Rebuilding Health Care Together:Submission to the Minister of Health

2012

Message from the PresidentThe New Brunswick government isconsidering ideas to chart a course forcare in our province over the next fouryears. We congratulate the government onasking for public input for this plan. NewBrunswick’s doctors offer an informedperspective on opportunities to enhanceour health-care system.

“Rebuilding Health Care Together” meansthat New Brunswick’s doctors andgovernment should continue to expand onour track record of working together tosolve tough challenges. Our province willsuffer from fiscal problems throughout thecourse of this plan, and patientexpectations have never been higher. It isonly through working together that we canachieve what is called the Triple Aim:higher quality care and better populationhealth at reduced cost.

As doctors, we are constantly focused on who our system is designedto serve, because they are right in front of us. Over the last year,600,000 New Brunswickers have visited their family doctor; just overhalf of that number saw a specialist. It’s likely that today, 25 thousandNew Brunswickers saw a doctor, and we have maderecommendations to them. It is ultimately up to every patient to decidewhether or not to heed our advice, and the same is true for thisprocess.

To get the benefit of physician opinion, we surveyed our members.The response was overwhelming. 400 members responded, with anexcellent balance of language, location, specialty, and rurality. Weused their feedback to compile the following priorities, and several oftheir comments are quoted verbatim in the report. These quotes arenot representative of the membership, but often provide a frankperspective on tough issues.

We look forward to participating in ongoing discussions on theseideas and will actively work with our patients and province tosucceed.

Robert E. Rae MD FRCSCPresident, New Brunswick Medical Society

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Leverage our LeadersThese days, headlines are discouragingabout the fiscal health of New Brunswick,and the wellbeing of her people. However,the spirit of New Brunswickers continues toinspire; landmark ideas have beengenerated here in recent years, from theminds of incredible political, business, andcommunity leaders.

The same is true in health care. Physicianleaders have contributed time and energyto help usher in provincial achievements.Hundreds of medical learners are beingtrained all over New Brunswick, throughvaluable partnerships with Dalhousie andSherbrooke universities. We have cultivatedstrong traditions of large corporate andcommunity contributions to healthfoundations, enabling New Brunswick tohave advanced medical equipment andtechnology. And we are leading changewith community challenges, most notably inEdmundston, Canada’s Live Right Nowwinner.

Clearly, physician expertise extends beyond an operating room or anoffice. And in times when many New Brunswickers believe healthdollars are wasted and mismanaged, we need to take advantage ofour homegrown leadership by providing opportunities for physiciansto contribute meaningfully to the governance and management of oursystem.

Other provinces’ doctors are dictated to by government. Nationally,trends point towards health system management by engineers,accountants, and lawyers. Governance changes seem to overlookthe importance of asking front-line workers how changes will impactpatients.

New Brunswickers have a history of working together. We have anopportunity to learn more from our doctors, and show the nation thatcollaboration is a better path forward.

To better Leverage our Leaders over the next four years, thegovernment should:

• Open the Regional Health Authorities Act to add leaders ofMedical Staff Organisations as ex-officio Board members andremove the prohibition on physicians running in Board elections.

• Support the rights of physicians to responsibly advocate forpatients by creating Regional Health Authority By-laws, Rules,and Regulations that encourage and value doctors’ input.

• Commit to consulting and working with doctors and other healthprofessionals by convening a multi-stakeholder group ofprofessional associations to guide the execution of this Plan.

• Forge a stronger relationship with doctors by partnering toexecute long-discussed ideas on primary care renewal, electronicmedical records, and sustainability in our system.

• Show physicians and other professionals that their input is valuedat all levels of the system by inviting input and acting onreasonable and thoughtful suggestions.

FACT: Research has shown that improvements in health care willnot occur without direct and meaningful involvement ofphysicians.1

Survey Respondent:

Physicians must be at the table inall levels of the decision makingprocess. This will allow effectivecommunication at all levels. Wehave a lot to offer for making thesystem more efficient and improvequality of care.

