Report to Minister of Health and Community Services,
Honourable Joan Marie Aylward, on Issues of Contention Between
Burin Area Physicians and Administration, Peninsulas Health Care Corporation.
Dr. A.W. May
August 26, 1999
I. Background/Terms of Reference
In a letter dated May 21, the Minister of Health and Community Services confirmed an agreement made earlier by telephone to Afact find, facilitate and make recommendations to the Minister regarding issues of contention that have arisen between doctors and the Peninsulas Health Care Corporation in the Burin area.@
The terms of reference were (1) to gather information about the issues identified by the three parties (Board/Administration, Physician Group, Representatives of Town Councils in the Burin Region), (2) to provide an independent objective commentary on the issues, (3) to facilitate and make recommendations regarding issues resolution.
The methodology was identified as (1) site visits, (2) interviews, and (3) review of relevant reports and documents. Representatives of each of the identified groups were requested by the Minister to provide background information and identification of issues. Letters from Dr. J. Foley, Aacting as a representative of medical staff,@ and from Mr. Jerry Appleby, Mayor of the Town of Burin are attached (Attachments 1 and 2). Also attached (Attachment 3) is a letter of May 28 from Mr. Frank Crews, Board Chair of the Peninsulas Health Care Corporation. A variety of supporting documentation was provided by the Office of the Deputy Minister of Health and Community Services.
Representatives of each of the three groups were contacted by letter on June 7 (copies attached as Attachment 4). Interviews were held with every individual or group who expressed an interest in meeting with me, with the single exception of a physician on the Burin Peninsula whose schedule was unable to accommodate several different suggested meeting times.
Interviews took place in Clarenville on June 3, on the Burin Peninsula during July 5-8, and in Clarenville on July 14. Most interviews were with single individuals, with the exceptions being meetings with a group of four physicians at the Burin Peninsula Health Care Corporation, several physicians at Clarenville, the executive members of the Health Care Corporation, a meeting with the mayors and other representatives of Burin Peninsula communities, and a meeting with the Board of the Peninsulas Health Care Corporation. Individuals were assured that any commentary they made would not be attributed. Some individuals (both physicians and corporation staff) were particularly concerned about the confidentiality of the interviews - not because of any fear of repercussions from the administration of the corporation, but rather because of a concern about working relationships with certain physicians.
I made notes during these interviews and conversations. My assessment, conclusions and recommendations are based on a review of the documentation supplemented by the first-hand analysis provided as a result of the interviews.
Because of the extraordinary sensitivity of some individuals to the issue of confidentiality of interviews, I think it best not to list the names of any individuals, but to summarize, as follows:
II. Results of Interviews
All of those individuals and groups interviewed were a) unfailingly cooperative and helpful, b) genuine in the concerns expressed, and c) frustrated by the length of time various issues have been identified and studied without apparent progress or resolution. Not surprisingly, there are different perspectives on various aspects of the affairs of the corporation, and some viewpoints in diametric opposition.
It would be very difficult, if not impossible, to reflect the tenor of the conversations without providing direct quotes (though without attribution) from individual conversations. The reason is simply that there are two opposing views of the situation held within the corporation; one view by a small group of senior physicians from the Burin Peninsula, and the other by a much larger group including both physicians, and other professional staff.
The small group of senior physicians (four individuals) were interviewed together, and on that occasion they presented me with a ABurin Physician Statement@. While some other physicians had this statement in their possession during individual interviews, none took the opportunity to endorse it; neither did anybody make specific reference to it other than to the fact that it existed.
When I inquired of the CEO of the Health Care Corporation whether the ABurin Physician Statement@ was available to them, he confirmed that it was, though through an Ainformal@ route. Commentary on the issues raised in the statement was subsequently provided by the CEO.
The statement is a recounting of concerns and issues occurring over the past several years; indeed the opening statement is Aconcern regarding health care in the Burin Peninsula dates to the commencement of regionalization in 1996." In this statement, in my view, is the heart of the controversy.
Several themes emerged from the interviews, and they included 1) an overall sense of pride in the services being provided by the corporation, 2) frustration and dejection and even anger about the public controversy, 3) general acceptance of the fact of the Peninsulas Health Care Corporation, and impatience to get on with the job, 4) disapproval and frustration of the process whereby selective and distorted information fed to the media and municipal authorities places the corporation in a bad light, and 5) the lack of permanent Aon site@ administrative leadership.
The following commentary, verbatim from a variety of individuals, illustrates one or more of these points.
