The 2021 Health Care Crisis

Complex problems, bureaucratic complications, and missing political leadership

Ok.

So John Haggie didn’t lie when he told NTV in August he had a secret plan to fight the doctor shortage crisis.

He just bullshitted.

Big time.

Two weeks after the province’s medical association outed Haggie’s nose puller for what it was, he turned up on the St. John’s Morning Show.

Now likely Haggie figured this would be a lazy interview. Townie Morning is not exactly a hotbed of cutting edge journalism these days.

Most importantly, host Ramraajh Sharvendiran wasn’t Ted Blades, host of the province-wide show On the Go, who had complained publicly that Haggie was ducking Blade’s request for an interview with Haggie. The interview was a subtle frig you to Blades.

Woulda worked too, if Sharvendiran hadn’t turned out to be a tough customer.

Listen to the interview. Almost 15 minutes. Cutting John off in midstream when he wasn’t answering simple questions. Countering Haggie’s talking points with facts about the backlog of orphan patients at a clinic to take care of the thousands of orphan patients in metro. It was fun to listen to compared to the job-application puffballs politicians often get these days.

John claimed in the summer he was working on short-, medium-, and long-term plans.

Well,  the short-term plan is whatever the health authorities slap together every day to fill in for the latest doctor who left.

Not really a plan at all.

The medium-term plan was whatever talks John and his officials have with the medical association now and again about how to find new doctors and keep them.

Nope. Not a plan, either.

And the long-term stuff was coming from neutered reformer Pat Parfrey and his minder, arch-bureaucrat Sister Elizabeth.

Again:  not a plan to find more doctors, as Haggie well knows.

Parfrey wanted to make actual changes in Haggie’s department. Haggie told everyone who would listen to frig off. No way. He would not allow it.

The department was *his* to run. No way The Mancunian is gonna let anyone tell him how to run it either. Not some junior saw bones and certainly not some kidney man.

The most de facto Premier Haggie would let de jure Premier Andrew Furey do is cobble together some bureaucrats  and union bosses to chatter about social determinants of health. In other words, they could talk as long as they wanted about nothing that would change the way health care works in the province.

Meanwhile, almost 20% of the province’s people don’t have a family doctor, nothing is changing in a health system that’s desperately needed change for decades, and, last week  the province’s medical association cut off talks with the province on a contract they’ve been negotiating for four years.

Haggie didn’t face reporters’ questions about the breakdown with the province’s doctors.

No.

The former president of the national *and* provincial medical associations and the guy whose department actually negotiates with doctors gave doctors in the province and the public the finger.

He let the finance minister take the bullets.

Siobhan Coady had some talking points, which she delivered bravely and earnestly, if ineffectively. Unfortunately for her,  the talking points coupled with Haggie’s performance made it clear the government doesn’t have a clue what to do to fix serious problems in health care.

The result is that the province heads into the fall sitting of the legislature that starts today with a major political crisis on top of the lingering, and unresolved health problems everyone *except* the folks in government call a crisis.

Haggie was right when he said the problems in health care today aren’t caused by one thing. Even the issue that’s on everyone’s mind right now – a shortage of family doctors –  comes for several things at once.

There are the immediate problems of COVID. Doctors have changed how they see patients. Some doctors have retired or scaled back their practice, too, just the same way people in other businesses that deal with the public have changed.

Part of that is because of money. Family doctors in Newfoundland and Labrador run small businesses. They get paid by the provincial government. They make the lowest of family doctors in Canada. Rather than pay them the same rate to treat patients by telephone or video conference during COVID,  the provincial government set up a new fee code that paid them less for the virtual visit than they’d get for a face-to-face.

And then the bureaucrats told doctors they could only see so many patients that way each day.

Bingo.

That lowered the number of patients doctors could or would see in a day.

A bigger part of the problem has been around for a while. The doctors in our province are like their patients:  they are older. In 2014,  about half the doctors in the province were aged 50 years or over. There were a couple aged over 90, at the time. There were six doctors aged between 80 and 90. There was a pile in their 70s. The big knot – the folks shouldering a big chunk of the family practice load  -  were the docs in their 50s and 60s. They are the face of primary health care.

That meant – in 2014, mind you – that over the next 15 years, there’d be an issue as doctors aged out of practice anyway. We are now halfway down that timeline and not much has happened to replace all those family doctors.

There’s a big catch in replacing them. Younger doctors don’t practice the same way older doctors do. The polite way to put it is that they have different expectations. Younger doctors don’t want to see as many patients and they don’t want to spend as much time at work as the older doctors who are in practice today.

