Wednesday, October 5th, 2011 the Nova Scotia Health Minister Maureen MacDonald appeared on CBC Halifax’s Information Morning to address some of the comments I made on Monday.
You can hear Minister MacDonald’s comments here:
Without commenting point-by-point, the Minister said when she took over the department she looked at where they could make savings and spoke to experts on the issue. What is interesting in our family’s journey through the health care system in Nova Scotia, and from what I hear from others across the province and Canada, is that management and administration and government conduct internal discussions. They talk among themselves. No one talks to patients and families. We’re the people who actually experience the system first hand and we are left out of the conversation. It’s all a bunch of people playing with numbers on paper and imaginary flow charts.
I also don’t hear a lot of conversation with nurses or doctors. The operational changes to the Berwick Clinic were decided without checking with the doctors first. As a consequence some doctors are reducing the hours they’re available to patients. There was an assumption made that isn’t the reality.
The Minister says she wanted to avoid upheaval in the system. Upheaval for whom? Those of us who have experienced the system first hand know it doesn’t work. Upheaval can’t hurt. Upheaval may just be the remedy.
After all, according to the Minister she was the one who prompted the local health authorities to begin looking for cost savings and cooperation. They had a decade to do that, but didn’t have the impetus or vision to consider cutting costs.
She also referenced the new Stroke Strategy. Here we have a prime example of the communications breakdown. Managers may know there is one, but front line workers don’t know about it or haven’t been briefed on it. This reminds me of a post-election comment made by a long-time Liberal organizer and senator after the election which first brought the Progressive Conservative party to power under Brian Mulroney. The Senator said, “We pushed all the usual buttons, but didn’t realize until it was too late that they weren’t connected to anything.”
This is a problem when your discussions are as incestuous as those among the health care elite.
The Minister says that under the changes implemented by her department with the local authorities that patient care has improved. Can we have proof of that? And can that proof be more than numbers on a page? In my newspaper days my editor kept a book on her desk titled, Lies, Damn Lies and Statistics.
For example, in May the Minister released a report that said Emergency Room closures in Nova Scotia were down from the previous year. Between April 1, 2010 and March 31, 2011 provincial ERs were closed for 200 hours less than 2009-2010. That’s positive. But when you divide the 18,920 hours ERs were closed in the year that translates into 788 days of closures in one year! Two years and two months worth of closures in 365 days. That’s not a lot to crow about.
In addressing what has happened in other provinces which have amalgamated their health care authorities she likened Alberta’s savings as “insignificant”. I believe she was misinformed. Alberta cut their health care authorities in order to redirect $1 billion from administration to patient care. This is where we play with words. The system didn’t “save” any money, but it did redirect it. Now, Alberta can serve as a lesson for us when it comes to comparing apples to apples. Alberta is a much larger geography and bigger population base and has unique challenges presented due to isolation and heavy industries. They have realized a need for more than one health authority, but they are still operating with 50% less administration than before. The Minister didn’t address how New Brunswick, which is a closer model to us, is doing with their reduced administration. They went from eight to two, which a retired executive and former hospital board member tells me “is still too many”.
Typically the health care elites have circled their wagons. That doesn’t change the fact that the system is sick and top-heavy. Each health authority has a board of directors. Then there are the administrators: the CEO/presidents, the vice-presidents, and the directors. Below them are the facility managers, department heads and supervisors. There are also volunteer local boards for each facility, which mostly fundraise. Then we get to the people who actually work with patients. No wonder people need name tags.
I am reminded of the time in the late 1970s when we found the Canadian military had more officers than enlisted ranks. It’s a Canadian trait, probably due to the fact that we’re so well educated, that we have more managers than workers. That doesn’t ensure good delivery of health care.
I think a piece which appeared in The Irish Times in June, written by a former regional manager of the Health Service Executive (HSE) sums up our situation. She wrote, “At the heart of all cultures is a world view or paradigm that decides how everything is done, regardless of what corporate plans say. This paradigm defines boundaries and tells people how to behave inside the boundaries in order to be successful in the organization and their careers. Culture decides what rituals are acceptable, whose stories get heard, how power is distributed, and what controls and structures are put in place. The way things are done in the HSE, because of the un-integrated mix of cultures, is through endless meetings, unread reports, hero nurses, waiting lists, trolleys, turf wars, vested interests, competition, shabby buildings, parallel working, confusion of roles and massive bureaucracy.”
The writer continues, “More than 50 years ago the philosopher Thomas Kuhn wrote about the circular arguments that arise when a health problem has to be solved. Each group of professionals argues in defense of their own world view and invariably talk through each other at unproductive meetings. None of this is good for service users who receive conflicting advice as a result. … Unfortunately, the cultures of the HSE and the professions do not like adventurous people because they are a threat to the status quo.”
In our health care system the status quo is struggling to live up to the Hippocratic oath to “never do harm to anyone”. The status quo can do with upheaval. That may be the prescription needed.