Health Care Quality Council?

Health Care Quality is a pressing issue.  In Alberta, a government mandated and appointed committee has been studying this since 2003.  Results so far are meagre.  The committee, since 2006 known as the Health Quality Council of Alberta has, according to their website ( http://www.hqca.ca ) lots of the Mission, Vision and Values statements familiar to those of us who spent our careers in bureaucratic organizations.  A recent press release (June 29, 2011) sounded promising but a careful reading of it reduced its "News" to 4 points:
     1. We've had some meetings.
     2. We've talked to some people in the medical establishment.
     3. We'll give you a similar report this fall.
     4. We may have an actual report in 2012 (after the next election?).

This despite the fact that one of the important issues dates back to 2001, viz.
   "Efforts continue to validate the presence of a waitlist for lung surgery in 2001, including patients that died while on that waitlist many of whom had cancer."

There is a definite need for measuring quality of outcomes and ensuring more accountability but the Council's language is not encouraging there either, viz

“Health care is delivered by a complex and interconnected set of service areas.  Our experience and knowledge show us that lasting gains in quality health care and patient safety are possible when the focus is on system improvements rather than individual components or care providers.”
Health Quality Council of Alberta, 2009 – 2010 Annual Report,  p. 19 http://www.hqca.ca/assets/pdf/Annual_Reports/HQCA_AR_2010.pdf

Can we actually improve a "system" without addressing its components and the individuals who make up that "system"?  The "system" is an abstract concept, merely allowing us to talk about the entirety of the complex arrangement of component individuals involved.  Efforts to improve the "system" are as vague and ideologically weighted as efforts to reform "society" without blaming any individual or organization within it. 

Check out the website and other work of the Health Quality Council and see whether you think they are on the right track to bring real life improvements to the quality of health care and patient safety in Alberta.

Democracy Needs to be Delegated

     All the political parties seem to talk about "listening to the people" and the opposition parties also propose various "democratic reforms".  Sometimes, though, one wonders if there is a clear idea of what "democracy" really means.  The new Alberta Party has proposed a term limit of 10 years on a premier.  With a little thought, this can be clearly seen to be anti-democratic.  If democracy means anything it means "power to the people" - that is, the people as a whole having the power to change the rules of a society.  Term limits give one group, at one point in time, the power to limit the choice of another group, at a different time.  [Hazel McCallion has been Mayor of Mississauga for 32 years and the electorate recently confirmed their opinion that she was still the best choice.]  Premiers are, of course, not directly elected - another problem with the AB Party proposal, it encourages the false notion that we have a presidential rather than a parliamentary system in Canada.
     The term limit idea also perpetuates the notion that the basic problem is that we have the wrong people in office.  We all know that when we elect a new crew, it does not take long before they are behaving just like the old crew.  What are needed are reforms to the processes.  We need greater transparency, accountability, and better means for citizen input into decision making.  In short, we need to delegate decision making to "the people".  New technologies are enabling much more exercise of direct democracy.  If 7 plus million people can vote for Jose Bautista to be in the MLB All-Star game, surely it is time we could do at least plebiscites on issues.  Citizen initiatives and referenda are useful steps forward.  Individual MLA's could do more by way of developing processes to allow feedback on emerging issues.  Political parties can continue to develop meaningful processes for input into their own agendas.
     Overall, there are many ways, especially through the new technologies, that we can have input.  However, we also need to keep in mind the words of John Adams - democracy can only survive where there is "a wise and virtuous populace". 

Rural Development in Chains?

