Mental Health in the Public Sector: the toll of a top down approach
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.
Merrilee Fullerton
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Reader Comments (136)
I welcome any relevant input you may have and hope you can contribute as you see fit.
I'll see if I can find the link for the Stats Can info you mention.
Regards,
Dr. Merrilee Fullerton (realist)
www.waittimes.blogspot.com
I think the powers that be are still trying to follow the NHS trends but it won't work.
Speaking to a couple NHS directors back in March I was told that one program that did work well was giving patients the funds for their own health care to manage. Patients with chronic conditions were asked what it would take to keep them out of hospital. Some said they needed to have someone do their groceries. Others said they needed a driver. They were given 18,000 British pounds to spend on their own program developed in conjunction with advisers and apparently it is working.Money isn't being misspent...hard to believe I know but maybe more easily tracked than money in the NHS!
Whether it is patients in control of delivering their own pain medication by infusion pump, controlling their funding for their own unique needs or providers being able to access funding and programs they need to enhance patients' lives and make their own profession "livable", it is all about control...but not the top down kind.
Granted, there has to be some organized method of delivery but when the bureaucratic tangle gets too big and prevents people from coping or innovating then this needs recognition and addressing.
Anyway, if you don't have mental health, any physical health you may have loses its significance.
See CIHIs most recent report on wait times:
http://secure.cihi.ca/cihiweb/dispPage.jsp?cw_page=media_25jun2008_e
We're going to be swamped.
The study recommends that the province invest in a web-based ordering system that would allow standardized, real-time collection of the reasons for ordering tests and the test results. The authors believe this would ensure the tests ordered would be more appropriate, reducing the number of scans ordered and decreasing the wait times for medically necessary procedures.
Who will judge?
How will this be enforced?
How will the scrutiny required to enforce such a system be maintained as more patients and more providers discover the loop holes that help their patients get access to care?
People are not widgets to be swung around on assembly lines and 'processed' through a central "agency".........ICES has missed the mark.
And in relation to mental health, get a load of Dr. Allan Hudson's comments regarding the Champlain LHIN lagging behind on many wait times......
In the Ottawa CItizen June 26:
"Dr. Alan Hudson, the man in charge with reducing wait times for essential services for Ontario, blasted the Champlain Local Health Integration Network, saying: "you are the worst....in the province.
"I can assure you the government's expecting a fairly comprehensive explanation of what's going on here."
So it seems the "overseers" do not have much understanding of what makes different regions different. The fact that Ottawa is sitting right next to Quebec which has a worse problem than Ontario in terms of human resources and infrastructure might have something to do with it.
It also might be that the highly educated and informed citizens of Ottawa are getting themselves on to wait lists at the earliest possible time so as not to wait even longer.
When I hear things along the lines of the difference between "patients needing care" and "patients wanting care" it makes me shudder.
Sure, save the system, sacrifice the patients. Makes no sense to me....but if Allan Hudson's job depends on belittling various LHINs because of their insurmountable problems then I guess all of us providers had better start seeking shelter somewhere......not sure what will happen to patients in this kind of blame game scenario......
Now where is the whip?
Years gone by the party line was that one CT is worth a room full of Neurologists. Now that there aren't enough specialists to see patients to triage the presentation, those tests continue to be ordered and costs are mounting because the screening is, shall we say, unacceptably coarse grained.
So the solution is to monitor test requests real time?
Will someone then assume the clinical liability of rejecting requests that are deemed a priori "unnecessary"? Infrastructural shortcomings are already onerous in Ontario. The ramifications are immense for the viability of practice Ontario.
ref
"Asymptomatic brain infarcts were present in 145 persons (7.2%). Among findings other than infarcts, cerebral aneurysms (1.8%) and benign primary tumors (1.6%), mainly meningiomas, were the most frequent. The prevalence of asymptomatic brain infarcts and meningiomas increased with age,..."
Incidental Findings on Brain MRI in the General Population N Engl J Med 2007;357:1821-8.
The plan is good. All will conform
While reading the entries, I immediately thought of the Monty Python "Machine that goes ping" for the 1983 move Meaning of Life.
http://www.youtube.com/watch?v=arCITMfxvEc
Hard to believe that 25 years later that apart from titles, this have not changed one freakin' iota.
