Who to trust?

The Nova Scotia Health Authority has trouble communicating what they’re doing. Auditor General Michael Pickup made that point in the fall. It’s worth remembering that in 2011 former Auditor General Jacques Lapointe, having studied the problems with the cost overruns of the Truro hospital, recommended “The Department of Health and Wellness should put a process in place to ensure only complete and accurate information is presented to Cabinet.”

The former AG determined that inaccurate information was presented to justify the construction of a new hospital. And here we are almost a decade later and we’re still questioning the veracity of health executives.

It seems that after each appearance by an NSHA representative before the Legislature’s Public Accounts Committee their testimony is questioned.

For example, in April 2017 Dr. Bob Martel, a palliative care doctor from Richmond County, took issue with a statement from NSHA CEO Janet Knox that paramedics can offer in-home palliative care to 1,000 patients who have signed up for the service. Martel wrote, “On the surface, this statement is factually correct, but is misleading in that it leaves the impression with political officials interviewing Ms Knox that these paramedics are offering palliative care services to 1,000 patients. The number refers to the patient population registered as special palliative patients with Emergency Health Services over the last two years. What it really means is that EHS will respond to calls from these patients and their families in a different way: no lights and sirens, more sensitivity around issues of resuscitation and on occasion, administer bridging pain and symptom relief to patients who do not have access to their regular physician or palliative care practitioner. … This program is neither meant to provide primary palliative care nor is it qualified to assess or administer comprehensive palliative care. … It is too bad that Ms Knox was not challenged on this point as it appears that she successfully conveyed that all is well in palliative care …”

http://thechronicleherald.ca/editorials/1457478-opinion-paramedic-program-is-not-true-palliative-care

Now Herald columnist Jim Vibert questioned the information provided by – or left unsaid – by Rick Gibson, NSHA’s senior medical director, who appeared before the Public Accounts Committee in December. Vibert writes, “Gibson told MLAs the authority now has what it needs to plan for future doctor requirements across the province … But even as he was speaking, the NSHA was issuing a tender “for a more robust data system to better track and report on physician information, including credentialing, privileging and recruitment”.”

Vibert continues, “No mention was made of the tender at the committee, and members could be excused for coming away with a sense that at least the NSHA is working from good information, when it is in fact just going about the process of buying better data.”

It was, as Vibert says, not a complete picture. I am reminded of the line from A Few Good Men, where an angry Jack Nicholson screams, “You can’t handle the truth!” Is that what the NSHA executive feel about the right of the public and politicians to know about the state of our health care system?

Are Nova Scotia health executives too cute with details or uncomfortable with facts? As Vibert says, “Say what you will about the health authority – and I have – they are good at teaching us who to trust.”

http://thechronicleherald.ca/opinion/1536671-vibert-haruspicy-isn’t-revealing-the-fate-of-health-care

 

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Replace the NSHA leadership

It has come to this. James Moir, a former president of Maritime Medical Care and former chairman of the QEII Health Sciences Centre, has called for the government to fire the leadership of the Nova Scotia Health Authority.

The delivery of health care in Nova Scotia has reached a point where we are moving from insider conversations, measured statements, calls for study and other platitudes to putting our names to public calls to fix the system by firing of those who failed to deliver.

Read Moir’s comments here:

http://thechronicleherald.ca/opinion/1535593-opinion-fire-health-care-kingpins-they’ve-failed-miserably

The government was bold enough to change the system, and now we need that same boldness to fix the remaining impediment to success.

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Nova Scotia’s doctor deficit

Kevin Chapman with Doctors Nova Scotia told CBC’s Information Morning host Don Connolly that there are currently vacancies for 70 family physicians in the province. That’s as of December 18.

Using quick shorthand we can get a better idea of how many people are without a family physician. As a rule of thumb, most solo or dual-practice family physicians in Nova Scotia have 2,200 patients. For some longer-practicing physicians’ (the ‘old school doctor’) file numbers creep past 3,000.

