On Slack
In defense of inefficiency and unsustainability
This week at the Botšabelo MDR-TB hospital in Maseru, Lesotho, we had a mortality rounds meeting, reviewing the case of a patient who had recently died on the ward. Medical and nursing staff came together to discuss in detail the patient’s care and whether there were things that could have been done differently that might have kept him alive. The entire team was present, and practical, actionable ideas were brought forward and changes to practice made right on the spot.
Earlier in the week, Mahli was talking with the doctors after morning rounds about how, despite how successful the MDR-TB treatment program is, how patients are frequently lost to follow-up and reinfected. “People get better from out treatment, but then we send them back to the conditions that made them sick in the first place. How can we continue to support people to stay healthy, to eat and live well once their treatment is done?” It’s a line of questioning familiar to readers of A Larger Scale. As I wrote in A Healthy Society, “The roots of our most significant health problems are not clinical: they are social, political. This means that the solutions must be political as well.”
People get better from out treatment, but then we send them back to the conditions that made them sick in the first place.
But that’s not the point of today’s post. The point is, the questions were being asked. The team was taking time to think through bigger problems than those of the single patient in front of them and taking care of that patient’s problems as well.
Why were they able to do that? A large measure is that these are doctors who have chosen to work in an organization – Partners in Health – that has that mindset to begin with. The second reason is that, right now, the hospital isn’t full. There are only a few patients on the ward and they are ill but not desperately so. It’s not always like this, different times of year bring different pressures. The Christmas holidays, for example, often bring more patients in as people return from working in the mines in South Africa to see their family. Once home, where they are eligible for more health care support than when they were away, they present to clinic and are discovered to be sicker than they imagined. The hospital fills up and those moments for reflection and change are back-burnered to take care of urgent medical needs.
Efficiency and sustainability are obsessions of health care management and international development. It’s natural to think that we should get the most we can out of our public investments or charitable donations. The risk is that, in search of short-term accountability, we make demands that run counter to the larger goal of long-term improvement in people’s health and wellbeing.
Writing in the Toronto Star last week, Mark Brender, National Director of Partners in Health Canada tackled the dangers of a short-term sustainability focus in international development. Too often, funding agencies demand that a project have a meaningful impact and then be handed over to national governments or other local providers. This means ending the requirement for external support within a short period. But, as Brender points out, “Poverty and job creation and education and safety aren’t solved in three-year grant cycles, in Canada or anywhere else,” he goes on to say that, “Sustainability requirements are more about funders’ unspoken needs for an exit strategy than a measure of smart project design.”
This is one of the things I particularly admire about Partners in Health. Once they come to a country, their mission may change, but they don’t leave. As Mark wrote, “the long-term change we seek is the outcome of supporting good work and being in it for the long haul. We will see positive outcomes a lot faster if we think of sustainability as flowing from impact, not the other way around.” When there was a massive earthquake in Haiti in 2010, Partners in Health was key to the response because they were already there and still are. The relationships are long-term and sustainable because, to again quote Mark, “Something is sustainable when we decide to sustain it.”
“Something is sustainable when we decide to sustain it.” - Mark Brender
Many reading this will make the connection to a quote from Building on Values, the report from former Saskatchewan premier, Roy Romanow during his time leading the National Commission on the Future of Health Care in Canada: “Medicare is as sustainable as we want it to be.” Providing public health care for all without payment at the point of delivery is a massive social investment. It’s a wise investment, one that recognizes the value of human lives regardless of their income and social status, and one that makes us a more productive and more united country. It’s a part of the solution to the problem of illness and its unequal distribution, but it’s not a short-term easy fix. The prevailing demand for ever-increasing services and ever-decreasing collective contribution is the source of unsustainability. If we want good care for all we need to commit to the reforms necessary to improve delivery, and we need to be willing to pay for it.
“Medicare is as sustainable as we want it to be.” - Roy Romanow
Of course, we want our public investments to result in systemic sustainability. Of course, we want to use our resources in the most efficient way possible. But we are too often penny-wise and pound-foolish. The emphasis on short-term handover or maximal productivity at all times undermine true efficiency and sustainability. If you run your vehicle at top speed all the time and never take time to change the oil or rotate the tires, it’s a recipe for breakdown and accidents. Redlining our health care system and staff is a recipe for burnout and patient harm.
Below is an excerpt from A Healthy Future on the need for slack in the system, making the case for building in slack to save the public system.
Also, a reminder that copies of A Healthy Future: Lessons from the Frontlines of a Crisis are 20% off until Dec. 29 using the discount code 0909-20 at http://www.ubcpress.ca/a-healthy-future.
