By now we are all sick to death of the pandemic! People are restless, depressed, frustrated, tired of following what often seem to be illogical rules, pushed to get vaccinated, never knowing if they can see loved ones, and more.
Let me be clear: my wife and I have been loyal subjects, following every rule that is imposed on us without public complaint and taking every vaccination made available. I am no anti-vaxxer, not even close. But I do respect the rights of those whose opinions differ from mine to express their opinions in a mature, controlled manner without shouting and without nasty language. We are a population of persons, all of us from different cultures, educational backgrounds; some of us steeped in science, some very suspicious, some having become amateur virologists during the pandemic.
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In the 1980s the health system raged with a fractious debate! What to do with Mental Hospitals? While there had been horror stories for years about abuse of ECT procedures, the Jack Nicholson film One Flew Over the Cuckoo’s Nest, released in 1976, no doubt added much to the debate! The film had humorous moments but was heart-attack serious in its depiction of therapies and drug abuse. The debate ended with mental hospitals being closed in Canada with many patients then becoming residents of Level 4 facilities in the long-term care system or elsewhere.
As the debate raged on, those of us who were a bit cautious warned: “we know that some of the practices in some of the old mental hospitals left much to be desired. But full-on closure must also be coupled with seriously strengthened social systems; otherwise, many who used to be admitted to these hospitals will now be on the street…. homeless.” That caution was not heeded and for the last 30-plus years the homeless population has been increasingly numerous and visible. John Chilibeck, in his article in Brunswick News on December 1, explained the Fraser Institute Report on New Brunswick’s budget surplus. In that report, the author said that the cost of senior health care will take the New Brunswick government from surplus to significant deficit. As a senior I did not get upset at the author! Writers are intended to report and explain facts. He did so with quality.
Who is the villain here? What is there about being a senior that causes health care costs to be incurred at 5 times that of persons 20 years of age? Am I, at 77 years of age, now a villain? Should I and my fellow seniors be demonized? Not at all. Here’s why. The Higgs government was elected on promises of reform within government. The Premier has no patience for deficits so paying down provincial debt has been a huge priority. He has turned his attention, equally, to the long-standing call to reform local government which Jean Guy Finn identified, in his landmark report, as long overdue in this small province struggling to grow and develop. Education has been another area targeted for reform and there have been, Covid notwithstanding, some inroads apparently.
Health has been, as Jeffrey Simpson pointed out in his book Chronic Condition in 2012, the area fraught with incredible political minefields. In February 2020, government released its initial plan for Health Care Reform. To financial people, it made sense: cut the loss leaders, a first principle of successful business. But health and long-term care is not about financial logic but about providing what the population believes to be efficient, safe, quality service within reasonable driving distance. The plan, as announced, backfired and was one large embarrassment to government. Recent headlines by other professional writers in Brunswick News have said: Build Back with Private Health Care, and Fourth Wave Highlights Health System’s Fragility. Both articles were superb in content and challenging thoughts. It is nearly the end of October 2021 and those observing the scene are waiting anxiously for the reforms promised by Premier Higgs to be announced. The public knows the system is broken, nurses and many physicians know it is broken. Most with whom I speak have limited confidence that government can, in fact, rescue the system.
The pandemic has taken a toll on everyone who works in the health and long-term care system and has forced a level of change and disruption totally unheard of in modern times. It has, in fact, robbed many great people of what once was the joy of going to work every day. The distress felt within the system, particularly the hospital and long-term care sectors, is made so much worse by virtue of the place from which it all started in early 2020. The pandemic has tested every health and long-term care organization; those with great workplace cultures at the beginning tend to fare well as they work through any crisis. If the workplace culture has elements of toxicity, undue work stress, internal communication issues then working through any crisis, let alone one that is prolonged for two years, is a formula for disaster. Over-crowded waiting rooms, long wait times up to 10-12 hours. The headlines have been in the news for years. Staff do the best with the knowledge and training they have along with systems available to them. But the issues of overcrowding and perceived slow response times continue. Why is that? And what do the health authorities need to do to fix it?