Working with the basic of 70 vacancies x 2,200 = 154,000 patients without a family doctor.

Under the Nova Scotia Health Authority’s collaborative care practice model doctors will have an average patient load of 1,400. In which case 70 x 1,400 = 98,000 people without a physician.

In either scenario the 42,000 names on the NSHA list of patients waiting for a physician is a grossly understated fiction.

And what happens to people without a family physician? Their only alternative is to treat hospital ERs as a walk-in clinic. And in 2015-2016, 48 percent of ER visits in Nova Scotia were for non-emergencies. Using an ER for medical care is not good for patients. It focuses on the current concern, doesn’t develop a relationship with a medical professional who can help develop a long-term care plan and catch abnormalities before they become dangerous, and expensive. Forcing people to use the ER as their primary contact for care illustrates the level of failure of care.

The NSHA’s inaction on physician recruitment is shoving the system to a fiscal breaking point. How much longer can we afford an executive who fail to produce better patient outcomes?

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Questioning the costs and care of CCCs

The Nova Scotia Health Authority is advertising for health care professionals to join the collaborative care practices.

Is this a real request or a public relations move to mute some of the Auditor General’s criticisms about the NSHA’s secrecy, lack of transparency and poor communications?

If the NSHA needs to reach physicians, nurses and other professionals, it has only to reach out to their associations, regulatory boards and colleges. This ad, it would seem, is more about looking busy and active than being productive.

The other issue is whether these collaborative care practices are the panacea the NSHA would have us believe they are. Or are they just about a different type of bloated bureaucracy?

Four years ago I was invited to attend a medical information day by the Minister of Health. At that day we heard medical students say they wanted to collaborate in a family practice. What I heard said was this next generation of doctors wanted practice partners. They wanted someone to share the work with, to bounce ideas off, to help keep up with medical advances, and to cover for holidays and sick days. The impression was that new doctors wanted to work with two or three others. I did not hear anything along the line of the collaborative care centres/practices the NSHA is promoting. It could be that an aversion to commit to a solo practice – which students say is not presented as an option in medical school – has been misunderstood by the bureaucrats who embraced the idea of over-building a response. A doctor opening a solo practice doesn’t give the ribbon-cutting photo ops of a clinic opening.

Students didn’t say they wanted this and many of the experienced physicians, surgeons and specialists question this model of care delivery. The feeling is that CCCs are an expensive way to deliver care to fewer patients. Below are the detailed questions and concerns of long-time Yarmouth County family physician Dr. Peter Loveridge, MB, BS, DMRD, FRRMS, who lectures in family medicine at Dalhousie University.

This is a copy of a letter Dr. Loveridge wrote to the Doctors Nova Scotia newsletter in response to an article. He asked helphealthcare to share it. It has been lightly edited for clarity to a lay reader.

The Editor, Doctors NS magazine

I am not sure if DostorsNS is set up for comments, but I would like to comment on the article highlighting … collaborative practice. I am a rural doctor who has worked in Yarmouth County for more than 40 years. The article does not give a balanced view of this approach, and leaves many really major problems unaddressed. In replying to this I did take the trouble to go through the 29 pages of “strengthening the primary care system…”, a rather turgid read full of bureaucratese and jargon.

I write entirely as a remote rural doctor. I have nothing to say about urban practice, though it seems now that the inhabitants of HRM are now experiencing the same problems we have had to deal with for decades. I will use the HA example of serving a population of 10,000 people, though the geography of rural NS rarely leads itself to such neat packages.

