Nova Scotia tried decentralized health care: it didn’t work

August 2, 2021 – During the 1993 federal election campaign, Prime Minister Kim Campbell said that a 47-day campaign was not long enough to discuss the changes she envisioned. This was shortened to the infamous: “An election is no time to discuss serious issues”.

With Campbell’s candour in mind, I was disappointed to read Jim Vibert’s piece in the July 24thChronicle Herald where the leader of the Progressive Conservative party promoted the return to de-centralized health authority.

Having interviewed PC leader Tim Houston Vibert writes, “They [the PC Party] don’t like the Nova Scotia Health Authority and want more decision-making decentralized to the regions and communities that know their health-care priorities better than bureaucrats in Halifax. That does sound right.”

Sounding right and being right are not the same thing. Nova Scotia has been there, done that and it didn’t work.

While it sounds reasonable, this is a spreadsheet solution that doesn’t factor in human nature. Spreadsheets have been the downfall in provincial health care because people muddy up theory.

Memory is selective, which coupled with current anger and disappointment, clouds the history of failure with our past. Nova Scotia had a decentralized health care system, which was so piss poor that the 2013 provincial election was fought on the idea of a centralized health care system, which was more streamlined and less bureaucratic. That election sent the NDP to defeat and the Liberals to a majority.

Prior to 2013 Nova Scotia had nine district health authorities plus the IWK. In the easy fantasy world of ‘things-were-better-then’ some people believe health care was better when health care was left to these nine sets of local executives to administer. I suggest anyone who thinks that didn’t need or experience health care at the time.

Here’s what happened when we had nine local health authorities:

1.    We had an army of executives duplicating the work across the province. The idea behind a provincial health authority was to streamline the process, reduce duplication, have fewer high-paid executives and funnel more money to front-line patient care. The failure was we built a new system and put old thinkers in charge. Old thinkers brought up from the regions.

2.    Nine health authorities competed for money and staff. It was unfair to smaller, rural places because larger population areas as well as those authorities run by executives who were better connected, got Halifax’s attention.

3.    There was uneven service and access to care between the various health authorities.

4.    Separate health authorities added to wait times because there was no coordination for resources. We had numerous under-utilized assets. Patient care was to be delivered within 100 kms of the person’s home. If a specialist lived outside that catchment area patients couldn’t automatically be referred. Secondly, while surgical wait lists grew, a number of operating rooms across the province were dark. Pictou lost their surgeon and his GP wife when in frustration he left the province because he couldn’t get OR time. The reason for this? It was a budget-stretching device by the local health authority. The operating rooms in Amherst were another under-utilized asset. Once the NSHA was functioning hip and knee patients across the province were given the choice of waiting up to 24 months for care at home or travelling to get surgery within two weeks.

5.    Physician and specialist loss. I detail the losses in this June 2016 post: https://helphealthcare.wordpress.com/2016/06/13/a-quick-scorecard-for-physician-loss

6.    Unhappy employees. When surveyed, 52 percent of front line health care workers (doctors, nurses, specialists and others) distrusted their employers. Working conditions were so bad that a surgeon told me the head of their health authority “was so stupid they lowered the IQ of any room they entered.” See this 2013 post for details: https://helphealthcare.wordpress.com/2016/06/13/a-quick-scorecard-for-physician-loss/

7.    Slower delivery of care. Because each health authority was a kingdom until themselves, it was a challenge to get care in another authority. There may have been a process in place, but the reality was a series of frustrating – sometimes fatal – delays in getting the right help.

8.    Cronyism. Local board members told me they weren’t heard or listened to. Local boards were populated with friends of the executives, who oversaw the appointment process. Several board members from different health authorities told me they often felt bullied, silenced, disregarded, dismissed and ignored. 

9.    Hidden failure. Because of the multitude of regional health districts it was easier to hide failure of care. Patient families were often told they didn’t understand the situation or that it was an one-off. But with a province-wide health authority we could begin to see systemic problems, like the proliferation of bed sores across a wide spectrum of facilities. We also saw uneven sanitization and ambulance wait times.

10. Lack of purchasing power. A centralized purchasing department can achieve efficiencies of scale in pricing not available to smaller organizations. Plus, given shortages of certain drugs and treatment materials, a larger buying organization has more sway with suppliers.

