What’s the science for the status quo?

I have great respect for health care consultant Mary Jane Hampton, but that doesn’t mean we’re always going to agree with each other. A case in point is her Tuesday (May 15^th) conversation with  CBC Info Morning host Don Connolly.

You can hear her here:

http://www.cbc.ca/informationmorningns/2012/05/15/why-cutting-district-health-boards-is-not-the-answer/

Her position seems to have drastically changed since the fall when she told Connelly the sustainability of our system was a “slow motion train wreck.” I liked the succinctness of that comment so much I quoted her in a November 11^th post (see https://helphealthcare.wordpress.com/2011/11/14/why-save-our-secret-system)

To condense her points, Hampton says that moving to one province-wide health authority won’t save money, won’t improve service delivery, is a sideline issue to delivering quality health care and what we need is good management which is nimble and close to the issues.

I was particularly struck when Hampton said, “There is no science as to whether the right number of health districts in Nova Scotia is four, nine or 12.” She expressed her belief that one health care unit is not the best solution for Nova Scotia. Well, reversing her question, where’s the science to prove we are better served with 10 health authorities? How we can have nimble management with ten separate authorities, overseen by 264 senior executives, all working independently of each other?

When former TD Bank chief economist Don Drummond delivered his report on reforming Ontario’s health care system he noted, “we have been referring to Ontario’s collection of health care providers as a “system”. In reality, the province has a series of disjointed services working in many different silos. The Ministry of Health and Long-Term Care must work with its health care providers, administrators and stakeholders to co-ordinate roles, simplify the pathways of care and improve the overall patient experience. Ontario needs to integrate silos and reduce administrative red tape that impedes efficient and effective service.” In other words, less is more.

A collection of silos is probably a good description for Nova Scotia’s situation

Introducing the subject of scientific study for the correct number of health authorities is interesting. Has anyone studied how many districts are right for Nova Scotia? Whether they have or haven’t the Canadian national average seems to be one health authority per million people. If authorities in other provinces can deliver health services to this many people, why do we think Nova Scotia is so different? Hell, we even have a more compact geography than most provinces, so that should help.

Where’s the business case for the status quo? What is the estimated cost of alternatives? How do we perform compared to the rest of Canada?

Ontario, for example, has one health authority for every 943,000 people. Nova Scotia has one health authority for every 94,000. This suggests we either have too many administrators or we need better administrators, which was one of Hampton’s points. Nationally, in 2010 Canada spent 11.9 percent of GDP on health care. Ontario spent 12.3 percent. What is Nova Scotia spending?

Why don’t we look at per capita costs for health care delivery? For example, my health authority, Annapolis Valley Health (AVH) serves 83,000 people.  AVH has a CEO and six vice presidents. British Columbia’s Fraser Valley Health serves 1.4 million people with a CEO and six vice presidents. So AVH serves six percent of the population of Fraser Health with the same sized administrative overhead. And while BC wages may be higher than Nova Scotia’s, their cost structure per patient is more cost effective. (And until we see how much our administrators earn, we don’t know if they’re working for less than national pay rates…)

We have to get our costs under control. The Drummond report on Ontario’s health care warned that opting for the status quo would cause health care spending to consume 80 percent of all government spending by 2030. Nova Scotia already spends 40 percent of its budget on health care.

If we continue with costly duplication are we not heading to a privatized system?

The harsh reality is Nova Scotia is too small and too poor to continue the folly of thinking we’re that much different than the rest of Canada. If one district health authority per million is the norm, why can’t we hire the people to manage it and redirect the savings to more front line care for the sick?

Those in charge of our system seem to imply that one province-wide health authority would have to operate as the 10 separate ones do now. I believe one authority would be able to direct more money for front line care, would better coordinate resources, and provide a uniform level of service to all Nova Scotians.

In the CBC conversation, Alberta was given as proof that reducing health care authorities doesn’t save money.