In the bad old days of 20 years ago, such a population would have been served by a group practice of 4 doctors. (Five if you were lucky and 2 or 3 if you weren’t.) The docs paid for everything out of their (usually) FFS earnings. There would be 3 ancillary staff (+/- 1) and they did all the managing of the practice. Usually one of the senior physicians would have some management oversight. Didn’t much matter about the details, as no-one other than the physicians was responsible for payment of the overheads. The practice would receive about $250k per physician in fees, sometimes in a high volume practice a bit more; in a practice with a lot of elderly, multi-morbidity patients, a lot less. Hospital in-patient coverage, ER coverage, nursing homes, surgical assists, and obstetrics, often in collaboration with other practices, was almost universal. Works out to a cost to the taxpayer of about $100/year/patient.

Now, consider the NSHA’s obsession with collaborative care centres and supposed medical homes, each one serving about 10k patients. Sorry, the geography doesn’t work. My municipality, population just under 8k is 2/3rds the size of Luxembourg. The two population centres are a 45-minute drive apart, and it’s an hour-and-a-half from one end to the other on a good day. The unfortunate people in Weymouth (Digby County) are expected to get service in Digby, a 45-minute drive on the only unimproved section of highway 101. Westport, where previous governments managed to maintain a physician presence for at least 50 years and maybe longer, face an hour-and-a-half drive and two ferry crossings. Try doing this in February with a northwesterly gale and blowing snow – these times can be tripled. The people in Westport, a prosperous fishing community which contributes mightily to the GPP, are not amused. Administrators in the NSHA give every impression of having zero understanding of this problem and are not interested in getting enlightened.

So, consider the unaddressed problem with all this talk: the money. Here is at least a realistic yearly estimate of running the cost of such a place:
4-5 doctors – $1 million
2 NP’s – $260k
2 practices nurses – $160k
2 adaptive team members (the NSHA’s jargon, don’t really know what it means) – $160k
6-8 clerical staff – $250k
management – $100k

Then the rent or capital cost of a building holding a minimum of 17 health care professionals and its maintenance, utilities, supplies, insurance, etc. That’s a $2.5 million capital cost and $200k maintenance as a very conservative estimate. If the non-physician staff are unionised, you can add at least 30% to the costs.

This works out to about $2.6 million a year (building cost amortised over 20 years, but being it the government, in all probability it is higher than this), and an annual cost per patient of $260, more than double the cost of a traditional group practice.

If you, as a rural doctor really want the bile to raise in your gorge, you can read this last spring’s article in the Halifax paper about the DFM clinic in Spryfield. Here, 10 physicians, 14 residents and at least 12 other clinical staff manage to look after 4200 patients, and no, they can’t possibly manage any more. Patients are not guaranteed that they can see “their own” doctor, the concept is discouraged. Dalhousie family medicine is anything but transparent with disclosing finances, but a very conservative estimate of the costs works out to about $1400/patient/year. No mention is made of things like ER shifts, nursing homes, obstetrics, etc. I truly despair about what training the residents would get, it is not in the real world.

It is often stated that new doctors want to go into turnkey operation where they do not have to be small business owners. This may be true, but when these same people go into a CCC and find out they are subject to the whims of an (appointed) manager … this begins to pale rapidly. My kingdom is pretty humble, but at least I am the King, and if I need a new fax machine I just order it. I do not have to put in a requisition, wait for three quotes, and if the manager deems it important enough, wait two months for it to arrive. There may be some merit in joining a well run CCC, but joining a bad one, which outnumber the good one by two to one, is a nightmare, I’ve been there.

Of our first 10 residents graduating from our program, only one is in a CCC. 3 left the province, 2 to do ER, one to a rural community in BC, 3 to Shelburne (not a CCC) one to Yarmouth, one to Clare, one to Dartmouth, and one to Cape Breton. After 10 years of post secondary education most docs want to be their own master and actually don’t want to be employees in name only with none of the benefits. Though the CCC, which our one resident is in, is the best run one in our district, she is not happy. She wants to work half time as she has a baby, and the CCC is not flexible enough to charge her part time expenses. Another young doc (not a recent graduate) left the place as he worked mostly in ER’s and they couldn’t accommodate him either. I will refrain from commenting on the other places, though I did survive 6 weeks in one. …

