Over two years ago I posted on the challenges that are healthcare reform. The specific impetus at that time was a January 10, 2017 article by Andre Picard (Globe and Mail) who provided his assessment of the real challenge facing our healthcare system across Canada - leadership. His article came on the heels of the decision of Saskatchewan to abolish its (latest) current regional structure in favor of a single administrative structure. Quoting directly from his article he concluded:
"Complex health systems do not run themselves, and our current loosey-goosey collection of leaderless, milquetoast administrative bodies is not doing the job.
If you want a well-managed, efficient health system that provides value for money, you need to hire good managers, pay them decently, empower them and hold them accountable.
Until we do so, the number of health regions won't matter, and the quality of health care will not improve appreciably."
Since then nothing much has changed and yet the same - tired - winds of change are blowing across the country. We see that Ontario is considering joining the fray of healthcare structural reform with abolishment of Local Health Integration Networks that have been part of its system since 2007. Rumors continue to swirl around potential for consolidation of British Columbia's current regional health authorities into one central authority akin to what exists in Alberta and Saskatchewan. Saskatchewan's restructuring has continued apace with what I would view as the normal challenges that come with such major system change. And next week in Alberta, with the conclusion of its provincial election, we are have the potential to see a number of 180 degree changes in that system including highly touted cuts to administration, reversal of plans for delivering laboratory services (again) and the potential to abolish Alberta Health Services in favor of a return to regional health authority structure.
Mr. Picard puts forward some strong words and a conclusion I have no difficulty agreeing with. My perspective is established out of a 25-year career in healthcare administration spanning roles in Manitoba, Saskatchewan and Alberta and a stint within a provincial Ministry of Health. Since departing the formal healthcare system over 7 years ago I have remained a keen observer of the system, hearing the concerns and complaints of those who try to navigate the system and receive less than optimal results, observe the macro results we achieve (or don't achieve) for the resources invested, see how Canada compares to other jurisdictions across the world, and continue to connect with those who still labor valiantly to try to make a difference in service of patients, clients and residents. Despite the best efforts of very many committed individuals - those who are good leaders and those who see healthcare not just as a job but as a vocation - we continue to perform at far less than desired or optimal levels.
So what accounts for this challenge in performance and lack of change over the last 20+ years? Andre Picard touches the surface of the issue and proposes a small sampling of potential solutions. I'd like to build upon his recommendations.
The issues we face in healthcare are large, complex and not amenable to half-hearted, politically-motivated solutions. If we - the collective we - are serious about reform in the pursuit of a system that is effective, efficient and sustainable than we must face, discuss and deal with the hard realities before us. With healthcare typically being the largest expenditure of any provincial government - on average 40% of total expenditures - there must be concerted, sustained and integrated efforts to manage this accountability responsibly. In my humble opinion, grand and repeated efforts at achieving positive change through restructuring - changing deck chairs on the Titanic - have been the cause of far more disruption and regression than positive change and progression.
Likewise, the challenges facing our healthcare system will not be resolved by the continued bureaucratization and centralization of decision-making and cost-control. When I left healthcare leadership it was as an increasingly frustrated senior vice-president. In my final years as a so-called decision-maker, with budgetary accountability of some $300 million, I found myself prevented from making the simplest decisions on my assigned accountability. Inevitably it felt as though any decision that required an expenditure or reallocation of even $5,000 required input and consensus of an entire senior executive team.
If anything it appears that the current reality has only gotten worse. Cost management has taken on extreme proportions with many provincial health systems mandating, restricting and banning many expenditures. I wish I could say I was making some of these stories up - but I'm not. In efforts to deal with projected deficits in the area of hundreds of millions of dollars front-line managers and staff are often told to not order paper, pens or other non-patient care supplies. Salary and position freezes are the norm as well. Many systems are also banning any form of travel outside their province. So at a time when we might need to be less insular we are becoming more limited in our ability to exchange information and ideas. Efforts at staff recognition and engagement (e.g., bring in a pizza for lunch) are frowned upon. The system now requires multiple approvals, moving up the chain of command, for even the simplest decisions. In effect, our systems and our "leaders" are spending dollars in an effort to save pennies.
This lament comes with a set of recommendations that is not so simplistic as restructuring or penny-pinching. They do however require a significant change in how we collectively think and act. But as Einstein once said, the very definition of insanity is doing the same thing over and over again and expecting a different result. Time to try something different, perhaps unique, and requiring more than a bit of courage and commitment. And a style of leadership, at all levels, that we have not had for some time.
First, given that healthcare is so important to our collective experience of our lives and now takes such a huge proportion of our total expenditures it is beyond time that our political leaders and parties approached long-term planning of programs and expenditures in a non-partisan manner. In this I take a page out of how I understand Australia sets defense policy and manages associated expenditures. In this case an all party committee debates and sets joint direction on a multi-year plan that transcends normal political cycles (e.g., 4 to 5 years). Recognizing that defense decisions and requisite systems (e.g,. aircraft, ships, tanks) require long development cycles, consistent and reliable levels of expenditure, and overall sustained vision to be effective, Australia's political parties have committed to maintaining direction regardless of which party is in power.
