Governance Eats Policy For Breakfast — Why Healthcare Can’t Change

The Hub published my op ed. You can read it at TheHub.ca or below. Enjoy!

When it comes to fixing health care, governance matters more than policy

Without good governance, new policy will struggle with implementation like all the old policy.

Few voters had first-hand experience with hallway medicine or Canada’s world-famous wait times before the pandemic. Lockdowns changed everything. Health policy failure moved from fear-filled headlines into a tangible crisis everyone could feel.

Failure begs for better policy, or new policy to fill gaps. Planners and policy writers jump to offer solutions: surgicenters, funding reallocation, redesigned models of care, and so on.

New policy, however, cannot fix old policy, unless we know why the old failed in the first place. Most policy fails on implementation, not from bad design. Furthermore, we cannot fill policy gaps unless we understand why gaps exist. Gaps form around constraints and incentives, not from a lack of creativity. The policy environment dictates viable policy options.

How a system functions has more to do with how its governed than with the policy ideas in play. Implementation failure, constraints, and incentives all fall under the larger umbrella of governance. Governance and policy overlap, but they are different.

To fix health care, we need to start with governance: how do we make decisions? Who gets to make them? If we do not, a new policy will deliver the same old results.

Policy to the rescue

Take surgicenters as an example. Surgeons and specialists join together to build a non-hospital, outpatient surgical facility. Each centre offers a specific basket of specialty care, for example eye, orthopedic, or endoscopy services. Surgicenters can offer comfort, convenience, quality, and efficiency that hospitals struggle to match.

Surgicenters exist around the world. They are not new. In Canada, we have been trying to move care out of hospitals for decades. We want to save money and shorten waitlists. Why aren’t Canadian cities littered with surgicenters?

Current incentives and constraints make surgicenters impractical and onerous. Currently, hospitals supply nursing care, equipment, and use of the facility. Physicians use everything but do not pay for it, making non-hospital facilities a tough sell. On top of this, billing rules, regulation of independent health facilities, licensing for necessary lab and imaging services, as well a basket of other restrictions all weave together into a policy environment intolerant of (publicly funded) independent facilities.

We do not need a policy about surgicenters. We need research on why surgicenters do not exist in the first place and what to do about it.

Thomas Sowell, American economist and author, said once, “The most important decision about every decision is who gets to make the decision.”

Sowell expanded this in his book, Knowledge and Decisions: “The most fundamental question is not what decision to make but who is to make it—through what processes and under what incentives and constraints, and with what feedback mechanisms to correct the decision if it proves to be wrong.”¹

Before making a change, every hospital administrator must ask, “Who needs to be in the room?” Spectacular new policy will fail in even more spectacular fashion if you ignore governance. Informal governance can matter even more. Decision makers are often not the ones listed on the organizational chart: colleagues influence through personality without title or position.

Governance eats policy for breakfast

Peter Drucker, the legendary management consultant, once said, “Culture eats strategy for breakfast.”² We can say the same about health policy: governance eats policy for breakfast.

Dr. Dave Williams, a former astronaut and leader at NASA, served as CEO at Southlake Regional in Newmarket. He said, “It’s not clear who runs the hospital.” He was making an observation, not a complaint. “Compared to what I’m used to, it’s challenging to get things done.”

Without clarity and fidelity to best practices, governance will drift. Sowell, again, sums this up:

Even within democratic nations, the locus of decision making has drifted away from the individual, the family, and voluntary associations of various sorts, and toward government. And within government, it has moved away from elected officials subject to voter feedback, and toward more insulated governmental institutions, such as bureaucracies and the appointed judiciary.

Is this a problem in Canada? Brian Lee Crowley, managing director of the Macdonald-Laurier Institute, thinks so. Governance drift leads to central design—a temptation for all political parties.

In his book, Gardeners and Designers: Understanding the Great Fault Line in Canadian Politics, Crowley dilates on how gardeners approach governance.³ A gardener prepares the soil, removes waste, provides support, and tends to progress. Gardeners celebrate the surprise inherent in what grows and blooms. They do not manage growth for a specific policy outcome they designed in advance.

Designers dream about how to make health care better. Gardeners ask the more important question: how can we get good ideas to grow? A gardening approach to governance leaves plenty of essential (gardening) work for government. It empowers those closest to the problem and leaves design, experimentation, and implementation to them.

We cannot try to “fix” health care with new policy. Without good governance, new policy will struggle with implementation like all the old policy. We need to do first things first. Governance eats policy for breakfast.

The Medical Mind: Should Social Policy Define Medicine?

A medical mind is precious and fragile: hard to create, easy to corrupt. Doctors invest over 10,000 hours learning how to diagnose and treat. The medical mind exists to help patients and should serve no other purpose. But it is easily corrupted, distracted from its main purpose.

If patient care matters, we must protect the medical mind from service to popular, non-medical ends.

Hard to Create

Medical students submit to a 4-year shaping program: an immersion in a peculiar thought process. Residency continues the formation for another 2, 4, or even 12 years.

The medical mind continues to develop, in practice. Ultimately, patient care adds the fine and necessary texture.

Forming a medical mind is more than taking courses and learning techniques. You cannot become a doctor by memorizing Google Scholar or watching a video.

A mind is more than information. It is an information processing tool, created at great cost.