Now, I will have a brief word about nurse practitioners. I don’t have a problem with the concept, in fact, when I was a resident, many decades ago and across an ocean, we had such creatures (we didn’t call then that), as we did when I first came to Pubnico 44 years ago. But community NP’s in western NS work from 9-4 Monday-Thursday. It is rare they see more than 10 patients a day and an average is 7. Most family physicians see at least 30 patients a day, 5 days of the week. I’m sure you have seen on the news the case of the young lady in Lockeport who couldn’t get a diagnostic mammogram.. The small print stated she had 5 NP’s in 4 years and the service had been withdrawn from their community, leaving her high and dry. The reality is that if a 4 person group practice, because of retirement, moving away or death, is replaced by a 3 doc + 1 NP practice, the remaining docs will have their workload increased by 30%. This may well make the practice unsustainable. If you think NP’s are going to do the extended hours, weekends, ER shifts, surgical assists, hospital inpatients and the like, you are dreaming. There also has to be consideration of the costs of an NP. NP’s earn about $110k/year, but their benefits raise this to about $130k/year. They have to have support staff and an office. This cannot be done for less than $50k/year, so the total annual cost is $180k. Given the limited number of patient encounters, the cost per encounter is close to $100. The corresponding cost for a family doctor is $32, or a bit less than $40 if the patient is over 65. This does not make economic sense, but any mention of this is considered to be hostile to nurses. It is time for realistic talk here.

The bottom line of all this is that the traditional solo or group practice is a very cost effective way of delivering care. Practices have always collaborated, it is just that government haven’t controlled it. Everything else costs at least twice as much, and there has not been a single credible plan as to how this is going to be funded.

Peter Loveridge

 

 

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A bigger bomb for Kings County medicine

In a Facebook discussion about the post A Medical Bomb Drops in Kings County, a contributor who supplies the medical sector, listed the doctors leaving the county. Janet Knox, who worked for years in Berwick and Kentville, would know these physicians professionally, if not personally:

The current list of retiring, sick or departing doctors is this:

1. Dr. Siva is on medical leave and will not be returning to his Kentville practice.
2. Dr. J Seaman/Kentville is retiring Jan 2018
3. Dr. P. McGuire/Kingston is retiring Dec 2017
4. Dr. Ainamo/Kingston retried June 2017
5. Dr. Langille/Berwick retired this year.
6. Dr. George/Berwick closed his practice and is doing other medical work.
7. Dr. Soma/Kentville is relocating to Windsor, NS
8. Dr. Keough/New Minas recently closed his practice and has relocated
9. Dr. Bander/Digby will be retiring in 2018. (Dr. Bander is not in Kings County, but is part of the Valley medical community).
…and there will be more.

Last evening I was told that Dr. Ruddy, an ear, nose and throat specialist in Kentville, is also closing his practice.

Assuming the first eight doctors on this list have an average patient file of 2,000 (several of the longer-practicing doctors, like Dr. Seaman, will have significantly more) it’s fair to say that 16,000-to-18,000 residents of Kings County have, or are about to, become orphaned patients. In seven months 27 percent of the citizens of Kings County have lost or will lose their primary physician. They are added to the thousands of other county residents without a family physician. This could take the count of orphaned patients in Kings Couty to 50 percent of the population!

What will happen to these 30,000 people? The Annapolis Valley District Health Authority has three points of contact: Valley Regional Hospital and clinics in former hospitals in Berwick and Wolfville. Without a family physician the logical place for patients to go is to the ER. How will they cope? VRH is bursting at the seams. It is not uncommon to wait four and five hours to be seen by a doctor in the ER. That’s stressful and wasteful, not to mention, for a true emergency, damaging to a person’s health.

And don’t count on a collaborative care clinic (CCC) to provide medical salvation. Later in the week Helphealthcare will publish the unvarnished thoughts of a long-time, free-speaking physician about these.

