A CALL FOR TRANSFORMATIVE CHANGE IN HEALTH CARE

Introduction

This post deals with the governance of our health care system and how it can be improved[1]. The system is in crisis and demands transformative change. Winston Churchill said “never let a crisis go to waste”. Fortunately, we have a 10-year blueprint for action, based on thorough research and consultation. We have the grand strategy for transformation. It now needs to be implemented.

Our health care expenditures are higher than those of other province while our performance outcomes are lower than the rest of the country. That is the problem we face in health care and nothing short of transformative change will fix it.

The PERT report[2] informs us that we have the highest per capita health care spending in the country, $6443, in 2019, compared with $5619 in Nova Scotia, the province with the next highest spending. Health costs are rising, along with the number of physicians, despite the fact that our population[3]  fell over the period 2016-21, by 8142 people. Since 1992, the year of the cod moratorium, our population has fallen by 580,109 to 522,253, a decline of 10% while Canada’s population rose by 36%.

The Health Accord, in their summary[4] of the situation, tells us that “we have the worst health system performance among all Canadian provinces”. They cite the “worst life expectancy, highest death rates for cancer, cardiac disease and stroke and the highest rate of chronic disease in Canada”.

The Social Determinants of Health

The Health Accord has also determined that we can improve the health and health outcomes of the population of our Province through acceptance of the critical role performed by social determinants of health, and through intervention to achieve a higher quality health system that re-balances community, hospital and long term care services. They concluded that such intervention, if implemented holistically, will lead to a healthier population and that the long-term impact will be even greater than the impact of measures to restore sick or unhealthy people to good health. We need to direct funding to basic income support, improving food and housing security, with special attention given to education, learning, care , and  addressing the complex needs of children and youth.

Their research led them to the conclusion that health outcomes can be improved not only by reforming the health care system itself but by injecting more resources into the “social determinants of health”. There must be a dual approach to health and both must be part of the province’s 10-year health plan.

This conclusion adds urgency to the need to reform the present system and to make it more cost effective. Given our fiscal position it is not feasible to make significant improvements in social programs, in education, in early childhood development, in food security, in housing, in income support and in other social programs, without reallocating resources from the health sector. We must find efficiencies in the health care system itself if we are to put in place the social supports to make people healthier. With such a reallocation of resources, we can reduce the demands on the health care system because people will be healthier than if we relied solely on treating health problems rather than preventing them in the first place.

PERT reports that we have over 180 health care facilities. While our population has declined by almost 2% from 2016 to 2020 the number of physicians per 100,000 people has increased to the point where the number is now higher than the national average, 262 in 2020, compared with 242 for Canada. Yet there are many people without access to the medical care they need, particularly in rural areas.

We have to ask the question whether these high health care costs, combined with poor health outcomes, arise because of the same faults in our political and governance systems which led to the Muskrat Falls fiasco? Are there lessons we can learn from the Muskrat Falls project and from the Muskrat Falls Inquiry, which concluded that the project was “misguided” in its planning and evaluation, as well as in its governance and decision-making processes.

While there are limits to what can be done to change the health care system in the short term, we all know that fundamental reform must take place soon. Can this reform be performed incrementally, or must there be more revolutionary, transformative change?

David Vardy

NL Council on Health Quality and Performance

On February 17, 2022, the Health Accord NL delivered its Report entitled “Our Province. Our Health. Our Future. A 10-year Health Transformation”. Before the end of this month, I understand the same group, led by Sister Elizabeth Davis and Dr. Pat Parfrey, will be releasing their Report on how the 10-year Plan should be implemented. On May 5, 2022, I presented a brief to Sister Davis and to Dr. Parfrey, dealing with some of the issues in their 10-year plan. I am grateful to Sister Elizabeth and to Dr. Parfrey for giving me the opportunity to present and for engaging in a full discussion of the issues I have raised. My brief is attached.

This post deals principally with Action 11.4 contained in the Plan, proposing the creation of a NL Council on Quality and Performance. The role of the Council is described as follows (p 205):

“Accountability for improved outcomes is the responsibility of the health and social systems that deliver care. In support of this accountability, the Council would have three major roles: (i) reporting on quality and performance of the health and social systems to the public, providers, institutions, and governance structures; (ii) developing and executing the evaluation plan for the Health Accord; and (iii) providing leadership for the learning health and social system. The Council is envisaged as directly connected to Quality-of-Care NL whose focus is evaluation, research, and knowledge translation.”

