Category: System

Canadians took a bold, progressive move in the 1960s and created Medicare. And we’ve blocked change ever since.

Sure, we dribble in new technology. Embarrassment demands we buy at least a few PET scanners and robotic surgical assists. But our core system is unchanged.

Government and Organized Medicine insist that basic clinical services work the same as in the 1960s. Patients see their family doctor. Doctors send patients for ‘high-tech’ X-Rays, ultrasounds or blood tests. Patients drive to licensed and controlled lab facilities. Then they trudge back for results days later.

Ancient ‘High-Tech’

Point of care lab machines now cost only a few thousand dollars. They give accurate results in minutes. Doctors could collect samples and get most common tests done while seeing their patient, if the government allowed.

Currently, family doctors must send patients to a lab for simple ECGs, unless doctors want to buy machines and provide the service for free. Instead, government forces patients to drive to a lab, pay for parking, wait for the test and then wait again for results.

Dentists and auto-mechanics have all the common tests and tools needed for their work. Who would go to a dentist who sent patients across town to get X-Rays? Or an auto-mechanic who couldn’t scope a car’s error codes? No wonder so many people attend emergency departments for care.

Destructive Innovation

Patients want information. They want it much faster than the current system allows. Why not let them create their own information?

Regulators make it too onerous – or just impossible – for doctors to offer very basic services. It punishes patients. Many people struggle to get out of their houses let alone visit multiple labs.

At some point, patients will realize they can buy point of care lab machines for the price of a new TV. They could check their own blood work with the new tech from Theranos (USA Today).

Eric Topol wrote two best sellers on how patient owned technology will change medicine: The Creative Destruction of Medicine: How the Digital Revolution Will Create Better Health Care and The Patient Will See You Now: The Future of Medicine is in Your Hands.

Cynics say patients doing self-tests would just create more doctor visits to investigate false positives. It would increase utilization, payers’ biggest fear. But hospitals already use point-of-care tests. And patients have been checking their blood sugar levels at home for decades.

Medicine Resists Change

Voters understand that there isn’t enough money to provide all the latest technology and services. People know Medicare cannot function on a 1960s paradigm forever.

Yet politicians do not engage.

Governments block progress by building walls to keep people trapped inside old ideas. But walls do not stop the pressure for change. At best, they pretend to trap it. Time and change crush those who resist. Not even Medicare can resist change forever. For now, it seems medicine wants to stick with the 1960s and hopes the wall holds.

photo credit: nbcnews.com

A friend’s dad scolded me years ago.

“Don’t ever say you don’t have time,” he said. “It’s a lie. You always make time for what you value.”

“Same thing for money,” he continued. “Don’t ever say you can’t afford something. You always sacrifice for what you want.”

Some grownups are really dumb, I thought. I can’t afford a motorbike. What’s he talking about?

As an adult, I realized the truth in what he said. We find time and money for what we value most.

Hospital Beds vs Bureaucrats

While voters hope logic drives tax spending, politicians just pay for what they value, what they promised to deliver. Government is not a business.

So when it comes to healthcare, what does Medicare value more: beds or bureaucrats?

Bureaucrats are generally smart, well-intentioned people who serve voters in good faith. Most people agree we need hospital beds AND bureaucrats. But how many of each?

Ontario closed 17,000 hospital beds between 1990 and 2013. Ontario has not cut a similar number of bureaucrats (If you know otherwise, please share it in the comments).

In Ontario, there are 1.7 acute hospital beds per 1000 people, ½ of the average for other OECD countries.

According to a recent presentation by Matthew Lister, there are 32,000 healthcare bureaucrats in Canada. That equals 0.9 healthcare bureaucrats per 1000 population. He also wrote about it in the National Post: Canadian Healthcare Needs to be Leaner.

Ontario has 1.7 acute care hospital beds per 1000 population.

And Canada has 0.9 bureaucrats per 1000 population.

Sweden has 0.4 bureaucrats per 1000 population. Australia has 0.255, Japan has 0.23 and Germany has only 0.06 bureaucrats per 1000 population.  Looking at it differently, Japan has 30,000 healthcare bureaucrats for 130 million people. Canada has 32,000 bureaucrats for 35 million. Does it make sense to have so few beds and so many bureaucrats?

Expensive Bureaucracy?

Steve Paikin of The Agenda asked whether $50 billion for healthcare was going too much to bureaucracy and not enough for health care in Ontario.

Others have said similar things:

• Alberta healthcare needs fewer bureaucrats. Edmonton Sun
• Too many rules by unaccountable bureaucrats. ArgusLeader
• Are government bureaucracies too big? Becker-Posner Blog
• Too many bureaucrats in the kitchen. Spectator
• Fixing the bureaucracy (takes more than dealing with the size). Policy Options.
• Death by bureaucracy – DailyMail, NHS
• NHS bureaucracy up 50%

Voters do not mind the cost of bureaucracy as long as public services perform. That changes quickly when politicians choose austerity.

