Nova Scotia Healthcare Solutions Paper A Start

The reset button needs to be pushed at the Nova Scotia Health Authority (NSHA).

We have had enough and we are not going to take it any more was the call from
the podium on Sunday afternoon in Sydney Mines (with the Minister of Health in the
audience). 80 doctors had signed a declaration requiring immediate response from the NSHA
and government to stop any further deterioration in healthcare in Cape Breton Regional
Municipality. 600 local residents showed up in support. Note that doctors presented essentially
the same message about Cape Breton health care services one year ago in a similar forum to
the same audience imploring the NSHAs management to act. It is no wonder people are
frustrated with the current situation.

There are a rapidly growing number of cases, both published in the media and shared privately
about the non-system disconnected, not communicating, non-agile, non-people-centred as
well as front-line staff and managers who feel helpless and unable to effect the changes that
they know have to happen.

The NSHA has quickly become a bureaucratic nonsystem which cannot respond quickly on
behalf of dying or very ill people. Instead timely decisions are lost in complicated and irrational
top down program bureaucracies. Department of Health and Wellness (DHW) goal of less
administration has actually resulted in far greater confusion and more layers of approvals. The
NSHA expects patients to fit its distribution of services, policies, and procedures, without
explaining the rationale, or adequately involving patients and providers in the planning,
implementation, and review. How is this patient-centred?

Our aging population, and its impact on healthcare resources, has been anticipated for the last
30-40 years. It is extraordinary that we are so unprepared for this natural evolution when every
other sector of the economy has seen it coming and has changed. Our growing lack of
confidence has contributed to significant doubt in the ability of the DHW to manage our health
system effectively.

How is it possible that the NSHA and DHW say they are coping well when patients, families,
and front-line providers day-to-day real experiences are poorly managed? Most communication
is reactive damage control instead of proactive and inclusive. Without truth, there is no trust;
without trust there is no meaningful relationship; without meaningful relationships there is no
path to change.

Collapsing the 9 district health boards into the NHSA while balancing the provincial budget were
election promises of the Liberal government. Both goals have been achieved with considerable
fanfare. But what is the cost short and long term?

In the 2015-2016 Statement of Mandate published by the DHW, The Health Authorities Act
established the roles and responsibilities of the Department, the newly established Nova Scotia
Health Authority (NSHA) and the Izaak Walton Killam Health Centre (IWK).
DHW is responsible for:

providing leadership for the health system by setting the strategic policy direction,
priorities and standards for the health system.
ensuring accountability for funding and for the measuring and monitoring of health-
system performance.

The NSHA & IWK are responsible for:

governing, managing and providing health services in the Province and implementing
the strategic direction set out in the provincial health plan
Engaging with the communities they serve, through the community health boards.

It is the last point where the NSHA has failed.

Positive and exemplary work done by previous governments has effectively been structurally
dismantled within DHW. As a consequence data on which pivotal decisions were made is now
out of date because critical human resources and accurate data sets are not available within the
DHW. One of the consequences is medical and nursing human resource planning which has not
kept up with demand. This has led to reduced access to timely patient-care.

Recommendations:

1. Politicians do not have in depth knowledge about health care and should not be
expected to provide solutions to complex, interconnected processes within the health
care system. The public knows this. It appears that political interference in the day-to-
day operation of healthcare in Nova Scotia is far too frequent. People within the NSHA
report that many decisions must be vetted by the premiers office. If true it questions the
very reason the NSHA was created to be an arms length independent body.
Furthermore, why are politicians announcing the creation of health centres, dialysis
units, and changes in service modeling when the NSHA is supposed to be managing
routine healthcare delivery? Stop the political interference in healthcare delivery.

2. GOVERNANCE: The need for governance exists whenever a group of people come
together to accomplish a goal. There are three dimensions authority, decision-making,
and accountability. It is the most important structure to get right, like a house foundation.

In 2016, the NSHA was responsible for the allocation of $2.074 billion and management
of 23,400 employees. In addition, physicians and myriad other variables must be aligned
in a common vision and mission safe, high quality patient care.

Good governance starts with a strong, representative Board of Governors. It is ultimately

responsible and accountable for ensuring timely, equitable delivery of care. It does so by
hiring the Chief Executive Officer (CEO), vetting the senior leadership team, overseeing
operational governance and ensuring sound quality of care and fiscal policies. The
present NSHA Board is invisible to the public to whom it is ultimately responsible.
Meetings are not open. What is discussed is not available. They do not represent a
broad section of Nova Scotians. There is no current healthcare expertise. Board
members are all very well connected and unlikely to experience the same healthcare
non-system challenges that the average person must navigate. Problematic is the fact
that the current board was not involved in choosing or vetting the senior management
 team of the NSHA.

In contrast, the IWK Board of Governance has had representation from nursing,
medicine and the broader public for decades.