Encourage Healthier Living21st century lifestyles are increasinglyunhealthy. It has been said that we areraising the first generation who will notoutlive their parents, due to poor healthbehaviours2. Doctors will always be thereto care for people when they need it – butwe can do so much more to prevent,delay, or reduce the incidence of gettingsick. The adages persist: an apple a day,an ounce of prevention, health is betterthan wealth.

Decades ago, we began a war ontobacco as a society. Through aggressivepolicy, smoking became less common. Thatwar is not over. But a second front hasopened up, and we encourage thegovernment to take the same aggressiveaction as society did against tobaccodecades ago. This next battle is the battleof the bulge.

New Brunswickers lead the least healthy lives in the entire country byalmost every measure. We eat fewer vegetables and are lesseducated than other provinces, and two-thirds of us are overweight orobese. As a result, chronic diseases most commonly associated withpoor lifestyle behaviours are exploding. Despite high correlationsbetween lifestyle and health3, only 54% of New Brunswickersstrongly agree that their health largely depends on how they takecare of themselves.4 And while this phenomenon is not new, ournewer generations will need even more education, motivation, andaction throughout school and beyond to foster healthy living.

New Brunswick’s doctors are exploring the evidence to inform ourown action on this issue. In our survey, members suggested using aplethora of tools: taxes and tax breaks, laws and bans, policies andpersuasion, marketing and media. The message to us was clear: weneed strong action against obesity.

To better Encourage Healthier Living over the next four years, thegovernment should:

• Implement the coming public policy recommendations on healthyliving which will be made by New Brunswick’s doctors over thefall and winter of 2012/13.

• Further develop Community Wellness Networks and theiralignment with the Healthy Eating and Physical Activity Coalitionof New Brunswick.5

• Follow in the footsteps of Ontario, Nova Scotia, and otherCanadian provinces by creating a specific Childhood ObesityStrategy with a timeline and measurable outcomes.

• Further develop and strengthen Policy 711, which establishedNew Brunswick as a Canadian leader in healthy eating in ourschool system.6

• Work with professionals and patient groups to emphasize therole of the patient in their own care and in their own illnessprevention.

FACT: Canadian kids get an average of 14 minutes of physicalactivity daily after school; however, they get an average of sixhours of “screen time” a day outside of school hours.7

Survey Respondent:

There needs to be furtheremphasis and education on a publichealth level about increasingphysical activity. This would preventsignificant health care costs downthe road.

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Primary Care RenewalYesterday’s model of patient care wasfamiliar: a family physician could answermost health-related questions in short order.Physical exams were the most insightfulways to learn about the problem lurking ina sick patient. Physicians directed, andpatients did as they were told.

Those days are over. Care is morecomplex; physicians can’t see as manypatients as they once could, as care takeslonger to provide. Multiple tests might beordered. Patients are encouraged toparticipate in their own care as equalpartners. The best health care often comesfrom teams of professionals.

Other provinces have taken differentapproaches to dealing with thisphenomenon in primary care. Some haveplaced family physicians with otherproviders, and for problems that don’trequire a physician, patients will seesomeone else. These teams are led byphysicians and are electronically linked.Other provinces have been unable toresolve doctor-nurse politics, so they havecreated two duplicative systems thatcompete with each other. We believe thatdoctors should be leaders in clinicalsettings. We have the most comprehensiveeducation, the deepest clinical expertise,and the highest expectations ofaccountability. We also believe otherhealth professionals have incrediblyimportant and specialised roles in care,delivered by teams of providers.

New Brunswick has been examining different models for years. Weare the last province in Canada to maintain an antiquated andbureaucratic billing number system. Doctors are impatiently waitingfor action and have put forward a number of our own ideas. Thereare better ways to practice. We should start with a commitment thateveryone deserves timely access to a family doctor; that physiciansshould be encouraged to practice with other providers; that change isdifficult and requires time.

