About me: I’m a firefighter/paramedic who has been an Advanced Care Paramedic for nearly 30 years working in all aspects of EMS: municipal, provincial, flight, industrial and fire department. My opinions are my own.
On Nov. 7th Premier Danielle Smith announced sweeping healthcare reforms that will see AHS lose much of its power as the monopoly overseer of healthcare. Its powers are to be separated into 4 separate organizations answerable to a health board. These organizations are Primary Care, Acute Care (which AHS will now report to), Continuing Care, and Mental Health and Addiction.
Currently we see a divide in support for these reforms. Against the reforms are public unions that represent the bulk of AHS employees and establishment ideologues who believe in centralizing healthcare under control of a cabal of experts. In favour of these reforms are the Alberta Professional Fire Fighters & Paramedics Association, non-metropolitan municipalities, the Alberta Association of Nurses (who represent non-union nurses as well), Nurse Practitioners, and private addiction organizations.
When asked what the fundamental problem with AHS was Danielle Smith said, “It’s a policy making body, it’s a recipient of the lions share of funding, it’s a service provider, it contracts out to its competitors, and it evaluates performance.” Her intention is to keep it firmly in the business of service delivery and suggested it ought to be ‘Alberta Hospital Services’.
To understand why this mission creep outside of service delivery has been disastrous let’s examine my area of practice; Emergency Medical Services (EMS).
Structural Issues
AHS directly operates EMS in much of Alberta and operates just over half of the ground ambulances in the province. The rest is contracted out to 31 different EMS operators (private and municipal). Currently a conglomerate of some of the largest EMS contractors, municipal Fire Departments, are renegotiating expired contracts with AHS to provide ambulance services in their municipalities. Fire Departments in Alberta comprise roughly 30-40% of registered paramedics in the Province and they want things to change. They want their ambulances to serve their communities and they want better conditions for their staff.
Municipalities and Fire Departments have a vested interest in ensuring high quality EMS in their jurisdictions. When responsibility for EMS provision was stripped from municipalities and given to the province (AHS) in 2009 the promise was a borderless system in which heavily staffed metropolitan regions would largely benefit surrounding municipalities as ambulances would pour out of metro regions into suburban and rural communities during surges in rural call volume.
Unfortunately, the opposite has happened. Suburban and rural municipalities all face a similar problem; their ambulances are continually getting redeployed into Edmonton and Calgary to do calls for a chronically short-staffed AHS. The borderless system is creating a diffusion pressure in the wrong direction.
While non-metropolitan municipalities are making up for AHS’s inability to keep ambulances staffed they also face a wall of bureaucracy when trying to implement changes that will serve their staff and community.
Attempts to implement projects like a municipal community paramedic program that would see Fire Department medics treat urgent care patients in their home before untreated conditions become emergencies were stonewalled by AHS. These are programs that unburden ambulances and Emergency Departments and improve healthcare. Programs, I might add, that had widespread municipal and provincial government endorsement.
Attempts to implement projects like a Community Response Unit (a Fire Department paramedic staffed first response SUV) that would keep Fire Department paramedics in municipalities, while Fire Department ambulances were stuck in cities, required external pressure from Alberta Health (the ministry) before AHS would play ball.
AHS attempted numerous times to fix EMS hallway wait times with ad hoc solutions that were always short-lived until Smith was elected, then suddenly a 45 minute offload mandate was implemented (along with a few other system improvements). Suddenly the problem was (mostly) fixed.
Conflicting Incentives
This isn’t an indictment on AHS leadership. If you or I were running AHS EMS as mandated by the Government of Alberta, we likely couldn’t do any better. Our mandate, our condition of employment as imposed by the Province would not be to “provide the best service for community x”, it would be to manage the Provincial system as a whole. We would be required to control distribution of funds in a responsible manner to contractors, provide oversight of EMS, be subordinate to the needs of hospital and acute care administrators above us and ensure a borderless system so that resources flow to where they are most needed.