The Alberta argument is an unfair characterization of what happened. Alberta wanted to cut a billion dollars from their health care costs, so dropped from eight health authorities to one. This transition was interrupted due to political interference and infighting. So naturally all of the transition expenses were thrown into a shortened time frame. Those who bemoan the executive compensation costs for change don’t address the costs of maintaining our current 264 executives (10 CEOs, 72 VPs, 162 directors). Whether they go or stay we will be on the hook for their retirement packages, in addition to their on-going costs (the $50 million + we pay each year in salaries), plus office expenses, cars, travel, benefits and other perks.

As I have said before, why not use the Alberta experience as a lesson for how to properly engage in transition? We don’t have to mimic or import failure.

And Nova Scotia is no shining star when it comes to being agents of change. Governments traditionally allow themselves several years to get the books in order or for their programs to take effect. Our health care system is even more generous with its timelines. We take 18-24 months to negotiate 24-month contracts. Capital Health allowed themselves six years to initiate their Promise and Milestones commitment to the community. They’ve given themselves five years to meet the provincial requirement for off-loading patients from ambulances and for 20 years they’ve not known what to do with an empty floor at Dartmouth General.

The Minister is no better. She gave health authorities 21 months to tell the public how much they earn.

It has taken our health authorities 11 years to consider the potential economic advantages of consolidating some services. Having made that decision, they allowed nine months to study the benefits and are allowing another 18 months to initiate the consolidation of four services. Human Resources and IT are not being consolidated in the same time frame.  Their target date for implementation is “later”.

I’m afraid our system is too full of questions and not enough answers. Where are the performance results to justify the status quo? And if these results exist, are they real? Our health authorities are accustomed to issuing unchallenged comforting platitudes. For example, the IWK, wrote on their website, “We are consistently tracking our process against key performance measures, rationales and targets.” However, the accreditation surveyor found, “The team uses a list of corporate project goals and objectives. The written goals presented are not measurable or specific to ambulatory services.”

Health care, like so many government services, spends its time looking at process – not results or outcomes. And with lives at stake we can’t afford their leisurely, non-nimble way of working.

We want results. Can our system of silos provide any?

For some reason those opposed to change – meaning those who might lose their jobs – decry the loss of local voice in health care decision making. When have local voices had a say? In Berwick the head of the health council quit because he wasn’t consulted about reductions to the community clinic. Wolfville residents learned of their clinic cutbacks via a flier in the mail. Windsor residents were told by administrators at Capital Health they couldn’t have a dialysis unit.

The only aspect of local decision making in our health care system is when a cloistered group of executives talk among themselves to decide what’s best for the community. The local aspect comes from the address of their offices, not consultations with people, patients or patient families.

So would one centralized authority in Halifax be any less receptive than nine authorities spread across the province? Our reality is that having a health care authority office in your town doesn’t guarantee anyone listens. Talk to ex health council members and you’ll hear nothing but disappointment and dissatisfaction. Our health authorities and the health department are deaf to the people.

It’s worth asking when Halifax became the enemy? If half the province’s population were located in Truro, Yarmouth or Inverness it would seem appropriate to locate the main health authority office there. Since Halifax has the lion’s share of the population, as well as a medical school and largest medical infrastructure why not have the office there?

So the question remains how we help health care by slavishly adhering to the status quo?

This week’s health care cuts

The latest health care cuts come from Annapolis Valley Health. I’m told that the clinics in Wolfville and Berwick are having their X-ray facilities reduced by 30 and 40%.

I’m told that prior to yesterday (May 7^th) the EKW clinic in Wolfville took X-rays Tuesday, Wednesday and Thursday. Now, they’re only taking them Tuesday and Thursday. That’s a 30% cut in services.

The WKM in Berwick took X-rays daily from Mondays to Friday. Now they will only do this Monday, Wednesday and Friday. That’s a 40% cut in services.

If you look at the days, that’s a five-day service down from eight days, but it looks like the Valley Health authority are saving on a staff position(s). I haven’t found any announced reason has been given to staff for the cuts.