Have a happy Canada Day weekend folks! We all deserve it.
Best wishes for a safe and happy Canada weekend as well....but before I go here are a few more links you may find interesting:
http://www.ctv.ca/servlet/ArticleNews/story/CTVNews/20080626/wait_scans_080626/20080626?hub=Health
http://www.canada.com/ottawacitizen/news/story.html?id=71766c61-9ef9-4dda-8e62-4685b4fcb7a8
It is very difficult to know with any certainty whether or not a patient's scan was "unnecessary" until the scan is done. There are just too many unknowns. Compared to the US, where there is more defensive medicine practiced, I'd say that the number of MRIs and CTs ordered in Canada are not that large.
I still recollect a patient I saw with my attending neurologist staffman as a student back in the 1980s. It was a 50 year old lady whose family had brought her in because of continued headaches. The neurologist found no signs or symptoms that he felt would necessitate a CT scan. Remember that over 20 years ago, CT scans were relatively new and difficult to access...regular GPs couldn't even order one.....so the gatekeeper was the neurologist in this case. The patient was denied the CT and went on to have an inoperable brain tumor. I met her again when she was admitted under another service and let me just say that the family was not very understanding about the need to have restricted her access to the CT. It was all very unfortunate.
Hindsight is 20/20.
Who are we trying to save and serve? The patient or the system?
noblesse oblige
As part of ongoing adjustments made by the MOHLTC, one thing being tried is to get the public to roll back their expectations.
This is a 45 billion dollar business where we get your money and manage it for you, as we feel is best. Most are happy, but it is the raised expectaion points of free exchange of informtion world wide that causes us the most stress, as it raises the publics belief that all this should be available. We have determined it should not be, until we have vetted and rationalized these new services. Thta's why we are a "late adopting" health service. It works.
New messages will start coming out soon, pointing out that our core free service remains good, and our system of rationing and delays over new products are good because it protects you all and hurts very few. In the information campaign will be the many examples of overuse of unproven drugs in the US and there harmful affects, and why direct to consumer ads are bad.
We believe this will help damper demand for new services from most, as they could jeopardize your access to our "free" core system. The beauty of herd management.
The plan is good.
http://pt.wkhealth.com/pt/re/aha/addcontent.8430924.htm;jsessionid=LlzBlXnfLpPHTqqYbqGK32FKG0M7nRF3LZtLSZPdwNrpx7GFGJ9Q!-785659172!181195629!8091!-1
The 2008 AHA Scientific Statement on noninvasive coronary angiography suggests the symptomatic patient at intermediate risk for coronary artery disease is most likely to benefit from noninvasive coronary angiography. ...
... there is also a wide range of patients who can already benefit from these forms of advanced cardiac imaging.
Doesn't this have the potential to save a large amount of time with a physician? If my scan is clean, why ever see my GP?
http://canadianpress.google.com/article/ALeqM5heMkmdBO4tVoOMBg6DAI_JUu51eQ
Yep, shows structural abnormality and, here's the beauty, MRI has no radiation to concern one.
Part two is to address functional MRI abnormalities with entirely normal appearing structure.
And then, treatment.
Note to our new Minister, things just changed.
OK, so full body scan, full suite of blood work, good to go!
not so peachy
Go figure.
http://www.canada.com/ottawacitizen/news/story.html?id=11ed34da-d122-4306-93fe-04016cb13fdb
I suspect there will be no need for a family doctor to be affiliated with a freestanding NP clinic once sufficient doctor NPs trained in the medical model are available to supervise the non-doctor NPs.
http://www.ama-assn.org/amednews/2008/06/16/prl10616.htm
Like it or not we are now in direct competition with the nursing profession for ownership of access to the primary care system and ultimately our professsion's survival.
In the end I am not hopeful and suspect family medicine will lose due to the government's unquestioning support of the nursing profession's well thought out strategy to encroach on pretty much all areas of our existing scope of practice. This government support in conjunction with a complete failure in leadership from our own OMA, OCFP, and COFP will ensure we are reduced to operating at the margins of the system (rural medicine, GP with specialist interest, etc.).
http://www.thewhig.com/ArticleDisplay.aspx?e=1089454
While the former was to elevate training, it resulted in more office time, less hospitalized patient care and a sense that ER doctors belonged in hospitals (and they became 3 year programmes).
