Health Care Reform: 201 or early steps

​In last week’s column we outlined steps to set the stage for major change in large organizations. Having dealt with determining priority and forces of support and opposition, we concluded that with such a complex, highly political system, it is imperative that government “strike while the iron is hot.”  In other words, there are times when the electorate is just ready to support change in its cherished programs and reading the mood and readiness is critical.
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The electorate has been calling for change in health care in New Brunswick for over a decade but the messages have not been clear.  Government response and public desire have often been on opposite sides of the street.  While the public has wanted an improvement in the Ambulance system and its life-saving services, governments snarled it up with issues of which is not where the mood of the public was.  They want their loved ones attended to as quickly as possible.

Successful Emergency Medicine is guided by “the Golden Hour” which is the ideal shortest period of time following a traumatic injury in which surgical intervention may or may not prevent death.  And in the treatment of strokes the time frame is in the 3 hour range at which one hopes the patient gets to a facility staffed with doctors and nurses specially trained in the diagnosis and treatment of stroke.  Failure to properly intervene in the ideal timeframe often leaves the patient with lifelong disability.

The principle also applies with heart attacks and other major emergencies.  Informed, professional assessment and treatment at the scene is critical, as is treatment en route, but getting the patient to the fully equipped and staffed emergency centre needs to take place quickly.  The priority needs to be stabilization, airway, get to the hospital as quickly as possible regardless.

So if we are to get to health care excellence, which was the goal of the 1992 health care reform, those who are steering change must not get distracted by vocal interest groups.  There are hundreds of interest groups that want to ensure that their favorite issue is embraced in a reform strategy, but it is essential that government keep their eye on the ball.  Having determined the key priorities for immediate action, as discussed last week, it would be all too easy to get distracted.  Particularly with the prospect of elections looming, both municipal and provincial.

Of the hundreds of interest groups, each is important and each must have their issues heard, but the number of issues that are of concern could be overwhelming.   And both the public and the politicians need to be able to discern between what is a group legitimately advancing health care concerns as opposed to those that may be simply a front for candidates or parties seeking election publicity.

Indeed, that was much of the distraction in the 1992 Hospital Regionalization efforts in which party politics got all mixed up with professional interests, local job protection and more.  So in many cases the seriousness of the mission got lost in the political bluster.  That is why Jeffrey Simpson refers to health care as the Third Rail in Canadian Politics!

Regionalization of hospitals was very serious work and I took it very seriously.  My job as CEO of Region 3, that had 13 facilities, was to take small regional facilities, clinics, small hospitals and the regional centre and to integrate them into a whole.  These were wonderful small communities that were so proud of their facilities.  They had invested much sweat-equity into creating these little community hospitals.

Unlike the large regional Centre, all built and paid for by government, these facilities were literally built by the local farmers and trades people, working pro bono!  One big farmer told me passionately:  “I put up walls; painted, worked for many days on that hospital…..don’t you dare touch it!”

But it was 1992 and way back in 1971, Anne Somers had published “Health Care in Transition” that called for integration of health facilities and this was 20 years later.  Indeed, most of these facilities gave wonderful care but struggled to maintain surgical services at any level.  For the most part, anaesthesia was administered by family doctors who, with additional training in anaesthesia, were able to keep patients safe during surgery.  Surgeons, however, were aging and nearing the twilight of their careers.

New surgeons coming fresh from training, for the most part, want to practice in centres where there are multiple surgeons so they can share the after-hours coverage and where access to other specialties and ICUs is available in the event there are complications.

The reality is that anytime you put a patient under general anaesthesia and make incisions in the human body; there are risks; not minimal risks but large risks.  My surgeon friends, skilled and talented people, tell me that you never know exactly what is to be found in an abdomen until the incision is made.  And anaesthesia is really the science of taking a human being to the point of near death and bringing them back to consciousness again.

So when I have my surgery, I really want to be in the centre where there are multiple specialists, cardiac arrest procedures and equipment, nurses trained to advanced levels, and state of the art monitoring equipment.

All of that was true in 1992 and going to small communities, even though it might be a relatively short drive to the regional hospital, and suggesting that we need to think through a more modern, less risky approach to secondary care was often treacherous territory!  Physicians and local surgeons wanted nothing to do with it for their own reasons, communities and physicians were ever so proud of the great service they offered the community, and political parties (COR and Tory) took every advantage to score points, often at my expense or that of our Board members.

One board member had to resign because his business was threatened!

Another area of complexity in which planners could become distracted is the Nursing situation.  Nursing is a major, central player in health care and the profession needs to be a focal point of reform.  There are many issues that need to be tackled that include Education, Licensure, Regulation, Nurse Practitioner status and training, safety in the workplace, recruitment and retention, and much more.  This area alone could, if done comprehensively, dominate the planners’ agenda with many sub-issues that could serve to distract.

For instance, on the safety issue the entire issue of security in the health authorities needs to be front and centre.   It is a mission-critical service not managed by the Health Authorities.  Yet health authority staff bears the brunt of breaches.  So how do you get to a better day when those that control the contracts reside in another department of government.  And at what level should security staff be trained?  Should they be bona fide peace officers?  Armed?
Each of the priority areas for reform is so huge that no one central group will be able to initiate and manage effective change.

The lesson of Health Reform 201 simply is:  lay the facts, not a collection of perceptions, out before the public, assemble an intelligent, informed transition team, work out a strategy, and let the team act as political shock absorbers for there will be many potholes!
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Ken McGeorge,BS,DHA,CHE  is a retired health care ceo, part time consultant and columnist for Brunswick News.