I understand there are to be reductions in the ECG department.

Is it because of fewer X-rays being required or is this due to budget pressure? If it’s due to the budget, shouldn’t we question the business decisions of AVH executives? Earlier they made reductions to food services in the Kentville hospital that would save $100,000 a year. But for all the cuts they’re making, AVH president Janet Knox (who commutes from Halifax at what cost to the health authority) still thinks it’s acceptable to drive food across Kentville to provide a subsidized lunch for 160 workers at the corporate offices.

I understand that everyone at the corporate bunker pays something for their lunch. But they only pay the cost of the food, not market value. I don’t have a problem with providing food at cost in hospital cafeterias. People who are in the hospital under duress have access to this and shouldn’t be further penalized by having to pay restaurant prices. I feel that food-at-cost in the hospital is part of the universal access of our health care system. But why in gawd’s name are we subsidizing a lunch program for well-paid executives and white collar staff? They’re merely at work. They’re not under duress. What other civil servants and public employees get a subsidized lunch? What does this cost the system? Does their subsidized lunch come on the backs of our sick?

Knox says the food staff who work at the corporate bunker work reduced hours. Well, how many hours a day is this perk available? What does it cost? And why is that coming out of a budget that we’re told is so stretched? This is the same authority which traditionally has the highest overheads in Canada.

Annapolis Valley Health cut front-line services to the sick, but not lunch for the executives. It’s outrageous. And how wide-spread is this across the province?

Cut the chaos, share the pain

Thankfully we have avoided a strike at Capital Health. But in the two weeks leading up to the mediated settlement, Nova Scotians went through hell. A strike at Capital Health doesn’t just impact citizens in Metro, it impacts services and treatments of citizens from one end of the province to another. It was chaos.

In numerous interviews and opinion pieces the Minister of Health and Wellness has resisted any change to Nova Scotia’s health care administrative structure because she wants to avoid chaos. Well, the last two weeks in Halifax were a very public example of the type of chaos which already exists in our health care system. Patients and patient families have long known of and experienced the chaos and frustration of our system, but it takes the publicity of a strike to raise its visibility.

This is the second time Capital Health has prepared for a strike situation in less than a year.

Settling this recent contract illustrates the folly of maintaining 10 health authorities in this province. We negotiate one contract for teachers. But we negotiate 50 contracts for nurses and another 50 contracts for other health care workers. So with these two contracts settled we have 98 to go.

Anyone who thinks harmony has returned to the system is sadly mistaken. The precedent set by the two recent Capital Health arbitrated contracts means all other unionized bargaining units in the province will expect the same kind of settlement. Why should they expect anything less? We talk about wage parity: paying men and women the same amount for work of equal value. Why not geographic parity for work of equal value?

Had we a coordinated health care system in this province with one health authority negotiating with two bargaining units we might have labour peace, patients wouldn’t be subjected to the hell that those scheduled for care in Halifax endured, and we might have saved money by negotiating one lower pay raise across the province that is closer to the Dexter government’s one percent target. But now, thanks to the failure in Halifax to achieve negotiated versus arbitrated settlements, we are on track to pay more as various contracts come due.

There should be a move to work for the greater good, but when you have 10 separate health authorities fighting to protect their individual budgets we ensure constant labour turmoil. It’s not the job of Capital Health’s negotiators to think of the impact of their positions on the province’s nine other health authorities, but the reality is that what happens to one, sets the standard for the others.

As the strike deadline grew closer, so did calls to bring in legislation to remove the right of health care workers to strike. Does that make for better employee relations? I’ve never belonged to a union, my career was in management, but this seems a one-sided solution. Taking away the right of these workers to strike is akin to disenfranchising them, like taking away their right to vote. And why is the solution always placed on the back of the workers and not management? Why do we act as if health care administrators are infallible?

