Dr Y and the Art of Intimidation

Posted on April 3, 2011 by susanonthesoapbox

There are 6500 doctors practicing medicine in Alberta;  2000 of them refuse to participate in the Health Quality Council (HQC) review.  These are intelligent, dedicated professionals practicing in ER, internal medicine, paediatrics, anaesthesia, rural practice and addiction-rehabilitation medicine and they all insist a judicial inquiry must be called.  Have they been intimidated or is this something even more fundamental–a complete breakdown of the system?

The seeds of scepticism were sown years ago.  It started with the Getty regime when the PCs reorganized health services into 17 health regions in order to increase efficiency and reduce costs.  Reorganization failed miserably on the cost reduction front, but set the stage for culture of intimidation which is only now emerging from the shadows.

The Klein government continued the consolidation trend.  Klein rolled the 17 health regions into 9 to further decrease duplication and the associated costs.  Makes sense—assuming that providing healthcare through 9 health regions actually reduced costs, but it didn’t.

Stelmach came up with the mother of all consolidations.  He rolled the 9 health regions into one:  Alberta Health Services.  This occurred on April Fool’s day 2009 (I’ll resist the urge to make factious comments).  The AHS executive team reports to the AHS Board which is appointed by and reports directly to the Health Minister.  Notwithstanding the Health Minister’s ingenuous protests to the contrary, the AHS board “governs” the health region only to the extent it is allowed to “govern” by the Health Minister.  This became blindingly obvious when Minister Zwozdesky directed the AHS to fire Dr Duckett and 4 board members resigned in protest.

The AHS is well aware that it works for the politicians (not the doctors) and dutifully carries out their wishes.  For example, when the government grew weary of doctors advocating for the replacement of aging facilities at the Tom Baker Cancer Centre the AHS imposed a gag order on the oncologists.  Dr Peter Craighead says that doctors were “forbidden by AHS to provide the media with any comments relating to capacity or new cancer centre issues.”*

In addition to gaining power over the doctors by taking control of their employer (the AHS), the government developed a peculiarly intimate relationship with the College of Physicians and Surgeons.  So close in fact that a member of the government could (and still can) call a member of the College and suggest that a doctor may be unbalanced and a mental health assessment would be in order.

The Alberta Medical Association (AMA) has a slightly different relationship with the government—perhaps because the AMA represents the doctors in contract negotiations and this, by definition, creates an adversarial relationship.  Nevertheless, the AMA is reluctant to be openly negative about the government unless it has no other choice.  The AMA’s criticism of the government’s bullying in the renegotiation of its trilateral agreement with the government and AHS is a recent example.

To put it bluntly, the government politicized the AHS and the College of Physicians and Surgeons and uses them to punish doctors who step out of line.  It uses bully tactics with the AMA which cause the AMA to be guarded and cautious.  With the AHS and the College operating as the government’s enforcers and the AMA held at bay, intimidation becomes easy.

So what does an act of intimidation look like?  Sometimes it takes the form of accusations of incompetence and mental instability as in the case of Dr Sherman, Independent MLA, who criticized ER wait times, and Dr Ciaran McNamee, thoracic surgeon, who criticized cuts to resources for lung cancer patients.  Sometimes it is a letter of reprimand as in the case of Dr Stan Houston who expressed concern over the government’s failure to renew the contracts of 4 public health doctors during a syphilis crisis, and Dr Lloyd Maybaum who challenged the government’s decision to eliminate a 76 bed psychiatric wing at the new South Health Campus.  And sometimes it’s outright termination as in the case of Dr Swann who was fired from his position as medical officer for the Palliser Health Region for speaking in favour of the Kyoto Accord and Dr Anne Fanning who was fired from her position of head of Alberta’s tuberculosis program for criticizing the government’s decision to make program cuts.

Here’s what intimidation feels like:

Heather Forsyth (Wildrose MLA) tabled a letter from Dr Y in the Legislature**  Dr Y’s letter is eloquent and terribly sad.  He says:  “There are so many of us, wanting to do the right thing for patients, but who are working in fear…if we speak out.  This culture continues to this day.  It causes moral distress as we are placed in an impossible position.  What had been especially troublesome was the direct observation among peers that no level of public dissent would be tolerated by the Health Region…or by the later AHS.  I have direct knowledge of several health professions, who were negatively impacted by their efforts to advocate for better healthcare.  They were silenced or worked out, or discredited, one after the other.  I have also been negatively impacted by this “muzzling of physicians voices,” and this “culture of silence” was simply reinforced.  Anyone questioning the status quo would be “dealt with” rapidly and effectively.  Like colleagues around me, it was evident that the political decision-makers had a strong-hold on what had become a centralist, non-patient focussed health system.  Like many other physicians, I felt and continue to feel intimated by AHS and Government.   Many of us are afraid to advocate for our patients.  Yet we have an ethical duty to advocate in the best interest of our patients.  We have repeatedly observed the punitive consequences in those who did so, and realize that the risk is immensely high.  Our moral distress continues and is getting worse.

 

The PCs reacted to Dr Y’s letter by quibbling over a point of order because the letter referred to Dr Sherman by name.  They said absolutely nothing about its content.

The government is holding fast to its position that the HQC review is enough, arguing that the doctors should be comforted by the fact that they can give evidence under a cone of silence.  But the government is missing the point.  The doctors are not asking for a review shrouded in secrecy.  Quite the opposite.  They want the AHS to waive the non-disclosure agreements so they can speak freely.  Furthermore, what the doctors really want is testimony, under oath, from senior bureaucrats and politicians, especially the present and former Health Ministers, on healthcare issues.  Only a public inquiry has the power to compel such testimony in a transparent public forum.  And this is precisely what the government is afraid of.

In the words of Dr Y:  Anything short of a judge-led public inquiry, with full power and accountability, will not restore any level of trust in the Government and its Health portfolio.  Many of us feel that we may be beyond a point of “repair”.  Physicians who are intimidated do not make the best partners in rebuilding the healthcare system, and Albertans continue to pay the price with their lives”.

