Politicians Can't Fix This

I have a friend – that’s not the important part – who knows a lot more about politics than I do. I was commiserating with him one day about a newly minted Minister of Health, one who had no background or experience in administering healthcare. His perspective was that the worst thing about waking up as premier, having won the election the day before, was looking at who else in your party got elected and trying to figure out how you are going to make a Cabinet out of that!

Besides the premier, the rest of the politicians lucky enough to have won this popularity contest wake up to the glow of that but also this cloud of reality; on day one, the clock starts ticking, counting down to the next popularity contest. As the successful ones, starting on the first day after their election triumph, they know that every gesture and statement will factor in to the likelihood of them winning the next election. That will form the foundational principle of everything they do until that election is called, whenever that might be. The uncertainty of election timing means that the successful politicians must start campaigning on day one, whether they form government or opposition. The game is still afoot, just played in marginally less overt terms than when the writ actually drops.

Elections are called at least every five years, usually more frequently than that. Whether by legislation or practice, five years is the longest a government can rule without asking the public how they are doing, formally. The result is that any plan that takes longer than five years to produce braggable dividends is of limited interest the politicians making the decisions. Unfortunately, many of the solutions to our present circumstances in healthcare take longer than five years to solve. The echoes of decisions made in the 1980’s are still reverberating in our system today.

It is worth pointing out that, for most of them, “Politician” is a not a career so much as a stepping stone. Most people who run for office never get elected. The ones that do might get a couple of terms, give or take, before they move on to something else. A few are more difficult to get rid of even when we want to, but they are the minority. The result is that none of these politicians have any long term investment if they get to manage a department. This is not their vocation, this is not their career. This is just the latest step up the ziggurat of attention, a mountaintop most know they will never peak.

If a new crowd won this election, it is imperative that they change things. After all, the new crowd won the election because they convinced the electorate that the old crowd were doing things wrong (providing the old crowd didn’t do that for them). So, now they have to follow through on that by changing … things. Old political appointees, who may have had no skills transferable to the portfolio to which they had been politically appointed, must be fired and replace with different political appointees similarly unqualified.

How do you tell if a government project/announcement was purely political or only somewhat? If the new crowd out-and-out cancel the the project, it was purely political. It was something dreamed up to increase the likelihood of someone in the old crowd getting re-elected. It served no other purpose, therefore it is safe for the new crowd to get rid of it (and show the public they are doing things). If there was any merit underlying the announcement (or it is too far down the road to implementation to be cancelled), then they will have to change it in some way. Then they can tell the electorate that the project, though necessary, was so flawed in planning or implementation that, only for their intervention, it all would have gone awry. Only thanks to the wisdom of the new crowd's’ intervention was success snatched from the jaws of failure.

Characterizing running government by popularity contest may be a gross simplification of democracy, but, in the case of running a healthcare system, I will stand by it. Politicians are members of the public until and unless they get elected. Their first priority, then, is getting elected. Their second priority is getting more of their party members elected than any of the other parties. Then they need to get themselves into Cabinet. Political scientists might say that things like competency, platform or priorities have something to do with success in these efforts, to which my response would be “Donald Trump”.

You don’t need to take my word for it – like that was even a possibility – let’s look at what evidence we have. Canada implemented the Medical Care Act in 1968, so we are approaching sixty years of experience with how politicians administer healthcare. How are they doing? Perhaps the fact you are reading an instalment of “Why Can’t I Find a Family Doctor?” might answer the question at least in part.

It would be easy to pillory politicians by name; it certainly would be selfishly satisfying, but this is not the platform for personal gratification. Ultimately, it is less about the vagaries of individual politicians and more about the process that puts them in positions compromised by the fact that their skill sets may (usually?) have little to do with their work as Minister of Health. Speaking about the burden of paperwork (as we will in a later instalment), my favourite quote was that paper cuts, bad process kills.

I was speaking to the Dean of Medicine at a school that had a parking problem. New construction in the area of the medical school had compromised parking and the Dean was having trouble convincing the powers that be to do something about it. In the course of explaining it to me, the Dean said that politicians love cutting ribbons. The Dean went on to say that the press wouldn’t come to a ribbon cutting in a parking garage, hence the challenge.

Hospitals get built where politicians need votes.

I am just going to leave that up there for a moment …

Healthcare resources are located where politicians think will be most helpful when the next election is called. While it is possible to point to some decisions as having resulted from legitimately identified healthcare delivery problems that went through a process of determining the best possible solution properly implemented, the truth is resources are allocated based on political expediency more ofter than healthcare efficiency.

None of this should come as a revelation to anyone willing to give up the time to read this poor submission, and yet … why is it not a point of more focused discussion when it comes to how healthcare dollars are spent? If Canadians know their healthcare dollars are not being spent purely on the basis of need, why do we allow it to persist? Why do we not call it out? Why do we need to have large fund raising campaigns to fund necessary equipment for a publicly funded healthcare system while the money that should be so used is being spent on getting politicians re-elected?

The root cause of the problems we have in healthcare today is that the people making the decisions about managing the healthcare system usually have no knowledge about managing a healthcare system until they find themselves in the position of Minister of Health. Their primary motivation is getting re-elected and the work that they do in the position for which they are not qualified will be at least coloured by the imperative re-election is to them.

What could go wrong?