Imagine you have a municipality approach you about a program they think makes sense what do you do? Do you hand over funds and do a bunch of work to figure out how municipalities with different policies and mandates than yours will integrate seamlessly into your system? Probably not. How do you know if the municipality is going to meet your standards and reporting requirements? How do you maintain quality control over staff that aren’t yours? What will this mean for your ideal future plan of providing a similar service directly in that community? How much work are you going to have to do to figure out integration? What will you say to public sector unions when they complain that you’re giving work to competitors? There are lots of risks for you as an AHS manager or executive and no upside. In fact what the municipality wants (excellent service in their community) conflicts with your mandate.
As Danielle Smith pointed out, AHS is doing more than service delivery here. These executives are also contracting out, providing oversight, providing funding and enforcing contracts and the result is an artificial scarcity in EMS.
Hallway wait times are sometimes still an issue (healthcare is still scarce relative to demand) but my experience is that the issue has been dramatically improved over the past 10 months since mandated 45 minute offloads were implemented under Smiths administration. Hospitals are somehow finding ways to release ambulances. Clearly the capacity to make this happen was always present so why did it take top down political pressure to finally make it happen?
Again we go back to AHS being mandated to do too much creating an incredible amount of internal resistance to doing the things necessary to offload ambulances. Moving a stable ambulance patient into a waiting room chair, taking on a higher patient load, creating a waiting room for stretcher patients staffed by nurses, having registration staff come cot side to register patients, removing bottlenecks to admit patients are all extra hardships that hospital staff are understandably resistant to do in order to get EMS out the door faster.
It is a priority for communities to have ambulances in them ready to respond, yet EMS is at the bottom of the barrel when it comes hospital administration priorities. You can’t really blame them. Getting ambulances released faster makes the hospitals job harder. So AHS has a conflict; does it create hardship for the hospital system or hardship for the EMS system? History shows that without an external mandate or oversight AHS chooses hardship for EMS. Maybe it shouldn’t be put in the position of having to make this decision.
The Morale Problem
Two decades ago EMS was fun. Paramedics were seen as practitioners exercising their best clinical judgement on calls and felt respected by employers and medical directors. We were engaged at every level and had meaningful opportunity to create change in our system and in our station. There was healthy competition between jurisdictions as we all sought to raise the level of our service above other respected services in the province. Street medics were regularly researching protocols and equipment and writing proposals because doing so tangibly improved our ability to provide high value to our community. Protocols were guidelines that respected the practitioner exercising clinical judgement in the specific unique context of each call. If our care was called into question we would defend our care face to face with our medical director and develop the high levels of mutual trust and respect necessary to providing higher standards of care and competence.
This type of environment is possible in a decentralized system, where systems of control and adaptation are closer to the people being served. But since 2009 AHS has had a mandate to be the sole provider/overseer of EMS in the province. Given this mandate its only reasonable to standardize care, putting protocols and policies in the hands of a few experts. Given the wide variety of practitioner experience and competence level across the province it makes sense to ensure policies and protocols are homogenized to the level of the lowest common denominator. This level of centralization requires a shift away from practitioner engagement and towards bureaucracy and policy. This inevitable shift in environment caused by centralization means that the system no longer looks at us as respected practitioners exercising our best clinical judgement but rather looks at us as objects of compliance, interchangeable human resource units.
In past 2-3 years during the pandemic we’ve seen this top-down bureaucracy on steroids. It has never been more apparent that the system sees us as objects of compliance. Go to heroic lengths to save a patients life and get written up for forgetting to wear eye protection (might get covid through your eyeball) and you start to get a sense of how dehumanizing the system is to us human resources. I heard various unsubstantiated rumours (good luck finding any official numbers) throughout the pandemic that up to 60% of full-time paramedics in AHS metro regions were off on stress leave.
Whatever the real number of practitioners off on stress related leave, it was evident to our eyes that even though AHS were reporting higher numbers of employed paramedics, there were fewer AHS ambulances and paramedics on the road. Why come to a toxic workplace when you can get paid to stay home?