 

*Calgary Herald, Mar 20, 2011, p A11

**Hansard, March 14, 2011, p 338, 339

Posted in Alberta Health Care, Politics and Government | Tagged , , | 2 Comments

Apples and Oranges

Posted on March 27, 2011 by susanonthesoapbox

The Premier was asked to investigate 330 cases of death or unnecessary suffering due to ER waits, 250 cancer deaths while on the surgical wait list and a culture of intimidation that prevents doctors from advocating on behalf of their patients.  He had 2 choices:  set up a public inquiry or proceed with a Health Quality Council (HQC) review.  He opted for a HQC review and showed remarkable speed in triggering the review under the HQC Regulation (Reg 130/2006) and appointing a blue ribbon Advisory Panel* to assist the HQC.  Why the haste?  Just 3 weeks ago his Health Minister was committed to an AHS review of the 321 ER cases (now up to 330).  Minister Zwozdesky indicated that the AHS review had been ongoing for 4 months and was blasé to the point of indifference as to its progress—the AHS “…had assigned a senior physician to conduct that review…It may not yet be quite complete, but I’ll try and get an update for you”.**

Minister Zwozdesky had barely finished speaking when things blew up—again.  Credible allegations of the 250 cancer deaths came to light.  Reputable doctors specializing in psychiatry, cancer treatment, emergency procedures and infectious diseases described a culture of intimidation that threatened to end the careers of those who advocated for their patients.  The PCs quickly realized that an AHS “review” of the 321 cases, let alone the cancer deaths, was not going to cut it.  So they switched to Plan B—the HQC review—and have refused to reconsider notwithstanding the barrage of criticism resulting from that decision.  They’ve argued that the HQC review is similar to a public inquiry because a public inquiry would have to be called by the government, would be subject to legislation (the Alberta Public Inquiries Act) and would make recommendations to the government.  This is simplistic and confuses apples with oranges because they are both fruit.

Why is Plan B unacceptable to the opposition and the doctors?  Go back to the purpose of the review.  Is the purpose to identify flaws in the healthcare system so that they can be rectified or is it a public relations exercise intended to defuse a situation which threatens the PCs on the eve of an election?  Put another way:  who is the review intended to serve, the people of Alberta or the PCs?

Let’s compare the two processes, starting with the HQC review.  The HQC is appointed by the Minister and is accountable to the Minister in all respects.*** Most importantly, the HQC must obtain the prior approval of the Minister before it makes any recommendations. Its CEO, Dr John Cowell, is in charge of the review.  He can be fired by the deputy minister if he fails to carry out his work in accordance with the Minister’s directions.  Notwithstanding this clear incentive to do what the Health Minister tells him, Dr Cowell says he’s not anyone’s lapdog and would resign if there is interference.**** Contrast that with comissioners on a public inquiry who are appointed for that sole purpose and are not beholden to the government for ongoing employment or future funding.

The HQC’s mandate is to assess patient safety and the quality of health service.  It conducts reviews at the request of the Minister and the AHS.  In the past it has reviewed the Government’s response to the H1N1 pandemic, medication mix-ups, the re-use of single-syringes and emergency and urgent care procedures.  While these reviews are meaningful,  not one rises to the level of complexity or magnitude of this inquiry.  A public inquiry’s mandate is as broad as it needs to be to serve the public interest.

Nevertheless the HQC is soldiering on.  It recently released its Terms of Reference.  Part A addresses quality of care and safety concerns for 330 patients who received emergency care in 2009 and 2010 at the University of Alberta Hospital.  Remember the dates—they’re important.  Part B addresses the role and ability of physicians to advocate for patients where they believe their safety and quality of care may be “compromised due to system resources or policies”—this must be a euphemism for a culture of intimidation.  When the review is completed the HQC will release its recommendations (subject to the prior approval of the Minister as per Reg 130/2006) for both Part A and Part B.

The HQC review will be a “quality assurance activity” under section 9 of the Alberta Evidence Act.  The Premier is adamant that section 9 provides full immunity and anonymity to the doctors who testify.  This is not the case.  Section 9 simply states that the evidence a doctor gives in the HQC review cannot be used against him in another action.  The critical question is:  does an “action” under section 9 include a professional disciplinary action which results in the suspension or loss of one’s license or is that an internal HR process outside the protection of section 9.  Furthermore, section 9 affords absolutely no protection in the shadowy world where a doctor is sidelined, demoted or terminated because he has failed to demonstrate “leadership and teamwork”.  No hospital administrator will state that the demotion or termination was the result of a government phone call demanding that doctor’s head on a platter because his advocacy had become “intolerable”.*****

The HQC review will take place behind closed doors, shrouded in secrecy;  but a public inquiry is, by definition, public.  It is intended to serve the public and is usually open to the public.

A public inquiry is an investigative process, the HQC review is not.  The public inquiry can (1) compel witnesses to appear and testify under oath, (2) treat false answers as perjury and (3) compel the production of documents.  This critical distinction has been brought to the Premier’s attention many times.  His response is: “the Health Quality Council has very rigorous and robust terms of reference, and they can go back as far as they want.  They can call anybody to deliver the evidence.****** In this comment the Premier has significantly expanded the scope of the HQC review.  Remember the HQC Terms of Reference restricted the review of ER cases to the 2009 and 2010 time frame…the Premier just made the time frame unlimited.  Remember also that the HQC does not have the power to compel witnesses to appear…the Premier blew through that limitation when he said that the HQC “can call anybody to deliver the evidence”. It would be entertaining to test the Premier’s sincerity by calling the existing and past health ministers, Gene Zwozdesky, Ron Liepert and Gary Mar, to testify unfortunately Reg 130/2006 won’t allow it.

One final distinction, in addition to making recommendations for improvement, a public inquiry, unlike the HQC, may make findings of misconduct which is defined as “improper or unprofessional behaviour” or “bad management”.  Could this be the Premier’s real concern?

So back to the original question: what is the purpose of the healthcare review?  Is it a sincere effort to understand systemic healthcare problems and rectify them or a PR exercise designed to carry the PCs through the next election?  I believe that the HQC will try its best to identify flaws in the system and make meaningful recommendations to address them.  However the fact that the HQC cannot compel the attendance of witnesses or the production of documents and requires the prior approval of the health minister before it makes its recommendations confirms that the HQC lacks the power and the independence necessary to carry out the investigation and bring about real change.  No amount of bafflegab on the part of the Premier and the Health Minister will unshackle the HQC from its legislative mandate.

