Houston’s Prospects In The Next Election Will Depend On Health Care Leadership

Posted September 10, 2021

The seeds of the Liberal defeat in the Nova Scotia election were planted eight years ago.

Shortly after taking power in 2013, Premier Stephen McNeil amalgamated the nine district health authorities into a single unit, the Nova Scotia Health Authority (NSHA), which has more than 23,000 employees. This provided two opportunities for positive change.

A single authority should need fewer senior management positions. Support functions could be centralized. It is easier to manage one central accounting system than nine regional ones. A central information technology function can support a robust website; most of the nine regional ones had modest offerings. Despite clumsy handling by the government, the collective bargaining processes were unified.

Secondly, resources and responsibilities could be managed on a province-wide basis. Specialists can be shared between regional hospitals. Agreements with related services that are not part of NSHA, such as ambulances and long-term care providers, can be negotiated province-wide.

Opportunity does not guarantee achievement. It is a big job to integrate nine organizations into one, realizing the efficiencies and creating a common culture that empowers and supports the front-line caregiver. It requires a CEO who is knowledgeable in their field and skilled in organization design and recruitment of the right talent.

That is not what happened. Janet Knox had been the CEO of the Health Authority in the Annapolis Valley, home to Stephen McNeil, so they had come to know each other.

He appointed her to be CEO before appointing a board to oversee operations. No doctors were included in the board membership.

The province was divided into four zones. Her senior management team, which was also chosen before the board was appointed, included executives who held dual responsibilities both as leaders of a zone and managers of a program of care. As a practical matter, the zone leadership responsibility received little attention. Opportunities for cost savings were not fully realized.

Some of the leadership group was very weak but Knox was reluctant to change them or the structure. Unsurprisingly, this led to dissatisfaction among doctors and other front-line caregivers. McNeil was far too slow to allow a change at the top.

It would be wrong to say that there was no progress. Collaborative care centres have become an important resource for delivering primary care. The authority has performed well in dealing with COVID.

That said, the performance of the NSHA was not good enough. Too much decision-making was controlled by head office, far from the points of contact with patients. Doctors were vocal critics and believed by their communities. This paved the way for Houston’s successful campaign strategy.

Brendan Carr was recruited by the board to be CEO of the NSHA at the end of 2019. On September 1st, Houston and Health and Wellness Minister Michelle Thompson dismissed the board and Carr and replaced him on an interim basis with former Port Authority CEO Karen Oldfield. She will head a four-person team with three current and former health deputy ministers.

Her foursome plus Thompson and Houston will tour the province to hear from frontline healthcare professionals later this month. This is good political theatre to emphasize the sincerity of Houston’s core campaign promise.

It does not set the stage for effective governance going forward. It is good for them to get a firsthand feel for the issues faced by caregivers, and to label goals for the authority.

But to govern the authority from some combination of the Department of Health and Wellness and the Premier’s Office would be to repeat McNeil’s mistakes, which contributed to Rankin’s defeat.

It is not obvious why Houston had to dismiss the existing board and CEO while doing his listening tour. The board provided regional insights and necessary diversity of perspective.

Oldfield has no experience leading health care or large distributed organizations. Though the port’s customers have thousands of employees the Port Authority itself has only about 100.

Houston should promptly recruit a new board of experienced leaders from different parts of the province, including representatives from the African Nova Scotian and Mi’kmaq communities.

The board should as a first duty develop criteria, to be approved by Houston, for choosing a new CEO. They should then commence a Canada-wide search for the best possible candidate. Getting the right person will be crucial to Houston’s success. Getting it wrong will haunt him at the next election.

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  • Your piece this morning was excellent. It is rare indeed to read intelligent and experienced commentary on public administration.
    The latter has been largely ignored and disparaged for the last 40 years. I spent 30 of those with the feds while the bureaucracy was being downsized and becoming ineffectual and five with the UN, which was in the early days being sidelined.
    Keep at it!

    Maxwell Stanfield | September 12, 2021

  • Your article is “right spot on”. Everything that I and my colleagues in the health care field have been saying is covered.
    I greatly fear that we have reached the tipping point where desperate people will take desperate measures without the benefit of critical thinking.
    The situation on the ground is much worse than we have been told and we will soon be made aware of that. Since we do not have a robust health outcome measurement tool kit in this province, the delays in diagnosis and treatment brought on by both COVID and the lack primary care will be enormous. Primary Care, as we know it, cannot survive.
    As I enter my 40th year as a physician and as a keen watcher of health policy development and operations over the years in this province, I can assure you that travelling “dog and pony shows” are rarely if ever effective. They do provide cover and thus space for the government to beat down critics but do not produce an actionable plan. In 1988 I presented a paper to the Nova Scotia Royal Commission on Health Care on the challenges of providing rural health care. That assessment is as valid today as it was in 1988. Unfortunately we have actually slipped back from 1988 to a situation where on the Labour Day weekend the only emergency rooms available to manage even primary health care problems were in Antigonish and Sydney leaving the whole population of Cape Breton somewhat stranded.
    In June I learned on Facebook that my primary care physician was leaving our area to take up a hospitalist position at a nearby hospital where he nets more income for half the hours. I did not as much as receive a letter in the mail from him indicating that he would be no longer available to provide care – an interesting professional development in physician-patient relationships. I do not have a family physician and I am not on the list of the 75,000 + who are registered without one. Of course I am not as vulnerable and so not as much concerned about navigating the system.
    Mr. Houston has a formidable challenge and I fear he has promised too much given those challenges. First he must level with the population and actually chart out the challenges. Second, he must be careful of the advice he is receiving from an entrenched bureaucracy who contributed to the current state of affairs and thirdly, he must look to other jurisdictions that have begun to wrestle the problems to the ground: New Zealand, The Netherlands, the National Health Service in Britain and Israel, to name but a few. He should also remember that front line workers have much to contribute. If they are not part of the solution, they certainly will be part of the problem.
    I cannot tell you how many times I and my colleagues tried to reach out to Janet Knox, Brendan Carr and the DHW et al about these issues and never once received even an acknowledgment of our correspondence.
    You once referred to me and my colleagues, who were vocal critics of the NSHA, as “snipers”. I guess that moniker was also how the NSHA echo chamber saw us.

    Robert Martel MD | September 12, 2021

  • You nailed it in your column today re the NSHA Houston health care mistakes.
    I am just an ordinary citizen with no ties to anyone in the government or with the NSHA system.
    But do think I have some common sense and maybe that isn’t a good thing at times, lol.

    I wonder why and maybe he did but don’t think so, what the former members thought of the ongoing system and how to fix it. Maybe they were prevented from an opinion. For sure I don’t know.

    See where Karen Oldfield will head a four person team with 3 current and former health deputy members. Scary to think 4 people will do this and no doctors etc. in the mix. Two great doctors who have tons of experience are Dr Sam Campbell and Dr John Ross who used to be and maybe still are in the Halifax Infirmary Emergency One of them a few years back even wrote a report on the hospital system and its problems. Not sure what was adopted from that report.

    Sure Houston wants to make it better and sure hope realizes he can’t do that in four years for a variety of reasons an ordinary citizen like myself can realize. Keep on the backs of the government Bill. They need lots of help no matter what party is running our province.

    AKM | September 11, 2021

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