Friday, May 6, 2016

An Open Letter to the next Minister of Health

With the Trumpocalypse just about six months away, I thought I'd take a moment to give politicians some unsolicited but useful advice.

Hon. Next Minister of Health
Any Province, Canada

Jan-Dec 1-31, 1950-2020 (take your pick)

Dear Next Minister:

Your next job, to be perfectly blunt, will stink. At the best of times, there will always be some stakeholder group - doctors, nurses, advocates, business leaders - tearing a strip off of you in the press. At the worst of times, you won't be able to do anything right for anybody. You'll be blamed for events and mistakes you probably knew nothing about, or at the very least had little-to-no control over.

You're inheriting a portfolio that, apart from the birth of a healthy child, is centered around human misery in all its forms. From birth defects to botched assisted-suicide, bipolar disorder to bunions, it's womb-to-tomb, head-to-toe tragedy.


Just because the job is thankless, though, doesn't mean it can't be done well. What do you need to get health care "right"? Start with being mindful of a simple fact: your party has 10 years (give or take) before the backlog of screw-ups and scandals gets you thrown out of office. Throw in a healthy curiosity and some plain old common sense, and you should do fine. That in mind, here's Ten Simple Steps for being a Great Minister of Health:
  1. First and foremost, since you've got 10 years at the most and you'll never make everyone happy, stop thinking in terms of the politics and do what's right. Nobody will care about who said what in Question Period next week, and people see right through spin and the cynicism of photo-ops.
  2. Disabuse the civil service and your staffers of their bright ideas. Stop creating solutions for non-existent problems. Stop designing new bureaucracies to correct the inadequacies of the existing bureaucracies. Stop spending millions on glossy strategic plans and radio ads. Stop engaging stakeholders when you don't plan on heeding their advice. Give up the grand plans for reform before you've wasted so much money that you're shown the door before your 10 years is up.
  3. Give up the fantasy that health care can be treated like an industry. Lean, Six Sigma, TQM...these are all wonderful models for the manufacture of inanimate objects. We've now had 30-odd years of spending impressive sums of money to implement them in the health care sector without much evidence of improvements in population health. It's advances in treatment and prevention, not models of efficiency, that improve care.
  4. Listen. Not to CEOs, not to pundits, not to think tanks, not to consultants...but to the patients and providers on the front lines.
  5. Recognize the system will never be perfect. Health care is, for better or worse, now a massive matrix of interconnected, interdependent systems. It is simply impossible to "fix" all that ails the system, even if money were no object.
  6. Start with the most pressing problem - hospital overcrowding - not manufactured ones. Hospital crowding should only ever happen in the rarest of circumstances, and only in a local emergency like an outbreak or industrial accident. Build the long-term care (LTC) capacity, build the hospice beds, and eliminate the backlog. Front line workers have been screaming about the issue for decades, and the collective misery of people languishing in hospital or burning out their caregivers at home must end. The "it helps for a short time, then the wait list just goes back up again" argument simply does not hold water here. Once all the people that truly need LTC are in LTC, there is no more wait list.
  7. Feed and house the mentally ill. While your stress might come from an obnoxious reporter or angry constituent, try and imagine the stress of not knowing where to get your next meal, or whether your landlord will finally replace the moldy drywall and turn on the heat. And the effect...you know, that headache you get at the end of a stressful day? That's a melancholic or psychotic episode in someone with severe mental illness. Approving another medication won't alleviate the extreme stress of poverty.
  8. Don't screen for what you can't treat. What's the point in implementing mass screening programs for diseases whose treatment is inadequately funded to begin with? Wanting to catch diseases sooner is a laudable goal, but how much money are you diverting from treating people that are acutely in need of care? For example, there is now evidence that supports screening long-term smokers for early-stage lung cancer. But if you don't have the thoracic surgeons, anesthesiologists, OR space, radiologists, pathologists, oncologists, chemo nurses, and radiation technologists to diagnose and treat the lung cancers you find, you're not helping anybody. In fact, since screening inevitably entails false positives, you might actually misuse scarce human resources and make things worse for everybody.
  9. Take ownership of the addiction crisis. The sad truth is that prescription drug abuse is now a systemic problem in Canada. We're long past the point of needing to lay blame on a single cause, and our existing treatment infrastructure is inadequate and ineffective. Things are also getting worse. The treatment of chronic pain is now inextricably linked to drug abuse, and we've seen flagrant disease mongering (adult ADHD, social anxiety, restless legs) create the same problem with stimulants and anxiety medication. Worse still, doctors are turning away from treating these patients out of fear of censure by their professional Colleges, and generalized angst around making the problem worse. We can no longer imprison addicts, and the treatment infrastructures around addiction management need to be expanded and fundamentally reworked. Major investment is also needed in pain medicine, establishing multidisciplinary, multimodal treatment centres free of the warped incentives now in place (particularly with methadone maintenance).
  10. Cure your Ministry's obesity and ADHD. Every Ministry has wasteful, redundant processes and obsolete programs in place. Because of its size, importance, and ever-changing evidence, a Health Ministry is particularly vulnerable to this. Be aggressive with trimming the fat, especially as reforms are put in place. Likewise, when you embark on a shift in policy, do it thoroughly, carefully, and to its completion. We would all be better off if you devote your efforts to one major problem (such as the LTC crisis), instead of doing 1000 things poorly to look more in control than you actually are. Remember, nobody cares about the politics, and you'll almost certainly be gone in about 10 years. 
I didn't want to give you advice, Hon. Next Minister, on a crisis of the day like a doctors' pay dispute or nurses' strike. Those things will come and go, and might not happen at all on your watch. 

Yes these things will cost money, but they're essential to the well-being of Canadians and the function of their treasured health care system. If the promise of benefit is tangible and sincere, Canadians have never been afraid to pay for what matters.   

I have no vested interest in how your time in Cabinet turns out. The job sure as hell isn't easy. I only wish to see my family members and friends well-served by the health care system, and my dearest friends and colleagues less stressed as they toil in your clinics and hospitals. I wish you the best of luck.

Yours sincerely,

Dr. Frank Warsh


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