This has been *the* problem in Canadian health care as well. Too much middle management, too much teaching of "best practice" by people who couldn't hack working shift work, so did masters degrees & returned to order staff about 😠.
I'm a "retired rather than be fired" (no covid vax) RN in Ontario, Canada. The stories I could tell!! Things are, of course, way worse now. Many of the best staff quit because of vaccine mandates, and those who complied are sick all the time....☹️
Management is the slow creeping death of efficiency in any large organisation. I’ve worked in the public sector in the UK and at a university there, both organisations that exceed the magic number of 500 employees. (An organisation of 500 or more is perfectly capable of being managerially self sustaining, in that managers can find enough stuff to do to manage things internally without actually doing anything else.) I have been banging on for years about how managers destroy quality, customer service, efficiency, delivery - all the things they aim for on paper but ruin in practice. The NHS (UK’s national health service) is a bloated managerial wreck, and throwing more money at it will only make it worse, as instead of funds going to employing more nurses, doctors and other “doers”, the admin side will see to it that they siphon off such funds for their own. If ever there was a deadly virus, it is not the biological sort, but the administrative-managerial one.
Thanks for the comment, and I like the virus analogy. Everything I hear about the NHS sounds like it has all the same, predictable problems as the healthcare system in Canada - ones that anyone with open eyes could predict of a government monopoly.
Yes, the NHS does seem to be like what you described for Canada. Back in the 50s, 60s and 70s the NHS worked very well, hence the nostalgia and almost religious reverence people still have for the NHS today. The irony is, though, that back then the NHS was wholly state owned. Margaret Thatcher kicked off the privatisation of so many state, that is people-owned, enterprises, the NHS being one of them, and brought in the managers. Creeping privatisation by something I got to know as “internal recharges” or similar things whereby the organisation has to buy in and charge for internal services requires admin - I think this lies at the root cause of managerial disease.
You neglected to mention that standards require re-triage at regular intervals, meaning repeat work. It would be better just to see the patients in a timely manner.
Some places in Europe actually have a family doctor urgent care clinic in front of the emerg. They see everyone, no triage. The simple stuff just gets dealt with. The complex stuff passes through to the emerg in back.
Yes - I didn't even want to go there because I was already pretty rambly. But now our big ER's have a triage AND a re-triage nurse.
I like the European idea! I had pushed for being able to triage low-acuity patients to a nearby (walk through the hospital and across a pedway) primary care clinic when it was open. The idea died in the cradle, because once a person is triaged they become the legal responsibility of the hospital. Forcing them to wait for 14 hours if OK, allowing them to sign a paper saying they are leaving AMA (against medical advice for the non-medical folks who might read this) are both fine. But mentioning to them that they can get faster service about 400m away triggered the lawyers.
I tried pushing the same idea in Halifax. Was told that we could NEVER send a patient who presented in emerg to another site, even if it was one block away and we respected the patients choice and had confidence in their ability to get themselves there.
Like you say, I was told that once they are in emerg, they are the hospital’s responsibility, unless they discharge themselves “against medical advice”, which implies that the advice is “stay put till you’re seen”, or they “leave without being seen”, which amounts to passive aggressing them out the door. I can’t see how, having been triaged as low acuity, the advice couldn’t be “take yourself across the road to the walk in clinic”. You would think that the liability associated with neglecting a patient in the waiting room for hours on end would greatly exceed the liability associated with a proper triage assessment followed by sage advice to go immediately and directly to a more appropriate venue. (Unfortunately, due to changes in the fee schedule and doctor shortages, these days the walk-in clinics are horribly backed up, so sending patients there might not work).
I also tried convincing folks to let us set up a walk-in primary care clinic in the hospital, as close to emerg as possible, perhaps using outpatient department spaces that are generally vacant after 5 on weekdays and all day on weekends. I thought it would appeal to family docs who wanted interesting work in a supportive setting. At that point, I was told that the low acuity patients weren’t the ones causing delays in emerg, so it wouldn’t help. Alternatively, I was told that emerg docs needed to see some low acuity stuff, to give them a break from saving lives all day long (in truth, they could pick up shifts in the hospital-based walk-in clinic, assuming they could curtail their urge to run tests on everything and everybody). Either way, nonsense! In truth, the emerg is funded based on volumes and acuity, and the low acuity patients contribute more than their share to the total funding, so emerg doesn’t want to give them up. They still get paid for the ones who leave without being seen, so in effect it’s free money and there’s not much incentive to reduce those numbers.
