My book by this title commences with this question on the inside front cover because I wanted readers to understand that making our health system work for New Brunswickers is not about simple improvement but about transformational change.
Being a writer was never in my career path at any time until the opportunity afforded me nearly two years ago by Brunswick News. They asked for a series of commentaries on Health Care Reform and I was only too happy to oblige. It was, in fact, a labor of love for me because I, like thousands of others in the health and long-term care system, have seen so many events happening, policies announced, projects approved for which there seemed often to be a gap in logic! Many days I, and many others, would end the day with many questions about the wisdom of decisions and strategies.
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?”
“Mental illness is one of the leading the leading disabilities in the world with 4 of the 10 leading disabilities being mental disorders!” So says the Action Plan for Mental Health in New Brunswick published in 2011. The plan was a visionary document and has a wealth of statistical and historical information regarding Mental Health in New Brunswick.
Twenty percent of Canadians suffer with some mental disorder while 80 percent are said to have someone in their family or close circle of friends suffering from one of many mental disorders. Mental Illness is referenced in the report as “The Orphan of Health Care” which suggests that it does not receive the priority that it deserves.
Time was when the family doctor knew each patient, each family, their idiosyncracies, pressures, distress and pressure points. That was in the days when medicine was considerably less complex and doctors worked 70-80 hours per week. Office visits were not limited to 10-15 minutes and there was no such thing as “only two things per visit; if you have other issues to discuss with the doctor, you will need to book another appointment”.
That was also in the days when housecalls were common which served to render urgent in-home care but gave the doctor some insight into living conditions and family dynamics. The thousands of drugs that have an impact on the body and the moods just were not available so treatment of known mental challenges was pretty limited.
There has been a good deal of concern within the public, the media, and advocacy groups about the Covid-19 outbreak in Region 5. For the provincial leadership team, it was akin to the opposing team hitting a game winning home run in the bottom of the ninth after a stellar pitching duel. It was a big disappointment. And the doctor who was thought to have been the carrier and whose life has been badly scarred will deal with the aftermath for years to come, no doubt.
People had a right to be frightened; it is a wicked virus made even more wicked by the fear that the warnings starting with the WHO and many others in regulatory and advisory roles play. The fear of this awful virus has ensured that businesses closed, that commerce came to a halt, and that our lives have been put on hold as we “stay the blazes home”. And just when we see light at the end of the tunnel and we think we can get back to the golf courses and Tim Hortons, we get broad-sided.
The discussion at the Horizon Health Authority Virtual AGM this week suggested that even though the Premier has not been able to conclude the consultations with municipalities that he promised, thanks to the Pandemic issues and distress, the CEO remains convinced that the plan needs to go ahead as originally announced. This, now, has raised the hackles of persons in rural communities and has now created strong pushback from some.
Having now had 5 months to ruminate on what was announced and how it was announced, and having consulted with some knowledgeable people in the field, what appears obvious is the classic stalemate! Rural Health Care thinking versus Urban Health Care thinking. What appears obvious is that the rurals were handed a plan that took them by surprise and did what they should do…push back!
That was the headline of a CBC story carried on the news on June 5, 2020; the story went on to discuss the issue of inadequate home care in New Brunswick as illustrated by the case of Paul Ouellet’s sister, Lorette. And the issues of inadequate funding of home care in New Brunswick were well documented in the Council on Aging Report.
In the story, the health authorities’ position of “move long term care to health” was recited again by Karen McGrath, CEO of Horizon, in which it was noted that she has been asking for structural change for two years. The structural change referred to is to move long term care to the Department of Health or to the health authorities, the theory being that somehow that would improve the flow of persons requiring long term care more smoothly and expeditiously. This is also a position taken strongly by unions.
Oh, that it was all that simple. However, achieving reform of long-term care in New Brunswick requires significant change at deeper levels; otherwise, we are just “moving the chairs on the deck of the Titanic”. New Brunswick has wasted countless tens of millions of dollars in executing “restructurings” that were not well thought out. Ask any veteran of NP Power for a few illustrations!
The Telegraph Journal editorial in the June 6 edition is “bang on” in terms of issues in Health and Long-Term Care. Recent publicity in response to the unanticipated outbreak in the Campbellton Region drives home the issues of the need for health and long-term care reform much documented and written about for a decade in New Brunswick.
At the heart of this is leadership and communication. New Brunswick has many stellar health and long-term care professionals; people like Jennifer Russell, Linda LeBlanc, Cindy Donovan, Chris Goodyear and thousands of others. Each wonderful professional that I know is dedicated to utilizing the terrific training and experience that they have had over many years and decades.
