After 14 years of government planning and activism, Ontario healthcare is a mess.
The ideal political healthcare platform should offer help. It should not take control.
We need public servants, not public leaders. The ideal healthcare platform would tell us what government promises it will never do.
We need to know that government will never tell doctors how to treat patients; that it will stay out of doctors’ and nurses’ way.
Let doctors and nurses figure out what patients need.
Creativity and innovation applied by thousands of doctors and nurses on the front lines of care would crush the performance of any plan devised by brilliant people at Queens Park.
We need politicians who promise to help when asked. We do not need militant politicians who command and direct. We need government to promise to serve, not lead.
We need politicians to embrace complexity and the humility it requires.
There is too much for government to know.
It is impossible to create plans and laws that dictate clinic schedules and how many patients doctors must see. We should train smart healthcare providers and then get out of their way.
Does this mean that government should never do anything? Am I an anarchist?
Of course not.
We need politicians to know what government is supposed to do.
Government should referee.
Great referees enable great games.
Referees never tell players how to play. And they never play the game themselves.
Referees start the game and then they get out of the way.
They punish misconduct.
They watch closely.
But referees never direct play.
No Plan
Doug Ford has been criticized for not having a crisp shiny new plan.
I thank God that Doug Ford doesn’t have another new plan to inflict on doctors and nurses.
Doug Ford knows that doctors and nurses know more than Doug Ford.
If only other politicians were smart enough to know this too.
I would far rather a politician who offered no plan but promised to work with doctors and nurses.
We need politicians who promise to not pass laws without consultation.
We do not need politicians with laws up their sleeve they are dying to pass.
We need politicians who repeal more laws than they create.
Healthcare is smothered in regulations, plans and projects designed to cement someone else’s political legacy.
Demand a Plan vs Demand No Planning
What does it mean to ‘demand a plan’?
It assumes that 1) a plan would help 2) a plan is possible and 3) the planner could deliver on the plan they suggest.
1) A plan may not help. Plans are rigid and complicated, whereas life is messy and complex.
2) Plans generalize and standardize. Buildings need plans and blueprints. Humans need care and relationship. We need clinical guidelines and we need the wisdom to know when they do not apply.
3) Planners can never know enough. There is far too much information for any one group of super smart people to know. (Hayek’s knowledge problem)
We should demand no planning and stop demanding a plan.
Planners and Traders
There are two kinds of people: those who believe life is full of problems to solve, and those who believe life is full of tradeoffs.
Solvers look for solutions to every problem. Traders look to improve what they can without making everything else worse in the process.
Healthcare bureaucrats are solvers. They believe in ideal solutions to every complex problem. They believe every cancer can be cured and every crooked bone made straight.
Young doctors graduate as solvers. They apply enthusiastic medical solutions to every problem. They see benefits. Side effects are rare and less real than cures students see in training.
Older docs have seen many things they cannot fix. Best efforts can make things worse, not better.
Experienced docs learn that life is not about making bad things perfect. Life is about tradeoffs. We improve one thing but often at the expense of something else. Everything has pros and cons, risks and benefits.
Healthcare needs a political platform that promises what government will not do.
What will politicians stop doing?
We need government to stop planning our lives and telling us what to do.
We want government to make sure the game occurs, not tell the players how to play or try to score goals themselves.
Political platforms have become wish lists and IOUs for handouts and dreams. Each candidate tries to out do the other with “costed” plans for things that cannot be solved with all the money in the world, and for which no one is smart enough to design a plan.
This is nonsense, and everyone knows it.
Perhaps this speaks to our own stupidity. Maybe we are the ones to blame?
We attack candidates who do not promise world peace with a 5 step plan. Politicians and political staffers know it’s a hoax.
It’s not that world peace takes 6, or even 10 steps. It’s that steps can never create peace any more than jelly beans can create rainbows. Peace happens in the hearts and minds of people, not in 5 steps.
In the same way, quality, efficiency and service happen in the hearts and minds of those who provide patient care, not in the 5 pillars of the Canada Health Act, or any other law.
We need a government that knows what the job of government is and avoids trying what no government has ever been able to do.
We need politicians who believe in the wisdom of the people they aim to serve.
We are electing public servants, not monarchs or dictators.
I want politicians who promise what they will never do. So far, I haven’t heard that yet.
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Once again eloquent Shawn… And perfectly on mark! Bravo… Like many others. This one is reading material for my waiting room!
Thanks Paul!
Sure appreciate you reading and taking time to post a comment. We need to spread the word!
Cheers
This is the what I like about Ford’s healthcare plan: he said he would talk to frontline workers and THEN make a more detailed plan. Voting for the candidate who says he will spend the most on healthcare is a big part of why we are in the healthcare mess.