The Parkland Institute published a research report that articulates the problem like this:
Organized by neo-liberal styles of management and governance and facilitated by technologies of knowledge and governance, what resulted was a “command and control” style of organizing and governing EMS with hidden and not so hidden deleterious effects for paramedics and the EMS system as a whole. Based on this research, it appears such consequences have only worsened over time as paramedics increasingly appear to be treated as “cogs” or “pawns” in a never-ending game of trying to garner efficiency out of an already very “lean” system. (p.3)
Central to the consequences of this social organization is the structural violence against paramedics due to a “culture of … neglect. (P21)
When paramedics are viewed as objects instead of subjects by system logics, it makes it easier for others who are tasked with managing the system to treat paramedics as such.(p.34)
I hear from AHS metro medics about how low trust the system is. Its management by carrots and sticks and they’re all out of carrots. Management is weaponized by unhappy staff against coworkers that irritate them. Don’t like your partner report them for a plethora of policy infringements. You used your iPhone map to navigate to the call because the AHS mapping system is lagging and not user friendly? Thats 2 or 3 policy infractions, bring out the stick!
Again, structurally the system simply doesn’t have the capacity or incentive to engage in real leadership or mentorship that will solve interpersonal conflict constructively, invest in systemic change (better maps) that will eliminate the problem, increase morale and create higher trust. There is a policy and an HR algorithm that is easy to employ, doesn’t require any difficult looks in a mirror and is risk free.
An AI algorithm moves ambulances around based on calculated need (system status management) without regard to the human in the box that may desperately need to eat something or have a bathroom break. Of course there’s an algorithm for bio breaks too. Just follow the appropriate program, hope there’s no bug in the system (like a busy supervisor who can’t answer the phone) and no desperate need for you at this moment and you can get a bio-break of precisely 30 minutes before you’re plugged back into the matrix.
Even the mental health supports are formulaic. Feeling burnt out valued human? Call this 800 number and go through a checklist of algorithmic questions. Feel better now? Ready to work?
Eventually ChatGPT will be able to fully replace all the AHS managerial and HR functions and we can all look forward to peak efficiency as a cog in the machine of our new AI overlords. I, for one, welcome them!
When AHS accurately reports that they’ve increased their paramedic numbers by 11.2% between 2019 and 2022 one might be inclined to think that morale isn’t a big issue. But it’s the unreported numbers that tell a the real story. How many of those paramedics are staffing ambulances at any given time? What’s the staff turnover rate? How many of paramedics are off on medical or mental health leave? How many are quiet quitting by remaining on the staffing roster but prioritizing other jobs? How many are slow rolling through their shift? What is the experience level demographic?
The morale problem has created a situation where experienced practitioners are exiting AHS via stress leave, career change, early retirement etc which not only creates staffing shortages but also creates a younger and more inexperienced workforce with a dearth of quality mentors to support their professional growth.
And the morale problem is spilling over into contract providers.
EMS Death Throes
APFFA Vice President Elliott Davis (Firefighter/Paramedic) has been calling for change, “The Alberta Professional Fire Fighters’ & Paramedics’ Association believes in order to achieve improved ambulance response times and a community focused pre-hospital care system that prioritizes the well-being of its practitioners, a structural change to the provision of health is in order." Like all fire-medics, Davis is employed by a municipality that bleeds staff and resources out of its borders and into the big city.
Fire Departments don’t face the same morale crisis AHS does and so they pick up the system slack with their full compliment of medics. However, continued exposure to the AHS system wears on fire-medics too, and it certainly wears on municipalities who have a vested interested in ensuring good EMS delivery to their communities. Mayors, Fire Chiefs, municipal CAO’s, and private operators are all cognizant of this as they attempt to renegotiate ambulance contracts in ways that benefit their community and improve staff conditions.