But as our late Chief of Staff at DECRH, Don Morgan, used to say: “we all see the health world from where we stand.” That observation was made as we were in the midst of one of several major controversies during the regionalization of hospitals in 1992.
As the weeks and months have dragged on and as the public becomes increasingly anxious about basic issues in our society, it is increasingly important to sort out reality from perception. The outbreak in Campbellton is disturbing, aggravating, and disappointing. It illustrates clearly that the best laid plans often can get sidetracked by undisciplined behavior.
Nationally and internationally, the attention has turned to Long Term Care and legitimately so. Chris Selley, in his National Post article of May 27, “Shameful Nursing Home Report Shows How Canada’s Lockdown Strategy Went Wrong”. In the article he refers to recent reports from the federal government, Ryerson University’s Institute on Ageing that make it clear that the Covid-19 risk is very high amongst those of us over 60 who live in long-term care.
Based on analysis, his conclusion is that “Canadians who aren’t elderly or in long-term care homes have faced a risk of death that’s no worse than the 2009 H1N1 outbreak.” His article goes on to underscore that the vast majority of people infected by the virus do, in fact, survive and do well.
We have known from the beginning that it is a powerfully contagious virus and for those with underlying medical conditions, it is lethal. We know that and it is said that the vast majority of those dying during the pandemic have been persons with one or more co-morbid situations. In Italy, a major hot spot earlier on, it was 99.2% of persons who died that had at least one other illness. That makes frail elders and persons living with Chronic diseases vulnerable targets.
To the astute observer, information and knowledge seems to change almost daily as experience and research combine to help us understand what we have experienced and will yet experience. Pharma companies and university research labs around the globe are racing to be the first with a drug and first with a vaccine. The rewards for success are enormous.
In late 2019 the world heard about the outbreak of a strong virus but its seriousness on the world stage was not felt to be so serious. That led some of the major news outlets in the US to use terms like “pandemic panic” in assuring the public that this was nothing to worry about.
The first rule of politics: don’t ever waste a good crisis! In exercising the need to continue to cultivate voter support, times of crisis present a magnificent opportunity to curry favor with voters and potential voters. The longer the “crisis period”, the more opportunity for elected officials to raise the level of their political capital or spend it.
Such has been the case with the Covid-19 pandemic. In Canada we have been spared the drama that seems to play out in some jurisdictions; in some of these situations the stakes are enormous and competition for air time and influence is beyond anything we can fathom in New Brunswick.
But clearly, as the Canadian version of pandemic drama unfolds we see where “the ship is leaking” and the best that can be done now is to mitigate the risk and damage. In Canada, the eyes are clearly on Long Term Care. Covid-19 has brought deaths amongst seniors and residents of long-term care facilities to the fore. Thankfully, New Brunswick has been spared this drama in long term care.
The Prime Minister, in his Tuesday message, invested good air time assuring Canadians of Canada’s commitment to supporting the provinces in improving the system of Long-Term Care. His words of commitment and assurance constitute a message that seniors advocates have wanted to hear for decades: It is our seniors who built this country, who helped to get Canada to where it is today, and we need to see that their care is good and safe (a paraphrase).
In New Brunswick, that message has been communicated for many years by the Senior Citizens Federation, the Nursing Home Association, the Special Care Home Association, the Coalition of Seniors and Nursing Home Residents Rights, the Home Care Association, and others. Over 40 years ago, health planners and professional leaders were trying to prepare Canada for the day when Senior Care would need a higher priority.
The health and long-term care systems in Canada, however, are influenced strongly by the forces of the status quo, that being hospitals, emergency departments, professional interests, funding crises, and construction of superb facilities. In times leading up to elections, it seems that the public gives more credit for ribbon-cuttings and promises of new initiatives and funding than in the substance of what is behind those announcements.
Our lives have been forever changed with Covid-19, so say just about every informed observer of human behavior and public institutions. Just imagine….90 days ago our lives were moving blissfully along, snowbirds enjoying the south, New Brunswick political people debating an attempt to reform health care, rural communities upset, unions also not so happy.
And south of the border the press was wondering why people were concerned about a virus in China. The virus had already established itself firmly in Wuhan but United States media downplayed it as did prominent health authorities.
Please enjoy this presentation that was initially scheduled for March 26, 2020 and was cancelled due to social distancing recommendations.
