Improvisation necessary in health care

Complex and rigid system needs agility training, writes

In health care, forget the grand plan. Improvise.

Health systems are the most complex enterprises on the planet: labyrinths of hospitals, nursing homes, laboratories, clinics, drugs and devices, dozens of occupations, a zillion protocols and regulations.

Machinery this complex is rarely nimble. It's hard to marshal the vast array of moving parts to confront a new challenge — or even an old one that develops slowly and inevitably, like aging. The 85-plus cohort is growing four times faster than the general population. Yet Canada has eight times as many pediatricians as geriatricians.

It's not for lack of planning. Every federal and provincial report on health care produced plans for major system change. Multi-year strategic plans are standard organizational fare.

Planners forecast workforce needs and build models to guide decisions about educational program enrolments and how many doctors to poach from other countries.

The grand plans never get implemented, and the pace of change remains stubbornly slow. Interest groups veto change regardless of the evidence in favour.

Public health experts sounded the alarm for decades about pandemic preparedness, yet it took months to get adequate personal protective equipment for providers during COVID.

There's no coherent strategy to tackle decades-inthe-making obesity rates and unmet mental health needs. If you need a heart bypass or a MRI scan, medicare is there for you. If you need a nutritionist or help for a troubled child, see you in 2024.

Some very good plans gather dust while some deeply flawed plans are executed to ill effect. Ill-fated plans start with the wrong assumptions or focus on symptoms without understanding root causes.

About 15 years ago, several million Canadians were without a family doctor. Planners assumed there had to be a severe shortage of family doctors. Medical schools nearly doubled their capacity and there are now more family doctors per capita than ever before. Today, several million Canadians are without a family doctor.

Did the planning note that doctors working in multidisciplinary teams could look after more patients without working longer and harder? No.

Did it investigate why younger doctors were turning their backs on full-service practice to work in walk-in clinics or fill in for doctors away for a few weeks or months? No. Billions spent, nothing solved.

The system's rhythms and planning cycles were designed for stable and predictable needs. Then a new virus knocked the world and health care out of their orbits. Commerce and schools shuttered.

Virtual care that had barely made inroads in Canada became the new normal within weeks. Hospitals became COVID centres. Vaccine research, testing and approvals reached breakneck speeds. It looked like transformation was possible after all.

Appearances deceive. The system didn't transform; it scrambled to adapt to a crisis, with mixed success. The collateral damage has been enormous, from massive surgical backlogs to a demoralized, alienated and burntout workforce. Many nursing homes became death camps.

Maybe COVID is a unicorn. But a prudent system will prepare for sudden disruptions. Without a culture of rapid adaptation and on-thefly planning, health care will at best stay afloat when rocked by the unforeseen turbulence of a pandemic.

It's been largely a hand-wringing undertaker to the horrific opioid crisis. It's hard to see it doing much better against new chronic conditions triggered by viruses or climate change.

Put simply, this immensely complex and rigid system needs agility training. An obvious focus should be surge capacity.

Luckily, COVID severely tested but mostly didn't overwhelm hospital capacity, albeit by cancelling surgeries and ignoring others' medical needs.

There's no nimble way to plan and build a full-service hospital. The solution is to stockpile the material to assemble field hospitals in days or weeks. That takes major investment and logistical ingenuity.

The workforce challenge is even more daunting. Health care is an elaborate choreography of specialized roles. A system able to pivot to deal with cataclysms needs versatile generalists.

Every health-care worker has to be prepared for an unspecified Role B, most likely some aspect of communicable disease control or treatment. There should also be a reserve corps — younger retirees, volunteers, trainees — who can be called into service. It's the only way to get more boots on the ground in a hurry.

For a golden century, the health system delivered classic theatre, with new takes on a pleasing repertoire. Contemporary drama is different: The roles are more demanding, exhausted troupes struggle with wrenching scene changes, and the show is in progress while the next act is being written.

If the system is to succeed in an uncertain future, the actors have to embrace performing without a conventional script. Farewell Hamlet, hello Live at the Improv.