Looks like a PR exercise to me.

*The Advisory Panel members are: Dr Zaheer Lakhani, The Honourable Anne McLellan, Mr Art Price, Dr Simon Sutcliffe and The Honourable Allan Wachowich QC.

**Hansard, March 3, 2011, p 175

***Health Quality Council of Alberta Regulation 130/2006, sections 15 and 16

****Calgary Herald, March 15, 2011, p A3

*****Calgary Herald, March 19, 2011, p A4

******Hansard, March 23, 2011, p 510

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Does Your Doctor Drive A Ferarri?

Posted on March 19, 2011 by susanonthesoapbox

Last week the need for a public inquiry into the 322 ER cases and 250 deaths on the waiting list boiled over as doctors came forward with proof of the culture of intimidation that stifles patient advocacy.  But it’s not just individual doctors who have experienced harsh treatment at the hands of the government or healthcare administrators.  The Alberta Medical Association (AMA) is renegotiating its 8 year trilateral master agreement, which expires on Mar 31, 2011, with Alberta Health Services and Alberta Health & Wellness (let’s call them the Government for the sake of simplicity).  The negotiations took a nasty turn last month when the Government told the AMA that unless it signed a new 3 year master agreement by Apr 1, 2011, nine key programs would vapourize.  The AMA reacted with shock and anger.  In a show of magnanimity the Government granted a 90 day reprieve.

The Government’s display of brinksmanship is more than a ham fisted negotiation tactic.  It’s a breach of faith.  First, it is unprecedented to chop existing programs while a contract is under negotiation.  Second, these 9 programs were established in lieu of fee increases as a way to reduce overhead costs and help offset the fee freeze.  Third, axing these programs flies in the face of the Government’s 5 Year Health Action Plan, which is continually trotted out by the Premier and Minister Zwozdesky in response to any criticisms of their management of healthcare.

What are these 9 programs and why is their termination so controversial?  Three programs are financial and the remaining 6 are value-added.  The financial programs are the Business Costs Program (BCP) which sets the value of office visits—the elimination of the BCP will decrease a physician’s income by approximately $25,000/year;  the Continuing Medical Education program which provides a $2,500/year reimbursement for mandatory continuing education and the Retention Benefit which ranges from $4,840 to $12,100 depending on years of service.  The elimination of these 3 programs will reduce a doctor’s income by approximately $35,000/year.

The 6 value-added programs fall into three categories.  First, programs that provide counselling support and referrals to physicians and their families, including a program that The Lancet* recognized as a leading example of quality and innovation in physician health.  Second, programs that underpin the 5 Year Health Action Plan. These include programs to support system changes, programs to improve access to primary care and the Practice Management Program which is key to setting up primary care networks (PCNs).  In addition there is a parental leave program which provides 17 weeks of support at $1000/week.

The AMA worked hard to ensure that Minister Zwozdesky understood the criticality of these programs.  Dr White, President of the AMA, met with the health minister to review his concerns.  Initially the health minister distanced himself from the controversy with vague statements like “They’re at the table, I think, even as we speak, possibly.  I’m not sure.  They are negotiating, and the process, from what I understand, is working”.** The Minister makes it sound like he’s not part of the process.  Perhaps he’s forgotten the meaning of the word “tripartite”  and the fact that his department is a party to the agreement.  A week later the Premier said “Yesterday—good news—the AMA reached an agreement with government in terms of a three-year funding agreement.”*** Apparently he thinks the negotiations are over.  Nothing could be further from the truth.

The very next day Dr White set out the AMA’s position:  “We do not have an agreement, we’re far apart, we’ve got a lot of work to do. This is the first time the profession has been broadsided by government and it’s really pissed us off.  We’re very angry.  We’re very disappointed, and I can tell you the relationship between mainstream medicine and government is at it lowest ebb in a long, long time”.**** Does that sound like a deal to you?

So stepping back for a moment, why are the doctors so outraged?  The dollar value of the programs is only $35,000/year, they make buckets of money and drive around in Ferraris, don’t they?  Well, no, they don’t.  Most doctors fresh out of medical school start their careers in debt (average debt in the US is $150,000).  Their incomes don’t increase as their experience increases.  In fact if the government continues to freeze fees, their net incomes will plummet.  One way to offset this decreased revenue is to pack in more patients.  Most doctors see 30 to 40 patients a day already—it boggles the mind to think that they could squeeze in more patients and still have time to complete their charting and billing work.  Overhead costs continue to rise.  The cost of leasing space, employing staff and purchasing medical supplies can easily chew up 40% of a doctor’s income.  All in all, a physician’s net income can be in the $100,000/year range—significantly less than one would expect for 10 years of education—so the elimination of programs valued at $35,000/year is a major financial hit.

In addition to the personal financial impact, the loss of these programs undermines the doctors’ ability to deliver on the promises made on their behalf by the Government in the 5 Year Health Action Plan. The AMA attempts to address this gap by setting out key expectations in the “agreement in principle” (still to be finalized).  In addition to freezing rates for 2 years and then increasing rates in year 3 by the cost of living, current programs and benefits will continue for 3 years and some programs will be guaranteed to continue beyond that.

More importantly, the AMA wants the Government to specify exactly how it will achieve the lofty goals and targets set out in the 5 Year Health Action Plan and identify the funding, resources and timelines required to get there—a brilliant move that will make the Government accountable for its promises at long last.  The AMA expects clarity on physician engagement in decision-making process (this could be a bit tricky considering the reluctance of physicians to speak up for fear of losing their jobs).  Lastly, the AMA requires the new master agreement to be functionally and fairly managed, as opposed to bureaucratically or unilaterally managed.   The President of the AMA put it this way:  “The concept of ministerial responsibility, which is paramount in democracy, must be clarified and enshrined in the agreement.”***** Reading between the lines this means that the master agreement should not be administered by a politician—a novel concept.

