Forget refreshed, go with ministerial experience

A post-election comment suggests the Premier name a new health minister because given the mood in the province “it would be difficult to move things forward. A fresh face” and a new deputy health minister “could mark a refreshed approach to the problems in our system.”

That, I believe, is a simplistic, unrealistic solution. The problems in the system existed long before the 2013 election. It is the constant shuffling of health ministers that allowed the systematic problems to continue and thrive.

As I have repeatedly said: we change governments, we change health ministers, we reorganize the system, we reorganize individual work flows, we change how front-line health care is delivered and whether the government is red, blue or orange, the problems persist. What doesn’t change are the health executives. Does no one see a cause and effect connection?

Constantly changing health ministers allows the health executives to have the upper-hand when this “refreshed approach to problems” are presented. The people who have done well and are most comfortable within the system are hardly likely to change it.

Health ministers – and premiers – don’t oversee the day-to-day delivery of health care. That’s the responsibility of health executives.

No health minister advocates for under-staffing or throwing up roadblocks to doctors who want to practice in the province. Health ministers are politicians. Their lives would be easy if everyone had a doctor, there were no nurse shortages and buildings weren’t disintegrating.

So the problem has to be the tightly micro-managed way the Nova Scotia Health Authority (NSHA) has chosen to operate.

The heads of the NSHA aren’t particularly responsive. For example, in October 2009 I had a meeting with Dr. Lynne Harrigan, who was then vice president of medicine for the Annapolis Valley District Health Authority, now vice president of medicine for the NSHA. At the meeting Dr. Harrigan told me that when the Valley Regional Hospital opened there had been “a double cross in the local medical community” which left most Valley doctors without hospital privileges. Without privileges doctors couldn’t see any hospitalized patients. Doctors were informed, via letter, when one of their patients was admitted to hospital. Eventually, after the patient was released or died, another letter would be sent to the physician noting the discharge/death. Doctors were not necessarily consulted or informed of the care and status of their patients while in hospital.

That “double cross” (her words) happened 15 years previously. This is eight years later and the situation was never rectified. If health executives were genuine in their desire to work with the physician community that would have been one step. We should judge people not just by their words, but their actions.

We are told that doctors don’t want to have solo or rural practices. There has been an argument, advanced by the NSHA, against old-style practices. While most new doctors want a better work-life balance there is currently is no accommodation for medical mavericks who are prepared to go it alone or work in a smaller medical partnership than what Doctors Nova Scotia describe as the “aspirational collaborative care practice model” that the NSHA is set on establishing.

Even on a fee-for-service basis, where the doctor assumes the risk of establishing their practice in under-serviced areas – assuming any physician wants to go to such a place – the NSHA prevents it. Technically, they don’t. They don’t say a doctor can’t open in a Wedgeport, however, they won’t “credential” the physician. This is a clever way to control where and how doctors practice. NSHA have seen other provinces lose court cases over limiting where physicians practice. So the NSHA doesn’t say you can’t practice here, instead it withholds these credentials, which means a doctor can’t order lab tests, can’t access diagnostic imaging or write prescriptions. In essence, without these no medical doctor can make a living. (A psychiatrist can.) This is the impediment to practice and it could be changed instantly on Janet Knox’s or Lynne Harrigan’s say so. It does not require NSHA board approval, a change in legislation or consultation with the College of Physicians and Surgeons.

One Nova Scotian physician told me the idea that no one wants a solo practice “is a lie”. A medical student has written this site to say that the idea of solo practice isn’t even mentioned in medical school. Those are two issues to be addressed.

It all comes down to whose definition of collaboration you use. A little respect wouldn’t be amiss.

I’m told of a fall meeting called by the NSHA where a group of doctors were told, “you people are fat cats who think you know it all. You’re a bunch of elitists who are out of touch.”

Another comment was that a particular senior NSHA manager is “somebody who could make peaceful monks want to hurt each other. He’s got this way of communicating that gets everybody on edge.” At a meeting attended by 100 physicians, a doctor in attendance said, “We were appalled at the way we were spoken to. We were first told this was to be an ‘engagement meeting’ where we were going to develop community-based solutions in collaborative care. Essentially, he (the NSHA manager) put up a list and said this, this and this is going to happen. Take a look at the document given to you.” The engagement was another top-down edict from NSHA to doctors. It was to give cover for decisions made by those who don’t engage with front-line care.

We shouldn’t be surprised by this one-sidedness. In 2011 the IWK stupidly posted on their website that they no longer were recording complaints as criticism, but instead would consider it “feedback”. I wrote about it here:

Last year a doctor told me of a “consultation” between the NSHA VP and a group of Halifax specialists. This was also supposed to be an opportunity for doctors to speak about their challenges and share ideas. Instead, it was yet another top-down presentation by the NSHA. Doctors were not given an opportunity to speak. It was such a waste of time that one frustrated physician told the NSHA VP to “shut up” and let them speak.

No doubt such events are considered “consultations” by the NSHA executives.

A long-serving health minister is the best hope we have to break through corporate complacency for better care. And happier working conditions for those in the health care system. A long-serving minister will be the bullshit detector. Be angry. But be angry at and disappointed with the right people. Otherwise, no meaningful change will ever come.

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