The insurance costs compelled FPs to reappraise their engagment with the hospital.
Now PCR strains the relationship with hospitalized patient care yet again. Stressing continuity of care until it dies crossing the threshold of the ER. Sad. The current "hospitalist" programmes are a surrogate for the now absent old style family doctor. They are a sacharine subsititute.
When the FP no longer has the exclusive health records, no longer has the personal relationship, no longer prescribes nor makes referrals to specialists, what makes them desirable to the patient? (Note I said desireable, not valuable.)
All must be control by siloed budgetable groups.
Do the powers that be not realize that this will be the overall demise of family practice, acronym groups included...to be replaced by independent nurse practitioner clinics that will cost a ton more?
This whole thing will come full circle when the nurse practitioner system will cost too much and then lets see who the fall guy is.
The government and nursing initiative is killing off family practice to their own detriment. What a mistake.....but nobody is listening.
The Conference Board of Canada gives us poor ratings for productivity and innovation in its newest report (see link several posts ago) and just watch what happens to productivity in primary care...it is going to go through the floor while costing a ton of money with little or no improvement to patient outcomes (mark my words..and of course no "proof" or evidence to base this on just common sense...but who pays attention to that).
Since Ontario is essentially on its way to becoming a non-profit provincial HMO with 13 million subscribers I suspect, but do not know over what time frame, the same creative forces are at work here as well to relegate the family physician to the dustbin of history particularly in the large urban areas where it matters most with the voters.
I don't believe the author's cure suggesting that FPs should move into the specialist's turf will solve the issue though. The nurses have already beat us to that again aided and abetted by the OMA and the MOH with their programs to train the nurse anesthetist, colonoscopist, midwives, etc.
If the premise of this author's article is correct, that it is really technology which is driving the demise of the family physician on a global scale, then most of our discussions on this blog are likely just pissing in the wind over the long term.
I have no intention of becoming a "trained seal".
http://covertrationingblog.com/new-business-models-for-healthcare/reinventing-primary-care
I do believe that Canada is going to come up significantly short on specialists as well and the family docs will provide some specialist services (this is already happening by the way).
One area that is being overlooked is the importance of genomics/pharmacogenomics and family practice. There will be a significant role for family doctors in this field. Nurses simply don't have the expertise or medical background to understand the nuances of different genetic tests in my opinion. And as much as some "experts" think that this will all be solved by some computer algorithm, they should think again.....because although there are some routine cases, many patients differ in some unique way or another. This will require significant expertise, well beyond that of following an algorithm.
What can I say? I believe the experts are wrong because many of them work in ivory towers or are detached from the front lines and have no real understanding of the variability that exists amongst patients.
As for productivity--a primary care system taken over by salaried nurses is not only going to be unproductive, but very, very costly.
The concept was to ration access to services by limiting the number of access points (physicians). It was about COST. Now it is about CONTROL? Doubt it. It is still about COST using CONTROL...which means that the nurses taking over primary care are very likely to find themselves sliding down the ladder of autonomy and pay. Meanwhile, family docs will be looking for the exit or never going down that road in the first place. And voila, destruction of what is probably the most efficient form of primary care.
Amazing what work from the ivory towers can do.
I think that Dr. Rich is probably correct that there will exist a market for patients who want to pay for a medical practitioner other than a state mandated one whose first loyalty is to the government.
Family Health Teams will become the government sponsored model while other models will serve more independent minded patients with dollars to spend on their own care.
Cost: we have no problem with "cost", because we have unlimited resources, if we need more money, we can increase the tax base. Up to now, that has not been an issue. Because of the current desire to not increase the tax base, given that insufficient funds exist through the tax base to provide all needed services, we ration. We intend to ration at the margins, affecting only small groups who have insufficient votes to alter the system. The "big 7" occurred as a result of rationing too much and attracting too much political heat. As a result we backed off that approach, and now concentrate rationing of services to groups who have no power.
Why FFS must be controlled.