To foster effective Primary Care Renewal over the next four years, thesystem should be re-designed to reflect the following principles:

• Every New Brunswicker should have a personal family doctor,and deserves timely access to primary care in an appropriatesetting.

• Patients benefit from care delivered by a team of interdisciplinaryprofessionals, who work together to meet the needs of thepatient.

• Physicians and other team members should have access toelectronic medical records.

• Primary care, like all health care, should be evidence-based andpatient-focused.

• Good primary care includes preventative care and qualitypatient education.

• Delivery of primary care must be flexible and adaptable to meetthe needs of the community.

• Physicians should be encouraged to practice in adequatenumbers in areas of the province which need it most, whichcannot happen with our antiquated billing number system.

FACT: New Brunswick’s Primary Health Care Steering Committee,which has been recommending change to primary care, has beenmeeting for seven years - through the lifespan of three differentgovernments.

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Survey Respondent:

Enough talk about primary carereform. Get on with it.

Tools for InnovationGoing hand in hand with primary carerenewal, electronic medical records (EMRs)are electronic tools that help physiciansenhance patient care, and are found inlarge numbers in most other Canadianprovinces. Right now in Ontario, 70% ofprimary care physicians are using EMRs8;that number is 50% in Alberta9. Both ofthose programs have been around foryears, and both are in part governed bythe respective provincial medicalassociation.

The New Brunswick Medical Society hasbeen advocating for a provincial EMRstrategy for years, but without one, ourrates of adoption are less than 10%. Arecent analysis of New Brunswick’selectronic health status found our hospitalscompared favorably with the rest of thecountry, but EMR use was low.

Evidence shows they help patients byenabling primary care renewal, withshared records for teams who care for onepatient; enhancing quality of care, byreducing dangerous errors; and savingmoney and improving the patientexperience, by reducing duplicate testsand appointments.

We see patients coming into the office twice, when having the righttest results in hand would require only one visit; we see the danger inprescriptions that are handwritten and misunderstood by other careproviders; we see the patients who have to tell providers theirpersonal information again and again as they go from our offices tothe emergency room and back. And we see the large impact EMRshave had on these problems in other provinces10; we need that here.

EMRs should be linked to other health information systems, such asthose found in hospitals and those focused on drugs, to gain accessto digital imaging and labs. Ending the ‘paper chase’ would increaseaccountability from providers and patients, which has spin-offbenefits. For example, narcotic drug abuse could be curtailed if weknew more about the people obtaining prescription medicationillegally.

To equip physicians with Tools for Innovation over the next four years,the government should:

• Immediately partner with New Brunswick’s doctors to equipphysicians with electronic medical records, in partnership withthe federal government’s Canada Health Infoway.

• Over the next year, work with the New Brunswick MedicalSociety to create a program to help physicians through thechange management processes associated with EMRs.

• Set annual targets and performance incentives to encourage50% of primary care physicians to fully adopt the functionality ofEMR programs by the end of this plan.

• Quickly assess and learn lessons from leading provinces on themost cost-effective and timely ways to integrate EMRs withinstitutional information systems found in hospitals and labs, witha goal of integrating this information seamlessly in four years.

FACT: Interestingly, the challenge faced elsewhere of physicianresistance to EMRs was expertly assessed to be “less of achallenge” here11; in fact, New Brunswick’s doctors are leadingthe charge.

Survey Respondent:

It is obvious that EMRs areessential and long overdue. Wecan't afford to wait for the Cadillacsystem that will soon be outdatedanyway. Let's just get started. Anychange will be an improvement.

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Care Settings and NavigationCaring for seniors is a complex task anddemands much of our professionals andfamilies. It’s estimated that caring forseniors costs five times as much as thoseunder 65, and just 5% of the populationaccounts for 84% of hospital and homecare costs12.

As one of the ‘oldest’ provinces inCanada, this is an urgent challenge.Unfortunately, our mix of services doesn’taddress seniors’ needs. We have too manyhospital beds filled with seniors waiting togo elsewhere - as high as a quarter of allbeds, one of the highest rates in Canada.This leaves us with a paradox: for manyseniors, unnecessary stays in a health carefacility are dangerous to their health.