They aren’t fond of general practice. They like to focus on things maternity, sports medicine, or palliative care that are potentially more lucrative. Some head for the emergency room where, at the very least, there is a routine of shift work and lots of nurses, pharmacists, and specialists ready at hand to back up the doctor and help carry the work load.  They prefer urban over rural for a whole bunch of reasons.

They talk teams, which is what they’ve been taught. The problem is that teams like they have in hospitals don’t exist on the street and they aren’t likely to exist any time soon. That means there’s a big gap between the reality of patient care and what young doctors learn. That’s an astonishing failure of  medical education.

The result is that even if you could lure a young graduate into family practice as it is today, it will take two to three times as many of them just to treat the existing patient load carried by a single family doctor today. In Newfoundland and Labrador, literally only a couple of the 30-odd that that just finished family practice training at Memorial will actually enter family practice here. We haven’t been recruiting new doctors to keep things as they are, so the expectations versus reality mismatch of new doctors will just complicate things even further.  

Put all that together and this is how the numbers fall out. There are 1332 doctors in the province today, according to finance minister Siobhan Coady. Roughly half of those are family doctors. The numbers are the same they’ve been for the past seven years.

And that is the problem.

The folks in health care have known about the problem for more than a decade. They did nothing to fix it.

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The causes of the problems are complicated. The obstacles to a solution are complicated too.

Listen to Haggie’s Morning Show interview. He talks about hospitals and the province’s  regional health authorities. Wonderful stuff, except that family medicine happens outside hospitals and the regional health authorities.

Health care in Newfoundland and Labrador is dominated by bricks and mortar and the people who run them and work in them. That’s why Haggie – and every health minister before him – talks about the bricks and mortar. Health care in this province is all about the bureaucrats and unions.

You can see that bias in the make-up of the Health Accord team. All the people who created the current system – bureaucrats, politicians, and academics – with all the waste and inefficiency Pat Parfrey talks about are in charge of mapping out the route ahead. Money and empires are the order of the day in every bureaucracy so not surprisingly people are talking about money and building bigger and bigger empires. Policy is people and all those people drawing the pictures like the way things look today.

That mindset cascades down from lofty heights to the front lines. One program turned over to the department last October creates something closer to the kind of quick response from specialists that teams in hospitals can deliver. Trials showed it improves care and lowers costs. Yet, the project has gone no where and – as you might have guessed – bureaucrats have capped the monthly billings. The result is patients aren’t getting care they need in a timely way. What’s worse, rather than actually controlling costs, the government is running two systems at a cost higher than it should be.

Running through all of this are the problems at the political level. The popular idea is that Premiers run everything like kings used to do. Academics like Donald Savoie have pushed this idea for years. The reality is that every cabinet runs differently. Sometimes even within a particular cabinet different issues will get different handling depending on the issues involved and the power of the people involved around the cabinet table.

The month before Andrew Furey became Premier,  SRBP looked at the potential obstacles to meaningful change. One of them was a caucus that was “ leaky and fractured.”  It was an issue no matter which of the candidates took the job. “ John Abbott might find himself like Jim Bennett. Then again, Andrew Furey might find himself channeling Roger Grimes, who emerged from the 2001 leadership owing everybody and not having enough seats or goodies to give everyone the prize they think they deserve.” 

There was another element. The Liberal caucus is full of seasoned politicians. They weren’t in 2015 but by 2020 they’d been through the wars and killed the last leader who pissed them off. Both Furey and Abbott were newbies and neither likely impressed the saltier of the old caucus sweats.

The new Liberal leader needed to establish himself as the biggest, toughest politician in the room. Win the leadership with overwhelming popular support. Pick out the toughest in the school-yard or prison-yard – take whatever analogy you like – and take him down hard, just to get the others in line.

 Something impressive needed to happen.

It didn’t.

The opposite happened.

The election fiasco just made things worse.

The result is that – as with pretty well every cabinet and caucus  for the past decade – the current crowd running the place are less a monolith in lock step behind a dictator than a bunch of people generally ambling in the same direction.

To one extent or another that’s true of every cabinet and every caucus in every Westminster country. Some are tighter and some are looser than others. The looser ones don’t make for the most effective government. Furey and his head shed run one of the looser governments in a long string of ineffectual administrations.

Government is a machine with lots of moving parts, all of which have sharp edges. It’s hard to move the machine in the direction the politicians want when everything is working. When there is lots of friction – complex problem,  bureaucratic complications, and a lack of clear political direction – problems don’t get fixed. People inside government spend their time trying to keep from getting shredded on those sharp edges as the machine lumbers along.