“We should demand no planning and stop demanding a plan” until AFTER the discussions with frontline workers.
Exactly. Well said, Gerry! We need a commitment to work with doctors and nurses. I haven’t heard any other party say that.
If he is receptive to guidance from real experts and not the self serving bureaucrats, we’ll be ok. If he needs to pay more money for physician services, I think I know a department that can be cut 90% without any adverse effect.
You said it well, Ernest. We need politicians to serve people on the front lines and not listen to people who come up with plans as a form of job security.
Thank you for this incredibly insightful article. It’s the first time I have heard something that resonates with me and has any substance. You really got to the root of our health care crisis and provided a way out of this mess.
Wow. Thanks Martin!
I really appreciate you taking time to read and to share a comment!
Cheers
Well that is certainly a perfect political world, I agree, as I have been a nurse for many years, and it is disgusting how often politicians inject themselves into health care with a plan that works for no one and only hides the real objective, for example LEAN with local injections. So really involve the front line in something they think will improve things, waste 20 minutes for huddles, now I do not get a break I have been waiting for 3/4 s of the shift. Get the front line to decide where the cuts take place, but do not share that that is the objective, when maybe an admin staff could go instead of a nurse. Nice plan! Or tell the public that private health care is to their benefit, but those with no money, we can’t afford to provide a bed, so continue to stigmatize people with mental health and addiction issues, starting with triage. So when no one is looking post a sign in the lab that lists prices of the various blood draws, Nice plan. And low and behold, the auditor general tells us that the P3 builds cost 8 billion more than they should have, Nice plan. So Doug Ford not having a plan now, NO THANKS! I am not in to guessing games with health care and personally all this mess began with the Harris regime, so yes we all should be public servants and. Behave as such, I agree, but more loose reins for politicians and health care…..NO way, follow the Canada Health Act period, good enough for me!
The Canada Health Act became law in 1984 and has not been “modernized” by the Federal Government since 1984. I doubt that any resident of Ontario wants to follow an Act that has not been “modernized” by the Federal Government for 34 years.
Hey Sue,
Thanks so much for your thoughtful comment. I agree: Lying about change by pretending you have no agenda is bad. That’s very different from saying you want to work with people on the front lines.
To be clear, we need politicians to have a plan to work with doctors and nurses. So, we are asking for no autocratic plans inflicted on us, but we also welcome a plan to work together. I am using the message of ‘no more planning’ to grab readers’ attention to check out what, exactly, I’m trying to say. Glad to see it inspired you to read and share a comment!
Again, thanks so much.
Cheers
I was OHIP’s lawyer. There are many Ontario Ministry of Health and Long-Term Care laws and programs that continue to exist for the purpose of keeping many civil servants employed and for the purpose of political public appointments to Ministry boards and tribunals. For example, OHIP coverage for insured persons while outside Canada and the OHIP three-month waiting period for uninsured persons for OHIP coverage continue to exist for the above-noted purposes.
“There are many Ontario Ministry of Health and Long-Term Care laws and programs that continue to exist for the purpose of keeping many civil servants employed and for the purpose of political public appointments to Ministry boards and tribunals.”
Absolutely!!! Everyone should know that if a department does not utilize their budgets, they lose their budgets. Loss of budgets means loss of jobs. So…in order to keep your budget and your job, one must continue to make new rules, refine the ones you have and push paper/attend meetings to show that you are doing something…anything…
Paul, they call it “March Madness”. If anything is left in the budget at year end, spend like crazy because you won’t get more for next year unless you spend it all today.
When I was a summer student in U of T anatomy dept in 1969, I was shocked at some nonsensical wasteful card holders that were bought for the library. As a lowly student I asked why these useless things had been bought. The answer: ” We have to spend the rest of the budget for the year.”
Year end spending happens in most businesses to ensure refunding. Wouldn’t it be novel to reward spending less while achieving objectives. It’s exciting and I hope not naïveté, to have docs/ nurses have significant budgetary input. It’ll take years to streamline. Re programming politicians to work for and with healthcare front line staff will be monumental but it must be done and done ASAP because….people’s lives depend on it.
Well said, Don. Once upon a time, that used to happen. We’ve past the golden years when costs meant nothing and everything was covered, no questions asked. We’d better change soon!
Wow. People would never know these things, Perry, unless you shared them. How much more do we not know?
Thank you!!
Multi-million dollar projects are great for politicians to announce but they often miss the mark and don’t fix the real problems on the front-line.