Nova Scotia has done well during the COVID-19 pandemic. How would we have acted if we also had to coordinate our responses, reporting, testing, treatment and vaccinations between 10 separate health districts? A centralized system – as imperfect as it is – managed to do better than other provinces, states and nations.

Reorganizing the delivery of health care in Nova Scotia away from a centralized authority to regional bodies is a two-year process, which would divert hundreds of millions of dollars from patient care to a system which does not guarantee better health.

 

 

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2 Responses to Nova Scotia tried decentralized health care: it didn’t work

  1. peter l loveridge says:

    Allan, with respect I have to disagree.

    The Valley regional board was, indeed the most inefficient and badly governed district board in the province. You have written about its many failings. The consolidation was supposed to save money. It managed to increase the # of $100k / year executives from 800 ( too damned many) to 2700 (obscene), so that now we have the most expensive administration in the entire country. We have people dying while waiting for ambulances. We have waits for over a year to get an MRI, or an appointment with many specialists. 71000 patients have no family doc, and the real number could well be over 100k. In Yarmouth we have had a net loss of docs, which has accelerated under NSHA. This month we lose our 2 pediatricians, we are down to a single Ob/Gyn., you cannot get a FD appointment for weeks or months, and the hospitalist program is precarious at best, as is the obstetric program.

    30 years ago we had orthopedics, urology and public health on site. Now these are run out of Kentville, and the orthopedic service can only be described as terrible. Psychiatry is a disaster, and not only here. ERs in the 2 community hospitals in our district are closed seemingly more often than they are open.

    You mention cronyism, but what were the original appointments of vice presidents but this. I know one of the original vice presidents well since her childhood. She was appointed to a $300k job without having worked even an hour in health care. In her previous gig she presided over a $120 million fraud in the immigrant entrepreneur program. Most of the others were no more qualified. No-one in the NSHA ever responds to feedback, letters and emails are not acknowledged, let alone acted upon. Do you really think some desk walla in Kentville should be telling people in Yarmouth and Bridgewater how to run appointment for lab and imaging?

    Even worse is the culture of bullying any dissenters practiced by the NSHA, the cases of Rob Miller and Chris Milburn being prime examples. No, the NSHA is not an example of how to run a health care system. In my nearly 50 years of practice in this province it is by far the worst we have ever had. The sooner it is gone, the better

    • As I said, we developed a new structure and put old thinkers in charge. The moment the executive was announced we knew the outcome. It was about optics. The reorganization was such a dramatic change the government health advisors suggested it would be moderated by using a familiar face. We should have gone outside the province.

      We are over-executived, always have been and will be until we get a government and board with balls. We need to introduce performance standards for health care and the individual executives. Until then we will continue to have more pencil pushers than patient-seers.

      Health care however it is modelled will be hellish so long as the board is filled with cheerleaders. I don’t see anyone on the NSHA board who has actually experienced health care in Nova Scotia. They might have had a minor ache or pain, but not been a patient or had someone in care to understand the screw ups or issues.

      As soon as the election is over I have other ideas to share on how to improve the delivery of health care. But the political opportunism of a campaign makes ideas and promises worthless. Usually it’s throwing more money at the issue without any real understanding of how money is spent. If it’s a good idea presented by a defeated party, it’s lost because the winning party doesn’t want to look like it had no ideas of its own.

      I have been silent during the pandemic because that was a priority for all of us. However, the simplistic solutions and concept that things-were-better-when presented during the campaign are offensive to the truth and a workable solution.

      I doubt 71,000 Nova Scotians are without a doctor. I think the number is in excess of 100,000.

      I wonder if the ER situation would improve if there was a universal rate of pay for ER doctors vs the three-tiered rate we currently have. As for nursing shortages, we didn’t seem to have them when we had teaching hospitals. But perhaps I was too young and too healthy to notice. Growing up in Kentville, the BFM Hospital and NS Sanatorium were both teaching facilities with on-site nurses’ quarters. Students saw patients during their education. Now an RN arrives at work without ever having had to deal with a patient. They have such debt that it’s more attractive to go into management with higher pay, no shifts and regular hours.

      Whatever happened to Nurse Practitioners? They were always in the news, then disappeared.

      I have been silent, but I have been thinking about what can, should and must be done.

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