FFS represents "independence" from control if the fees are fair and reasonable. Thus it must be cut off. The BC government tried the approach of restricting access by limiting licenses - it was found wrong and had to stop that process. Our approach is just to fund FFS at such a low rate that physicians are forced to move to the budgetable silos of the alphabet groups. Fortuntely the OMA has been supportive in this approach.
Why
It is obvious that physicians who are funded appropriately can acquire patients who will see them for care, and follow their care plans. We don't want individualized care plans designed around patient needs. We want standardized care plans that can be budgeted and follow our guidelines.
Thus the FFS route must be cut off and the route that appears to work is to fund it at less than cost of living, thus forcing physicians into alternative MOHLTC funding streams.
Why fund Nurses:
We can hire salaried nurses at about a 4 to 1 cost compared to physicains. Thus we get 4 employees who follow our instructions, for each physician displaced who generally haven't been following our instructions.
We must have compliance with our rules, and the nurses, becuase they are seeing increase in their funds and roles, have been accepting their new opportunities with relish. The new physicians are accepting their new roles in the alphabet groups with relish. The only group fighting is that relatively small group of freestanding FFS physicains struggling to maintain their independance. There aren't many left, and the new OMA contract will finish off that group forever.
THe plan is good.
Eighty (80) percent of the 'alphabet group' physicians you talk about are in the FFS-based FHG and CCM models, and can get out at the drop of a hat. So MOHLTC is nowhere near where it wants to be on this one.
The new contract will simply continue the Chinese water torture of FFS physicians (unless they decide to take a stand).
Not likely, but you never know. If there is something in the new agreement that lets NPs leech in on the FFS pool, then we could see some fireworks. Similarly, if there is a zero percent FFS increase for fiscal 08/09, the sky will light up.
Happy Canada Day!
He may go to his political grave for it, but the Liberal leader has at least put the pros and cons involved in walking the talk on global warming on the table for Canadians to debate.
By comparison, the medicare debate is in a political cone of silence. No party has the guts to make the case for a different medicare mix, but none of the expensive plans designed to ensure its future has delivered truly sustainable results."
http://www.thestar.com/Canada/Columnist/article/451567
The FHG/CCM docs while happier than the pure FFS dinosaurs are still very much of the mindset they can drop out of their model at anytime, and I would say they still think very much independently and are not happy with any new guideline introduced. The mindset in this group is that one will put up with the guideline hoops for now as the extra pay is sufficient to compensate for the jumping. At some point though the PITA factor will outweigh the compensation factor and then the sky will light up and all that relish you speak of will become ketchup.
In terms of not funding the margins as those voters do not matter, I think the "planners" have not considered the proxy voters for the marginalized groups. One group which we see increasingly having problems with access is the parents of the boomers. Typically they can't get in to see their alphabet grouped physicians so we see them for all kinds of issues. Often the boomer kids come along and are very angry at the lack of access their elderly parents have despite being registered to HMO Ontario.
So while the MOHLTC may think the over 80 year old group may not stand up and vote against the system, their kids sure will and at the grass roots level there is a ground swell of discontent over the lack of timely access to one's government prescribed alphabet physician.
It might be time to put up the bunker's periscope or venture outside and ask the boomers what their number one concern is regarding the current system? My guess it will either be access to timely primary care for their parents or themselves. Ignore these groups and issues at your peril.
Happy Canada Day!
Government has been fed a load of mash.
The trajectory that the "plan" is on now is for decreasing productivity and increasing costs.....this is just dumb and getting dumber.
The MOHLTC appears to want to "believe". The nursing leaders are wrong in that the system will not be made stronger by having nurses take over the bulk of primary care services.
What should be happening is the very flexible family doctor should be the buffer...a transition between the simpler tasks that it can do very efficiently and quickly and the more complicated problems that the specialists can deal with but don't want to be saddled with all the details that the family doctor is ideally suited to manage.
By all means, provide all family docs with the same support that is being given to docs in Family Health Teams. Watch productivity rise when there are assistants who can process paper work and be of assistance to minor issues....but leave the independence of the family doc so that innovation and motivation and productivity will not be killed off.
The MOHLTC is heading the WRONG way.....and there are cheerleaders encouraging this much to the long term detriment of primary care and cost control and even to the detriment of "control" that the government seems to want so badly.
Do you really think that the bureaucracy of government is "controlled"? That is laughable.
