As noted in my commentary of January 13, 2024, the way out of the Chaos in health care, referenced by Horizon officials and the media, is not for the faint of heart. The chaos results from years of serious inattention to core issues by government at both political and civil service level. Emergency Departments, Primary Health Care and Long-Term Care, as the three areas named in the chaos over the Christmas period, are three of the elements of what is, in public policy, the most complex system known to man. Don’t take my word for it. Peter Drucker, one of the all-time most famous authors, teachers and researchers on organizations called hospitals “the most complex form of human organization we have ever attempted to manage.”
So, when political and civil service persons attempt solutions to crises as simply making cuts, changing boards, changing CEOs they miss the point. Fixing healthcare performance is not a matter for sound-bytes and photo-ops. That is why the reforms of 1992 in New Brunswick started with the organization and consolidation of hospitals with the intent of consolidating managerial and clinical program direction under regional sets of policies and regulations. But there has been so much tinkering since that time that the goals of reform have been all but missed.
The good news is that now a floodlight is on what the media refers to as Chaos and the new health authority boards and administrations are under renewed expectation to perform. As government normally operates, targets of blame for chaos will no doubt be sought. That has been the New Brunswick way. After long delay, for instance, the job ad for the new Horizon CEO finally appeared on LinkedIn.
The depth of the inefficiency of the health and long-term care system in NB cannot be over-stated. Just this week I had yet another senior describe for me, as happens regularly, a situation that would be considered very, very sub-standard in systems that have excellence and efficiency as the basic building block.
Primary Health Care is the basic building block of health care service and has been for generations, even centuries. That the Canadian methods of organization and delivery of health care have been undergoing metamorphosis for years is a gross understatement. New Brunswick has been slow to adopt serious reforms leaving tens of thousands of citizens lacking in access to the very basics of health care. Many months ago, four prominent Fredericton family physicians, all retired, created a blueprint for reform and should have had their report adopted as the way forward for government strategy. Didn’t happen.
Similarly, with Long-Term Care, the sector has been awash with informed advocates pushing for essential change with volumes written in reports, studies, articles, and speeches. Yet we wait while frail seniors sit on wait lists for long term care while vacant long term care capacity exists and the waiting time, often many months, resulting in deterioration of their physical, mental, and emotional state. Go figure.
The initiators of reform in 1992 had a leg up in that they understood how important it was to make changes to the core of health care. Along with restructuring the hospital system (not popular at the time with some rural communities), government also established the beginnings of a means of planning physician manpower under a committee of physicians and executives called PRAC (Physician Resource Advisory Committee). All of that was to be the beginnings of getting some order into the planning of health and long-term care services in the province. Core issues are critical for reforms to proceed.
In the current situation, nearly 30 years later, the same principles apply. The core issues in moving the performance of Primary Care start with a plan; where there is no plan chaos takes over. There are some initiatives happening that are encouraging with multi-disciplinary primary care clinics but provincially the progress is not fast enough for the 50-60,000 persons suffering without access to effective primary care services.
Similarly, we have had sluggishness in Long-Term Care where sound ideas for reform have been on the table for a decade with little apparent interest in “fixing what is broken” until recently.
Why the sluggishness? Why does the obvious elude policy-makers? How can policy-makers stand by when thousands of New Brunswickers are crying foul, not receiving the service guaranteed to them in the Canada Health Act?
First of all, both elected officials and civil servants tend to under-estimate the complexity of the system. Government has little influence or control over how physicians, nurses and other professionals are trained or regulated. To effect meaningful change in medical practice or nursing well being, one needs to have a serious working understanding of training, regulation, influence of advocacy groups, and how to work in that complex environment in order to effect reasonable change of direction.
In 2008 there were 7 regional hospital corporations and the thinking was that if they simply merge them together into two large corporations, that will lead to Nirvana! Wrong. It was accompanied by a board structure that was not constructed for serious change; this was followed by years of instability in leadership with CEOs and board chairs replaced and appointed at the will of the incumbent premier. The basic structure flew in the fact of excellent organizations in that it had a centralization of control of services that are essential to hospital excellence.
Simply stated, it was a structure that did not seem to achieve the service excellence that the public needs.
Secondly, given the complexity of health and long-term care, instability with the regulatory departments and with the governance structure has been unhealthy. Organizations that achieve and sustain excellent service do not normally turn executives and leadership over with the frequency that we have seen in NB. Key personnel in the regulatory branches at senior levels turn over sometimes every year or thereabouts. Not healthy.
Third in New Brunswick is the convention of scape-goating and “throwing people under the bus”. Government, either at political or civil service level, has a hard job acknowledging that sometimes their regulations, their lack of knowledge and collaboration, their regulatory processes contribute to the issue at hand. In my interactions with great achievers in the system, all of whom not only performed at a high level but had potential to achieve much more, there have been several who were either terminated, transferred, pressured, or asked to resign for reasons having nothing to do with performance. That does nothing for the well being and reputation of the system that needs, so badly, major change.
So, what are the odds of New Brunswick achieving the level of change required? Very low if there is not understanding at various levels that business as usual and change as usual will only kick the can down the road. A serious overhaul of how the province directs, finances, regulates, plans health and long-term care is essential…. now.
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@example.com or www.kenmcgeorge.com
Ken McGeorge, BS,DHA,CHE is a career health care executive based in Fredericton, NB, Canada.