Currently its not clear what benefit AHS gets out of granting municipalities what they want: reducing the amount it redeploys rural and suburban units into the city, and granting contractors more autonomy in the way they deliver service and staff units. In fact these demands fly in the face of AHS’s current government mandate to treat EMS (all healthcare) as one homogenous borderless blob rather than a population of individuals located in diverse jurisdictions with different contexts, needs and community resources.
Where does this leave negotiations? Fire Departments grow increasingly intolerant and impatient with AHS’s inability/unwillingness to meaningfully address their concerns. Being an AHS contractor means:
Inflexibility - Before AHS took over EMS in 2009, integrate Fire/EMS Services had the flexibility to adjust staffing levels and assignments dynamically to deal with surges in call volumes. If ambulance calls were surging staff would be taken off of fire trucks and more ambulances would be manned. Vice versa if a big fire event demanded more firefighters. Off-duty staff would be called in to backfill stations. This flexibility is the strength of the integrated Fire/EMS model, however it is lost with the introduction of AHS. Staff assigned to ambulances are prohibited by AHS to act as firefighters and there is no flexibility to staff more ambulances if the need arises.
Lower Staff Morale - When assigned to an ambulance, firefighter/paramedics face the same toxic environment destroying AHS paramedic morale. Fire Departments are losing staff because of this and having to deal with more mental health absences. It creates tension on shift as staff members feel punished for being assigned to the ambulance while other lucky members get assigned to fire apparatus.
Unreasonable Mandates -The Covid -19 vaccine mandate created headaches for Municipal administrators. For example if your municipality had a reasonable employee policy like ‘get vaxxed or tested’ (to give employees a choice in how they would come to work safely) it conflicted significantly with the AHS requirement for its contractors to mandate vaccines. AHS mandated that not only Fire Department ambulance personnel get vaccinated, but also that everyone in a building with those ambulances get vaccinated. Secretaries, materials management, FD dispatchers etc were all required to get vaccinated even if they were in separate parts of the building far away from paramedics with separate HVAC systems. This meant that now municipalities were forced to deal with employees who fervently did not want the vaccine and spend an incredible amount of time and energy trying to navigate a problem imposed by AHS.
Out of Area - The one compelling reason for a Fire Department to continue to do EMS, even under the conditions above, is that at the very least they can ensure that their community is being served by a high quality, experienced, well trained and supported team of paramedics who live in and are invested in those communities. However, Fire Department ambulances are often doing the majority of their calls during their shift in the city and out of their area. Why is Spruce Grove manning an ambulance with top-tier staff to do calls in Edmonton all shift?
Fire Departments are increasingly grappling with the idea that it might be best for their staff, organization and municipality to do what Airdrie Fire Department did in 2010 and drop EMS altogether. Most suburban municipalities are growing and planning new fire stations so it’s unlikely layoffs would be needed.
This would be music to the ears of many of my firefighter colleagues, who love providing EMS but can’t stand how they’re treated by AHS when assigned to an ambulance for their shift. You know theres a problem when firefighters, who run into burning buildings without hesitation, sit outside their station for 15 minutes before an ambulance shift doing mental resiliency exercises prescribed by a therapist to deal with the toxicity they’re about to confront.
Airdrie Fire still has paramedics, but they are no longer exposed to the toxic AHS system. Mind you these paramedics aren’t allowed to do much more than first aid outside of AHS oversight and approval and so it sometimes puts them in ethically sticky situations between doing what is right and doing what is legal.
If Fire Departments follow Airdrie’s lead and paramedics stopped doing EMS it would be a disaster for AHS. There is already a shortage of paramedics to replace the current staff shortage. The shortage would be catastrophic if Fire Departments pull out of contracts. The system is on its last legs.
Luckily AHS’s mandate is changing and this offers a glimmer of hope not only for municipalities but (I would argue) for AHS as well.
A Glimmer of Hope
EMS operators are held accountable for ensuring full staffing levels by AHS. A contractor could lose their contract or some of their funding if they fall short. But, AHS itself receives no withholding of funds when it regularly fails (by a large margin) to staff its full compliment of ambulances. This double standard of accountability creates a constant tension between ambulance operators and AHS. Operators not only suffer the consequences of their own failures (rightly so) but they also suffer the consequences of AHS failures by having to relocate out of their communities and into short staffed AHS zones. AHS on the other hand suffers no consequences for its own short-falls.