A FB friend recently lamented the arrival of Tim Horton's in Nipawin, SK.  Part of the argument was a distaste for the products and ambiance of Tim's.  The other part of the argument was that familiar to the anti-Wal-Mart element, about how big chains would over power the local merchants.  As someone interested in rural development, I had the following thoughts:

  1. Choice. If one doesn't like Tim's, one has the option of not attending the premises.  I, too, find the appeal of Tim's illusive.  I find them too small, usually not very clean, and the service level unpredictable.  Then again, I don't like coffee. However, whenever I do accompany my wife to one, it is invariably full of folks who seem to be enjoying their experience.  I suspect the same thing will occur in Nipawin.
  2. Jobs.  One of things rural communities need is jobs.  Tim's will provide these - all the way from part-time high schoolers up to the franchisee.  [The franchisee is often forgotten.  Here is someone bravely betting that they can create, manage, and sustain a local business.  One of their main challenges will be finding enough people (among those who claim to want "jobs") who can be sufficiently motivated to show up punctually and regularly, and deliver a level of customer service which will sustain the business.  I wish them well.]
  3. Opportunity. The other businesses in town in similar lines have the opportunity to compete on the basis of quality of product and level of customer service.  As mentioned above, Tim's has their vulnerabilities.  Perhaps, the local bakery can put in a couple of tables, brew some good quality coffee, and welcome their customers to "set a spell" and have some fresh baked goods with their coffee, or tea.  Is there a market for a tea house, for those who find Tim's a glorified cafeteria?  The other area of opportunity is in increased clientele for all.  Like Wal-Mart, I suspect Tim Horton's in Nipawin will bring in new customers from a wider geographic area and bring existing customers out more often.  Studies and experience have shown that this is usually the result of an addition to a community's retail sector.  It is the phenomenon that some call "increasing the size of the pie" rather than assuming there will be increased competition for a fixed sized customer base.
  4. Affordability.  I grew up in Lloydminster in the days before "the chains" came to town.  Groceries, for example, were provided by a couple of independents and the local Co-op.  Prices were always 10 - 15 % higher than in Edmonton, service was unpredictable, especially if you were not one of the in crowd, and some of the produce [especially at the Co-op) was of such poor quality it had no business being on the shelves.  So, we welcomed the day when Safeway came to Lloydminster.  Thanks to intelligent management, the Co-op eventually reacted and now-a-days competes well, including having a range of fresh produce which doesn't take a back seat to any of its competitors.  All of this is an example that overall, the cost of living improved because prices went down and the quality of products and services went up.  The same can happen in any small town - including Nipawin.

So, in conclusion, I say welcome to Nipawin, Timmy.  The vast majority of folks will find you a positive addition to the community, even if you are not exactly my cup of ... er  ... coffee.



Health Care in Canada - 1945

Charlie Leech was a dairy farmer who lived near Newboro, Ontario in 1945.  He worked hard to support his family, milking more than 20 cows twice a day, growing corn, haying and doing all the other chores on a family farm.  In addition that spring, his mother had died and he had been the one to take care of all the matters of the estate.  Worn down perhaps, he developed a bad cough and the periodic chest pain he experienced became more severe. On May 19, 1945, he went to visit the family's doctor in nearby Westport, Ontario.

This was in the days before Canada had a "free" "Health Care" system so Charlie had to pay $3.00 for the office visit.  Dr. Goodfellow was troubled by the increasing chest pain and recommended Charlie see the best cardiologist in the region, Dr. W. Ford Connell at the Kingston General. So, on June 13, 1945, Charlie drove in to Kingston and met with the well regarded specialist.  Dr. Connell did an examination, talked to Charlie about his family, extended his condolences regarding Charlie's mother, and sent Charlie down stairs for a chest x-ray.  That cough was a miserable one too.  Charlie paid $6.00 for the x-ray.



Back he went to Dr. Connell who wrote a prescription for three medications to deal with both the cough and the chest pain. 



 Charlie thanked Dr. Connell, and, because he liked to pay promptly, settled the bill for his visit directly with Dr. Connell.

