Andrew Furey is an orthopedic surgeon.
He specializes in accident injuries. As Premier, he still spends a few days each month treating patients so he can keep his medical licence.
The process is pretty simple.
Someone shows up on a table in front of a surgeon like Furey with a specific complaint. The doctor figures out what is wrong , then fixes the complaint. Slide that injury out and slide another one in.
Some follow up work - maybe the patient spends a bit of time in hospital, maybe discharged with a few follow-up appointments - but eventually that person with that complaint is gone on their way with no more contact with the surgeon.
That’s transactional care.
John Haggie is different type of surgeon.
Same idea, though.
That’s transactional care. Happens over a short time. Has a narrow focus, usually centred on a single problem.
There’s another kind of care. It’s called relational or relationship-based care.
This is the care your dentist gives you. Or your pharmacist. Or your family doctor. Over a long time and involving lots of different kinds of issues. Even your dentist will treat you for different issues if you stay with her long enough.
Health care involves both types of care. This is the First Basic Idea to keep in mind. No matter whether you are talking about doctors, nurse practitioners, physiotherapists, psychologists, chiropractors, or pharmacists, they will all provide transactional care or relational care.
Second basic idea is that health care in Canada is delivered by both the public and private sectors. Most family doctors, pretty well all dentists, most pharmacists, a great many physios and so on run small businesses paid for insurance of one kind or another.
We are not just talking about Blue Cross or Manulife and the like. MCP is an insurance program, too. It covers some medical services but doctors also can charge patients directly for services MCP doesn’t cover. Drugs are paid for by public and private insurance programs, although in Canada publicly funded drug insurance programs only cover drugs and pharmacy service for some groups.
Third basic idea is to understand how health care evolved in Newfoundland and Labrador. From the time of Responsible Government in 1855 until the Commission Government in 1934, the Newfoundland government paid for hospitals, education, and social services - called public charities in the annual budgets - all run by the private sector with the exception of the General Hospital in St. John’s. The private hospitals as well as private doctors, pharmacists, and dentists charged people directly for services and most people in the country did not have ready access to any form of medical care.
The Commission Government introduced Cottage Hospitals around the island. People in communities along the coast paid a small annual fee, if they could, and could get care at the hospital. As the Heritage NL website describes it,
A distinguishing feature of the cottage hospital system was the creation of a type of health insurance. In order to receive treatment, a family or individual had to be “on the books” of the hospital, meaning they had paid a fee which entitled them to treatment. This fee was originally $10.00 per family or $5.00 per individual per year, which eventually increased to $15.00 and $7.50, respectively. In areas with nursing stations but no hospitals the fees were $3.00 for individuals and $6.00 for families. This was a variation of an outport practice where families would pay a fee to the local doctor every year through the merchant, which would cover the costs of the doctor's visits. The fees covered all medical procedures except for childbirth and dental work.
On the Great Northern Peninsula and in southern Labrador, the International Grenfell Association offered health care and ran an orphanage - these days misrepresented as a residential school - mostly for the non-Indigenous families.
After Confederation, the private hospitals and health services carried on. The new provincial government started building new hospitals in major centres to go with the cottage hospitals. The major change came in the 1990s when the provincial government took over the private hospitals and organized regional health authorities. The idea was to create a health system that was locally governed and oriented to local needs in the same way economic development, education, and local government were being organized. The zones for each would line up, ideally, and help to break down both the way provincial government ruled everything centrally (from St. John’s) and in silos, one department disconnected from the other.
That was the thinking that lay behind the 1992 Strategic Economic Plan and other government reforms of the time. The same thinking also ran through the companion 1995 Strategic Social Plan. That plan also wanted to shift health care away from the dominance of bricks-and-mortar to allow for more private sector delivery.
The 1995 plan for health care was based on three basic ideas. First, the population would inevitably be much smaller and much older than the one in 1992, eventually having more people over 65 and under 15 than in the ages in between who would be the prime economic producers. Second, all those old people would drive up the cost of both acute and long-term care.
Third, and most importantly, even with more money coming from oil, and potentially from the federal government, the pressure on health care spending would become unsustainable. We’d never be able to find enough money to meet all the demands if we continued to deliver health care the same old way.
That same old way – now mostly government owned and run - consumed two thirds of the health budget in the 1990s. It was also sluggish and notoriously inefficient. The solution would be to encourage more private sector delivery. In long-term care, for example, things would shift to what is now called aging in place: people would stay in their homes and get the care they needed from a beefed up home-care sector and stronger family-oriented medical practices based in communities rather than buildings.
