Someone or something needs to control health care, set an agenda, perform long range strategic planning, monitor performance, make corrections, bring in new ideas, and eliminate old ones. That is a tall order in the context of a health care system that is perhaps our most complicated decision making environment; one that has such an immediate and direct impact on individual people.
We as members of society expect “someone” to make those decisions. That “someone” is generally government and in the end politicians. I now believe that the system is complex enough that it can’t and shouldn’t be left to the politicians to govern. It’s too complex. The inter-relationships are myriad. The demands are too great. The opportunity for political opportunism is too great. Policy decisions get made above the fold. The electoral cycle demands that no real work occur in the first year after an election and the last year before the next. The negotiations cycle with professional associations is unwieldy and not fleet enough to respond to new demands. In the end, although we expect politicians to guide, lead, and make bold decisions, the very nature of politics in our current environment means that they cannot.
We need bold decisions that may not be pleasant, will not make everyone happy or everyone the least unhappy, that might even fail and need change. This is not the business that I see politicians in with regards to health care. The best the provincial leaders could do was talk about an “innovation fund” – we don’t need more study, we need real, significant, game changing action; some of those actions would result in politicians and parties not being re-elected – for this simple reason, those actions cannot occur.
Who should run health care? We should have an agency that with government negotiates the public contribution to health care, sets long term strategic goals, devises structure and plan, isn’t politically aligned, and is, by lack of political master, is more able to manage the politics of health care. Something with the same kind of power as the Ontario Health System Restructuring Commission of the 1990s, which was able to operate above the political fray. Perhaps the Bank of Canada is useful model – an agency that works to set monetary policy for the country within parameters agreed to with government
It’s a big idea. It’s tough. It requires politicians to give up something that I think many feel they have to be in because it is so important to citizens. At the same time, I suspect that many would be happy not to own the “third rail” of health care. No one wants to be the party of record when the current system fails and yet they feel compelled by circumstance to fiddle.
This space is not for small ideas. It’s a place for us to talk, not about the possible but the necessary. We need this change.
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To Jana – you commented on the idea of equal voice. Equal voice is right but equal access or opportunity in decision making shouldn’t and can’t be an objective in terms of OUTCOME. Our system right now is full of those who are more equal than others – and usually that place has been gained from emotion – as examples – 5th generation chemo agents that cost thousands of dollars and save no one, merely add time, increasingly early premature saves at a million dollars plus, wait list strategies that were at least as much political as practical – where is the equity in any of those examples? Equity would rest fully on an idea of value and the number needed to treat and would not be dependent on the idea of loudest voice or most politically active. Health care administration requires a form of justice – application of principles without emotion – when there is clearly not enough resource to meet all of the needs.
This is really not an issue of one form of organization being inherently ‘good’ and another inherently ‘bad’. Rather all forms of human organization are best suited for particular types of health care and both are necessary. Both suffer from the vagaries of politics – that is how people are. Maybe we should be asking ourselves what are acceptable political and ethical behaviours that will best support the health needs of people we are here to serve. Of course individuals will have their own preferences for how this is done, as will various professional groups, as will various communities of people, as will various provinces as will various countries, as will the UN and World Health Organization and International Aide Agencies that also do astounding work world wide. Not one person or group can claim they are the sole and primary source of virtue – each has its place in the overall system. Maybe this is the missing political element – having a basic understanding, genuine respect for each other and seeking ways we can better coordinate our collective efforts in a manner that best serves the needs of those we all are trying to provide health care for.
The concept is an interesting one. However, the basic premise that more regulation is needed to bring around necessary change is faulty from a historical perspective. Reforms in health care are usually a result of change in government or economic crises. Reforms attempted for other reasons mostly fail.
All the regulation and various agencies/councils which have emerged over the past decades with numerous efforts at organizing and collaborating and measuring and monitoring and integrating and coordinating, have not managed to hold cost or expectation to a sustainable level.
I agree that the complexity of health care is a problem but rather than looking for another group to add to the complexity, I would like to see health care dollars be more directly associated with patient care.
