Politicians dream of efficient healthcare. Patients look for service, access and quality. Physicians want freedom to deliver outstanding, high-quality care designed around patient needs, not bureaucracy. We all want superlative healthcare.
It already exists. Or at least it could, if we let it.
The secret does not lie with integration, IT, collaboration, transitions of care, prevention, oversight, quality management, screening, or all the other things you hear about. These all help and are necessary. But none of them can do everything.
The Secret to Superlative Healthcare
The small doctor’s office offers the best hope for patients, politicians and providers. Here’s an example:
A physician showed me her clinic recently. She holds the mortgage on 1000 square feet in a newer professional strip plaza and renovated it to hold up to 3 physicians (only 2 currently). Twenty-foot ceilings allow for a mezzanine. It is simple, clean, bright and attractive. She works 6 days per week, with one full time and one part-time secretary. A massage therapy clinic leases a mezzanine and offers easy access for her patients.
She knows all her patients – has a relationship with them – and wants to see them healthy. Her patients know she’s devoted to them. She shows it.
But she also wants efficiency. She knows that waste means fewer resources for her patients.
Owner Operator
If her patients need mental health services, in-office nursing care, or any other allied health service, why would we design a system that sends patients away from an office like hers?
If we funded this physician to hire a healthcare worker, we have every reason to expect that she’d apply the same expectations of patient-focused, high-quality, efficient care for the new staff.
Would she tolerate
- Long breaks between patient visits?
- Notes that require more time to write than time spent with patients?
- Leaving appointments open on the schedule?
Never.
She would expect the same focus on patient service and efficiency that she applies to herself. Wasted resources mean fewer resources for other patients.
New Programs
So, why do bureaucrats insist on creating new behemoths, with weighty tomes of policies and procedures, so that allied health can ‘integrate’ with primary care, in a separate location? How does this help patients? Every new solution seems big, and wasteful.
Of course, not all offices run like the one described. But many do. The ones that do not, go out of business or move into government run clinics.
Superlative healthcare starts with small physician businesses. Ideology prevents government from ceding resources or control to physicians. Government wants to control as much as possible. It needs resources for the bureaucratic giants it designs and runs.
Small is Good for Patients
We do not use the excellence that already exists. Let’s let physicians lead and design care around patients’ needs. Let’s push government into a supportive role and let the front-line professionals meet the needs of patients they know and love.
Physicians could replace the work of many bureaucrats if they were allowed to manage resources through their own offices. The secret to superlative healthcare isn’t radical. It’s obvious. But it might require fewer bureaucratic jobs.
It’s difficult to get a man to understand something, when his salary depends on him not understanding it.
Upton Sinclair
photo credit: cnn.com
What I don’t understand is that the gov’t does fund Nurse Practitioner Led Clinics. Why couldn’t this model work for doctors as well. Of course, that would be a lot like the Family Health Teams that the gov’t is undermining. Why is that? I did get a reply on another site that said it was because drs in FHT’s were only working 29 hrs/wk. It may be true of some, but I doubt all. I realize the model above is still different from an FHT. But why couldn’t something that brings the best of NPLC’s, FHT’s and private practice models together be considered. It could be awesome and win-win-win-win (patient, dr, support staff/partners, gov’t) if well thought out and based on consideration and respect for all stakeholders.
Great question, Valerie!
For those of us interested in the business/leadership/management side of healthcare, government scores very poorly on basic business skills. They have no levers to drive service, quality and efficiency at the practice level. Policy, bureaucracy and process cannot be confused with leadership without creating havoc. We need keen leadership in FHTs. Trying to create an amalgam of multiple providers working ‘to their scope’ independently under one bureaucratic tent cannot deliver a seamless product focussed on the only truly important person in the whole show, the patient.
We should at least try giving funding for allied health providers to small physician practices. Let them hire staff. Then watch the outcomes. It’s not complicated.
Thanks again for taking time to read and comment!
Best
Shawn
I think that is what I was trying to say, but not clearly enough. But hopefully drs in this model would not be expected to work 6 days per week!! Would you see a “small physician practice” as having more than 1 dr? That way the workload could be split, and the office open longer hours, more accessible to pts., avoid unnecessary pt visits to ER or walk-ins, without burning out the drs and staff.