The issues will not go away by simply trying to change a few policies or hire more staff. In my July 22 commentary, I developed the need for strong leadership to deal with some challenging issues. Not until those at the top understand that the “fix” requires more than just talk and more than mere motions and political positioning. It requires a “deep dive” to get to the real core issues, as challenging as that will be. In 1962, Dr. Malcolm McEachern, the father of modern hospital administration, described emergency departments in his classic text, Hospital Organization and Management. In it he listed 8 critical elements that are required to make an emergency department function and, in the narrative, there was not even a hint that the Emergency Department would be used as a replacement for the doctor’s office! Originally the department was developed for the care of patients presenting with fractures, trauma and other life/limb-threatening conditions. Consequently, he emphasized the basics such as the visible presence of an involvement by specialists, proximity to the operating room and much more. It was a place where those conditions that could not be dealt with in the family doctors’ office could be managed effectively. So what has happened in the meantime? It is said that at least 80% of the visits to emergency are not life-threatening; serious, important, but not fitting the traditional definition of emergency. They arrive, as has been stated on numerous occasions, because they cannot get access to a provider of primary care services who can deal with the problem. In the old days, they call their doctor. Not so in 2021 for many reasons described in earlier commentaries. Who could argue against the idea of vaccination against a dreaded disease? In the 1950’s we took smallpox and polio vaccines; I was too young to know whether there was objection, but if so, it was quiet. I just recall all the kids in my school going to the gym and getting it; it was our duty and privilege.
While the influenza vaccine has been the contributor to death for hundreds of older New Brunswickers over many years, and while there is an annual plethora of sources of influenza vaccination, there has been consistently a core of people in society, including health care professionals and staff at all levels, who have not joined the parade. And each year, nursing home beds become available as people die from influenza. In most cases, those who have succumbed in long term care have been people with high levels of multiple co-morbid conditions. Any one of the conditions could claim their life and the influenza tips the scale for them. As a father and grandfather, I have watched each year as influenza goes through the schools that my kids attended causing significant absenteeism; and we just came to accept it. Meanwhile, the standards of design and inspection of public washrooms in our communities often does not encourage great personal hygiene and, while cited decades ago as an issue, remains an issue. Mr. Higgs’ remarks to Brunswick News as reported on August 14 is right on the money. For decades that has been a message echoed by some of the most qualified leaders in the system in New Brunswick. Indeed, as the system has stumbled since the initial reforms of 1992, the issue of politics in the system has come up over and over and has been a source of major discouragement to many wonderful clinicians and administrators. When you have trained for anywhere from 4 years to 15 years to become the best you can be, the last thing you want to see is inconsistent direction, over-concern for photo-ops and tactics that respond to symptoms without solving real problems.
Many seasoned observers describe the Canadian health system as the third rail in Canadian politics; that is, the politics of the system is so powerful that governments deal with issues very gingerly. That was ever so obvious in the 1990’s when the great work initiated by the McKenna government became the target of would-be politicians who wanted to get elected. Changing the direction of anything in health care is challenging and cannot happen by issuing edicts or policies or election promises. Once the announcements are made, the hard work begins, work that involves responding to angry people, professionals or the public, showing people a better way when they didn’t know a better way was necessary. Green Party leader, David Coon, described by many as a very thoughtful, insightful politician, got headlines recently in expressing shock and horror at the conditions he found in the DECRH Emergency Department when he went for treatment recently. He described overcrowding, confusion, and very long waits in the Emergency Department.
In the fall of 2020, I was called to give some advice to people dealing with what turned out to be a tragic case in which the patient was misdiagnosed in emergency and sent home. Shortly after that, I heard from another family with a similar story in which the results were staggering. Then comes the Lexi Dakin, case in which a distraught teen was forced to sit in an uncaring waiting room for hours before she gave up and the rest of her story is sad history. There was, just recently, the case of the young mother, having delivered a baby a few hours earlier, coming to the hospital with post-partum hemorrhage and told to wait. She went to the Dumont, across town, and was cared for immediately. The public service provides the stability and due diligence required in order for a society to benefit from government-legislated or approved services. Maintenance of roadways, water and sewage systems, providing emergency measures services, policing and ever so much more. Government legislates, the public service executes and regulates. That system has served our civilization well for centuries.
