The Centre Cannot Hold Summer Series: Wait Times are a Feature, Not a Bug

In the 1990s, as a response decades of overspending, governments facing fiscal pressure made a deliberate choice: cap enrolments in health professions, reduce training spaces, limit billing numbers. The long wait times that followed weren't an accident. They were the plan — a way to slow demand without raising prices.  Thirty years later, we're still living in the system. This episode is about how we stopped planning for the people we need, and what that costs us now.

How it All Broke Report

Kelly Lamrock Interview

How It All Broke Videos

Transcript

SPEAKER_00 0:11

Hi, welcome back to Shift and my special series, The Center Cannot Hold, based on the 2024 report, How It All Broke, by Kelly Lamrock, Child Youth and Seniors Advocate for New Brunswick. The ideas and concepts of this special series are all his. I'm just trying to bring his insights to more people so we can think more deeply about how our government works or doesn't work to improve health care. And I think Mr. Lamrock's report does this better than I've ever seen. And trust me, I've read a lot of reports. In the last episode, we set the stage for this series, talking about why it's not incompetent people or insufficient money that's breaking our systems. It's the governance model itself, the assumptions baked into how government makes decisions at the center. Mr. Lamrock identified five specific flaws, and today we're going to explore the first one. Mr. Lamrock calls it lack of effective human resource planning. And here's how he describes the problem. In a sensible system, governments would establish an acceptable service standard in social programs, model the demand for that service, calculate the number of professionals needed to meet the standard, and then budget accordingly. Where gaps between the standard and the available resources exist, training programs would be funded and spaces would be correlated to the resources needed to meet that standard. In New Brunswick, and remember likely most other provinces, nothing like this happens. And it's amazing how many critical programs are delivered without any hard targets for staffing beyond let's all do our best. Let's use Mr. Lamrock's example in the report, Psychologists. He says in New Brunswick that they know that there's been a spike in the number of young people presenting at emergency departments in crisis. We know that this speaks to the lack of primary care and early intervention capacity within the mental health system. Nearly three-quarters of school psychologist positions in New Brunswick are unfilled, and wait times for primary mental health care are high. So you might expect that somewhere in government, someone has at their fingertips certain important facts. How many people are likely to require mental health services? What is an acceptable wait time before a mental health issue deepens into a crisis, which will require more and costlier interventions? Combining the demand with the acceptable wait time, how many psychologists are needed? Door enrollments or recruitable professionals in other jurisdictions add up to that needed number? If not, how many spaces will we need to fund in our training programs given the likely retention and recruitment rate? You would think that if you ask those questions, there would be an answer. And you would be wrong. If you ask for modeling, you will almost always get a list of program initiatives and other things that the government is doing to hopefully increase the number of psychologists. Some of these activities reflect considerable effort. However, effort is not the same as results. We are working hard and hoping to fix this. It's not the same as we need to produce X number of psychologists, and our current pace of success is consistent with getting there. If you ask how many of any one professional we need and how we know we're going to get them, the governing culture returns the bureaucratic equivalent of an error message. The critical shortage is made more maddening when you realize the doctoral programs in New Brunswick are both admitting and graduating as few as two graduates in a year in clinical psychology. Two, the most popular undergraduate program in New Brunswick liberal arts universities is psychology. Yet, for all of those hundreds of interested and qualified young people, we do not generate actual psychologists. It does not require statistical analysis to know that if you need dozens of psychologists and you're adding two per year, by the time you fix the teen mental health crisis, that generation will need gerontologists. Government sometimes explains the lack of training spaces by offering a list of recruitment programs. But a recruitment-only approach to professional shortages seems inadequate. If recruitment alone would work, we would be able to identify jurisdictions where the problem is they have too many psychologists or nurses or doctors. We are unaware of any recent debates in any North American jurisdiction centered around the question, how do we get rid of all these extra nurses and doctors? There are no surplus jurisdictions. You cannot recruit your way out of a training problem. The impact of this on our health and health care is direct and devastating. Take long-term care as an example. Some years ago, the New Brunswick Nurses Union produced a report establishing the vital role that registered nurses play in long-term care. Without nurses playing a part in developing and executing care plans and supervising other care providers, the system simply cannot produce results. And the New Brunswick Nurses Union found that many care facilities were operating without meeting government's own standards for registered nurses per patient. The shortfall was so widespread as to cause inspectors to simply stop writing it up. Further, the shortage of staff for nursing homes and special care homes has led to a situation where beds and infrastructure exist but cannot be accessed because of a lack of staff. Yet no current plan exists which identifies staffing numbers tied to freeing up those beds and a training plan to get us there. No one has hard numbers modeling future demand, service standards, and hard targets for the number of nurses needed, let alone a capacity model for how to achieve these. In many ways, our human resource models are built to solve an austerity problem rather than a service shortage problem. This dates back to the 1990s, which we explored in the first episode, a period where government reviewed most social programs with an eye to reducing expenditures and did not quantify impact for reasons both operational and political.

