Health Care Reform 101: an introductory course

True to their promise from last fall, the Higgs government has succeeded in capturing the attention of New Brunswickers around health reform.  The announcement of what is referred to as a plan that includes major changes to small, rural hospitals was the second step.  The actual first step was the announcement of the expansion of Nurse Practitioner appointments within the health authorities on January 27.

Anyone involved in the health reforms of 1992 knows that a frontal attack on rural hospitals is a formula for certain push-back, speaking mildly.  My friends and I remember well the fact that despite the logic, people on the ground were interested in only one thing:  will my doctor be able to look after me and my children when we are sick particularly at night or on the weekends.
It was difficult enough in 1992 when 55 hospital boards were dissolved in favor of creating 8 regional hospital boards.  But now you have a population for whom that is forgotten and the power of social media.  Social media can win and lose elections!

The aftermath has been predictable with local MLAs taking real heat at a time when election talk is in the air and rural seats are critical.  Dwight Eisenhower said:  “Farming looks easy when your plough is a pencil and the cornfields are a thousand miles away.”  And so it is with those who would initiate health care reform.  From Fredericton the world looks vastly different than it does at 2 a.m. in Plaster Rock!

Yet Health Care Services need reform for all the reasons described in the press in the past several years.  Labor issues, professional practice issues, shortage of professionals, aging population, economics and more.  But those in rural communities do not want to see their service reduced; they read about care in urban centres:  long waits in Emergency Departments, orphan patients, and they do not want that.

So where should those who plan reform commence?  Remember we are talking about the health system, referred to by Peter Drucker as the most complex of all businesses. It is a huge challenge for government hanging onto minority status as we have seen.  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.  But it is clear that the leadership cannot commence with “cut and slash” language.

So just where do you start?  Which, 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.

In dealing with the rural hospital issue regulators have a conundrum.  In the days when these hospitals were initiated, it was not uncommon to be able to recruit a physician with surgical training who could do much of what was needed to care for the local population.  These older doctors, when not doing surgery, often did some family practice in order to generate income.  And they operated as solo practitioners, on call pretty much all the time!  Anaesthetic services were provided often by family doctors who took some additional training and they, too, practiced family medicine when not busy in the Operating Room.

In most parts of North America that style of medicine has vanished in favor of superb primary care, emergency service appropriate to the locale, and concentration of specialists and sophisticated equipment in regional hospitals.  The intent of the regional structure put in place in 1992 was to create an environment in which diagnostics and care was integrated throughout each region with professionals working together, not as competitors but as colleagues across the region.

In today’s health care environment, when patients  need advanced medical intervention, the best and safest care is normally found in centres where professionals work together to resolve health problems for patients.  In seeking my surgery, I choose to be operated on by a surgeon who is busy because I then know he or she has lots of practice and others have confidence.  I also want it to be done in an environment where the surgeon has back up in the event things go wrong and has access to the latest skill sets available.

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 and the events of the last two weeks in NB look, to the outsider, as more Pillar and Post management.  Apparently the Minister has had some private conversations but when the “plan” was announced, the alleged private supporters were not to be found.

There are many 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 we are 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 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 and 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).

In using this tool, planners could readily see that the proposals as written in the “plan” would fail to get support.  And in analyzing forces that would favor the proposals, the tool, if used correctly, would show weak support.  The fact that the health authorities or government think that certain strategies are good means very little in the public eye.  The health authorities and government are lumped together as part of the machine that keeps essential services going but not sources of inspirational leadership and vision.

Getting a fix on Health Reform Priorities that will stand a chance of public acceptance will require thinking at the table that has been absent.  There are some great minds in this province that can raise some penetrating questions and serve as emissaries to sell a plan.  But government must reach beyond its boundaries and that is where real courage will come.
Ken McGeorge,BS,DHA,CHE is a retired health care CEO, part time consultant and columnist for the Brunswick News. February 20, 2020