Lax leadership at the NSHA

Once again we have dynamic proof of the lax “leadership” of the Nova Scotia Health Authority. I use the word “leadership” loosely. I don’t mean to imply vision, inspiration or success in the role, merely referencing those at the top of the corporate pyramid.

Currently the Premier and Health Minister, as well as many Nova Scotians, are upset that the NSHA didn’t send a representative to a physician recruiting event in St. John’s which was targeted to the practice of rural medicine.

NSHA’s explanation/excuse is that they haven’t done well at it in the past and it’s too expensive. As excuses go that’s a bit rich. This executive have a reputation for spending. When they headed the Annapolis Valley District Health Authority (AVDHA) their administration costs were three percent above the national average. As a perk, which is on-going, they provided subsidized lunches to 160 white collar workers toiling away in the corporate bunker. This involves employing two catering staff on-site at the executive offices, trucking morning and afternoon snacks as well as a hot and cold lunch entrée the five kilometres across town from the hospital. This was/is considered a reasonable cost for these executives. One assumes that a subsidized lunch program has been introduced for the NSHA corporate offices in Halifax. Which hospital kitchens provide it?

The decision not to travel the great distance from Halifax to St. John’s seems like they’re trying to hide their past failures by inaction.

Interestingly, every other province and territory had recruiters at this event. The recruiter for the Yukon told the CBC that she had developed “60 soft leads” from the event and expected those to become “10 hard leads”. The Yukon, like others, used this as an opportunity to develop relationships with medical students, which they maintained throughout the students’ years of study. The Yukon knows who is ready to graduate and makes offers before others.

NSHA hasn’t done a stellar job in recruitment among local medical students, so why should we think they could woo students studying in Newfoundland? The biggest impediment to practicing medicine in Nova Scotia has been the NSHA. In pursuit of its collaborative care masterplan the NSHA has discouraged physicians from practicing where those physicians were interested in practicing. It has dictated unacceptable terms and conditions. And then it just basically treats people like shit. The most recent example is the $10 million spent to litigate the case of Dr. Gabrielle Horne – which Dr. Horne won. That’s not a positive message for any professional considering relocation.

Speak to anyone in Nova Scotia’s health care system and you don’t hear happiness. What you hear are people counting the months until they can retire and get away from the bullshit. I wonder if this count-down has seeped into the executive suite. CEO Janet Knox and Vice President Dr. Lynn Harrigan are around 24 months from retirement age. Have they adopted a don’t-rock-the-boat position as they wait for their numbers to add up?

Another disincentive for action is the fashion in health care for new-hires to reward those who gave them their positions with lucrative consultancies, thus doubling or tripling the executive’s retirement income.

But why would we expect this leadership to perform? In the nine years of covering health care in Nova Scotia I have not heard from a politician, physician, patient, nurse, front-line worker, supplier, other health executive or union representative who had positive impressions about the system or those in charge. No one has pointed to any example of success or innovation in the careers of these executives. Those who work in the system are unhappy. Those who use the system are unhappy. And politicians – in and out of government – are unhappy.

Given how this leadership has performed, why would any young professional with a world of choice, choose to work for the Nova Scotia Health Authority?

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NS Health tries to reinvent the wheel

For several weeks the CBC have been reporting about the successful doctor recruitment program exercised by Nanaimo, B.C. and Goderich, Ontario. Both communities have sold doctors on the idea of living and working in each place.

Both communities made their recruiters available to answer questions and arrange services on the ground. Goderich and Nanaimo sold their destinations as desirable places to live and work. This is somehow considered a revolutionary idea. It’s only revolutionary to reporters who don’t hire people and overly bureaucratic operations, like the Nova Scotia Health Authority, which lacks people skills.

This is a 4,000-year-old Roman wheel. It’s round and still rolls. NSHA would have to study the theory of a wheel before accepting its functionality.

Once again, health care executives try to re-invent the wheel.

In my 40+ year career it was and is standard practice for an employer to help a new hire transition into the community. As an employer if we hired someone from outside the community or if I was recruited to move, accommodation leads were provided. I was told about the community and what it offered. I was taken around and introduced to people. Banks used to rotate young staff throughout their system as part of the training process, so the banks maintained an inventory of suitable accommodations for their staff. It’s not rocket science, it’s a version of the Welcome Wagon.