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Mr.

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Lamrock uses an analogy to explain what happened. Imagine a wedding reception where the host is providing guests with an open bar. The eventual cost of that open bar, if all drinks are provided free of charge, will be driven by demand only. If the host sees the costs getting out of control, there are ways to regulate the final bill. One could begin charging for drinks, which might cause some people to rethink their need for a drink. Or one could ration the service, give each guest a fixed number of drink tickets regardless of what they actually need. With bar service, these are fine options. Applied to healthcare, these methods may deter people from needed care because they can't afford it. How would one control the costs of an open bar if charging money or limiting drinks is unacceptable? The third option would be to limit the number of bartenders handing out drinks. If one reduces the number of bartenders qualified to serve drinks from six down to three, the wait times for drinks goes up. But the slower pace of service will control costs. In fact, the long lines may reduce demand in a way that higher prices would. Some guests may see the long wait and decide that they really don't want the service at all. At the end of the last century, governments essentially controlled healthcare costs by reducing the number of providers and portals, thus increasing wait times to slow the annual rate of healthcare spending. Hospitals were closed. The billing system for physicians became more restrictive. Enrollments in medical, nursing, and other health programs were capped. The wait times that resulted were a feature, not a bug. The annual cost of healthcare was now predictable because the system could only dispense services at a certain rate. What governments did not do during this period was set standards with hard targets for acceptable wait times. They did not calculate the future costs of delay, and they did not model future demands relative to the immediate training restrictions. Some of this was a legitimate policy response to fiscal crisis. Some of it was political, because if you have a standard for an acceptable wait time and you need to increase it in order to lower human resource hirings, then you would have to admit that you made the wait times longer on purpose. And can you imagine any government actually saying that? You would have to admit the longer wait was a policy choice, and those calculations would become discoverable. So it was better for government to simply curtail the number of healthcare professionals and know that some of the wait times would go up, but not set hard targets for what the trade-offs would be. That way no one was actually accountable for the results. The test for wait times became simply what the public could bear, not a standard driven by evidence. The unintended consequences of this was that once the caps and limits became the norm and the training spaces were limited, it affected the educational plans of younger people. Once jobs and training spaces became limited, the number of people even considering the profession also became limited. I remember this well, applying to nursing school in 1995. Are you crazy, people would say? There's no jobs out there for nurses. At my 25th nursing reunion last fall, we counted 86 graduates for the class of 2000. Here, too, governments generally choose to avoid accountability for the consequences of its actions. Funding of universities and colleges was reduced, and governments avoided setting targets for the number of people trained and the number of spaces available for future professionals. Even today, when the Department of Post-Secondary Education, Training, and Labor was asked how the number of spaces in professional programs correlates the number of vacancies to be filled, they replied that they do not allocate funding based on seats. In any sensible system, one looks at the projected demand for service and sets standards for how quickly that number of people should get the service. You calculate how many professionals it would take to provide the service within acceptable time limits. You look at the expected retention rates of new graduates, apply that to the number of vacancies and determine how many people you need to train. Then you sit down with the training institutions and determine what they need for resources to provide that many training spaces. As Mr. Lamrock says, you don't give someone $10 to prepare a four-course lobster dinner and then act shocked when they return from the store with a tuna sandwich. You set the standards and you calculate the most efficient funding model. That's what healthy organizations do. It's just not what governments do. Because 30 years ago, political credit was taken for hitting fiscal targets and the buck was passed downstream to providers, health regions, hospitals, school districts, colleges, universities to announce the consequences. We are trying to get a bureaucracy built for 1994 to solve the challenges of 2024. It's almost as if we're afraid to ask the questions because knowing the answer might create responsibility to enact radical change. And eventually, a lack of future planning creates fiscal problems as well. A failure to train enough nurses will eventually lead to overpaying for travel nurses in numbers suspiciously close to the original training shortfall. We pay more for less on an emergency basis because we didn't do the planning on the front end. That's how we roll. In the next episode, we're going to look at how this connects to the way governments actually budget, because it turns out the budgeting process is almost completely disconnected from any of this, from service standards, from outcomes, from reality. And it has consequences that run even deeper than the workforce crisis. Thanks again to Mr. Kelly Lambrock for highlighting this first of five governance flaws that we will be exploring in this series. Thanks for listening and remember, systems don't change unless we do. This is Shift. See you next time.