Privatization is Not the Solution to Problems in Our Healthcare System, Healthcare Leadership Is
If you are working in the healthcare industry, have had a loved one go through the health system, or have just been reading the news over the last few years – especially during the pandemic – you probably all have the same opinion: Canada’s healthcare system needs to change.
As described in a recent Globe and Mail article, the real problem lies with primary, acute and long-term care, all of which are failing. However, the answer is not about increasing private-sector delivery of publicly funded care. That already happens. All of Canada’s publicly funded care is privately delivered. Doctors are independent contractors and hospitals each have their own board and make their own decisions, albeit decisions are guided by how public funds are distributed.
Some argue that the solution is fixing the care that we provide to marginalized patients across the country: This is a crisis that has been exacerbated by the pandemic. Not to mention the nursing shortage and the burnout experienced by overextended and underpaid nurses and personal support workers.
But why do we see the solution to a failing health system as privatization? To be clear, when pundits talk about privatization here, we assume that they mean privately funded, i.e. a for-profit system. There are countless examples of public health systems creating a two-tier system and producing worse outcomes. As described by Andrew Boozary (MD, MS, MPP, CCFP): “In 2016, Saskatchewan attempted to reduce its MRI wait times with a pilot initiative that offered privately provided MRIs for those willing to pay. The pilot backfired. Instead of becoming shorter, MRI wait times increased. ... Study after study has outlined the alarming discrepancies in death rates and health outcomes between public and private long-term care and retirement homes during the early waves of the pandemic.” Then there is the mixed public–private funding and provision example that had a deleterious effect on the Australian hospital system.
Instead of scrapping medicare and taking the dangerous and inequitable path of charging people money to save their lives and take care of their health, we should reform our current system. (Andrew Boozary)
Some argue that in the best health systems in the world, the private sector has some role to play, leading many to believe that we need a US-type health system. But if the best example of a private health system is in the US, and for which its health system ranks dead last out of 11 commonwealth countries, why does Canada turn to this model as the solution? Canada currently ranks 10th, which begs the question: Why not look at the similarities between the US and Canadian health systems to determine what makes them rank last?
Obviously, there are many moving parts, one of them being how physicians are paid. We can talk at length about how fee-for service hinders accountability, but there are other transformative changes that would need to happen before that. Finding the ideal model of care for a given health problem takes creativity, a little experimentation and time. The right environment allows for this. Few hospitals in Canada possess the right environment. The main reasons for this are that hospitals do not understand strategy, management and innovation.
Hospitals do not understand strategy
Shouldice Hospital in Markham, ON, is seen as one of the most innovative private hospitals in Canada. Is it because it is private or because they specialized in a service?
When you have a hospital specializing in a certain procedure with private delivery (just as almost every general practice in Canada is via private delivery) and public pay, costs are contained, service is exceptional and the outcomes are amazing. Isn’t that what we really want?
Instead, we have public hospitals trying to do it all from MRIs to heart transplants to diabetes management. Hospitals include safe buzz words such as innovation, diversity and “delivering tomorrow’s care” in their strategic plans that gives them the security of not having to commit to anything and enables a do-it-all strategy. But strategy is about making choices.
Hospitals do not understand management
Hospitals unfortunately still operate like the industrial era organizations: top-down, hierarchical and needing to follow a chain of command. The private sector is seen as more innovative not because they are private, but because health technology companies today have adopted 21st-century management models that empower employees and promote creativity and experimentation.
In a previous article, I talked about the importance of coaching as a management style to get the most of your employees. But in order to create an environment that facilitates innovative models of care, employees need to feel safe enough to bring up ideas and make mistakes. Most managers in healthcare, however, fail to create an environment with enough psychological safety.
Creating psychological safety requires managers to actively listen, be empathetic, be vulnerable and have enough self awareness to know when they do not have these qualities. Unfortunately, all too often, senior leaders are swamped with the amount of work, covering a portfolio designated for multiple positions. Thus, they cannot fully take the time to listen, empathize with and coach their teams. Furthermore, proper management training is almost non-existent in hospitals or clinics, leaving managers to lead teams the way that they know best, i.e., the way they were managed.
