Few voters had direct experience with hallway medicine or Canada’s world-famous wait times before the pandemic. Lockdowns have changed everything. The health policy failure went from fear-filled headlines to a tangible crisis that everyone could feel.
A failure calls for a better policy or a new policy to fill the gaps. Planners and policy writers are racing to come up with solutions: surgical centers, reallocation of funds, redesigned models of care, and more.
A new policy, however, cannot fix the old policy, unless we know why the old one failed in the first place. Most policies fail in implementation, and not because of bad design. Moreover, we can only close policy gaps if we understand why they exist. Gaps form around constraints and incentives, not a lack of creativity. The political environment dictates viable policy options.
How a system works has more to do with how it is governed than with the political ideas at play. Failure to implement, constraints and incentives all fall within the larger framework of governance. Governance and policy overlap, but they are different.
To fix health care, we must start with governance: how do we make decisions? Who can make them? If we don’t, a new policy will produce the same results.
Politics to the rescue
Take the example of surgical centers. Surgeons and specialists unite to build a non-hospital and ambulatory surgical facility. Each center offers a specific basket of specialized care, for example ophthalmological, orthopedic or endoscopy services. Surgical centers can provide comfort, convenience, quality and efficiency that hospitals struggle to match.
Surgical centers exist all over the world. They are not new. In Canada, we have been trying for decades to take care out of hospitals. We want to save money and shorten waiting lists. Why aren’t Canadian cities littered with surgical centers?
Current incentives and constraints make surgical centers impractical and expensive. Currently, hospitals provide nursing care, equipment and use of the facility. Doctors use it all but don’t pay for it, making non-hospital facilities a hard sell. On top of that, billing rules, regulation of independent healthcare facilities, licensing of necessary laboratory and imaging services, and a host of other restrictions all weave together into an environment. policy intolerant of independent institutions (funded by the state).
We don’t need a surgical center policy. We need research on why surgical centers don’t exist in the first place and what to do about it.
Thomas Sowell, American economist and author, once said, “The most important decision about every decision is who makes the decision.
Sowell developed this in his book, Knowledge and Decisions: “The most fundamental question is not what decision to make but who should make it – by what processes and under what incentives and constraints, and with what feedback mechanisms to correct the decision if it turns out to be wrong.”
Before making a change, every hospital administrator should ask themselves, “Who should be in the room?” Dramatic new politics will fail even more dramatically if you ignore governance. Informal governance may matter even more. The decision makers are often not the ones on the organizational chart: colleagues influence by personality without title or function.
Governance eats politics for breakfast
Peter Drucker, the legendary management consultant, once said, “Culture eats strategy for breakfast. We can say the same thing about health policy: governance eats politics for breakfast.
Dr. Dave Williams, former astronaut and NASA executive, served as CEO of Southlake Regional in Newmarket. He said, “We don’t know who runs the hospital.” He was making an observation, not a complaint. “Compared to what I’m used to, it’s difficult to get things done.”
Without clarity and fidelity to best practices, governance will drift. Sowell, again, summarizes this:
Even within democratic nations, the center of decision-making has moved away from the individual, the family and voluntary associations of all kinds, towards government. And in government, it has moved away from elected officials subject to voter feedback, and towards more isolated institutions of government, such as bureaucracies and the appointed judiciary.
Is this a problem in Canada? Brian Lee Crowley, CEO of the Macdonald-Laurier Institute, thinks so. Governance drift leads to a central design – a temptation for all political parties.
In his book, Gardeners and Designers: Understanding the Great Fault Line in Canadian Politics, Crowley expands on how gardeners approach governance. A gardener prepares the ground, removes waste, provides support and tends to progress. Gardeners celebrate the surprise inherent in what grows and blooms. They are not managing growth for a specific policy outcome that they have designed in advance.
Designers dream of improving healthcare. Gardeners ask the most important question: how can we grow good ideas? A gardener approach to governance leaves a lot of essential work (gardening) to government. It empowers the people closest to the problem and leaves the design, experimentation and implementation to them.
We cannot try to “fix” health care with a new policy. Without good governance, the new policy will struggle to be implemented like all old policies. We must first do the first things. Governance eats politics for breakfast.