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:
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In all the noise made in public about health care issues, the pleas from interest groups, unions, associations, societies, almost without exception, are for “Government to do more; we need more…..”
Seldom does one hear any discussion about issues of efficiency and effectiveness of the current services and systems. Why is that? It goes against the grain of interest groups to acknowledge that there may be other ways of achieving better service. And because health care is a highly-charged political system, majority governments have only 2-3 years at most in order to make a dent in improving one of the most complex and convoluted sectors of our society. We, the people, have a love affair with our health care system and heaven forbid that any politician should do anything to offend my doctor or my daughter, the nurse, or all those other people who the public believe to be working very hard to keep services going. On Friday, January 8, 2021 the New Brunswick Labor and Employment Board handed down its decision on the fate of LPNs working largely in the Health Care System in New Brunswick. There are 4000 LPNs in the province with 2500 working in the hospital sector. That the decision came as a shock and disappointment to the eighty five percent of Licensed Practical Nurses who launched the action would be an understatement.
For many years, as the LPN profession has matured, there has been a strong and growing unease with this professional care delivery group being represented by CUPE and 85% of the LPNs initiated an action to be moved from CUPE to another union. This involves a long and expensive process of application and hearings with the New Brunswick Labor and Employment Board. This decision represents, as well, a set-back to the vision, expressed by many, to introduce reforms to the health care system. As discussed in previous commentaries, the entire culture of care needs major overhaul. While there are many moving parts in creating a true culture of Patient-Centred Care, one major element is the creation of a clinical workforce that truly works together in complementary, not competitive, roles. The roles of PSW’s, LPNs, and RNs need to be clearly identified so that they function in true complementary fashion with all functioning at full scope of practice and collaboratively with all health care professionals. The workplace in which those dynamics come together under informed leadership is a true delight! In the lead up to Christmas during the legislative session of the Province of New Brunswick, the Minister of Health re-affirmed her commitment to consultation with the public relative to health care reform. She is an honorable person who will always do as she says; I know that.
The challenge will be to engage in consultations that are truly meaningful to the population being served and who pay taxes. They are the customers and, in the end, the customer is always right! The customer knows when a great product is being delivered but most often the customer is not sufficiently aware of all that it takes to get a quality product to market, a product that can be sustained in quality and price in changing times. On the other hand, government officials working in offices with desks and computer screens in Fredericton, Bathurst, or Miramichi, or elsewhere, often have their thought processes directed by their own set of experiences, their own educational background, the experiences and backgrounds of those around them and the very culture of government and the civil service itself. According to Christian tradition and teaching, two thousand and twenty years ago a shepherd and his pregnant wife were faced with sleeping on the street. An Innkeeper was merciful and allowed them to use the stable where, later in the night, the wife delivered her firstborn son. By modern standards, delivering in a stable with hay, animals and their smells, no hot water, and dim lighting would be thought of as reckless, substandard.
The celebration of Christmas typically brings memories from childhood and for persons of faith it brings strong and important reflection on the meaning of Christmas as expressed in the Holy Bible. Along with reflection comes a towering sense of charity amongst people as reflected in year end giving to charities, the Salvation Army, Feed the Family and food banks and others who do great work with thousands of families. Some specifically target people “living on the street”. In his TED talk in 2015, Bill Gates warned the world: there will be another pandemic soon. He warned governments to get prepared by developing good plans and doing “Germ Games, not War Games”. He said no need to panic but we need to get going to be ready for the next epidemic. Using the problems with combating the Ebola outbreak in 2014 he showed that the world is not ready, that the WHO is not the body to mobilize resources and systems, that there is a need for an overall global health system to respond to outbreaks.
As our Emergency Measures Leaders will attest, proper planning is a tough discipline and it is often difficult to get busy people to take emergency preparedness seriously. It is difficult to mobilize political support because it has little electoral appeal. For those of us in the health professions, it is much more satisfying to look after sick people, frail elders, accident victims and those with terminal illness than to invest hours in planning for the unimaginable. How much relevant pandemic planning has taken place since 2015? None that would be recognized. At this point, we are all experiencing Pandemic Fatigue, tired of hearing it as the main news item as if nothing else is happening except the US election! Tired of being locked down! Tired of following arrows and being so anxious in the grocery store! Tired of not being able to see family without someone making you feel guilty. Is the upper limit 5 or 10 or 20 this week? The prospect of Christmas being so very different from the way it has been forever is depressing to many!
As some have suggested, much that once was wholesome and fun in normal living has been stolen. One hopes the departure is temporary, but some may suspect otherwise. We have had many serious outbreaks in our history and several just within the last two decades, namely SARS, H1N1, Ebola, Influenza, Measles, Cholera and more. Each has been serious and each has been deadly. Remember just two years ago in New Brunswick we were a bit panic-stricken with the detection of a few Measles cases that somehow got into the schools. In the view of many, the Auditor General’s Report was revealing, welcome, and finally placed some issues in public view. All those news stories about long waits and ambulance no-shows seem to have firm foundation.
