Nova Scotia Healthcare Solutions Paper – A Start

 

The reset button needs to be pushed at the Nova Scotia Health Authority (NSHA).

“We have had enough and we are not going to take it any more” was the call from the podium on Sunday afternoon in Sydney Mines (with the Minister of Health in the audience). 80 doctors had signed a declaration requiring immediate response from the NSHA and government to stop any further deterioration in healthcare in Cape Breton Regional Municipality. 600 local residents showed up in support. Note that doctors presented essentially the same message about Cape Breton health care services one year ago in a similar forum to the same audience imploring the NSHA’s management to act. It is no wonder people are frustrated with the current situation.

There are a rapidly growing number of cases, both published in the media and shared privately about the non-system – disconnected, not communicating, non-agile, non-‘people-centred’ as well as front-line staff and managers who feel helpless and unable to effect the changes that they know have to happen.

The NSHA has quickly become a bureaucratic non–system which cannot respond quickly on behalf of dying or very ill people. Instead timely decisions are lost in complicated and irrational top down program bureaucracies. Department of Health and Wellness (DHW) goal of less administration has actually resulted in far greater confusion and more layers of approvals. The NSHA expects patients to fit its distribution of services, policies, and procedures, without explaining the rationale, or adequately involving patients and providers in the planning, implementation, and review.   How is this patient-centred?

Our aging population, and its impact on healthcare resources, has been anticipated for the last 30-40 years. It is extraordinary that we are so unprepared for this natural evolution when every other sector of the economy has seen it coming and has changed. Our growing lack of confidence has contributed to significant doubt in the ability of the DHW to manage our health system effectively.

How is it possible that the NSHA and DHW say they are coping well when patients’, families’, and front-line providers’ day-to-day real experiences are poorly managed? Most communication is reactive damage control instead of proactive and inclusive. Without truth, there is no trust; without trust there is no meaningful relationship; without meaningful relationships there is no path to change.

Collapsing the 9 district health boards into the NHSA while balancing the provincial budget were election promises of the Liberal government. Both goals have been achieved with considerable fanfare. But what is the cost – short and long term?

In the 2015-2016 Statement of Mandate published by the DHW, The Health Authorities Act established the roles and responsibilities of the Department, the newly established Nova Scotia Health Authority (NSHA) and the Izaak Walton Killam Health Centre (IWK).

DHW is responsible for:

  • providing leadership for the health system by setting the strategic policy direction, priorities and standards for the health
  • ensuring accountability for funding and for the measuring and monitoring of health- system

The NSHA & IWK are responsible for:

  • governing, managing and providing health services in the Province and implementing the strategic direction set out in the provincial health plan
  • Engaging with the communities they serve, through the community health

It is the last point where the NSHA has failed.

Positive and exemplary work done by previous governments has effectively been structurally dismantled within DHW. As a consequence data on which pivotal decisions were made is now out of date because critical human resources and accurate data sets are not available within the DHW. One of the consequences is medical and nursing human resource planning which has not kept up with demand. This has led to reduced access to timely patient-care.

Recommendations:

  1. Politicians do not have in depth knowledge about health care and should not be expected to provide solutions to complex, interconnected processes within the health care system. The public knows this. It appears that political interference in the day-to- day operation of healthcare in Nova Scotia is far too frequent. People within the NSHA report that many decisions must be vetted by the premier’s office. If true it questions the very reason the NSHA was created to be an arms’ length independent body. Furthermore, why are politicians announcing the creation of health centres, dialysis units, and changes in service modeling when the NSHA is supposed to be managing routine healthcare delivery? Stop the political interference in healthcare

 

  1. GOVERNANCE: The need for governance exists whenever a group of people come together to accomplish a goal. There are three dimensions – authority, decision-making, and accountability. It is the most important structure to get right, like a house

 

In 2016, the NSHA was responsible for the allocation of $2.074 billion and management of 23,400 employees. In addition, physicians and myriad other variables must be aligned in a common vision and mission – safe, high quality patient care.

 

Good governance starts with a strong, representative Board of Governors. It is ultimately responsible and accountable for ensuring timely, equitable delivery of care. It does so by hiring the Chief Executive Officer (CEO), vetting the senior leadership team, overseeing operational governance and ensuring sound quality of care and fiscal policies. The present NSHA Board is invisible to the public to whom it is ultimately responsible.

Meetings are not open. What is discussed is not available. They do not represent a broad section of Nova Scotians. There is no current healthcare expertise. Board members are all very well connected and unlikely to experience the same healthcare non-system challenges that the average person must navigate. Problematic is the fact that the current board was not involved in choosing or vetting the senior management team of the NSHA.

In contrast, the IWK Board of Governance has had representation from nursing, medicine and the broader public for decades.

The 2016 NSHA organizational structure runs over eight pages of microscopic font. It appears to be a spaghetti of overlapping, top heavy roles. Job One for a new government is to build a new governance structure based on current and future reality. Meaningful input from the public is critical to informed decision making and to align the vision of governance with real-people experiences and actual service delivery.

