances, there is nothing better for care than a face-to-face encounter with an experienced and caring primary health care provider.  Oddly enough, prior to the pandemic and all the panic that surrounded it, it was impossible to get a diagnostic test or a routine prescription filled without seeing the prescribing physician in the office.  It has been said, for decades, that good medicine requires the personal, in-person assessment by the physician.  Actually, prior to the panic driven by Covid, there was no payment for physicians in the fee schedule unless they actually saw the patient.

This, actually, has been said to be a central factor in the reluctance of many physicians to delegate more routing services to Nurses and Nurse Practitioners; they have not, historically, been able to bill Medicare for the services of such personnel although they can finance them from their gross business revenue.

More to the point is the challenge of treating people, ordering investigations and medications based on a story told on the phone or zoom call.  In the care of elders this is a particularly difficult challenge for many reasons.  The Health Council advises us that a large percentage of persons over 65 live with more than one chronic health condition.  This explains why some elders live with daily consumption of many drugs, sometimes up to 25.  No such patient goes for physician visit with just one or two things wrong; often there is a complex mix of symptoms emanating from a variety of challenges.

In 2009 and then again in 2014 there were innovative models proposed for the organization of primary health care with three promising models from other provinces aimed specifically at seniors.  No traction, no response.

The numbers that government suggests as declining for persons waiting on the list for Primary Care service provider do not, as Barbara Simpson’s August 6 Gleaner article suggests, tell the full story.  Some have just stopped looking and gotten discouraged. 

The political and public policy issues are these:  first of all, the Canada Health Act stipulates this service to all Canadians as one of the main pillars of the legislation.  Secondly, the current government has promised health reform and in so doing cited its key strategic bullets of which Primary Health Care is one.  If government could have fixed this issue alone, would you not think it would have been fixed years ago when the signs and symptoms were similarly bad?  The truth is government cannot fix it despite the talk. 

The trustees commenced some good work but there is an entire strategy of reform that must be documented, detailed, new partners brought to the table, new compensation methods explored along with new organizational models.  And the most difficult will be changing the conventional “after hours clinics” into a structured and integrated Urgent Care System.

So, will this be laid out in any form in the mandate letters to the Health Authorities?  The eyes of many will be watching.  The public will feel much better if we can have the confidence that a new day is coming and can see a visible strategy at work.
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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