Accountability is an assurance that an individual or an organization will be evaluated on their performance or behaviour related to something for which they are responsible. An organization which follows the principles of accountability; transparency, participation, evaluation and feedback will, according to best practices, be more likely to be successful.
When you hold all employees accountable for doing what they are supposed to do, it breeds trust among individuals and teams. It allows people to count on each other; whether that means meeting deadlines, fulfilling duties, or feeling comfortable enough to approach a co-worker or manager for help.
At its heart, accountability is about a relationship between those responsible for something, and those who have a role in passing judgement on how well that responsibility has been discharged. When accountability works well, it enables a degree of feedback between the government and the public that it serves.
While strong accountability is not a panacea for solving the numerous challenges that government faces in a complex environment, it can improve government. It generates incentives for responsible individuals to act in the interests of the public. Sometimes this means that heads must roll following a major failure, but a healthy system of accountability also promotes improvements in how government works.
It has been nearly a year since de facto “Martial Law” was declared in health care in this province. The first action was to dismiss the health authority’s board of directors and fire the CEO. The Nova Scotia Health Authority was formed on April 1, 2015 as an amalgamation of nine existing regional authorities. Their mission to achieve excellence in health, healing and learning through working together and their vision for healthy people, healthy communities, for generations, have yet to be realized. Their performance was less than stellar because the principles outlined above were ignored or stymied.
The authority was established by legislation and began operations in 2015. The first chair was Steve Parker (2015-2018) followed by Frank van Schaayk (2018-2021). Janet Davidson replaced Mr. van Schaayk after serving as acting CEO of the authority in 2019 when Janet Knox left the position.
Under the Houston government, a reorganization of the administration of health care followed, more aligned with a corporate model in the appointment of lawyer Karen Oldfield as (interim) president and CEO, after she served for more than 18 years as president and CEO of the Halifax Port Authority. Mr. Houston simultaneously appointed Ms. Oldfield as Deputy Minister of Priorities and Planning for the Government of Nova Scotia, a role fundamental to the strategic priorities of the province. She is familiar with government operations given that she served a former Tory premier John Hamm as chief of staff in 1999 but has limited experience in running a large health behemoth. So far her tenure has left something to be desired when it comes to transparency and feedback. Clearly she has a lot work to do to win over her employees and Nova Scotians.
It is not an exaggeration to characterize health care delivery in this province and in Canada as a crisis on the precipice of collapse. So it might be considered justifiable by some to suspend usual processes and oversight in the name of getting the job done in times of crisis. We do it in war and in natural disasters; it is considered good prudent management.
The invocation of the Emergencies Act in February by the federal government is a case in point. What is fundamentally different from our situation in health care is the requirement for civilian oversight after the fact to assure that there has not been an abuse of power. That oversight should be a formalized process with a definite legal framework and timeline in the hands of an independent body. That is what the health authority board was mandated to do.
Mr. Houston and now Mr. Higgs, premiers of neighbouring provinces, have suspended oversight and thus accountability, thereby centralizing powers in the hands of a few who ostensibly report to political masters. Undoubtedly, both these men believe they are acting in the best interest of their constituents but in that zeal to right the sinking ship, there is the risk that they will fail to appreciate that transparency, participation, evaluation and feedback will become casualties.
Politicians become comfortable hearing what they want to hear, hence the phrase echo chamber advice. Most politicians who go down to defeat do so because they lose touch with the broader constituency, focusing instead where they are comforted; on their base. The last election was a good example: Mr. Houston did not win the election in as much as Mr. Rankin lost it.
It is an absolute that extraordinary times require extraordinary measures but at no time is it more important to have those in power surround themselves with content experts who are neither living in an echo chamber nor afraid of speaking truth to power in time of crisis.
When Premier Houston was asked recently when he would change Ms. Oldfield’s interim status; he bristled with annoyance and promptly denigrated critics, doubling down by shaming them for daring to criticize. Undoubtedly, the weight of the many challenges at hand is taking a toll on the premier but unless bridges are built with those critics, the premier’s aggressive and transformative agenda will never be realized.
Change management requires two elements to be successful; one is content experts who are respected by those that they lead and secondly, and perhaps more importantly, champions on the front lines to implement the changes needed. For last two decades we have lacked both and so we are in a mess. The old saying applies, “when you hold a hammer in your hand, everything looks like a nail.”
In these unprecedented times, politicians and bureaucrats need to understand that a nuanced approach is required otherwise they will appear disorganized, confused and misguided.
People are dying waiting for treatment, countless others are suffering. We need immediate action to address critical situations in communities that were promised better. Recently one of my neighbours waited three hours for an ambulance to respond to an urgent appeal for help. The ambulance had to come from Antigonish and then had to return to Antigonish (208 kilometres) because the two nearest health facilities were closed. The patient had sepsis and was admitted. Another young patient injured in an ATV roll-over had to wait for an ambulance to respond from Sydney. We must do better!
We can do better but first we must restore a sense of trust in our system so that both workers and consumers feel their opinions have value. Both need to know that the people managing the system actually do know the business and have experience and training that qualifies them as change managers.
It is discouraging to have four politicians hold a news conference to talk about alternative models of health care delivery, make pronouncements on how they will fix the system without a single content expert at that news conference to assure people that their leaders have consulted with them. On the contrary, there is ample evidence that we got into this mess because politicians had all the answers when they clearly were motivated by political expediency rather than evidence.
Once again, without credibility trust cannot be built. Without trust, no one will go the extra mile. In a crisis, as in war, it is not the usual approach that wins the day, it is the extraordinary effort. We will not find enough of the new nurses and physicians we need to fix this problem in the short term so it behooves everyone to roll up their sleeves as we are in for a very tough five years, likely longer.
The very least the politicians can do is get out of the way while enabling those who know the business do their work. We have to reevaluate the model of care because the current model is broken. When two large urban emergency centres are telling their patrons to stay away, as Moncton and St John have done recently, there is no further proof needed that the system is not coping, and that is before the flu season and the fall COVID-19 surge are upon us.
This is not scaremongering but a reality check that should make citizens demand that our health governance model be transparent, accountable and welcoming of input even from those who are not friendly to the governing establishment.
Dr. Robert Martel
Cap Auguet