Staffing Shortages Are Not The Only Challenge Facing Health Care
Posted May 24, 2019
Health care is easily the most complex and most politically charged arm of the provincial government. Nova Scotia has challenges in the adequacy of human resources and how they are organized.
We don’t have enough family physicians and are short in a few specialties. The government has responded by funding more seats at Dalhousie medical school. It takes years to produce additional graduates, but this is an important part of any sustainable strategy.
At the same time, efforts to recruit more foreign doctors continue. The awkward division of labour between the Department of Health and Welfare—which controls pay and recruitment incentives and the health authority, which does the recruiting—does not make this job easier. The uncompetitive pay levels have not been fully addressed.
Newer doctors often have a greater insistence on work-life balance than the ones who are retiring, meaning that more of them are needed to fully replace those who leave.
The number of people searching for a family doctor will eventually shrink but it will be a slow process.
Three factors will increase demand for new nurses. The current population has many who are close to retirement age. Nurses are increasing their role in primary care, an important contribution to alleviating the shortage of family physicians. Plans to free-up hospital inpatient beds will require more nurses for home care and new long-term care facilities.
There are 4,700 licensed practical nurses, and the department feels that the ongoing supply of graduates will meet demand.
There are 10,000 registered nurses (RNs). Serious shortages exist in some areas such as Cape Breton, where out-of-province recruiting may be needed.
There was a small net reduction in the number of licensed RNs in 2018. The current year will be better because universities will be graduating the last class from the former four-year program, as well as a cohort from the new three-year program—a one-time increase of 315 graduates.
As well, the government has provided ongoing funds for about 65 more seats at the universities. The department feels that this should reduce current shortages and support future increases.
There are now 200 nurse practitioners in the province. An increase in funding means that this number can continue to grow as a support to primary care.
Overall, the department feels that the nursing shortages are not large and are being addressed on a continuing basis. The doctor shortage is also being addressed, although painfully slowly.
Most health care professionals work for, or through, the Nova Scotia Health Authority, which began operations in 2015. Managing it may be the toughest job in the province.
There are more than 23,400 employees (not including doctors) located in 145 hospitals, community health centres, and other locations. Successes with patients go largely unreported while system failures often make headlines and occupy a disproportionate share of editorial comments.
The decision to consolidate nine regional health authorities into one was correct. The potential saving in management overhead was never very high and has so far not been fully realized.
But the opportunity to look at service delivery through a province-wide lens can yield enormous benefits, particularly for care from specialists. It never made sense to seek a full roster of specialists in each of the nine regions.
It is now easier to have the different regional hospitals focus on particular programs of care with adequate resources. Any specialty needs a critical mass of doctors to be viable for both patient care and recruiting of talent. Patients can go to whichever hospital has the most readily available resources.
The big advantage of having nine regions was the sense that important decisions about quality of care were being made by people close to their community. That sense did not need to be lost in the change to one authority, but it was.
Authority CEO Janet Knox created a byzantine management structure. Under it, her senior management team included several vice-presidents managing different programs of care such as emergency, cancer, mental health and others.
The senior team operates out of a 6,300 square foot office in Bayers Lake, far from the front lines. It has, inevitably, been labelled Fort Knox by critics.
In addition to programs of care, four of the vice-presidents each oversaw one of the zones into which the province had been divided. This greatly limits front-line decision making and makes it difficult for local leaders to be strong voices in their communities for choices made about care delivery.
In October, Knox announced a new position of Vice President and Chief of Zone Operations. The successful candidate will begin in June.
In theory, this should allow more decisions to be made by people who have frequent firsthand exposure to patient care issues. As currently structured, it will not.
Most of the staff in hospitals, including operating rooms, cancer care, dialysis, emergency, critical care, mental health, and primary care still report through to a vice president at head office.
The right role for head office is to ensure that front line caregivers have the right training, technology, and tools to do their jobs, and to work with the department on long-term planning for facilities and human resources.
The two big challenges for Nova Scotia’s health care system are improving access to primary care and moving inpatients who no longer need hospital care to other locations.
These require having enough health care professionals and an organizational structure that maximizes their ability to contribute. There is progress in staffing, but the current structure is not a platform for success.
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