Dr. Merrilee Fullerton on Healthcare

The conversation on the previous journal entry including C. difficile outbreaks in hospitals across Ontario is worth continuing so please feel free to post comments that may be relevant.

However, I think it is also time to discuss the damage that top down control is creating on members of the public service including nurses and doctors as shown in a recent study from the Association of Professional Executives of the Public Service, APEX.

In an article June 16, 2008 from the Ottawa Citizen, "Public sector ' a toxic place to work' ", a national inquiry into the management and working conditions of the public sector is called for.

Bill Wilkerson, chairman of the Global Business and Economic Roundtable on Addiction and Mental Health is reported to have said that absenteeism, disability and claims and distress among Canada's nurses, doctors, teachers, police, military and bureaucrats have reached a crisis proportion and it is time for a major study into what is "sabotaging taxpayers' investment" into these critical services.

What is it that is creating such high levels of distress?

What is wrong with the culture of the public workplace?

Disability claims in Canada are climbing and currently 30-40% of claims are for depression. Cost to the economy: 51 billion (4% of GDP).

The APEX study showed that 64% of executives think of leaving their organization at least every month. More than half want to leave because of lack of recognition.

It is the first study to show the toll of technology and how the reliance on technology has become "counter productive".  About 75% of the nearly 2,100 surveyed say technology increases their workload; 66% said it adds to their stress and 49% said it decreases their productivity.

"People are drowning in technology and risk averseness and the lack of clear lines of accountability" says Wilkerson and "senior bureaucrats could feel "policitized"-torn between being neutral, non-partisan professionals being drawn into the political arena".

The last paragraph provides the most clarity:

"Part of the problem in the public sector is the ambiguity around who is in charge. Departments have to manage with a slew of "one-size-fits-all policies" and answer central agencies from Treasury Board to Privy Council Office. As a result, departments don't feel like they are employers in their own right," says Mr. Wilkerson. "

This certainly applies to productivity issues in the medical world. When top down approaches constrain  highly trained and responsible  professionals and create an inability for them to  function to their full capacity we have reached a significant tipping point.

Mr. Wilkerson and senator Michael Kirby plan to convene a workplace summit this fall into the productivity and health of the public sector, "especially the hardest hit health care sector".

Let us hope that the solution is not more rules and regulations and stifling of innovation, entrepreneurship and independent decision-making....but I'm not holding my breath.

 I've printed this news release in its entirety because I think it confirms what many of us have been thinking for some time. There is no plan. There is simply a reactionary process by which patients' concerns get media attention then a whack of money. One of the posters here outlined a nice little sequence of events that leads to this outpouring of financial compassion..usually goes like this:

1. Media latches on to a story about patients who are receiving care that seems suboptimal.

2. Money gets poured on the fire to squelch the flames sometimes immediately,  sometimes later.

3. A report is promised but it usually doesn't materialize. If it does, it is usually late and without any announcement.

4. The public is distracted by the dollar signs flying about and figures all will be well. 

5. Usually someone within the health care system is blamed. This can be the hospital CEO, the physicians, the cleaning staff or other.

6. In most cases, a government appointed overseer is brought in to sort things out and say more money is needed---something most people involved probably already knew but it still looks good. The fact that we are spending millions of dollars so that we can say we need to spend millions of dollars more seems to be lost on many.

7. Political optics are good for the short term and on we go........never addressing the real issue, which is the lumbering health care behemoth with an insatiable thirst for cash.

Long term plan? Ahh, the LHINs perhaps--  mind you they are still wet behind the ears and show no signs of being able to deliver on a very tall order while simultaneoulsy  sparing the politicians the difficult task of telling the public that all health care cannot be  "free".

Smitherman Admits Liberals Have No Plan for Health Care

The Liberals 10-year strategic report on health care is a year overdue.

(Queen’s Park – June 11, 2008) Yesterday the members of the Standing Committee on Estimates learned that the McGuinty Liberals had yet to develop and publish a 10-year strategic plan for health care; a commitment it made under the Local Health System Integration Act, 2006. According to a 2007 Ministry press release, the McGuinty Liberals promised this report would “set out a vision, priorities and strategic directions for our health care system over the next 10 years.”

“The McGuinty government has broken its own promise to produce a plan to address the gaps in Ontario’s health system,” said Witmer. “Whether it’s improving access to care, modernizing health infrastructure, shortening wait times or promoting good health, Ontario requires a long term vision. A vision the McGuinty Liberals have failed to produce.”

When confronted by PC Health Critic, Elizabeth Witmer, Smitherman said “It’s true to say, and I have to take responsibility that we haven’t hit our marks on this.” The Minister went on to suggest that the report would be published sometime in 2008, however Ministry officials refused to specify a specific date this would happen. As well, during the committee proceedings Smitherman suggested the report was held back due to the 2007 election. “I think that the difficulty that we were into, to be direct with you, was that the window last year got too close to the election,” said Smitherman.