Kings County is one of the more dynamic economic contributors to the province and region. There are significant employers here, like Michelin and several large food processors. Kings County is not only the richest agricultural area of Nova Scotia, it is one of the top three agricultural areas in Canada. It has a booming wine sector. It’s also a financial centre. It’s a major retail destination. It’s an academic (Acadia University, NSCC) and regional medical centre. Aside from the angst of not having a family doctor is the economic impact of a lack of medical professionals. The longer it takes for people to be seen by a doctor and receive care translates as time lost at work. Those on a fixed salary are costing their employer. Those paid on an hourly basis could be losing income. Companies, institutions and the overall economy could be losing millions of dollars a week as people sit in waiting rooms to be seen. Could this impact a company’s decision to invest here?

Kings County is an attractive place to live. It’s an easy commute to Halifax and the airport. It has good dining and great social life. For outdoor enthusiasts there is the Bay of Fundy, Minas Basin, Harvest Moon Trail and various lakes to explore and play with. For the intellectually-motivated, there is a rich cultural life. Traditionally there is a strong cluster of other professionals to interact and work with. Property prices are reasonable. So are rents. In other words, if you are a highly trained professional, locating your practice here means you don’t have to put your life on hold. Yet, if Kings County is having such trouble retaining and recruiting doctors, what are more remote countries facing? How desperate are others?

The dirty little reality is that the Nova Scotia Health Authority has failed miserably in keeping a key population – the doctors – happy and healthy. We have a new system, which is, alas, populated by old thinkers. To fill all the empty practices we need a change at the top.

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Rev up recruitment

Nova Scotia’s Auditor General, Michael Pickup, revealed the shocking news that a physician recruitment plan for the province wasn’t put in place until the spring of 2017! Further, he said that the recruitment efforts of the Nova Scotia Health Authority and Department of Health weren’t coordinated.

This is a surprise because physician recruitment, retention and loss has been a long-running, hot topic in Nova Scotia. A key campaign theme in the 2013 provincial election was the recruitment of more family doctors to the province.

So, compounding the surprise that it’s taken four years to launch some sort of last-minute, uncoordinated recruitment plan, was an interview NSHA CEO Janet Knox gave to CBC Information Morning. Host Don Connelly said to Knox, “I suppose that every conversation you have or hear is about doctor recruitment.” Knox responded, “No, it’s only been in the last year that has been a topic.”

Really?

How sheltered a world does Knox inhabit? Given the fortress-like mentality of the Nova Scotia Health Authority, the secrecy of its operations and invisibility of the NSHA board Knox seems to have designed a corporate structure and culture that provides her with a level of deniability about the biggest topic in medicine. Her response suggests she doesn’t read newspapers, listen to radio, watch television news, have summaries provided or actually listen to doctors, medical groups and politicians of all parties. I don’t mention the public because the public hasn’t a snowball’s chance in hell of reaching her.

In her CBC interview Knox said she had made 60 trips across the province to “engage” with Nova Scotians. That level of travel is not reflected in her expenses. She expensed $28.40 for a lunch with a Dr. Mayne in June, but there is no detail or suggestion of mileage for such extensive, expensive travel across Nova Scotia. It may be that she is provided with a car and operating costs, but that also isn’t itemized anywhere in her compensation or expenses.

http://www.nshealth.ca/sites/nshealth.ca/files/ceo_trvlhosp_reporting_april_2016_to_jul_2017_0.pdf

“Engage” is an interesting word. Language in health care is critical. It’s not merely to discuss actual medicine, it’s important for public relations. NSHA says it “engages” and holds “consultations” with medical professionals. But their definition of “engage” and “consult” is not a two-way communication. It’s not even fact-finding because it is devoid of the listening function. I have heard of senior specialists telling NSHA executives to “shut up” so they – the front line medical professionals – can speak. Another meeting I heard of had 40 doctors shout “liar” to an executive. Then there was the meeting that left many in tears and shock. At that meeting the NSHA executive advised doctors not to renew office leases.