Great points Rick, and very interesting to hear you had the same issue.
You will be interested that one of our local walk in clinics was having problems attracting docs because of overhead rates and low payment-per-patient. They asked for some support from the health authority (it would have been minimal - they just needed a little help) and were told in no uncertain terms to go fly a kite.
So the health authority instead created and funded a few local urgent care clinics. They are fully staffed by a nurse and a secretary who both have salary, benefits, and pension plans. The doc gets paid per-hour to see a slow flow of patients. My rough calculation is that - per patient - the cost to the government was at least 3-4 times what it would have been if they had just supported the almost-viable walk in clinic.
Years ago, around 1980, my RN mother went back to work in a Victoria hospital. she had formerly been head OR nurse in the 60s. Her return to work coincided with the shift from head nurse RNs to the introduction of "managers" on the wards. She said it completely changed the dynamic of nursing, to have non-medical (for the most part) staff running the hospital from a nursing perspective. Changed in not a good way. The level of management bureaucracy has grown by orders of magnitude in the past 40 years, as anything public sector does, to be overwhelming the institution in many ways: in BC health care takes up roughly half of the provincial budget. Of that, 69 percent goes to pay wages. of that 48 percent goes to pay management wages. So those are people who have no contribution to the actual purpose of health care: providing actual health care.
I think management begets management. A manager suggests a new metric that must be measured (ie: suicide screens on all ER patients). So suddenly there are 500,000 suicide screens done in NS every year. Thus we need a new manager and staff to process that data and "optimize" our screening. The fact that the suicide rate is rising and there is no proof we have done anything is besides the point. The measure is not success in preventing suicide, it's a spreadsheet showing that we're doing a good job of suicide screening everyone.
From 2020 onwards UK GPs and dental practices were instructed by the NHS/govt to screen all people for potential Covid infection symptoms before allowing entry to buildings. Anyone requesting a face to face appointment was asked set screening questions and those flagged as 'possible Covid' on the basis of the screening questions were either directed straight to the Covid 'red room' for assessment or if the red room was occupied they were instructed to wait in their cars/outside until they could be be admitted directly to the red room. The screening questions evolved over time - initially fever, cough and travel history...then fever, cough or altered/loss of sense of taste/smell.
At some point people stopped listening to the questions (eg people would automatically say no to the questions and then come to see the GP because of a cough); at some point the receptionists distilled screening down to 'have you got Covid symptoms' which was just as ineffective but quicker.
Then in December 2021 the NHS directed us to expand the questions to the following:
1. Do you or any member of your household/family have a confirmed diagnosis of Covid-19 in the last 14 days?
2. Do you or any member of your household/family have suspected Covid 19 and are waiting for a Covid-19 test result?
3. Have you travelled internationally in the last 10 days to a country that is on the Governmet red list?
4. Have you had contact woth someone witha. confirmed diagnosis of Covid-19 or been in isolation with a suspected case in the last 10 days?
5. Do you have a high temp/fever, new continuous cough or a loss/alteration to taste/smell
If any YES answers to 1-5 - further RESPIRATORY PATHWAY screening questions advised:
Do you have any new or worsening respiratory symptoms not already mentioned above which suggest you may have a respiratory virus?
List 1 respiratory symptoms could include runny nose, congestion in nasal sinuses or lungs, sore throat, sneezing or coughing
List 2 symptoms of respiratory virus/infection - such symptoms may also be related to a non respiratory cause therefore caution would be applied in consideration of allocation to the respiratory pathway in the absence of other symptoms noted above: Breathlesness, wheezing or chest tightness, muscle aches, tiredness or shortness of breath.
Any YES would be seen in the RED ROOM.
If we had followed these recommendations it would have slowed reception down so much to cause bottlenecks on the phones and at reception. And it would have stressed staff (some would have resigned) and patients alike. Not to mention confidentiality issues (receptionists taking a full history over the intercom!) and the fact we had only one red room so putting all fatigued achy breathless people in the red room (all the people with TATT, anxiety, depression, chronic pain, anaemia, statin side effects, heart failure, obesity...) would have broken the system completely.
We opted to ignore the directive, anticipating harm from bottlenecks at doors, harm from people not being able to get appointments, harm from the screening no longer functioning as a screening and harm to the wellbeing of staff by making their jobs more difficult and more stressful. Other practices followed the directive without question.
