You never know how a government reform project will turn out in practice, except probably not as expected. My remarks therefore do not tend to influence those responsible for Bill No.oh 15, but rather the people who will have to implement it, in the hope that the customary mistakes of the past will not be repeated. I propose seven principles based on great, but sometimes unfortunate experience, which I explain in detail in my book Dealing with Healthcare Myths. We need to take a step back, to see the big picture of health care.
Principle 1: Solutions are largely responsible for failure. Basically, the health system is not a failure. It works, but it’s expensive. But we don’t want to pay the price. We want the benefits without the costs, the salaries without the taxes. This is why our governments intervene, often in a technocratic, hierarchical and maladaptive way.
Doctors and health specialists are good at finding new and expensive ways to treat disease. In addition to the immediate costs, people are living longer, which increases the costs. Governments, therefore tight but reluctant to cut services, are intervening administratively, further reorganizing structures, further centralizing power and increasingly measuring results. This is what makes our health care system sicker.
Principle 2: The problem is that solutions are imposed from across the divide between service delivery on the ground and service administration from above. While doctors, nurses, and other professionals scramble to complete their tasks according to their own protocols, an overlay of ministers, civil servants, CEOs, and managers create reports, flowcharts, metrics, and data. other controls that often do nothing but drive service providers crazy. Therefore, perhaps we should stop complicating everything by imposing changes from above and bring together the professional body and managers to rethink together the delivery of services according to the current constraints.
Principle 3: Health is not managed like a business, because it is a vocation. I am not a “client” of my doctor and I do not consume health services (but they can consume me).
I hope we see our care providers as dedicated human beings, not indifferent “human resources”. Anyone who runs health like a business is a threat to our public and personal health.
Principle 4: Health organizations are assemblies of professionals who do not manage themselves like programmed machines. The CHUM is not a factory, the MUHC is not Walmart. In my new book Understanding organizations… finally! I describe professional organizations as assemblies because people come together in their hospitals and other institutions to work independently. These organizations are therefore highly decentralized. On the other hand, the “programmed machine”, like any mass production company, is centralized. Its work is largely standardized by technocratic controls. It’s fine for grilling burgers, but not for treating cancer.
Principle 5: Performance measures are ill-suited to professional work. Unlike the United States, markets do not drive our health care system because we know they can be insensitive. However, we accept the intervention of governments, often boorish and more focused on the ax than on the scalpel, especially with their measures. Certain calculations are necessary, of course, to contain the overall costs, but not in an obsessive way.
We can measure the number of burgers that come off the grill, but what about the success rate of a psychiatrist, or even sometimes a surgeon? (Need a good surgeon for a tricky procedure? Go for one with a high mortality rate because they take on tough cases.) Do you know any numbers that can’t be manipulated, especially by a specialist? ?
Beware of “efficiency”, in health as in education. This often boils down to savings, to a reduction in measurable costs at the expense of benefits that are difficult to measure, such as the quality of a service. (I challenge anyone to measure what a child actually learns in a classroom.) In health, as in education, it is more about personalized service on a human scale than interventions on an economic scale. Let us therefore avoid merging health establishments for administrative convenience. On the pitch, the bigger it is, the worse it is.
Principle 6: Health requires nuanced management, not centralized direction. Enough leadership, CEOs, hierarchy, organizational charts, compliance programs, etc. Health is based on responsible professional practice supported by wise management.
“Leader” and “leadership” conjure up the image of one person as the proverbial maestro on his podium. Unfortunately, promoting leadership promotes the centralization of power while everyone else is relegated to the role of subordinate. (Have you noticed that when a government promises more decentralization, there is usually more centralization?) Transferring authority from the minister’s office to the CEO of Santé Québec can be interesting, if it is not limited to moving the centralized power. This change could be an opportunity to think differently. Why not decentralize in the name of decentralization, not to an intermediate level, but to the people directly involved?
Any “leader” who takes the term seriously runs the risk of macro-leadership rather than micro-management. Honestly, I don’t know which is worse. Micromanagement meddle with what managers are not concerned with, while macroleadership decides from above without suffering the consequences. In other words, for health to be effective, there must be open communication and respected collaboration on both sides, by people who know the field well.
Principle 7: Most health facilities, especially hospitals, function best outside of the public and private sectors, as plural sector (not-for-profit) community facilities.
That is to say, we do not need health services provided by state bureaucracies or commercial enterprises, but rather by autonomous organizations rooted in the community. (Who would like to volunteer in a public or private hospital?)
The community plays a big role in the success of health care in two ways. First, the establishments must listen to the people on the ground, beyond the orders of a ministry from above. Then, they must function as communities of invested people. Yet a former minister of health actually nationalized them by getting rid of their boards and managements, at the expense of their community affiliations and themselves as communities. (Where was the courage to challenge this in court?)
So, enough reorganization, enough organizational charts that multiply the directions, enough unrestrained measures, enough centralization in the name of decentralization, enough division between the provision and administration of services. Let’s reorganize brains instead of institutions, stepping back to see what health care is, and what it isn’t.