The Need for Oversight: Commissioner LeBlanc

Public review processes are needed to improve decision making and to ensure that all the evidence is weighed competently before decisions are taken. How does the Health Accord propose to raise the level of discourse and to make health care decisions more responsive to medical efficacy and remove them as spoils for political gain? Major health care decisions continue to be made, with no forum for public review, notwithstanding Recommendation #1 of Muskrat Falls Inquiry Commissioner Richard LeBlanc:

The Council recommended by the Health Accord bears directly on the concerns which prompted the Muskrat Falls Commissioner to propose fundamental changes in the governance and decision-making process in our Province. Each year major projects are built to improve health care and many well exceed the $50 million threshold identified by the Commissioner, including new hospitals, clinics, long term care facilities and new medical technology such as positron emission tomography (PET) scanners. On top of that there are major new costly treatments for disease which deserve robust, evidence-based public review before their adoption.

Health economist Dr. Michael Doyle has proposed a similar concept to that of  the Council for the purpose of improving decisions in the health care sector. His proposal more directly aligns with the advice of Commissioner LeBlanc than with the direction of the Health Accord.  Doyle proposes a model based on the Public Utilities Board, which would provide for an open transparent process for dealing with major health care decisions, relating to building new hospitals and clinics, introducing new treatments/medications and the acquisition of major new equipment.

All major decisions in the health care system should be informed by an open and transparent, evidence-based process, with all stakeholders at the table, especially health care consumers. The model, if applied to the proposed Council, would enable the Council to advise on such major decisions and improve the quality of the decisions by bringing forward information on the medical efficacy of the investments in question with a view to providing health care consumers with quality care at least cost, similar to the mandate of the PUB.

Information would be presented to the Council by various stakeholders and by experts, who would present to the Council and whose evidence would be open to challenge and cross-examination. The Council would assimilate this information in open public hearings and make recommendations well in advance of the decisions to be taken, which might include the replacement of a hospital or clinic or the introduction of new medication or treatment.

The Health Accord’s 10-year Plan speaks to the need for reform of the air and road ambulance system. Would such reform be a task which could be considered by the Council, who might be tasked with assessing proposals to improve the Province’s ambulance system?

The Health Accord quite rightly identifies the need for improved accountability. They see the Council playing an important role in achieving accountability by formalizing a process for evaluation. One of their key objectives (p 207) is to “Develop an evaluation agenda to measure system performance including metrics for appropriate medication use across the health system to inform interventions on overutilization and underutilization by providers and institutions, access to comprehensive primary care, adverse events, wait times for critical procedures and services, and backlogs of surgeries.”

Ex ante advice or ex post facto evaluation, or both ?

Evaluation is critically important, but it is an after the fact, ex post facto analysis, one which should be complemented by an ex-ante analysis, that is before the fact, before the decisions are taken. Dr. Doyle and I would like to see the Council play a bigger role to inform decisions before they are taken. This ex-ante role is the vision embraced by Commissioner LeBlanc.

When I raised this issue with Health Accord leaders, they emphasized the importance of an evolutionary and  “iterative process” which would encompass both ex ante and ex post facto considerations. Their answer is consistent with the following objective (p 205) set out in their report: “Create an organization, protected by legislation and arms-length from government, which provides information and advice, in an iterative process, to improve quality and performance of institutions and providers in the health and social systems. This should evolve from structures already created to provide clinical interpretation and knowledge translation of data and to improve quality in the province.” (my underlining)

Consumer Advocacy Needed

The Council should play a vital role to inform health care decisions before the decisions are taken and this information should be presented before a body which is at arm’s length from government and from major stakeholders. Citizens have a critically important role to play. As health care consumers they should be encouraged to participate in the process of identifying health priorities and needs as well as in advising on the medical efficacy and costs of alternative health care options. This can be achieved by creating a consumer advocate who would present to the Council on costs, quality and performance. It could also be encouraged by providing intervenor funding so that groups of consumers can present evidence to the Council. Consumer advocacy and intervenor funding are frequently used to enable tribunals such as the PUB to seek advice from health care consumers.

Politics versus Science

Health care decisions are fraught with politics. Health care is too important to us all as a society to become a pawn in the political system. The leaders of the Health Accord have correctly concluded that health care must be driven by evidence and not by politics, that improved quality demands information and advice along with knowledge translation for the benefit of the layperson.

Our health care system needs transformative change, and it can only be achieved by making decisions more transparent and by educating the public as to how the system can better serve the needs of our citizens. The status quo is not an option.