Learning to ignore rules that don't make sense or are even harmful is the sign of a thinking, moral human being. I am thankful that a few of the managers I deal with are in that category. But the ones who see it as their job to force all of their "underlings" to follow destructive rules are incredibly damaging to morale and function of any workplace.
We need some sensible legal scholars to dismantle healthcare management. The fast track ambulatory care in the anteroom of the ER makes a lot of sense to peel away the non urgent cases. Incent the FPs enough to staff this with maybe an exemption from the increase on Capital Gains inclusion effective as of June 25 and I would be there!
You might be interested to know that when Trudeau et. al. changed the small business tax structure a few years ago, numerous docs I know curtailed their work. They realized it wasn't worth it. If they worked hard and made "too much money", the tax rate went as high as 75%, at which point why bother. So in the name of "fairness" and "tax the rich", the government disincentivized physicians from working extra hours. Great job by the libs.
So well said! There is no aspect of healthcare in any country or setting which managerialists cannot make worse. It really is a cancer in care and a specific form of corruption which bleeds the taxpayer and as you so rightly say, kills patients. In the UK it took off in the Blessed Margaret's time with a fake market and 'trusts' and fake competition covering Stalinesque centralization. How they loved pretending to be business folks! I remember being asked to a 'breakfast meeting'....no doubt they had seen one on TV with arrogant chaps in red suspenders shouting at each other. (Of course the croissants were stale.) The marker for this nonsense was the invasion of the car park with managers only spaces of course.
And let's not forget the lawyers role in assisting this destructive work. In my professional lifetime even quite large hospitals could essentially be run by a senior doctor, a matron and an administrator. It would be interesting to see a proper comparison between UK and Canada. At least in the UK there is a private option. Yet here we are...and when will the members of what used to be professions stand up to this? Of course it metastasized to colleges and unions etc but all of this needs sweeping away. Nothing will change until the whole rotten system totally collapses. At least there do seem to be some moves to introducing private practice here but it will be under the central management cosh no doubt.
It was very similar here in Canada. As I understand it, up until the 80's and early 90's, hospitals were run by local boards - typically a senior physician or two(often retired or semi-so), a nurse or two at same career stage, and a few prominent community people. They could actually make decisions on purchasing/services/procedures. Each hospital did its own thing. (You might be interested in Dr. Mahmood Naqvi's book - I can find you a copy if you wish https://www.saltwire.com/atlantic-canada/lifestyles/surgeon-releases-book-on-his-role-in-cape-breton-health-care-100656879/)
The first centralization in my lifetime happened when the district health authorities were created and centralized services to certain hospitals, and dictated to hospitals on what they could and couldn't do. These were much more political entities, with full-time highly-paid managers with healthcare management degrees, who served at the pleasure of the sitting government. Things went nuclear when the NSHA was created. No more pretence of local autonomy or flexibility. You are now part of The Borg, and if you don't like it your only choice is to quit. There was enough of a backlash, and enough problems, that they backtracked somewhat and created the 4 'zones" which have pseudo-autonomy, but in reality have to do everything they are told as dictated from on high. The original idea of the NSHA cutting down on the number of bureaucrats (predictably) failed miserably, as a more centralized system requires more managers and more minion-managers.
The managed care of our health system in the states will soon pass up the IRS with lousy rules and regulations this all could have been avoided 4 decades ago by not having businesses provide healthcare as an incentive instead providing people the money to buy insurance that fits their needs. It's called a market driven force. I'm afraid that opportunity is long gone? too bad.
Sorry about that, I read your original comment really late at night and missed that! Doh!! I totally agree with your point!
The original problem in US Healthcare was the legislation post-WW2 that (?un)intentionally tied patient's health insurance to their workplaces. Many Canadians think that the US healthcare problems are a result of too much free market and not enough socialization and centralized control, when in fact the US gov exerts an incredible amount of control and spends and incredible number of tax dollars (over 1.5 trillion per year) on healthcare, hugely distorting any purported free market.
All that said, you are far better off in the US right now if you get sick. It's a little more expensive than in Canada, but you are much more likely to get care in a timely fashion.