Furthermore, hospitals need to, perhaps, step away from hierarchical models to organizational design. Complex problems are not solved through healthcare hierarchies. Agile networks are needed. Having multiple layers of middle management between the front-line staff and decision-making executives affect the rate at which change can be implemented.
A 2017 meta-analysis showed that transformational leadership, which is associated with flatter hierarchies, was positively related to “effective nursing unit organisation culture” and led to lower patient mortality rates and higher patient satisfaction.
Hospitals do not understand innovation
For hospital staff to take full advantage of their potential to spark innovation, they must think outside stricter definitions of the term. Hospitals often mistake innovation for process or quality improvement. These improvements are far from the transformational changes needed to put a dent in health outcomes.
Those tasked with innovation in healthcare delivery have historically not been responsible for direct patient treatment. Through my experience, I have witnessed that the most “innovative” ideas are suggested from the top. Ideas from front-line staff – those who are the most intimate with the problems – are either ignored or lost moving upward though the chain of command.
When Hacking Health helped organize a Design Jam in 2014 at CHU Sainte-Justine Hospital in Montreal, QC, nurses and allied health staff were invited to participate in the development of ideas to many of the problems that they had in the hospital. This event led to the creation of 34 innovative projects some of which have already been implemented. The chief executive officer (CEO) was so impressed by the outcome that the hospital developed a deployment program for innovative projects. The program is now managed full-time by one of the hospital’s hackathon participants.
Looking toward the future
Hospitals are one of the few sectors that are still stuck in the 19th century in terms of processes and leadership. This is not because we do not have the technology or the right ideas. Yet we talk about privatization as the solution to fixing our problems. Studies show that this is not the direction in which to go. However, this does not mean that we cannot learn and shamelessly steal a few lessons from the private sector as to what makes some examples great.
The private sector understands strategy better. They are able to leverage their strengths and focus on what makes them different. The private sector has also found new ways to manage the next generation of employees. Thanks to ideas about leadership from innovative companies such as Google, Adobe, Facebook and IBM, the private sector simply facilitates the right environment for innovation. Lastly, the private sector understands that to truly excel, innovation cannot simply be a small evolution; it needs to be a revolution, a new way of thinking. And what better way to source these ideas, but from the ones that are closest to the work.
All of the issues within our health system stem from archaic leadership mindset at the top. To truly change our health system, we need radical and courageous thinkers (read: rebels) who will be able to challenge traditional ways of doing things. The private healthcare start-ups understand this, and this may be the reason why we think this is the direction in which we need to go.
The issue is not that we need to privatize. The issue is that hospital boards and CEOs need to reconsider the qualities and mindset we need in a senior leader for the future of health.
About the Author(s)
Nicolas Piperno, MSc, MBA, PMP, is a healthcare consultant who has worked with numerous hospitals across Ontario. His most recent work was as interim director of Strategy and Improvement at Grand River Hospital in Kitchener, ON. Nicolas is also the Toronto Chapter leader for Hacking Health, a global movement that catalyzes healthcare innovation by pairing innovators with healthcare experts to build solutions for front-line healthcare problems through the use of emerging technology. He can be reached by email at email@example.com.
Elaine Rose wrote:
Posted 2023/08/29 at 09:48 PM EDT
I enjoyed your article. Most likely because you are stating what I have been saying for years. "Hospitals ... operate like the industrial era organization: top-down, hierarchical and needing to follow a chain of command" is a concept I addressed in my doctoral thesis in 2015. The concept wasn't new then, but no one has picked up on this. Hopefully, the more we share these ideas the greater our chance of someone hearing. People often seem to believe the lies and misinformation easier than the truth. If someone hears something often enough they will start to believe it is true - so let's start telling the truth, the journey to belief should be shorter.
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