The biggest determinant in our lives is culture, where we are born, what the environment looks like. But the second biggest determinant is probably governance; good governance or a certain kind of governance makes a huge difference in our lives.
The need for governance exists whenever people come together to accomplish a goal. There are three dimensions to good governance: authority, decision-making and accountability. It is the most important structure to get right, like a house foundation.
On May 13, 2017, we published “Health Solutions,” a paper which examined some of the challenges faced by those trying to reform health care in Nova Scotia.
We did not receive a response from the Nova Scotia Health Authority (NSHA), the Department of Health and Wellness (DHW) or the Minister of Health.
In that paper we made seven recommendations. The second: “The NSHA board of directors needs to be overhauled and reincarnated as a body with content expertise in health and 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.”
With the recent announcement of several changes to the board of the NSHA, it appears that the minister has read George Bernard Shaw: “Those who cannot change their minds cannot change anything.”
For that we are grateful. It is a beginning in a long process to turn the ship around.
We remain hopeful that in time the minister and the new board will look at each of the recommendations/suggestions in the “Health Solutions” paper and see them for what they were intended to be; supports for a health care system that the authors fiercely believe must be reformed.
Health care is not like any other business. It is a dynamic living organism that requires frequent adjustment and spontaneous response. It rarely lends itself to rigid insular thinking as we have witnessed for nearly six years.
People do not naturally embrace change, they need a lot of help. What has been happening in health care across Canada is social change on a grand scale. Nova Scotia is no exception. Government has failed to grasp the challenges but most importantly perhaps, it has failed to appreciate that change agents must be credible and enabled to effect change.
To achieve this, a broad-based, inter-professional clinical advisory group should be regularly consulted to provide meaningful input to the NSHA, its board and the DHW.
This will provide the new board with balance to what may be entrenched thinking within management structures. For example, in the British National Health Service, it is mandatory that management seeks out contrary opinion in order to assure that negative outcomes can be avoided.
The NSHA must develop an outcomes framework. It could be modeled on the work done since the mid-2000s by the National Health Service in the UK (https://www.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.
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. It is encouraging that the Minister of Heath has reinforced the board with individuals who have knowledge of the “business” they are running.
The minister must be mindful of the extra challenges faced by rural residents of this province. It is not clear whether that reality is reflected on the new board but it is encouraging that the new chair has roots in rural Cape Breton.
It is hoped that the new board will look at the management model and consider four functional zones to enable clinical and financial decision-making and priority setting reflecting more closely the unique needs of each region.
Decisions made in Halifax, without a clear understanding of the day-to-day life in Cape Breton (or any other Nova Scotia region) can lead to declining access to quality care and foster community dissatisfaction. Despite what has been advanced by NSHA as regional zones within the current iteration of governance, the lack of effective local decision making remains the single most important barrier to reforming health care in this province.
So to the new chair, I say, despite the difficulties, dissatisfaction is a great starting point, for it is right there that we have the most power, strength, and energy to push change through.
Dr. Robert Martel