Introducing “The Centre Cannot Hold" Summer Series

This is the episode that sets the stage. In 2024, Kelly Lamrock — New Brunswick's Child, Youth and Seniors' Advocate — released a report that asks a question most of us have been afraid to ask: what if the problem isn't the people in our systems, and it isn't the money, but the governance model itself? 

This series is built on that report, and this episode explains why it matters far beyond New Brunswick.

How it All Broke Report

Kelly Lamrock Interview

How It All Broke Videos

The Second Coming (Poem)

Meet the Advocate

Transcript

SPEAKER_01 0:11

Hi there, welcome to Shift. So I'm not a big fan of poetry, but there is one I came across randomly somewhere along my life called The Second Coming by W. B. Yates. He wrote it in 1919 in the aftermath of the First World War, in the early days of the Irish War of Independence. The world as he knew it was unraveling, and he was trying to find the words to describe what it felt like. The whole poem is actually really good as far as poems go. But I've always remembered this line Things fall apart, the center cannot hold. That phrase comes to me often when I think about healthcare in Canada right now. Not because there's full-on anarchy or complete breakdown. There isn't. There are extraordinary people showing up every day doing their best and holding things together through sheer force of will and professional commitment. But the center, the architecture underneath everything, is not holding. And it hasn't been for a long time. Some people are starting to recognize this. Some places are starting to change, but the changes being proposed are often not big enough or bold enough to bring true transformational change. I think Aaron Beckwell described it in a previous episode. What we're doing is like moving deck chairs around on the Titanic while it sinks. It's a great metaphor, and this is what it's felt like for decades in healthcare, minus the guy playing the violin. So I decided to really dig into this idea of structures that hold our system in place. And the way I decided to do this was a focus summer series. As someone who's worked in the space of healthcare improvement for almost two decades, I continue to see these structures defeat so many of our efforts. Sometimes these structures are invisible to the people trying to change the system, but often they are seen and ignored because they feel too big to take on and change. Earlier this summer, I was listening to a new podcast called Health Policy Offscript, which I highly recommend, where three respected health system policy analysts, Stephen Lewis, Dale McMurchie, and Ivy Burgo, talk about health system policy levers that could be pulled to affect change. In one of their episodes, Stephen Lewis spoke to Kelly Lamrock, who wrote one of the best reports I've ever read, focused on what we don't often talk about, how governments themselves hold our systems back from change. Their report was called How It All Broke: Fixing How Government Manages Social Policy in New Brunswick. Kelly Lamrock serves as the Child Youth and Seniors Advocate in New Brunswick, an independent officer of the legislature. His job is to watch out for vulnerable people and tell the truth and the system fails them. He released this report in 2024, and although the report focuses on New Brunswick, I know for sure that these are the same issues in every province across the country. Because while the examples in his report are local, the structural diagnosis belongs to all of us. He's describing the governance assumptions that all of our provinces share. How they plan or don't plan, how they budget for things or don't budget for things, how they measure results or don't measure results, and how they decide what gets funded and what doesn't get funded. He is describing with remarkable precision why reform keeps failing. Not any one reform, not in any one province, but why reform as a concept. The idea that government can learn and adapt and build systems that actually work for people keeps running into the same walls over and over again. Over these six episodes, we're going to walk through the report together. I'm going to read you Lamrock's words with some minor adaptation, and I'm going to try to weave in examples because I want you to connect what Mr. Lamrock is saying to how we experience the system as citizens. So let's start with how Mr. Lamrock frames the report. He says, it's important to remember the strengths of our public system. After all, every single day, thousands of people who rely on our system of care and support have great experiences. Every day, thousands of highly trained staff provide care in schools, daycares, nursing homes, youth centers, and hospitals. We have great training programs with many qualified instructors. Many care facilities have governing boards staffed with dedicated leaders and volunteers who care deeply about their work. Many community organizations have employees and volunteers who work tirelessly to provide the support to people who need it. Our public services are a huge reason why Canada is a great place to live. It's because, unlike our neighbors to the south, we try to marry freedom with a strong social safety net that provides stability, equality of opportunity, and protection from terrible situations that can happen to any one of us at any time. If we consider all of these reasons why we are fortunate to live in Canada, the predictability and reliability of services is a major one. There are countries, and I have lived in them, where you can't be sure if an ambulance will come if you need it, if the hospital will have the supplies in the cupboards, and in one country I lived in, you weren't even sure if there would be money in the ATM when you needed cash. Canada should never be like this. When citizens begin to worry that services will not be there or they can't get access to the services they need, trust in public services breaks down and everyone starts looking out for themselves. Paying for private care, traveling to other countries, because we think our public system can't offer the quality of care we expect. It's a dangerous story that can begin small and grow quickly. We can already see this happening in Alberta where doctors may soon be allowed to charge privately for the services they offer, just for those who can pay. It's a direct assault to the core values and principles of our Medicare system. But I can also see why things like this are starting to happen. In too many places today, emergency departments can't meet the needs of