Time and time again i’ve seen front line health care innovators get discouraged because they aren’t allowed to try a new solution. So much red tape to get through. Too many stakeholders to bring to the table. Everyone has to agree before we move forward. Everything has to fit into the grand master plan, purportedly to follow policy, maintain uniform standards and avoid any risk to patient care.
We need to trust the front-line health care workers to identify problems, conceive of solutions, try them out, discard what doesn’t work (these aren’t failures by the way) disseminate what works and congratulate all involved in the success.
You are right Shawn, this is a more messy process but that is how the real world works. Constant, messy, managed evolution. Your sports analogy is bang-on.
“Constant, messy, managed evolution.” Love it.
Unfortunately, what you describe is very hard for government to embrace. It means letting go, loosening the reins.
Thanks for posting a comment!
“Perhaps this speaks to our own stupidity. Maybe we are the ones to blame?”
Yes, Shawn…very wise words. Canadians are very interesting in how they place governments on a pedestal and expect them to cater to our every want and wish (notice I did not say need).
Watching provincial elections and federal elections over the past few decades, I have noticed a trend. With each election, promises are more numerous, grandiose and free. The political parties have learned that Ontarians and Canadians can be bought. It doesn’t matter if you follow through, the one with the best promises gets 4 years in office. Yes…we are stupid. We have fallen for it hook, line and sinker…and we get the government that we deserve as a result…
Well said, Paul. We are being bribed with our own money (and debt).
“A democracy cannot exist as a permanent form of government. It can only exist until the majority discovers it can vote itself largess out of the public treasury. After that, the majority always votes for the candidate promising the most benefits with the result the democracy collapses because of the loose fiscal policy…”
We need to prepare for what’s next. Debt has an awful way of not going away.
Thanks for posting a comment!
As an outsider to Ontario, I note that ON is the only province that simultaneously had an outstanding physician/administrator/researcher/clinician (who previously led a large academic consortium), as deputy minister AND an elected physician minister with different, complementary, laudable background & skills. In ON, the politicians for health you describe are/were some of us! While I agree that we have to find a way to distance government from our health system without separating completely (and without privatizing completely), the health system in ON does not seem to have lived up to Amanda Goodall’s research showing that health institutions led by physicians perform better at all levels (patient outcomes, staff morale, finances, etc). Just looking at the facts, and without any prejudices, as a non-Ontarian I wonder what happened?
You have to have once been a civil servant in the Ontario Ministry of Health and Long-Term Care. Almost all “decisions” are, in effect, made by senior management civil servants, that is, by Assistant Deputy Ministers in the Ministry, Executive Directors of Divisions in the Ministry, and Directors of Branches in the Ministry. Ministers and Deputy Ministers in the Ministry merely “rubber stamp” almost all of the “decisions” made by senior management civil servants.
Great response, Perry!
Great comment, Johny!
1) None of the last 2 MD Minsters of Health ran a private practice, and the ADM of health was an academic. Non business people will never understand the issues in running a medical business.
2) Public health docs are trained to take control in the face of crisis. ON healthcare is in crisis, ergo….
3) Uber academics are used to being the final authority on things.
4) Goodall’s research was on institutions, that is, businesses that could fail. The government cannot fail; it only raises taxes and increases funding to failing programs.
So, I believe Goodall’s advice remains intact. I believe an MD is necessary, but not sufficient, for leadership in medicine/healthcare.
Thanks for posting a great comment!
“the health system in ON does not seem to have lived up to Amanda Goodall’s research showing that health institutions led by physicians perform better at all levels (patient outcomes, staff morale, finances, etc). Just looking at the facts, and without any prejudices, as a non-Ontarian I wonder what happened?”
That is because they stopped being ‘physicians’ once they started working for the government…
Shawn …… EXACTLY !!!!
Your best post … in my opinion.
Just came from a LHIN meeting where the MOH will spend 28 million/yr adding ANOTHER layer of bureaucracy to orthopedic services.
Smaller/less activist gov’t means better health care in Ontario.
Thanks Ramunas!
You managed to coordinate things, Shawn, when you improved your emergency department. You detailed the planning and effort that was needed in your book “No More Lethal Waits”.
Thanks for mentioning this, Gerry. We had a vision of what needed to change, but we had no idea about the specifics. The team built the solutions that worked best in our environment.
Government tends to do the opposite. It builds on specifics without a clear vision other than to make things more bureaucratic and specific.
OK, credit where credit is due!
This is the best thing I have read from you in…forever! 😉
Though you and I have been engaged in some rather colourful dialogue, I think I can wholeheartedly agree with you on this one.
Well done, sir.
Now, as long as we stay away from discourse on the OMA we should be just fine 😉
Wow. Sam, thank you so much!
And very funny too. Deal. We can stick to this message. 🙂
Talk soon,