The hope is that with these new health reforms AHS will now be held accountable for its short-falls so that it will actually start meeting expectations the way its contracted operators do.
Allowing Failure
It isn’t clear to anyone, including the Alberta Government, exactly how EMS will look under these reforms. A committee is being formed to implement the transition and I expect they’ll be receiving a lot of input from stakeholders/lobbyists looking to tip scales in their own favour. Based on Smith’s comments though it seems clear that AHS will report to “Acute Care” starting in fall 2024 and that it will no longer be in the business of contracting out services, funding or (contractual) oversight.
This means 31 operators will hopefully be negotiating, alongside AHS, with Acute Care. Integrated (Fire/EMS) Departments will be able to make their case to the same people that AHS is making its case to. This Acute Care organization would presumably have a different mandate and philosophy that lines up more with decentralization and less with homogenous, unified, borderless blob. This also means that, presumably, AHS EMS will be held accountable for its shortcomings just like contract providers.
Imagine municipalities got what they wanted and suburban and rural EMS providers were no longer required to relocate to the city. Immediate pain would be felt in metro EMS units. It is likely that inherent weaknesses would be very apparent and very easy to identify. Currently AHS EMS is held afloat by redeploys from contracted providers. Left on its own it would fail quickly and it would quickly become apparent where the system is failing.
This is exactly what needs to happen. For too long suburban and rural services have been masking the fact that AHS EMS is DOA. It’s time to call this Code and move on to support what’s alive and salvageable.
I feel for my metro colleagues who would suffer at the hands of a top-down bureaucracy in its death throes. All the toxic ways its been treating staff to manage the unintended consequences of the toxic ways its been treating staff will no doubt ramp up…that’s all the organization knows how to do by nature of its structure. But, in the end the crisis will force AHS EMS to undertake meaningful structural reform. One would hope those changes involve some sort of decentralization into smaller more autonomous work units that allow more organizational respect and engagement of paramedics.
Concerns Moving Forward
Privatization
Day 1 of any political science class you’ll learn that it is political suicide to suggest any alternative to universal healthcare. Universal healthcare has become a core Canadian value on both sides of the political spectrum. So any suggestions of healthcare privatization strike fear into the heart of the electorate and tapping into this fear is a useful tool for UCP opposition. But, there are two separate concerns that are often conflated by Albertans concerned with “privatization”.
One concern is the legalization of healthcare; allowing paramedics to start community care paramedic services attracting willing, paying customers, or allowing physicians to start private concierge practices to private clients. The worry detractors have is that practitioners starting private practices will create a 2-tier system for the ‘haves’ and ‘have-nots’ and that practitioners will leave the public system for the private system and undermine public healthcare leaving it short-staffed. This is unlikely to happen under Danielle Smiths reform plan, not just because of her “Public Health Guarantee” but also the fact that the Canada Health Act expressly prohibits paying out of pocket for medically necessary healthcare.
This is unfortunate because most high performing OECD healthcare systems (ie Sweden) have parallel legal healthcare markets which actually seem to alleviate stress on public health and actually improve healthcare for everyone. But, detractors of private healthcare markets can rest at ease, this type of high performance freedom is still mostly illegal in Canada.
A separate concern is that private enterprises will get public funds and government contracts. The worry here is that private enterprises, with their icky profit motive, are likely to find ways to cut costs and thus provide substandard health services. This is already happening in EMS as corporations like Medavie and Associated Ambulance have contracts to provide EMS in numerous communities.
It’s not clear to me exactly why profit motivation would disqualify someone from being a good service provider. Being a public employee doesn’t exempt one from wanting to profit (aka get paid) for providing healthcare. Public unions are constantly demanding more money.