The AMA is to be applauded for standing up to a Government that has demonstrated a “no holds barred” approach to dealing with the medical profession.  The new master agreement will benefit not just the doctors but all Albertans.  We must show our support for the AMA and our doctors by writing to the Premier, the health minister and our MLAs to urge the Government to accept the terms requested by the AMA.   If we don’t our doctors will do what any reasonable person would do in the circumstances—pack up their medical bags and drive their VW’s somewhere else.

*The Lancet, Nov 14, 2009

**Hansard, Mar 2, 2011, p 151

***Hansard, Mar 15, 2011, p 355

****Calgary Herald Mar 16, 2011, p A8

*****AMA President’s Letter March 14, 2011, p 2

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The King of the Moon

Posted on March 13, 2011 by susanonthesoapbox

Dr Raj Sherman is a passionate man.  He’s been an outspoken advocate for healthcare since 2006 when he told the Edmonton Sun that an 11 day wait in ER was unacceptable.  He came to the attention of the PCs who urged him to “get out of the headlines” and “come inside” where he could truly make a difference.*  He was elected MLA for Edmonton-Meadowlark in 2008 and became the junior minister for health.  He thought he could transform the system.  He was dead wrong.

Healthcare services were slashed.  Health ministers came and went.  Small improvements were made, only to be lost again under a new regime.  And the population of Alberta kept growing.  Dr Sherman was reduced to pleading with healthcare professionals to work “within the system” in the hope that the PCs would someday recognize the depth of the crisis.  At the same time a culture of intolerance and retaliation spread throughout the health regions.

It makes you wonder:  who is Dr Sherman and why does he continue to fight for healthcare?  Rajnish Sherman grew up in India.  He comes from a family of doctors on his mother’s side.  He describes his father’s family as “freedom fighters” and credits his paternal grandfather with convincing a group of dissidents that bombing the Indian Assembly was a bad idea (they set off a symbolic firecracker instead).

Raj speaks of his grandfather, a rural doctor, with great respect.  He describes an evening when the moon was high, the sky was soft and hyenas were baying in the background.  His grandfather said:  there are three things in this world you cannot hide—the sun, the moon and the truth.  His grandfather told him that Raja means king.  Nish means night, moon.  You are the king of the moon.

Fast forward to today.  Raj Sherman has learned a harsh lesson—being “on the inside” did not equate to having the power to fix the healthcare system.  In fact, by going inside Raj was silenced.  His efforts to find a middle ground between the politicians and the ER doctors were thwarted.  His colleagues, frustrated and disappointed, took matters into their own hands and wrote numerous letters to the Premier and health minister between 2008 and 2010.

The public was blissfully unaware of these letters until Oct 2010 when Dr Parks wrote to the Premier and health minister describing 322 cases of compromised care in an overburdened ER in Edmonton—and the letter was leaked to the press.  Finally Dr Sherman had had enough:  the values of the Tory party and his loyalty to that party collided with his values as a physician and the values his grandfather taught him on that starry night in India.  He took his arguments to the Premier and was expelled from the party.

Passionate people are well advised to work closely with dispassionate people when navigating through volatile situations.  Initially Dr Sherman attacked the Tories head on.  His allegations of a cover up of cancer deaths went pear-shaped and threatened to destroy his credibility.  Luckily he was saved by the growing controversy over the stalled Alberta Health Services (AHS) review of the 322 cases and the Premier’s flat out refusal to conduct a public inquiry into the matter.

Dr Parks played a pivotal role in this process.  His response to the Premier’s statement that the AHS was capable of conducting the 322 review was clear and unequivocal—it won’t happen.  Dr Parks also rejected the Tories suggestion that the Health Quality Council (HQC) could conduct the investigation.  His rationale makes sense for a number of reasons.

First, a culture of intimidation and retribution permeates the AHS (and the government for that matter).  Doctors who advocate for their patients or criticize government plans to close beds, downsize staff and mothball facilities find themselves the target of smear campaigns and complaints to the College of Physicians and Surgeons.  Retribution is swift and sure.

Take the example of Dr McNamee.  He raised concerns about wait times for cancer surgery with the Tory caucus in 1999. He lost his position and his reputation when his mental and professional capabilities were impugned.  Dr McNamee sued the health authority and the two doctors who managed it.  The case was settled and Dr McNamee moved to the US.  He now teaches at Harvard.   The important point here is that Dr McNamee and others like him whose advocacy will “… no longer be tolerated**…” are required to sign a confidentiality agreement when their battle with the health region is settled.

A confidentiality agreement is a legal contract requiring silence.  The only way to speak on the matter is if the other party waives the obligation of confidentiality or disclosure is ordered by law.  Given that the AHS is not about to release the doctors it has punished so that they can give a public account of their failed efforts to advocate for their patients, the only way to hear this testimony is to compel it by law, namely a public inquiry with subpoena power.

Second, doctors who are not bound by confidentiality are afraid to speak for fear of retaliation.  Protection from retaliation is standard in all whistleblower legislation and is a key element of whistleblower policies for all major corporations.  It exists in the AHS policy as well.  However, doctors know from personal experience that the “protection” offered by the AHS policy is about as useful as an umbrella in a hurricane—just ask Dr McNamee.  Since the immunity provided under the AHS policy is worthless, the doctors are well advised to request immunity from the government on the public record.

Returning now to Dr Raj Sherman.  The King of the Moon has found a compatriot in the King of the Sun.  Whether by accident or design, Dr Sherman’s passionate advocacy has been reinforced by Dr Parks’ analytical approach with the result that the King of the Moon and the King of the Sun are now in alignment.  They are pushing for a public inquiry into the 322 cases and the 200 deaths on the wait list.  They will accept nothing less to uncover the truth.  And neither will we.

 

*Hansard, Nov 24, 2010, pp 1548-1554.

**Calgary Herald, Mar 11, 2011, p A4

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The Press Did It

Posted on March 6, 2011 by susanonthesoapbox

The MLAs were back in the House for two days and already the Premier was getting feisty.  What set him off?  Legitimate questions from the opposition.

