Ken McGeorge: Too little, too late: restructuring in crisis leads to error

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Two health and long-term care issues have been prominent in New Brunswick media in the last few weeks. First, we had the medical society presentation of their ideas for health reform, to which the minister’s response, as reported on February 21, was that he would negotiate with them.

The second was the on-going issue of travel nurses and, yes, over 300 New Brunswick nurses have joined the travel nurse industry, and that is in addition to all those who have just thrown in the towel, retired early, or chosen other career directions. Recent stories from nurses who have moved to other provinces have been alarming.

Both represent crises created by years of indecision and failure to recognize emerging trends and population forecasts. The travesty is simply this: the health system is a very complex industry in which there are no simple solutions to anything. One of the areas of complexity is the large number of skills sets and professional groups required to maintain the vibrant health system required by the public. In these difficult areas, change does not take place on a dime, and promises of hiring and recruiting often don’t materialize as communicated.

At the core of the health and long-term care systems, medical and nursing professions are the most dominant both in numbers and in the key roles they play in the effectiveness of the system. Consequently, any thoughts of ensuring system success for future must have, at the core, a productive means for policy-makers and these professions to engage not only in periodic negotiations but in overseeing and managing system developments.

Primary health care is in a sorry state still with 60,000 New Brunswickers “without a family doctor.” That is the measure by which people have traditionally described the success or failure of the health system, and health care service has, for hundreds of years, commenced with primary care or at the desk of the family physician.

Suggesting that e-visit, other “apps,” or access to an after-hours clinic represent a substitute for good primary care is misleading and incorrect by any measure.

The NB Medical Society website said it was hopeful, with the announcements in 2021 of an emerging health plan, action and direction would be forthcoming. Since that time, now three years and counting, changes have largely involved window dressing in terms of real effectiveness.

Yet the situation the province faces has been evolving for nearly two decades or longer. Astute, informed observers have watched as the profile of medical practice has evolved and seeing that evolution, and armed with population profile forecasts, it would have been sensible for the medical society and government to have been engaged in serious discussions many, many years ago. Those discussions should not take the form of negotiations but a serious attempt to collaborate on the evolution of medical practice and the messages for public policy. These are not the type of discussions that go well on the front page of the paper or on TV news shows.

Similarly with the nursing profession. This noble profession, with the traditional image of Florence Nightingale at the core, has been known for well over 150 years for professional pride, diligence, attention to detail. As was outlined by the American Nurses Association in 1965, the recommendation for future was the creation of two levels of nursing. The Hall Commission in 1966 in Canada recommended a strong university nursing program as well as a “bedside nursing program.”

In the last few decades, nursing education has been predominantly a university issue, contrasted with the conventional hospital based, three-year nursing programs that were the long-standing tradition. The Licensed Practical Nursing Program has grown from apprenticeship to a full two-year diploma program offered by community and other certified colleges.

For many years in some hospitals in New Brunswick, the engagement of LPNs was not a factor which meant all nursing positions were filled by university graduates of quality four-year degree programs. New Brunswick began to see the re-emergence of LPNs in hospitals and their prominence in nursing homes in the 1990s. It was an important strategy for patient care.

Unlike the medical profession, the nursing profession is regulated by the Nurses Association while the terms of engagement, compensation and workplace policy has been negotiated at the table between government and union negotiators.

Having invested many days and weeks at the negotiating table with local and provincial bargaining as well as labour board and arbitration sessions, I can say categorically the bargaining table is not the place to have dialogue about the evolution of professions and public policy ramifications. Not a chance. But it is a process that must be respected, it just is not the place for high-level public policy discussion.

Rather, important and critical public policy discussions should be taking place in an environment in which trust is developed, both “sides” respect each other for their unique contributions to the health of the population, the discussions focus on public policy directions and what is the best interests of the health of the population. These high-level discussions then will yield elements that need to be negotiated into contractual provisions, but that needs to happen in a different forum, the bargaining table. The university faculties of nursing and college administrators all have some keen interest in and influence on training which usually is funneled through the Department of Post Secondary Education and Labour, not with the Departments of Health, Social Development nor the health authorities.

Just as government is so well known for its “silos” that mitigate against communication and efficiency, so are the professional development systems. Community colleges operate under one set of regulations and legislation with the normal complexity of two distinct language organizational issues. Private colleges similarly, and universities operate in an entirely different legislative framework and policy development structure.

Medicine is also an extraordinarily complex piece of business with the university structure, university senate, faculty councils in addition to medical society and regulatory structure.

To suggest the process of dialogue is easy would be irresponsible and that is why good dialogue and collaboration requires great skill, wisdom, experience, and knowledge. This level of discussion and policy exploration requires knowledge, skill, experience that is quite rare. That is why, in some jurisdictions, other skills are brought to the table such as the Health Care Restructuring Commission in Ontario.

Any hope of success requires those at the table be those who have no stake in any political agenda. No photo-ops, but participants must have skills of tact, diplomacy, creative thinking and an abundance of knowledge of the elements of good primary care world wide.

Right here in Canada we have had the Sault Ste Marie Clinic that was described by Roy Romanow as “Canada’s best kept secret in primary care.” And that was 22 years ago. This model of interdisciplinary care has now become very common in other jurisdictions in Canada and is seeing some development in New Brunswick which is encouraging.

There is and must be, in New Brunswick, a new and improved means of developing and executing public policy in health and long-term care.

Ken McGeorge, BS,DHA,CHE is a retired career health care CEO, part time consultant, and columnist with Brunswick News; he is the author of Health Care Reform in New Brunswick and may be reached at kenmcgeorge44@outlook.com or www.kenmcgeorge.com