Human Resource Plan

The attached brief goes beyond expanding the mandate of the proposed NL Health Council on Quality and Performance in order to depoliticize health care decisions. My brief treats as equally important the development of a human resource plan for the medical sector. It chronicles my frustrations in obtaining information under the Access to Information and Personal Privacy Act (ATIPPA) from the Department of Health and Community Services on the cost of training physicians at Memorial University’s Faculty of Medicine and in securing from the Department a provincial human resource plan.

In my ATIPP requests I asked the Department to provide the cost of training a physician at Memorial University, whose Faculty of Medicine is receiving $54 million this year from the Department. I asked how many physicians the Faculty has graduated and how many are still practicing in the Province. The Department could not provide this information to me, as a concerned citizen[5].

I also asked the Department to identify who is responsible for the province’s latest medical human resources plan and to supply the plan to me as a concerned consumer. I was told the Department does not have access to such a plan and there is no GNL agency “responsive” for “planning the human resource requirements of the medical sector…” My questions and the responses of the Department follow.

I raised these requests with the Health Accord and asked if they intend in their implementation report to address the role of Memorial’s Faculty of Medicine and assess whether the Faculty is supplying the physicians that are needed, particularly in rural areas, on a cost effective basis.

Conclusion

We all agree that the current allocation of resources between different sectors in the health care system (acute care vs. population health) is way out of balance.  So, we need to correct the balance, as pointed out in the Health Accord.  However, more importantly, we need to scrutinize the decision-making mechanism that allowed it to become so out of balance in the first place.  Otherwise, in future years we will be inevitably back in the same predicament. 

Much of the capital expenditures in health care can be considered very expensive sunk costs (identical to Muskrat Falls) as they have no alternative use.  So, decisions need to be prospectively thought through and evidence based, as they are irreversible and will haunt future taxpayers (in terms of their costs) and patients (in terms of lost health outcomes from the potential benefits of alternate uses of those resources) in perpetuity.  These types of decisions don’t lend themselves to an “iterative type of decision-making process.”  There will be only one opportunity to get it correct and that is before the concrete is poured.

I also deal in my brief with the complexity of the healthcare system and the opaque role of the Department of Health and Community Services. My brief contains a plea for the implementation report to define the role of the Department in system planning, reform, management and execution.  

The governance of our health care system requires large scale transformation, beginning with the Department, which stands at the apex of the system. The Department is entrusted, but clearly not empowered, with lead responsibility and ultimate accountability for cost, performance and outcomes.

The implementation report by Sister Elizabeth Davis and Dr. Pat Parfrey must identify the central oversight role of the Department of Health and Community Services which must, on behalf of the Premier and his government, become the champion of transformative change. This will afford our Premier, himself a physician, the opportunity to become the energetic champion leading us all toward the improved health outcomes and lower costs which the province demands. 

I encourage the reader to take the time to read the full brief, attached as an Appendix.

David Vardy

[1] See my ATIPP requests and response HCS-379-2021  at https://atipp-search.gov.nl.ca/public/atipp/requestdownload?id=18528  and HCS-380-2021 at  https://atipp-search.gov.nl.ca/public/atipp/requestdownload?id=18307.

[2] See https://thebigresetnl.ca/wp-content/uploads/2021/05/PERT-FullReport.pdf page 170.

[3] See Statistics Canada quarterly population data at https://stats.gov.nl.ca/Statistics/Topics/population/PDF/Quarterly_Pop_Prov.pdf .

[4] See https://healthaccordnl.ca/ Facts.

[5] See my ATIPP requests and response HCS-379-2021  at https://atipp-search.gov.nl.ca/public/atipp/requestdownload?id=18528  and HCS-380-2021 at  https://atipp-search.gov.nl.ca/public/atipp/requestdownload?id=18307.

APPENDIX

PRESENTATION ON “REPORT OF THE HEALTH ACCORD FOR NEWFOUNDLAND AND LABRADOR: OUR PROVINCE, OUR HEALTH, OUR FUTURE, A 10-YEAR HEALTH TRANSFORMATION” DATED FEBRUARY 17, 2022

 DAVID VARDY

May 5, 2022

Key Points and Questions

A. Our health care expenditures are higher and are growing faster than the rest of the country while our performance outcomes are reportedly lower than the rest of the country. How does the Health Accord respond to the Province’s fiscal crisis?

B. Public review processes are needed to improve decision making and to ensure that all the evidence is weighed competently before decisions are taken. How does the Health Accord propose to raise the level of discourse and to make health care decisions more responsive to medical efficacy and remove them as spoils for political gain?

