Monday, July 13, 2009

Alberta Health Services Are Sick - Do we Know Why?

It is clear that Alberta health care is not at all well. But can we accurately diagnose this illness and do we have the right measures for a treatment?

The symptoms are clear. Wait times are not reducing quickly. The costs of health care continue to exceed funds allocated. Whatever the Minister calls it, there is a freeze on hiring to positions subject to a personal review by Stephen Duckett, the President and CEO of Alberta Health Services. Programs are being cut back or closed and some staff are being called and asked to resign. Morale is low and other jurisdictions have pounced in the hope of luring Alberta health care personnel away from the Province. Rumour has replaced effective communication as the primary source of information within Alberta’s health system. There is a great deal of upward delegation.

These are symptoms and they suggest part of the diagnosis, but our health care system illness is in fact quite complex. First, many people have given up their personal responsibility for their own health. They look to doctors in particular to treat things which could easily be treated by themselves or prevented by taking better care. A recent Health Quality Council report makes clear that many take themselves or their children to emergency for things that hitherto have been treated either by the patient themselves or by a GP or nurse practitioner at a much lower cost.

Second, we have focused our health care system on a model of illness as opposed to prevention. The most dramatic impact on health and well being over the last two centuries come from better quality water, seat belt legislation, clean air legislation and anti-smoking measures. We are generally failing on other aspects of social health – obesity, sexually transmitted disease, fitness. We focus few health care resources on these aspects of well being.

Third, we have elevated one profession – nursing – to such a position that nurses are now responsible for many aspects of health practice, especially in relation to management. While we should welcome professional development, it is clear that the system has allowed the Peter Principle to apply to the nursing profession. Many do not have the management skills for the positions they hold and more lack the communication skills needed to effectively manage people. Nurses are also well paid given the outcomes their actions produce. There is a need for more effective management and a complete review of nursing as a practice and its place in our health care system in general and management in particular.

Finally, we have applied structural and tactical solutions to what are in fact performance issues. Experience elsewhere suggests that spending more is not the route to improvements in the performance of the healthcare system. In fact, in Britain it was noted that as more was spent on health care productivity and performance went down. Money is not the problem, focus and performance are.

The issue is not public versus private, costs versus wait times, but how can we secure value for money from the substantial investments we have made and continue to make in our health care system.

One would think, then, that appointment a health care economist to the most senior management position in Alberta’s Health Care system would make sense. After all, one aspect of economics is the adjustment of activities so as to produce more effective allocation and use of resources so as to improve productivity and performance. But the key skill set is not economics, but change management and communication.

Stephen Duckett arrived in Alberta in March. He came from the position as CEO of the Centre for Healthcare Improvement for Queensland Health in Brisbane, Australia. He was Secretary of the Australian Health Department from 1994 - 1996 and has held leadership positions in the Victorian Health Department, at La Trobe University and as Chair of the Boards governing The Alfred and the Brotherhood of St Laurence. He was also a member of the National Health and Hospitals Reform Commission in Australia. He is now paid a base salary of $575,000 with a bonus of up to 25 per cent for performance, based on "objective and quantifiable results," according to Alberta Health.

He has written a lot, mostly focused on linking expenditure to performance. He is clearly a successful academic and health economist. Some of the changes he initiated in Queensland are showing signs of paying off – wait times are down, though not in all categories and a limited number of cost efficiencies have been achieved. But researchers in Queensland suggest it is too early to measure the impact of the reforms Duckett and his colleagues initiated.

His change management skills appear limited. Communication, seen now to be poor within Alberta Health and between Alberta Health and the public: it is clearly not one of his strong points. His ability to engage and involve colleagues in managerial positions and to focus their efforts is already seen to be weak, though it is early days. He appears to have a large ego, which can be valuable if turnaround is the task as opposed to continuous improvement or moderate change. He does not appear to delegate well – he is now personally reviewing all capital expenditure over $150,000 and each job vacancy as they arise. He has done little to build trust and understanding amongst health care advocacy groups. The research community has been offended by remarks he has made which, they claim, are ill informed. He does not appear to welcome criticism, as is evident from the announcement of a code of conduct which stifles criticism from the professionals within the health system.