Dr Swann started the ball rolling by asking the Premier to explain why the throne speech failed to address the crisis in healthcare.  Mr Stelmach replied:  there is no crisis in healthcare, in fact, quite the opposite is true, because over 60% of Albertans were “very satisfied with the health care they’re receiving”.*   He referred to the recent Environics poll and the Health Quality Council in support of this statement.  When Dr Swann told him that he’d had gotten it backwards—the Environics poll showed that two-thirds of Albertans felt the healthcare system was in crisis as a result of ineffective management, Mr Stelmach made the following bizarre comment:

“I think 36 percent or so of Albertans had concern(s) about health.  You know, that is a very small percentage given that constantly, every day in every doggone paper there is something negative about health care delivery in this province, yet thousands – thousands – receive health care in this province on a daily basis.”* True, thousands are receiving healthcare every day, but that’s not the question, is it?

Then Mr Mason picked up the ball.  He asked the Premier whether the PC’s had failed to meet Albertans’ healthcare needs and expectations.  (It would have been nice if Mr Zwozdesky stepped in at this point to assist the Premier, but it’s likely a career limiting move to correct your boss on the public record, even if he’s already heading for the exit).  Mr Stelmach responded with this:  “…you know, we can make all kinds of jokes about health care, especially about what you’ve seen lately in the papers, obviously:  if it doesn’t bleed, it doesn’t lead.  But I’m very confident that we have one of the best health care systems in Canada.”*

Doggone papers?  If it doesn’t bleed, it doesn’t lead?  Ah, now I get it…the non-existent healthcare crisis is the press’s fault.

Let’s start with the “if it doesn’t bleed, it doesn’t lead” comment.  The implication is that the profit motive determines which stories make it to the front page.  Really?  Sean Collins, a senior producer with National Public Radio (the US equivalent to CBC) says “Journalism is not run by a scientific formula.  Decisions about a story being newsworthy come from the head, the heart and the gut”.** This is a very effective way to analyse a story.  A “head” story is characterized by empirical reporting backed up with verifiable data.  A “heart” story is emotionally moving, personal and often involves babies and small dogs.  A “gut” story typically creates a reaction—usually panic—but is empirically unsubstantiated.  The classic summertime “gut” story is a shark attacking a tourist which results in thousands of tourists boycotting the beach, notwithstanding the fact that only 10 swimmers are killed each year by sharks worldwide.

The “healthcare crisis” stories are “head” stories or “heart/head” stories.  The failure of the government to budget the $320 million/year required to operate the new South Health Campus hospital is a classic “head” story.  The story of an MLA’s father suffering from a heart attack but not being able to get treatment in an overcrowded ER waiting room is a “heart” story which quickly turns into a “head” story when it includes data indicating that wait time targets are not being met.  None of the healthcare crisis stories are “gut” stories notwithstanding the fact that, much to the government’s chagrin, they embolden the public to write to their MLAs demanding a solution.

But here’s the bigger issue:  The press plays a critical role in a democracy.  It brings issues which are the responsibility of the government and which affect the welfare of Albertans to the public’s attention.  To disparage the press with cheap shots shows a stunning lack of respect for both the news media and the people of Alberta who rely on that media in order to understand what the government is doing with their tax dollars.  It may make the Mr Stelmach uncomfortable to have the press and the public breathing down his neck, but that’s called accountability.

So here’s a news flash for Mr Stelmach:  The press did not create the healthcare crisis.  You and your party did.

*Hansard, Feb 23, 2011, p 10, 11

**Quoted in Dan Gardner’s book, Risk, p 192

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The Mysterious Wedge

Posted on February 27, 2011 by susanonthesoapbox

Like the proverbial eagle, the 2011 Budget has landed—with less hoopla than expected.  Yes, the $39 billion budget came with a $3.4 billion shortfall but it left health services intact.  This was a wise decision on the part of the Tories given that over 60% of Albertans feel that healthcare system is in crisis and the cause is inefficient management.  Not that the government had any choice.  Just last fall the government unveiled the 5 Year Health Funding Plan which underpins the 5 Year Health Action Plan.  To shave even a penny off the health budget in the face of these announcements would have been the height of hypocrisy, if not political suicide.

While others were focusing on the healthcare and education budgets, I decided to spin the spending pie chart *and examine the mysterious wedge called “Other”.  This wedge is so interesting because it’s so big—it accounts for 13.8% of the spending budget.  That’s $5,382 billion.  That makes “Other” the third largest expenditure category after health and education.  It’s larger than social services at $4.1 billion (10.6%), agriculture, resource management and economic development at $2 billion (5.1%), transportation, communications and utilities at $1.9 billion (4.9%), and debt servicing costs at $585 million (1.5%).  In fact it’s larger that the last three categories combined and is one and half times larger than the deficit itself.  The deficit will be offset by further draws on the Sustainability Fund (also a concern but a topic for another day).

The really tantalizing question is—what is “Other”?  Clearly it’s something other than social services, transportation, communications, utilities, agriculture, resource management, economic development and debt servicing costs.  What else is left?  In my experience, a category called “Other” is a catch-all for the bits and pieces that are too small or insignificant to put into a category of their own.  Since a wedge as small as 1.5% (debt servicing costs) made it on to the pie chart as a stand-alone wedge, logic would dictate that “Other” is packed with little wedges which are smaller than 1.5% or $585 million.

On the other hand, another reason to create a category called “Other” is to mask its contents and cost in order to avoid public scrutiny.  In the past, the Tories have buried private sector subsidies in this wonderfully nondescript no-need-to-look-here category.  These subsidies off set revenue received from non-renewable resources (royalties and tax payments) which in this budget is expected to be 23.4% or $8.3 billion.

In Nov 2010 the International Institute for Sustainable Development (IISD) reported that the Alberta government subsidy for upstream oil activities was estimated to be $1.05 billion.  These subsidies are intended to increase exploration and development through a combination of tax breaks and royalty reductions.  Well, the subsidy doesn’t appear on the pie chart, in fact Energy doesn’t appear on the pie chart.  So a peek at the business plan for the Department of Energy is warranted.

