​Health Care Reform: What Should it look like?

Adam Huras, in a very thoughtful piece in Monday’s Brunswick News, outlined the fact that Premier Higgs has backed off ER cuts and seems to have had second thoughts about the health care reforms announced in February 2020.  It is absolutely true that both the Premier’s office, Departments of Health and Social Development and other departments have been pre-occupied by the pandemic.
The pandemic, vicious as it has been internationally, has created huge issues for policy makers trying to keep abreast of the latest changes in forecasts, etiology, transmission methods, mitigation methods and ever so much more.  Had the measures announced in February gone forward as outlined, there is little doubt that a health system already beset by major issues would have been in a major state of confusion or pandemonium.  That is not the voice of extremism speaking; it is the voice of experience, however!

Further in the article, the Premier, who was committed to major reforms in the health system long ago, acknowledges that the reforms as announced perhaps were not well conceived and raises the rhetorical question: “what was that going to accomplish anyway?”

Then later in the article, the positions of support for the reforms, as expressed strongly by the health authority leadership, is repeated.  Mr. Lanteigne contends that the plan was “based on facts.”  But the electorate showed no confidence that the health authorities could deliver quality, timely, relevant emergency care to residents of rural New Brunswick.  In their opposition, they cited long delays in ambulance service, huge wait times in emergency departments in regional hospitals.

In the aftermath, some of the “facts” have leaked out more thru social media and rumor than otherwise.  For instance, it is said that on a typical night shift there might be 2-3 cases that arrive for care and the cost of care is paying a physician and a nurse to staff a department largely empty.  That is the nature of rural health care and if they are paying professionals to care for such limited volume, there are many other ways to do that.

I am old enough to remember when the only emergency department in the city of Fredericton had such low volume that doctors were not immediately available in the building.  For years, the public was well served with a call system that worked.  Now before my critics say “yes but that was 40 years ago” let me note that in other rural parts of Canada governments and doctors have gotten very creative in the way that physicians are compensated in low-volume, rural practices.

The Rural and Northern Physician Group Agreement developed for rural and northern Ontario in 1996 has evolved to assist rural communities in recruiting and retaining quality physician staff.  It is a blend of capitation and fee for service with factors built in for the unique characteristics of practicing in rural areas.  By developing this strategy, the government of Ontario and the Ontario Medical Association recognized, years ago, that providing health care in rural areas is vastly different than providing service in urban areas.  It is not that one is good and the other is bad; but they are different, like day and night.

In New Brunswick the argument often given is that “a large portion of the population lives within 50 km. of a regional centre.  That, however, does not account for the other large portion of people who do not live within 50 km. and over that have no choice by virtue of employment, career, vocation.  New Brunswick planners seem very attracted to the idea that “one size fits all”, that if a policy or practice works in Fredericton it should work in Campbellton or Beresford.  That has been the goal of Equal Opportunity and is the point in public policy where health and long-term care become compromised.

Further in the article, there is reference to the rapidity with which long term care patients (ALC’s) were moved from hospital to nursing homes.  That move certainly did show what can be done with political will. What is not acknowledged is that, based on the feedback I have received, perhaps as many as half of those persons did not need to go to a nursing home at all.  It is suggested by knowledgeable people that admission to home care or to Special Care Homes, where costs are dramatically less than nursing homes, was not explored.  It was believed that hospitals needed to have beds cleared for the forecast volume of Covid patients so haste was the order of the day.

Skeptics are already suggesting on social media that health care reform in New Brunswick is enjoying the calm before the storm, that after the election the province will dust off the February plan, presumably armed with a majority government.

I would choose to be less cynical and believe that governmental leaders are pretty smart, that they learn from errors, and will seek new directions that target issues of concern to the public.  The consolidation of clinical expertise in centres of excellence, for instance, has been a goal of the health authorities, and wisely so, for years.  If that is a key element of the new strategy, will it benefit the public?  Absolutely.  Will there be short term pain?  You bet there will.  Is it worth the pain?  Indeed.
Then what about renewed focus on fixing the Regional Hospital Emergency Wait times and the lack of good urgent care?  All of that is part of a renewed commitment to coherent Primary Health Care Reform.  Will that be top of the list?

And dealing with governance of the system and leadership issues therein?  That is not a topic often discussed by the public but is of far more importance to the public than fights with rural New Brunswick.  Related to that is the large issue of workplace culture which, again, is not much discussed by the public but is of great concern to employees and physicians alike.  In a conversation on this topic recently with an informed source, the point was made that as people get closer to retirement, when retirement is a year away or less, they become much more willing to express their true assessment of the organizations.

Will that be part of reform?  In February I did not see or hear an expression of a compelling vision for the future; maybe it was there but drowned out by the noise.  The public can and will become interested in health care reform that appears to consist of steps that will get the system toward performance excellence.  But, as the Premier says, “There’s no sense changing for changes sake…”

With a compelling vision, it is possible to get the right people in the same room to put a plan together that will satisfy the public that the real issues they experience are not only on the radar screen but are being dealt with.  But we are well beyond the day when a plan can be created in secret and imposed on an unsuspecting public without serious pushback.  In February I heard from many who were vocal; they were not dumb, ill-informed, protective people.  They were good people, frightened that on top of other assaults, they are now to lose again that which is critical to their community. 

Lesson to planners:  Health Care is the Third Rail in Canadian Politics!

Ken McGeorge,BS,DHA,CHE  is a retired CEO in major teaching hospitals and long-term-care facilities. He was co-chair of the New Brunswick Council on Aging and is a columnist with Brunswick News and author of Health Care Reform in New Brunswick. His email address is kenmc1@bellaliant.net.