How Medical Minds Work

With one hand, doctors reach backwards and hang onto medical knowledge. With the other, they grope forwards for new ideas and solutions.

Medical knowledge is not monolithic; it always changes. But neither it is a clean wipe of the medical hard drive to start fresh with a blank mind every Monday.

Given this two-handed approach of past-plus-progress, a medical mind must remain open.

The fact of new information makes some of what we think we know wrong, by definition. The history of medicine is full of attempts to treat using tools which caused obvious harm in hindsight.

Thus, a medical mind must adopt the scientist’s “pride in his/her humility.” Doctors must promote the limits of our knowledge because what we think we know might not be so tomorrow.

Easy to Colonize and Corrupt

The medical mind could remain protected, hidden inside the institution of medicine. But the town comes in, as it should. Doctors serve real people, who live outside.

Inevitably, social ideas colonize medicine. Continue reading “The Medical Mind: Should Social Policy Define Medicine?”

Healthcare’s Iron Triangle is Hindering Innovation (via The HUB.ca)

I wrote this for The HUB — loads of other great content there too.

Government, the medical profession, and public-sector unions are preventing improvements in our health care.

The Honorable Monique Begin (et al.) wrote in 2009, “When it comes to moving health care practices forward efficiently, Canada is a country of perpetual pilot projects.” Governments need “financial control” and remain “leery” of committing to programs. Pilot programs are easy to shut down “to avoid criticism” or if “budget priorities shift.”¹

At first glance, we might blame voters. Canadians rank health care as a top priority in most elections over the last several decades. Voters like Medicare; politicians are loath to change it. The last federal election stood out for (almost) hinging on a debate about health policy. As Sean Speer put it in August, “We are having a Section 92 election in a Section 91 moment.”² Most of the time, politicians from all parties work hard to avoid saying anything meaningful about health care—especially during an election—aside from pledging support for more of the same.

But we cannot blame health care stasis on politicians or the voters they need to woo. Medicare cannot change because it is locked in an iron triangle consisting of government, the medical profession, and public-sector unions.

Veto Power

The health care triangle is stronger than any party inside it; each party holds de facto veto power over major decisions. Each party seeks to improve its standing and power within the triangle relative to the other parties. When a government attempts change from inside the triangle, it can manage only minor tweaks or redesign. For example, regionalizing services, then centralizing them, then regionalizing again.

Veto guarantees that modern Medicare shares more similarities to its 1960s design than any evidence of meaningful innovation since then.

De facto veto power often gets constitutionalized into law. Consider two examples. In 2012, the Ontario Medical Association won a major battle with the government over labour dispute resolution and representation rights. The government agreed to abide by a binding resolution process with doctors. The government also granted the OMA exclusive “representation rights” agreeing to negotiate with the OMA and no one else. Or consider also that in 1991, the government gave the OMA power to collect dues from all Ontario doctors, whether or not doctors were members or even supportive of OMA policy. Ostensibly, The Ontario Medical Association Dues Act, 1991 empowered the OMA to fund its negotiations with the government, but the bulk of every OMA budget has funded issues unrelated to negotiations for decades.

This is not to pick on physicians; nor is it an attempt to reopen the debate about “rep rights”, arbitration, or dues. We could multiply examples of constitutionalized privilege for the regulatory colleges, universities, public-sector unions, and government itself.

The issue is constitutionalized privilege—the iron triangle between government, the medical profession, and public-sector unions. (Note: the medical profession includes medical associations, licencing bodies, and training programs, not individual doctors.)

Iron Lady Breaks Iron Triangle

In the early 1980s, Prime Minister Margaret Thatcher tackled a similar rigid coalition. John Gray, a political philosopher, described it as “the triangular relationship between government, business and the trade unions.”

Thatcher set to work smashing the relationship. However, she left the welfare state “comparatively intact… the political thrust of early Thatcherism was in the direction of the dismantlement of the corporatist policies of the 1960s and early 1970s.”³

Canada needs something similar: break the health care iron triangle while leaving the welfare state comparatively intact. The (once) friendly relationship between government, doctors, and unions has ossified and become hard, brittle, and inflexible: unable to manage stress or major change.

Institutions, like young trees, become weak and spindly shielded from the pressure and strain of social competition. Secure in the functional monopoly afforded by corporatist-style policy, institutions come to see themselves as existing to mitigate frictions between the other parties within the triangle instead of shaping the individuals inside the institutions themselves. As Yuval Levin, an American author, often says, “Institutions become performative instead of formative.”⁴

We have no shortage of ideas to improve health care quality and efficiency, such as funding reform, integration of health services, public-private partnerships, and so on. But these ideas do not even reach the level of tactics to implement change. They are the outcome we hope to see after change has been allowed to occur. We do not lack ideas; we lack strategic vision.

The pandemic exposed the lack of resilience in our health system and the desperate need for substantial growth. All parties in the iron triangle agree the system needs change. But the parties cannot agree to any solution which does not benefit their own weight and influence inside the arrangement.

Health care’s iron triangle rests on the concentration of power—a tripartite monopoly. The best way to undermine a monopoly is to invite new parties into the relationship. Break concentrations of power into multiple smaller units. It can be done: Thatcher found a way to do it in Britain. It starts by addressing the iron triangle as the root of resistance to change. If we do not, Canada will remain forever a “country of perpetual pilot projects.”