I would like to make particular reference to commentary which occurred in meetings with the municipal representatives and with the Peninsulas Health Care Board. The following commentary emerged from the meeting with the municipal representatives.
These statements are presented as they were made by various individuals at the meeting; they do not represent a balanced view of the actual situation, in my opinion.
I began the conversation with the Peninsulas Health Care Board by presenting a tentative analysis as follows:
Discussion of these and other related matters around the board table emphasized that this is one of the last Boards to be regionalized, and that local combinations had already occurred on the Burin Peninsula, so that there is a history of change and the difficulties that go with change. It was emphasized that the Board supports regionalization and feels that it has been making significant progress on the issues. There is also a feeling that more progress would have been made in the absence of the present controversies.
Board members identified several individuals at the centre of the problem. These are senior physicians and the Board=s view is that they disagree with regionalization although their behaviour was difficult before that.
Board members observed that there have been regular meetings with Municipal Councils/Chambers of Commerce. Some municipal authorities have decided to become involved as spokespersons for the small number of disaffected physicians. A crisis mentality has been created by doctors and mayors and this is detrimental to the overall well being of the system. Fearmongering creates serious morale problems and it will lead to problems in retention of physicians and therefore become a self-fulfilling prophecy. A small number of individuals is destroying public faith in the system. We cannot go on as at present. On the CT Scan issue and other allegations about services being downgraded in Burin, it is observed that Anothing has left Burin@ and the hospital at Burin is now as well staffed as it has ever been. Indeed, pediatric and psychiatric on site specialists have recently been added.
Ensuing discussion centred around the frustration of knowing what the problem is, but not being able to do anything about it. In response to a question from me about the motivation of individuals, the general consensus was that this was nothing more or less than a bid for power and influence, being able to call the shots to your own advantage and preservation of the status quo. Individual Board members expressed great frustration at the amount of time they have had to spend dealing with a problem which has been insoluble in spite of their best efforts, and they have reached a point where they feel that decisive action must be taken to reign in unacceptable behaviour or find a means to part company.
What emerges from all of this is essentially two stories or two general views. The first view, held by a small number of senior physicians, is that there are continuing major management, administrative, communication and like problems and that these problems have been exacerbated by the creation of the Peninsulas Health Care Corporation. Among the consequences are deterioration of working conditions, deterioration of medical services, and overall deterioration of the quality of health care on the Burin Peninsula. Both municipal authorities and media are being utilized in an attempt to drive this message home, and since nobody would be very interested in internal power struggles, the means used to drive the message home is the publication of Aincidents@ which purport to illustrate the deterioration in the system as a consequence of either amalgamation, or remoteness from Clarenville, or poor management, or some combination of all three.
The other general view, held by all but a handful of senior physicians, is that a few senior individuals are attempting to maintain power, control and personal privileges to the ultimate detriment of the system as a whole. While there is a general view that administrative process could be improved, and in particular that there should be permanent on-site managerial/administrative leadership, the system is functioning as well as or better than it ever did, that putting issues in the public domain with municipal authorities and media is unacceptable (especially when they are distorted in order to put the health care system in a bad light), and that it is time to get on with the job of building the corporation and delivering on its mandate.
As might be expected when there are two camps, or two views of the world, there is some truth on both sides, but I have come to the conclusion that the overwhelming weight of the evidence is on the side of the majority, comprising most of the physicians interviewed, other professional staff, support staff, administrators, and Board. I believe that it is a factual conclusion that a small group of physicians has not adapted and does not wish to adapt to the fact of the Peninsulas Health Care Corporation, and are actively in opposition to its ongoing implementation both within and outside the corporation. There is a significant amount of evidence for this in the documentary record, and it is certainly the preponderant view of almost all the individuals interviewed within the Health Care Corporation at all levels. Meanwhile, the ANotes From Meeting with Peninsulas Health Care Corporation@ on April 23, 1999 at a hotel in Marystown, being the record of a meeting with senior officers of the Corporation together with municipal authorities, four physicians, government representatives and Mr. Marvin Ralph as facilitator present a rather astonishing, and in my view definitive confirmation of this conclusion. (Attachment 5).
The problems in the Peninsulas Heath Care Corporation centre on the presence of several senior physicians in Burin who have not adapted to the fact of the Peninsulas Health Care Corporation. Specifically, the influence and authority they enjoyed in a smaller system has been diminished. It should be noted that these problems predated the creation of the Peninsulas Health Care Corporation, but have been amplified and exacerbated since that time by the fact that senior management is not consistently present on site. The discontent is expressed as frustration on communication, and a refusal to accept decisions which are allegedly made remotely and without consultation. Because of the inability to influence matters directly, issues have been placed in the public domain via municipal authorities and the media. In so doing, the issues have been coloured to suit the circumstances of alleged lack of communication and remote management.
