"What should be simple is unnecessarily complex..."

Chair of the Health PEI board, Derek Key, delivered an address at the Health PEI Annual General Meeting last night that highlighted, with eloquence and precision, jurisdictional quagmires that are holding back the efficient delivery of health care on the Island.

In his introduction:

Health PEI was created 12 years ago as an arms-length Crown corporation responsible for the operation and delivery of publicly funded health care within the province. As chair of the board for the last two years, I can share with you, of course, that the board has not always been as successful as it should be; most importantly it’s important that we all understand that Health PEI is not actually an arm’s length Crown corporation; in fact there are many areas where Health PEI has no authority at all in the operation, or the delivery, of publicly funded health care services in the province.

Later in his address he elaborated:

Our other notable failure is jurisdiction.

If we remember what the Health Services Act says about Health PEI being an arms-length Crown corporation, responsible for the operation and delivery of publicly funded Health care services, there are questions that should arise in each of our minds such as:

Why doesn’t Health PEI recruit more people to address the shortages that exist today and more importantly the shortages that we know will exist tomorrow. Well the answer is simple: Health PEI has nothing to do with recruitment. Recruitment’s handled by the Department of Health, and I’m told that there’s a long history as to why that exists, but it doesn’t change the fact that it’s a significant jurisdictional impediment.

Second question: when qualified applicants approach Health PEI, why are these nurse practitioners or nurses or lab techs not hired? Again Health PEI is not responsible for hiring: the Public Service Commission is responsible for hiring, so the fact that it takes months between deciding that a position should be posted, or that there’s a need within Health PEI, and actually filling the position is a serious impediment, and unfortunately, given the barriers that exist, it takes far too long to complete a hiring process for someone who’s seeking a job at Health PEI.

Third question: why is it taking so long for Health PEI to construct the community health centers that were promised by government so long ago? The Department of Transportation and Energy is responsible for the planning design and construction of all physical structures, so while it took 14 months to construct the Empire State Building, a hundred and however many years ago, it takes longer than that to create a plan and a design for a community health center in Prince Edward Island. That’s fundamentally wrong from where I come from.

Fourth question: why are the work schedules for nurses and other practitioners within hospitals and long-term care facilities still being completed so inefficiently on paper and in scribblers; scheduling and call-out software has been a priority of Health PEI for years. We also have no learning management system technology, that ensures that our employees have the training to do their job safely and efficiently. In fact we do not even have a Health PEI intranet that allows for internal employee communications. All of our technology needs fall under the responsibility of ITSS, and given their responsibilities, in fairness, throughout the government structure, legitimately, the needs of Health PEI are not always the first priority. But that doesn’t change the fact that those are critical elements that are outside the control of Health PEI, and they lead to significant problems in the delivery of health care services.

And my final obvious question, that I’m sure is in all of our minds: how about addressing the scope limitations the pharmacists and nurse practitioners? If there is low-hanging fruit that exists that would allow better, quicker, more accessible health care delivery for many day-to-day needs, would be in expanding the scope of pharmacists and health care practitioners to a level at least comparable with other provinces. Again, Health PEI, as an independent Crown corporation, has no authority over that; instead that requires legislative attention and the necessary cooperation to make the changes that are required to improve health care delivery in Prince Edward Island.

So, in short, while the legislation contemplated creating an arms-length Crown corporation responsible for the operation and delivery of publicly funded health care services in Prince Edward Island, in reality what was created was an entity that necessarily must cooperate, and collaborate, with the Departments of Health, Public Service Commission, Transportation and Energy, ITSS, Treasury Board, and of course the Legislative Assembly, for everything from recruitment, to hiring, to facilities, to technology, to scope a practice for our professionals.

What should be simple is unnecessarily complex, and in many instances outside the jurisdiction of Health PEI.

None of these are new issues, and they are not issues unique to Health PEI: the decade I worked closely with the provincial government, the notion of centralization vs. decentralization was not far from discussion of any issue.

Should there be one website for the Province, or should each department have its own?

Should every department have dedicated IT staff, or should IT staff be centralized and doled out to departments as needed?

The centralizers, in recent generations, have won the day, and through government you will find centralized structures for IT, communications, infrastructure, hiring: those that Key outlines that serve the healthcare system in addition to all other public bodies.

Temperamentally I am a decentralizer: I have structured my work life to allow me end-to-end control over all the systems that touch on my role, from server specification on up. There is nothing I find more confounding than having to submit a ticket to have someone somewhere do something, on their schedule, that’s a bottleneck to me doing something quickly and efficiently.

I’m equally mindful of the issues with scale this introduces: there is only one me.

The same tensions exist in systems planning for government: it’s great when Jimmy is the dedicated IT technician for the Bark Inspection Division, but what happens when Jimmy goes on vacation?

In theory it makes sense, for all manner of reasons—efficiency, cross-training, scaling, being a few—to centralize government services, to have one entity for HR, one for building buildings, one for managing computers. And in a situation of abundance and plentiful skilled leadership, in practice this can work well and smoothly.

But it rarely does, or at least it’s rarely perceived to work, and the clients—the line departments and crown corporations and agencies—are frequently vocal about this. Centralization might make sense, they argue, but not for them, as they serve a special and important function that requires dedicated attention. This is often not the case, and is simply frustration with having to wait, as scarce resources require deliberate triage, and not every project can receive attention first.

Key makes a cogent argument, however, that health care delivery actually is a special and important function, and does require dedicated attention, and I tend to agree with him. Health care delivery is complicated, and demands focused resources working in unison, not disparate teams stumbling to cooperate. Health PEI, now more than ever in the hands of a competent, focused board, and an experienced and skilled senior leadership team, should be unshackled, and empowered to recruit and hire staff, build its facilities, and manage its own IT systems, and to guide scope of practice regulations. It should, in other words, be empowered to carry out its mandated responsibility for “the operation and delivery of publicly funded health care within the province.”