For Medicare to work, we need to build a robust and resilient health system
“Health systems were never designed for this kind of surge. I think federal governments for decades have been underfunding things like public health preparedness.” This is what then federal health minister Patty Hajdu had to say in April 2020 when questioned about Canada’s readiness for the pandemic. A 2006 pandemic preparedness report coauthored by now chief public health officer of Canada Theresa Tam had suffered the fate of many such reports, its recommendations gathering dust as people moved on from the 2003 SARS epidemic. The owner of a dumpster bin company in Regina broke the story of the federal government’s disposal of two million N95 masks and 440,000 medical gloves in 2019 without replenishing the stockpile. In March 2021 Canada’s auditor general released a scathing review of the Public Health Agency of Canada’s preparation: “The agency was not adequately prepared to respond to the pandemic, and it underestimated the potential impact of the virus at the onset of the pandemic.”
Ontario premier Doug Ford cut $200 million from public health agencies in his province in 2019. Two months after the first cases of COVID-19 had arrived in Canada, we learned in question period that not a single additional dollar had been dedicated to public health in Saskatchewan. Cuts to public health are often buried in global budgets and thus difficult to delineate, but spending in prevention and health promotion is frequently first on the chopping block when competing for funding against clinical care. Failing to plan for the future is beyond unwise.
This applies beyond the field of public health to the provision of health care overall. Governments have been “redlining” their health care systems, running them at or slightly beyond capacity at all times. This manifests in chronic understaffing in acute and long-term care settings, staff burnout and turnover, and an inability to respond to added pressures when they arrive. In Saskatchewan, this was taken to extremes with the 2008 introduction of the “Lean” program, an ill-fated attempt at hyper-efficiency based on Toyota’s production line philosophy. One peer-reviewed evaluation of this experiment found the cost of contracts for its implementation to be far higher than any savings, with no improvement in patient outcomes and a significant decrease in job satisfaction among nurses.
The current nationwide health care crisis – with shortages of family doctors and nursing staff, overflowing emergency rooms and pediatric wards, and long wait times for imaging and surgery – is the long tail effect of a major stress event on an already overstretched system. It is an acute-on-chronic problem with no easy solutions. There are, however, some principles that can help us plot our way to the other side and rebuild a health care system that works for people:
• Public care is the best care. We need to resist the temptation – and the efforts of those who would profit from this crisis – to throw up our hands and let the forces of privatization take over. The dismal record of the for-profit sector in protecting long-term care residents should be enough to kill that idea, but free market absolutist ideologues wait eagerly in the wings to take advantage of this moment. We should not only fight to keep what is within Medicare public but also keep our eye on the larger cost savings and improvements in outcomes associated with expansions into areas such as Pharmacare. A major area of focus needs to be increased access to primary care, including concentrated efforts to address the nationwide shortage of family physicians. High-quality primary care gives patients comprehensive attention while they’re still well, catching illness earlier, improving patient outcomes, and reducing pressures on our emergency rooms and in-patient wards.
• The system needs slack. We have tried running a health system with just enough or not-quite-enough capacity. It doesn’t work for patients, it doesn’t work for providers, and it certainly doesn’t work for pandemics. As I wrote this chapter, Mahli was on call and the pediatric department was beyond swamped. Every in-patient bed was full, every emergency room bed was full, and there were dozens of kids in the waiting room. This had a lot to do with the “triple-demic” wave of RSV, influenza, and COVID rocking the lungs of Canadian kids at the time, but it isn’t an isolated event. It has more to do with the fact that the province built a brand-new, shiny children’s hospital in 2019 that had fewer in-patient beds than the old Royal University Hospital pediatric ward it replaced. When you build a bookshelf, you shouldn’t build it for the books you already have.
Whether it’s short-staffing in long-term care, rural emergency rooms that can’t stay open, or the lack of mental health and addictions beds, we have undershot capacity for years. It’s time to go in the other direction. It’s time to create good jobs in the care economy, an investment in people that pays back. It’s time for us to train, credential, and hire more people than we think we need. I’m not talking about having people sit around and be paid to do nothing. I’m talking about not having people run off their feet every shift, about not burning out everyone we have and being unable to recruit anyone new because the dream of the caring professions has become a waking nightmare.
Public health is a good place to start. Testing and contact tracing for infectious diseases, for example, is a place where “excess capacity” can be well-applied to control endemic diseases like syphilis, gonorrhea, tuberculosis, and HIV, all of which have seen significant spikes in Saskatchewan during COVID. Added capacity allows for more research and quality improvement, more promotion of evidence-based information on immunization to combat growing anti-vax disinformation, and more time to work upstream, addressing the social determinants of health. In acute and long-term care, ending the constant experience of working short-handed will allow for greater collegiality, higher retention, and better patient and resident experiences and outcomes. By “overstaffing” in health – and in other crucial areas such as education – we can build the kind of robust and resilient public system that goes above and beyond for the well-being of Canadians in ordinary times and is prepared to tackle the unprecedented.
As always, a thoughtful critique of the health care system. Thank-you