The revenue side of the statement of operations reveals an interesting item called “Energy Industry Drilling Stimulus Program”.  Items in the revenue column normally increase overall revenue, however this item is a deduction from revenue.  In 2009-10 this subsidy decreased revenue by $1,119 billion.  In the 2010-11 fiscal year the subsidy was budgeted to decrease revenue by $732 million, however the 2010-11 re-forecast shows the decrease to revenue will be $1,660 billion—more than double what was expected.  Put another way, the IISD estimate of $1.05 billion in government subsidies to the upstream oil industry is likely correct and, if anything, understated.  However, this is an austerity budget and the Stimulus Program disappears in the 2011 to 2014 time frame.

Albertans have suggested that the government has mishandled healthcare and is  responsible for the healthcare crisis.  Similar concerns have been raised on a broader scale—the relationship of the government with industry.  Are the stimulus programs properly applied at a time when basic social services are being cut or frozen?  Secondly, are the existing programs which collect non-renewable resource revenue (budgeted at 23.4% or $8.3 billion in 2011-12) properly managed?  A coalition of unions, including the United Nurses of Alberta and the Alberta Union of Provincial Employees believes that the government has failed to collect billions of dollars in resource revenue and has asked the Auditor General to investigate.

Hopefully the audit process will shed some light on this mysterious wedge and we’ll have an answer to the $5,382 billion question—what exactly is “Other”?

*Calgary Herald, Feb 25, 2011, p A5

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FOIP

Posted on February 20, 2011 by susanonthesoapbox

On Valentine’s Day while others were buying chocolates for that special someone, I was brooding about the new Alberta Health Act.   I can’t shake the feeling that the underlying purpose of this legislation is to slide Albertans down the path to greater privatization.  Is this a good strategy or a bad one?  No one knows because we don’t have enough information to make an informed choice.  Nevertheless, our government is forging ahead without our input, let alone our support.

But maybe I’m being paranoid.  Let’s start with the facts.  The Premier was asked whether his government was moving toward greater privatization.  He said: “No, now go away.” Well, he didn’t say it quite that way, what he said was: “I don’t know how many times I have to repeat in the House that this government is firmly committed to a publicly funded, publically administered health care system.  Period.” * (I extrapolated the rest from the word “Period”).

Notwithstanding the Premier’s response, speculation and paranoia continue to rise.  Why? Because the government’s actions do not align with the Premier’s statement.  In fact if you examine what the Premier said you’ll notice that he ducked the question.  He didn’t deny that the government was moving toward more private insurance and private healthcare, he simply confirmed his support for public healthcare.  Public and private healthcare systems can co-exist;  the concern is that public healthcare will suffer if there aren’t sufficient resources to support both the public and private systems.  In the world of PR and politics if you don’t like the question you’re asked then you answer the question you wish you’d been asked.  In my world the Premier’s answer gives the PC’s plenty of wiggle room.

Remember, these questions didn’t spring out of thin air.  They were triggered by the leaked government policy paper called Alberta’s Health Legislation: Moving Forward. The policy paper sets out a two phase process to change Alberta’s Health Act.  Phase 1 consists of building public confidence—a recent Environics poll showed that 63% of Albertans feel the healthcare system is in crisis so the PC’s a long way to go on that front.  Phase 2 sets up a process to erode existing provincial laws** which protect medicare by changing them into regulations that the Health Minister can unilaterally amend in the backroom without the public scrutiny of a legislative debate.

Phase 2 will allow the Health Minister to delist services so that they are available for private health insurance.  It will permit doctors to work inside and outside the public system (unlike the existing system where doctors must choose to opt-in or opt-out).  In order to stem the tide of doctors flocking to the private sector for the bulk of their practice, the Minister can mandate doctors to devote a portion of their time to the public system.  (The fact that the government is prepared to order doctors by law to work in the public system is an indication of how undesirable the public system will become).

Dr Raj Sherman confirmed that this policy was approved by the Health Minister in July 2010 and presented to all government MLAs.

So who do we believe—the government or ousted MLAs and other professionals who’ve analysed the leaked policy paper?  I’ve found that the best way to resolve a dispute where each party says the other one has got it wrong is to get more evidence.  So on Valentine’s Day I sent the Department of Health and Wellness a FOIP request.

The Freedom of Information and Protection of Privacy Act gives us the right to examine the records of any public body.  The FOIP website is clear and easy to follow.  I completed a Request to Access Information, wrote a cheque for $25 and sent my request to Ms Barbara Joyner, as directed.  I asked for “any and all records and documents including but not limited to correspondence (email or hard copy), presentations, briefs, reports and studies pertaining to the private insurance options which are the subject of a Government of Alberta presentation entitled Alberta Health Legislation: Moving Forward”. I even attached the page of the powerpoint presentation which referred to private insurance options.  I’ve had no response thus far—but it’s only been a week and a half the PC cabinet have resigned their posts so the department may be a little distracted.

The paranoid side of me wonders whether this exercise will be a repeat of the Liberal’s experience in the fall of 2005.  The Liberals made a FOIP request with respect to Klein’s Third Way. The government informed them that there were 6,331 pages responsive to the request and it would cost $8,400 to produce them.  Nine months later the Liberals received 168 pages and had managed to negotiate the cost down to $1,081.  The 168 pages were practically useless and arrived long after the spring 2006 Legislative Session was over.

FOIP is a critical democratic tool.  It can provide access to valuable information that will contribute to the debate…but only if the government makes it accessible.  In his 2010 annual report, Frank Work, the Privacy Commissioner said:  “If you’re going to promise transparency then deliver it…Let the public see, let the public judge, let the public find ways to make the information useful and relevant to themselves and others.

I hope that my request will skip across the placid pool that is the Department of Health and Wellness and land safely on the other side, however the sceptic in me thinks it will bounce twice and make a soft “foip” sound before it sinks like a stone to the murky bottom.  I’ll keep you posted.

*Hansard, Nov 29, p 1637

**These protections are enshrined in the Health Care Protection Act, the Health Care Insurance Act, the Hospitals Act and the Nursing Homes Act.  The Canada Health Act alone will not protect universal care and equal access to all services.