I think we would all like to see more dollars directly associated with patient care but, to be blunt, what does that mean? Who decides on what patient? Who decides how much for each patient? Who decides when and how treatment?
Health care isn’t organic, it does require some sort of structure. I contend that we have the wrong one, or not enough of one and that has allowed providers to make it up as they go along, for the loudest voice to win, for professional organizations to drive agendas and so on.
I’m all about less structure and more doing. That leaves more for patients and their care. But to think that it will “just happen” is magical thinking.
Any large institution with a hierarchical structure will inherently be subjected to the alternating whims of the powerful “elite” at the top of the hierarchy. In other words there is always politics. The law(s) needs to be made “inalienable”.
That is why the community based based primary care model of health promotion and prevention with a team/matrix for the more acute needs works better. It is more “organic”, functions within rather than outside the community and can be integrated better in the decision-making process of a community more fluidly than the larger corporate paternalistic ‘curing’ deity model that has dominated the developed world since industrialization.
And who decides how much resource is going to go to each of the entities/projects? I think we are myopic at the local level and think that the thing we do is the most important thing in the world. And we believe we do it well, forget measuring.
The local level might be able to decide the how, but when there are not even close to enough resources to meet the need, someone or thing has to decide the what.
I’m tired of the “paternalistic” assertion. Complex service delivery needs a structure, authority, measurement, and consequences. The current political based structure isn’t working.
A good example is the Cuban polyclinic – essentially a large family health team with allied professionals and 5 specialties on site. And frequent access to other specialties that go to those polyclinics. It’s primary team based care with community outpatient level specialty services. Great model in many opinions – but who decided that, who allocated the resources, who said that the primary care docs had to work in that model, that the specialties had to do their work in that way? Someone did, and all participants didn’t willingly agree – because they thought they were too good, too unique, too smart, too whatever.
So I go back to the real problem – who provides the structure?
I am not advocating a lack of structure. I am advocating a matrix structure where there is equal voice. That means that the evidence speaks with as much clout as the community. Decisions are made with whatever evidence is available which, face it, is not much but is growing in body and volume if not precision. In terms of quality maintenance for administration and delivery continuous iterative review and transparency of all (defined and redefined) principal components are required. These reviews need lessons learned reviews in the same iterative manner. These are also needed at all delivery levels where the innovation actually occurs. Administration in traditional hierarchy (paternalism) is where stagnation occurs because it is not intimately aware of the details of the nuance of change.
What I see at the end of your last comment referring to one type (Cuban polyclinic ) of community driven system.
But then you took the perspective of a tertiary care trained clinician rather than clinician community-member- participant and perhaps also an expert consultant to advise in the evidence for the overall effect from the Resource management activity for the Region, similar SES, population bases within their country and relate it in the situation at their decision making unit. . . . .
Coming to a consensus within a community might help avert the “because they thought ‘they ‘ were too good , “too unique”, “too smart” , “too whatever” because they are contributing their good, unique, smarts to their larger unit AND smaller unit . . . .on the ground as I mentioned previously. . .rather than just one big Pillar somewhere and talking amongst themselves and perhaps not applying it in a way that could really make huge differences and maybe even add to a body of evidence more rapidly than previously we could have imagined!
We have many health care programs, services, roles, professions, agencies … operating in silos … taking up almost half the provincial budget … during a major period of international fiscal constraint due to massive historical overspending … probably a good time to take stock and refocus much of what we do.
How do we constructively establish a health transformation agenda (and temporary agency) to engage the often competing stakeholders … with a core objective of rationalizing and realigning health care services, policies & regulations, structures and funding across the many silos currently operating in both primary care and more traditional hospital based services?
There is no shortage of options, international comparisons, supporting rhetoric and selective use of statistics and facts… but polarized positions on what the overriding themes and changes that we need to operationalize?
