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Never mind the evidence! An expert unpacks Alberta's unending experiment in health-care staffing

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Joshua Bergman

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 health 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.

Strangely, 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 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. 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 Bergman's reckoning, the experiment really began in Alberta with Ralph Klein's Progressive Conservative government in the early 1990s. From day one under 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, 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,” he said. 

"It became apparent that the deficit and debt issue was a smokescreen for an ideologically motivated attack on social programs,” Bergman said. "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.

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, 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 added, "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, 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 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 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 David Climenhaga's blog, AlbertaPolitics.ca.

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