“We have had enough and we are not going to take it any more” was the call from the podium on May 7 in Sydney Mines (with the Minister of Health in the audience).
Eighty doctors had signed a declaration requiring immediate response from the Nova Scotia Health Authority (NSHA) and government to stop any further deterioration in healthcare in Cape Breton Regional Municipality. Six hundred 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. In the Strait-Richmond area, the NSHA has refused to consider a proposal from the Community Health Board for improved palliative care services. Recently the Minister of Health and the local MLA have indicted that they are willing to review the need for palliative care in the area after the election. It begs the question who is running the health system?
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-centered, 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. The 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-centered?
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 nine 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 2015-16 Statement of Mandate published by the DHW, the Health Authorities Act established the roles and responsibilities of the department, the newly established NSHA and the Izaak Walton Killam Health Centre (IWK).
The DHW is responsible for providing leadership for the health system by setting the strategic policy direction, priorities and standards for the health system and ensuring accountability for funding and for the measuring and monitoring of health-system performance.
The NSHA and 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 and engaging with the communities they serve, through the community health boards.
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.
After careful thought and soliciting opinion from a broad representation of health care reform interested parties, we have summarized our ideas in seven recommendations. For more detail you can go to: https://drive.google.com/open?id=0BwdmRtHT695ZdmphTW9Vdkg4NlE.
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 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 foundation.
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.
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 Nova Scotia), can lead to declining access to quality care and united community dissatisfaction.
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 advice.
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.
Develop an outcomes framework, modeled on the work done since the mid-2000s by the National Health Service in the United Kingdom (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.
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.
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.
Please read the whole paper: https://drive.google.com/open?id=0BwdmRtHT695ZdmphTW9Vdkg4NlE.
Dr. Ajantha Jayabarathan,
Family Physician, Halifax
Retired Deputy Minister of Health, Chester
Dr. Robert Martel,
Palliative Care, Arichat
Dr. John Ross,
Professor, Dalhousie University, Halifax