There is not a uniformity of view among physicians at the hospital on these matters and a definite split between the more senior physicians and newer arrivals.
Generally speaking, the newer arrivals do not wish to take sides, are not interested in the history, have adapted well to the circumstances of their surroundings, and with different degrees of emphasis simply wish the situation to be cleared up. Some of them are particularly distressed by commentary in the public domain on their qualifications and training. Some of them allege that it has been made clear by more senior physicians that they are not needed or wanted in the hospital.
Allegations have been made in the public domain that the situation at Burin will result in departures of physicians. This may become a self-fulfilling prophecy, not because of the general allegations that are made by the senior physicians, but simply because the more recent arrivals will not accept the environment of confrontation and tension on issues in which they are not participating and have little knowledge, and will leave in order to find a more congenial working environment.
The senior physicians may continue to disagree with decisions and actions taken by senior management and the Board, but they must accept that the accountability of management is to the Board, and the accountability of the Board is to the relevant provincial authorities. They must also accept that if, after consultation, and even though they disagree very clearly with the need or wisdom to take certain actions, those in authority are nevertheless entitled to take those actions and to be accountable for them (but their accountability is not to the disaffected physicians). If any physician is unable to accept the circumstances of his employment or arrangements with the Health Care Corporation, and all avenues within the Corporation for redress have been fully utilized, it then becomes appropriate to seek employment elsewhere.
The time for decisive approaches on this issue is overdue. Given the attention by municipal authorities and the media, it is unfortunate but inevitable that such action must be undertaken in the public domain, whatever the sensitivities. The alternative is a deteriorating working environment for all employees of the Corporation, including physicians, and perceptions in the public domain that the quality of heath care is deteriorating. Newly recruited physicians will not stay under these uncomfortable circumstances, and as the word gets around it will be increasingly difficult to recruit replacements.
The situation may well have reached the point where animosities cannot be patched up and antagonistic positions cannot be reconciled. Under these circumstances decisive management action, difficult as it may be, and backed up the highest authorities in the provincial health care system, is required sooner rather than later. This cannot be done remotely. The presence of a competent and experienced individual, with full credibility inside and outside the health care system, and the full backing of more senior authorities is required on site. This could perhaps best be a temporary situation although there will be a need for a permanent managerial presence (it may be medical or non-medical) for the indefinite future. It is regrettable that these conclusions are stated in unequivocal terms, since disaffected individuals are undoubtedly convinced of the strength of their case and their position. It is, however, precisely because of this that it becomes necessary to be both clear and decisive about the response.
I should emphasize that the medical competence of all physicians in the system is unquestioned by any one of them. There are issues of personality, professional courtesy and administrative process, but not a single physician spoke ill of the competency of any other. Dedication to patients was evident in most of the interviews, both medical and non-medical. I concluded that the people of the Burin Peninsula currently enjoy a high standard of health care.
The Peninsulas Health Care Corporation is now at a turning point where the road ahead can be clearly toward an integrated system, strengthened in all its parts, with particular attention to the issues which have generated controversies on the Burin Peninsula. The alternative would be to split the corporation and allow the Burin Peninsula to go its own way. It is really difficult to find the logic in the latter view. Apart from the comment of one interviewee who said simply Aand if we were the smallest Health Care Corporation in the province, what progress would we then make?@ there is a genuine wish and a genuine will by staff and physicians generally to get on with the job of building the corporation. To newly hired individuals, e.g. new physicians, the history of amalgamation is completely irrelevant to their present circumstances. To employees who have been recruited to corporation-wide responsibilities, the imperative is to get on with their jobs.
There is an issue which is beyond my mandate, but since it forms such an important part of the most recent controversy, a brief comment is in order.
Through a combination of interviews and documentation, it became very clear that medical Aincidents@ recently amplified in the news media have resulted in badly distorted versions of events being placed in the public domain. The role of the media in giving credence to and amplifying such events is extremely problematical. For the record, it should be said in unequivocal terms that the several incidents reported in the media as evidence of deterioration in quality of health care on the Burin Peninsula fall more in the nature of fearmongering than informed commentary.
I have only two recommendations, and they flow almost automatically from the preponderance of commentary in the interviews and the growing volume of documentation which continues to describe problems but fails to address them. The recommendations are as follows: