Two years after Nova Scotia "de-regionalized" – merged its nine health regions into a single provincial health authority – an informal, blue-ribbon group has offered up a scorching analysis of the exercise.
It concluded that the Nova Scotia Health Authority, which has 23,400 employees and a budget of $2.1-billion, is a "non-system – disconnected, not communicating, non-agile, non-'people-centred' as well as [having] front-line staff and managers who feel helpless and unable to effect the changes they know have to happen."
That is, sadly, a description that applies to many provincial and regional health administrative bodies around the country.
In fact, the small group that wrote this cri de coeur – including former deputy health minister Kevin McNamara, emergency doctor John Ross, geriatric psychiatrist Jeanne Ferguson, palliative-care specialist Robert Martel and family physician Dr. Ajantha Jayabarathan – serve up a timely reminder that virtually all the problems in our health-care system are engineering and administrative failings, not failures of medical care.
Mercifully, they do not suggest the classic Canadian solution of throwing more bodies into a mismanaged system but, rather, call for the system to be better structured and managed so we can allow the health professionals we have to do their work unencumbered by seemingly never-ending bureaucratic hurdles.
This is a knowledgeable quintet and they have good ideas. While the solutions are specific to Nova Scotia, again, the advice would be well-heeded in all regions of the country.
In their short report, they make seven recommendations, including:
- The body (or bodies) that oversee health delivery – be it the NSHA or otherwise – should operate independently, at arm’s length from the government. In every province and territory, there is too much political interference and micromanagement and, as in Nova Scotia, decisions are too often vetted by the Premier’s office;
- Governance matters. The board of directors and senior managers need to have authority, decision-making power and be accountable and transparent. The role of elected officials is to set broad objectives and benchmarks; then they should get out of the way and let the system be managed by professional managers who are, in the authors’ words, “agile, competent, aggressive, anticipatory, and guided by the mantra ‘think globally, act locally.’”
- Have an element of regional autonomy. Almost every province has alternated between centralized and decentralized structures. The enduring lesson from these experiments is we need a bit of both: Some things, such as payroll and purchasing, are best done centrally, but there has to be an ability to deliver care in a way that is adapted to local needs. Patients in Cape Breton do not have the same needs and wants as those in Halifax, so a one-size-fits-all approach doesn’t work;
- There needs to be checks and balances both within and outside the system. The Nova Scotia report suggests an interprofessional clinical advisory group to tap into the knowledge of providers. It is essential that patients have a strong voice, too, one that extends well beyond having token seats on committees;
- Measurement matters: You need to have frameworks and clear-headed analyses of changes that are made to figure out what works and doesn’t work. Rather than one-off, pilot projects – another Canadian favourite – there should be a process of continuous improvement and scaling up successful innovations.
"People do not naturally embrace change," the authors of the report note. That is especially true of the bureaucracy, because our system tends to discourage risk-taking and rewards inertia.
Patients and taxpayers have a role to play here, too: They have to be less tolerant of mediocre access to care and expect more value for money for their tax dollars.
The defining feature of the system is waiting. That's pathetic. And, for the amount of money we spend on health care, it's unacceptable.
Still, when you're in the right place at the right time in the Canadian health system, you get superb care.
But the journey in, around and out of the health system is far too often long, convoluted and disorganized.
We need to re-engineer the system, and one key element of the modernization needs to be better management. We need to spend a lot less time and money rejigging the organizational flow chart and focus on patient flow through the system.
Ultimately, it doesn't matter if there is one, four or nine regions if there are no clear lines of authority, no accountability and no laser-sharp goals for improving patient care, individually and collectively.
André Picard