The myth of Collaborative Care Clinics

The NDP introduced Collaborative Care Clinics (CCC), the Liberals embraced them and medical professionals question them.

The idea may seem benign and logical, but not every doctor wants to practice this way. The myth is that CCCs are the answer.

It’s been suggested to me that the medical community, even doctors in solo practice, have always collaborated in medical care. Family physicians are the front line. When a patient presents with a case requiring more investigation or specialized care, the physician refers them to the appropriate specialist. That specialist is one the physician knows, likes, trusts and can work with.

So collaboration isn’t anything new. It makes sense. And it makes sense in small rural setting as well as an urban location.

There are doctors who like their independence. Or at least prefer to pick who they work and share a practice with. Witness the number of shared practices across the province and country.

The reverse side to CCCs is forcing physicians to work with people they don’t like, have conflict with or under conditions they don’t like. What then?

Breaking up, firing, replacing members of the CCC can be messy, create hard feelings, leave patients in limbo and is unnecessary. Nova Scotia currently believes the CCC is the one-size-fits-all solution to health care delivery. So what contingency plans have the Health Department and Health Authority for dealing with discord among professionals forced to work within a CCC?



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12 Responses to The myth of Collaborative Care Clinics

  1. Tim Segulin says:

    “The reverse side to CCCs is forcing physicians to work with people they don’t like, have conflict with or under conditions they don’t like.”

    This is the first criticism I’ve heard about collaborative health centres. I had understood they were generally well regarded in the medical and nursing community and in government (including by other provinces who took a look at the first ones NS instituted). They were created under the NDP as alternatives to rural ERs which could not be kept open 24/7 and that was causing great anxiety in some rural communities. They were based on a concept advanced as I recall by ER physician Dr. John Ross.

    If this is the principal criticism of CCCs, then it seems to me they can’t be doing too badly. I’m sure doctors have found themselves working alongside or under other doctors they didn’t like before and that may have even led to conflicts. Same for nursing staff.

    If the subtext here is that the medical profession resents the intrusion of nurse practitioners upon what previously had been entirely their turf, I must say I don’t feel terribly sympathetic. If some rational combination of the two make the NS health system perform better – even in rural areas – for the same public money, then it’s worth it. Maybe in time as young doctors replace retiring older ones, such lingering resentments will fade.

    The big issue with NS public health is making a program that consumes over 40% of program spending somehow sustainable and accessible in a timely manner irrespective of where patients live, as demand increases with an aging population and revenues are flat or declining. If lateral thinking like CCCs further that goal, then IMHO they’re worth it.

    • CCCs aren’t a total failure. But they also aren’t the only solution. Ask the people in Weymouth.

      The comments I heard weren’t about physicians against nurse practitioners, it was about being forced to work with people they didn’t like or get along with. Just because someone is well-educated doesn’t mean they can’t be a jerk. It’s not unheard of for some people to dislike co-workers. But for highly-educated, mobile professionals like physicians we have to recognize they have options that others don’t.

      The public seems to assume doctors can be ordered about and told where and when to work, as if filling in a shift at a fast food restaurant. It’s hard enough to get some physicians to move to some communities – if all the young people have fled a place because it doesn’t offer anything for them to do, why do we believe doctors are overly anxious to move there? They want more out of life than work and sleep. If we find a doctor willing to move to a remote community why throw up roadblocks to his/her locating there? This heavy reliance on CCCs can be such an obstacle for some.

      • Tim Segulin says:

        I would hope we are making some effort to attract people who have grown up and have a stake in rural communities to train as doctors who might actually like to serve them some day. I don’t know how practical that is, or if we have even tried.

        Quite apart from that, if all medical graduates prefer the bright lights and more diverse cases afforded by the big cities, how are we ever going to be able to staff rural clinics? I wonder if graduation from NS medical school might not come with some sort of requirement to serve in NS rural areas for a few years. Perhaps we might require say 3-5 years out of 10 after graduation? Constantly rotating doctors is not ideal for rural patients, but better than none.

        As for doctors “being ordered about”, family doctors are of course private contractors to the NS government. Yes, they are mobile, in demand elsewhere and should not be mistreated, but I think the people of NS who have paid the majority of their education expenses, and continue to pay their income should also have some say.

        With all respect, last I heard the Government of NS and even the Department of Health and Wellness governed for the benefit of the whole province, not just HRM.

