When it comes to health and social services in New Brunswick there are several realities:
- Transfer payments are declining by virtue of federal directive;
- The prospect of the province balancing its budget in the near term are dismal at best;
- The health system does not perform well on a number of fronts by comparison with other developed countries;
- Resources are, by all measures, more than adequate to provide great service;
- The Department of Health budget is balanced this year and the government has initiated a number of measures to conserve expenditures;
- An extraordinarily large proportion of frail elders occupy acute beds which is neither good care nor a fiscally wise strategy.
- There are issues of public confidence in the quality and effectiveness of service at a number of key areas.
If I were premier and did not have to be concerned with re-election and just wanted to redesign the system so that quality improves significantly, access is improved remarkably and effectiveness improves measurably, there are five policy changes that I would instigate:
Primary care reform
In collaboration with the New Brunswick Medical Society and several other key professional groups, I would accelerate the process of primary care reform. I would replicate the Sault Ste. Marie, Ont. and Tabor, Alta. models in Fredericton, Moncton, Saint John, Edmundston, Bathurst, Miramichi with smaller versions in every rural community.
Physicians are currently the gatekeepers to essential diagnostic and therapeutic interventions. All too many people either have no access to a family doctor or have their clinical condition come to diagnostic finality all too late.
Much of the traffic to after-hours clinics and family doctors offices could be managed by a good primary care clinic or an urgicentre, in which sound organizational principles are employed.
This is really the key to much of what is not working well in the system: we have great, well-trained professionals; the problem is one of organization and financing models. Primary care services for frail seniors is particularly disjointed and inefficient; just following a frail elder through the process is exhausting.
'True rural health-care plan'
New Brunswick needs to create a true rural health-care plan that would require the clinical staff in larger centres to play a facilitating role, not a passive role. In this plan, I would redefine what we call “hospitals”, leaving small communities with geriatric facilities with enhanced community health centres attached; the long term care and community health centre staff would be integrated into a coherent health-care team.
Properly done, health-care services in rural areas can be improved while removing what the public refer to as emergency departments and hospitals. Other models exist in Canada and we need to learn. Part of the plan will involve engaging advanced trained paramedics as is done in other jurisdictions.
A succession of governments have struggled to create a plan; all too often these plans are directed by people who seem to have had no prior experience in dealing with successfully administering a good rural health program.
Focus on culture and leadership
The constant negativism that has engulfed health care is creating an environment in which mediocrity is too often accepted, excuses are too often accepted and professional pride and pride of performance is compromised.
It is a truism that without vision the people perish; yet it is possible to downsize, restructure and move forward but it cannot be done without clear vision, strong leadership at many levels within the organization.
Clinical leadership, in particular, needs a great deal of investment and cultivation. There are many great resources available and many great models to emulate.
Establish the New Brunswick Health Council to become a source of independent, non-partisan oversight on the operations of the health system, providing independent advice on technology diffusion, organizational effectiveness, benchmarking, quality assessment.
Create centres of excellence
I would create centres of excellence and, in the process, consolidate technology. It is not possible to maintain quality of service without very tight management and oversight of technology and its use.
'It is not wise or prudent to try to run surgical facilities scattered throughout the province. A critical mass of a minimum of four specialists are required in order to maintain quality that is competitive in today’s climate.' - Ken McGeorge
Centres, such as Lahey, Ford, Mayo, Cleveland, IWK, Sick Kids, MNI, do not become excellent by accident. There are some key principles that must be followed.
It is not wise or prudent to try to run surgical facilities scattered throughout the province. A critical mass of a minimum of four specialists are required in order to maintain quality that is competitive in today’s climate. If the truth were ever known, there are many cases of missed or seriously delayed diagnosis and treatment owing to inappropriate focus on proper clinical investigation.
There should be three to five Clinical Investigation Units established as part of a re-organization, in which patients with obscure diagnoses would have their cases subjected to multi-disciplinary investigation.
Merge the departments of Health and Social Development
I would also merge the departments of Health and Social Development and give the new department a clear mandate to make the system work. In that process, a true commitment to Lean Six Sigma must be used and applied on the key strategic issues that matter.
New Brunswick is the only province in Canada where health and social services are in separate departments. New Brunswick is also the province that has the highest proportion of acute beds occupied by patients classified as alternate level of care (ALC). There is no real communication between Health and Social Development in the areas that are important to the issues of Home First, ALCs, nursing home admissions and such.
An integrated department needs to be led by people who have enjoyed success in leadership and change management in the health and social services field or in a related field. Both departments have experienced significant restructuring in recent years, in some cases engaging in strategies wherein the logic is not clear.
Both departments have had significant workplace issues often not necessarily recognized by those in authority. Actually, an external review would be very helpful and there may be some information coming that will be helpful from the current Ernst and Young study. Some of the principles used in the Ford Motor Company restructuring should be explored if not adopted.
Erosion of public confidence
The continual focus on cutting staff, cutting bureaucrats, cutting fat is leading to an array of services in which public confidence is being eroded.
The current fiscal issues and growth of the “greying population” have been forecast for 30 years with limited appropriate response and leadership. Government and the many interest groups need to take a deep breath, take a time out, and re-align the system, not just cut it.
It is possible to restructure, downsize, and re-align services while improving quality at the same time. But it requires leadership and vision.