New Brunswick has been blessed, over many years, with superb public servants, many of whom are called back into service long after retirement by other agencies and governments, the private sector, and more. Brilliant would be a label attached to some of the leading civil servants with whom I have worked. Loyal and dedicated would also apply to many. The entire population of the Atlantic Provinces is 2.2 million or 1.7 million on the mainland, all reliant on the free flow of tourists, goods and services, commerce, education, health care, research and the military. The population, spread over a significant land mass, is about the size of Montreal.
Jason VandenBeukel, editor of the opinion pages for the Telegraph Journal, said in an article on June 24 that Nova Scotia’s border rules are nonsense. And he is correct. Thus it has been for the duration of the pandemic. Imagine a population group the size of Montreal having 4 different approaches to pandemic management, vaccine roll out, and all the hundreds of other elements involved in pandemic management. Tough as it has been in Montreal, at least they had the one common voice of one premier who, with his expert advisors, has provided direction. The public service provides the stability and due diligence required in order for a society to benefit from government-legislated or approved services. Maintenance of roadways, water and sewage systems, providing emergency measures services, policing and ever so much more. Government legislates, the public service executes and regulates. That system has served our civilization well for centuries.
New Brunswick has been blessed, over many years, with superb public servants, many of whom are called back into service long after retirement by other agencies and governments, the private sector, and more. Brilliant would be a label attached to some of the leading civil servants with whom I have worked. Loyal and dedicated would also apply to many. Every service regulated and overseen by the public service, however, needs to be changed regularly in order to prevent stagnation and to ensure that public funds are used wisely based on current knowledge and best practice. Such it has been for generations with such things as ferry services, property assessment systems, public education, natural resources, the fishery to name just a few. Failure to adapt would mean, for instance, fish stocks could be depleted prematurely or lumber becomes scarce or rivers become unduly polluted. For years, the public has been expressing its disapproval of horrific long waits in Emergency Departments along with frustration and anger when their doctor retires or leaves the practice only to be left with either the Emergency Department or an After-Hours Clinic as their source of primary health care services. In recent years, the media has carried a seemingly endless stream of articles and commentaries on topics ranging from hospital staff absenteeism to violence in the workplace toxicity. We have heard the cries from gifted specialists in various surgical disciplines who claim to have access to no more than one day per week in the Operating Room for elective and urgent surgical cases.
The stories are endless and the public has been growing increasingly restless. The professionals, on whose work the reputation of our health care services depends, are getting increasingly restless. The Minister of Health has recently spoken about the Department of Health taking over the recruitment of doctors yet it is difficult to envision recruitment and retention success until some major shortcomings of the system are cleaned up. Health Minister Dorothy Shepard was quoted in Savannah Awde’s article on March 23rd as suggesting perhaps a correlation between outbreaks in long term care facilities and learning curve. I expect she was suggesting that staff had to learn about proper use of PPE and other elements in mitigating spread of infection in care facilities.