C. While there are limits to what can be done in the short term we all know that fundamental reform must take place soon. Can this reform be performed incrementally, or must there be more revolutionary change?

D. Health care decisions should be driven by the needs of clients and by scientific evidence on the efficacy of treatment. Politics plays too large a role. The system cannot be reformed without a better way to deal with the all-pervasive politics. We need to adapt and adopt a PUB model for reviewing major health care decisions to move them into a more transparent, evidence-based and accountable forum.

E. Is there a need for a more transformational approach to human resource deployment (e.g., between urban and rural), including a comprehensive review of the role of Memorial University and its Faculty of Medicine in training medical personnel?

F. Our health care system is too complex, and accountability is too diffuse. It needs to be simplified and accountability must become more real and less ethereal. These should be incentives and consequences. The implementation report should focus on what accountability means in practice, identifying how accountability is executed and by whom.

G. The Health Accord must begin by defining what role the Department of Health and Community Services should play in system planning, reform, management and execution.

H. The proposed Council on Quality and Performance should be designed to effect transformative change in building an evidentiary basis for health care decisions and to achieve an appropriate balance between medical efficacy and social consideration, one in which medical efficacy is dominant, rather than politics. It should inform and guide decisions on an ex ante basis, before they are made, rather than simply reporting after the fact, ex post facto, as an audit. As proposed in your February report, will the Council shape future action or audit past decisions?

I. We are told that the system is in crisis. Winston Churchill told us: “never let a good crisis go to waste”. Does the consensus-based, evolutionary, cautious approach taken in the Health Accord allow the government to avoid the transformative change which the crisis demands? Will it perpetuate the status quo?

J. Major governance changes are needed and should reduce the number of entities in play rather than increase them. Rather than emulating complex systems designed for larger jurisdictions our system should be fitted to the small size of our population yet sensitive to its large and dispersed geography.

MAIN PRESENTATION

  1. The Health Accord planning process is a great opportunity to benefit the Province and to improve the health and well-being of its citizens.
  2. It is an opportunity which may not be repeated. You have unmatched credibility and a powerful mission. You have a broad mandate to serve the people.
  3. Government is the servant of the people, not its masters. You have a mandate to inform and educate the public as well as its government. You have a duty to speak truth to power and to advise why our health outcomes are so poor despite the alarming rise in spending and a duty to recommend transformative change.
  4. The highly consultative approach taken in writing the Health Accord has served to inform and educate the public, which is a vital step towards renewing the health care system. It needs to go even further to enlighten the public on how the system works and how it is performing in terms of quality and cost relative to other jurisdictions, as well as relative to our historical performance.
  5. The Health Accord should not be silenced by any lack of unanimous consent among stakeholders, nor should it delay immediate action to achieve transformative change.
  6. The health care budget is the largest component of the Province’s public spending and its rising costs must be addressed openly and transparently, in planning the future of our health care.
  7. Politics permeates this province and will always play a role in public policy decisions. It is naïve to think otherwise. Yet health care in this province suffers from the dominance of unbridled political considerations. Reform of the health care system urgently demands a reform of the role of politics in the decision-making process!
  8. There has to be a better way, one which allows informed discussion and decision-making so that politics has a less corrosive influence. Your recommendations have the potential to improve the governance of our health care system by making health care decisions more transparent and more evidence based. They must also be more responsive to the needs of all citizens and more responsible to the straitened fiscal position of the Province.
  9. Good solid evidence will lead to better decisions, on the acquisition of new equipment, the adoption of new treatments and the building of health care facilities. Good solid empirical evidence, based on good medical and social science, will allow better outcomes for the massive resources allocated to health care. Good science and good evidence, combined with transparency and public participation, will lead to better decisions.
  10. We need to build better institutions which will allow stakeholders to present their evidence and perspectives in a public forum not unlike the Public Utilities Board and how it conducts oversight over public services such as the supply of electric power. The PUB allows for all stakeholders to be engaged and to have standing in an open public forum. This is a model to be adapted and emulated in health care. The recommendation for a Quality Council affords an opportunity to adopt and adapt the PUB model.
  11. We must demystify health care by taking it out of its sanctuary, taking it down from its pedestal, and elevating the role of citizens/patients/clients. Citizens must have standing in a public process. But they must also have a lot more information on the costs and benefits of health care and alternative treatments to empower their participation in a highly specialized field where they must challenge information supplied by powerful and well-funded stakeholders. A PUB  type forum for reviewing major decisions would draw upon national bodies such as: Statistics Canada, the Canadian Institute for Health Information (CIHI), and the Canadian Association for Drugs and Technology in Health (CADTH) to test evidence presented by stakeholders (See attached articles by Dr. Michael Doyle).
  12. Citizens, as health care consumers, must understand how the system operates and how much it is costing them as citizens. People in our province need to know how the costs of health care in this province and its quality compare with the performance of other provinces. The information on cost and quality is needed on a macro level, system wide, but also at a more micro level in terms of specific treatments, comparing one system with another over a period of time.
  13. A publicly funded system should be no less transparent than one where the patient pays for each appointment, for each operation, for each day in hospital, for every hip and knee replacement. The patient should know what the cost is, whether the cost is recovered through user fees or through general taxation.
  14. To start off we need to benchmark our system against other systems and understand the variations in input costs and medical outcomes. The benchmarking must encompass the costs of each part of the system along with the outcomes achieved. Your report offers a good start in this benchmarking task but your final implementation report would be incomplete without going much further. This is a big task, but it should begin in your report to government.
  15. Benchmarking is used to establish performance and productivity norms from which progress can be evaluated. Benchmarking would include the number of physicians and other medical personnel relative to other jurisdictions. It would include the cost of medical procedures, including procedures carried out in the Province but also those outsourced to other jurisdictions.
  16. As our population has decreased our physician supply per 100,000 people has increased over the past 20 years by almost 50%, and still there are supposedly massive shortages. The number of physicians per 100,000 people in this Province is 262 compared with a Canadian average of 242. (CIHI Table 1: Physician Workforce by jurisdiction, Canada, 1968 to 2020, Excel, see table below). Over the past 52 years it has gone from 65 physicians per 100,000 people to 262, a fourfold increase, compared with a factor of 2.2 nationally.