Posted in Alberta Health Care, Politics and Government | Tagged , , | 2 Comments

Darwin’s Finches

Posted on February 13, 2011 by susanonthesoapbox

Last year when the Health Minister was struggling to explain how the government was going to approach activity-based healthcare funding he said something truly brilliant.  He said the government was making improvements and “As for whose idea it was, it matters not to me whose idea it was… if it’s a good idea, we’ll do it”.* This was insightful because creative idea generation is exactly what we need to crack the complex problem of providing high quality healthcare without bankrupting the province.  The question is:  Did Mr Zwozdesky really mean it?

Before we go there, let’s start at the very beginning:  Where do good ideas come from?  Are they the result of a blinding eureka moment and arrive on the shore of consciousness fully formed like Botticelli’s Venus, or do they evolve slowly, fortified by a serendipitous encounter, a fortuitous accident or the concerted efforts of others?  Steven Johnson in his book Where Good Ideas Come From says it’s all of the above.

A good idea is a creative spark which collides with other ideas and is improved by the free flowing dialogue of a diverse mix of people.  The improved idea may trigger a breakthrough on a hunch that has been simmering in the back of someone’s mind, it may careen down a misguided path, only to come back much improved, it may meet with a serendipitous accident which improves it one hundred fold.  It took Darwin almost 2 years to connect the extraordinary diversity of the Galapagos finches with his theory of evolution and that happened only after Darwin read Malthus on Population “for amusement”.  The bottom line is that a good idea needs a collaborative open environment in which to grow.

Turning now to how the Alberta government developed its solution to the healthcare crisis—the Health Minister started with the right question.  He asked:  “What is it that people want?”** He assembled the Minister’s Advisory Committee on Health (MACH) to dialogue with Albertans.  Albertans told MACH they wanted improved access to health care, reduced wait times and a sustainable health system.

So far so good, but here’s where the process when sideways.  MACH returned to base and passed this feedback on to the bureaucrats who translated what they “heard from the people” into legislation–the new Alberta Health Act.  The purpose of the new Act is to provide a health charter setting out principles and responsibility (ETA: some time in the future), a health advocate to solve citizen’s concerns (reporting directly to the Health Minister and ETA:  some time in the future) and what Minister Zwozdesky described as ”the single most important part of this bill”—the ability to input through an “engagement process”(ETA:  some time in the future).***

To be fair, the government also made a 5 year funding commitment to health care and published a 5 Year Action Plan.  Unfortunately the funding commitments is limited to the capital costs of new facilities and diagnostic equipment and does not provide an operating budget to hire the doctors, nurses or other healthcare providers who will be required to staff them.

So the end result of this bright idea is legislation aimed at increasing the ability of Albertans to talk about health care problems, not to solve them.  This is not surprising for a number of reasons.  One, the mandate of the MACH was to find a legislative solution.  Two, the composition of the Committee included health care professionals and academics but did not include any representatives from the Union of Alberta Nurses or the Alberta Medical Association—the two organizations that best represent what is really going on in the trenches.  Three, the proposed legislation was vetted in the PC Caucus.  Now, Caucus may be an effective tool for political leadership and decision making, but it can hardly be described as an open diverse environment conducive to the free flow of ideas.  If you have to ask for permission to voice a good idea, the idea dies—just ask Raj Sherman.  Four, the PC’s hold the majority of seats in the Legislature so the efforts of the opposition parties to bring forward alternative solutions fell on deaf ears.  Why?  Because in the Health Minister’s view the only good idea is his idea.  And here we are today, still talking about our health care problems with no solution in sight.

Darwin didn’t get from his Galapagos finches to the Origin of the Species by listening to the sound of his own voice.  The Alberta government won’t get from the healthcare crisis to a sustainable solution without meaningful input from a diverse group of outsiders:  experts, healthcare professionals, and dare I say it, politicians from across the aisle.  To paraphrase Steven Johnson, you can develop small ideas in a locked room cut off from the insights of others, but if you want to make major change…you need company,

*Hansard, Feb 22, 2010, p.208

**Hansard, Nov 30, 2010, p 1705

***Hansard, Nov 30, 2010,  p 1704

Posted in Alberta Health Care | 2 Comments

2+2+2 = 222

Posted on February 6, 2011 by susanonthesoapbox

Remember those silly math games we played as children—what’s 1 plus 1?  Two?  No silly it’s 11!  As children these games were quite amusing, but as adults they’ve become tiresome.  The PC’s should bear this in mind when they make their breathless announcements about “new” additions to our healthcare system.

This week we learned that the South Health Campus, a full service Calgary hospital, will be  phased into operation starting in 2012.  There’s just one snag—there’s no budget for operating costs.  In other words, the SHC will be finished but the lights won’t be on.  Not to worry says Health Minister Zwozdesky, “The funds will be there, one way or another.” Ms Wasylak, the AHS VP for South Health Campus, is “…confident our partnership with the government is going to allow us to have all the people and get the building running”. Well, that’s reassuring.

Ms Wasylak’s confidence is based on her belief that the Alberta government will not renege on its 5 year funding commitment to the AHS.*  I’m not so sure.  Why?  Because on Feb 24 Premier Stelmach will deliver what he calls a “tough” budget.  This is the same budget that was not “tough” enough for Mr Morton, the frontrunner for Premier Stelmach’s job.

I’m worried about Mr Morton for a number of reasons.  First, he is a right-wing small “c” conservative, notwithstanding his recent efforts to soften his hard line image.  Second, Mr Morton was the Finance Minister when Health Minister Zwozdesky made the 5 year funding commitment on behalf of the government and surely noticed that the SHC budget (like many healthcare initiatives) contained no provision for the estimated $433 million annual operating costs.  Apparently this did not trouble the Finance Minister enough to stop the funding commitment from being made in the first place.  Third, the first 2 years of the 5 year funding commitment should be embedded in the Feb 24 provincial budget—the very same budget that triggered Mr Morton’s threat to resign rather than face the ignominy of presenting a budget he could not support.  This is important for a number of reasons.

