​Health Care Reform: impediments to progress

Paula Doucet, the leader of the New Brunswick Nurses Union, and a strong advocate for the profession, lamented, once again, the slow pace of essential change in health care in a letter to the editor on Saturday, January 28, 2023 in Brunswick News.  And the general public would tend to agree with the sentiment that change has been slow to discern.

There apparently is, however, a good deal of activity in the background in which some new clinic models are being created, strategies are apparently in place to reduce surgical wait times, and more, according to the Trustees of Vitalite and Horizon.

The challenge for the Higgs government, and those he has placed his trust in for reform, is that having promised reform, on many essential issues, it often means catching up to what others are already doing in other provinces and countries.  Roy Romanow, in the report of the Romanow Commission on Canadian Health Care in 2002, had already discovered the superb quality of primary health care offered at the Sault Ste Marie Clinic in which physicians, nurses, nurse practitioners, social workers and many other professionals work together to manage the health care of a defined population group.  He called it “Canada’s Best Kept Secret”.

New Brunswick continued to reject multidisciplinary primary care to the extent that when a popular and experienced physician from another province came to NB to speak on the interdisciplinary model of primary care, he was asked prior to arriving “just what are you going to say to those people.”

Meanwhile, the Medical Society put forward a “Team-Based model” in which family doctors were collocated in an office, sharing resources but it stopped short of being the older model of group practice for when one doctor leaves the team in the new model, the patients report having to start all over again in finding primary care.

In my training, as part of the skill required to solve real issues, I was exposed to the need for Root Cause Analysis.  It goes like this:   so, you have a ton of staff vacancies and recruitment is not producing sufficient candidates.  Classic response:  increase recruitment, poach from other provinces, get serious about offshore recruitment.  All strategies that have been alive and well for decades.  And those strategies may, if pushed hard, lead to a few more recruits.
But why are people leaving the workplace in the first place?  Is it one that sincerely does everything in its power to promote excellence?  Does the leadership demonstrate just how important happy and contented professionals are to  quality of care?  are employees leaving because they are just not feeling the professional or personal recognition that every human being needs? 

The health professions are stressful and much of the stress is induced by working conditions and the culture of the organization.

In the last twenty years, the work environment and professional profiles of many of the key professions has changed as has the age profile and caseload that present for care by these great people.

Today’s work environment, be it in community primary care, eldercare, institutional service and care has changed radically in 30-40 years and all that speaks to the organization of care, duties performed by professionals, the need for a team-based practice be it in primary care or in institutional care.

But many of those changes have not been reflected in the structure of primary care, the structure of hospitals and other care facilities.  Rotary Club was told by a leading primary care physician recently that only a small fraction of those completing family medicine training, actually go into family medicine practice, with the others opting for more regulated practice in palliative care or emergency medicine.

Similarly with nursing in which the highly educated RN (and those with graduate degrees) tend to be faced with an institutional organization that has not changed much in 40 years.  Highly educated RNs, for instance, desiring a more regulated day job get attracted to nursing management positions, even though the fundamentals of management and leadership are not exactly part of the education of nurses.
I have served on the boards of great associations, in other provinces, that had an eye to the future and forged such a collaborative relationship with government that they have been part of the solution to the major changes in health and long term care.  For those associations in New Brunswick who continually call for change, and those refrains have been repeated for decades, they must figure out how to be relevant to the policy change process.  Simply calling for more or calling for change on their terms is insufficient.

Both the Medical, Nursing, Physician Assistant, and Social Work Associations and their unions really need to figure out how to become meaningful players in the solutions to tough issues.  Leaving change to elected officials and civil servants is woefully inadequate.  Associations cannot continue to appear to be advocating for change then back away when some of the change options require a serious look at reality along with serving as agents of change in the redirection of professional practice.  They just cannot have it both ways.

But it is tough for the several dominant associations and unions because they are funded by current member dues with the members expecting they are going to work to get increases in compensation and benefits for them, protect the profession from government intrusion or other threats.  It is dreadfully difficult for them to seriously examine the reality of the current patterns of service delivery and propose real solutions that will work if those solutions imply near term and future significant change in practice.

Interdisciplinary Primary Care Clinics has been a source of huge threat to professionals for decades in New Brunswick.  If Sault Ste Marie and Taber, Alberta could make it work so well 20 years ago, how have we not gotten real reform years ago in New Brunswick?  Letting RNs, LPNs, and Physician Assistants function at full scope of practice in institutional settings is an idea that other hospitals in other jurisdictions figured out 30 years ago, yet we still struggle today in New Brunswick.

With all the publicity about staff recruitment and staff stress, not one word has been published, except in these commentaries, about the essential nature of corporate commitment to making positive corporate and workplace culture a priority.  When that happens and is supported by the essential supporting actions by the governing authorities, many of the issues of workplace stress, distress, turnover, absenteeism begin to moderate if not dissipate.  But the unions and professional associations have to be at the table as engaged partners and collaborators, not as adversaries.

Much has been written about the “silos” that keep people within the health and long-term care systems from service excellence.  If New Brunswick is to get to consistent service excellence, the leaders of the silos need to have a serious change of heart, of focus, of commitment.  We are all New Brunswickers and when it is you, your spouse, your child, your parent needing professional care, you want it to be superb.  We have some illustrations of superb care already in New Brunswick; so, we all now need to commit to creating that better way with consistent service excellence as the mantra.

The relationship between government and associations and unions should not always be confrontational but should reflect a measure of collegiality.
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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