Maybe our challenge lays in: establishing broadly acceptable goals; engaging credible stakeholder representatives who seek broader solutions; creating an interim structure and process for renegotiating the many regulatory, fiscal, professional and political silos; establishing a clear path for future development, and, sustaining the collective political will that is necessary to work together to build a preferred health care approach that will more effectively capitalize on the many existing strengths and abilities available in a more cohesive manner. The past is the past … what are we collectively doing to build a more cohesive and sustainable future?
Although the appeal of removing politics from our decision making is very appealing, I question how this would be operationalized in the immediate term and sustained in the medium and long term. Who would the arms length agency be ultimately accountable to? Who would run such an organization and what would the terms of reference be?
Isn’t politics part of the accountability equation to the citizens who vote their politicians into office and pay taxes to provide such services? Maybe we should question what is generally acceptable ‘politics’ and cynically accept as ‘just political behavior’?
Although creating an ‘arms length and non-political health care agency’ to stimulate needed changes – this can only work as an interim short term (few years) step – before the inherent politics inevitably re-emerges. How do we get agreement on: i) what changes ii)relative priorities ii) resource allocations iii) who is and is not included in the decision making iv) how is this operationalized across Ontario v) how are rigorously and honorable counter proposals considered …. all are inherently politically charged … so how do we go about engaging diversity of perspectives … constructively?
We cannot avoid the basic fact that people are inherently political (i.e. try to influence others to support what they believe in) – our fundamental choice individually and collectively is to decide what is acceptable ‘politics’ and acceptable political behaviors with the ability to evoke sanctions -social, electoral, professional, regulatory, legal … if warranted …. another hotly ‘political’ area.
Why don’t we strive to create a political environment that expects we collectively tackle any health care issue through rigorous evidence based, respectful, transparent debate of the issue followed by the creation of compassionate health care service delivery models that primarily serves the health care needs of the people needing this care? Why can’t we expect of ourselves and each other that we provide health care in the most cost effective and humane manner? Why not?
I’m pretty cynical about the state of politics and the political class these days. Not the average joe backbencher who really believes that politics is about representing her or his constituency but the political class whose life long journey has been politics, often ideologically driven. That’s another discussion.
About accountability – such an agency would be accountable to society at large and have a relationship with government in terms of discussing the size of the funding envelope. I would point you to Oregon – where a 20 year iterative process has been going on. The public was involved initially in a 2 year education process about health system and funding and makes iterative decisions on what will be paid for an what will not – the results will likely surprise you.
Politics is not accountable to citizens at large – politics has become accountable to the most strident voice, the largest demographic group, the media whipping of the day, the person who can best manipulate the media to get what they think they need. Witness the furor around liberation therapy with little real evidence that it works.
So although we can’t avoid the prediliction of people to be political, if the agency is set up well, has the right governance and accountability mechanisms, is consultative and thoughtful, tough but seen as fair – why can’t it work? I’m not here to tell you the how, I”m here to suggest the what. Clearly what we have now doesn’t work as well as we would expect, why should we apathetically accept it? The Bank of Canada works and we trust it to do it’s job. You can’t go to the media and lobby to have the interest rates raised because your investments are doing poorly – it simply doesn’t work that way. It has clear targets (control inflation at 2 percent for example) and has mechanisms to effect that goal.
Politics can’t be changed because it has become a reflection of ourselves – we need an organization that is better than us to do for us what we cannot.
I agree with most of your observation – particularly your last statement. However, I hope we do not all just throw our hands up in the air and hope somehow it will all get resolved … if good people with good ideas, honorable intentions and expertise do this we are in very deep trouble as a health system and society. Politics always is a reflection of ourselves and the society we are creating together … sometimes hard to look … but no more challenging than the excruciating ethical positions health care places these same people in every day of their career. Watching front line staff respond to SARS, a paramedic working in a major multi-vehicle traffic accident scene, a cancer surgeon or ICU nurse having to tell a parent their child is terminally ill … yet every day these people find the strength and courage and humanity to return year after year. Most retain their humanity, some become hardened and cynical, most see a higher purpose in their work. My question is why have we as a society that created such an incredible human undertaking become distracted by political and other scandles, allow greed and status to undermine our collective efforts … we all looked away and stopped demanding constructive political dialogue within the health sector and with other parts of society. We can do better … one person at a time … the simple truth is that politics will always be a reflection of our choices … lets choose wisely and humanely … and see what we can all build now that the times are a’ changing…
Oh what a complicated issue – and I’m glad for it. I suppose on the spectrum I’m more Hobbsian than Millsian in my outlook. Politics has become circus, a forum for ideological endeavour, where ideology trumps pragmatic and thoughtful discourse almost every time. And the thoughtful citizenry now devotes to politicians the amount of time they deserve while the radicals on all sides advocate for their ideas as the way everyone else should live.