She made a good point. For everyone in the health and long-term care systems, and their regulators, the Departments of Health and Social Development, the learning curve has been long, steep, and difficult. In the early days of pandemic, mid-March 2020, all that the worldwide Scientific community knew for sure was that there was a bad virus on the loose, originating in Wuhan, China where that government’s official line, as recorded in the Wuhan Diary, was: “Not contagious between people; it’s controllable and preventable.” Introduction:
“Nursing education has been a key factor in the quality of health care throughout Canada’s history, and the quality of education for nurses has been a major focus for the CASN throughout its considerably shorter history. The progress in educational standards has clearly been substantial since Dr. Mack first established his training school in 1875. History suggests, however, that this progress is always tenuous and subject to erosion or subversion by external forces. The overriding goal set by the Association’s founding members for nurse educators to join together and present a strong voice in support of quality in nursing education continues to be as relevant in today’s complex environment as it was in 1942.” This was the conclusion in a most interesting history of nursing education entitled “Ties that Bind”, published by the Canadian Association of Schools of Nursing, 2012. And, so, it has been since the early days of the Grey Nuns and the Sisters of St. Joseph in their early work centuries ago in Quebec which preceded Dr. Mack’s first School of Nursing in St. Catherine’s, Ontario in 1874. Then other nursing schools opened in major cities, including Halifax, NS, shortly thereafter. In those days the medical and nursing professions worked together in changing the face of health care and introducing formalized and much-improved training for nurses and physicians. The Flexner Report published in 1910 set the tone for what we now know as strong, university-based education for physicians and nurses. Up to that point, for both professions, education was really based on the apprenticeship system with hospitals relying on both medical and nursing students to provide essential care for patients. How did we get here? “Nursing education has been a key factor in the quality of health care throughout Canada’s history, and the quality of education for nurses has been a major focus for the CASN throughout its considerably shorter history. The progress in educational standards has clearly been substantial since Dr. Mack first established his training school in 1875.” The Tie that Binds report, produced by the Canadian Association of Schools of Nursing in 2012, is a fascinating history of how we got here!
In any superb health system, there are a few key ingredients, factors that are essential for quality and public satisfaction. Nursing is one of the big ones! It has always been thus since Florence Nightingale. In New Brunswick, government and the profession and universities have some issues to resolve if the profession is to grow and develop in a manner that will meet public need and the need of employing organizations. In recent years the public has been exposed to much publicity about violence in the workplace, overworked, stressed nurses, large numbers of impending retirements with insufficient persons being trained to fill the positions, nurses without full-time jobs, unemployed Nurse Practitioners……and more. 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. Municipal Elections and Health Care Reform: Why I Am Not Running for one of the health authorities4/16/2021 In May 2021 we will go to the polls to elect our municipal council leaders in New Brunswick. I have great admiration for all who are putting their hats in the ring; serving in municipal leadership is not as glamorous as other highly visible appointments might seem but the issues are serious, particularly in these days of social and political change and unrest.
Following a career spanning 50 years in health care leadership in three provinces and now with the added exposure of multiple post-retirement assignments, including writing columns for Brunswick News, a few have suggested that I run for a seat on the health authority board. That was from the few who actually are aware that some health authority board members are actually elected in the Municipal election process. Some say that my columns and book help them to understand issues that otherwise are dealt with in brief news articles or video clips. I did think about it……I actually got the nomination papers and had enough people to sign to make it legal. Minister Shepard was quoted in Savannah Awde’s article on March 23rd as suggesting perhaps a correlation between outbreaks in long term care facilities and learning curve. By that, I expect she was suggesting that staff had to learn about proper use of PPE and other elements in mitigating spread of infection in care facilities.
She made a good point. Everyone in the health and long-term care systems and their regulators, the Departments of Health and Social Development, the learning curve has been long, steep, and difficult. Going back to the early days of pandemic, mid-March 2020, all that the world knew for sure, including WHO, Centres for Disease Control, Dr. Fauci, Dr. Tam and thousands of other “experts”, was that there was a virus on the loose, originating in Wuhan, China where the that government’s official line was: “Not contagious between people; it’s controllable and preventable.” There is a strong body of opinion amongst fiscal conservatives in New Brunswick that the provincial budget should be balanced and the debt should be reduced if not eliminated. I have had that discussion with several strong advocates of that position and the logic is clear. The overwhelming interest on debt could build nursing homes, it could free us from fiscal bondage, it is just the prudent business strategy for government. These same advocates point out, correctly, that any business that carries debt at the level carried by the province would be in deep trouble if not bordering on insolvency.