In 2013 I added a page called Doctor Recruitment (see above). As an example of what companies do to attract and keep staff, I wrote: “Earlier in my career I was publisher of The Kings Country Record in Sussex, New Brunswick. While I was there, Denison Mines decided to develop a potash mine in the neighbouring community of Penobsquis. Denison’s vice president of human resources flew from Toronto to meet with me. He did that because of my age and marital status. I was a single executive in my 20s. He wanted to know about life outside the office. He said, “If I’m going to ask people to transfer from Toronto with all the nightlife and cultural options they have there, what can I promise these highly-motivated professionals?””

Health care is supposed to be about people. So why is it so thick, so unresponsive, when it comes to human resources? The NSHA and its executives don’t have a good record for recruitment, retention or respect. When health executives speak of “patient-centred care” that’s not a philosophy, but a reminder to them of their media training and speaking points.

This week the government announced it was topping up doctors’ pay by $39.6 million. That’s positive. What is less positive is the fact that just before this we learned the NSHA was comfortable spending $10 million to litigate a losing case against an individual doctor.

And last week I ran into a just-retired front-line health worker. She had worked for the Annapolis Valley District Health Authority for 28.5 years. She had over 1,000 banked sick days – days she could have taken off, but didn’t – and at the end of her career no one from the health authority said good bye, gave her a card or in any way acknowledged her three decades of service or retirement. She ended her shift and walked out the door. Period.

Hers is a telling experience because health care is riddled with early retirements of people who love their work, love making a difference to patients, but are fed up with the shit they take from disconnected, inconsiderate and inconsistent executives.

Given our history it makes you wonder why anyone would work for this crowd.

Problems off-loading ambulances continue…

Poor public memory contributes to poor health care.

The news this evening was of long delays in off-loading patients at Halifax hospitals. On Monday there were 17 ambulances backed up at the Halifax Infirmary emergency department. One waited up to 10 hours for patient to be accepted into the ER.

The Nova Scotia Government and General Employees Union (NSGEU)

blames the current government for staff shortages that cause longer wait times. The executive medical director for the central zone of the Nova Scotia Health Authority, Dr. Mark Taylor, claimed that a higher volume of ambulance calls – 53 versus their normal 45 – was the cause for the delays.

Taylor said while it’s true that the number of ambulances waiting at the Halifax Infirmary emergency department peaked at 17, he said, “Most of them were under two hours so they were rotating through.”

https://globalnews.ca/news/4080008/halifax-infirmary-emergency-department-has-reached-dangerous-tipping-point-nsgeu/

Apparently Dr. Taylor doesn’t know that the provincial standard for off-loading patients from an ambulance is 20 minutes. We shouldn’t be surprised because Capital Health, now the NSHA, have failed to meet the standard for the last eight years.

This is not a new problem. It first surfaced in 2010. At the time the Capital Health Authority told the then NDP government they would improve their standards by 10 percent per quarter to reach the provincial requirement. The then health minister allowed this.

No one mentioned how long that would take. In theory it gave the authority until September 2016 to meet the provincial requirement. It was a totally bullshit target designed to remove the problem from the minister’s desk and let the health authority ride out public memory and the government mandate.

It’s cynical, but it works for the executives. Here we are eight years later and nothing has improved.

So, with each news story the public expresses outrage, and they and the unions say the government should do something. The health authority pretends it’s a unique situation. Everyone forgets that this issue was in the news in February, when a one per cent rise in call volume had paramedics waiting for hours for their patients to be seen. That time the NSHA trotted out a different executive – we don’t want to repeat faces and names in the news or the public might remember this is on-going problem – they put their senior director of acute medicine, Madonna MacDonald, before the media to explain that the health authority was trying a number of approaches to address the “complex” problem.

In October 2017 CBC reported that hospitals were struggling to meet standards for off-loading patients. That time two QE2 ER doctors were left to speak to the situation.

http://www.cbc.ca/news/canada/nova-scotia/ambulance-offload-times-patients-wait-hospital-paramedics-1.4350598

http://www.cbc.ca/news/canada/nova-scotia/health-care-ambulance-offload-delays-paramedics-hospitals-1.4345855

I’ve raised the issue in October 2017:

https://helphealthcare.wordpress.com/2017/10/10/slow-ambulances-nothing-new/

and April 2012:

https://helphealthcare.wordpress.com/2012/04/26/capital-healths-poor-performance/

and January 4, 2012:

https://helphealthcare.wordpress.com/2012/01/04/if-it-happens-in-ontario-is-it-happening-here/

and July 30, 2014:

https://helphealthcare.wordpress.com/2014/07/30/health-care-whats-in-a-name/

and February 7, 2015:

https://helphealthcare.wordpress.com/2015/02/07/why-arent-ambulances-included-in-universal-care-coverage/

and March 16, 2015:

https://helphealthcare.wordpress.com/2015/03/16/a-worrisome-timeline-for-change/

and June 12, 2015:

https://helphealthcare.wordpress.com/2015/06/12/how-fast-is-health-care/

and on November 6, 2016

https://helphealthcare.wordpress.com/2016/11/06/health-cares-five-and-seven-year-timelines/

The public and unions can blame the government du jour, but the real villains in this story are the health care executives who fail us, year after year, decade after decade, government after government.