I think if you look at health politics on the micro and meso level, good people don’t get involved because of two issues – the pattern of people who have are involved and rewarded for that involvement, and either lack of understanding about how the system works or system literacy to allow them to do work within the system.
On the first, within health, I think many look at those in leadership and don’t see leadership, rather mediocre and uninspiring management without accountability, without professional improvement, without a sense that excellence is the expectation. We have a real problem in health of choosing leaders and managers based on time spent rather than the qualities that are necessary. Too many job descriptions, not enough job qualifications, no investment in training and development. And no committment to letting people go when they clearly are not doing or are not capable of their duties. And that comment it true for the clinical and administrative side alike.
On the second piece, system literacy, I think you have shown a great example of the problem. SARS, the trauma scene, the cancer patient – these are all examples of MANAGEMENT not leadership. Doctors for example are the ultimate managers – information hungry, detail oriented, risk averse – where leaders work with little information, see big ideas, and are willing to take risks for improvement. Doctors receive no system training while dental students have 1/3 of their time dedicated to how to run a dental practice – doctors receive none of this and receive no training on the complex system that they will be working in. It is a gross and damning failure of academic medicine – still mired in the idea of knowledge transfer and admission of the select few into the guild, totally oblivious to the reality that in 5 years all medical knowledge will be available publicly on a smart phone and that knowledge will no longer distinguish doctor from nurse from other.
I’d like a medical school to put a stake in the ground and say that it will train doctors to be health professionals in addition to being doctors. And I’d like that school to evaluate itself not on who becomes a doctor (they all do from everywhere) but how their graduates assume leadership positions and begin to influence the system.
A last and provocative point. Leadership and management systems for other professions are seen as a step up, for medicine they are seen as a step down – not as well paid as clinical medicine, derided by colleagues for “having gone to the dark side”. And the only qualification seems to be to have done some degree or program. From a business planning perspective, it seems to be all wrong.
Your thoughts are very provocative Mark and clearly grounded in first hand experience. Thank you for your honesty, obvious commitment and candor.
My basic premise is that health care reflects the values, culture and social structures of the country it is provided in. Health is inherently political – it reflects how we collectively allocate resources individually and amongst ourselves … which is inseparable from the underlying structures, biases and rationalizations we use to justify our decisions… not surprising there are many views on this.
How do we improve the quality and outcomes of the many health care decisions we make is really the question that remains on the table from my perspective? … at all levels starting with individuals through to longitudinal multinational randomized trials and cutting edge applications of scientific knowledge to health.
I would also suggest that BOTH management and leadership are necessary, but not sufficient, elements in todays rapidly evolving world of global instant international communications. Our current application of management and leadership tends to reflect more stable and predictable times … in a dynamic world. What will be the predominant organizing structures, methods, tools, policies and predominant values and ethics will guide future health care developments in future? To what end?
Do we have the necessary will to constructively work together and not squander the massive amounts of funding dedicated to health care in Ontario… jeopardizing other valued services and fundamental determinants of health.
I agree this will take profound Visionary Leadership… that is grounded and able to articulate a direction that will support the health needs and values of Canadians long into the future.
You are right this requires greater emphasis on competency based expectations and training for clinical and administrative leaders and managers at all levels. This also applies to technical staff, governing boards, policy level staff … as successful implementation requires higher performance at all levels.