How does the workload of medical personnel in our Province compare with other jurisdictions? How does the growth in medical salaries track the GDP of the Province, which has been falling in real terms? These are important questions which need to be addressed.

17. The current increase in physician supply numbers and in remuneration, for a declining population, is unsustainable and crowding out other public services. Specialists are drawing extremely high salaries and are among the highest paid people in the Province. Do we need to review how medical personnel are compensated? Are we using highly paid and skilled resources to perform tasks that can be performed at lower cost without compromising quality? This is a big issue in the deployment of human resources. Will the implementation report propose changes in how physicians and other medical personnel are remunerated, how they can be retained and how they can be deployed in unserved rural areas?

18. We use a provider-based funding approach for physician services, particularly GP services.  This means that GP funding follows the physician and is spent in a location where they decide to practice, notably urban areas.  Alternatively, a population-based approach would allow regions of the province to receive a “fair-share” of the GP budget based on the number, gender and age characteristics of the population in the catchment area.  Use of this latter approach would require GPs to physically practice in a rural area in order to earn that respective funding. Do we need a new, reformed compensation system to go hand in hand with a reform of how our medical resources are deployed?

19. There has to be more measurement and more understanding of how our system works, its strengths, its weaknesses, its opportunities and the threats it faces (a SWOT analysis). This has to be the beginning, not the end. The report does not describe the system as it is, its strengths and weaknesses. Most planning documents begin with a SWOT analysis which describes the existing system and identifies the parts which most urgently demand corrective action.

20. Governance of the system should be as simple as possible, and accountability should be clearly understood. Planning for the future of the health care system should be led by the Department of Health and Community Services and it must have the full span of responsibility and authority, along with the management information system needed to undertake strategic planning. Planning responsibility appears to be diffuse and ambiguous as illustrated by the responses I have received to the ATIPP requests I have shared with you (attached). The Implementation Plan should clearly define the responsibilities and accountabilities of the Department along with those of the other major participants, including provincial health boards and councils and Memorial University.

21. The final report should define what accountability means and how it can be achieved. It should not be a nebulous, ethereal concept. Your governance proposals should identify who is responsible for accountability and it should be explicit on the instruments which must be deployed, including incentives and consequences[1].

22. Many people want to keep things as they are, but the status quo is not an option. It should be rejected.  The system is by far the biggest employer in the province and offers salaries that far exceed that of an average worker. The system should be managed to provide health care and not as a means to redistribute income. If GNL wishes to create public sector employment for regional development purposes the funding should not be taken from the health envelope.

