How Can We Fix Healthcare?

Most people like recipes. A 3-step plan to tight abs guarantees thousands of readers.

Eat less move more is too simple and too hard.

Politicians and journalists ask me, “How can we fix healthcare?” I love the question. They rarely love my answers.

They want a three-step plan to fix healthcare. They want concrete solutions: programs, legislation, “A fix for a generation”.

But if Canadian Tire was struggling, would it call for new programs or legislation? Would Apple innovate with new government spending?

Kaiser-Permanente, a Californian healthcare company, provides care to almost as many patients as we have in Ontario. Does Kaiser-Permanente try to improve operations with subsidies, special programs or new regulations?

We cannot fix healthcare with money, programs or controls. The reason we keep seeing the same three tactics is because those are the only tactics government can use.

Don Savoie wrote a book that criticizes the federal government during the Harper years: What is Government Good At?

Savoie says that government generates ideas but struggles with implementation.

Lately, even ideas are becoming hard for government. Consider budgets: “The estimates process has become too complex, too convoluted, and too spread out in too many documents for MPs to invest the time to have any impact.” (p. 66)

How Can We Fix Healthcare?

Healthcare needs help with implementation. It needs help on the inside, from the inside. Healthcare needs the powerful elite to stop doing so much and start empowering different ways of thinking inside healthcare.

Focus on facts  

Atul Gawande wrote about Dr. Warren Warwick, an outstanding CF doctor, a leader in his field. No one seems able to achieve the results that Dr. Warwick does.

Gawande spent a day watching Dr. Warwick design solutions one patient at a time. Warwick dealt with real people, not idealized patients. He took direction from what worked for the patient in front of him.

He was not a slave to the latest guidelines, even though he helped write the guidelines. He applied evidence to reality instead of forcing reality into checkboxes.

We love to dream about better healthcare in the way kids dream about what super power they would choose. Majority governments come close to having superpowers.

But superheroes with grand ideas create dystopian societies. Grand ideas forced on the crooked timber of humanity create grotesque masterpieces.

Facts infuriate those bent on finding idealized solutions. Ideas are malleable. Reality is not malleable; it is hard (Hayek).

Let facts guide us to fix healthcare.

Empower front line care

The most important decision about any decision is who gets to make the decision.

T Sowell (paraphrase)

Let doctors and nurses make decisions. Let professionals, who provide care, make decisions about care. The only time decisions should be made by someone other than those at the front lines of care is when the people on the front lines of care cannot make the decision.

Bureaucrats create problems when they think they understand care better than those who provide care.

Those ‘in charge’ want to step in and fix things. Instead of building solutions with the team, they build solutions for the team.

Many people cannot resist solving other people’s problems. If a leader sees a problem that no one else sees, her first job is to convince others that a problem exists, not to solve it. Leaders create chaos, if they solve problems that no one else sees, just because they have the authority to do so.

Even if they ‘fix’ a problem in the name of patient safety, quality or some other virtuous goal, the solution will not stick. Staff will undermine it.

The next leader will campaign – and win – on a platform that promises to reverse the uninvited solution.

Leaders — politicians especially — must empower people working on the front lines of care. If a problem is important enough to fix, then it is important enough for the front lines to own the solution.

Embrace imperfection

Real clinical cases rarely look like the textbooks say they should. ‘Classic cases’ of pneumonia and appendicitis are unusual. That does not mean that pneumonia and appendicitis do not exist.

Each patient is unique. Patients report symptoms differently. They rarely offer all the details that professors tell us to observe. Diseases change over time. Early appendicitis looks very different from late or chronic appendicitis.

Perfection does not exist in medicine.

Perfectionists crave ideal solutions. Messy details frustrate them. In a weird paradox, those who criticize guidelines, like I just did above, are often guilty of the same perfectionism. Imperfect guidelines bother us. Purists would rather use nothing than take advice from an imperfect tool.

Life is messy. Patients’ lives are messy. We should expect our healthcare system to appear messy too. There will be more exceptions than rules, if we want excellence for each individual instead of mediocrity for all.

Simple, but hard

Healthcare does not need more ideas or grand designs. It does not need a new program or piece of legislation. We should eliminate failed programs and clunky legislation, instead of propping them up with more resources.

To fix healthcare, we need to think differently inside healthcare. Politicians and regulators need to let it happen. The solution is simple, but hard.

Photo credit: dccomics.com

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16 Replies to “How Can We Fix Healthcare?”

  1. We will have to look outside the box….certainly outside of the North American paradigms.

    We should look to the world’s top rated health care systems, study them, learn from them…and then follow the evidence to wherever it leads us.

    Sowell is certainly right about who gets to make the decisions….certainly those married to the present paradigms should be excluded from the decision making.

    1. Well said, Andris.

      We love to compare ourselves to the USA. We gloat about how much better we perform on the things we choose to measure. But we keep buying their technology and sending our sickest patients there.

