​Leading Out of Chaos: solid plan, solid strategy, solid leadership, new thinking

Did you find it odd that the most joyous season of the year had to be tainted with cries from the hospital authorities for people to stay away!  In the messaging, the situation at emergency departments was described as chaotic.  It was not a time that instilled confidence in what is definitely a distressed health care system.  Government raised hopes during the last election that this would all be fixed.  In fairness, the promises and raised expectations took place prior to the Pandemic and that was yet another tragedy for which the province was seemingly ill-prepared.

Marg Melanson, the Interim CEO of Horizon, who has given stellar leadership since the major government intervention on July 20, 2022, came out on Saturday with the promise to fix the problems.  I do believe that she is sincere, committed, heartbroken about the public discomfort.  But the issues causing the Christmas, and other elements of Chaos, date back long before her time, long before Dr. Dornan’s time, long before the time of Premiers Higgs, Galllant, Alward, or Graham.

Melanson inherited an organization that was struggling before the pandemic for reasons cited earlier in these columns.  Cyclical and unplanned leadership change and political intervention do not make for superb organizations to thrive.

Just recently, Horizon announced that Clinical Assistants would be recruited for emergency departments.  These are said to be graduates of foreign medical schools who require clinical experience under supervision for a period in order to qualify for medical licensure in New Brunswick.  This has the potential of being a good move.  In the larger teaching hospitals, interns, residents (physicians in training), and some clinical associates provide an abundance of clinical care in emergency departments, intensive care units and the nursing units in hospitals, so there is great precedent for this move.

There have been a succession of ministerial announcements introducing measures, such as E-Visit, that are thought to be helpful and which seem to have been modestly helpful to a few. But as has been written in these and other columns for years, the issues contributing to the “chaos” are core issues that cannot be resolved by quick band-aids, announcements of hope, firing more people.  Core issues are not corrected by another app on your phone or a government 800 number to call.  But frankly, government has shown little sign of ability to deal with the core issues in a systematic and bold way.

In speaking with health authority leaders, the largest elements contributing to the “chaos” stem from the growing percentage of acute care beds occupied by persons who really should be in long-term care.  When the hospital beds available for ALCs are occupied (over 30%), there is a very serious trickle-down impact on the hospital emergency departments.  It is really simple:  the number of frail elders getting into health crisis is growing at a rate that is unprecedented due to the demographics of NB.  This is a crisis that has been predicted for 40 years so where have all the policy people been during those years.

The New England Journal of Medicine describes this in great detail in a commentary November 1, 2023.

Elders get into health crisis for a couple of reasons.  First is the obvious, noting that 30 percent of the aging population has multiple chronic health conditions that need managing, any one of these conditions often capable of creating a health crisis for the patient. 
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Second, if the patient is one of the many thousands who still do not have access to efficient primary care services, the hospital emergency department is the only health service option, as distressed as that department may be with waits up to 19 hours to be seen by a clinician.

The third reason is that there has been a dramatic change taking place in the practice of primary care or family medicine for decades and the policy of government and Medicare just simply has not caught up.  It would have been pretty easy for an astute, experienced policy analyst to have seen the changes taking place 20 years ago when alarm bells should have been ringing and policy, including physician compensation models, should have been on the table for major change.  But that has not been done and only in the recent months that we have started to see the development of comprehensive primary care clinics.  Alarm bells were ringing in the 1990’s.

The public still operates under the illusion, based on conventional family medicine of the last generation, that everyone needs their own personal family doctor and until that concept is replaced with modern, up-to-to-date thinking and service, we will continue to have the emergency department as the ultimate health centre for the public.

Much of what gets people into a health crisis does not necessarily need immediate physician attention as has been demonstrated in the PRIME model in Winnipeg and other primary care models that serve the aging population.

In interdisciplinary care clinic models, the clinic has up to date records on all rostered patients including diagnostic test results, medications, health care status and much more.  In some clinic models, a patient may be assigned to a Case Manager who stays in touch with the patient so that when signs of crisis appear, the Case Manager can ensure intervention, normally preventing a visit to the emergency department.

In the evolution of family medicine, doctors introduced the widespread promotion of the emergency department for evenings, weekends, and statutory holidays many years ago.  The 811 service also contributed to pushing people to the emergency department as the source of urgent, non-emergent care.

The failure of government to recognize the seriousness of the evolution of family practice, the changing patterns and the impact on the public and on hospitals is a travesty albeit predictable. The caseload of emergency departments has changed radically from a few decades ago.  Consider the impact of the aging population combined with the impact of the mental health issues and increasing drug and other addictions.

Government, as difficult as it may be for them politically, has to figure this out and make sure they have the people with knowledge and experience at the table to guide a reform process.  Dr. Paula Keating, President of the NB Medical Society, decried the lack of leadership in stabilizing primary care.  Since this has been such a “hot button” issue for so many years, and since the same themes have been repeated for decades without focused action, no wonder we saw the use of the word “chaos” over the holiday period.

Horizon’s commitment to address the chaos is commendable and I wish them well.  My sense is that since the themes are so old that perhaps they may wish to entertain consultation with some people whose skill set and knowledge base might add value to their efforts.  In Ontario when there was a need to do radically different things in northern and rural health care, the province did just that by bringing a prominent figure to the table who could make some calls that neither politicians nor civil servants were able to do.  The result:  a system that works and performs well for the public and the physicians!

What the public will need to see is not more promises but strategy and an action plan that has a reasonable chance to succeed in meeting the challenges of this decade.

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