There Is A Cancer In Healthcare

By Gerrit Van Wyk.

Little boxes all the same.

Malvina Richards wrote a song in the 1960’s about how our world’s become like little boxes of different colors, but in the end made and looking all the same. It was social commentary, but could as well have been about our Western belief in a world of machine-like boxes, all the same.

Headline news this week was that the Minister of Health of the province of British Columbia (BC) announced the province would be sending cancer patients across the border to the US for radiation treatment, because it is incapable of fully servicing its population itself. Needless to say, it created a firestorm. The opposition party deplored the crumbling state of healthcare, which is a bit rich, considering it did nothing more than play politics itself during the several years it was in power, and commentators lament the state of healthcare in Canada offering the usual ersatz solutions to it.

Healthcare in Canada has been a preventable slow-motion disaster for a long time, like the Titanic sailing into an iceberg, and we are finally reaching the point in the drama where the lifeboats are coming out and the HMS Healthcare starts breaking apart, slowly and inexorably.

If you think about it carefully, the problem is not that BC doesn’t have the capacity for offering the service itself, it is that the province is incapable of using its resources efficiently, and the question becomes why.

The first reason I would offer is, like a hidden body of a mafia hit, healthcare in Canada is incarcerated in the concrete of a bureaucracy, and like Malvina Richards’ little boxes, bureaucracies are all the same. At the top is a layer of managers believing only they know how to fix the problem, without the need to engage with people who actually work on the front lines. To the extent they do, its no more than a pat on the head.

In a second news report during the same week, a group of emergency room (ER) doctors in one of the busiest ER’s in BC released a scathing letter describing the ongoing crisis in their department. What is of concern is not their predicament, what they describe is a province-wide problem, but their claim their health authority asked them to hide this from the public, that by being socially responsible they are violating communications protocol, and, most troubling, that they resorted to do so anonymously for fear of retaliation. Like robots, they should shut up and put up. As Rudyard Kipling said, theirs is not to wonder why, theirs is just to do or die, and that’s not acceptable in a democratic society.

As to be expected, the Minister of Health responded to their letter by blaming the previous government, now the opposition, for the problem, saying the current government is doing what it can to fix things. But does it? And how?

There is an approach to problems like this one may reasonably expect to succeed 85% of the time, and likely to start showing signs of improvement in less than 12 months, but the government and its bureaucracy won’t consider something like that, which brings me to the second reason for the mess.

Jamshid Gharajedaghi said when one game makes the rules, no matter how many games you create, they are all the same kind. Little boxes. Bureaucracies are created and ossified by a worldview, or perspective of reality, that the immensely complex biological, social, and technological world of healthcare, instead is like a simple machine that can be controlled and fixed, as the Minister suggested in his response. The opposition broke the machine and we are now trying to put it together again. If, as many are suggesting, healthcare is not the machine the Minister and his bureaucracy believes in, but instead is complex, we, and the minister, have a major conundrum. More of the same is not going to help.

Complex problems cannot be solved top down by managers with cookie cutter solutions, or clever academics, consultants, and planners. None of them can see more than a fragment of the complexity I’m referring to, and that fragment is not enough. A few years ago, I had a meeting with a senior bureaucrat in a Ministry of Health about the information technology (IT) problem of that province. He listened to me politely, then explained he had a masters degree in Public Health from Harvard University, and pulled his laminated plan for the province’s IT from his drawer. In other words, he could learn nothing from a front line worker like me, and could solve the problem on his own, despite never having spent a second working there. That is the problem we are up against.

Complex problems can only be solved from the bottom up with the help of people working in the trenches, which is what the approach I’m talking about does. I’ve repeatedly seen and experienced the autocratic, or some may say totalitarian control of dialogue and bullying of front line workers in health care bureaucracies, such as is happening yet again in BC, which seek to hide their own failures from public scrutiny. My point is an openness to conversation and dialogue is a prerequisite for fixing the problems mentioned above, and the Minister must create an environment where that is possible, not blame a past that cannot be changed, muzzle dissent like in a dictatorship, or protect an inefficient monolith that prevents that from happening. We need a new, more open, and different attitude to change the future.

I believe BC has the resources to treat its population effectively, but to do so must use it very differently from what we are now, and to find out how, we must bring together many different perspectives. It is no longer enough to blame political parties for the past, blame the unions, muzzle healthcare workers, etc. To fix the problems and face the future, all the above must have the opportunity to bring in their perspectives. Instead of being part of the problem, they should become part of the solution.

The underlying problem is the politics, immense distrust, and social and psychological baggage in the way. Johan Strümpfer and Steven Lewis talk about creating an incubator outside of this swamp for incubating and trialing ideas in practice, and cascading those that work out. It requires a safe space where people can talk and experiment openly without fear. If BC’s minister of health truly wants to fix things, this would be a worthwhile initiative to invest in.

There are no guarantees within complex contexts, but what I’m talking about doesn’t require vast amounts of financial and other resources, has a track record worth looking at, and circumvents the quagmire that created the mess we are in. Would the minister be prepared to go to the cancer centers and ER’s that hit the headlines, and allow them participate in initiatives that may help them? Health workers are professionals, not infants or robots, they want their work environments to improve, they know why it is a mess, because they experience it, and they have ideas about how we can restore it to health. All we need to do is ask them.

There is a big opportunity here. Tommy Douglas and his government is remembered, wrongly, for Medicare. Their real legacy is the weakest and most defenseless against the consequences of illness in society never suffering again because they can’t afford it.

Will the government of BC and Minister of Health take this opportunity to make a real difference? What do they want their legacy to be?