Sister Elizabeth Davis used to run the regional health authority in and around St. John’s.
She famously confronted people upset by decisions taken in restructuring and re-organizing by telling them that that she had no connection or concern for the decisions she made. She got paid no matter.
Her claim was in part a psychological dodge, a way of passive-aggressively disarming her critics with the implication they had dirty self-interested motives while she herself was as pure as the driven snow.
What Davis said was true. She had a sinecure. She had no interest in what happened at all, meaning she got the same result no matter what she did. Liz could be brilliant or she could be a thud and she still got three squares and a warm bunk until she croaked.
That lack of interest bureaucrats get from their sinecures is not a virtue. Far from it. The lack of interest in or concern for the consequences of their decisions that classic bureaucrats display is exactly the root of most problems in the organizations they manage. They have no incentive save any personal desire to do good, which, as human psychology teaches us, is most often no incentive at all to stop stunnedness or worse from happening.
We know the species all too well in Newfoundland and Labrador.
Like Ed Martin and all the bonused-up managers who built Muskrat Falls.
I had one job, Martin told Richard Leblanc: build the dam and the power lines. Literally true. Didn’t matter if it worked or what it cost, implicitly. He just had to build it. And ed and all his fellow bureaucrats got a fat salary, massive “bonuses”, and an obscene severance package disconnected in any way from their actual performance. We know this because when the crowd currently running the place had had enough of the political damage from supporting bonuses for incompetence, they said other bureaucrats told them the politicians could not stop the bonuses people got for just showing up. They could have, by the way, but that’s another issue. All the managers had to do, in other words, was keep breathing and every couple of weeks they’d hear the cha-ching as their accounts got fatter and fatter, which they did right up to the second they stopped working at NALCOR and went off to some other cushy, high-paying job.
The 30 or so people who showed up one night last week to an update on the Health Accord heard the word manager and the word policy a lot.
Sister Liz started by reminding us all about the social determinants of health and why they were so important to the Health Accord she helped create. She talks about SDH like the Virgin whispered it to her one night in a mystical appearance floating above Waterford Bridge Road. The reality is that people have known about the impact of education, hosuing and the like on health care for decades and included in policies already.
Three things about that.
First, the Health Accord was supposed to be about health care spending *today* and over the next decade. Premier Andrew Furey put Sister Liz and Pat Parfrey together on the Health Accord in November 2020 to “reimagine the health care system in order to best deliver services to meet the needs of people in communities across the province” given the financial problems the provincial government has.
The release played down that bit of context about money but didn’t wipe it out altogether. “The Provincial Government has controlled health care expenditures,” the official announcement said, noting that health care is the “province’s largest annual investment” and that “the Canadian Institute for Health Information noted last year that Newfoundland and Labrador is a leader in Canada for managing health care expenditures.”
Second, the social determinants of health are not actually about health care spending today. The cost of health care now come from genetics, some luck, (two things we cannot change anyway) and decisions people made in the past (something we have been able to change in the past). So if we want to change health costs *today*, we had a shot at changing one of three factors but literally decades ago. Since neither Liz nor Pat built a time machine, we cannot do much to change the number of people with heart disease and cancer and other major illnesses *today* the treatment of which takes up so much of health spending *today.*
Third, the social determinants of health are not actually about health care spending and the health system at all, to be brutally frank. They are things like education, income, housing, food, clothing, attitudes, and so on, all of which influence how healthy people are. But they are not health care “investments” to use the political dodge-word or spending, to use the plain English one.
If you smell a rat at this point then your nose is working just fine. You see, Andrew Furey’s Health Accord put all the people who created the health system that isn’t working in charge of fixing it. Changing it. Transforming it. Reimaginging it. That was doing the same thing again and expecting a different outcome. Literally the definition of insanity. After all, we “cannot solve our problems with the same thinking we used to create them.” Even if Albert Einstein did not say it, the sentence resonates because so many find it to be intuitively true. We need to change policy - what we are doing - and to do that, we need to change thinking. People have a hard time changing how they think. Policy is people. Therefore…
Incidentally, when it comes to the social determinants of health, one of the big ones is education. We know that in Newfoundland and Labrador about half the people cannot read at a level needed to function in modern society and two thirds or more cannot do math at that modern survival level. Math includes logic of the kind we just walked through. If that, then this. So if you followed the logic and hit the right answer, bonus. If not, ask around. Out of every three people you ask, odds are one should be able to help you understand that to change the policy, you need to change the people making it. Not ask the same folks and bring back more who’d left and bring in others who have no relevant background.