A simplistic and naive recommendation? In my view not any more than the multiple and misguided restructuring efforts that have plagued healthcare since the mid 90's. A challenge to be sure in the increasingly polarized reality of our political systems. Within the Alberta context for example I grant that it is indeed more than a stretch to imagine Rachel Notley and Jason Kenney coming together, overcoming their sizable political differences, and developing and holding to a long-term vision and plan for healthcare. But that IS the political maturity and leadership I believe Alberta (and every province) requires - and has been sorely missing - if we are to move beyond the empty rhetoric and expensive misfires of healthcare reform that has characterized the last 20 years.
Second, presuming the political solution and will identified above, we must craft a true long-term vision for what our healthcare system should be and what it should deliver. Again, in my opinion, our systems have been operating without a true, empowering, action-oriented and well-understood vision for some time. We've had platitudes to be sure - patient-centred, commitment to quality, accountability, [fill in the blank] - but all too often I believe a healthcare vision has been subsumed, subverted and overridden by short-term financial and political agendas. The first step in this process? Broad-based and transparent engagement of the public and our service providers. The effective creation - and implementation - of a meaningful and sustained vision and plan for health will not come if we can't achieve broad-based understanding and commitment of a majority of our stakeholders in making it happen. This is fundamental to the success of any venture. However, for a variety of reasons (e.g., fear? arrogance?) the formal system and our political masters have shied away from anything but cursory, perfunctory, and even deceitful "consultation" processes. The intent more often than not has been to manage noise rather than create true engagement and constructive action.
Third we need to ramp up the collective courage to make the hard decisions and choices that are before us. The changes we need to achieve the outcomes we say we want (e.g,. quality health care, cost-effective, patient-centred, sustainable) will not come without courage. We do not lack for knowledge, data and research. Much of what we know about what contributes to healthier populations has been reinforced in multiple studies dating back to the 1970's. I suggest to you that another study - on mental health reform, rural health services, manpower planning, [fill in the blank] - will not fundamentally alter our understanding of what our issues are, where are systems are failing, and what we must do. Do we have 100% perfect information? No. But if we believe we need that before taking action I suggest you prepare yourself to accept less than optimal performance in perpetuity. We need courage and leadership to address the hard changes before us.
So how do we incent the type of leadership we require within our systems? When I've posed this type of question to others one of the common responses I've received is that we need to move away from our publicly funded health care system and allow the private sector to drive needed change. Again I may be naive, idealistic or blinded to the possibilities, but I do not believe the profit motive is one that is required - or desirable - within our healthcare systems. I still believe that a publicly funded and managed system can deliver on its commitments if it is allowed to. I do believe that we have the leadership talent in the system to work for better change if we empower staff, managers and leaders to do the right things, to make courageous decisions, and be supported for doing so. The reality for the past many years however is that caution, risk aversion, and even indecision have been rewarded over any form of action. Too often those who have been prepared to take action have been chastised, demoted, isolated, or even dismissed. Other potential leaders have left of their own accord, having become discouraged by their inability to make the difference they believe necessary. Others have simply quit in place, now being content to defer to others higher up in the chain of command, or to participate in innumerable and never-ending committee work - our proverbial bridge to nowhere.
Finally, and just as critically, we need to overcome the challenge of the type of leadership culture we have created over the past 20+ years. While we often hear assertions, particularly from politicians, that our system is overburdened with overpaid administrators I believe the issue is more profound than that. In my view, due in large part to the actions and behaviours of our politicians, the healthcare system is over managed and under led. We have raised several cadres of healthcare administrators within a culture that has valued "noise management", risk management, and decisions and accountability (or lack thereof) by committee. Accountability has become diffuse by design. For those wishing to push forward with strength and vision they often encounter policies, procedures, and processes to confound Solomon.
Aside from the challenge of the maturity of our political process noted at the outset of this post, I believe this latter point may be one of the most challenging to overcome. Changing the culture of leadership - which sets the stage for all other required change in the system - is daunting. How does one change a leadership mindset when more often than there is a predilection in succession planning in choosing those who act, behave, and look most like us? Wholesale change is certainly not desirable. We need the benefit of corporate memory to inform us, guide our actions, and prevent us from repeating past missteps. But we also need more innovation, creativity and courage than ever before. I fear that our current leaders may not overcome their own unconscious bias to make that happen. I fear too that there may not be many of those potential leaders remaining in the system to choose from and develop to make the necessary difference.
The challenges healthcare faces are immense and they will require political maturity, vision, courage, the right incentives, appropriate accountability mechanisms and a new style of leadership to overcome. A tall order. Can it happen? Only if we have the strength to do the hard work and not simply engage in what seems expedient in the moment. Only if we have the courage to risk and hold true to the values that I believe informed most of us to enter into the healthcare field in the first place.
In this case it truly is all about leadership.
Greg Hadubiak, MHSA, FACHE, CEC, PCC
President & Founder