That plan never got out the door. One of the last things the Wells cabinet did before Clydeleft office was approve their version of the strategic social plan for release. The first thing Brian Tobin did was cancel that and order officials to destroy copies of the plan. Thankfully, some survived. What appeared in 1997, instead, was a strategic plan that will look very familiar to people today because it and all the assumptions behind it are in the health accord. No surprise in either case that government relied on champions of the status quo to head both planning efforts: Penelope Rowe in 1997 and Elizabeth Davis in 2021. People are policy and you cannot get new ideas from people whose every instinct is to keep everything as it is.
Both the 1997 and 2022 plans share two features: Firstly, and chiefly, the emphasis on preventative medicine, now called “social determinants of health”. The second is the related shift of attention away from the day-to-day costs and operations of the current system and onto issues that won’t bear fruit – if they bear any fruit - for decades into the future. All of the innovation in service delivery and in the centrally controlled bureaucracy from 1995 disappeared. What 1997 and 2022 keep is the reliance on a heath care system dominated by a heavily centralized bureaucracy. That wasn’t an accident in either case.
Andrew Furey likes to say the health system is broken. It is broken, in some ways, but that doesn’t explain why he picked the people who broke it to fix it. And it doesn’t really explain why the old system stopped working and cannot work in the future.
One of the big reasons the system cannot continue is that the 1997 and 2022 approaches simply carried on with the same assumptions as the earlier models. That included the primacy of government bureaucracy as well as the assumptions about communities that went with it. There was no allowance for change.
On the financial side, we still cannot afford it. The 1992 forecasts all played out. Health care costs continue to climb as the population ages and, despite having both oil revenue way above the 1992 assumptions, health spending continues to strain the available funds. Health spending consumes 40% of the 2022 budget compared to about 25% in early-mid-1990s. And as a share of health spending, the bricks-and-mortar bureaucracy of regional health authorities now eats 76% of compared to 66% 30 years ago.
Those changes are beyond just the rate of inflation. In 1995, the government spent less than $1 billion of a $3.5 billion budget on the health department. That’s equal to $1.5 billion today, when the health budget alone is equal to the entire provincial budget 25 years ago. And the relative share 40% today versus 25% of all spending then - is not merely result of natural growth, however anyone might want to define. The growth in the bricks-and-mortar share of health spending shows how much consolidation of health authorities doesn’t save money at all. It just consolidates more and more power in the hands of fewer and fewer people
Demographic changes over the past 25 years have mapped precisely what government officials forecast 30 years ago. They are clear in 1997 as birthrates declined and people left the province or moved into larger centres. Yet in the late 1990s, the provincial government diverted money to replace Western Memorial Hospital to equip a full-service hospital in Stephenville that included a maternity Ward when births were declining. It was based on old assumptions about the population as well as the political one that would not allow change. The Stephenville hospital struggled for years to recruit enough doctors, never managing to keep the place fully staffed or providing all the services government promised. Meanwhile, the major hospital on the west coast struggles to work in facilities that were outdated 25 years ago. The replacement hospital was a featured promised in 2007 and remains unfinished 15 years and four election cycles later.
Bureaucracy is about power. Power is control. And the one thing bureaucrats want to control more than anything is money. Those simple relationships explain the growth in health care spending over the past 25 years and the relative changes to spending on bureaucratic systems without seeing a corresponding improvement in actual health care. There are few specific examples that show how deeply entrenched the power and money relationship is within health care.
Many surgical procedures can be done cheaply and effectively in private clinics. But Newfoundland and Labrador has been notorious among provinces in its fight against letting even simple procedures take place outside the bricks-and-mortar system. In the late 1990s, an entrepreneur in central Newfoundland wanted to offer mobile kidney dialysis along the coast of Newfoundland. Bear in mind this was a time when coastal communities were shrinking and the provincial government didn’t have much money to spend. The idea promised to improve access to vital care but it died from from both bureaucrats and unions, both of which insisted that the service could only be provided in a hospital by unionized workers.
The same thing happened recently with ophthalmologists and cataract surgery. So wild was the bureaucratic resistance to the notion that the health minister initially accused one doctor of being a crook. In its spittle-filled rage against the idea of surgery outside a hospital – and therefore the control of bureaucrats – the bureaucrats passed regulations that made illegal everything currently legal and made legal the one thing the cataract surgeries they didn’t want to legalise outside a hospital. They fixed it once someone pointed out the mistake. Eventually, the bureaucrats relented but they capped access to the service done in a private They won in the end.