From my vantage point, I think this would require a transitional non-partisan agency, like you are advocating for … much like a ‘Geneva Table’ used by international diplomats. This is honorable work. Unfortunately, health care structures and incentives have focused on financial gain and status as the predominant measures of success… often at the expense of the intrinsic values and rewards of serving others. What is the ‘right’ balance? … the choice is ours to be made as individuals and more broadly …
Thanks for the positive comments. To Rob, I agree exactly. We somehow denounce the idea of private enterprise in medicine and at the same time are happy with the health care system “not being run like a business”. I am on the opposite side of that argument – if it is to be a publicly provided and funded system then there is even greater argument to run it like a business. In it’s current form, it is an inefficient monolith that cannot deliver efficient, quality care. It should be run like a business with the same quality and efficiency dictates. For those who would criticize and say I’m in favour of not treating sick patients and similar drivel – if we value a publicly driven system and we are the owners (ie, the taxpayers) we should have the same expectations that investors do in any company – which is return on investment. That means the maximum out of every dollar, transparency, and accountability. Those demands would drive inefficient and ineffective providers and institutions out of business or seek them to find new leadership, new ways of doing business etc.
We need to run health care like it was a business that we owned. We don’t.
Please see the community driven model.
Where all your arguments are bubbled together. They are networked at each community unit. You understand how the systems work then. How an integrated, collaborative strategy works.
Take the hierarchy away.
Yes, train more about how to run an office and then “manage/executive style, MBA stye”. Yes, train more about how to communicate with people other than your own specialty. That is, work concretely within your community and learn how to apply the knowledge in real life at the ground (where the public are) level. It is amazing. It really drives it home! It forces you to do real problem solving!
I love this article by Mark MacLeod! It was well worth staying up late to read it and I guarantee just the idea of a healthcare system with an independent authority to run it will give me sweet dreams!
While this idea would require huge changes and bring with it massive challenges, in the long run without it our healthcare system is doomed to repeat the same mistakes and make new ones, and we will remain its powerless victims of its political machinery.
In Ontario while we wait and hope and dream and work for such big ideas to catch on, we would greatly benefit from having an independent oversight mechanism in place to add some accountability to the entire healthcare system, hospitals and long term care and nursing homes. That oversight is available to us anytime the government chooses to extend the mandate of the Ontario Ombudsman so that he and his team could conduct complaint investigations, and yet for 36 years no government has opted to do so. As it stands now, and has for decades, we are subjected to abuses by the healthcare system and we are expected to the stoicly bear the brunt without complaint, or if we do complain we cannot expect meaningful resolution. Not to mention the fallout politicians experience due to healthcare scandals, each era replete with them in long term care and nursing homes for instance that the ORNGE scandal of late has made some forget about, and that contribute to the public’s lack of confidence in political leadership. The polticians responsible for running our healthcare system seem to me to be a law unto themselves regarding decisions they make that affect us all.
Are we so powerless that we don’t feel it possible to think big and to insist upon change?
Ontario Ombudsman oversight of our healthcare system is not only necessary to help restore the public trust in it, it is possible, but only if politicians do the right thing and get out of the way of the will of the people they serve. It’s one a small seed of a big plan but once planted it could grow into bigger and better things for the future of healthcare in Ontario.
Your first paragraph pretty much describes the what private enterprise does every day.
Except health is not for sale.
I agree that taking politics (including the Ministry of Health and Long-Term Care bureaucrats) out of the loop is probably an excellent idea. However, keeping them out is probably insanely difficult as the Ontario Health System Restructuring Commission discovered at the end of its mandate. Regrettably the bureaucracy (bright people in a horrible situation) exists to provide political cover first and oversee services second, so do not transition them without completely new leadership The entity would need the power to compel not only funded agencies and but also professional associations to change practice and behaviour. As I said I think the idea is insanely difficult but the current reality is such that something new needs to be done. I have seen 20+ years of muddling through and all the evidence indicates that marginal changes are not enough. You have my vote.