      • So much of the conversation is about attracting doctors to rural Nova Scotia. What is overlooked is how little is done to maintain the doctors already there. For example, VHR lost an orthopaedic surgeon because they had no money to pay for her. She travelled all over SWNova performing surgeries. I drove one person to Yarmouth for a surgery. There I met others who she had operated on in Bridgewater, Middleton and Kentville. But VRH had a five surgeon quota. She was the sixth surgeon. So she moved out of province to a place where she would be paid. Her radiologist husband left with her.

        At the same time Pictou lost an orthopaedic surgeon because he couldn’t get OR time. The former health authority saved money by keeping the OR dark. He also moved out of province. His physician wife went with him.

        Yarmouth lost six family physicians in 11 months. Sydney lost 23 in 24 months. Halifax had two heads of emergency quit within two years. No one ever asked why. When I asked doctors why, most rolled their eyes in response. One was candid about her departure. Too candid for me to comment publicly.

        Those are the cases I know about. Weymouth recently found a physician willing to move there to take over a solo practice. That wasn’t allowed because of plans in place for Digby.

        I had people in one Valley community ask me how they could attract a doctor to their community. They were waiting for the then district authority to assign one to them, but had gone two years without. Doctor recruitment is basically perfunctory. An ad is posted and that’s pretty much it. It’s not aggressive as other destinations. I suggested the community do some of their own marketing, but not market the place in the typical manner. The people who market small communities usually speak about what a great place it is to raise children. Well, if you’re a new grad, you may not even be dating, let alone be anywhere near thinking of a family. And what if you’re gay or lesbian? “Family” can be an uncomfortable code. Another issue is downtime. If a doctor of whatever age agrees to move to a smaller community, they have no time off. Whenever they’re out in public, people hit them up for an appointment or impromptu examination. I’ve seen doctors pushing a cart in the grocery store stopped by people asking about their aches and pains. I even heard one person ask the doctor to write a prescription they could take to the store pharmacy four aisles over!

        I’m not suggesting that we only focus on cities or that doctors are only interested in cities, but part of the problem with doctor recruitment overlaps with the decline in rural populations. If people who grew up in a place don’t see a reason to stay, why do we expect outsiders who don’t even have that family connection to want to live there? Forget bright lights, people want more than life in front of the TV.

        Six years ago Dr. Lynn Harrigan told me of a “double cross” that happened within the Valley medical community when VRH opened. In the two decades since opening, no one worked to resolve the rift in the medical community. There are local doctors who still don’t have medical privileges for VRH.

        There’s a lot of finger pointing when it comes to access to physicians. I suggest the fingers aren’t pointed in the right direction.

  2. Tim Segulin says:

    You certainly seem to have your finger on the pulse of the issue of doctors in rural NS.

    It seems to me that the main problem here is lack of funding, inadequate availability of OR hours and health questionable services management more than anything. That, of course, is nothing new.

    I can understand any NS government trying to find *practical* ways to reduce the cost of the system, but that crucial judgement of cost cutting versus the consequences it causes may be lacking.

    • Thanks. But when it comes to funding, I have continuously asked how much is enough? No one has an answer. Study after study says that the more money pumped in to health care, the higher the cost of solving problems.

      We fund a system without any monitoring of outcomes. The problem with health care is that we don’t know what works, what doesn’t and what’s a waste of time and resources. And those in charge are not responsible or accountable. They just reap pay and perks without any performance targets.

      • Tim Segulin says:

        I’ve long felt that the most pressing problem we have with public health care in NS (an maybe in other jurisdictions) is how we manage it.

        Without being any sort of expert, I suspect the current system has become a Byzantine quilt of patches and fixes superimposed upon a system that may have worked pretty well at one time for a demographic that has changed considerably. The result may well be that the system more or less works – with some egregious exceptions – but has become unsustainable and less responsive to non-emergency patient needs.

        Few if anybody really understands how it works, and since real lives actually depend upon it, my gut feeling is the politicians we elect to bear responsibility for it know precious little about how it works and so are intimidated by it and thus held intellectual hostage by Deputy Ministers and the Department who know far more about it that they do and irrespective of the government’s agenda may have some of their own.

        The result is that nothing much ever changes, no political party proposes any serious in-depth investigation or the kind of radical reform likely needed, and so it trundles along consuming an increasing proportion of the provincial budget with a patch here, a fire put out there. My fear is that on day it will fall before a Chaoulli style Supreme Court challenge, collapsing into a public/private system which ends up costing us more and with the arrival of profit-driven health care providers from the US, becomes irreversibly embedded here by NAFTA.

        You clearly have some thoughts on this. If you were the Premier, how would you proceed?