      I am certain that we could learn something from other countries.

      Thanks for sharing a comment!

  2. Well said Shawn.

    Physicians feel a moral superiority over the public,and hence are paralyzed to act over the inadequacies of physician compensation.Canadians feel a moral superiority over Americans and gloat about how much better our health care system is while ignoring reality.Introducing private money into hospital/physician service payment (like every other country except Cuba and North Korea)will be the only thing to save Canada’s system from the race to the bottom.

    1. Thanks Ramunas.

      While I agree that we need to look at different models, I do not think that private money will save us. The American system has ‘private money’ but health management organizations are often just as draconian and bureaucratic as our provincial governments can be at times.

      We need to think beyond funding. We need to think about the management inside the system. We need to think about centralized control, as a concept: wherever we find it….by a government or large corporation.

      I think we lose all hope of progress when we start talking about funding and ‘private money’ too early in a conversation. It just sparks anger before the debate has begun. Funding plays a part, for sure. But we should start the conversation somewhere else or the whole things goes off the rails before we even get started.

      Thanks so much for sharing your comment!

      Cheers

  3. Shawn….you are off that restructuring committee.

    ” Private money” + ” Public money” is what ALL of the world’s top rated health care systems have in common.

    I know that I sound like a record, but we need a symbiotic public / private hybrid system that characterizes ALL of the top rated world class health care systems without exception.

    As for managing the system, our is top heavy with over compensated bloated bureacratic drones… the image of Jabba Hutt comes to mind .

    Canada has .9 health care bureaucrats per 1000 with Germany managing with .06 per 1000….Canada has x15 the number of bureaucrats than Germany ( which is higher rated) with Ontario promising even more.

    Canada has ( 2015 numbers) 2.22 MDs per 1000 with Ontario at 2.20 : 1000…Germany has 4.11 per 1000.

    Canada’s health care system is hyper managed, micromanaged , promising even more in Ontario….the quality of managers being diluted as the numbers increased….and what happens to the inept managers? They get shuffled about within the system instead of being sacked….the bad apples being transferred from one barrel to another.

    Ontario, in particular, needs someone willing to wield a chain saw to the bureaucracy….the LHINs in particular.

    The new managers should be recruited from outside of the present North American health care systems, from the world’s top rated systems…at a minimum, our own managers should get their training and MBA’s from the top rated countries.

    Speaking of Ontario’s health care bureaucrats what is their cost?….not only their salaries, pensions benefits but their overheads with all the implied expenses which the tax payers have to pay for.

    The average gross income of Ontario MDs is around $ 339,000 from which all the overheads are covered….I seem to recall that the average cost of an Ontario health care peer bureaucrat is over $1.25 million.

    The tax payers of Ontario get a bargain for each $ from their MDs and are getting shafted by their health care bureacrats.

    Price is what the tax payer pays, value is what the tax payers’ get….they get value from their MDs and disvalue from those ‘managing’ the health care system.

    1. Yikes…voted off the committee for uttering one disagreeable comment? Sounds rather totalitarian, Andris 😉

      I agree with much of what you have written. And I agree with your comment about other systems using public and private funding. I was only trying to say that we do not need to turn every discussion about healthcare improvement into a funding debate. Funding is one issue amongst many — an important issue, no doubt, but only one amongst many. If we allow the reductionists to turn all healthcare discussions into a debate about funding, we will never get change.

      As you know, there are many who will fight to the death before allowing ANY substantive change to our current system. If we allow them to turn every debate back to a discussion about funding, they win. They will walk away and say, “See? I told you so. Those guys are just greedy capitalists who want a private [read: American] system.”

      Fixing healthcare requires a bigger discussion than just deciding where the money will come from. I think we should start with our ideas about facts vs. utopian designs, who gets to make decisions, and what shape should the system take. Or in other words: epistemology, freedom and ontology. Until we debate the core principles, we cannot debate the particulars.

      Thanks so much for commenting! I hope I’m allowed back on the committee soon. 🙂

      Cheers

      1. Sorry Shawn, but the ” I don’t think that private money will save us” comment ” triggered” this ageing snowflake.

        It may not be THE solution, but it is a part of the solution.

        I see our present health care predicament as a Gordian knot….so many are fiddling with it , struggling with it , the best brains are brought in to study it…everything that the self styled experts do, makes the knot larger and even more complex….I keep on thinking …” What would Alexander do?” …” What would Alexander do?”

        “Politicians will do the right thing only after every other alternative is exhausted”….surely we are reaching the point where our Canadian governments , a Federal and Provincial, run out of alternatives.

        I’m in favour of a chain saw.

        President Obama had the opportunity to do the right thing to place US health care on a world class footing….and he came up with yet another alternative.

        When Obamacare utterly collapses , out of its ashes the US will have one more opportunity to do the right thing…but , one suspects, that it will end up with one more failing alternative.