23. The Health Accord describes the health outcomes but does not quantify the financial and human resource inputs. It does not assess where performance is weak and where efficiencies can be achieved. Hopefully this shortcoming will be corrected in the Implementation Report. I see no plan to reduce the growing cost of providing services and no alternative plan to curtail growing remuneration for physicians and other health care providers. I see no plan to remove the unbridled politics from health care decisions and to make them more evidence-based and less politically driven, including decisions on new hospital facilities, new treatments/medications and expensive new equipment.

24. Implicit in the recommendations of the February 2022 report is a damning criticism of the system. Examples:

25. Do we not have a five-year plan for cancer, cardiac disease and stroke? It is disturbing to learn we do not have such plans.

26. Is the current system not based on principles and criteria? I fear it is not.

27. The fact that this needs to be said is a powerful criticism of the system. Why does the Health Accord have to identify such an egregious weakness? Does it speak to a fatally flawed health care system which cannot be fixed without a major transformation, one which is unlikely to be recommended by the very people who may be negatively affected by transformative change.

28. Can the system reform itself from within or does it need to be imposed from outside? By bringing representatives of the system within the Tent and seeking their consensus did the esteemed co-authors of the Health Accord damn its Action recommendations to the least common denominator, those changes which will gore the fewest sacred cows?

29. I do not sense that the report recognizes the strained and parlous fiscal state of the Province. The PERT report spoke of the need for our health costs to align more closely with those in other Canadian provinces. This imperative does not seem to be a guiding principle for the Health Accord. This is a fundamental problem with the report as it currently stands which will hopefully be addressed in the pending implementation report.

30. The recommendation for action by the federal government to fund a basic income is in alignment with the social determinants of health advocated in the Accord. This is a worthy goal but will be challenging to achieve. Have the authors of the Accord consulted with Doug House who led the Economic Recovery Commission, which developed a detailed proposal to reform our income support program? The House proposal recognized the enormous cost of developing a new guaranteed basic income piggybacked on top of existing programs and concluded that the new program must replace existing income support, including Employment Insurance. Fish harvesters resisted such an integrated approach because the new plan would be less advantageous for them than the support received under Employment Insurance. Even a guaranteed basic income, let alone a universal basic income, will be difficult to achieve, even on a pilot project basis and even when the funding is federally provided.


31. There is very little discussion in the February Health Accord report of the role of the Faculty of Medicine. Is this Action 10.4 an admission that we have no human resources plan? As you know I have submitted an ATIPP request to DHCS seeking information on the cost of providing physician services and access to the province’s human resource plan for training and recruiting medical practitioners. The information I requested should have been immediately available, but the Department sought an extension to the normal thirty day deadline, indicating they were struggling to respond. When they finally responded they told me there was no provincial human resource plan available. If I need information about the system I was told I must write to each institution, despite the fact that most of them report to the Department of Health and Community Services and are funded by the Department.

32. On the subject of governance, the report contains the following Action 11.1

Will this new authority take over from the existing regional health authorities? My reading is that the program delivery functions of the new Authority will be limited to programs “such as the ambulance system and information systems” which leads me to believe that the existing RHAs will continue to be vested with “regional” programs and that tertiary care will continue to be provided at the RHA level. How will the new Authority operate and where will its planning be undertaken?

33. Health Economist Dr. Michael Doyle developed a concept for a quality council (attached documents) which would advise on major decisions such as the need for a new PET scanner or a new hospital, which would conduct public hearings, similar to the PUB, and where a consumer advocate would be appointed to represent the interest of health care consumers. The Council would recommend whether GNL should purchase a major piece of equipment and where it should be placed. It would hold hearings on the need for a new hospital or for the dismantlement of an old hospital. Would this advisory function on major capital projects be part of the mandate of the Council recommended in Action 11.4?

34. If not, then there is definitely a need to create some kind of quasi-judicial process to remove major capital decisions from the realm of politics and rebase decisions on best practices, empirical evidence and scientific principles. The imbroglio over the Corner Brook PET scanner comes to mind. As noted earlier the proposed Council should be similar in mandate to the Public Utilities Board which is to ensure that high quality, reliable public services are made available at least cost. There should be a dual focus on quality and cost and the new Quality and Performance Council should emulate the PUB model. The PUB has an ex ante role in making and recommending decisions but it also has an audit and an oversight role. Will the Council be advisory only or will it make decisions? Will it play an audit and/or oversight role?