Not only are our services and needsunmatched, the complexity of the systemoverwhelms patients and even theirdoctors. There are so many questions toask – which service is best for me? Whopays for this? And does anyone have aplan?

Add these challenges to the problems posed by simultaneous multiplechronic conditions, increased dementia, and polypharmacy, and it’sa conundrum that drains our most energetic families. We can dobetter to serve patients in an appropriate setting, and equip them withan understanding of how services will work together for them.

To improve Care Settings and Navigation over the next four years,the government should:

• Develop guidelines and policies to help make our hospitals andhealth-care facilities more navigable for seniors, along the linesof Ontario’s Senior Friendly Hospital Strategy.

• Support the development of peer-led provider education on howto prevent delirium and address multiple co-morbidities.

• Carefully review and engage physicians on recommendationspertaining to health care that come in the report of the Premier’sPanel on Seniors.

• Review and tackle both capital and health human resources toreduce seniors’ hospital admissions, and to safely transition theircare elsewhere as soon as possible.

• Create new, community-based long-term care navigator positionsto work with individuals and their families to assist them inaccessing community-based resources available to them throughgovernment, public, or private agencies.

• Examine interactions between the Department of SocialDevelopment and the Department of Health to eliminateunnecessary bureaucratic processes and foster bettercollaboration.

FACT: We have 11% more seniors than the national average; inNorthern NB, seniors are approaching 20% of the population. InBathurst, seniors outnumber children by a 3:2 margin13, one of thehighest ratios in the country.

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Survey Respondent:

The care elderly receive inhospital isn't appropriate for theirneeds. Their health deterioratessignificantly while waiting inhospital.

Spend Dollars and Time on PatientsNew Brunswick’s doctors supportaccountable, effective decision-makingprocesses in health care management. Infact, we want to be active partners inmanagement. But we’re noticing a markedincrease in the amount of people walkingaround hospitals with laptops andcalculators, rather than stethoscopes andIVs. Notable business leaders arequestioning how many health authoritieswe need. Patients wonder why hospitalsacross the street need two different sets ofmanagers, based in cities hundreds ofkilometres away. If you need long-termcare, your assessment is done by theDepartment of Health; if it’s funded, youneed the Department of SocialDevelopment.

We see a microcosm of this management in our offices each day. Ata time when 50,000 New Brunswickers have no family doctor, manydoctors across the province are wading through red tape. AcrossCanada, 61% of doctors said that more paperwork is increasing thedemands for their time, behind only “increasingly complex patients”and “managing patients with chronic diseases”.14

We need to have a thoughtful conversation about the administrationof our health care system periodically to assess whether we arespending our money and time in the right places.

To better Spend Dollars and Time on Patients over the next four years,the government should:

• Create a partnership with the New Brunswick Medical Societyand commit to reviewing and revising government forms(including transport, social assistance, and education) togetherwith professionals to reduce the amount of time taken up bypaperwork.

• Thoughtfully review the Regional Health Authorities Act and thegovernance structure to ensure that our system management is aslean and effective as it can be.

• Clarify the role and effectiveness of Facilicorp NB by showinghow it and other provincial health initiatives are saving money.

• Develop an an Activity-Based Payment system in hospitals whichensures that money follows the patient, regardless of where theyare treated.

• Share cost information involved in care with professionals toinform us on how our clinical choices affect health carespending.

• Partner with professionals to develop a roadmap toregionalisation, not centralisation, that outlines which tertiarycentres provide which service, reducing the need for eachhospital to have identical expensive equipment and services.

• Have a structured, adult dialogue about how we can best servepatients in both official languages across the province.

FACT: New Brunswick beats the Canadian average in numbers ofCT scanners, hospital beds, health staff, and MRI scanners.15

Survey Respondent:

More medical staff should have adirect role in planning budgets forour hospitals. Great sums of moneyare sometimes lost on unnecessaryor poorly planned projects.