Senior health executives of my vintage would tell you “this is not my first rodeo”! We have seen major outbreaks of highly infectious diseases for as long as I have been alive which is 75 years! Polio was alive and not well when I was a kid with iron lungs as the way to save lives of thousands of people. Then Jonas Salk invented a vaccine which we, as school kids, took without any choice. Our family knew only one thing: with the vaccine the likelihood of tragic illness was all but eliminated; avoiding it left us with a great chance of getting a dreaded disease. So Rotary Club and Bill Gates Foundation have now made strides in the near elimination of polio worldwide.
Then measles, chicken pox, and influenza. Now, at our age and for good reason, we are doing the Shingles Vaccine because it is such an awful disease; vaccine is not a guarantee but lowers the risk enough to make it worth the $400 we pay!
Hats off to New Brunswick and its leadership. During this dreadful time of pandemic, with the cooperation of most of the population, but not all, the numbers seem to be favorable relative to the rest of North America. Thankfully, while frail elders and residents of long term care are prime targets, there have not yet been serious issues. The thanks for that can be given not only to provincial leadership but also to the rapid response of Nursing Homes and Special Care Homes. And the fact that 4 political parties are pulling together is a model for North America!
Have there been problems of execution of procedures? Yes indeed. Have employees and administrators responded with determination? You bet they have. Listening to operators share their experiences thus far shows the determination, dedication to residents, focus on safety that families would want to see and hear.
Well over a month into the journey ....
Prominent Wesleyan Pastor John Symonds and his wife, Willo Ann, created a song that is making the rounds on Facebook expressing the spirit of the proper response of the public to this pandemic: “Cough if you want to, sneeze if you will but I came here to stay…………it’s a battlefield, brother, not a recreation room, it’s a fight and not a game…..cough if you want to, sneeze if you will but I came here to stay”, sung by the piano in their living room! This folksy little song expresses the spirit of what officials are trying to get us to understand as the key method of preventing the spread of this disease. Just stay home!
But it is not entirely that simple for sick people need to be cared for, essential services provided, policing to be done, groceries to be on the shelves and secured, electricity needs to be generated and distributed, elders in homes and care facilities need to be cared for, fed, clothed, bathed and entertained.
Premier Blaine Higgs and Dr. Jennifer Russell have been the calm, factual, steady face of the battle against this awful virus in New Brunswick and thankfully it has not gotten to the level that it could have at this stage were it not for rapid response.
The world continues to adjust to new and different times, many in shock, many experiencing the distress that always comes with such a crisis, many inflamed by what they hear or read either on social media or television or wherever is their source of information.
That the disease is dreadfully serious is well beyond question. It is taxing the energy of the wonderful health care professionals who provide care to those stricken with the virus. That health care facilities are distressed is beyond question, many having been at a point of crisis long before Covid-19!
Covid, and each of the viruses and infectious diseases that have preceded it, follows a familiar cycle: discovery in the country of origin, early management in that country, notification to the World Health Organization, alerts to other countries, and the international war on the disease commences. The war is always complicated because in the early days, little is known about the virus, how it behaves, how it is transmitted, what drugs and treatments are effective, if any, what the incubation periods are and much, much more that engaged thousands of brilliant people around the globe in research laboratories and regulatory centres.
The world has been torn apart in just a few days; the growth of cases in various countries is alarming while some countries report no incidence of the virus whatever. In North America, New York seems the hardest hit and we hear daily briefings from the White House, various governors, our Prime Minister and increasingly our premiers. The briefings each day seem to ramp up the intensity and seriousness of the Covid-19 issue, and in New Brunswick the faces of Premier Higgs and Dr. Jennifer Russell have become welcome sights to a concerned public.
Floating hospitals and military field hospitals are being activated in the United States and hospitals are being directed to vastly increase their capacity.
In the short time since early February the world has been brought to a virtual standstill due to one miserable little bug, Covid-19. Universities shut down, graduations cancelled, meetings postponed, vacations cancelled, much normal social and economic activity grinding to a halt. Millions of people worldwide will receive no paycheque until the dust settles!
The stock market went crazy requiring the Fed and Bank of Canada to restore confidence, a rare intervention significant of the seriousness of this bug and its potential impact on human health and the economy.
Dreams are being dashed for millions of people due to this one, little bug whose impact on humans can, albeit rarely, be lethal. As one physician pointed out, 99.9% of people less than 50 years of age who contract the virus will recover. But for those in my age group who have compromised immune systems and other co-morbidities, the prospect is serious and often lethal.