        1. Andris, you make me smile: “Triggered’ this aging snowflake”, said with tongue firmly planted in cheek. Very funny!

          Thanks again for sharing your thoughts. I know many people favour your chain saw approach, too.

    2. Good thoughts. We should be looking to Germany in particular. While I agree with Shawn that it is too early to introduce the concept of “private money”, the reality is that I am not sure that government alone can provide all the funding that is needed. I agree with Andris that the bureaucrats are a big waste of money. I have attended regional meetings with directors of LHINs and for the most part they are quite clueless and add nothing to the conversation.

  4. Here is an example. In Canada, palliative care is promoted as a priority service that should be available to all. Here in Ontario, there is a regional palliative care program, a Cancer Care Ontario palliative care program, a provincial clinical lead as well as 14 LHIN leads for palliative care, and another government-struck committee called the Ontario Palliative Care Network.

    As a practicing palliative care physician in the community, I am aware that practically every community in Ontario, and likely in the rest of Canada, provides palliative care differently, with a different structure and different mix of providers. There is nothing inherently wrong with this, as one has to use the resources at hand in order to provide the best care possible, and there never seem to be enough people working in this field, despite what I have seen as an improvement in Family Physicians’ involvement.

    But the issue is that to my knowledge, there has never been an assessment done of what works well in each community and where we struggle. What is the point of multiple committees and levels of committees and paid physician positions if no one is looking to the providers themselves to learn about what works and what doesn’t?

    There is no doubt that we can all learn from each other, but that simply finding a system that works in one community and porting it elsewhere is not going to work. This is the top-down approach and it failed and continues to fail here in Ottawa. Meanwhile, a system of coverage that has existed for many years continues to be misunderstood, if considered at all, by the bureaucrats and pseudobureaucrat physicians who ostensibly are hired to use their insights and connections to inform the evolution of care.

    The problem, and my issue with this blog post, is that we have been saying the same thing for years. Front-line health care providers continue to be ignored as the political/government machine continues to churn out layer after layer of bureaucracy. I would like to know what Dr. Whatley suggests physicians can do to effect change. Describing the problem and the outcome is not enough to expect from leaders. The dotted line from one to the other is where leadership really exists.

    1. Thanks for sharing this great example, Paul.

      You wrote, “I would like to know what Dr. Whatley suggests physicians can do to effect change.”

      I assume that you do not want a step by step recipe, because that would be exactly what the top-down, centralists have been doing to us for years. Your question assumes that physicians CAN ‘effect change’. I agree but not in the way many people might envision it. When doctors think of ‘fixing’ a problem, we tend to think of it in the same way that we would fix a displaced fracture. That is, we would fix it. Inside state medicine (socialized medicine, single payer healthcare, whatever name you prefer), doctors have much less control than people think [I’m saying this for readers…I know you know that, Paul.] So at best, we can try to raise awareness, influence through relationship and offer better options.

      Just off the top of my head, I would:

      1. Get involved. If your clinical care area is being overrun by non-physicians who assume that they direct medical care, then your clinical area needs more physicians assuming leadership. In many cases, doctors have run away from leadership and then complain that they have no voice.

      2. Form alliances and build a team. Even the most totalitarian bureaucrat has a hard time resisting a united front from an alliance of palliative care docs, palliative care nurses, home care, pharmacists, patient advocacy groups, etc. You don’t necessarily have to lead the alliance, but at least help it form and support its growth.

      3. Offer concrete, context-specific solutions. Again, bureaucrats find it hard to argue against grassroots solutions.

      4. Outperform them…or, shame others into changing. Sometimes you just have to do things differently — better than everyone else — and shame others into changing their ways. This is not an easy path to follow. But it works. Everyone will hate you for a few years, then everyone will try to take credit for the ideas you pioneered.

      5. Say No. I put this option last with intention. Too often, we say No first. No doubt, we must punch back now and then. But punching back too soon eliminates any opportunity to do #1 – #4.

      I’m sure you and others could come up with dozens of other tactics to influence change. Influence comes from relationship, so it never hurts to start by trying to make friends with the people who have been hired, ostensibly, to tell you how to provide care. Everyone responds to a different mixture of spheres of influence: rewards, rules, morals, social pressure and concepts. I find LHIN-types respond most to social pressure. If you can show them that some other LHIN is doing something, your LHIN will fight to not be left behind. The problem is that social pressure works in reverse too: Unless someone else is doing it, LHIN-types often avoid being the first to try something.

      There are books written on this. These are just a few comments.

      Thanks again,

      1. Great answer, Shawn. Relationship is important and while one can hope that those hired and paid to build such relationships will do so, I guess it is, as you say, up to the front lines to create the momentum for this. Sad that health care dollars are spent without accountability to build underperforming agencies and groups.

        I will certainly try to find the time to implement some of your suggestions.

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