Robert Paterson's Radio Weblog
What is really going on beneath the surface? What is the nature of the bifurcation that is unfolding? That's what interests me.

Seniors Part 2 of 3

Healthcare Delivery - The Skilled Labour/Management Supply Shortage and the Workplace Culture Crunch – We have come to rely on a very sophisticated healthcare delivery system that relies on complex technology and systems. It therefore depends on attracting and retaining a very sophisticated workforce who can operate and deploy this technology effectively.


Most of the public debate on healthcare has focused on the capital and financial aspects of the system. This increasing dependency on complex technology and a shift in demography will compel us to focus on the human aspects of the system.


The current shortage of nurses and doctors is only the first step in a much larger and longer term shortage of skilled labour.


Most doctors and nurses in the system today will retire in the next 10 years and the age cohort that is coming that can replace them is one of the smallest in modern history. Simply seeing the problem of replacement in financial terms is too simplistic and does not get at the root problem.


Every sector of the economy is looking for skilled labour from the construction business, to medicine for we are living through a workplace revolution driven by technology and by demography.


What is different about the new technology and why does it force a change to the workplace?


In the past, tools were relatively simple and were task specific. The result a workplace based on the culture of task and supervision. Now the tools tend to be suites of technology that in themselves manage or observe complete systems. We are moving from a workplace where the tools acted as an extension of the body and worked on things to a workplace where tools act as an extension of our minds and enable us to understand complex systems. This type of work demands a radically different workplace culture and a revision of the role of the manager.


No wonder there is so much stress at work, the tool set has changed before the culture has.


The situation is a challenge today. Most workplaces are experiencing great stress. The Healthcare workplace is at the high end of the stress curve.


But if we think that things are bad now, demography will make them worse.

What are the trends that support this bold statement? We need to look again at the relevance of the shift in demography ands ask ourselves how this shift affects the changes in skill and management requirements and hence the viability of a hi-tech medical delivery system?



Look at the chart. What is shows is that for the first time in the history of the human race, the age pyramid will be inverted.


Now the power is shifting from the supplier of financial capital to the supplier of Human capital.


The chart shows us that there are no easy answers to dealing with this systemic shortage. Ignoring it will be fatal, especially for a small place such as PEI.


How will this shortage play out in the healthcare arena on PEI? DVA’s national statistics[1] are a useful proxy for the whole healthcare system and show us the impact of a decade long squeeze on the supply of Nurses and Doctors.


In the DVA system, 68% of its doctors will be eligible to retire by 2010 and 41% of nurses will also be eligible for retirement. These demographics do not include the dimension of migration to the US.


Much of the discussion today about solving the skilled labour supply issue is focused on money. This is a distraction.



The real issue is working conditions.


The small new cohort has more choices available to it than any other. All skill based professions from the building trades to aircraft design will be hiring from this small segment. In the medical profession graduating nurses will look at regions where nurses have little access to full time work and exposure to doing double shifts and look else where. Graduating doctors will look at regions where they are cut off from their profession and are exposed to being on call for extended periods and look for work in a big city.


Those nurses and doctors who are already working like this are suffering from acute burnout. Many nurses are either leaving Canada or the profession. Doctors do not want to work outside of the concentrated major urban areas.


It will be hard to attract skilled staff anywhere in Canada. In a small place like Prince Edward Island, it will be relatively more challenging.


Successful recruitment and retention will depend less on money than on working conditions and lifestyle.


The workplace in healthcare will have to be redesigned..


Is this too tall and order? In the solutions section, we will explore an option that can significantly improve the care experience for patients while significantly reducing the load on the medial professional.


Investment in the New

So we are indeed looking at an unfolding crisis. The lead time appears long but only by acting now, will we be able to avoid the crunch.


Do we have the funds to invest in the new?