And mfO, I hear what you are saying....but the plan is bad and ill conceived and it is going to get us into worse shape than we are in now.
Can anybody say "Barer-Stoddard"?
As for marginal groups, no one cares, as long as the marginal groups can not get "voting" power. The "big 7" bailout occurred becuase central wasn't watching "voting" groups. We've learned.
http://www.cbc.ca/whitecoat/2008/04/aging_ageism_and_the_silver_ts_1.html
My grandmother had a heart attack at the age of 70 years and her children were called in the wee hours of the morning to come to Kingston as soon as possible. Some young resident had decided to make her DNR based on her hair colour and her lack of treatment also reflected that status. Not one question had been asked regarding her previous health and the fact she was completely independent prior to admission. When we arrived and actually spoke with the cardiologist who knew the family he apologized and said it was a small MI and that the DNR order was inappropriate. A week later she went home on a beta-blocker and lived in her own at home for another twenty years.
This sort of ageism was alive and well back then and it is even worse I find currently. A day does not go by when one of our local ERs sends an unaccompanied elderly patient home with an unresolved serious problem and the instructions to follow up with their family doctor despite not having one, or not being able to access one in a timely fashion. These patients do not know how to navigate the system and often end up in our clinic since we are just down the road from two large emergency rooms.
Over the last few months I have seen elderly patients sent home with sugars over 25, significant DVTs, and spinal compression fractures only with the instructions to "follow up with the family doctor" which doesn't exist. Often the appropriate investigations are not even done to arrive at a diagnosis. In the past these patients would at least get a follow-up in the appropriate clinic, but no longer. The mantra so often is "treat em and street em" except that the "treat em" part is no longer part of the deal it seems. I guess this is just another group of marginalized patients who don't vote so they don't get the care they require.
Usually what we do with these cases is call up one of their kids and have them take the parent back to the ER with instructions to not leave until proper follow-up is offered. If no kids are nearby we will make arrangements for follow-up.
I sure wouldn't want to be over 70 years and have to negotiate the current health system on my own in Ontario. While it may not be as bad as the case in the link below I am sure we are not too far off for those who are marginalized.
http://www.cnn.com/2008/US/07/02/waiting.room.death/index.html
You can substitute the home-grown with poached cheaper IMGs but will the population accept them remains to be seen. Talk to some of the clinicians involved in evaluating these IMG physicians and there are many serious problems. It is not the hard skills or passing knowledge exams where the problems exist, but with their communication and other soft skills.
Study reveals the impact of not having a primary care physician: thousands of ER visits and hospital admissions could be avoided with
access to a family doctor.
D'uh.
Of course, frequent readers to this excellent blog can shed light on the more interesting finding: hospitals in communities with new Family Health Teams are also seeing increases in their emergency department visit volumes (particularly at the lower end of the acuity scale)?
Of course, we are also told that these lower acuity clients do not meaningfully contribute to excessive ER wait times.
Who do you believe anymore?
Conrad Hilton when he said, "The curtain goes inside the tub to shower."
This is consistent with what is happening in my neck of the woods....the walk-in clinic in my area that has been in existence for 20 years and has recently become a FHG/walk-in clinic (FFS) and contributes to keeping patients out of the ER (this info from a public health individual in my area) with significantly lower ER usage from area citizens compared to the Family Health Team with all the bells and whistles and added government funding for NPs. The FHT uptake area that I'm mentioning actually has a significantly higher usage of the ER.
Now you could argue which came first, the chicken or the egg, ie did the FHT get established in an area that was seeing higher than average rates of ER utilization or now that it is in existence, is the ER utilization going up?
In the case I mention, the FHT was essentially a renamed group of doctors that received additional funding for NPs and governance and infrastructure.....it existed before.
I suspect that the ER usage has gone up since the FHT was established because at least one doctor there has retired. And as a CPSO report indicated not so long ago, the docs in teams are seeing fewer patients and working fewer hours but the additional providers such as NPs are picking up patients. Do NPs keep patients out of the ER? Maybe that is the question that needs to be asked and answered.
http://www.canada.com/ottawacitizen/news/story.html?id=ecd8af41-0e5e-4dd4-8b0c-9b68a2c2df7c