Better care will only come when the public make the effort to remember who is responsible for this consistent failure. Those people aren’t in Province House, they’re at the secretive bunker containing the offices of the Nova Scotia Health Authority.

Stinky health care spending

The stink surrounding questionable executive expenditures at the IWK is growing.

The details are laid out here:

http://www.cbc.ca/news/canada/nova-scotia/iwk-tracy-kitch-auditor-general-stephen-darcy-1.4555146

The details seem to be adding up to a type of abuse that most of us have felt was unbelievable in a small place like Nova Scotia where everyone knows everyone.

Coming on the heels of this expanding questionable expense scandal are the legal costs incurred by Capital Health and the Nova Scotia Health Authority to defend themselves against a legal action by Dr. Gabrielle Horne.

Jim Vibert, writing in The Chronicle Herald, says legal experts believe the health authorities spent $10 million of taxpayer money on their defence!!

http://thechronicleherald.ca/opinion/1550008-vibert-justice-demands-full-accounting-for-dr.-horne’s-ordeal

This gobsmacking number is unacceptable. It is too great an expenditure to not be publicized and questioned. Who authorized this? And how is it acceptable to piss away so much money on such a questionable case? The health authority managed to have the monetary award for Dr. Horne reduced, but they were still found guilty. They were wrong. And we, their employers, are left holding the bag while they spend unlimited amounts to protect their reputation and income.

Dr. Horne spend $1.3 million to defend her reputation, so with the $800,000 award granted by the appeals court, she is out money, and patients were deprived of her skill and research. Where is the penalty for the people who failed in their obligations, who were judged in the wrong by the court? What penalty or suffering or inconvenience did they endure?

The Horne case should inspire a provincial cap on how much a government agency, board, commission and minister can spend on legal fees. Allowing public officials and executives to treat the public purse as a bottomless resource for them to hide behind and cover their failures is wrong and immoral and, in this case, doesn’t contribute to better medicine in Nova Scotia. We need fixed limits on legal budgets. The NSHA won’t like it, but tough, it may be the only way to make this super secret authority truly accountable.

The questionable expenses and outrageous legal bills stink to high heaven.

When someone in the public employ behaves badly, does something illegal and/or actionable, they, not the taxpayer, should pay. It is unacceptable that the public health care system is left to pay for these wrong, and perhaps illegal, actions.

Many times a case like this would have been settled privately without the necessity of going to court. It’s ironic that a body as secretive as the NSHA would do something so publicly, which raises the question: was this action about an issue or vanity and vengeance?

How much does this saving cost?

Halifax cardiologist Dr. Gabrielle Horne has had a $1.4 million damage award downgraded to $800,000.

In 2002, Dr. Horne, who was a rising medical star, had her hospital privileges reduced after a dispute with a hospital director of the former Capital District Health Authority.

Fourteen years later, in July 2016, after a 33-day trial into administrative bad faith a jury awarded her $1.4 million. It was the largest such award in Canada for damages to reputation and career.

The health authority appealed the award. So did Dr. Horne.

The health authority may feel they saved $600,000 with the decision of the Nova Scotia Court of Appeal, but at what cost? How much more was spent on lawyers for this appeal? How much staff and executive time was eaten up by this? And more critically, how much has this cost Nova Scotia and the Nova Scotia Health Authority’s reputation?

As we try to recruit new doctors what does the appeal say to prospective physicians about how we value and respect medical professionals?

Dr. Horne has still prevailed. It took her 14 years of fighting an unsympathetic system and she won. Two years later, she may have less money coming from the NSHA, but the court hasn’t questioned the facts: she was wronged!

The message is simple: this is a health regime that doesn’t value doctors. Of all the places in the world to practice medicine, why would a doctor choose to come to work among an executive class who won’t admit a wrong and will use the weight of the public purse against them? The only hope to salvaging the province’s and NSHA’s reputation is for a change at the top.

How much as this saving cost us?