Premier Higgs has announced a health summit in June 2020 at the conclusion of a 3-month period of consultation with people in the province on health care issues. John McGarry, Chair of the Horizon Health Authority Board of Directors, has appropriately said that the summit must concentrate on more than rural health care issues and he is absolutely correct. Since the province started down the road of a planned approach to health care in 1992, there has been a long drought! Instead of rain in response to the drought we have seen for decades now a series of unrelated initiatives leaving the health system resembling a patchwork quilt.
There have been many health summits in recent years. During the term of David Alward, the Canadian College of Health Leaders and the Institute on Public Administration, both New Brunswick Chapters, held a summit in Moncton with Minister Flemming and Jeffrey Simpson. Not much has happened. Then the NB Medical Society sponsored really well-organized event involving some national leaders early in early 2015. What is aggravating to those of us close to the scene is that hopes get built up when these events are held and supported by our leaders. At both of these events, and there have been more, many of us walked away with a new spring in our step expressing hope and optimism.
Many of the issues faced by those who would offer leadership in healthcare services stem from incomplete understanding of the health field, hospitals, and professions and how they all come together. It is a unique, complex business with lines of accountability, or lack thereof, unlike any other! That, together with the fascination that the public has with doctors, nurses and hospitals, explains why Jeffrey Simpson refers to healthcare as the third rail in Canadian politics.
In times like these we need to bring back the images of Florence Nightingale and Dr. Malcolm MacEachern. Florence, of course, set the bar for nursing practice and professionalism. Dr. MacEachern was, a couple of generations ago, the father of Hospital Administration in North America and, indeed, around the world.
It is Friday, 4 p.m., the chest infection that you have nursed for a week is not getting better and has you weak and sick. You call your family doctor’s office; a recorded message says “call telecare, go to an afterhour’s clinic, or go to the Emergency Department.”
None of those is a good option that will lead to optimum care. A common outcome from a call to Telecare is that at the end of the call there is encouragement to go to the Emergency Department. When that advice has been heeded, what could take 10 minutes of professional time has always taken many, many hours. Sitting in a waiting room when I should be home in bed with prescribed medical therapy is not an attractive option.
Presentation at an After Hours clinic will possibly get you medical care, but each operates differently, some with a “wait and take your chances”, others where you call to make an appointment, while still others require you to go to the clinic in person to get your name on the list after which you may be seen a few hours later. And in no case does the after-hours clinic have access to any of your records, particularly of medications you may be on or to which you may be allergic, or, better still, what antibiotic worked for you the last time!
In writing this column, I am working from an office in Augusta, Georgia where I see Prompt Care, Primary Care, and Urgent Care usually within a 5 minute drive of my office! And when you go to Urgent Care with flu-like symptoms or other symptoms, the receptionist calls up our records from the hospital on the computer and can tell right away what hospital and emergency visits you have had, what clinical interventions you have had, results of diagnostic tests. You can get routine lab testing on the spot along with some imaging scans. You can be out and back home with any essential medications within an hour!
Each of these facilities, including Emergency Departments, advertises time to wait and Time to Care, the latter being the measure of efficiency. Each facility seems to take great pride in the lowest possible “Time to Care”. Why is that?
Unlike the New Brunswick urban system, the method of payment to physicians and clinics is dependent on customer (patient) satisfaction; as with buying cars or fast food, there is a doctor and patient financial relationship that recognizes that while the service provider has time pressures, so do I as the patient. I need to get home to heal; I need to get back to work as quickly as possible.
This is a sharp contrast with the semi-socialized system that seems to direct primary care in New Brunswick. In our system, we have the blessing of not having to worry about whether there is a co-pay charge or whether our insurance has somehow lapsed or whether the treatment is covered. Most of what we need for life sustaining care is available with the presentation of the Medicare care.
In our system, we are patients but there is no buyer-seller relationship; strictly doctor-patient, professional, mysterious, wonderful in many ways. But the waiting times, the delays, the inability to see our records, the inability to check diagnostic test results. This is 2020 and New Brunswick is supposed to be an IT leader……but not in health.
My friends in Augusta have access to a portal at which they can obtain on the internet their full hospital medical record, results of diagnostic tests including lab results. And a new resident in the area can find a family doctor pretty much the same day. And the discovery of a bad gall bladder can be fixed on the same day as its discovery!