Two years ago, the Centre for Health Information received a new way of connecting family doctors to specialists. A unit of Memorial’s medical school that specialized in the innovative use of technology in medicine took a program developed in Ontario, adapted it to Newfoundland and Labrador, and added new programming and features to take the whole project to a new level of capability and adaptability. The test program provided the new system improved access to care, reduced wait-times for patients needing care, reduced the patient load for specialists and saved the health system money.
The health department did two things: it capped the number of doctors who could use the system and it capped monthly billings for specialists as part of a standard cost-control approach. Although they knew the new system would reduce costs in the old referral system, the health bureaucrats preferred two systems with capped costs even though it was more costly and less efficient.
That leads us rather neatly to primary health care teams.
The idea isn’t new. They’ve been around for years as doctors, nurses, and pharmacists – among other health professionals – tried to shift the system in hospitals onto the street. The basic elements were there already. It was just slow for family doctors to deal with specialists, physios and others.
The ready solution was an electronic records system that linked health care providers together. eConsult - the system the health department is currently capping - was a natural evolution of those early ideas of collaboration among health providers outside a hospital. It allowed family doctors and nurse practitioners to consult with specialists, share information, confirm a preliminary diagnosis, and collectively sort out the best treatment for a particular patient. They all shared the same up-to-date medical information. And the referral systems took days not weeks or months.
Electronic records sharing and things like eConsult also overcame the rural-urban divide. A doctor or nurse practitioner working in an isolated community without other health professionals close by could now reach out to anyone in treating a patient. It was another innovation from a unit that grew at the medical school out of the efforts of doctors like Max Howse who pioneered what is now called telemedicine. Not only is eConsult being strangled in the government bureaucracy, by the way, but the medical school has abandoned technological innovation of the kind pioneered by doctors like Max Howse.
Since so much of health is in the public sector, there’s just no need to reinforce the private side of health care. There is just no for eConsult or innovations like it. The health bureaucracy will just use old fashioned software and methods since they are easier to manage. No change needed. That’s the beauty of power. You alone decide.
Other provinces use primary care teams run either by the government health system or in the private sector. In Ontario, for example, health teams target specific populations – like homeless people or Indigenous communities – that have unique issues handled more effectively by teams rather than the existing primary care approach. In Alberta, private sector teams work with different providers all in the one office. A combination of public and private insurance payers – MCP is an insurance program like all the others – works very well.
But in other provinces – including Newfoundland and Labrador – the payment system MCP uses make it very hard for private sector to adapt to a new team-based system with everyone under one roof. Funding has long been identified as a major barrier to the wider development of collaborative teams. Fee-for-service doctors must treat large numbers of patients to get the cash-flow needed to maintain small offices. Rewards for collaboration, even among family doctors in the same practice, are limited. And there is no funding through the government-operated insurance and payment scheme – MCP - that would cover the introduction of nurse practitioners into an established medical practice as the recent experience of NPs who set up their own practice makes clear. Again, when you own the pay system, it’s easy to ignore the little people and just do what you want. There is no incentive for a bureaucrat to support the private system, which competes for resources with the one you control. That’s true in times of plenty. It is doubly true when money is tight.
Eastern Health is not only the province’s largest health bureaucracy, it is now also the de facto core that will become the One Big Bureaucracy or OBB that will absorb the other health regions into it. Eventually, it will swallow the private sector as well. That’s where the collaborative teams come in. The provincial government has been touting its new teams approach as both the answer to a shortage of family doctors across the province but also as a model the rest of the country will follow.
The OBB teams are interesting if you look beyond the media lines to the details. Each team will have a geographic catchment area. A CBC backgrounder from last fall included smaller numbers about the size of the catchment population but in at least one recent interview an EH official used the figure 20,000. Let’s use that one because the math is easier.
All patients within that area will deal only with that team. If a family doctor has closed a private practice and joined the collaborative team, the patient will be assigned to a clinic regardless of whether or not their doctor is working at that clinic. There will be three doctors on the team as well as nurse practitioners and other health professionals. All will work for the regional health authority.
The team’s clinic will work like a walk-in clinic. Although OBB’s director of family practice told reporters recently that patients will be “attached to a provider”, in practice, no one will have a family doctor or any other primary care provider who sees them consistently over a long time. A patient who shows up with a complaint will see whoever is available to deal with that issue. If you toss out relational medicine, as OBB has done, even regular visits for refills or new tests or don’t need a doctor to do them or even a nurse practitioner. Given the number of patients and the potential for constant staff rotations within the OBB, the likelihood of any patient seeing the same person - let alone the same doctor or NP -to deal with a recurring issue is doubtful. Seeing the same person over several years would be almost impossible to count
It doesn’t take too much imagination to see the benefits of this to the folks running the OBB. They can immediately dismiss any claim anyone doesn’t have a family doctor. They will have a clinic to look after them. OBB can also move staff around easily to cover staff shortages for any reason. Right now, there’s a notional cost associated with moving doctors from one region to another to fill gaps. That will There are no downsides for the bureaucrats.