We should, of course, give Stephen Duckett the benefit of the doubt. He has only been in post for three months. But one never gets a second chance to make a good first impression. So far, he is not doing well. He is not helped by a Minister who shows signs of intolerance and appears to be opposed to transparency.

The next session of the legislature, which will be preoccupied by deficits, debts and the decision of the Premier not to increase taxes of any kind, will also start to find itself facing more and more health care issues. They will begin in the guise of budget issues, but smart politicians should refocus the debate on performance, quality and value for money. They should demand a high degree of transparency, strong and effective communication and a high degree of performance accountability for Stephen Duckett. Albertan’s will be watching.


harrigan said...

Very interesting and thought-provoking. Nice to see commentary that is other than knee jerk reaction, rhetoric, and fast and easy answers.

I agree completely with some of your points, and disagree with others.

"First, many people have given up their personal responsibility for their own health, easy now that they are no real user fees for the core service." - Come, on now - with respect, this is nonsense! I think Albertans are smart enough to figure out that a lot of their taxes go towards health care. For many years, Alberta was one of the only Provinces that had user fees - there was no difference in usage.

"Second, we have focused our health care system on a model of illness as opposed to prevention." - Most certainly. Well put.

"Third, we have elevated one profession – nursing – to such a position that nurses are now responsible for many aspects of health practice, especially in relation to management." - You mention Parkinson's Law - I am assuming you mean the Peters Principle. You raise some excellent point here, but the issue really isn't whether a manager used to be a nurse or a physician or a physiotherapist or an accountant. The issue is whether or not those appointed to managerial positions are skilled in management and are provided with the ongoing education and support needed. All too often, people are appointed to management and not provided with sufficient support. In positions as daunting as frontline management in health care these days (as you point out, very little real decision making is delegated, but all managers are held accountable) this is even more important.

"Nurses are also exceptionally well paid given the outcomes their actions produce" - Wow, I could not disagree more! Nurses are now reasonably well paid, but the outcomes of their actions can be tremendous, literally life or death!

The remainder of your essay was very good and thought provoking. One problem that isn't as highlighted as much as it should be is that AHS and the Provincial Government believe that it is entirely appropriate to spend day after day making decisions behind closed doors, then come out, pretend to hold a public meeting, be extremely vague and refuse to be open about what has been decided, all the while talking about the importance of transparency and accountability.

Sorry to ramble on. Thanks for the interesting blog!

David Harrigan
(Director of Labour Relations, United Nurses of Alberta)

Stephen Murgatroyd said...

Thanks for this thoughtful response.

I corrected the Parkinson-Peters Principle error, removed the word "exceptionally" from in front of well paid with respect to nursing and also removed references to health care premiums. I think this helps - gets rid of "noise".



Brenda said...

Thank you for this post Stephen. I also disagree with your statement that nurses are over paid in relation to their responsibility. Because while nurses have been bumped into management responsibilities, individuals with very little education and often very little experience are now the ones administering direct patient care.
I think an important place to look for cost controls is when doctors order tests, treatments and drugs. Often now doctors will ask patients if they want this test or that test. There must be a cost/benefit tied to each of these decisions. While we would all appreciate being able to make health care decisions without regard for the cost - this is no longer realistic. Doctors are still the ones making most decisions in the health care system - they must have cost in their decision matrix.
Wellness must be integrally integrated into the work of students in the public education system. This mean going beyond information dissemination to knowledge building. Our youth are just as likely to come up with the next innovation to help us get unstuck with health care.

Stephen Murgatroyd said...

We can disagree about nurses, pay and performance but we dont disagree about dictors, technology, tests and costs. My intent was to move the debate from costs to performance and from structure to purpose.

Satya Das said...

Agree that we need a wellness perspective.
Also agree with Mr. Harrigan's point about management.
In fact, we should be guided by "lean" philosophy which frees professionals to do what they do best, and removes or diminishes their time-commitment to functions (administration, paperwork) that take away from what they were hired to do. It may be that certain nurses and doctors have a flair for management and administration as well as caring for the ill; a "lean" philosophy would enable these folks to capitalise on their strenghts.
-- Satya Das