Doctor after doctor said meetings, conference calls and other “consultations” were a one-way information stream, where NSHA executives and zone managers deliver corporate decisions about how doctors practice medicine. It is not a collaborative process, which is ironic given how the NSHA has focused on developing collaborative care practices / collaborative care centres (CCC).

Four quick things to know about collaborative care:

  1. The NSHA’s focus on these has actively discouraged, limited and/or prevented family physicians from establishing medical practices where they wish or taking over an existing practice;
  2. CCC’s are more expensive medical models, which Ontario has abandoned;
  3. Because the CCC may be called a “collaborative” practice, doesn’t make it so. A long-time family physician maintains doctors have always collaborated with other professionals to deliver care. Many doctors and other medical professionals have said putting people in the same location can’t make them cooperate or like each other. I was copied on an email which said, “… in the spring I received a copy of an email from a doctor in XXXX to a colleague complaining about the CCC there. He estimated that its operating costs were double what another clinic cost and the various members of it hated each other so that they stopped speaking to each other.”
  4. And there is the big lie of CCCs. It’s a lie based on a false impression. The public has been sold on CCCs as a centralized, convenient one-stop medical delivery facility. A patient won’t just find their family doctor there, they will have access to a variety of medical professionals. The way the CCCs have been sold is that one visit handles all. Here’s the rub: a patient may access a variety of professionals at a CCC, but those will require a variety of appointments. Another physician wrote, “Just because people are located in the same spot doesn’t assure a patient they will be able to be seen on the same visit. The evidence is that the costs are higher and that access per clinician seems to be reduced not increased. There is a cost for unnecessary collaboration.”

Our doctor numbers are not good. The implementation – of any and everything – is not good. Communications are not good. So what expectations can the public have?

If you study the NSHA website there is a reference to succession planning for a new executive. To help health care perhaps this recruitment should be accelerated and a quick deadline set. And met.

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A medical bomb drops in Kings County

A medical bomb has been dropped on the people of Kings County.

In October, a doctor in New Minas closed his practice. In November patients of two Kentville doctors learned that that practice was closing at year’s end. One of the doctors has been out on medical leave for over a month and decided not to return to this practice. His practice partner opted to also leave for another practice.

Then, in the last week, another long-time Kentville doctor announced his retirement.

These four departures leave approximately 10,000 patients in Kings County without a family physician. This wave of orphaned patients, doubles the number of residents without a family physician, which equates to about a third of the residents of Kings County without a doctor. With no replacement doctors for these practices the ER at Valley Regional Hospital, clinics in Wolfville and Berwick, and the walk-in clinic in New Minas are about to get a hell of a lot busier. That’s assuming there are doctors available to work those clinics. At least one of the departing doctors also worked the Berwick clinic.

So what’s the Nova Scotia Health Authority’s plan? What has Janet Knox got up her sleeve for solving this problem? And solving it NOW! We want remedies now, not some mythical plan that kicks in after Knox retires (she reaches retirement age in the next three years – typically health care executives quickly take retirement, collect any payouts, draw their pensions, then return as high-priced consultants, thereby doubling or tripling their income overnight).

Knox has been a health executive for over a decade. I am unfamiliar of any accomplishments during her tenure at the Annapolis Valley Health Authority or the Nova Scotia Health Authority. Other than progressively moving up the corporate ladder, what has she done for patients and to improve patient outcomes?

Not having a family physician means people receive a type of superficial care because medical professionals who have no relationship with the patient, treat the illness du jour and potentially miss other long-term changes in the person’s health. I know a resident, who waited three years to find a family physician. Once she had a doctor, he found an undiagnosed lung cancer. Recently a woman suffered a stroke because eight of 12 markers for temporal arteritis went unnoticed. That patient has lost her sight. Relationships with physicians are an important part of successful diagnosis and preventive medicine.

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