The 2016 NSHA organizational structure runs over eight pages of microscopic font. It
appears to be a spaghetti of overlapping, top heavy roles. Job One for a new
government is to build a new governance structure based on current and future reality.
Meaningful input from the public is critical to informed decision making and to align the
vision of governance with real-people experiences and actual service delivery.
Physicians, nurses and allied health workers on the front line know a lot about
healthcare but are left out of the decision tree. That needs to change immediately. In
small countries like Sweden and the Netherlands, centralizing decision making in health
care failed as a strategy. Nova Scotia is a small province with less than a million people.
It compares well to Sweden and the Netherlands in geography. They have returned to a
decentralized operational model where local people make the decisions based on
national objectives and benchmarks. They have recognized that a one size fits all
approach does not work. Management has to be agile, competent, aggressive,
anticipatory and guided by the mantra, think globally but act locally. It must be held
accountable for decisions. We do not have to re-invent the wheel in Nova Scotia.

The Board of Directors needs to be overhauled and reincarnated as a body with content
expertise in health, real public representation, and with an accountability framework
where maintaining the health and productivity of the population is the focus. It should
open its regular meetings and post meeting minutes for the taxpaying public.

3. Four functional zones should be created immediately to enable clinical decision making
closer to the unique needs of each region. If the rally on Sunday May 7 has taught us
anything, it is that decisions made in Halifax, without a clear understanding of the day-to-
day life in Cape Breton (or any other region in NS) can lead to declining access to quality
care and united community dissatisfaction.

a. Every attempt should be made to assure that all Nova Scotians get the same
access to evidenced-based healthcare regardless of location.
b. Leverage purchasing power and standardization of medical equipment by
streamlining procurement and supply management
c. Centralize some functions of human resource management, such as payroll and
collective bargaining, but enable zones to match patient needs with available
human resources, allowing local problem solving, combinations of health
professions and scopes of practice.

4. A broad based inter-professional clinical advisory group should be regularly consulted to

provide meaningful input to the NSHA, its board of directors and the DHW. This would
provide a check and balance in large public organizations like the NSHA. It also creates
a group that has expertise in providing overall system-level advice.

5. Emergency plans to address access-block need to be developed within six to nine

months in each zone. The plans should not be a one size fits all solution but rather
community and zone specific. Each zone has different priorities of health needs and
different mixes of health professionals. Collaborations and sharing of resources
people, equipment, facilities, will need to be considered. For a time, extra resources may
 need to be committed to a specific zone to address priorities identified by that zone. The
plans should focus on:

a. Access to primary care physician and non-physician. While collaborative care

teams may be appropriate in some jurisdictions, the NSHA must be open to a
wide variety of primary care options that address local patient needs, achieve
expected health outcomes, and are fiscally responsible. Again one size DOES
NOT fit all. Each zone should identify their current inventory of primary care
services.
b. Access to home care, temporary respite, and long term care. What creative
options are there in communities? This is a critical need today that is growing.
c. Access to joint replacement first start with rapid access to initial assessment
who really needs surgery? For example, a multidisciplinary mobile unit could
assess and triage patients to identify those better served by supervised weight
loss and/or physical conditioning. For surgical candidates - condition patients
pre- and post-op to maximize surgical outcomes. NS is leading the country in
some of our wait list times. We must think out of the box to address this crisis.
d. Access to timely emergency care how will that be assured using present
assets, both fixed and mobile and available human resources?

6. Develop an outcomes framework, modeled on the work done since the mid-2000s by
the National Health Service in the UK (https://www.gov.uk/government/publications/nhs-
outcomes-framework-2016-to-2017) It is critical to evaluate what works and what doesnt
so we can continuously improve over time.

7. People do not naturally embrace change they need a lot of help. What has been
happening in healthcare across Canada is social change on a grand scale. Nova Scotia
is no exception. We need far more complex system design and function experts. The
NSHA should incorporate industrial engineers where daily front-line decisions are being
made. In 2017, patient care requires continuous patient flow through a complicated
system. Furthermore, psychologists should be part of HR departments and should be
included in all change-management processes. Healthcare into the future will require
continuous change, just as technology, work, and social structures are rapidly changing
around us. We must continue to adapt. Changing health care is really an experience in
social engineering. Inspired competent leaders look to where others have done this well,
and ask for help. Physicians and nurses know a lot about health but not much about
complex change management strategies. Clearly the NSHA leaders do not know much
about it either.

We recognize that we do not have all the answers but we do have something to contribute to
the dialogue. We believe passionately in our province. We see a robust health care delivery
system as a key plank to realizing prosperity in this province. We ask for your help to make that
happen. This paper is a start in an iterative process. We need LOTS of input, additions, and
adjustments from everyone, not just healthcare experts. We are all affected. We must all
contribute. All opinions are valued.

Dr. Ajantha Jayabarathan, Family Physician, Halifax, NS solutionpaperns.@gmail.com

Mr. Kevin McNamara, Retired Deputy Minister of Health, Chester, NS
Dr. Robert Martel, Palliative Care, Arichat, NS
Dr. John Ross, Professor, Dalhousie University, Halifax, NS