They will have easier control over costs. OBB will effectively absorb more of the health care budget. Eventually, it can replace the existing private sector health care service with a new bureaucratic one. The new OBB model will also solve all the problems identified in the move to teams - regulatory, funding, training, etc. - by simply defining them out of existence. Don’t have a family doctor? Poof. You don’t need one. No one has a family doctor. You now have a clinic. Patients are just inconveniences, anyway. Remember the two page news release about appointment reminders. Eastern spent a page and a half blaming patients for not remembering.
There’s also a tidy bureaucratic redefinition of human resource needs in all this. There are more than 600 family doctors in the province today. About 300 of them are supposedly seeing patients full-time. Either way, it would only take 26 clinics of 20,000 patients each to cover the entire province. That’s 76 doctors. Even if you allow for a few more clinics to cover large geographic areas like Labrador – there are fewer than 30, 000 people there in total – you still need far fewer doctors than the current system. Nurse practitioners are far cheaper again and the new clinics will likely use NPs to take up the workload from the doctors anyway. Lower cost and by redefining care to suit bureaucratic needs, problems melt away.
Some family doctors will also like the new team approach. New doctors have a different idea of what the job should involve. They like the steady paycheque, defined holidays, and fixed work hours without the complications of running a small business. That also fits with common attitudes to medicine among family doctors.
David Reuben and Christine Sinsky are American family doctors who work – respectively - for UCLA Medical Center and the American Medical Association. He’s in geriatrics. She’s vice president of “professional satisfaction.” In a 2018 paper for the Annals of Family Medicine, Reuben and Sinsky noted the changes in American medicine over the past 25 years.
Among the most important changes have been the shift in emphasis from acute to chronic illness care, the increased percentage of physicians who are employed by large medical groups and health systems, the exodus of many physicians from hospital care, the increase in patient access to health information (e.g., via the Internet), and the introduction of the electronic health record (EHR), …
On the face of it, that’s a big difference from Newfoundland and Labrador where the large health care bureaucracy – public not private – is absorbing more doctors. Many local doctors join the bureaucracy willingly.
What Reuben and Sinsky call transactional care is all the paperwork, data entry, and other grunt work that comes with bureaucracy. But in Canada and in the United States, it is also part of the business of running a private practice. That is flipped. What’s important to note is what they see as personalized care of patients, how they define being a doctor: “Physicians are experts in making diagnoses and initiating successful treatment (which may be implemented by other health professionals),….”
They would like to see doctors spend their time on these tasks:
customizing care for individual patients by synthesizing data from diverse, often discordant sources; adjudicating competing needs of multiple conditions; adjusting the treatment plan to align with patient’s personal preferences and goals, and working together with colleagues regarding mutual patients
None of that involves actually dealing with people. It’s managerial. Bureaucratic. It’s just differently bureaucratic compared to the grunt work Reuben and Sinsky say is taking doctors away from their true calling. And it is every bit as transactional as the care that OBB’s clinics will offer. Doctors in Canada, like doctors in the United States seem themselves less as people looking after patients and more as managers in a managerial system.
That’s not an accident. Newfoundland and Labrador is not immune to the larger trends in western society John Ralston Saul identified 30 years ago in Voltaire’s Bastards. What today’s elite claim is reason or evidence-based decisions “is no more than an administrative method.” The result is “a vast, incomprehensible, direction-less machine, run by process-minded experts – ‘Voltaire’s bastards’ – whose cult of scientific management is bereft of both sense and morality.” That is the only way one can define the practice of medicine as data management, as Reuben and Sinsky do, or more telling, as the job of figuring out what is wrong with a person and telling someone else - that is, the person actually dealing with the patient personally - how to fix it. That’s the OBB collaborative team model.
Nor are doctors immune to the trends in teaching that defines medicine as a process. Diagnosis by flow chart or decision-trees is a common technique in health professional schools these days. The medium conveys the message very well: decisions are mechanistic. The final result must be correct if individuals follow the correct process to find it. Training reinforces conformity and orderliness in a bureaucratic context.