As is so truly the case Doc, you have hit the nail on the head. I am literally gobbling smacked by the increase in paperwork, nursing care has become incredibly fragmented, every discipline known to man is now required to “see” the inpatient, the nurse is now required to document that this was done. Instead of walking a pt in the hall, the OT,PT, TA is tasked with this responsibility, the nurse is “scribe” nurses no longer speak about deep breathing and coughing, a consult to RT is required, nurses don’t discuss diet, dietary consult is required, we have admitting Doctors, family doctors, various specialists and hospitalists, that change weekly. IV pumps going in to picc lines that malfunction with glee, supper meals delivered within a two hour window anywhere from 4-6 pm -on the plus side this old nurse can at least identify a “nurse” they now wear white tops and black bottoms - Once again, thank you for telling it like it is.
Same thing is happening in family med. Our patients with heart failure go to HF clinic. Patients with cancer go to cancer clinic. Patients with a fracture go to bone health clinic. Near end of life there are automatic referrals to palliative care. And more.
None of the specialty clinics know the patient. They don't know their values, religion, family situation, finances, transport, and more. All of the various specialists/specialty nurses simply follow guidelines - which seems to involve putting patients on the maximum number of medications possible for that one problem, and not caring what knock-on effects it might cause.
Care is less personal, more fragmented and more expensive. We get "more" care but not better care.
My take on it is this. Anyone called a "manager" should have the power to actually "manage" things - ie: make changes. If the buck doesn't stop on his/her desk, then they are not really a manager, they are an apparatchik - a "useless eater". I think these big systems actually like these people as they act as shields to prevent the front-line minions from actually talking to and thus annoying the people who are actually in charge. The useless minions can "listen" to the front-liners frustrations, thus making them feel heard, without actually doing anything to fix the problem. And the higher-level manager gets to continue on happily oblivious, writing email updates about how swimmingly everything is going.
It sounds like I'm exaggerating, but this is literally the way the NSHA works.
Are the ER staff still mandated to call those pts that left the ER without tx on the previous shift?
Hiring a person that has no experience or health care qualifications to watch over 30+ people in the ER to get them water or a blanket was nonsensical. Should we even mention using staff that are not members of any licensing body over those that are qualified! Yes this happens too!
Great read, amazing that we can read or say this without repercussions.
There was a push to call the "LWBS" - left without being seen - patients. But what this required was for one of the physicians to take 1-2 hours out of his shift to go through multiple files and make multiple phone calls. Which means 1-2 hours where that doctor was not seeing patients waiting in the waiting room, some with urgent medical problems, who - ironically - might end up LWBS...
Not to mention the truckloads of unnecessary and redundant paper print-offs that are seen every single day.
Duplicate, triplicate, even quadruplicate lab results. Those med lists, Goals of care forms, DVT prophylaxis forms and so many others that get printed for every single patient, but are useful for only a very few.
And then there is the huge reduplication of redundant bureaucracy, with Canada's 13 provincial and territorial medical systems, the RCMP system, the Military system and Aboriginal system. They all have their multiple layers of bureaucracy to "serve" a country of less than 40 million people.
Everywhere in the world and at every time in history that socialism has been allowed ro run rampant we got the same results: Shortages, line-ups and inferior quality products and services. Unless we finally slay the Canadian Sacred Cow of socialist monopoly health care this will continue to get worse.
Thank you once again for your insightful piece criticizing our dysfunctional healthcare system. I used to think I was the only one confused about the roles and responsibilities of our numerous managers in our hospital, but it turns out I'm not alone. Thank you for validating my feelings.
Regarding the long waits in ERs, I am personally terrified at the thought of something happening to me or my loved ones and having to endure the extended waiting times at our local ER. We live just a 20-minute drive from the US and are considering getting some form of medical insurance so we can drive to the nearest US ER for urgent care if needed. It's a terrible situation.
I'm sad to say I think it's a very good idea to find some kind of insurance to go to the USA (or Mexico, India, or elsewhere) if you need care.
Even 10-15 years ago I was still defending the Canadian system in ways. At that time I would tell people that although a patient has to wait for non-urgent care, at least emergency care and cancer care are very good. But even then there were cracks. Now I regularly hear of people dying in waiting rooms, people waiting hours for an ambulance, and have had patients who died of cancer before they could get a first appointment with an oncologist.
On the bright side, palliative care and MAID wait times are very short, so they help bring the average wait time stats down.
This has been *the* problem in Canadian health care as well. Too much middle management, too much teaching of "best practice" by people who couldn't hack working shift work, so did masters degrees & returned to order staff about 😠.