Whether by luck or design, Mr Morton’s threat to resign triggered Premier Stelmach’s resignation and kick-started the leadership race.  In order to run for the leadership Mr Morton had to resign as Finance Minister and join the backbenchers.  As Mr Morton walked out of his Finance Minister’s office and climbed up into the back benches he had a revelation.  He realized that although he could not support the budget as Finance Minister, he could support the budget as a backbencher. How is this possible?  Did Mr Morton, backbencher, forget all the things Mr Morton, Finance Minister, found offensive in the budget?  Are backbenchers by definition less intelligent and ethical than Finance Ministers?  More importantly, why would Ms Wasylak, or anyone for that matter, take any comfort in a government commitment when it is made by this government?

One final point about the South Health Campus.  The SHC, together with the Peter Lougheed Centre, are slated to meet the burgeoning demand for increased maternity capacity (the “baby bump” if you will).  Calgary hospitals can deliver 11,000 babies a year.  Unfortunately Calgary mothers are having 18,000 babies a year—that means 7000 babies are being born in less than ideal conditions.  By 2015, the stork will be trying to find layettes for 20,600 babies.  The most that Calgary hospitals can handle, even with the SHC and the Peter Lougheed Centre in full operation, is 14,665.  That means that 5935 babies will be born under a cabbage in 2015 because there won’t be any room for them in the hospitals.  And guess what, there is no operating budget for the maternity related improvements at the Peter Lougheed Centre either.

But take heart, Roman Cooney AHS Senior VP of Communications says he’s confident the money will be made available—“I don’t think it’s going to be a barrier, although it will be a challenge”. I guess that takes us back to Health Minister Zwodesky’s comment that the funds will be found “one way or another”.

Instead of praying for the stork to deliver a bag of money at the same time it drops a baby we should focus on getting the healthcare funding plan to align with the healthcare promises the government has been making to its citizens, even the little tiny ones, because 2 + 2 + 2 = 6, not 222.

* NOTE:  The 5 year funding commitment promises to provide funding increases of 6% for the first 3 years and 4.5% for the last 2 years on the existing budget of $15 billion.  The AHS will receive $9 billion in base operating funding in 2010-11.  This amount rises to $11.1 billion in 2014-15.

Posted in Alberta Health Care | Tagged | 4 Comments

*Crunch*

Posted on January 30, 2011 by susanonthesoapbox

Hear that crunching grinding noise?  That’s the sound of the tectonic plates of the political parties moving in divergent, convergent and transformational directions.  On Tuesday Ed Stelmach announced he would not seek re-election.  On Wednesday Ted Morton said the provincial budget had been approved with his support but he wouldn’t commit to presenting it in the legislature.   By Friday he’d quit his post as finance minister and kicked off the leadership race.  Everyone is speculating about who else will enter the leadership race and whether we’ll witness a repeat of the 2006 leadership campaign which saw Morton and Dinning splitting the vote and a third place contender walking away with the prize.

But that really doesn’t matter does it?  The real question is:  What do Albertans want?  Rob Anders believes that Alberta is a “true-blue conservative province” and the only hope of survival is a right-wing fiscal conservative like Morton.  Other PC’s believe a more “progressive” PC like Jim Dinning is the answer.  Preston Manning suggests that in addition to the fiscal conservative/progressive split, there is a rural/urban split and a north/south split.  This rhetoric is premised on the belief that somehow the PC’s have figured out how Albertans—or rather how rural Albertans—will vote.  Did you hear that “crack”?  That was the sound of at least 6 different factions trying unsuccessfully to align.

But what if the PC’s have got it wrong?  What is the vote doesn’t turn on whether rural Albertans are fiscal hawks and urban Albertans are not?  What if the rural/urban and north/south “splits” don’t really exist at all?  This is where Kelly’s gall bladder comes in.  In the fall of 2008 my husband and I flew to Victoria for a weekend getaway, leaving our children to fend for themselves.  They’re adults, they’d be fine.  We were relaxing in our cosy little room at the Empress when the first frantic phone call came through.  Eden, Kelly’s younger sister, had just packed Kelly off to hospital and was parked there to advocate on behalf of her sister who was in so much pain she was incoherent.  Roy and I frantically rearranged our flights (thank you WestJet) and got back the next morning.  By then Kelly had progressed out of the ER waiting room into a lazy boy in the “Rapid Assessment Unit”.  Twenty-two hours after admission she was given a bed in the geriatric ward pending surgery.  The gall bladder was removed and the next day Kelly was sent home—only to return the following day with a raging infection that required an additional 9 days in hospital.

This wretched experience created a tectonic transformational shift in my relationship with the government of Alberta.  Over the next 2 years I became fully engaged in the political process.  I’ve watched the PC’s jeopardize the viability of the oil and gas industry with an ill-conceived royalty scheme and threaten the sustainability of our natural resources by its inept oversight of the development of the oil sands.  Billboards in the centre of London and New York really don’t cut it without an underlying commitment to prudent environmental stewardship.  The quality of our healthcare system has diminished to the point that Alberta is ranked 7th out of the 10 provinces for healthcare delivery systems.  Alberta’s educational system is next up for a “transformational change”–at the same time as the government is threatening to renege on the pay deal it struck with the teachers union.  To top it all off, the government recently announced that it is at an impasse with its 23,000 unionized provincial employees.

That cracking noise you hear is not the splintering of Alberta’s voting population into north/south, rural/urban or conservative/progressive factions but rather a tsunami of frustration created by the government’s failure to deliver on its promises.

The level of political engagement in Alberta has changed dramatically.  Calgary was the first to witness this heightened engagement in the recent municipal election where voter turnout reached 53% and Naheed Nenshi—a relatively unknown candidate—was elected mayor.  Albertans are seeing it at the provincial level with the creation of not one but two new political parties—the Wildrose and the Alberta Party.  The Liberals and the NDP are fading from the ballot and the PC’s who have historically kept a lid on party in-fighting became so dysfunctional that they punted 2 cabinet ministers in the last 2 years.  Albertans are becoming informed about the issues and are no longer willing to be soothed by promises which will be delivered later (the “trust us” gambit).  Whoa, did you hear that?  There goes another tectonic plate—this one is in the continental crust and it will transform the Alberta political landscape forever.

PS.  Kelly is fine now and a tad mortified by her gall bladder’s notoriety.

Posted in Alberta Health Care, Politics and Government | Tagged , | 2 Comments