Never mind the evidence! Full speed ahead! An expert unpacks Alberta’s unending experiment in health care staffing

Posted on October 28, 2016, 2:02 am
10 mins

PHOTOS: Nursing professional responsibility advisor Joshua Bergman addresses UNA’s annual general meeting in Edmonton Wednesday (Dave Cournoyer photo). Below: Conservative premier Ralph Klein, whose government began the province’s long experiment in health care staffing mixes as part of an ideologically motivated attack on social programs.

For nigh on 20 years, health care workers in Alberta and much of the rest of Canada have been subjected to a massive cost-cutting experiment at the hands of their heath system employers that is almost entirely unsupported by evidence.

To clarify, there’s plenty of evidence. It’s just that most of it shows the experiment doesn’t work, and has potentially dire consequences for patients and health care workers alike.

ralph-klein-szmurloStrangely, though, the lack of evidence doesn’t seem to matter to health care decision-makers, or to have restrained their constantly reassuring claims that all they’re doing is coming up with ways to deliver better care for less money. As a taxpayer and citizen, when you hear these promises, you have a right to be skeptical.

On Wednesday, Joshua Bergman, who is a professional responsibility advisor employed by the United Nurses of Alberta, gave a thoughtful and carefully researched talk to the union’s annual general meeting in Edmonton, in which he peeled back the history and the facts about what can only be described as an extended effort by right-wing governments and health care employers to de-skill the health care workforce.

One goal of this effort, which Mr. Bergman talked about, is to save money by using non-professional, unregulated workers to do the work of registered nurses and other professionals.

Another, which he didn’t touch on in his sober and balanced remarks, is to diminish the power of effective unions like UNA to represent their own members and to defend the rights of their members’ patients, families and everyone in society.

Now, I’ll pause here for a full-disclosure moment. I am an employee of UNA, and proud of it. Mr. Bergman, who is both a registered nurse and the holder of a masters degree in public health, is my colleague. Indeed, he occupies the office next door to mine.

Readers of this blog will know that I don’t often write about my work, but this, it seems to me, is a serious matter that deserves public scrutiny. And in a province that has been dominated for many years by market-fundamentalist political parties quite hostile to the idea of publicly delivered health care, it is a political story.

In Mr. Bergman’s reckoning, the experiment really began in Alberta with Ralph Klein’s Progressive Conservative government in the early 1990s. From Day 1 under Mr. Klein, it has been accompanied by rhetoric about the need to prevent deficits and claims current rates of spending in health care are “unsustainable.”

So the Klein Government’s deficit elimination program was touted as justification for massive cuts in health care spending that resulted in the elimination of close to 3,000 full-time registered nursing positions, Mr. Bergman observed. “But when Alberta received windfall oil and gas profits in 1994, the cuts were not reduced, new user fees were not withdrawn, nurses were not rehired nor were lost services restored.”

“It became apparent that the deficit and debt issue was a smokescreen for an ideologically motivated attack on social programs,” he stated. “The massive reduction in nursing hours created a new Alberta deficit – a deficit in nursing care that this province has never been able to recover from.”

Since then, he pointed out, the effort to dilute the number of RNs in the health care workforce and replace them “with workers who have a mix of skills in health care” has been relentless, under a dizzying array of terms so long it leads a layperson to the suspicion the goal has been to confuse the public as much as to reassure it.

Mr. Bergman mentioned the following names that have been used in this province for such schemes since the Klein era: service delivery models, care transformation initiatives, provider mix changes, scheduling optimization, rotation optimization, patient-centred care, the collaborative care model, workforce optimization, patient-first strategies, workforce transformation, scheduling transformation, CoACT, benchmarking and, lately, operational best practices. You can count on it, there are others. He asked: “How does an employee possibly keep up with this?”

What’s more, all are “used with little explanation of how they are the same or different or how they relate to each other,” he said. “Most have been very similar, but repackaged with a new name.”

“Unfortunately,” he added – and this is an important point – “a number of these changes don’t appear to be based on any obvious evidence and appear largely driven by the goal of saving money, or ‘bending the cost curve,’ as they call it now.”

Indeed, Mr. Bergman noted, quoting a well-known health care researcher, “nurse staffing is one of the few areas in health care in Canada where evidence is ignored in decision making!”

He went on: “We now have two decades of national and international research that has consistently demonstrated a clear relationship between inadequate nurse staffing and poor patient outcomes, including increases in mortality rates, hospital acquired infections including pneumonia, urinary tract infections, sepsis, pressure ulcers, upper gastrointestinal bleeding, shock and cardiac arrest, medication errors … and longer than expected hospital stays.”

So while it’s important for governments to be responsible stewards of Alberta tax dollars, Mr. Bergman observed, “this approach must be balanced with evidence and the obligation to promote and protect the health of Albertans.”

If this isn’t done, he warned, it “truly becomes an experiment that may put the health of Albertans at risk.” This is a pretty diplomatic way to put it, if you ask me.

Meanwhile, the claim something must be done because health care costs keep growing and the system is “unsustainable” also continues to this day.