I'm a "retired rather than be fired" (no covid vax) RN in Ontario, Canada. The stories I could tell!! Things are, of course, way worse now. Many of the best staff quit because of vaccine mandates, and those who complied are sick all the time....☹️
Management is the slow creeping death of efficiency in any large organisation. I’ve worked in the public sector in the UK and at a university there, both organisations that exceed the magic number of 500 employees. (An organisation of 500 or more is perfectly capable of being managerially self sustaining, in that managers can find enough stuff to do to manage things internally without actually doing anything else.) I have been banging on for years about how managers destroy quality, customer service, efficiency, delivery - all the things they aim for on paper but ruin in practice. The NHS (UK’s national health service) is a bloated managerial wreck, and throwing more money at it will only make it worse, as instead of funds going to employing more nurses, doctors and other “doers”, the admin side will see to it that they siphon off such funds for their own. If ever there was a deadly virus, it is not the biological sort, but the administrative-managerial one.
Thanks for the comment, and I like the virus analogy. Everything I hear about the NHS sounds like it has all the same, predictable problems as the healthcare system in Canada - ones that anyone with open eyes could predict of a government monopoly.
Yes, the NHS does seem to be like what you described for Canada. Back in the 50s, 60s and 70s the NHS worked very well, hence the nostalgia and almost religious reverence people still have for the NHS today. The irony is, though, that back then the NHS was wholly state owned. Margaret Thatcher kicked off the privatisation of so many state, that is people-owned, enterprises, the NHS being one of them, and brought in the managers. Creeping privatisation by something I got to know as “internal recharges” or similar things whereby the organisation has to buy in and charge for internal services requires admin - I think this lies at the root cause of managerial disease.
You neglected to mention that standards require re-triage at regular intervals, meaning repeat work. It would be better just to see the patients in a timely manner.
Some places in Europe actually have a family doctor urgent care clinic in front of the emerg. They see everyone, no triage. The simple stuff just gets dealt with. The complex stuff passes through to the emerg in back.
Yes - I didn't even want to go there because I was already pretty rambly. But now our big ER's have a triage AND a re-triage nurse.
I like the European idea! I had pushed for being able to triage low-acuity patients to a nearby (walk through the hospital and across a pedway) primary care clinic when it was open. The idea died in the cradle, because once a person is triaged they become the legal responsibility of the hospital. Forcing them to wait for 14 hours if OK, allowing them to sign a paper saying they are leaving AMA (against medical advice for the non-medical folks who might read this) are both fine. But mentioning to them that they can get faster service about 400m away triggered the lawyers.
I tried pushing the same idea in Halifax. Was told that we could NEVER send a patient who presented in emerg to another site, even if it was one block away and we respected the patients choice and had confidence in their ability to get themselves there.
Like you say, I was told that once they are in emerg, they are the hospital’s responsibility, unless they discharge themselves “against medical advice”, which implies that the advice is “stay put till you’re seen”, or they “leave without being seen”, which amounts to passive aggressing them out the door. I can’t see how, having been triaged as low acuity, the advice couldn’t be “take yourself across the road to the walk in clinic”. You would think that the liability associated with neglecting a patient in the waiting room for hours on end would greatly exceed the liability associated with a proper triage assessment followed by sage advice to go immediately and directly to a more appropriate venue. (Unfortunately, due to changes in the fee schedule and doctor shortages, these days the walk-in clinics are horribly backed up, so sending patients there might not work).
I also tried convincing folks to let us set up a walk-in primary care clinic in the hospital, as close to emerg as possible, perhaps using outpatient department spaces that are generally vacant after 5 on weekdays and all day on weekends. I thought it would appeal to family docs who wanted interesting work in a supportive setting. At that point, I was told that the low acuity patients weren’t the ones causing delays in emerg, so it wouldn’t help. Alternatively, I was told that emerg docs needed to see some low acuity stuff, to give them a break from saving lives all day long (in truth, they could pick up shifts in the hospital-based walk-in clinic, assuming they could curtail their urge to run tests on everything and everybody). Either way, nonsense! In truth, the emerg is funded based on volumes and acuity, and the low acuity patients contribute more than their share to the total funding, so emerg doesn’t want to give them up. They still get paid for the ones who leave without being seen, so in effect it’s free money and there’s not much incentive to reduce those numbers.
Great points Rick, and very interesting to hear you had the same issue.
You will be interested that one of our local walk in clinics was having problems attracting docs because of overhead rates and low payment-per-patient. They asked for some support from the health authority (it would have been minimal - they just needed a little help) and were told in no uncertain terms to go fly a kite.