On several occasions since 2006, George Smitherman promised to release his report in the spring of 2007. In a June 2006 letter sent to all the Chairs and CEOs of Ontario’s LHINs, Smitherman wrote, “Our government is in the process of developing a 10-Year Health System Strategic Plan to be made public next spring.” In December of that year, Smitherman told members in the Legislature that “we will develop the 10-year plan over the coming months, with an expected release date in spring of 2007.”

“The election last fall would have been the appropriate time for Ontarians to have their say,” stated Witmer. “It’s disappointing the Minister was not confident enough to bring his report forward at that time.”

Currently, the McGuinty Liberals spend 46 cents of every program dollar on health. Even without a plan, spending on health care is projected to rise to $42.4 billion next year.

“The government’s failure to deliver on their promise has left health care providers operating without a clear sense of direction. Ontarians deserve better. They deserve to know how this government intends to meet the challenges of risings costs, an aging population, overcrowded emergency departments and a shortage of health care professionals. How much longer must we wait for this government to take action and develop a long overdue plan?”

-30-

For further information contact:

Elizabeth Witmer, MPP

(416) 325-1306

I would think that the report from Canada's Health Council released today has no hidden surprises for most of the readers of this blog.

The first paragraph of the media release:

"Despite the nationwide commitment to build real and lasting change and the infusion of billions of dollars brought about by the 2003 Accord on Health Care Renewal, progress falls short of what could, and should, have been achieved by this time, says the Health Council of Canada's latest report to Canadians, Rekindling Reform: Health Care Renewal in Canada, 2003-2008."

Jeanne Besner, Chair of the Health Council of Canada says, "As we reflect on the speed and direction of health care renewal, we find the glass is at best half full."

This is a curious statement amidst the cheerleading that goes on in health care transformation these days. With so much political need for short term wins it is rare to hear such honesty. Many of us working within the system understand the predicament but unfortunately much of the public is led to believe that the current transformation is going to solve most of our problems...and there are even some, both public and political, who still deny there are problems.

We can't fix the problems if they cannot be identified or spoken about.

Change has occurred in some areas as identified by the report:

1. Major purchases of medical equipment and information technology have boosted the number of services delivered.

2. Some jurisdictions have improved the way waiting lists are managed and provide wait time information.

3. Most Canadians have better access to health information and advice through telephone help lines.

4. Some Canadians have better access to publicly insured prescription drugs and to primary helath care teams. 

In other respects progress so far is not cause for celebration:

1. Catastrophic drug coverage and safe prescribing lags.

2. Home care is inadequate.

3. Aboriginal health has not improved significantly.

4. Primary Interprofessional team access is uneven, not comprehensive or available when patients need it.

5. Electronic health records and IT are not on track to meet the goal of having 50% of Canadians with and EHR by 2010.

According to Dr. Besner, "Governments promised to eliminate inequities and ensure all Canadians have equal access to the same services, such as primary health care, home care and prescription drugs, regardless of where they live in the country. Governments must renew their commitment to nationwide change."

I can say that the "nationwide change" that Dr. Besner refers to must be bigger than the transformation we have seen in Ontario.  The inequities in Ontario, as far as I can tell, are growing more significant with the transformation strategies. We have have-not patients on more levels than we've ever had before to my knowledge. We have more hospitals with varying degrees of support and we have a growing need in many areas that are unlikely to met with more government money or government spear-headed change.

If we are to address the growing numbers of patients with diabetes, cancer, and other chronic diseases as well as acute events such as pandemics, bacterial outbreaks of various kinds and more social needs than in the past, government will not be able to manage alone.

We know this already with private foundations and philanthropy that continues to grow across Canada to support our public institutions.

If we are to truly transform and create renewal of our health care system, its institutions, and its providers while simultaneously introducing and managing new industries such as genomics, patients will need to understand the urgency of the situation and understand their own leadership potential. Gone are the days when a few elite leaders existed to organize the masses. Patients must be seen to be leaders themselves and empowered with the ability to manage their own health care.

This will not be achieved in a top down approach driven by government need to micromanage and control. In my opinion sustainable renewal can only be achieved through the acts of  individuals in many, many capacities from volunteer work, to mentoring, to community patient leaders. 

The process must be driven by patients and to achieve this the politics must be  uncoupled, at least in part, from the provision and transformation process.  I'm not certain our politicians have the stomach for this and so politicians and our governments will continue to promise what they cannot deliver. Perhaps the courts will need to do this job.

At least the Health Council of Canada is able to admit that the government is not delivering...a step forward and for me another drop in the glass. 

