Health Care Reform 101: an introductory course

It is clear by now that the provincial government is intent on shaking things up in New Brunswick and most New Brunswickers think it is about time!  Many issues face the Premier and his government that have been the topics of angst in the electorate for decades including municipal reform, the performance  of the education system, infrastructure, extremes in labor relations, economic and jobs development.

So where do you start?  It is a challenge for government hanging onto minority status.  A strong majority status is to be preferred when wading into major reform for many of the reasons already mentioned in previous commentaries.  The commencement of major reform in 1992, difficult as it was, was made much easier with Mr. McKenna’s huge majority and lack of social media!
But make no mistake; the public is looking for leadership on this very complex and challenging file and the Premier and the Minister of Health have both made it clear that they have some great plans in mind.
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So just where do you start?  

What, of all the issues that distress the public, do you deal with first, second, third?  In a highly political environment with elections and by-elections always looming, it could be tempting to respond to issues that might elicit quick positive voter response.  There are certainly lots of those issues such as primary care, family doctors, and nurse practitioners, access to specialist care and to nursing homes.  There is no shortage of issues that, if dealt with, would please voters.
But in dealing with any of the issues that require major attack, there will always be major sources of pushback since every change, regardless of how noble its goals, require people to change at some level.  Such change may be quite cosmetic and minor or it can be extreme in totally re-arranging how patients are cared for.

A change might involve a major initial investment either by government or by professional interest groups or both.  For instance, one change that must take place immediately is the completion of the integrated health record that seems to have baffled health service regulators and planners for nearly 3 decades.  Getting to the route of the “bafflement” and imposing a fix will undoubtedly mean a major change for some group of people, be it health care professionals, technical support vendors and personnel, administrative and clerical people.  But it is nonsense to say that in this little province we should not now have a state of the art integrated health record that links clinics, doctors, pharmacies, hospitals and clients.

But this is only one of the major areas of “bafflement”.  Pick the issue that is top of mind and there will be major cheerleaders and major sources of pushback taking the role of adversary.

Within the health system in NB at this time there is nothing that resembles a sense of priority areas for focus.  Since 1995, governments have drifted from pillar to post putting out crises, pacifying professional interests, calming the public when rumoured changes are advanced as if true plans, creating the impression that bigger is better, restructuring will contain costs, and more.  That honestly has been 25 years of pillar to post in the absence of a plan.

With the many large issues to be dealt with, how do you get any sense of consensus on areas of priority focus?  In my experience, it has always helped when the key players are in the same room looking at the same evidence.  What people read in newspapers, see and hear on  Radio and TV, see on social media, and pick up at the coffee session at Tim Horton’s does not constitute evidence sufficient for any decision-making.  Do we have a doctor shortage or not?  Do we have a nursing shortage or not?  Is there a real safety issue in hospitals and why?  Can health care cost growth be contained or not?

Will it make a difference to the public if we integrate specialist services across the province?  If so, how and why?

These and dozens of key questions need to be posed and answered with hard evidence, not simply speculation, perception and hunches.  Hard evidence.  Then when all have looked at the hard evidence are we ready to try to establish a sense of priority for moving forward.  Moving forward without that discipline and without cultivating key allies is a formula for political disaster.  Like it or not, there are many groups within the health system who, when the chips are down, enjoy a very high level of public trust and acceptance.  The public trust and acceptance is gained not so much through the work of the representative bodies as it does from the behavior of key personnel in executing their professional duties.

The next step is critical!  And all too often this is missed on political folks in New Brunswick.  In 1976, Prof. Dick Beckard of MIT taught a group of us about the value of Force Field Analysis in planning change.  This principle was adapted to the Social Sciences from Physics by Prof. Kurt Lewin:  It provides a framework for looking at the factors (forces) that influence a situation, originally social situations. It looks at forces that are either driving movement toward a goal (helping forces) or blocking movement toward a goal (hindering forces).

My own career has involved directing change in small and large organizations and this principle has provided, over and over, a way of at least mentally visualizing whether a given change will go smoothly or not.  It enables the proponent of change to place weighting on the forces that will contribute to success or failure and can be used to avoid some big messes.

In explaining it, academics helped us see visually on a flip chart the power of the influence of various constituents and, therefore, enabled us to adapt plans, arrange detours, identify potential allies, and more.

In recent history in New Brunswick, for instance, we had the Council on Aging in 2016 that produced a formula that had the potential to guide essential change in the health and long term care system.  But you had to be informed of how the system really works and where within the system the sources of power and influence really lie.

When presented in January 2017 all the key players in the system were present and, as many said to me, “finally we have hope for direction.”  It was a ready-made platform for lining up the serious forces within the province that could support major change.  But that opportunity was lost and government now must figure out how to regain that sense of readiness for change, the willingness to support and move forward with tough decisions.

In politics and public administration, timing is everything and there are times when “the iron is hot” and it is time to act. This is a crude reference to the old blacksmithing days when Blacksmiths put hard iron into the fire which they wanted to shape into something useful.  I have watched as horseshoes have been fashioned, but the blacksmith had to take the iron from the fire when it was red hot and pound it on the anvil with his hammer until it was the correct shape and size.

Force Field Analysis is simple tools that can help decision-makers know how to ensure that “the iron is hot”.

Ken McGeorge,BS,DHA,CHE is a retired health care CEO, part time consultant and columnist for the Brunswick News. February 1, 2020