So the health authority instead created and funded a few local urgent care clinics. They are fully staffed by a nurse and a secretary who both have salary, benefits, and pension plans. The doc gets paid per-hour to see a slow flow of patients. My rough calculation is that - per patient - the cost to the government was at least 3-4 times what it would have been if they had just supported the almost-viable walk in clinic.
The beancounters haven't really made things better.
Great article! Unfortunately, it appears to apply to almost everything our governments touch.
Thank you.
Such a validating article.
Years ago, around 1980, my RN mother went back to work in a Victoria hospital. she had formerly been head OR nurse in the 60s. Her return to work coincided with the shift from head nurse RNs to the introduction of "managers" on the wards. She said it completely changed the dynamic of nursing, to have non-medical (for the most part) staff running the hospital from a nursing perspective. Changed in not a good way. The level of management bureaucracy has grown by orders of magnitude in the past 40 years, as anything public sector does, to be overwhelming the institution in many ways: in BC health care takes up roughly half of the provincial budget. Of that, 69 percent goes to pay wages. of that 48 percent goes to pay management wages. So those are people who have no contribution to the actual purpose of health care: providing actual health care.
Wow. Sobering stats!
I think management begets management. A manager suggests a new metric that must be measured (ie: suicide screens on all ER patients). So suddenly there are 500,000 suicide screens done in NS every year. Thus we need a new manager and staff to process that data and "optimize" our screening. The fact that the suicide rate is rising and there is no proof we have done anything is besides the point. The measure is not success in preventing suicide, it's a spreadsheet showing that we're doing a good job of suicide screening everyone.
Great post.
From 2020 onwards UK GPs and dental practices were instructed by the NHS/govt to screen all people for potential Covid infection symptoms before allowing entry to buildings. Anyone requesting a face to face appointment was asked set screening questions and those flagged as 'possible Covid' on the basis of the screening questions were either directed straight to the Covid 'red room' for assessment or if the red room was occupied they were instructed to wait in their cars/outside until they could be be admitted directly to the red room. The screening questions evolved over time - initially fever, cough and travel history...then fever, cough or altered/loss of sense of taste/smell.
At some point people stopped listening to the questions (eg people would automatically say no to the questions and then come to see the GP because of a cough); at some point the receptionists distilled screening down to 'have you got Covid symptoms' which was just as ineffective but quicker.
Then in December 2021 the NHS directed us to expand the questions to the following:
1. Do you or any member of your household/family have a confirmed diagnosis of Covid-19 in the last 14 days?
2. Do you or any member of your household/family have suspected Covid 19 and are waiting for a Covid-19 test result?
3. Have you travelled internationally in the last 10 days to a country that is on the Governmet red list?
4. Have you had contact woth someone witha. confirmed diagnosis of Covid-19 or been in isolation with a suspected case in the last 10 days?
5. Do you have a high temp/fever, new continuous cough or a loss/alteration to taste/smell
If any YES answers to 1-5 - further RESPIRATORY PATHWAY screening questions advised:
Do you have any new or worsening respiratory symptoms not already mentioned above which suggest you may have a respiratory virus?
List 1 respiratory symptoms could include runny nose, congestion in nasal sinuses or lungs, sore throat, sneezing or coughing
List 2 symptoms of respiratory virus/infection - such symptoms may also be related to a non respiratory cause therefore caution would be applied in consideration of allocation to the respiratory pathway in the absence of other symptoms noted above: Breathlesness, wheezing or chest tightness, muscle aches, tiredness or shortness of breath.
Any YES would be seen in the RED ROOM.
If we had followed these recommendations it would have slowed reception down so much to cause bottlenecks on the phones and at reception. And it would have stressed staff (some would have resigned) and patients alike. Not to mention confidentiality issues (receptionists taking a full history over the intercom!) and the fact we had only one red room so putting all fatigued achy breathless people in the red room (all the people with TATT, anxiety, depression, chronic pain, anaemia, statin side effects, heart failure, obesity...) would have broken the system completely.
We opted to ignore the directive, anticipating harm from bottlenecks at doors, harm from people not being able to get appointments, harm from the screening no longer functioning as a screening and harm to the wellbeing of staff by making their jobs more difficult and more stressful. Other practices followed the directive without question.