The difference between public sector organizations and private contractors is generally that contractors are more cost conscious. They have a limited budget to operate within and not operating within that budget means insolvency (personal consequences). Anyone who’s worked in the public sector knows that if you don’t spend all your budget, and maybe a bit more, you’re unlikely to be able to make a case to get more money in the next budget cycle. Budget overruns in the public sector don’t mete out the same dire consequences on the individuals in charge (often they get promotions or transfers) as do private sector overruns.
So greedy public sector managers get more money by blaming the government for not providing enough and greedy private sector managers look to cut costs. This means that the public sector is more costly to taxpayers than the private sector.
The finite amount of taxpayer dollars means hard choices for the government. There simply wasn’t enough money or resources to have AHS operate EMS in all communities so contracts were given to private services that agreed to provide those services within a budget. Those communities have EMS because of it.
No doubt those private services have more cost-effective ways of operating than AHS. The ambulances might not be as fancy, they might have more agile materials management procurement able to find deals on supplies, they might have more closely managed leave management policies and a slightly lower wage for practitioners, and they are providing a fully-staffed high-quality service to those communities none-the-less.
In fact I know a number of AHS EMS paramedics who have left AHS for those private services because they are happier workplaces. There is opportunity for engagement and creating real improvement within these services that doesn’t exist in the AHS monolith. One medic was able to start and implement a mental health program he was passionate about with very little bureaucratic resistance. They report feeling like they are part of a family as they work with the same group of people consistently rather than a revolving door of traumatized unfamiliar coworkers. This might explain why they don’t have the same staffing issues AHS has.
The only solution detractors seem to have is “more funding”. But my household already pays over $40,000/year into healthcare (the portion of our income tax that goes into healthcare), how much more should I have to pay for AHS EMS to provide coverage in my community with half its workforce getting paid to stay home because the workplace is too toxic?
More Managers
“Too many managers” has been a criticism long lobbed at AHS by conservative critics trying to explain why the system is so costly and ineffective. Now that criticism is being taken up by more left leaning critics of these reforms that see extra layers of bureaucracy being formed with the creation of 4 new organizations. But counting the number of managers might not be the best metric to judge system effectiveness.
As a thought experiment; imagine that a mega-corporation had a government protected monopoly to provide all consumer goods and services in a city. Poor service, long waits, high prices and stale bread could be explained by “too many managers, not enough workers.” But if that monopoly was broken and you now had hundreds of specialized businesses providing higher quality goods and services at lower costs you might actually have many more managers in the city than existed before. So I would argue that the number of managers isn’t the best symptom to look at when trying to diagnose and remedy an ailing system.
A better way to look at this might be “appropriate division of power”. If breaking the AHS monopoly and decentralizing its power into more specialized and localized units improves the morale problem, and empowers workers then you’ve just dramatically improved healthcare despite adding more managers.
Cost Concerns
Centralizing EMS cost a lot of money. For example centralizing EMS dispatch required building new high-tech facilities and hiring many more dispatchers to keep track of where all the ambulances in the province are and deploy them in a dynamic way in a borderless system. Meanwhile municipal Fire Department dispatch centres that had been dispatching EMS calls for years remained fully staffed and operational since processing fire calls requires a minimum number of dispatchers for safety and effectiveness. If you are a resident of one of these municipalities you’re not only paying for your Fire Department dispatchers but also new AHS dispatchers now to do the same job that was accomplished by one set of dispatchers before.
The system is loaded with these cost inefficiencies caused by the mandate of bringing all healthcare under the control of one-size-fits-all central bureaucracy. Unwinding this bureaucracy will no doubt cost money as well, how much is anyones guess. This certainly concerns me as a non-consensual funder of the healthcare system.
I don’t want to pay more than the astronomical price I’m already paying. But I know that paying a higher price for healthcare is a certainty if reforms aren’t undertaken, and I also know there is no amount of money that will cure what ails AHS. So, I’ll take my chances with these reforms. Right now taxpayers are paying for a system that traumatizes employees, we’re paying for those employees to stay home on leave, and we’re paying for casual employees to fill in for them. If the workplace improves for employees due to structural changes then it has to cost less in the long term.