      • You’ve put a lot of thought into this.

        The previous system of 9 provincial health authorities + the IWK, which is regional, was instituted by Dr. Hamm. His vision, I believe, relied on people behaving better than they did. Rather than having a deep connection to their particular geographic service area, we got independent fiefdoms, operating separately as if nothing else existed. One authority could have patients stacked up waiting for treatment space while a nearby hospital under the control of a different authority was under utilized. It became an inefficient, ineffective mess.

        It was great for executive careers because those ranks grew. Prior to the introduction of the merged system, on one block in Halifax there were 222 health care executives earning six-figure incomes. Not one of them ever saw patients.

        Prior to October 2013 Nova Scotia had in excess of 460 health care executives. Again, they did not see or deliver care to patients. Three weeks ago the Health Minister told me those ranks were down to 290.

        The total health budget hasn’t been cut, but money has been, is being, redirected. It’s a start.

        As for politicians being held hostage, that is something I wrote about years ago. Health authorities became good at bullying politicians during election campaigns so the only discussion on health care was who would give the most money to the system. Every new government gave more money, but results and outcomes declined. The first act of the current government was to replace the Deputy Minister of Health. Seriously. Within 24 hours of taking office, he was out.

        Then the merged NS Health Authority was created. That was a massive move. Interestingly, while the NDP publicly decried changing the system – both their Health Minister and Premier said they were against introducing chaos to health care – behind the scenes they were working on just such a merger. So they were two-faced. And no doubt a bit bitter since health care change was the primary issue in the last election. They were doing it, wouldn’t say so, and lost.

        We have had a lot of change in health care in 2.5 years. For me, I question how innovative a system can be when it relies on people who were part of the ancient regime. You wonder how many people have their positions because of ability or professional friendships.

        I have long questioned if we shouldn’t redefine roles and duties. For example, the head of the health authority studied to be a nurse and later took an MBA. How does that prepare her to oversee construction (a criticism of the AG of those who oversaw the Truro hospital) and maintenance of buildings, catering, housekeeping, HR, etc. I have suggested we hire hoteliers to manage the actual hospital buildings. That way you wouldn’t have toxic water, leaking pipes, rodent problems, etc. The health authority CEO doesn’t interfere in medical decisions, neither would the hotelier. But the hotelier knows how to manage and maintain a large facility, deal with hundreds of staff and care for thousands of guests a week.

        What we are struggling with is not unique. I was in England a few weeks ago and their issues are the same, but with bigger numbers. Bermuda is in a similar situation, with smaller numbers. And then there are the problems with the US system. I will be writing about that later.

        As for a for-profit style system, well those are also collapsing under the costs, bankrupted patients, greed and profit-driven inefficiency.

        You referenced the changing demographic. Nova Scotia’s population didn’t suddenly get old overnight. In spite of decades of warning, the system failed to prepare. It’s not the people’s fault we grow old. It’s the continuing failure of health professionals to plan. Governments change, but those health professionals remain, thus proving the consistency of the problem: them.

        The problem comes back to the same thing: management. Let’s not keep putting the same class of people in charge. Be bold, go outside the box and bring in people who have unique abilities outside of those we now rely on because clearly those skill sets aren’t working.

      • Tim Segulin says:

        “….while the NDP publicly decried changing the system – both their Health Minister and Premier said they were against introducing chaos to health care – behind the scenes they were working on just such a merger. ”

        Interesting. How you know that?

        At the time I felt that some sort of rationalization of all this DHA management was needed and told them so. Of course, this was the same Liberal Party that ‘rationalized’ Halifax, Dartmouth, Bedford into HRM. There was good reason to be concerned about them amalgamating DHAs, whether or not that might be a good idea in principle.

        I also think the NDP connection to public sector health unions may have limited what they might have said publicly about any DHA rationalization they may have been developing, which might subsequently have led to labor negotiations. Maybe this was not so much two faced as it was just early on in a developing process?

        The Liberals have instead taken an almost hostile posture toward public sector unions, and the polls so far have shown this to be electorally profitable – at least until the public perceive something to go wrong, like industrial disputes interfering with health services or doctors and nurses leaving.

        Earlier you mentioned the relatively low remuneration for doctors in NS. This has been a sore spot for my Dartmouth family doctor. About a year ago I asked him what policy changes would really help him. As a partner in a clinic he felt that the drop in clinics were taking so many patients that his clinic might eventually not survive. He and his wife are from NB and pointed out that if he were doing exactly the same job there he would receive around $30,000 more p.a. because NS has one of the lowest rates of family doctor remuneration in Canada. She is pressuring him to leave. I appreciate we need to keep our health costs down, but doctors and nurses – as you rightly say – are very mobile and in demand.