Learning to ignore rules that don't make sense or are even harmful is the sign of a thinking, moral human being. I am thankful that a few of the managers I deal with are in that category. But the ones who see it as their job to force all of their "underlings" to follow destructive rules are incredibly damaging to morale and function of any workplace.
We need some sensible legal scholars to dismantle healthcare management. The fast track ambulatory care in the anteroom of the ER makes a lot of sense to peel away the non urgent cases. Incent the FPs enough to staff this with maybe an exemption from the increase on Capital Gains inclusion effective as of June 25 and I would be there!
You might be interested to know that when Trudeau et. al. changed the small business tax structure a few years ago, numerous docs I know curtailed their work. They realized it wasn't worth it. If they worked hard and made "too much money", the tax rate went as high as 75%, at which point why bother. So in the name of "fairness" and "tax the rich", the government disincentivized physicians from working extra hours. Great job by the libs.
So well said! There is no aspect of healthcare in any country or setting which managerialists cannot make worse. It really is a cancer in care and a specific form of corruption which bleeds the taxpayer and as you so rightly say, kills patients. In the UK it took off in the Blessed Margaret's time with a fake market and 'trusts' and fake competition covering Stalinesque centralization. How they loved pretending to be business folks! I remember being asked to a 'breakfast meeting'....no doubt they had seen one on TV with arrogant chaps in red suspenders shouting at each other. (Of course the croissants were stale.) The marker for this nonsense was the invasion of the car park with managers only spaces of course.
And let's not forget the lawyers role in assisting this destructive work. In my professional lifetime even quite large hospitals could essentially be run by a senior doctor, a matron and an administrator. It would be interesting to see a proper comparison between UK and Canada. At least in the UK there is a private option. Yet here we are...and when will the members of what used to be professions stand up to this? Of course it metastasized to colleges and unions etc but all of this needs sweeping away. Nothing will change until the whole rotten system totally collapses. At least there do seem to be some moves to introducing private practice here but it will be under the central management cosh no doubt.
Stale croissants - ah you always make me laugh!
It was very similar here in Canada. As I understand it, up until the 80's and early 90's, hospitals were run by local boards - typically a senior physician or two(often retired or semi-so), a nurse or two at same career stage, and a few prominent community people. They could actually make decisions on purchasing/services/procedures. Each hospital did its own thing. (You might be interested in Dr. Mahmood Naqvi's book - I can find you a copy if you wish https://www.saltwire.com/atlantic-canada/lifestyles/surgeon-releases-book-on-his-role-in-cape-breton-health-care-100656879/)
The first centralization in my lifetime happened when the district health authorities were created and centralized services to certain hospitals, and dictated to hospitals on what they could and couldn't do. These were much more political entities, with full-time highly-paid managers with healthcare management degrees, who served at the pleasure of the sitting government. Things went nuclear when the NSHA was created. No more pretence of local autonomy or flexibility. You are now part of The Borg, and if you don't like it your only choice is to quit. There was enough of a backlash, and enough problems, that they backtracked somewhat and created the 4 'zones" which have pseudo-autonomy, but in reality have to do everything they are told as dictated from on high. The original idea of the NSHA cutting down on the number of bureaucrats (predictably) failed miserably, as a more centralized system requires more managers and more minion-managers.
The managed care of our health system in the states will soon pass up the IRS with lousy rules and regulations this all could have been avoided 4 decades ago by not having businesses provide healthcare as an incentive instead providing people the money to buy insurance that fits their needs. It's called a market driven force. I'm afraid that opportunity is long gone? too bad.
There are no market forces in Canadian medicine whatsoever. Businesses do not provide healthcare. The government does. It's the ultimate monopoly.
Are you in the USA?
Yes in the states.
Sorry about that, I read your original comment really late at night and missed that! Doh!! I totally agree with your point!
The original problem in US Healthcare was the legislation post-WW2 that (?un)intentionally tied patient's health insurance to their workplaces. Many Canadians think that the US healthcare problems are a result of too much free market and not enough socialization and centralized control, when in fact the US gov exerts an incredible amount of control and spends and incredible number of tax dollars (over 1.5 trillion per year) on healthcare, hugely distorting any purported free market.
All that said, you are far better off in the US right now if you get sick. It's a little more expensive than in Canada, but you are much more likely to get care in a timely fashion.