With the heat turned up on the superbug toll, Mr. Smitherman promises to report C. difficile cases in hospitals along with two other diseases,  Methicillin Resistant Staph Aureus (MRSA) and Vancomycin Resistant Enterococcus (VRE), by the end of September 2008.

It seems these days that Ontario's provincial health minister is busy cleaning up dirty "health spills" with great zeal but most often once the issue hits the media--health policy setting by the seat of one's pants, or should that be "diaper"....

In any case, with the reporting of these three infectious diseases...errr.."patient safety indicators", what will be done? More handwashing squads to supervise  medical and nursing staff to ensure proper handwashing techniques are adhered to? More prompted reminders from blackberries or cellphones? More squeegee hand sanitizers in the corridors?

Although I support the KISS principle, I must admit that I think the increasing emergence of C. difficile, MRSA and VRE have more to do with much deeper rooted issues than just hand washing practices and if the overcrowding and understaffing in hospitals is not addressed can we truly hope to make inroads in curtailing the growing number of nasty germs poised to humble medical science?

Even   a new U.S. study reports that other factors come in to play in the rise of C. difficile cases including a larger number of patients who are older and sicker. Dr. Marya Zilberberg, a University of Massachusetts researcher and lead author of the study examining C.  difficile in the US indicates that the number of people hospitalized with the dangerous superbug is growing by more than 10,000 cases a year. In Canada, it is blamed for 260 deaths at seven Ontario hospitals recently and for 2,000 deaths in Quebec since 2002. The virulent strain of C. difficile was rarely seen before 2000.

"The nature of the infection is changing. It's more servere," said Dr. L. Clifford McDonald, an expert at the U.S. CDC, as reported  in the Associated Press.

Many of the people  how died had other health problems and the study did not try to determine if C. difficile was the main cause of death.

If the nature of the infection is changing and other factors played a role in these deaths then reporting the number of cases will only be just a tiny beginning into the understanding of the dynamics of C. difficile. As we know, statistics can be skewed and less than helpful unless taken in context.

Once the reports are in, how will the hospitals be evaluated and what measures will be taken if any to correct the problem? It would seem that tertiary care centres would be more likely to have higher rates of resistant germs such as C. difficile because they treat the sickest of the sick and manage to keep patients supported who might otherwise die.  This does not mean that their sanitary measures are less stringent or that the health care workers are careless non-handwashers. There are many other complexities to be understood.

If we are to gather this information then ultimately something must be done with it. It will be interesting to see what transpires if anything or if this issue is just supplanted by something bigger and  more urgent. But it is the ethical thing to do and certainly being open and honest about infections harboured in our hospitals and other institutions is a beginning.

Let's hope that China can keep the lid on its own infectious diseases this summer and that all the athletes and visitors from around the world attending the Olympics manage to wash their hands before returning home. 

Have a clean day! 

The more things change, the more they stay the same...or something like that.

I read that Alberta is moving ahead in transforming health care by dismantling its nine regional health authorities and in their place is creating a regional superboard-the Alberta Health Services Board (AHSB). Voluntary Community Health Councils will be appointed by the AHSB to give  input on local health issues.

Can Ontario be far behind?

The Ontario government has denied that its Local Health Integration Networks are the same as Alberta's Regional Health Authorities but the concept certainly looks eerily similar. Bringing local health issues to the table is no simple matter and it may be that the unwieldy governance structures did not add to the "seamlessness" of care. 

But I have to wonder about the whole LHIN transformation which, like so many other transformations, doesn't change much at all....except perhaps to create some severance packages  for District Health Council personnel.

If LHINs were to be the Houdinis of Ontario health care, it seems the future may be well seen in Alberta. 

Alberta's Minister of Health and Wellness, Ron Liepert, is reported to have said: "Moving to one provincial governance board will ensure a more streamlined system for patients and health professionals across the province."

So no more local divisions to represent local needs but instead, a "streamlined system" with one governance board. I'm surprised the word "seamless" wasn't used as well.  Same jargon, different bag of tricks.

 Liberal Health Critic, Dave Taylor, said this week in the Alberta legislature that "no evaluation has been done of the impact of 15 years of restructuring on the health system in Alberta. In that time, the system has been completely restructured three separate times".

Sounds like a good make work project and an attempt to show the public something is being done...even if there is no proof, even if there is no "evidence-based" knowledge of the benefits of such transformation.

Yet, in health care transformation in Ontario we are moving to performance indicators and accountability agreements much lower down the health system hierarchy while there appears to be little or no evidence of improved or more efficient or effective delivery.

What is in store for Ontario? I can't say for sure, but I'm highly sceptical that LHINs are going to solve any real problems and its likely that in a few years they will be dissolved too...to make way for another round of "seamless" streamlining....so much so that we'll wind up exactly where we started.

I give the LHINs ten years...max. They've already had one.

Have a great long weekend and enjoy the outdoors wherever you are!