Thursday, June 30, 2016

Competing Interests

If you were to read any commission/blog/column/op-ed/plan/vision about a health care system, Canadian or otherwise, you're almost certain to find the same critiques show up over and over, albeit at different frequencies and with varying degrees of umbrage. The jargon might change - last year's "integration" is this year's "synergy" - but the messages never do.

1) We need to make the system center on the patient
2) We need to make the system more timely and efficient
3) We need to make the system more comprehensive
4) We need to make the system work more seamlessly
5) We need to make the system affordable and sustainable
6) We need to make the system equitable in access in terms of geography and patient demographics/needs
7) We need to hold the system accountable
8) We need to shift the system from disease treatment to prevention
9) We need to keep the system responsive to changes in population needs
10) We need the system responsive to advances in medical science and new treatments
11) We need to build capacity for the Epidemic Due Any Day Now
12) We need to reduce harmful errors
13) We need to focus on innovative solutions to system-wide problems

Did I miss any? Sure I did, most obviously any issue relating to health human resources. Really, though, what I did or didn't include is beside the point. What should be clear is that these issues "plaguing" any health care system cannot logically, never mind feasibly, all be addressed. Some of them are even contradictory. How can you build capacity without spending more money? How can you make something more seamless or efficient and more accountable at the same time? How can you innovate without risking more errors? Trying to achieve all these goals at once is essentially nonsense.

So what's a Minister/Secretary/CEO/leader/manager/senior-bureaucrat to do? Moreover, how should the general public make sense of it all?

For starters, we should stop doing what doesn't do much. What passes for prevention these days, apart from Pap smears, vaccines, and hiking taxes on tobacco, has yielded a trivial impact on population health. What's the Number Needed to Treat on FOBT testing? Mammography? Statins in people without diagnosed arterial disease? Factoring in participation rates - that generally stink - how effective are they in actual practice? How many hours of a GP's or NP's time is devoted to low yield screening, when everyone complains they can't get timely access to a doctor? And that's the stuff backed with evidence. Nutrition hotlines? Tax credits for fitness programs? Isn't the entire developed world getting fatter and fatter? How much do we spend on all this?  While it "feels" wrong not to (at least try to) prevent disease, that's really a matter of salesmanship: "We set up a free hotline to advise people on eating better. After 5 years the population is no healthier. Let's scrap the program and spend the millions on something that works, or not spend it at all."

Next is to eliminate initiatives that work at obvious cross purposes. If your wait times stink, don't implement an EMR. If you're trying to improve after-hours access, don't bring in a pay cut. If you're seeing too many medication errors, cancel the consultant hired to sell LEAN on the front-line staff. This will invite some fist-waving over sunk costs, but fretting over sunk costs is generally considered a fallacy. Once the expensive indulgences and self-defeating stuff is dispensed with, however, now comes the tricky part.

As it stands, most plans in health care systems are drafted with some sort of goal in mind. Quite often it's a target - so many flu shots, so long a wait in triage - but not always. Sometimes it's a set of guidelines or standards, that can be used to hold providers to account, but are somewhat flexible in application. In any event, the tendency is to start with an endpoint and work backwards. Unless enforced by the law (such as mandating immunizations) or attached to the right fiscal carrots and sticks, this approach by and large doesn't work.

Why not? Because unlike auto makers, sausage factories, fast-food restaurants, and hedge funds, health care is about people working with people. And apart from the general "welfare of the patient" - itself a notion open to interpretation - each group of actors in the system has its own motives and interests.

As a broad generalization, but I'd argue not an inaccurate one, doctors tend to be uniquely motivated by professional autonomy and income security. The rest - stimulation, altruism, prestige - will vary by the individual. Nurses, as a rule, value job security and solidarity. Administrators prize fiscal prudence and the impression of sound management. Public servants value predictability and compliance. Politicians will do whatever it takes to get elected or re-elected, but are always out to leave a legacy of serving their constituents. These competing interests must be accounted for when analyzing health-care challenges, and also explain why so many "bright ideas" fail to achieve anything.

Let's take a concrete example to explore this further, like ER wait times. Say you're the department head, and the hospital CEO is demanding the numbers come down. The way things often happen nowadays, the hospital's Board would green-light an efficiency consultant. Said consultant comes with a team of stopwatch-wielding observers to time and plot out every relevant and irrelevant act every member of the team performs. After a few weeks, you're given a glossy report loaded with recommendations, ranging from where the fax machine should be, to how the nurses can shave seconds off their blood pressure readings, to pre-printed prescriptions for common antibiotics. When you present the findings to your team, the veteran nurses roll their eyes with a harrumph, the senior doctors check their email, and the ward clerks scroll down their friends' new Pinterest posts. The nurse manager has problems with half the recommendations, some in the name of patient safety, others in the name of the current collective agreement. Nothing changes, and your recommendation to the nonplussed CEO is to recruit more doctors and nurses.

How would "motives/interests based" thinking work in this situation? For starters you'd want to find out where the problem is coming from. Is it a pile of patient complaints to a Board member or the CEO? Many complaints from one patient? A nurse whistle-blower? A reporter? A government audit? Say it's many patient complaints to the CEO. You get names and numbers, and make some calls. What led to the complaint? Is there a pattern - say, complaints come when a slow doctor is on or the grumpiest nurse covers triage? 

If it's a nurse, can you address things with the manager, without the threat of job action? If it's an under-performing doctor, do you need to re-jig how the department divides up third-party income (Workman's comp cases, insurance forms), to make the problem doctor pick up the pace when he or she is working? If it's a government audit that flagged the problem, does it make more sense to challenge the report? Or change how the department collects data? Would the Ministry facilitate the secondment of an epidemiologist or statistician to guide policy shifts?

None of this takes all that much time - a few phone calls and conversations with key people - and it's almost certain to cost less money and meet less resistance.

Understanding where your people are coming from before trying to dictate where they're going. What a novel idea.

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