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Align People andProcesses EffectivelyIn our survey of hundreds of physicians, weasked how we could best improvesustainability through improvements whichcorrespond to the Canadian MedicalAssociation’s Principles for Health CareTransformation: access, quality, healthinformation technology, patient-centredcare, accountability, and health humanresources. The resounding answer was thatthe key to success in all of these areasrevolves around how we design processesand how we involve different professionalsin patient care.

For instance, we weren’t surprised to hearthat we need more family doctors,specialists, nurse practitioners, physicianassistants, in-office nurses, extramurals, andother allied professionals. But we alsoheard that more administrative staff wouldenable better communication; that clearcriteria for referrals and centralised referralprocesses could shorten waits; and patientswho are educated and empowered to self-manage chronic conditions safely could betheir own best ‘provider.’

Equipping people with effective processes is just as important. Clearercriteria for when to order specific tests might cut down on unnecessarytesting, saving money and shortening waits for patients who could betterbenefit. Being able to follow-up on patients through telemedicine, whilenot replacing in-person visits, could be both patient-centred and cost-effective. Incenting providers to provide the best possible care, as we dotoday with some specific chronic conditions, could spur faster change.

Measuring processes and collecting information can also be apowerful catalyst for change, but also creates an expectation andawareness among the public and providers. Some of our respondentsnoted that information on wait times has been available for years, butin some cases, they are not improving. Shining a flashlight in theshadows means we need to act on what we find.

To better Align People and Processes Effectively over the next fouryears, the government should:

• Encourage practice change through incentives to use ElectronicMedical Records in a manner that regularly examines populationhealth and incents preventative quality care.

• Deploy a health human resources strategy that includes doctors,nurses, and other allied health providers to support collaborativeenvironments for care delivery.

• Pursue changes to scopes in practice in consultation withproviders and with consideration of the team-based careenvironment envisioned for New Brunswick.

• Consider the development of centralised referral processes andthe right staff to provide timely access to specialists for urgentand non-urgent referrals.

• Examine patient-centred methods of care provision through thesupport of telemedicine.

• Clearly explain action and inaction on trends in measured waittimes data through regular reports to the public on what is beingdone about attaining wait time targets.

FACT: New Brunswick’s surgical wait times have beencomprehensively reported for years. However, since April 2009,the average wait time for surgery has increased by 25 days, from155 to 180 days.

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Survey Respondent:

People want to provide bettercare: the structure is blockinginnovation and improvements.

SummaryMany of our fiscal challenges in healthrelate to our ageing and heavierpopulation, but many also reflect aproblem faced by every province inCanada: how to care for 2012 problemswith a system from 1961. Health care aswe know it was designed in a time wheninfectious diseases were weekly headlines,when computers took up entire rooms,when life expectancy was a decade lessthan it is now.

Our policies, structures, and payments arebehind the times. This inertia is incrediblyexpensive. Our seniors are stuck inhospitals at $600 a day because theydon’t have the right supports in thecommunity. Patients can’t find a familydoctor and go to the emergency room, atfive times the cost. We have to re-orderpricey tests because they literally get lost inthe mail.

So while it might seem counterintuitive to have to invest in some casesto get better bang for the provincial buck, there is a strong case forchange. In other cases, investment of time and energy is moreneeded than money.

A better system, four years from now, will empower doctors and otherprofessionals in their leadership roles; will support New Brunswickersin becoming one of the healthiest populations in the country; and willhave made intelligent investments to reap long-term dividends.

We have been leading on many of the issues above and we supportthe provincial government’s effort to establish a plan for action. Wehope that the provincial health plan will incorporate these ideas, andwill commit to work with New Brunswick’s doctors to execute some ofthe ideas we have put forward.

The New Brunswick Medical Society is, and will always be,dedicated to the health of New Brunswickers.

To find more information about the survey conducted tocreate this report and a comprehensive list of references forthe many studies outlined in this document, visit nbms.nb.ca

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