Health Care
Posted October 4, 2013
Health Care is a grinder issue.
Voters typically put it at or near the top of their priorities, and politicians strive mightily to say something useful on the topic. They often do more harm than good.
In the lead-up to the last election, the NDP promised to keep rural emergency departments staffed and open 24 hours a day, seven days a week. This turns out to be an enormously unproductive use of resources which are little used during night shifts, and could otherwise be used to improve daytime access to primary care.
Very few emergency department visits to smaller hospitals are for urgent or life-threatening causes, and if they are, the nearest regional hospital is likely to be a better destination.
Fortunately, the government sought advice from Dr. John Ross and has begun establishing Collaborative Emergency Centres which focus on providing timely access to primary care during daytime hours. Many of these cases used to show up in emergency departments.
Too often, political parties feature ideas that are, to put it gently, ill-informed. It is in this light that the various promises should be considered.
Perhaps the starkest example of shallow understanding is this statement from the Liberal platform: “According to the most recent data, 9 out of 10 patients wait 20 months for a knee replacement and 17 months for a hip replacement.”
Actually, that is not what the data tell us. Rather, they say that 9 out of 10 knees were done within 586 days (19.4 months), but that half were done within 143 days and the average has 208 days. None of these are figures to be proud of, but if the Liberals cannot even report today’s data correctly, their estimate of the cost to reach a six month standard (for 9 out of 10 to be completed, a standard not being met in any province) must be viewed as suspect.
More importantly, hip and knee replacements are only two out of almost one hundred procedures that are tracked and regularly reported. By what process was it determined that improving these are more important than, for example, bowel resections, kidney stone surgery, or aneurysm repair?
Likewise, the Progressive Conservatives are proposing to join four other provinces in funding research for liberation therapy (for Multiple Sclerosis) in spite of the available evidence which questions the safety and efficacy of the procedure.
It just does not make sense for politicians to choose favourites among diseases to be treated or procedures to be tried.
Not all of the ideas in the Liberal or PC platforms are bad.
The PCs want to move more straight-forward procedures out of big hospital buildings to less expensive and more accessible spaces, as happens with Scotia Surgery. They also want to expand the scope of pharmacists and prevent the threat of strikes from causing surgeries to be cancelled.
The Liberals want better approaches to Continuing Care and for patients with dementia. Both parties want incentives for doctors to locate in rural areas.
There is no question that we have too many health authorities, with the largest serving more than 12 times as many people as the smallest. Whether two (Liberals), or three (PCs), or some other number is best is hard for a distant observer to know.
They and the NDP want to find other administrative savings. All of them underestimate the problems caused when you gut the middle management level. For example, we already have nurse managers with a hundred or more direct reports. No sensible organization does things this way. It certainly makes it impossible to provide adequate support and oversight, let alone successful change management.
The platforms have lots more for those with the patience to read websites. Some of it is airy and harmless (“Improve community-based decision making,” “stop wasteful spending”).
The NDP platform on health care is commendably brief—expand dental care, provide insulin pumps to kids, and continue developing Collaborative Emergency Centres. It would be great if their intention was to let decisions to be developed and lead by health care professional and senior administrators. But, in practice, they have set new records for meddling and micro-managing decisions that should be made by Health Authorities.
Health care systems are big, complicated operations. They do not benefit from frequent political interference. How well they work will depend heavily on the quality of the senior leadership and the willingness of politicians to let them manage.
This is not to exclude the politicians from the process. But their role should be commissioning and evaluating evidence-based reports from knowledgeable players in the system, such as the one that was provided by Doctor Ross, and giving a green light to proposals they find persuasive. The 2007 Corpus Sanchez report also has lots of good ideas, most of which still have not been acted upon.
When the next government is formed, it should quietly put its health care platform on a shelf. Give a good listen to the leaders within the system. Maybe having four or five health authorities is a better idea. Maybe adding senior leaders will result in better ideas and better implementation.
The next time Nova Scotians vote they will reflect on whether health care has improved or deteriorated, not how we got there.
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