But as Mr. Bergman pointed out, just as the evidence suggests operational best practices and its many confusingly named siblings result in lower quality health care and worse outcomes, the evidence costs are unsustainable doesn’t hold up either.

In fact, he said, right now, health-spending growth is not keeping pace with inflation and population across Canada. “Since 2011, health spending in Canada has decreased by an average 0.6 per cent a year,” he noted. “Between 2011 and 2015, the health-to-GDP ratio has declined from 11.6 per cent to an estimated 10.9 per cent.”

“The continued claim that Alberta has the highest per capita spending on health care in Canada also isn’t true” he continued. “Alberta ranks fourth among all provinces and territories for per capita spending in 2015, and had the second lowest growth in per capita spending growth in Canada in 2015 at just 0.1 per cent.”

But lack of evidence has not stopped the “insidious and elusive” stream of “short-sighted cost-savings measures” in Alberta care facilities that runs counter to “the mountain of peer-reviewed evidence on the relationship between RN staffing and patient, staff, and organizational outcomes.”

Even with a government in Alberta firmly committed to preserving public health care, these ideas continue to emerge from the health care system.

Well, we can only confront them if we understand what’s actually going on, so it’s helpful for those of us concerned about health care policy to keep in mind an old adage mentioned by Mr. Bergman: “You can wrap an old fish in a piece of paper and call it change, but it’s still gonna stink!”

This post also appears on Rabble.ca.

6 Comments to: Never mind the evidence! Full speed ahead! An expert unpacks Alberta’s unending experiment in health care staffing

  1. Dave

    October 28th, 2016

    In Saskatchewan in the early 1990s, the government amalgamated several union hospitals into new regional health boards. The goal of the exercise was to reduce administrative costs. To do that the administrators of the several amalgamated boards were put in charge of planning the transition. The outcome was that all administrators kept a job on the newly amalgamated operation but many nursing positions were eliminated. At the same time the government closed several hospitals in small town Saskatchewan.

    So much for administrative efficiencies.

    In defense of the closing of these small hospitals it must be stated that many of them couldn’t attract a doctor to practise in the area. Additionally the hospitals were no longer effective in handling acute care patients and most people who were in need of health care went straight to the larger centres in recognition of that so that wasn’t entirely a bad change.

    Reply
    • Dick

      October 28th, 2016

      Please save my surgery from you and yours.

      Reply
  2. Sassy

    October 28th, 2016

    Yes, this is all so true. Today, a private assisted living facility (level 4 care housing around 80 residents) has only two RNs on staff. They rotate and only work office hours. In the public long-term care facility I’m most familiar with, the number of RNs might be around four. Low-paid, mostly immigrant LPNs and aides do almost all the care and the few RNs are relegated to administering medication and performing some management duties. Long gone are the days experienced RNs staffed these types of facilities. It’s so sad…. The NDP needs to turn this around next term.

    Reply
  3. anon

    October 29th, 2016

    Hospitals and health care in general are a service, so a business model just produces the stupid results we got from the Cons: very expensive equipment and high status wards like cardiac care were puffed up beyond need while operating rooms were shut down and patient care fell because of a lack of RNs.

    A good example is diagnostic imaging. It was outsourced and the result is very much higher costs and the same physician requisitions now generate almost trivial reports compared to the gold standard we had before out-sourcing.

    Throw out the business adminstrators and put the docs and nurses back in charge. The MBA types are simply parasites.

    Reply
  4. Nathan

    October 31st, 2016

    Maybe it’s not the money we spend on healthcare, but how we spend it. In my small town, we spend it on a staff of half time nurses at Public Health (one full time nurse in the lot) who all pull full benefits, etc. We spend it on nurses who have no right to be nurses with the way they treat elderly patients and the infirm. And then you file a complaint that goes nowhere because everyone is afraid of the union. They protect their members rights all the way to protecting them from disciplinary action from abuse of patients. This is not heresay, I have lived it firsthand with an elderly relative. I am all for more RNs, but not for the union that protects the worst of the bunch.

    Reply
  5. Buzz Bolenko

    October 31st, 2016

    Unions in Alberta are required BY LAW to represent their members as effectively as they can. Nathan’s complaint seems to be that the nurses’ union is good at its job. If unions fail to represent a member competently, they can be sued by the member. Labour relations throughout Canada are organized on the principle of an adversarial system, as are the courts. Nathan should ask himself if he thinks people accused of criminal offences should not have the right to be represented by a lawyer. The principle is exactly the same. Without the protection of a union – the effectiveness of which is often exaggerated by people like Nathan who don’t understand how the system works – many employees who are disciplined or dismissed would use the courts to sue their employer to ensure their right to due process. The costs to society would be larger but the results would be tilted in favour of employees who could afford legal assistance. Any employer with a unionized workforce can fire an employee with cause as long as there is due process. All the union can do is ensure that due process is carried out. If the employer was not able to fire the nurse referred to by Nathan, then it was either the employer failed in its job properly to make the case or because there was no case and the union proved it.

    Reply

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