Why can’t the Legislature institute a system of incentives to ensure management works more effectively, efficiently and empathically in resolving public sector labour disputes? Rather than punish the lowest paid, by removing their rights to withhold their labour, incentivize management to act more quickly by imposing financial implications on them if they fail to deliver 100% of essential public services, like health care. As it stands now, a health care strike impacts the workers (who go without pay), the patients (who go without treatments), but leaves the administrators unscathed. Administrators may be inconvenienced in their daily workload, but they don’t experience any loss of income or perks. Why?

Using recent nursing contracts as an example, two-year contracts in this province have been taking 18-to-24 months to negotiate. Is that really necessary? Is that in anyone’s interest? Let’s incentivize administrators by tying their incomes to performance targets and harmonious delivery of essential public services. This could be a model for all public sector contacts and bargaining units in Canada. If executives find that unacceptable they are free, as anyone is, to find employment conditions more to their liking. But it is not in the public interest to suffer through never-ending contract negotiations and disputes. Our current system diverts too much time, attention and resources away from actual delivery of health care. If ever there was time for a change, it is now.

Stepping up for change

For those who may have missed this news, Friday evening the leader of the provincial Liberal Party, Stephen McNeil, announced a reduction in the number of health care authorities is now one of their party’s goals. Reducing administration will free more money for front-line care for people. Let’s hope the other parties adopt – and quickly – similar goals.  The health, care and welfare of the ill go beyond party politics. But bravo for embracing positive and dramatic and necessary change.

http://thechronicleherald.ca/novascotia/90874-liberal-leader-focuses-on-health-care-education-and-energy-costs

Capital Health’s poor performance

I am glad that the strike at Capital Health has been averted, but I am mad as hell that it had to go down to the final minutes.

I wish I could believe that it had to play out this way, but there is too much history which suggests that our health authorities, and this one in particular, move at their own speed.

As I mentioned previously, their history of negotiating nursing contracts seems to be less about sincere, positive negotiation than a war of attrition where they attempt to wear down the other side by taking so long (18, 20, 24 months) to come to an agreement. This type of prolonged negotiation may provide job security for the HR types but stresses out the employees and the public. Employees don’t want to go on strike. When they’re on strike they’re the ones without an income. The administrators don’t miss a paycheque or perk. Since they don’t suffer any financial hardship there is no impetus or incentive for them to act differently.

We are dealing with public funds and the public welfare, and the Legislature should get off its comfortable ass and act. Rather than rewrite legislation to take rights away from one group, the Legislature should share the pain by forcing financial penalties on any administrators who cannot avoid disruptions to essential public services, like the delivery of health care.

In radio interviews, Capital Health’s president, Chris Power, has said that she doesn’t believe health care executives are over-paid. She feels their pay is in line with the private sector. Well, the private sector has to perform and achieve targeted results. If they fail, they’re out. That doesn’t happen with health care executives. What targets are they meeting? If their hospitals fail to meet national standards of care there is no negative impact on their incomes or careers. Why not?

These people have shown us they are in no rush to do anything. For example, in 2007 Capital Health came up with their Promise and Milestones documents, which they hope to achieve by 2013. Six years! Canada has won wars in less time.

For 20 years they have allowed an entire floor to sit empty in the Dartmouth General Hospital. In those decades how many Nova Scotians have had treatments delayed because there was no bed available?

The province has a target to off-load patients from ambulances in 20 minutes 90% of the time. Capital Health is nowhere near meeting provincial targets. In their fourth quarter report for 2010-2011 they admitted to off-loading patients in 133 minutes. That was up from the 114 minutes it took in the previous quarter. Capital Health promised to improve that by 10% per quarter. At 10% per quarter it will take them until September 2015 to achieve the provincial health department’s targets. That’s not performance. And what if they don’t achieve their own target? Aside from the pain and suffering and inconvenience to patients, what is the impact on executives collecting six-figure incomes? I don’t understand why the Minister and the Premier think it’s acceptable for this health authority to flaunt the regulations this way. Allowing public servants to re-set loose, self-regulating, multi-year soft targets is one more example that this administrative structure is not operating in the public interest.

