Consent

 The guiding vision, guiding principle of Canadians’ healthcare system is that it must consent to provide services we require. 

“We will not permit our healthcare system to be overwhelmed. We must not and we will not force our doctors and nurses to decide who gets care and who doesn’t,” Kenney said during a televised address on Tuesday, May 4, 2021.

https://www.theguardian.com/world/2021/may/06/canada-alberta-pandemic-north-america-coronavirus-covid 

The sentiments Mr. Kenney presented us in those two sentences have been commonly expressed by people engaged in healthcare provision, especially in public health.  

We have a provider-driven healthcare model in Canada as, I believe, have people in other countries.  We have two examples common to nearly every healthcare service event: 1.  consent - to provide service must be agreed to by the prospective patient recipient; 2.  rationing - healthcare is rationed out based on triage, queues, accessibility, ready capacities, and some cases, ability to pay. 

Our system is designed, structured, simply generally organised, by healthcare providers to meet the visions and purposes they define.  These providers include delivery administrators, finance executives and medical services personnel.  This system has certainly evolved over the centuries, but its basic premise has always been the same, its existence is provider-driven.

How else do we know this?  The current pandemic has driven the point home, to wit the above quote.  “We will not permit our healthcare system to be overwhelmed.”  It seems to me it was overwhelmed from the moment we realised a deadly pandemic was upon us.  A great many healthcare services were immediately facing postponement because the system simply did not have extra capacity to meet current needs and the new demand.  It is not simply a matter of lacking capacity for COVID-19 patients, it is all patients taken together.  Those decisions were not made by us, the people as source of demand for healthcare.  

“We must not and we will not force our doctors and nurses to decide who gets care and who doesn’t.”  Those decisions were being made immediately we knew the pandemic was upon us.  It’s just that those decisions were not made by front line healthcare staff, but by backroom administrators.  We go back again to the postponement of procedures indefinitely.  As well, these decisions were not made by us, the people as source of demand for healthcare.   

The pre-pandemic decisions to set the capacity of our healthcare system was likewise made by backroom administrators.  In this writer’s experience, almost to a person, front line providers want to see all prospective patients get the care they need immediately when the healthcare system has determined their need.  As well, these decisions were not made by us, the people as source of demand for healthcare. 

Imagine healthcare capacity decisions being made solely on the basis of people’s needs.  We need to revisit the statement, “We will not permit our healthcare system to be overwhelmed.” and ask, “Why not?”  What is the primary reason we cannot have our healthcare system overwhelmed?  Seeing as we the people own our healthcare system for the specific purpose of preventing and remedying losing of any part of our life to physical, mental, emotional anguish and premature death.  Period. 

Our chosen model of governance for our society is democracy, where each of us has an equal privilege and responsibility in how we govern ourselves as a society.  This means every one of us is due the healthcare each of us needs immediately upon diagnosis.  Imagine no queues for needed services.  Imagine people self-managing their care with the collaboration of those teams, all the time, every time.  That means we will have moments when some parts of our healthcare system will not be directly engaged in a health service event.  This is not evidence of an inefficient system.  This is evidence of a system effective in meeting needs as they arise. 

Epidemiologists and our own experiences seeking healthcare tell us the need for any specific service fluctuates day-by-day, even throughout the day.  It also fluctuates seasonally which may have season-driven cause such as is the case with seasonal influenza.  Needs for services for accidental injury, for mental and emotional health are sometimes seasonal and sometimes seemingly random.  The point is there is fluctuation.  There are moments when the system is fully engaged and moments when it is not fully engaged.  But we have worked diligently to ever avoid moments of it being overtaxed.

Now a new form of infection shows up and it probably will not be felt as a pandemic immediately.  It will be felt as one or two or a few individuals presenting with the new infection.  Even if countrywide it is more than that, community by community it will likely begin with a few cases.  In other words, probably manageable in the normal course of healthcare events. 

Let’s think of healthcare like fire department services, we all hope the fire truck never has to leave the station except to contribute its sirens and flash to celebratory parades.  However, should we have a fire, it is wonderful to have that highly trained, well equipped fire service.  Our homes and businesses depend on it.  More importantly, our lives depend on it!  Sorta like we depend on healthcare services. 

To avoid queues for fire service, we make certain we have enough resources, enough capacity to meet even those really bad fire situations.  We can’t have homes and businesses queuing up for fire men and women with their equipment.  

To avoid queues for healthcare services we must decide that human life is not simply binary, life or no life.  We must decide that time spent with life controlled by disease or injury is time without life, without the quality of life we expect, without sense of self.  That level of resources, that level of capacity will mean not all time is spent in direct patient contact.  We must accept that as a cost of doing business, so to speak.  

To me, queues are clear evidence of a healthcare system stretched beyond its limit.  Accidents and force majeure events almost always push the system over its designed limit as reflected in personnel overtime and burnout, supply shortages including bed shortages and ambulance delays and redirecting.  