 

A Post Script: This article in The Chronicle Herald tells us how much the lawsuit cost Dr. Horne.

http://thechronicleherald.ca/novascotia/1549558-dr.-gabrielle-hornes-14-year-legal-battle-cost-a-staggering-1.3-million

It’s a safe bet that the corporate costs for Capital Health and NSHA were far greater. Thinking about the higher costs of government actions, it wouldn’t be surprising if the NSHA/Capital Health legal costs were between $2-$3 million. Put another way, that could buy several mid-range or one top-of-the-line MRI machine. Or it could have paid the salary of a family physician for eight-to-12 years.

Still no national drug program after 15 years of hearings, studies and agreements

One of the universal areas of agreement in Canada is the benefit of a national pharmaceutical program.

Everyone agrees a national pharmaceutical program would save money through bulk purchases of drugs. Canada has the second highest drug costs in the western world. If we had a bulk purchasing program we could use the weight of our buying power to reduce costs and it would ensure we avoided shortages of certain drugs, which have and do happen. It would also be a benefit to pharmaceutical companies because it would help them adjust their sales efforts, production and distribution so they could make more money on lower per product prices.

No one disagrees this is a good idea. In fact, in February 2003 all of Canada’s health ministers – federal, territorial and federal – agreed to a national drug policy. It was part of the foundation for the 2004 Health Accord. A national drug policy was such a good idea the health ministers agreed two more times to institute it.

A royal commission first recommended this in 1964. In 1967 and 2002 there were a national forum and another royal commission. Then, in 2003 it looked like we might act. But we didn’t. Why?

Governments agreed to it 15 years ago. No one has spoken against it, yet successive governments of all political stripes have failed to institute one.

The idea is so popular that it’s virtually spurred an industry producing annual or semi-annual schemes for a national policy.

In 2004 in support of the new National Health Accord the Romanow Commission studied it.

In June 2006 a Federal/Provincial/Territorial Ministerial Task Force on the National Pharmaceuticals Strategy said, “…Prescription drugs also constitute the fastest growing and second largest category of health care expenditure in Canada. Like governments around the world, Canada is faced with the challenge of optimizing the benefits of prescription drugs for Canadians while managing the risks and complexities associated with this rapidly evolving sector.”

“After hospital care, Canada spends more on drugs than any other major category of the health care system. Since 2000, the total public and private expenditure on prescription drugs has grown by approximately 12 per cent annually. This rapid escalation in drug costs threatens the sustainability of public drug programs.

“To ensure that Canadians continue to benefit from robust public drug coverage, public dollars must be used efficiently. By collaborating on drug price and purchasing issues, Canada’s public drug plans can encourage greater competition, increase transparency and reduce market fragmentation to ensure Canadians get the best possible prices for pharmaceuticals.”

Two of that report’s nine recommendations were:

— Establish a common National Drug Formulary for participating jurisdictions based on safety and cost effectiveness;

— Pursue purchasing strategies to obtain best prices for Canadians for drugs and vaccines;

More information is here: https://www.theglobeandmail.com/news/national/with-universal-drug-coverage-canadians-could-save-billions-study/article34141670/

In February 2017 a study in the Canadian Medical Association Journal said if the government provided universal coverage for 117 essential medicines, which accounted for 44 per cent of the prescriptions filled in Canada we would save nearly $4.3-billion.

In June 2017 a paper A Better Prescription: Advice for a National Strategy on Pharmaceutical Policy in Canada said, “Canada needs a national strategy to fulfill its obligation to ensure universal access to necessary healthcare, including prescription drugs. A 2004 attempt at a national strategy for pharmaceutical policy failed because it lacked clear vision, logical planning and commitment from federal and provincial governments. The result of uncoordinated pharmaceutical policies in Canada has been more than a decade of poor system performance.”

The Better Prescription paper, found here: http://www.longwoods.com/content/25160 says “Since 2010, provinces have been voluntarily collaborating on prescription drug pricing through a Pan-Canadian Pharmaceutical Alliance; and some provinces, most notably Ontario, have been calling for federal-provincial collaboration to establish a universal pharmacare program to make medicines more accessible to all Canadians. At the federal level, the Liberals’ 2015 election platform included promises to negotiate a new health accord and to work to make prescription drugs more affordable in Canada, promises that ended up in the new health minister’s mandate letter after the Liberals formed government in late 2015. Perhaps not surprisingly then, in January 2016, when the federal, provincial and territorial health ministers met for the first time in many years, they created a working group to explore pharmaceutical policies aimed at reducing prices, at improving prescribing and the appropriate use of drugs, and at improving coverage and access to medicines for Canadians.”

