Health System Reform: make us proud again

Tommy Douglas would be most disturbed at what he reads in the press this week!  Two headline stories on July 4 in Brunswick News:  Sinking Faster than the Titanic (Dr. Mark Waite) and Moncton Orthopedic Surgeons stop accepting referrals for elective surgery.  That was not the vision that Mr. Douglas had nor any of those political leaders who went to the wall at a time of intense national debate in the 1950’s.  Ours was to be a system that provided for essential medically-necessary care of all Canadians.

Fast forward to 2022 and the water gets really murky.  Those who have been carefully tracking the trends for decades have seen this day coming for years; those with their focus strictly on budgets perhaps not so much.  Much has already been written and said about how we have arrived at this place and this is no time to point fingers and ascribe blame.  It is a set of health and long-term care circumstances that simply do not respond effectively to the demographic of 2022.

The Department of Health has had staff assigned to Primary Care and its reform for decades and the question often is raised “to what end?”  For the last 20 years, other models of primary care have sprung up across Canada and across the world along with alternate compensation models.  During that time, a few models have emerged in NB but no widespread change or trend at this point.  Also, during that time some leaders of alternate models from other provinces have visited NB sharing their knowledge and insights, but the up-take has been very slow.  The Medical Society has moved slowly in introducing the Family Health Teams concept that has been described earlier in these columns as a start.

A challenge of 2022 is that the model of primary care in New Brunswick has been based on a traditional, conventional model based on a family doctor managing his/her caseload of 2-3,000 patients in the manner in which that physician was trained, quite unlike the numbers of less than 1000 that apparently is the norm now for new practitioners.   Group practices helped but in recent years have not developed as true group practices.  Meanwhile, several “after hours clinics” have sprung up in New Brunswick with seemingly different policies, organizational arrangements, and hours of service depending on who is operating them not operated by the health authorities or government.

Volumes have already been written in these and other columns about the long waits and overcrowding in Emergency Departments.  This is a complex organizational challenge that does not lend itself to simplistic or conventional thinking, one-factor solutions.  The old adage of “ask why 15 times” needs to be applied in order to get to the root cause and without understanding “root cause”, any other solutions applied are simply cosmetic!  Reform, not simple change, begins with in-depth understanding of what is really driving the situations that are now manifesting as unacceptable health policy failures.

Public policy failure happens when government policy, intended to regulate a certain set of activities, is not in alignment with demographic changes, public demand for service, and many other factors.  Over many decades, the major public discourse from governments at federal and provincial levels has seemingly been focused on cost sharing.  The 50% cost sharing that was announced in 1959 is now closer to 30% if that, leaving the provinces with a huge gap in the transfer payment arena.  So regularly we hear the provincial premiers pushing the federal government on increasing their share of the cost burden on health.  Justifiably a stress point particularly if the province wishes to maintain a positive credit rating.

But deep beneath the issues of cost sharing and transfer payments are the things that are happening in the population and the health professions which have a serious impact on service needs and the tension between need and service availability.  All the while the population has been aging, for instance, the policies governing how best to provide care to the aging population have not kept pace.  There have been numerous, almost annual, reports either from governments, interest groups, or academics showing the pressure points and pointing to the need for action.  But action has not kept pace.

The wait times for orthopedic and reconstructive surgery have ballooned to the point of desperation.  The great surgeons who currently practice in our province have been trained to perform procedures that were unheard of 20 years ago!  Joint replacements, reconstruction of joints and their structures, realignment of painful spines and ever so much more.  Aside from sports injuries, much of the pressure on service stems from the changing demographics.  But ask any of these talented surgeons:  how much time do you get in the operating room each week?  Responses are usually not good!

Similarly with primary care in which the training of doctors and their practice expectations has not been met with public policy changes with sufficient breadth and scope as to meet the need.  Instead, we still have the conventional thinking of salary versus fee for service compensation (no too creative), nurse practitioner or family doctor (insular thinking), nursing home or aging in place or integrated long-term care.  And the list goes on.

The current primary care situation in NB can only be referred to as a public policy failure, as can the situation manifest by the huge issue described by the Moncton orthopedic surgeons.  Yet these issues have been forecast for decades?  Why the “shock and awe” of the current situation?  Are the claims made by these professionals legitimate or are they simply political power plays?  The health care system has been known for its political challenges for decades and Jeffrey Simpson (the prominent Globe and Mail writer) described health care as the third rail of Canadian politics, which sends shock waves to elected officials when they get too close.
On the surface, this week’s headlines need to be taken as strong signals that the frustration levels of key professionals, those whose skills are seriously needed in New Brunswick, is getting to the point of boiling over.  When have we heard such a steady barrage of issues as we have in the last decade?  But not just New Brunswick.

New Brunswick, the first-off-the-mark with health reform in Canada in 1992, was to be the working lab for the country; small enough and nimble enough that it could be a model for the country!  That was actually a stated goal in 1992 by those involved in leading reforms.  What happened to that dream?

Good public policy keeps two eyes peeled simultaneously:  one eye on dollars, costs, cost-sharing, bottom line; the other eye is on the policy that drives the costs.  It is that second eye that perhaps has not been as alert as the fiscal eye over the years.  Models of care that are causing such distress were designed decades ago.  More to the point, they probably were not designed so much as they evolved from conventional practice.  But changing demographics, the changes in profile of practitioners, the changes in demands for work-life balance, the increasing standards of education and training in a variety of health professionals all conspire to demand new models of care and practice.

But if the focus is on dollars, improving electoral opportunity, spending limited political capital, then the policy issues will be kicked down the street as they have been for 20 years.  Reform says:  we have a situation that dictates action; the action may not be universally popular; but we are going to get the best talent to the table to fix the issues and deal with any political fall-out.

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