This strike has been averted and now everyone will appear on-camera looking relieved and promising to get back to normal as soon as possible. Well, whose fault is it that it went this far? And whose fault is it that so many patients and families were stressed and negatively impacted by a dragged-out negotiation process?

It’s time for the Minister and the Premier to fix this system by bringing about radical change.

 

Capital Health’s strike threat

I am sick about the potential strike of health care workers in Capital Health. However, I don’t think we can legislate away people’s rights because they do something they’re entitled to do, but which we don’t like. That’s not good governance.

When my family member was in hospital we went through this. We watched as the hospital prepared for a strike. It’s a frightening and frustrating experience. In the end our strike was settled in the wee hours of the night. It was over so quickly I can’t remember if they actually did go out on strike or it was only for a few hours in the middle of the night.

Hopefully, in the next few hours we can avoid a strike. But if this strike ends quickly, and even if it settles hours before the deadline, I think the Premier needs to demand the resignations of senior executives at the health authority. The front line workers can’t be the only people to wear this. These executives have a history of foot dragging. Look at the nursing contracts in this province. Two year contracts took 18-, 20-, 24-months to settle. The VON contract expired 10 days after it was agreed to!

And even if a strike is averted, Capital Health’s administrators helped bring us to this situation. They should wear the blame for the angst, fear and emotional distress placed on patients and patient families. It’s not enough to appear before the TV cameras and make comforting announcements. You are judged by your actions. And that should be the impetus for change in the way we administer health care.

Capital Health says they don’t have the $26 million that projected raises will cost. Do we know if $26 million is a hard number? If Capital Health can’t pay staff, then should they consider spending over $100 million for a new building? What’s the point of a new building if you don’t have the people to staff it? And how much have administrative salaries, bonuses and perks increased over the last few years? Maybe there’s some fat there to be cut.

Remember, Nova Scotia is spending over $50 million a year to support 10 CEOs, 72 vice presidents and 162 directors.

We have had plenty of warnings that employee relations at Capital Health are not great. In the spring of 2011 a study found that 32 percent of Capital Health employees were dissatisfied with their working conditions. In their latest accreditation report one question asked employees if they trusted their employer. Only 50 percent of employees could answer yes. So where are the Minister and Premier? Why haven’t they done anything to improve employer-employee relations at Capital Health? Why do things have to get so bad that it comes down to the disruption – and chaos – of a strike threat?

This is a prime example of how our health care system doesn’t work.

 

 

An example of inconvenience

On Monday I ran into three people in different parts of the province with psoriasis. Their frustration seems to embody the problems with our health care system.

One man is a federal employee in a highly sensitive position. For him to receive treatment, his psoriasis has to flare up. Then he makes an appointment to see his doctor who confirms the psoriasis has flared up. The GP then sets up an appointment with this man’s dermatologist. This is the process they have followed for 15 years. It takes on average two weeks to get an appointment with the GP and as much as eight months to see the dermatologist.

This sufferer wonders, since he knows his body, knows the procedure and is known to the doctor, why he can’t cut out the middleman – his GP – and book directly with the dermatologist? It’s been the same two doctors for 15 years. As he says, it could cut out costs (the GP visit is billed to MSI) and time, not to mention his suffering.

Another sufferer has had his last treatment delayed four months because someone in an office was out sick when his last appointment was scheduled. So it had to be cancelled and rescheduled. That took months. It backed everyone up and delayed hundreds of appointments – most of whom have to drive across the province to be seen by this service. So it’s not like they can just run to see the specialist on a moment’s notice. People have to organize work schedules, travel, maybe home care for children or parents. The health care system is used to us catering to their schedules yet they don’t seem to have much regard or understanding for others.

Can we made the system harder, more difficult and inconvenient for people?