Health care is a very difficult topic for governments
Posted September 8, 2017
Health is a leading area of importance to voters, but politicians are experts neither in healthcare nor in organizational design. So political interference usually does more harm than good.
That does not diminish the accountability of the government.
The Liberals’ decision to amalgamate all health care boards, other than the IWK, was a good one. The touted benefit of reduced executive management costs is the least important advantage of the Nova Scotia Health Authority (NSHA).
More important is the ability to:
- insist that the most effective practices among the previous nine regions be implemented across all the others,
- direct patients awaiting non-urgent procedures to whichever facility in the province, within reasonable distance, has the shortest waiting list, and
- plan for staff and facilities on a province-wide basis. This has enabled thinking about how to replace the services provided at the Victoria General to extend well beyond downtown Halifax.
Although costs are pressured by both inflation and the aging population, the NSHA operated with no year-over-year spending increase. There has been real progress in establishing home care as the preferred alternative. Waiting lists for it have been reduced 97%. Wait lists for nursing homes have been reduced by 56%.
The elephant in the room is primary care.
The preferred, but not exclusive, method for delivery is collaborative care centres that include one or more doctors and a number of other health care professionals. These avoid the gaps in service that can occur when a sole practitioner is ill, on vacation, or retires. The diversity of skills allows for better and more cost-effective care.
Sometimes these operate in a broader version, called a Collaborative Emergency Centre, which includes elementary emergency care during daytime hours; overnight staffing does not include a physician.
CEO Janet Knox, in her speech to the Annual General Meeting acknowledged that primary care is a priority:
“We are building new and strengthening existing family practice teams across Nova Scotia. This year we added 23 new nurse practitioners and family practice nurses in 14 practices… In the past year, Nova Scotia welcomed 43 family doctors and 68 specialists. And nearly 70 more are scheduled to start in the next 6 months.”
The difficulty is that we have no idea whether that is more, less, or the same as what is needed. Nor are we told what the goals are for the coming year.
The Liberals have committed to expand or create more than 70 collaborative teams, but have further muddied the waters by letting physicians decide whether to join one of those or have a different kind of practice.
Neither the NSHA nor the government has communicated clearly. It would help to start by acknowledging some hard truths:
- Family physicians are a scarce resource. It is not cost effective to have them doing overnight shifts at smaller hospitals so that the occasional patient needing urgent or emergency care can be accommodated.
Stop pretending that they can provide care for real emergencies all night.
- The proposed changes to tax treatment of small businesses will hurt doctors a lot. Government will have to break from its formula for public sector workers to create a pay scale that will attract and retain family physicians. Encourage participation in collaborative care centres by paying more to doctors who work there.
- Nova Scotia has 1,352 family medicine/general practice doctors according to the Canadian Medical Association. That is about 15% more per capita than the Canadian average. As in every other province, there are nevertheless many Nova Scotians without a family doctor. Some don’t feel the need for one.
The right measure is that everyone should have access to primary care when they need it, not that everyone should have a family physician.
So far, the news is dominated by anecdotes of doctor shortages or other problems with delivery of care. Patients do not understand the difference between the two kinds of collaborative care centres, walk-in clinics, small hospital emergency departments, or other arrangements. Consulting the NSHA website will not help.
The NSHA needs to explain all this. It needs to adopt, and broadly communicate, a plan for implementing its vision for primary care. Nothing that has been provided to date would persuade Nova Scotians that there is a clear direction, a timetable, and a rigorous process for achieving that timetable.
Likewise, the NSHA must annually report successes and failures in achieving the intended results. If the achievement bears any resemblance to what has been accomplished in home care there should be cheers all around.
If progress proves more difficult, but the communication is honest and persuasive that the destination will be reached, Nova Scotians may show understanding.
As it is, the snipers are having a field day. Confidence in the system is eroding and the risk of unhelpful political meddling grows daily.
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