      • What I know, I know for a fact. It is not supposition.

        As for the labour situation, even Graham Steele understood the need to reign in labour costs. One of the reasons he quit cabinet (if you read his book). I’m told that each 1% pay raise in public salaries is a $50 million a year increase in costs. There comes a point when we have to slow down. But another problem is chronic under-staffing. We have nurses earning double their income because of overtime! That’s not good for them, the patient or the system. No one has laid off nurses, but we have lost a number in the last five years because they took early retirement. They were burned out and fed up with how they were treated by management (not governments du jour). Working conditions are so shitty that people struggle to find satisfaction in what they do. Consequently, they think more money will compensate for their unhappiness.

        As for how government treats health care workers, look at how the previous government performed. They had one brief (an hour or two-long) strike. That doesn’t seem like much, but I was in VRH when that was coming. It disrupted care, treatments and surgeries for months. Later the paramedics started to strike. Nurses threatened to. One two-year nursing contract took so long to negotiate that it expired 10 days after it was signed! The NDP pretended to treat workers better, but their actions show otherwise.

        As for doctor payments, this has gone on for ages. I’ve noticed that to compensate some doctors are reducing the size of their prescriptions. This brings the patient back for a top-up prescription faster and quietly generates more revenue for the doctor. Right now doctors are paid about $35 for a patient appointment. This is why they need to see so many in an hour. However, if you called the province’s 8-1-1 service, which is contracted out to a US medical services provider, the province pays $70/call. That is another hangover from the NDP.

  3. Bubbie says:

    As far as I can tell the Department of Health and Wellness doesn’t have a plan for anything, never did.

    I go back as far Conservative Premier Rodney MacDonald whose government developed a ten-year long-term care plan, there, also, have been million dollar reports such as the Corpus Sanchez Report and the Romanow Report, all with grandiose ideas and suggestions on how to improve our health care system. Nothing ever came about from either of these two prominent reports. As well, there have been a multitude of other studies, presentations, conventions and mini reports on how to improve the Health Care System costing untold amounts of health tax dollars and still nothing has been done to improve the health care system. To reduce costs there have been suggestions to make better use of Nurse Practitioners but there seems to be a great resistance to employing employ them.

    Rodney MacDonald “had a plan to have a plan within five years” to replace the V.G. Hospital within twenty years but was defeated by the NDP before the planning began After Darrell Dexter’s NDP defeated the Conservatives they cut any plans the Conservatives had to improve the health care system and had no plan of their own. The present Liberal government seems to be floundering as to what to do with health care system. We have a third world hospital that needs to be replaced, a 35-year-old emergency ambulance helicopter that cannot land on any hospital roof helipad because of its age. Mental health care is inadequate and wait time to see a health professional is through the roof; wait time for elective surgeries such as hip and knee replacement are three times longer than anywhere in Canada and the wait time to see a specialist can be up to two years long. The wait time for a long term care bed is eleven-months long and increasing, even after Leo Glavine’s plan to keep people in their own homes longer begins to be implemented. The two-year, “First of its kind in Canada” Dementia Strategy unveiled by Minister Glavine and the Alzheimer’s Society, eighteen months ago turned out to be nothing more than an expensive photo op where he granted $250 thousand to the Alzheimer’s Society to carry on their “charitable” work. According to the news, a Mental Health Panel led by Star Dobson of CTV’s Alive At Five fame and Dr. Stan Kutcher, Dalhousie University Professor and former NDP candidate has been formed to make recommendations to the Department of Health and Wellness. Minister Glavine stated he won’t make any commitments to their recommendations. Seems like another waste of taxpayer health dollars. After all this Minister Glavine says our Health Care is not in a crisis.

    Another story in today’s news reported that an elderly lady spent nine days in the QEll ER while her two daughters vacationed in Florida, leaving their children to care for their grandmother. The grandchildren felt they had to take her to the ER because they could care for her properly. Dr. Sam Campbell referred the leaving the grandmother at the ER as, “almost abandonment”. While I do not condone the vacationing of the daughters in Florida, it is Minister Glavine and the Liberal government that are abandoning the elderly and the Health Care system.

  4. Bubbie says:

    Just a correction to my previous comment. Stan Kutcher was a Liberal candidate and not NDP.

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