As is so truly the case Doc, you have hit the nail on the head. I am literally gobbling smacked by the increase in paperwork, nursing care has become incredibly fragmented, every discipline known to man is now required to “see” the inpatient, the nurse is now required to document that this was done. Instead of walking a pt in the hall, the OT,PT, TA is tasked with this responsibility, the nurse is “scribe” nurses no longer speak about deep breathing and coughing, a consult to RT is required, nurses don’t discuss diet, dietary consult is required, we have admitting Doctors, family doctors, various specialists and hospitalists, that change weekly. IV pumps going in to picc lines that malfunction with glee, supper meals delivered within a two hour window anywhere from 4-6 pm -on the plus side this old nurse can at least identify a “nurse” they now wear white tops and black bottoms - Once again, thank you for telling it like it is.
Same thing is happening in family med. Our patients with heart failure go to HF clinic. Patients with cancer go to cancer clinic. Patients with a fracture go to bone health clinic. Near end of life there are automatic referrals to palliative care. And more.
None of the specialty clinics know the patient. They don't know their values, religion, family situation, finances, transport, and more. All of the various specialists/specialty nurses simply follow guidelines - which seems to involve putting patients on the maximum number of medications possible for that one problem, and not caring what knock-on effects it might cause.
Care is less personal, more fragmented and more expensive. We get "more" care but not better care.
All so true! There seems to be a 'best' spot between not managing enough and micromanaging. I would say the same goes for most of life.
My take on it is this. Anyone called a "manager" should have the power to actually "manage" things - ie: make changes. If the buck doesn't stop on his/her desk, then they are not really a manager, they are an apparatchik - a "useless eater". I think these big systems actually like these people as they act as shields to prevent the front-line minions from actually talking to and thus annoying the people who are actually in charge. The useless minions can "listen" to the front-liners frustrations, thus making them feel heard, without actually doing anything to fix the problem. And the higher-level manager gets to continue on happily oblivious, writing email updates about how swimmingly everything is going.
It sounds like I'm exaggerating, but this is literally the way the NSHA works.
Are the ER staff still mandated to call those pts that left the ER without tx on the previous shift?
Hiring a person that has no experience or health care qualifications to watch over 30+ people in the ER to get them water or a blanket was nonsensical. Should we even mention using staff that are not members of any licensing body over those that are qualified! Yes this happens too!
Great read, amazing that we can read or say this without repercussions.
There was a push to call the "LWBS" - left without being seen - patients. But what this required was for one of the physicians to take 1-2 hours out of his shift to go through multiple files and make multiple phone calls. Which means 1-2 hours where that doctor was not seeing patients waiting in the waiting room, some with urgent medical problems, who - ironically - might end up LWBS...
The great circle of ER dysfunction...
Not to mention the truckloads of unnecessary and redundant paper print-offs that are seen every single day.
Duplicate, triplicate, even quadruplicate lab results. Those med lists, Goals of care forms, DVT prophylaxis forms and so many others that get printed for every single patient, but are useful for only a very few.
And then there is the huge reduplication of redundant bureaucracy, with Canada's 13 provincial and territorial medical systems, the RCMP system, the Military system and Aboriginal system. They all have their multiple layers of bureaucracy to "serve" a country of less than 40 million people.
Everywhere in the world and at every time in history that socialism has been allowed ro run rampant we got the same results: Shortages, line-ups and inferior quality products and services. Unless we finally slay the Canadian Sacred Cow of socialist monopoly health care this will continue to get worse.
Thank you once again for your insightful piece criticizing our dysfunctional healthcare system. I used to think I was the only one confused about the roles and responsibilities of our numerous managers in our hospital, but it turns out I'm not alone. Thank you for validating my feelings.
Regarding the long waits in ERs, I am personally terrified at the thought of something happening to me or my loved ones and having to endure the extended waiting times at our local ER. We live just a 20-minute drive from the US and are considering getting some form of medical insurance so we can drive to the nearest US ER for urgent care if needed. It's a terrible situation.
I'm sad to say I think it's a very good idea to find some kind of insurance to go to the USA (or Mexico, India, or elsewhere) if you need care.
Even 10-15 years ago I was still defending the Canadian system in ways. At that time I would tell people that although a patient has to wait for non-urgent care, at least emergency care and cancer care are very good. But even then there were cracks. Now I regularly hear of people dying in waiting rooms, people waiting hours for an ambulance, and have had patients who died of cancer before they could get a first appointment with an oncologist.
On the bright side, palliative care and MAID wait times are very short, so they help bring the average wait time stats down.