A thousand points of light

At a recent Crossing Boundaries forum on citizen-centred federalism, former Ontario CIO Scott Campbell made the case for engaging politicians in the debate over government transformation.

A number of key obstacles are blocking the path, he said. Dealing with them will take a searching public debate and it must be led by politicians. Moreover, we need a critical mass of them to get the job done. He concluded by challenging all of us to adopt the goal of engaging a thousand politicians on the file by 2008.

As someone who has spent the past 10 years trying to get politicians into this discussion, I winced as he spoke. I know first-hand how difficult it can be. They tend to view topics like this as “plumbing” issues, best left to the bureaucrats.

However, the wheel may have turned here. The goal is a good one and it is do-able. It is increasingly apparent to everyone why change is so important and what it will take to get there. Consider the healthcare system.

In the ongoing debate over how to get control over healthcare spending and reduce wait-times, everyone from Roy Romanow to the Fraser Institute agrees on at least one thing: better co-ordination within the sector is essential.

Technology is the critical enabler here. In the old world of telephones, filing cabinets and snail mail, there were natural limits to how many people could work together efficiently before a system got too big and began to bog down under its own weight. New technologies vastly extend these limits.

A recent pilot project, the Alberta Hip and Knee Replacement Project, shows how things are changing. It involved 1,200 hip and knee surgeries and was completed between April 2005 and April 2006. Its goal was to test new ways to deliver services to see if they would reduce wait-times.

By any standard, the results were remarkable. Wait-times to see an orthopedic specialist were slashed from 35 to six weeks; the time between the first consultation and surgery was reduced from 47 weeks to 4.7 weeks. A few basic changes are behind these impressive results.

First, instead of sending patients to a general practitioner, who would then refer them to a specialist, patients’ first stop was a team of specialists with the expertise to do a full assessment of the patient’s needs. In effect, the team was a one-stop shopping approach to a range of health services. This eliminated wait-times between the usual series of referrals.

Second, a case manager was assigned to each patient, whose task was to guide the individual through the various stages of the process, ensuring a smooth hand-off from diagnostic test, to specialist, to surgeon.
Finally, instead of keeping their own lists of patients, doctors “pooled” them.

This is much the same idea as the single lineups at banks. It allows the next person in line to go to the next available teller. This way, no one gets stuck at the end of a long, slow-moving queue.

Perhaps the most important finding from this pilot concerns the fragmented and disorganized state of the health system – and the gains that could come from better co-ordination between different stages in the treatment of patients. At the same time, the pilot helps us see what we must do to make that happen.

First, we must improve overall co-ordination by redrawing some deeply entrenched boundaries around roles and responsibilities, such as the role of the general practitioner. Second, we must be willing to collect, use and share information in new ways.

Unfortunately, changes like these often meet with serious resistance. For example, in sending a patient directly to a team of specialists, we are bypassing the general practitioner. Some people worry that we may also be undermining the traditional doctor-patient relationship. Or consider this: in creating an electronic health record, are we putting the patient’s privacy at risk?

Technology alone will not solve these issues. They are high-level policy questions that must be dealt with through democratic discussion and debate. So far, that has not happened. It is an open question whether it ever will.

But this much is clear: if we really want to make progress on citizen-centred government, we must be ready, willing and able to tackle issues around organizational culture and privacy. If we don’t, we will fail to really change how government works.

Worse still, existing practices are likely to become even more deeply entrenched, as we move to automate the processes around them.

Now, where can we find 1,000 politicians?

Don Lenihan is president of the Crossing Boundaries National Council, a not-for-profit forum focused on a more citizen-centred approach to government. He can be reached at dlenihan@crossingboundaries.ca