This paper tells us that in 2016 Canadians spent $30 billion on prescription drugs and $5 billion of the private spending was wasted! Further, it says that over $400 million is spent on unnecessary drugs for people over 65 and estimated that “one in six hospitalizations in Canada could be prevented if prescription drugs were prescribed and used more appropriately.“

Another paper, National Pharmacare in Canada: 2019 or bust? https://www.policyschool.ca/wp-content/uploads/2017/03/National-Pharmacare-Adams-Smith.pdf begins by saying, “It is the Canadian public policy issue that rears its head with regularity, never achieving much more than discussion, and yet never going away entirely. The issue is pharmacare, and once again it is back for discussion among academics and policy-makers, and once again it looks like the discussions will not go anywhere anytime soon. The proposal for a publicly funded pharmaceutical- coverage plan is frequently on the table in Canada, but it still is not in the cards.”

A second February 2017 paper, the Estimated effects of adding universal public coverage of an essential medicines list to existing public drug plans in Canada http://www.cmaj.ca/content/189/8/E295 “could address most of Canadians’ pharmaceutical needs and save up” to $5.83 billion annually if we covered 117 of the most prescribed drugs.

From 2006 to 2017 we have had study after study, paper and presentation after another on the benefits of universal drug coverage. Here are links to a few:

https://open.library.ubc.ca/cIRcle/collections/ubccommunityandpartnerspublicati/52387/items/1.0048260

https://www.ourcommons.ca/Content/Committee/421/HESA/Brief/BR8289787/br-external/CanadianNursesAssociation-e.pdf

http://www.pdci.ca/wp-content/uploads/2016/01/Pharmacare-Preliminary-Report-PDCI-January-2016.pdf

https://www.collectionscanada.gc.ca/eppp-archive/100/201/300/cdn_medical_association/cmaj/vol-162/issue-4/0523.htm

https://dspace.library.uvic.ca/bitstream/handle/1828/8612/Derksen_Cameron_MPA_2017.pdf?sequence=1

https://www.cma.ca/Assets/assets-library/document/en/advocacy/PD10-02-e.pdf

http://www.aims.ca/site/media/aims/Final%20-%20The%20Effectiveness%20of%20the%20Common%20Drug%20Review%20in%20Canada%27s%20National%20Drug%20Strategy.pdf

https://nursesunions.ca/wp-content/uploads/2017/07/universal-pharmacare-report-e.pdf

In 15 years we have produced at least 15 major studies on the benefits of a national drug policy. We have studied this topic to death. The benefits to people, patients and the system are clearly identified. The money to relieve the stress on the health care system is in the savings. In Nova Scotia’s case this 15 years of inaction has cost us in excess of $805 million in over-payments for prescriptions. That’s roughly half the projected cost of a replacement VG. What more do politicians, health ministers and governments need before they act?

 

 

 

Looking south to successful new disruptors

Two of the world’s richest men may launch the biggest, positive disruption to health care in several generations.

Warren Buffet and Jeff Bezos are teaming with JP Morgan Bank to create a company to help US employees find quality care “at a reasonable cost” and tackle the “hungry tapeworm on the American economy”.

https://www.theguardian.com/technology/2018/jan/30/amazon-warren-buffett-jp-morgan-healthcare?utm_source=esp&utm_medium=Email&utm_campaign=GU+Today+main+NEW+H+categories&utm_term=262367&subid=12294947&CMP=EMCNEWEML6619I2

They’re operating in the for-profit American system, but have realized that soaring health care costs are a threat to both people and the economy.

Buffet brings a benign practicality to business. Bezos understands scale. Both understand efficiency and the need to produce results.

Their collaboration and new vision could shake up the comfortable, semi-incestuous clique of like-minded, like-educated, like-back-grounded people who manage health care. We might see a new type of results-oriented executive class introduced to health care management. And that might provide Canadian politicians with the fortitude to think outside the box when hiring executives. So instead of hiring another executive clone responding to a job description written with their particular curriculum vitae in mind, health ministers seek people with a real history of success or, failing that, demand our executives meet performance targets. Remember, in seven years Halifax hospitals have failed to meet the province’s standard for off-loading ambulance patients within 20 minutes. NS health executives have not managed to bring capital projects in on time or on budget. They have failed to recruit doctors in sufficient numbers to meet the Physician Resource Plan. They have failed to retain doctors. They have impeded doctors in taking over established practices or opening new ones. They have a history of higher-than-average administration costs, and, and, and …

Buffet and Bezos present a truly positive disruptive opportunity for western health care.