Dr. Robert Martel: Nova Scotia health care 'keeps me up at night'

After more than 30 years working in front-line health care, Dr. Robert Martel reflects on some of the biggest problems facing Nova Scotia's health-care system and possible solutions.

Someone asked recently, what keeps me up at night as I prepare to sail off into the sunset? 

Well for a starter, we have one of the oldest demographics in the country and so as important a goal preventative medicine strategies are, for this group (my cohort), it is unlikely to impact health-care costs significantly over the next decade.

And so, the burden of illness will be more dramatic than it has been in the history of this province. 

Moreover Nova Scotia's aging citizens, and the remainder of the population, have expectations of the system that are unrealistic in this stressed funding environment. 

The most unlikely person ever to have been appointed deputy minister of health, Dr. Nuala Kenny, was appointed by former premier Russell MacLellan. Unlikely, because she was apolitical, was an internationally-renowned academic clinician, had superior verbal skills, was well informed on the subject-matter — and the kicker, she was a nun!  

Some were heard to say, irreverently, that health care was in so much trouble, an appeal to the Divine was needed to rescue it. Given the current state of health care in this province, I fear the Divine may not have been listening to her prayers.

In Nova Scotia, health care eats up $4.5 billion of the province's $9.5 billion annual budget. Almost $1 billion comes from the federal government — $40 million more than last year. Almost half of provincial government spending, 13.2 per cent of the province's economy and 70,000 jobs are dedicated to health spending. 
 
Home care, palliative care, home hospital, pharmacare, primary care, hospital-based care, tertiary care services, emergency health services and emergency care, health human resources planning, infrastructure and data management are a few of the big ticket items that need to be coordinated in a rational and economically sound plan to provide health services. 

How do we achieve this?  

Define what is possible

First, we have to start by defining what is possible because promising everything to all people is what has gotten us where we are.

Is that a tough discussion to have? Yes, no question, but it is the mature and morally responsible thing to do and it should have been done yesterday.

The United Kingdom has done it so what are we waiting for? It has not caused social upheaval or riots in the streets.

Unfortunately this discussion is uncomfortable, especially when led by politicians with little to no content expertise, regardless of political stripe, and when planning cycles are compressed within a four-year political mandate, two of which are straw years — the first-year, telling us how bad the previous administration was and the last year, paralyzed developing a re-election strategy. 

Our elected representatives need to be part of the discussion but they cannot claim exclusive ownership of an agenda which is clearly visceral and fundamental to the province. 

Solve electronic health record problems 

Second, we need to develop a data infrastructure that provides timely and meaningful information to planners and users of the entire system. Historically, we have been hung up on security issues and funding but inaction is actually costing more money.

This can be a minefield if not thought out carefully. The Ontario and Canadian governments have spent almost $2 billion (and climbing) on trying to develop an Electronic Health Record (EHR) and we remain without. 

Why has it been so difficult for Canada to pick up momentum when other countries such as Denmark, New Zealand, the Netherlands and the U.K. can point to areas of significant EHR success? I suggest that one needs to look at the quality of leadership to discover the answer.

Increased spending not necessarily the answer 

Third, the strategy that we cut operating costs to fund new initiatives is tired and patently useless. 

Nuala Kenny knew that without consulting her Divine source but the "opposition of the day’s" rhetoric around increasing the provincial deficit imperilling the province, demonstrated an appalling lack of respect for the electorate, Dr. Kenny and betrayed their understanding of how you fund restructuring and for that we have paid dearly (with more borrowed money).

The right people for the right jobs

Fourth, hire the right people for the job.  

Promoting internally advances one thing: the failed strategy that created the problem you are trying to solve. 

The bureaucratic gene pool in Nova Scotia is tired and in need of an injection of different thinking. 

Clearly the cheaper option is to hire locally but how well has it worked out for us in healthcare these past 30 years? Add to that political cronyism (of which all parties are guilty) and it becomes a recipe for disaster. 

Governments treat dissenting voices as enemies which increases the myopia of their vision. The taxpayers need a new lens, one focused on innovation, productivity, accountability and evidence. The much lauded Ivany report speaks so eloquently to these points when it comes to rejuvenating the Nova Scotia economy why not apply the same principles to health-care reform? 

Fat lady has not yet sung

I despair for my aging parents, my friends and my colleagues as things are going to get much tougher before they get better. We have a false economy in health care; a Ponzi scheme on a grand scale and the time has come for the investors, the baby boomers, to collect on that investment. 

What is the expected return on the sacrifices they have made for their 30-plus years in the workforce? There is no magic bullet but like Ray Ivany has stressed, change must come to attitude and expectation in this province to begin the process of renewal.

The taxpayers of Nova Scotia need to know if we can finance a restructuring of health care, what is going to be covered as a service after it is restructured and participate in developing a sustainable business plan to keep it going.

So this is what keeps me awake but I have faith in my province and my colleagues who, as a group, have provided me with an incredible sense of fulfillment these past 30 years and for that, I am grateful.  

The fat lady has not yet sung so I have some hope that we can solve this problem together.