Accountability?

Why does Canada have so many healthcare bureaucrats? Absent a convincing rationale, it seems politicians simply spend on things they value. And for now, they value bureaucrats, not hospital beds.

photo credit: thestar.com

People fix systems, not techniques or master plans. People build creative solutions to benefit other people. Attractive solutions usually fit real life. They look obvious after the fact, even intuitive. We wonder why no one thought of them before. But bad process leaves us wondering why something simple has to be so hard.

Doctors carry tremendous power to shape healthcare. They could fix it. Access, inefficiency and perverse incentives could disappear. Patient frustration could decrease while quality increased. Doctors spend a tonne of time with patients. They know common irritants, useless waste.

If seventy-five thousand practicing physicians decided to improve care, could any political party, stakeholder group or legislation stop them?

It would require doctors to agree on an approach. Not issues, an approach. They would need to think beyond issues and agree on a bit of political theory. If doctors remain mesmerized by issues, politicians will continue to bend issues towards their own political vision; at least until voter sentiment demands they abandon their vision to win re-election.

Doctors need to work through obvious, but exacting, steps to solve Doctors’ Political Blind Spot.

Complexity theory defies master-plans. Ignorance or stupidity makes us assume we could design a rigid plan that didn’t harm the people expected to live by it. Looking through complexity goggles, we might consider the following steps to build a political platform.

How doctors can fix healthcare

Physicians should:

1. Admit we practice in a political sandbox. This sounds easy. Physicians spend hours trying to convince someone they have a simple addiction. In the same way, it can take years to realize that nationalized healthcare, by necessity, makes doctors stakeholders/players/pawns in a political match.

2. Acknowledge that political theory informs political issues. Docs need to study a few classics of political philosophy and history to appreciate where astute politicians hope to shape the system.

3. Make implicit assumptions explicit. Doctors hold some basic beliefs but often adopt political positions that go against those beliefs creating contradiction, not just paradox. Doctors believe things like: only those who got all the answers correct should get 100% on an exam. Or, hard work should be rewarded. Or, everyone who wants to try to become a doctor should be given the chance to try.

But many political views grate against these assumptions. Who says students who do not answer all the questions don’t deserve 100%? Who says we should reward the efforts of those who work all night above the valuable work done by others in the daytime, between coffee breaks? And what’s this nonsense about ‘trying’. Those who want to become doctors should not be discriminated against. It has nothing to do with effort or performance.

4. List patient expectations. Providers, patients and providers-who-have-been-patients have written stacks on what must be part of great care. They highlight things like: respect, compassion, freedom, honesty and much more.

Emergent Platform

Political platform emerges in the gap between the current healthcare system and #3 and #4 above. It emerges between people – patients and providers – and current reality. Doctors could create a platform by advocating for change in the way current design insults values held by physicians and patients.

Such a platform must be fluid. It must adjust as issues change. It could not be an ideology or ideal plan because it’s based on a gap. Gaps are relative. The platform cannot be simply the values held by physicians and patients, nor can it be the current state nor some utopian perfect state. The platform is always the gap that results between the performance of the current in light of the values and principles accepted by those most concerned.

If we assume the gap is between the current issues, processes and policies and some realm of idealized policy/process, we will always be forcing the current state into some pre-conceived vision of the ideal.

If we assume the gap is derivative or relative to principles and not issues, we maintain the ability to adjust and correct. If we gap the current state against a utopian plan, we will drive for more and more forced fidelity to the plan. In this second case, failure indicates lack of effort, not faulty process.

Living Ideas, Reforming Traditions

Doctors should advocate for ideas and processes that fit with modern, lived experience. They should build on the best parts of traditional care and adjust to meet patient needs as seamlessly and invisibly as possible. Doctors should seek to provide care that fits into patients’ lives, not force patients to fit into a master plan of ideal care.

[Of course, we’ve over-simplified. Some patient needs will overlap and appear to cancel each other out (e.g., the desire to be taken care of and the desire for autonomy), and some physicians’ beliefs will overlap too. These will require debate beyond the space allowed here.]

If we really want excellence, innovation and true, patient-centred care, we should unleash the creativity of patients and doctors working together. Progress scoffs at perfect. Perfect is a dream that tomorrow proves out of date. Let’s couple the best of the past with the creativity of innovation to create a future system that fits patients, not some utopian design.

photo credit: https://upload.wikimedia.org/wikipedia/commons/2/22/Parliament-Ottawa.jpg