However, Government has the responsibility for a health and long-term care system, education system, provincial infrastructure, post-secondary education and much, much more. In each of those sectors, Health and Social Services representing nearly 50% of budget expenditures, structural cost growth happens year after year at 3-4 times inflation despite the best intentions of policy makers. To slow down the growth of debt or reduce it, government needs to find a way to generate operating surpluses year over year for quite a few years! Mr. Higgs was elected on his promise to get to fiscal stability and responsibility which meant trimming the debt and interest payments. Nursing is, along with Medicine and other health care professionals, a major part of the backbone of the healthcare system. A noble profession with roots in the image of Florence Nightingale. The profession, in modern times, has grown into huge numbers as its public image has remained high. And why not? These professionals have helped deliver your children, assisted in the Operating Room, managed the Operating Room, cared for your dying mother, and have dealt with many patients who are not always the sweetest customers in the world!
Embarrassed and shocked by the large numbers of deaths in certain long term care facilities largely in 4 provinces, the Federal government is now calling for Long-Term Care Reform or the creation of National Standards for Long-Term Care.
A bit late, don’t you think? For a half century, public policy experts have been observing the growing population of aging baby boomers and forecasting that the health and long-term care system would be distressed at unprecedented levels. But in much of that 50 years, while health care has seen a boom in expensive new services, much of the approach to caring for that small segment of the senior population deemed to be frail or compromised by multiple chronic diseases seems to have progressed little. We do have an unprecedented number of long-term care facilities, many superb, that have grown more by accident than by design. Long-term care has morphed into a significant industry in the absence of consistent regulation. Consulted to death? More talk? Where’s the action from the last round of consultations? The public can be forgiven for feeling skeptical because the health field has been the most “consulted” field in our society. In this province, consultant reports were presented in the 1960’s and finally acted upon in the 1990’s-but then, only in part.
Why the timidity on the part of governments? Why does common sense need more consultation? This round of consultations is taking place because government tried to implement what they thought were logical steps in healthcare reform in February 2019. The logic was clear: acute care beds occupied largely by frail elders in small hospitals should be re-classified as long-term care beds. Because small, rural emergency departments only see 2-3 patient’s over-night, why would you keep a doctor and nurse on staff to cover? Tim Hortons would not do that? Economically it does not make sense. I would guess that the cost per visit would be exorbitant relative to the cost per visit in a high-volume centre. It is hard to focus on the important when pre-occupied by the urgent. Covid-19 is the urgent and has our collective attention: the public, our institutions, our public servants, elected officials. And while we all just want to get out of this mess, it will be over in a few months and we will be in a new normal, whatever that looks like.
But please do not forget how angry so many in the population have been prior to the pandemic about the state of our health system. Rural people were traumatized in February with talk of eliminating what they believed to be an essential service. Urban people have been very angry about access to efficient primary care services, long waits for service, over-crowded emergency departments. As promised, Health Minister Dorothy Shepherd released her Discussion Paper on Thursday, January 21, 2021. The paper raised issues of Primary Care, System Efficiency and Safety, Access to essential surgical treatment, Mental Health and Addictions, Senior Care, and use of current technologies. The last thing in the world New Brunswick needs is more public consultation, summaries, and reports. All of these themes have been beaten to death for 20 years. What has held us back from progress is having a government with the political courage to face reality in the eye and move forward on a plan to fix what so many know is broken!
The results of this Discussion Paper consultation will inform the development of the new 5-year health plan. Apparently, New Brunswick currently has a 5-year health plan about to expire. Surprisingly front-line staff and consumers of care seem unaware of such a plan. Health care is such a politically sensitive issue that governments have to avoid issues and deal only with cosmetics or wade in without fear of losing legislative seats. The issues that plague the system stem from lack of consistent focus and informed, consistent leadership at various levels in the health system. Here are the issues that simply require courage to do the right thing: |
AuthorKen McGeorge, BS,DHA,CHE is a career health care executive based in Fredericton, NB, Canada. Archives
May 2023
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