Anyway, as your humble e- scribbler pointed out in April 2021, there was no surprise that “the Health Accord crowd thinks the biggest issue to tackle in health care is outside the health care system. They want to focus on the ‘social determinants’ of health….” Everyone at the Health Accord table “want[ed] to focus attention over the fence around their domain to what is happening in someone else’s yard.” Not an accident. And not an accident they are still talking about stuff that isn’t actual health care delivery today.
When Liz finished, Pat Parfrey started his slide show. Parfrey is an interesting character. Before he got sucked into the bureaucracy, Parfrey had lots of practical ideas about how to fix wasteful spending in health care. Most of it was about making simple changes - based on evidence - to what the people delivering care were doing. The obstacle Pat always ran into was that the health bureaucrats weren’t interested in actually doing those things. Doctors, nurses, and the like loved his stuff but the office-holders were none too keen on anyone upsetting their routines.
Now that he’s a health manager, Pat thinks we need more managers. That’s one of the things he proudly said at the update.
Another thing Pat did proudly was not to give an actual, verifiable, evidence-based update even though that’s what people expected. You see, a plan worth the name would have specific actions and a set of target dates for each. The update would be a simple sheet that showed the action, the target for implementation and where on the timeline you were to finishing it. Instead, Pat flashed up a slide that listed some actions but merely told us they were literally a couple done and a couple not touched yet. For everything else, they were developing “policy” with no hint when they might be done.
Another thing Pat did was point to meaningless examples of success. On housing Pat admitted that the housing crisis slipped by them all completely. Never saw it coming. They had a table that showed Newfoundland and Labrador with the highest rate of home ownership in the country so they figured the housing thing was sorted. So they got a big surprise when housing exploded in their faces last fall.
Logically that means they never asked anyone about housing. Logically, that means they likely didn’t ask about the other elements of the social determinants of health. Logically, that means the social determinants of health didn’t really drive the Health Accord at all. It was just a dodge. Yet for all that they missed, Pat had no trouble telling us that the Five Point Plan for Better Housing hobbled together in a panic in December was proof of the Health Accord’s brilliance.
Seriously.
He also talked about “Well-Being Week, the bit of fluff that so excited the bureaucrats that health minister Tom Osborne used that fact - that the bureaucrats were excited - as proof this Health Accord thingy was the bee’s knees. Nothing about actual lives saved, diseases cured, water turned to wine, or other assorted miracles. Just that people who do not actually care for patients were happy. Therefore: Goal!
No logic in any of it. Excited bureaucrats are like neutrinos mutating. Don’t understand the joke? Watch the video.
Another Pat Point was about an improvement in care for people who had strokes. We are now at the national average for that particular treatment, so yeah, that’s nice. The same story turned up on the news because the department issued a news release on it as part of their latest propaganda offensive during polling month.
Two things to remember, aside from the fact this is polling month, the time when da guv’mint knows a pollster is in the field and want to influence the results of the poll on its performance.
First, the Health Accord and the creation of the Big Borg Cube of Health Authority had precisely nothing to do with the stroke care improvements. The lovely chart Parfrey showed his audience that all the improvements started *before* either existed. Logically, that means - Indian Jones Redux - we could have done that and a lot more besides without any of the fuss, bother, and extra expense of the Accord and the re-organization.
Second, it took six years to move the needle on something that others were doing *before* 2018. This proves Parfrey’s old point, by the way, which is that there are lots of things we could do to improve actual health care *and* lower costs today, were it not for the sodding great pile of obstructions working in offices that have nothing to do with delivering care except hindering it.
And to confirm all that, Dave Diamond took the platform after Pat to tell his small audience he actually didn’t make many changes to health care organization once he became One of Twelve, otherwise known as the Cube’s Head. The reason was simple: it would disrupt important things. All the zones were the same as the old regional authorities, except in Eastern where he created an urban and a rural zone (something he could have done within the old Eastern Health authority) and add in a whole new layer of ubercrat vice presidents of reimagining this and transforming that, none of whom actually changed anything at all.
We know because the evidence shows it.
When the Globe asked the Cube to explain what happened with these ballooning costs for contract nurses, the Cube replied it could not comment because the decisions came from a different organization. Legally and factually untrue, as Dave affirmed. But just like the wait lists for procedures, they exist and don’t exist depending on what’s convenient for the Cube. Last week they existed because Dave needed to claim he’s cutting down the backlog of surgical procedures from COVID and other causes. A few years ago, there were no consequences at all from shutting down the provincial health system for two and a half months.
Another example of how things don’t change: Premier swans off to Dubai. Cube said last week that as a result of the Premier’s trip to Dubai to recruit nurses, the Cube made full-time job offers to almost 70 nurses currently working contracts in Dubai. Yay, hooray the trip was worth it, implicitly. And Furey made the difference.