That all costs money, my critics will say. That undoubtedly is true but more importantly it requires understanding that service providers have their first duty to their customer, the patient. Jim Sinegal, founder of Costco, makes the point that organizational success in dealing with customers is all about culture. That is why employees happily remain with Costco for years when other retailers experience turnover.
Then it requires vision of a system that places the interests of the patient at the centre and builds services and systems that ensure efficient and effective care. It also requires a commitment to putting the people with the best training, experience and skill in charge of essential programs.
We could build these patient-centred systems in New Brunswick. It will never happen as long as we keep violating the key principles that make the system patient-centric. When all is said and done, what makes this system so much more efficient is customer focus whereas in New Brunswick, until now, our system has largely been driven by the convenience of service providers. This relates to office hours, access to care, weekend care both in the community and in the hospital. Every service provider needs to start their work day by asking one simple question: if I were treating my parents today, how would my service be different?
In using the American health system analogy, we get immediately to the issue of cost and certainly when we hear tales of six figure invoices for what we deem to be routine surgery that is sobering. And when we hear about the large number of “charity cases” and persons without coverage that too is sobering. Just adopt the principles and apply them to New Brunswick.
For instance, the first thing that I learned many years ago studying some excellent centres is that the physician community plays a huge role in governance! By having physician and nursing leaders embedded in the governance structure, or even leading it, there is a better than average chance that policies and strategic directions of the organization will go down better with the professional community.
Another key element is reliance on efficient information systems, driven in the US by the critical billing system. Being able to get access to records and test results on line is huge.
The focus on getting patients processed efficiently with a minimum of delay is another feature that requires physicians and administrators to work very closely together. Both benefit because of the way the system is financed whereas in Canada the compensation and reimbursement models tend to present a wedge between physician practice and hospitals.
Another stunning feature is that staff functions at full scope of practice: LPNs, RNs, Nurse Practitioners, Nurse Anaesthetists, Family Practice Nurses and more. This stands as a serious contrast with New Brunswick where rivalries, inter-professional angst still is strong. This feature alone is a great roadblock to patient-centred care.
In examining other health systems, the Organization for Economic Cooperation and Development ranks the US and Canadian systems as the lowest amongst 10 western world countries. So we would not want to blindly parachute elements of one system over another. We should, however, have the courage to acknowledge that for all of our excellence in New Brunswick we can be so much better for our patients by doing some things that other systems have already shown to be effective. That starts with putting the patient at the centre and building programs around them, not around the convenience of service providers.
Ken McGeorge,BS,DHA,CHE is a retired veteran health care CEO, part time consultant and columnist with Brunswick News.
True to their promise from last fall, the Higgs government has succeeded in capturing the attention of New Brunswickers around health reform. The announcement of what is referred to as a plan that includes major changes to small, rural hospitals was the second step. The actual first step was the announcement of the expansion of Nurse Practitioner appointments within the health authorities on January 27.
Anyone involved in the health reforms of 1992 knows that a frontal attack on rural hospitals is a formula for certain push-back, speaking mildly. My friends and I remember well the fact that despite the logic, people on the ground were interested in only one thing: will my doctor be able to look after me and my children when we are sick particularly at night or on the weekends.
It was difficult enough in 1992 when 55 hospital boards were dissolved in favor of creating 8 regional hospital boards. But now you have a population for whom that is forgotten and the power of social media. Social media can win and lose elections!
The aftermath has been predictable with local MLAs taking real heat at a time when election talk is in the air and rural seats are critical. Dwight Eisenhower said: “Farming looks easy when your plough is a pencil and the cornfields are a thousand miles away.” And so it is with those who would initiate health care reform. From Fredericton the world looks vastly different than it does at 2 a.m. in Plaster Rock!
It is clear by now that the provincial government is intent on shaking things up in New Brunswick and most New Brunswickers think it is about time! Many issues face the Premier and his government that have been the topics of angst in the electorate for decades including municipal reform, the performance of the education system, infrastructure, extremes in labor relations, economic and jobs development.
So where do you start? It is a challenge for government hanging onto minority status. A strong majority status is to be preferred when wading into major reform for many of the reasons already mentioned in previous commentaries. The commencement of major reform in 1992, difficult as it was, was made much easier with Mr. McKenna’s huge majority and lack of social media!
But make no mistake; the public is looking for leadership on this very complex and challenging file and the Premier and the Minister of Health have both made it clear that they have some great plans in mind.
So just where do you start?
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.
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.
Ken McGeorge, BS,DHA,CHE is a career health care executive based in Fredericton, NB, Canada.