For sure. Small groups integrated with others in the community seems to offer efficiencies of the small office as well as the breadth and scope of a larger structure.
Thanks for commenting, Valerie!
Appreciate your comments Shawn. We have a 3 doctor practice like you describe, with 2 clerical and 4 part time RPN’s who work very hard to make our day and the patient experience go well. We are funded under an APP since 1998 and provide better service, work longer days and make more money than when we were FFS. We were recently approved funding for PT and RN(EC) but at the lower end of the going rate making it hard to compete with government (unionized) facilities. The FP’s are expected to cover all overhead but are not allowed to collect any outside fees for their services nor decrease the work we do. It has worked great with the PT because we can subcontract him from the hospital. But harder to pay out of pocket for a service that benefits the community but costs us.
I agree that government wanting to appear like saviors of the system inevitably bring with them a cumbersome burden of bureaucracy.
Thanks so much for taking the time to share this, Phil!
On top of the higher rates you mention at other facilities, the governance does not offer the same levers to focus attention on patient need. For example, managers in hospitals must please their superiors, not patients. Managers generally want to move up the ladder and not lose their jobs in the process. Physician managers in clinics do not have anywhere to move up to and do not worry about losing their jobs. They only worry about spreading resources to as many patients as possible while delivering outstanding service and quality. With aligned incentives and purpose, patients benefit.
Thanks again for taking time to read and comment!!
Shawn
I liked this piece. Seems that Ontario health care delivery at present has a lot of “make work projects.” A series of useless (or at least unnecessary) LHINS. Why not just 1 or 2 large LHINS? Same with “boards of health” etc? Colossal wastes of time, energy, resources and efficiency, with regards to the chronic duplication. Also get rid of the following unnecessary bloated little-known and under-performing agencies: Cancer Care Ontario, Public Health Ontario, e-Health, Health Quality Ontario, Office of The Chief Coroner, etc etc etc etc. Also no need for handsomely paid bureaucrat physicians either a la Hoskins (I certainly hope his salary is likewise being cut–interesting that query never made the media?!) Prior to Medicine, I studied politics, so I know my health policy!
Basically, what I am doing Shawn, is using your micro level office example to illustrate what a badly functioning system we have at the macro level.
I see a lot of analogies of waste and overlap in the educational system too. ie. no need for both a Catholic and public system, no need for thousands of people as boards of directors etc.
Speaking of the school system, I am closely watching this teacher’s strike. Not to stray too far off topic, but I am hoping to live vicariously through the teacher’s current strike challenge to the province–typically not a fan of the teaching profession myself, the doctors might be able to pick up and mirror the efforts and outcomes of any teacher strike action (or at least at the symbolism of sending the government a loud and clear message). I don’t care that teachers make way less than us, my trade-off argument is that 95% of doctors don’t get a golden, defined-benefit pension either X hundreds of thousands on retirement payroll.
Just sayin’
Wow. Excellent comments, Ken! Your political science background would help to balance many of these blog posts.
I’m glad you brought up Cancer Care Ontario (CCO). It seems Susan Fitzpatrick loves CCO. It holds credibility with MDs. It has bloated beyond cancer into the renal network, diabetes and even CTAS (emergency med)!
Bureaucracy begets bureaucracy. It needs to stop.
Thanks so much for reading and taking time to comment!!
Best
Shawn
I’m not a dr or even in the medical field – just a patient and taxpayer – but Ken Brown, you have nailed it!!! Dispensing with all the inefficient, ineffective and unnecessary layers of bureaucracy could go a long way toward improving our h/c system. I can remember when our h/c system was the object of envy from many other countries. And we have slipped so badly. Can’t help but think there are just too many administrators and bureaucrats whose jobs don’t really have a lot to do with medicine. They often get in each other’s way, or at the very least trip over each other, and worse, frustrate the efforts of true medical practitioners to the detriment of delivering effective, efficient, cost-effective health care.
Well said, Valerie! Thanks for taking time to comment!