In Newfoundland and Labrador, those international trends are either more obvious or amplified because of local social and political conditions. Outcome is less important than process. The idea is very familiar to bureaucrats, whether in government or in the military. The American Strategic Air Command was famous in the 1950s and 1960s for disciplining pilots who failed to follow the checklist for a given situation even if doing so would have meant the loss of the aircraft and the entire crew. In the early 1990s, the provincial government introduced quality management, which emphasized solutions not processes. It did not last long after 1995.
The local shift over the past 20 years toward a more corporatist society that suppresses dissent or divergent opinions has made it much easier for government bureaucracy to expand its dominance and control. Even opposition parties are co-opted into representing the same narrow band of interests within the dominant elite. That includes public sector unions and their political front in the provincial New Democratic Party. None will speak without a briefing by bureaucrats, which they later can parrot.
Since government officials make decisions behind closed doors, there is little chance for public opposition or even alternatives to emerge anyway. Government officials control the release of information and it isn’t unusual for them to keep important decisions secret. Take, for example, a decision by the provincial medical regulator – a government agency in all but name – to change the way it treats telemedicine.
Under the new administrative policy, medical care talks place where the doctor is. On the face of it this may seem like nothing. In practice, and with telemedicine becoming a more common way of filling gaps in medical care, this simple decision means that patients treated in Newfoundland and Labrador via video link with a doctor in another province would have to deal with a medical regulator in another province to lay a complaint about the care they receive. The difficulty that will pose should be obvious. It is easy to make decisions when no one knows what you are doing.
When alternatives do turn up, they can be immediately dismissed as marginal, improper, or dangerous. Take the case of the ophthalmologists as typical.. Alternate ideas are first suppressed with the force of law. Even when the government relented and allowed some surgeries to take place in clinics, the bureaucracy still capped the amount of work done outside its immediate control.
There’s no surprise that some doctors - all of them recent medical graduates - turned up in local media praising the the new collaborative health teams. Some of the doctors are Eastern Health employees. One of them is the Premier’s sister.
What makes their love of the EH version of collaborative teams stand out is not so much their personal connections to the teams and the bureaucracy behind them but that they reflect the way they have been taught to think about what they do for a living. It is mechanistic. It is about process. Medicine as a machine. Health care as a transaction. The patterns are unmistakable.
The collaborative teams will make it easier, as trends evolve, to replace doctors with not merely nurse practitioners but with computers. Computers are much better at sorting through numbers and following “if this, then this” logic than humans. That’s where medicine is headed. NPs won’t fare any better. They are facing the same threats as they follow a model of education that copies that of pharmacists and doctors. Bashing together the three health schools at Memorial makes since since their approach to health care makes the individual streams of medicine, nursing, or pharmacy only a difference of grammar, not of logic.
For OBB, it’s not surprising they picked a transactional model for health care. It’s what hospitals do and all the people who manage health authorities - doctors, nurses, MBAs - all work in a world of transactions at hospitals. Even their family medicine folks don’t practice medicine like their colleagues in the private sector. Money, which is the centre of EH’s management universe, is literally about transactions. You can the pattern of thought that follows. When you are a hammer, everything looks like a nail.
Nor is it surprising the politicians have fallen in line with the One Big Bureaucracy. Since the provincial health department is dominated by regional health bureaucrats or former health authority bureaucrats, they simply push what they know best. They redefine words to mean what suits their purpose, changing the goals to fit their desired outcomes. The politicians cannot challenge technocratic expertise. That would be like questioning Saint Janice and her holy orders during COVID. This is a hierarchical society with technocratic expertise giving unquestionable authority. And if the are doctors, they are already co-opted in the way they think.
The power of the health bureaucracy is staggering. When you control 76% of the government’s health spending budget, you command far more attention from politicians than the family doctors treating patients in private clinics all over the province who - at best - account for only about 25% of what the regional health authorities spend.
The politicians have no way to think of anything else, even if, by some weird turn of events, they even wanted to change the current system. Of course, when the top of the provincial political system is already an integral part of the health bureaucracy, that isn’t a worry at all that the bureaucracy’s plan will change.
Few other places will follow the collaborative model pushed by OBB. That’s because it can only succeed in the tory corporatist culture of this province. Think of it like Muskrat Falls, breast cancer, or the recent hack. All came from the way of thinking. All are examples of what not to do. And the people behind it - or their heirs - are thinking in the same way even though they call that change.
Create your profile
Only paid subscribers can comment on this post
Check your email
For your security, we need to re-authenticate you.
Click the link we sent to , or click here to sign in.