Given all that, when we are hit by an emerging pandemic, we find ourselves in a mess, to wit our situation in the current  COVID-19 pandemic.   

We must be prepared at all times.  It can be done when we decide it must be done and we then do it.  We must not simply think out of the box, we must design and deliver an entirely new box.  To do so, we must engage Canadians individually.  We have examples that we know how to do this.  We have  Canadians engaged one-by-one for defined  purposes through healthcare providers, health charities, federal, provincial, territorial health departments, researchers, epidemiologists and other risk assessors, policy makers at all levels.  We must accept that this initiative is almost certain to require we change healthcare delivery models, health funding, education for ourselves and our highly qualified healthcare personnel, even the way we Canadians and our healthcare personnel communicate with each other in everyday activities as well as moments of health crises.   

We must use the perspective afforded us by the people-driven vision leading the design and delivery of our healthcare system.  Our current provider-driven vision leading the design and delivery of our healthcare system causes premature deaths.

We must act to create and implement our healthcare system as though our lives depend on it.  

“In healthcare, efficiency kills, effectiveness saves.”  

Michael G Klein May 9, 2021 - Calgary, Alberta, Canada

Budgets in Public Enterprise

Imagine a world where public enterprise, ie government, constantly consulted we the people to determine our needs and how effectively those needs are being met by both private and public enterprise.  For each of these needs to be met, we require application of various resources.  Each of those resources bears a cost that can be measured in monetary value.  This will result in two required expenditures, capital expenses and operating expenses.  Capital expenses might be defined as future expenses as the resulting capital resources are used up in delivery of service beyond the current fiscal year.  Operating expenses represent resources used up during the current fiscal year.

Seems pretty straightforward.

Now as a democratic society we the people elect, or hire, people to manage the accumulation and delivery of resources.  This accumulation will almost certainly entail taxation of ourselves.  It might also include monetary assets that creation bestowed upon us, some of which are re-bestowed perhaps annually, some of which are used up then are gone forever. 

Okay, this is a broad picture of our situation. 

Some electees will be more capable, as in more effective, than others and that’s why we have elections.  No matter who the electees are we have a right to expect a careful identification and measure of need and a careful application, budgeting, of resources to meet that need.  The resources will be a combination of items - buildings, tools and the like, and human capacity in the form of trained and knowledgeable folks.

We always expect effectiveness, the needs must be met or there is no point in the expenditure of resources at all.  Efficiency is therefore not simply a measure of cost, it is a measure of cost while successfully and responsibly meeting needs.  Greater efficiency is achieved by using fewer resources while continuing to adequately meet need.  Greater efficiency is not achieved by simply using fewer resources. 

When both the determination of need and the determination of application of resources to meet that need are done transparently to we the people, we can then make knowledgeable decisions about both the urgency of the need and our electoral choice in whom we wish to govern the application of resources.

When these determinations are not made transparently, we are left guessing what’s going on.  Then we can only infer through past association with the electees whether the stories they tell about both the character and size of need and the application of resources to meet it, that the process of making these determinations have been made in some manner we can judge to be satisfactory. 

If the electees one day announce that steadily fewer and fewer resources, per person, are required to meet need, we really need to see and understand how that determination was made.  If that’s not forthcoming we must wonder if some other agenda than ours is at play. 

Why so?  Well if fewer resources are budgeted for, that must mean someone has found a way to deliver the required service more efficiently, of course while continuing to be effective.  The alternative must be that the electees have decided to not meet our needs effectively.

If less human capacity, ie fewer people, is budgeted for, that must mean those people work with a new delivery model that enables them to serve more people within the same human hours.  Thus some part of the management of the service of human capacity will be able to explain and describe the details of those improvements. 

In both cases without these analyses being available to we the people, we might suspect the resources of things were not being applied effectively with a portion being wasted.  We might also suspect the human capacity was over delivering.  If that cannot be demonstrated clearly, then what was the purpose of the reduction in application of resources of things and human capacity?

Perhaps our electees have decided that we the people do not understand our own needs and are overstating those needs.  Yet we know only each of us can define what quality we expect for our respective lives.  Not only that, a team of dedicated researchers at McGill conclusively proved this is so.  Thus to reduce our access to the resources before our needs are met is the exact opposite of effective government. 

We the people require a needs determination infrastructure that we can use to express our needs as they arise.  We require this infrastructure as it can enable us to hold people accountable, including ourselves, as we determine the degree of success achieved in meeting our needs.  Needs will then be transparently defined, leaving no one out, while clearly and understandably presenting those needs to all those who would wish to help us meet them.

We then require effective needs meeting service to be enabled and delivered and to have that done efficiently.  We need to identify and describe organisation and structure of service delivery to determine when agendas other than our own are being served. 

In conclusion, we must get real and voice our needs for politicians and others to meaningfully respond.  Then we must have our politicians get real, listen to us and serve our respective needs agendas, no one else’s.

Mike Klein December 9, 2019