Two problems. First, this is a routine recruiting thing and has been happening literally for decades. Put the fedora on Furey. He gets to play Indy this time and have no impact on the outcome.
Second, as the Ceeb reported - and again, consistent with decades of experience - fewer than half the nurses offered full-time jobs had written the licensing exam all immigrant nurses must pass to work in Canada. None had gone through the immigration process, either. When asked, the Cube’s VP of Reimaginary Recruiting said it would take a minimum of six months before any of them might start work here. Might.
What she didn’t say was that it would take longer since most of the nurses still had to write and pass the exams and all the other licence checks needed to make sure they were actually qualified to practice here. So minimum six months and maybe more like a year. And that’s the ones who actually stick with Newfoundland as their Canadian destination of choice.
What she also didn’t say was all of these contract nurses now working in places like Dubai apply to lots of countries and get offers from lots of places in those countries. Where they go is influenced by many things, including salary, benefits, working conditions, and so on. Ontario would inevitably be the destination of choice for most in Canada based on decades of experience.
Logically, then, out of the 70 or so offered jobs this time, fewer than half *might* wind up here upwards of a year from now, and out of that not very many are likely to “fall in love” with Newfoundland and stay as the Veep wished. That’s the recruiting equivalent of “and then magic happens,” which only happens in fairy tales, which is what Vee Pee H’aitch H’arr was actually giving us all, anyway.
In the midst of those stories, a hundred-odd local nurses graduating from the university told another all too familiar story going back to the last century. Only one in four of them had a job offer from the Cube and even that was only for temp work.
Not true the Cube shot back. They all have offers, although neither Vee Pee nor health minister reciting the notes she’d written for him could offer convincing let alone concrete proof the nurses were lying. “Any of those nurses who haven't gotten permanent jobs who want to replace those 20 agency nurses in St. John's, the health authority will hire them today,” the health minister said. Neat trick that would be since none of them are finished their training and cannot work legally without the nursing licence they’d get once they graduate and pass exams. No one asked anyone in the Cube to explain the logic of that line they used.
They all had offers, supposedly, right now but as CBC reported, “Debbie Molloy, N.L. Health Services' vice-president of human resources, said the health authority will be holding sessions with nursing school students to tell them about available opportunities.” So they don’t have offers but might get them in the future.
Then came the other bit. The tell. When bureaucrats are feeling on the defensive, guilty, and pressured, they fling accusations at their critics. Passive-aggressively. Not directly. Sister Liz did it. And the Veep of Unimaginative Worker-Chasing did it, co-opting the minister in the process. “We've actually incentivized a number of areas that are harder to recruit,” she said, “in hopes that someone will take a chance and, you know, try something that's a little outside, perhaps, [of] their comfort zone.”
It’s that sort of slimy innuendo - complainers don’t really want to work where the work is, or have other, hidden motives - that reveals the true culture inside the Cube, which is the root of the problem. It’s the same old culture that in the not-so-distant past had the health Cube not show up at all for jobs fairs where local graduates get charmed by all sorts of people looking to hire them away to exotic locales like Cape Breton.
Old Thinking =/= Change.
Old Thinking = More of The Same.
You see, contrary to Pat Parfrey’s wish, we do not need *more* health bureaucrats. We need different ones. Ones who think differently. Different thinking is the root of change. Pat used to think differently. Now he is just another ubercrat. Big title. Nice salary. Lots of meetings but nothing coming out of his head except the stuff someone else wrote for him. And he’s sandwiched between long-in-the-tooth ubercrats like he was on the panel the other night.
The thing is Pat must be miserable because he *knows* this stuff isn’t working. He knows sitting there as one of three updaters what he knew before which is that the Cube does what it’s always done. Like putting scanners in places where they cannot be properly used and supported, absorbing more drones into the Cube, reciting tired excuses.
Useless stuff, like changing the names of things constantly. Primary Health Care Teams became Community Care Teams became Family Care Teams before they even know what they are supposed to be doing.
FCT.
Nice acronym.
People like to pronounce acronyms.
FUBAR. Foo bar. Effed up beyond all recognition.
TARFU. Tar foo. Things are really effed up.
Maybe FCT will change. Maybe someone will notice that if Terrace In The Square can become TITS, then folks might pronounce FCT so it sounds like f*cked, which is what the whole Health Accord is anyway.
Great article Ed!
I would like for someone in government to start advocating for the end user - ie the one paying for this whole program, and who ultimately should benefit from the program. Seems to me that all the focus is on "the system" rather than the client.