35. This Action 11.4 recommending an NL Council for Health Quality and Performance could be a pivotal recommendation if the proposed Council is set up on the PUB model as a mechanism to provide a public forum for major health care decisions. The Council could be mandated to hear evidence on each major health care decision and could provide a forum for evidence to be brought forward before the Council. Intervenor funding could be made available for citizens or groups of citizens, as health care consumers, in order to bring forward relevant evidence. This might be combined with a Consumer Advocate to advocate on behalf of health care consumers. The Council might have the final say on some decisions and an advisory role on others. The pan Canadian Oncology Drug Review (pCODR), as an example of an alternative review mechanism, provides a framework for reviewing new cancer medications.

36. The report speaks to the Choosing Wisely program and to the misuse of medications and medical procedures. Correction of this problem is perceived to require education and other public sector supports. Is there not also an onus on the medical profession to take disciplinary action rather than to force the public to inject additional resources and thereby to make the cost of health care even more expensive? Is it true that physicians (most notably fee-for-service physicians) generally are not held directly responsible through their professional organization – financially or otherwise for quality issues, such as overprescribing, that are directly their responsibility (unlike other independent contractors).

37. Such a recommendation concerning the mandate of the proposed Council would align with recommendations 1 and 2 of the Muskrat Falls Commissioner.

38. I have a concern about accountability in the context of the new Councils and Authorities being recommended. What will be the role of the Department, the Deputy Minister and the Minister? One of the biggest problems in the current system is diffusion of accountability. A citizen seeking health care may present to a regional health authority with a major health issue. If left unsatisfied and unserved by the RHA the person might go to the Minister who may simply refer the person back to the RHA. How can we achieve true accountability by providing incentives to good performance and real penalties for failure to serve? It seems that the system has lots of carrots to offer but no sticks.

39. The report speaks to the need for interprofessional teams, which is good in theory, but raises the question as to who is in charge. Where does the buck stop? This has to be resolved. It is a fundamental accountability question. Somebody has to be in charge of each team.

40. Hopefully, these questions will be answered in the implementation report. Hopefully, the implementation report will cost out the financial impact of the recommended actions, the savings that will fund the new programs or the source of funds for additional programs in both the social and health sectors. Our fiscal situation does not enable new costs to be incurred without offsetting savings.

41. GNL has just given physicians an increase which will lead to more pressure on GNL and will exacerbate the parlous fiscal state of the province. The Health Accord does not provide GNL with fiscal options to restrain health care costs.

42. One of the key recommendations of the PERT was the need to reduce the government payroll. Don Drummond’s report for C D Howe makes that very clear and compelling. See the following excerpts from the attached report, “The Rock in a Hard Place”.

43. Another quote:

44. Healthcare worker compensation in NL grew by 332%, compared with 284% in the rest of Atlantic Canada and 228% for all of Canada, over the period 1997 to 2019. See quote below:

45. As someone who has spent over 25 years as a Deputy Minister I am concerned about the role of the Department of Health and Community Service, and whether it is fully discharging its management and oversight responsibilities. With the devolution of responsibilities to boards, commissions and agencies it is hard to see how the Department can ride herd on a highly complex and decentralized system. For a small province the health care system remains highly complex organizationally. We need to design a bespoke and simple system for Newfoundland and Labrador rather than emulate systems designed for much larger jurisdictions.

46. I submitted a set of ATIPP requests in November and December 2021 and the recent replies are attached. They portray a fragmented system where the Department is a mere bystander.

47. The Department of Health and Community Services is vested with authority to manage health care in the province. Yet it has no role in planning how many physicians we need. It does not have a complete database on health care system costs or the high paid physicians who control the system. Is this not the hallmark of a dysfunctional system? Your implementation report should identify the appropriate planning and execution roles of all major institutions and particularly of the Department of Health and Community Services which stands at the apex of the system with lead responsibility and ultimate accountability for cost, performance and outcomes.

48. Look at the attached replies I recently received from my ATIPP requests filed in November and December 2021. There is a group of physicians on the faculty at Memorial who charge fee-for-service yet have no administrative costs. On top of that they receive salaries. I have raised some questions about this anomaly. The Department tells me I must direct my questions to the University, to the RHAs and to other entities. This is most inappropriate. Is this not an abdication of responsibility by the Department? Will your final report deal with these anomalies in the funding of physician remuneration?

49. In my ATIPP requests I asked the cost of training a physician at Memorial University, whose Faculty of Medicine is receiving $54 million this year from the Department. I asked how many physicians the Faculty has graduated and how many are still practicing in the Province. The Department could not provide this information to a concerned citizen. I hope that your final report will address the role of Memorial’s Faculty of Medicine and evaluate whether the Faculty is supplying the physicians that are needed, particularly in rural areas on a cost effective basis.

