Shawn Whatley: When it comes to fixing health care, governance matters more than policy

Few voters had first-hand experience with hallway medicine or Canada’s world-famous wait times before the pandemic. Lockdowns changed everything. Health policy failure moved from fear-filled headlines into a tangible crisis everyone could feel.

Failure begs for better policy, or new policy to fill gaps. Planners and policy writers jump to offer solutions: surgicenters, funding reallocation, redesigned models of care, and so on.

New policy, however, cannot fix old policy, unless we know why the old failed in the first place. Most policy fails on implementation, not from bad design. Furthermore, we cannot fill policy gaps unless we understand why gaps exist. Gaps form around constraints and incentives, not from a lack of creativity. The policy environment dictates viable policy options. 

How a system functions has more to do with how its governed than with the policy ideas in play. Implementation failure, constraints, and incentives all fall under the larger umbrella of governance. Governance and policy overlap, but they are different. 

To fix health care, we need to start with governance: how do we make decisions? Who gets to make them? If we do not, a new policy will deliver the same old results.

Policy to the rescue

Take surgicenters as an example. Surgeons and specialists join together to build a non-hospital, outpatient surgical facility. Each centre offers a specific basket of specialty care, for example eye, orthopedic, or endoscopy services. Surgicenters can offer comfort, convenience, quality, and efficiency that hospitals struggle to match. 

Surgicenters exist around the world. They are not new. In Canada, we have been trying to move care out of hospitals for decades. We want to save money and shorten waitlists. Why aren’t Canadian cities littered with surgicenters? 

Current incentives and constraints make surgicenters impractical and onerous. Currently, hospitals supply nursing care, equipment, and use of the facility. Physicians use everything but do not pay for it, making non-hospital facilities a tough sell. On top of this, billing rules, regulation of independent health facilities, licensing for necessary lab and imaging services, as well a basket of other restrictions all weave together into a policy environment intolerant of (publicly funded) independent facilities. 

We do not need a policy about surgicenters. We need research on why surgicenters do not exist in the first place and what to do about it. 

Thomas Sowell, American economist and author, said once, “The most important decision about every decision is who gets to make the decision.” 

Sowell expanded this in his book, Knowledge and Decisions: “The most fundamental question is not what decision to make but who is to make it—through what processes and under what incentives and constraints, and with what feedback mechanisms to correct the decision if it proves to be wrong.”^{1Knowledge And Decisions, p. xxii https://www.amazon.ca/Knowledge-Decisions-Thomas-Sowell/dp/0465037380?keywords=knowledge+and+decisions+thomas+sowell&qid=1655309944&sprefix=knowledge+and+de,aps,120&sr=8-1&linkCode=sl1&tag=shawnwhatleym-20&linkId=d571f2389079717bc2c2ab4c6586d10f&language=en_CA&ref_=as_li_ss_tl}

Before making a change, every hospital administrator must ask, “Who needs to be in the room?” Spectacular new policy will fail in even more spectacular fashion if you ignore governance. Informal governance can matter even more. Decision makers are often not the ones listed on the organizational chart: colleagues influence through personality without title or position. 

Governance eats policy for breakfast

Peter Drucker, the legendary management consultant, once said, “Culture eats strategy for breakfast.”^{2“Peter Drucker (1909-2005) was one of the most widely-known and influential thinkers on management, whose work continues to be used by managers worldwide. He was a prolific author, and among the first (after Taylor and Fayol) to depict management as a distinct function and being a manager as a distinct responsibility. His writing showed real understanding of and sympathy for the difficulties and demands faced by managers.” https://www.bl.uk/people/peter-drucker} We can say the same about health policy: governance eats policy for breakfast.

Dr. Dave Williams, a former astronaut and leader at NASA, served as CEO at Southlake Regional in Newmarket. He said, “It’s not clear who runs the hospital.” He was making an observation, not a complaint. “Compared to what I’m used to, it’s challenging to get things done.” 

Without clarity and fidelity to best practices, governance will drift. Sowell, again, sums this up:

Even within democratic nations, the locus of decision making has drifted away from the individual, the family, and voluntary associations of various sorts, and toward government. And within government, it has moved away from elected officials subject to voter feedback, and toward more insulated governmental institutions, such as bureaucracies and the appointed judiciary.

Is this a problem in Canada? Brian Lee Crowley, managing director of the Macdonald-Laurier Institute, thinks so. Governance drift leads to central design—a temptation for all political parties.

In his book, Gardeners and Designers: Understanding the Great Fault Line in Canadian Politics, Crowley dilates on how gardeners approach governance.^{3Gardeners vs. Designers: Understanding the Great Fault Line in Canadian Politics https://amzn.to/3aWW80R} A gardener prepares the soil, removes waste, provides support, and tends to progress. Gardeners celebrate the surprise inherent in what grows and blooms. They do not manage growth for a specific policy outcome they designed in advance.

Designers dream about how to make health care better. Gardeners ask the more important question: how can we get good ideas to grow? A gardening approach to governance leaves plenty of essential (gardening) work for government. It empowers those closest to the problem and leaves design, experimentation, and implementation to them. 

We cannot try to “fix” health care with new policy. Without good governance, new policy will struggle with implementation like all the old policy. We need to do first things first. Governance eats policy for breakfast.