Physicians, nurses and allied health workers on the front line know a lot about  healthcare but are left out of the decision tree. That needs to change immediately. In small countries like Sweden and the Netherlands, centralizing decision making in health care failed as a strategy. Nova Scotia is a small province with less than a million people. It compares well to Sweden and the Netherlands in geography. They have returned to a decentralized operational model where local people make the decisions based on national objectives and benchmarks. They have recognized that a “one size fits all approach” does not work. Management has to be agile, competent, aggressive, anticipatory and guided by the mantra, “think globally but act locally.” It must be held accountable for decisions. We do not have to re-invent the wheel in Nova Scotia.

The Board of Directors needs to be overhauled and reincarnated as a body with content expertise in health, real public representation, and with an accountability framework where maintaining the health and productivity of the population is the focus. It should open its regular meetings and post meeting minutes for the taxpaying public.

 

  1. Four functional zones should be created immediately to enable clinical decision making closer to the unique needs of each region. If the rally on Sunday May 7 has taught us anything, it is that decisions made in Halifax, without a clear understanding of the day-to- day life in Cape Breton (or any other region in NS) can lead to declining access to quality care and united community

 

  • Every attempt should be made to assure that all Nova Scotians get the same access to evidenced-based healthcare regardless of
  • Leverage purchasing power and standardization of medical equipment by streamlining procurement and supply management
  • Centralize some functions of human resource management, such as payroll and collective bargaining, but enable zones to match patient needs with available human resources, allowing local problem solving, combinations of health professions and scopes of practice.

 

  1. A broad based inter-professional clinical advisory group should be regularly consulted to provide meaningful input to the NSHA, its board of directors and the DHW. This would provide a check and balance in large public organizations like the NSHA. It also creates a group that has expertise in providing overall system-level

 

  1. Emergency plans to address access-block need to be developed within six to nine months in each zone. The plans should not be a one size fits all solution but rather community and zone specific. Each zone has different priorities of health needs and different mixes of health professionals. Collaborations and sharing of resources – people, equipment, facilities, will need to be considered. For a time, extra resources may need to be committed to a specific zone to address priorities identified by that zone. The plans should focus on:

 

  • Access to primary care – physician and non-physician. While ‘collaborative care teams’ may be appropriate in some jurisdictions, the NSHA must be open to a wide variety of primary care options that address local patient needs, achieve expected health outcomes, and are fiscally responsible. Again – one size DOES NOT fit all. Each zone should identify their current inventory of primary care services.
  • Access to home care, temporary respite, and long term care. What creative options are there in communities? This is a critical need today that is
  • Access to joint replacement – first start with rapid access to initial assessment – who really needs surgery? For example, a multidisciplinary mobile unit could assess and triage patients to identify those better served by supervised weight loss and/or physical conditioning. For surgical candidates – condition patients pre- and post-op to maximize surgical outcomes. NS is leading the country in some of our wait list times. We must think out of the box to address this
  • Access to timely emergency care – how will that be assured using present assets, both fixed and mobile and available human resources?

 

  1. Develop an outcomes framework, modeled on the work done since the mid-2000’s by the National Health Service in the UK (https://gov.uk/government/publications/nhs-

outcomes-framework-2016-to-2017) It is critical to evaluate what works and what doesn’t so we can continuously improve over time.

 

  1. People do not naturally embrace change – they need a lot of help. What has been happening in healthcare across Canada is social change on a grand scale. Nova Scotia is no exception. We need far more complex system design and function experts. The NSHA should incorporate industrial engineers where daily front-line decisions are being made. In 2017, patient care requires continuous patient flow through a complicated system. Furthermore, psychologists should be part of HR departments and should be included in all change-management processes. Healthcare into the future will require continuous change, just as technology, work, and social structures are rapidly changing around us. We must continue to adapt. Changing health care is really an experience in social engineering. Inspired competent leaders look to where others have done this well, and ask for help. Physicians and nurses know a lot about health but not much about complex change management strategies. Clearly the NSHA leaders do not know much about it

 

We recognize that we do not have all the answers but we do have something to contribute to the dialogue. We believe passionately in our province. We see a robust health care delivery system as a key plank to realizing prosperity in this province. We ask for your help to make that happen. This paper is a start in an iterative process. We need LOTS of input, additions, and adjustments from everyone, not just healthcare ‘experts.’ We are all affected. We must all contribute. All opinions are valued.

 

Dr. Ajantha Jayabarathan, Family Physician, Halifax, NS solutionpaperns.@gmail.com

Mr. Kevin McNamara, Retired Deputy Minister of Health, Chester, NS

Dr. Robert Martel, Palliative Care, Arichat, NS

Dr. John Ross, Professor, Dalhousie University, Halifax, NS

3 thoughts on “Nova Scotia Healthcare Solutions Paper – A Start”

  1. Thank you for this very timely notice to the public. Saskatchewan has touted NS as the best example of the benefits of consolidation and centralization of health care administration. I hope fervently that our leaders here – and I mean our politicians – will grant both administrators and physicians the permission and the means to do our jobs better, as we so much wish to do.

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    1. Thank you for your feedback, Dr.Friesen. There has been a groundswell as people and healthcare providers alike have risen up and presented the problems created by the amalgamation process as well as the problems ignored, and its disastrous effects on people and the morale of doctors and other front line healthcare providers in the province.

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