50. The Department washes its hands of such information. They tell me “No GNL agency (is) responsive (sic) for planning of human resource requirements in the medical sector.” On top of that we have no human resource plan. See the following questions and replies, just as an example.

51. Do you think it is time for the Department to assume its proper responsibility for the management and planning of health care in the province? Remember the health care sector is responsible for 40% of net expenditures (Appendix VI of Estimates) or $3.2 billion of $8.1 billion.

52. Not only is the Department abdicating its management accountability it is renouncing its oversight role to measure outcomes, input costs and effectiveness of our health care system. Our health outcomes are poor in relationship to the increasing financial resources allocated to health as well documented by the Health Accord. Yet the Department presides over a system in chaos.

53. Your report deals with the governance of the health care system but has little to say about the role of the Minister, the Deputy Minister and the Department of Health and Community Services. This should be remedied in the final implementation report.

54. How will the Health Accord rectify this situation, where there may be political accountability but little in the way of true oversight of inputs and costs and inadequate responsibility for outcomes?

In summary the following key issues need to be addressed:

55. The fiscal impact of health care spending has to be addressed in the context of the fiscal framework set out by the PERT which focused on moving per capita spending closer to the average level in other provinces.

56. Accountability must be strengthened, not weakened.

57. The strengths, weaknesses, opportunities and threats (SWOT) must be identified, and action recommended to fix the system or rebuild it from scratch.

58. There has to be action to reduce the raw unbridled politics which dominate health care decisions. The final implementation report cannot and must not ignore the dominant, pervasive political pressures which exacerbate the fiscal demands of the health care system. A mechanism must be found, perhaps through a quasi-judicial entity, to remove politics and to add science and empirical evidence to major health care decisions, not just those relating to capital projects and expensive facilities.

59. There must be more information available to the public on how the health care budget is used. Citizens should be informed as to the costs they impose on the system when they use its services, whether the services are provided on a fee-for-service basis, on salary costs or on a capitation basis. The implementation report should address in detail the financial operation of the system and how its input costs and outcomes compare with other jurisdictions. 

60. The role of Memorial’s Faculty of Medicine in meeting the human resource requirements of the Province must be addressed in determining the most cost effective approach to meet the needs of communities, large and small, throughout the Province.

61. Finally, vested interests must not be allowed to override the best interests of patients and taxpayers. Sometimes consensus-building among various groups, including influential people inside the Tent, comes at too high a price. The inclusive approach adopted by the Health Accord is commendable for its extensive public consultations but is vulnerable to inappropriate influence by highly paid physicians and other insiders who draw economic benefits from our health care system.

David Vardy

Private citizen and health care consumer

Attachments:

Department of Health and Community Services, HCS-379-2021 Response to ATIPP Request from David Vardy, April 21, 2021

Department of Health and Community Services, HCS-380-2021 Response to ATIPPA Request from David Vardy, March 28, 2021

Doyle, Michael, Discussion Document: Proposed Newfoundland and Labrador Health Quality Council, 2006.

Doyle, Michael, The Need for an Improved Decision-Making Approach in the Newfoundland and Labrador Healthcare Sector, 2021.

Department of Health and Community Services, HCS-380-2021 Response to ATIPPA Request from David Vardy, March 28, 2021

Doyle, Michael, Discussion Document: Proposed Newfoundland and Labrador Health Quality Council, 2006.

Doyle, Michael, The Need for an Improved Decision-Making Approach in the Newfoundland and Labrador Healthcare Sector, 2021.


[1] As an example of “consequences” see the Financial Administration Act, Statutes of Newfoundland and Labrador, section 30(3).


OPINION POLL OVER-RATES INEFFECTIVE TORY OPPOSITION

Having survived in spite of themselves, in Opposition the Tories have been lazy and uninspiring.  The fact that it is summer, and the House of Assembly is closed, admittedly makes their job tougher, except that the Party’s manifest weakness is not a seasonal problem.

REMEMBERING CABOT MARTIN (1944-2022)

He was an exceptional person. A gifted intellect for sure; irascible and argumentative, too. What endeared him to many was not just that he was analytical and insightful, but that he was honest and forthright. He was a public policy wonk; resource policy interested him most. He loved to travel and read; people, with something to say, were always important.

GNL RUSHING INTO ANOTHER “SCHEME”: CABOT MARTIN

I must say that after the Muskrat Falls fiasco, I thought our government had finally learnt its lesson and would not to rush into another such scheme where calling it “green” was enough to suspend all critical analysis.