On his way home Charlie picked up his medications.  Their total cost was $1.65.  Now it is common to quote prices from "the old days" without adjusting them to reflect cost of living and purchasing power in the time period they took place.  Charlie was a dairy farmer so one comparison would be that the retail price of milk at the time was about 60 cents a gallon.  The price of milk in 2011 is approximately 7 times what it was in 1945.  Therefore, the total cost to Charlie of his medical adventure had been $20.65 or about $150.00 in current funds.  In return, Charlie had seen (promptly and on time) a family doctor who actually knew his family, been referred in less than one month to the top cardiologist in the area, had had a x-ray and paid for three medications.

     Charlie farmed for another 20 years.  His cough was never "cured" but that was because he was a heavy smoker.  That didn't help the heart either.  Less than two years after he retired, he succumbed to a heart attack, aged 70.  Charlie Leech was my father-in-law and coming across these documents in some old family papers caused me to reflect that perhaps health care was not so bad, back in the day.

Health Care debate growing

     There was an interesting exchange on Twitter last evening between Doug Griffiths, (@GriffMLA) MLA  and Progressive Conservative (PC) leadership candidate, and Rob Anderson,  (@RAndersonMLA) MLA and Wildrose Alliance (WR) insider, about the "health care" situation in Alberta. While Twitter is not the best medium for a sustained, in depth debate, it was refreshing to see some potential political heavywights engaged in a probing examination of where we are and what might be done.
     One of the things that initiated the debate was Griffiths' recent suggestion that health care premiums be reintroduced.  Anderson countered that "premiums won't do squat to fix our system".  Griffiths conceded that "Health needs many [other] reforms" but wondered how we are going to pay for the ever growing cost of our present system.
     I agree that reintroducing premiums is definitely not an answer, especially if there is no fundamental change in the philosophy and processes characteristic of our present "system".  On the other hand, Anderson's contention that "family docs are All private providers competing for publicly insured patients", as an example that we already have an element of private enterprise in our system, suggests a superficial analysis.  There is a huge difference between competing for fully autonomous customers (i.e. where patients control their own funds) and "competing" for government funding, which is a political process.
     Perhaps the major problem with our "health care system" is that it has become entirely "political".  What does that mean?  Over my years of teaching political science, I developed an excellent definition of politics as "the struggle for the power to set the rules for a society".  The key word in this definition is "power".  There are many sources of power.  Among them are influence and money.  Influence can change the rules of a society by, say, allowing PC insiders to jump health care queues. Money can change the rules by allowing the wealthy to fly to the Mayo clinic for an MRI they would have to wait months for in Alberta.
     As usual, the key to understanding a situation is to "follow the money" and especially the power to control the money.  One of the most corrupting characteristics of a "political" system is that a few insiders are able to control the money of others.  Taxation, we need to be reminded, is the confiscation of one person's money by a state apparatus which allows that money then to be spent by others for their own purposes.  Health care premiums are simply another tax (i.e. confiscation of money).  One attractive element of the WR position is that it proposes "funding following the patient" which one hopes means that the individual would be able to control how their funds are expended. Such a system would allow more of the private enterprise approach which, as it operates in, say, the food industry, would allow truer competition which, in turn, tends to allow the improvement of customer service and product quality.  There can only be competition if there is real choice by "clients" who have true power to control their own money.
     On that topic, we need much more transparency.  Whatever happened to informing us about what money is actually being spent on our behalf in health care?  In the early days of "health care" we would get an annual statement of what funds had been spent on our account, itemizing, for example, how many visits we had made to doctors and the charges associated with each visit.  Why do we no longer get this information?  Who audits doctors?  Are we to believe that no doctor in Alberta ever bills for a phantom patient visit?  I haven't heard of one, have you?
     In summary, we need to re-examine our basic assumptions and processes.  The Anderson - Griffiths exchange is a mildly encouraging example of that.  I see that @RajShermanMLA has also challenged "any/all PC candidates to a healthcare debate".  The more we engage in probes of our existing situation the more likely we are to correctly diagnose its problems and the more likely we can prescribe some remedies that will lead use to a healthier economic and political condition in our Alberta.