For decades the local ambulance service across the province was a mix of hospital-operated vehicles, Saint John Ambulance services, and systems in rural communities of volunteer-based services and services run by local businessmen or funeral directors! With this hybrid, there was a variety of levels of service from highly professional and efficient to fairly rough. There were some concerns with standards of service brought to government’s attention that in the mid-1990’s staff in the department of health commenced working on a plan that would provide standardization across the province. In those days, local ambulance services operated on one-year contracts and could easily have been cancelled if performance was a problem. One seasoned operator, who served on a government advisory committee, observed that there were regulations in place but no regulatory capacity; nothing happened to those operators whose standards were problematic. “Those who fail to learn from history are destined to repeat it.”Let’s get the lessons straight, well documented, and get prepared for the next one, as Bill Gates said prophetically in 2016! Despite the fact that outbreaks seem to come as a big surprise to the population and health officials, they are cyclical! This is the reality of modern times.
After months of media clips showing China dealing with this virus, the World Health Organization declared a pandemic on March 11, 2020, this announcement being based on very early experience and forecasts employing statistical models done by experts. This was after major US media outlets had down-played the seriousness and the U.S. administration was admonished for curtailing air traffic from China. Within the health and public policy community, there was very little knowledge of the virus and its characteristics. Sue Rickards, in her commentary on Friday, September 18, 2020, advocated the attack on chronic social and economic problems at their roots. It was a good piece that illustrated the shallowness of much conventional public policy decision-making.
Such has been the case with health care for generations until 1992 when true reform was initiated by the NB government. Taking the first steps to consolidate control and direction of acute care by merging hospitals into regional structures was an important first step. While that was a very difficult, highly-politically-charged step, it was only the beginning. What was to come later would and should make a serious difference for citizens of New Brunswick. In 1970, as a fledgling Acting CEO at the IWK Hospital in Halifax, I was approached by some persons from upper and western Canada who were Icons in the field of health services organization and management. Dr. Len Bradley, then Medical Director at the great Winnipeg Health Sciences Complex, and Dr. John Phin, formerly professor in the field of health administration in Minnesota. I had graduated just one year earlier from what was the Blue-Ribbon program in Hospital Administration at the University of Toronto. This was a small program available only to 18 persons per year who had had some previous experience in the health field.
My class included physicians, nurses, pharmacists, accountants….all having had just enough experience in the management positions in the health field to understand that they really needed a deeper, more rounded education in health administration. So, with superb professors such as Dr. Burns Roth, Eugenie Stuart, Dr. Peter Ruderman and many others we worked through courses in medical science, economics, human resources, health law, hospital organization and management, public health and much more. Brunswick News publications carried a lead article on Saturday, August 8, 2020 posing the question: Are We Beginning to Tune Out of Covid-19? The previous day, the Chief Medical Officer of Health, Dr. Russell, posed a similar question in commenting on the latest large gathering of people in celebration at a boating event.
From the beginning, back in late 2019, the risk, scope, etiology, contagion, control, treatment and much else surrounding this virus has been the subject of so much more controversy on the international stage than any other in history. The public can be forgiven for feeling more than a little antsy a full 9 months in! With previous outbreaks, particularly the worst ones in recent memory (e.g., SARS, H1N1), there was a huge spike, much publicity, much discomfort, and so little controversy because the science seemed less vague. Since the 1970’s we, as citizens, have become accustomed to the promotion of the annual “flu vaccine” which has been helpful but never forced on people. Indeed, the vaccines apparently get adjusted regularly and we typically are at the mercy of the pharmacist or doctor to ensure we are getting the latest vaccine. So, we are going to the polls! Last week had drama leading to the fact that the parties will not agree to the plan placed before them by the Premier. There are two vacant seats and, according to reports, at least three that want to be vacant!
Those who are seriously interested in seeing the health system get fixed should now start to memorize some lines so that when candidates contact you, you can respond with good questions that will force some response. In just how many elections have you heard the same promises? No more cuts! We will keep your emergency departments intact! No, we will not close rural hospitals. Yes, we will hire more doctors and nurses. We will add more nursing home beds; why we will even put some in your riding. One of the greatest that comes up in every campaign is: We will place new resources into Health Promotion and Disease Prevention. And sometimes that happens, yet the basic issues of the health system remain. 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. Rural Hospital Emergency Services: what happened to the consultation prior to final decision?7/6/2020 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. |
AuthorKen McGeorge, BS,DHA,CHE is a career health care executive based in Fredericton, NB, Canada. Archives
May 2023
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