patients in a timely way, schools are struggling to meet the increasing complexity of learning needs, childcare spaces are being cut, and on and on. There's just this sense that public services are breaking down all around us. But why? It's because it all comes from the same root cause, the same failed assumptions of government, finally hitting all the big social ministries at once. You could chalk it up to incompetent leadership, and to be fair I often do, but you can't tell me that everyone in all of these departments, health, education, social services, are incompetent. I believe many of them are trying to do the right thing or what they believe to be the right thing. However, if you put those people in a system designed to fail, they will fail. Mr. Lamrock argues that our governance models reward irrational behavior. It punishes anyone who tries to even define a social problem, let alone solve it. And this happens because the outcomes we expect governments to achieve are completely separate from the structures, processes, and incentives politicians and bureaucrats orientate themselves to. And this just didn't start happening. For decades, governments have embraced budgeting and planning models designed to avoid accountability for outcomes while focusing on bottom lines and political spin. The most obvious flaw is how governments continue to operate within rescue mindset. If the primary health care system fails, we'll catch them in the emergency room downstream. If a family is struggling, the classroom teacher will deal with it. If a young man falls into poverty for lack of training and support, social assistance will catch him. And when that fails, the justice system will take care of it. If mental health programs fail, the new urgent care center will deal with it. Governments have continuously ignored warnings about the failures of programs, let people fall through the cracks, and then often issue giant budget announcements in the billions to fund those downstream solutions. The problem is all of these downstream solutions are also now starting to pull at the seams, stretching beyond capacity. Mr. Lamrock goes on to say, we can comfort ourselves with the same fatuitous nonsense the system is fine. It's just the people that must improve. If only people stopped coming to the emergency room, if only families did better taking care of their aging parents, if only children had discipline these days, if only the homeless and addicted faced real consequences. It seems we can always point the finger at people who need services, but we can never seem to look at those who are producing the system failures year after year, budget after budget, election after election. Now I think it's important before we go any deeper that we give you the historical context because Mr. Lanworld talks about governance decisions that were made in the 1990s that shaped everything that came after. If you're from Saskatchewan, we still live with this history every day in our politics. And I think it's important to give the background of what was happening in that era, not only in Saskatchewan, but across Canada. In Saskatchewan, we like to start our healthcare story in the 1990s. It's like nothing existed before then. But let's remind ourselves, in the early 1990s, Saskatchewan was on the brink of bankruptcy. The previous government had spent the 1980s cutting taxes, selling off crown corporations, running deficits, and leaving the province with what at that time was the largest per capita debt in Canada. The incoming NDP government had almost no room to maneuver. The province's credit rating was in free fall, and emergency financial assistance was needed from Ottawa just to keep the lights on. What followed were years of painful cuts. In 1993, acute care services were removed from 52 small rural hospitals. The facilities themselves mostly remained open as health centers, and most are still offering non-acute services today. But the politics here has never let it go. And Saskatchewan wasn't alone. In 1995, the federal government cut transfers to the provinces by $7 billion in a single budget. Every province faced some version of the same reckoning. But the governance model that came out of that crisis, the one that said that fiscal targets must come first, that we measure what we spend, but not what we achieve, that model never got dismantled when the fiscal situation improved. And then it just became how we did things. And like Saskatchewan, most provinces kept the austerity governance model long after the emergency was over. That's the thing about emergency measures. They tend to outlast the emergency. Think about COVID and the top-down management and control strategies that were put in in the early days of the crisis to manage the chaos. But now that command and control approach has lingered far beyond what's been needed. So yeah, that's the legacy we live with today. And we can't have an open and honest conversation about changing the healthcare system unless we acknowledge it. Mr. Lamrock uses a story in his report about a man who stands under a streetlight looking for his wallet. A kind stranger helps the man look. After an hour, the stranger asks, Are you sure you dropped your wallet here? The man replies, No. He actually dropped his wallet in the alley across the street. So why are we looking under the streetlight? asked the stranger. Well, the light is so much better here, he answers. We didn't drop our wallet in the emergency department, but that's where the light shines. We didn't drop our wallet in the doctor's office, but that's where the light shines. We didn't drop our wallet in the ORs, but that's where the light shines. Mr. Lamrock has identified five flaws of governance that need to be put under the light, and that's what we're going to do over the next five episodes. Five specific governance flaws, each one a structural problem, each one fixable, and each one recognizable to anyone who has spent time trying to make change in health or social systems. The next episode, next week, we will dive into the first flaw. It's about workforce, about what happens when governments build systems and then forgets or refuses to plan for the people those systems need to work. If you've ever wondered why we never seem to have enough healthcare providers, this one's for you. So that's it for now. Special thanks to Mr. Lamrock for his brilliant report, and I hope the upcoming episode spreads his ideas and insights even further. Thanks for listening, and remember, systems don't change unless we do. This is Shift. See you next time.