The picture of health care painted by the recent cartoon “Welcome to sa国际传媒: Just Don’t Get Sick,” combined with the discussion of the challenges for sa国际传媒’s nurses and the tragic advertisement by the family of an 82-year-old seeking someone — anyone — to prescribe his ongoing medication, even for a fee, is not the health care that Tommy Douglas wished.
Blaming COVID for these problems is easy but wrong. They have developed over decades while being ignored by those who should have paid attention.
In 2003, 437,000 people in sa国际传媒 had no family doctor: by 2017 it doubled to 897,000. Hospital beds in sa国际传媒 dropped from 3.7 per 1,000 population in 2000 to 2.5 in 2019, with the increase in pressure on the bedside staff discounted.
Burnout and disenchantment was the result, even before the crisis. Nurses fled the profession, and the national shortage is now 60,000. sa国际传媒 has the lowest physician-to-population ratio in the First World. Such developments did not happen overnight, but no one did anything.
Many suggestions have been made to fix the crisis. Unfortunately, most focus on one only part of the problem.
Private insurance, by itself, will not reduce the shortages tomorrow. Setting up Urgent and Primary Care clinics doesn’t add any more to the current stock of community practitioners; it just reshuffles them. Likewise transferring GPs from fee-for-service to salary.
Done correctly, such changes may make life more livable, with reduced burnout, but care must be taken to ensure such groups have clinical leadership whom their members respect. Plans to fix the family doctor scarcity with nurse practitioners, while short 60,000 nurses, beg the question — where will they come from: Experienced, competent nurses already working in the system or new graduates with little clinical experience?
Adding university seats for doctors, nurses, and other clinical groups is necessary, but it is a government elected in 2030 or 2032 that will see the results. Do we have all-legislature support, or will political priorities change by then?
Quality learning positions in health-care institutions must accompany those university seats. Doctoring and nursing are not just getting university degrees but learning a craft that requires supervised practice in good clinical settings. Health authorities, unions, legal advisers and insurers must all face a different, more active role for junior doctors and junior nurses. Most students will welcome the opportunity.
The reason each suggestion addresses only one aspect of the problem is that no one group has overall responsibility for organizing a system of care.
Who is accountable for the current mess? Not the Ministry of Health: They will say they fund programs but don’t provide services. Their mandate letter to Island Health says that the board is accountable, but the board has no jurisdiction over community medical services.
The letter lists 43 (!) managerial actions to be taken, but doesn’t anywhere say: “Make sure everyone gets good health care, or if you can’t, tell us why.”
In sa国际传媒, and elsewhere, appointees to health authority boards are usually well-intentioned people with political and cultural alignment to the party in power, but no specific skills or knowledge of health care. No practising doctors or nurses need apply. We wouldn’t run a banking or engineering firm like this.
What about the other professional organizations? The College of Physicians and Surgeons has withdrawn into a role of checking qualifications and dealing with conduct infractions or physician illness by assessing penalties — necessary, but just like driver licensing.
Working for a healthy workforce, healthy practice conditions, good team practices and practitioners who are not isolated but supported should be their function. Previous governments and the medical association, by colluding over fee schedules for many years, have brought about the enormous income differences that are partly triggering this crisis. Nursing organizations focus on professional status or money.
Neither nursing nor medical organizations get together to say what good clinical care should be — so who does? Who speaks on behalf of patient clinical needs?
The fundamental problem is that no one with up-to-date clinical content knowledge is in a position to say what needs to be done. This is true both provincially and nationally. Health-care administration has become a bureaucratic system beholden to political masters who change every couple of years or more, sa国际传媒 being a recent outlier with Health Minister Adrian Dix.
Each political change usually brings a different approach, eliminating any longer-term planning. Tommy Douglas’s public administration has become political administration. Good administration is essential for any organization, but clinical knowledge is needed to say what health care should be doing, now and in the future.
A store cannot be successfully run by HR and accounting personnel only, with no merchandising experience, a credit union by people with no banking experience, an engineering or accounting firm without active engineers or accountants in governance. So why do we expect any difference in health care?
The governance role of identifying what we should be doing is separate from the management role of administering it. This separation works well in Europe and even the U.S., where Kaiser Permanente brings prepaid health-care services to more than 12.6 million people using separate medical governance and managerial structures.
In sa国际传媒, if our COVID experience was better than others, it was due to using a similar structure: Knowledgeable clinical decision-making about what should be done, coupled then with strong political and administrative support.
Similar principles must be used to reduce this mess. We need a governance body that is independent, with good clinical knowledge to identify the present and future needs of the health-care system.
We need thoughtful advice about what to do in the short term as well as setting clear and measurable clinical goals for the longer term. We need management to transparently work to these goals, to hold them accountable if they don’t succeed or have them openly tell us why.
This model saved lives during the emergency caused by a virus. It works in other environments. It is time to use it to save the health of the rest of our relatives, friends and ourselves.
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