Silo Integration
Breaking up AHS raises concerns about patients getting lost in a non-integrated system. Of course these issues currently exist. For example EMS regularly deals with marginal populations that have co-morbidities arising from substance abuse and mental illness. These people emerge from horrifically traumatizing childhoods and wander the streets engaging in open drug use, prostitution and other self-destructive behaviour until they have a health crisis (OD, septic infection from an untreated injury, uncontrolled diabetes etc). Then they are taken to healthcares last resort, the emergency department where they receive emergent care before they are released back to the streets to repeat the cycle.
These individuals need mental health treatment, addiction treatment, chronic health treatment but are being failed by our current ‘integrated’ system which just seems capable of treating them when they’ve arrived at deaths door. Wouldn’t it be nice if AHS was able to go to Acute Care and point the finger at how Mental Health & Addictions are failing to treat these people? Wouldn’t it be nice if there was some oversight holding Mental Health & Addictions accountable for failing individuals who end up in the ED?
It’s not clear to me how building systems of oversight and accountability can fail complex patients more than they are already being failed by the system.
Ideological Detractors
Failures of the health system are currently blamed on lack of resources and funding by those ideologically committed to our current health system structure. EMS has suffered an epidemic of “Code Reds” over the past several years with no ambulances available to respond. The solution presented to us is “more money” or “different managers”. I think it’s clear now to most Albertans that more money isn’t going to fix this problem and we’ve fired and hired enough leaders to eliminate individual leaders as the root cause. This isn’t about bad apples, it’s clearly a bad barrel.
Now that Alberta is embarking on structural changes we are likely to see these reforms blamed for inevitable short-comings. Detractors are going to be highly motivated to confirm their bias and project their fear and anxiety out onto social media as they find anecdotes of sub-optimal service delivery. The important question for the critical mind to ask as the inevitable fear-mongering begins is: compared to what?
Is this a new problem that didn’t exist before or has it always existed? Is it a bigger problem than before or are things trending in the right direction? What are the metrics of success and how do they compare now to then?
It’s important to NOT compare performance of a reformed(reforming) health system to the perfect utopia that exists in our heads, but rather to the dystopian reality that currently exists.
Final Thoughts
The devil will be in the details. My advice to those charged with restructuring the health system is to consider how the system serves healthcare workers.
Healthcare workers find joy and purpose in helping improve the health of their patients. That is why we chose this profession. Healthcare is what happens when a frontline healthcare worker interacts with a patient. Healthcare does not occur at the level of manager, executive or politician. The system MUST serve healthcare workers, or at the very least must not obstruct and demoralize them. Right now the inverse is true. Healthcare workers are there to serve the system and it’s a system that doesn’t even seem to like us.
I’m judged not by patient outcomes or patient satisfaction, but by how well I follow policy, direction and produce data for the system. Healthcare in Alberta is paying a huge price for this as healthcare workers check out.
Think of the Fire Department paramedics in Airdrie whose hands are tied and can’t treat patients to the full extent of their scope, nor transport patients to hospital when needed, because their municipality understandably washed its hands of the headache of being an AHS contractor. Multiply this by nearly every Fire Department in Alberta that employs paramedics but are limited in the service they can provide their citizens by AHS bureaucracy. Multiply this imposition of scarcity across all domains of healthcare and you start to get a sense of how dramatically and immediately healthcare capacity can be increased without provincial spending by simply letting us do what we’re good at.
The degree to which healthcare restructuring removes obstacles, allows workers meaningful opportunities to engage in their local work system, respects healthcare workers as clinical practitioners rather than cogs in a machine, allows municipalities and private organizations to implement healthcare solutions that don’t require provincial funding is the degree to which healthcare capacity and quality will be improved.
I would point out that some (many?) commercial companies have given their front-line employees more power to fix problems and customer complaints.. Customer satisfaction (and survival) should be the measure of performance.