One way of looking this question is to consider the difference between what we spend nationally now, $56 billion, and the risk in ten years of spending $100 billion a year. To make this feel more relevant locally, a similar increase on PEI would see our health and social services budget increase in 2010 to more than $600 million. At the beginning of the next mandate the demand will be for a budget of at least 400 million and the situation will be politically out of control as government fails to meet the wrong set of expectations form voters who want more of the same, the medical profession who want a bigger piece  and all the other portfolios who will be being squeezed.


A way forward for us today is to create an Investment or Transition Fund based on an amount that would be needed to avoid the cost of the “Crunch”.


What would we be prepared to spend now if we could be reasonably certain of reducing the crunch figure in the future. What would be the objectives of such a fund


Objectives & Outcomes

Reduce costs by reducing the load – Target a 2010 budget of  only $400 million but with a significant improvements in care, customer experience and workplace satisfaction. The key to meeting this stretch objective will be to reduce the load or demand on the system for expensive intervention as practiced today. How can we do this?  One way of reducing the load will be by increasing the wellness of the middle-aged and seniors. The underlying principles that we will use to do this will be to:


o       design and implement incentives and interventions that improve the self esteem, social and physical environment for seniors that will improve their health and thus reduce the load on the formal healthcare system

o       this outcome will be measured in overall improvements in mortality, in reductions of chronic illness and will be evidenced by lower direct costs to the healthcare system and lower costs in long term care


Reduce costs by designing and implementing an Alternative Healthcare Delivery System  that by its design improves the outcomes and experience of the customer and takes into account the needs and the availability of skilled medical professionals.


Impossible? No, the banks have already shown us how to do this and in twenty years have enormously improved customer satisfaction, increased volumes and better utilized their staff and their capital.



Today we have the emergence of Telehealth on PEI.


The chart shows some of the saving available, already. This type of approach will be essential. 


Some key design principles of the new delivery system will be that it:

o       is embraced by the consumer

o       takes into account the systemic shortage of skilled professionals

o       meets the distributed needs of a rural community

o       costs substantially less than the current interface

o       is supported by the medical profession


Reduce the hidden costs of the workplace and ensure that PEI has access to and can retain the very best staff by designing and operating a Workplace Culture that fits the needs of its participants – We need to design and build an alternative workplace for the medical professional that will enable small communities such as Prince Edward Island attract and retain the very best talent. This will be measured by:

o       A significant reduction in the signs of burnout such as  stress related illness and leaves, vacancies and iatrogenic errors caused by staff errors

o       Prince Edward Island being able to attract the talent that it requires and to retain it


Reintegrate seniors into the Community - Increase the wealth creation and the regeneration of community and reduce illness and hence demand by introducing measures that Reintegrate seniors into the mainstream of economic and community life - Seniors will shift from becoming a “Burden” on the productive economy and rightfully reclaim their historic human value and the builders of community.

Approach – Dealing with the Barriers to Change

This is a demanding agenda. Changing mindsets is not  task to be undertaken lightly. What approach can we take that will give us confidence that we can be successful?



It is helpful to remember that change does not begin with the Mainstream. All successful new product introduction has followed the pattern shown in the slide from VCRs to cars on PEI.


When we come to design a new Alternative Healthcare delivery system for PEI, we will use this pattern to guide our path and to point us to the customers and the practitioners that will move first.



We know how to change powerfully held mindsets of consumers – The beliefs that support the current system are deeply held by the system’s consumers. Most Islanders believe that they need more beds in acute care hospitals and that they need better access to more drugs. Most staff in the system share these beliefs. Changing such deeply held beliefs is not easy but our Island history provides a pattern for seeing the elements for change.


The precedent is the automobile. Today Prince Edward Island is arguably a society more attached to the automobile and everything that goes with it than any other than perhaps California. Yet for years, Islanders actively resisted it.


How did change in this attitude come about?

·        By seeing the value. Pioneering neighbours showed  the more conservative that the new automobile improved their lives.

·        By having a critical mass of supporting infrastructure available such as gas stations, repair, insurance etc. Brings in the Innovators

·        By a drop in the price to fit the pocket book of the ordinary person. Henry Ford shifted the car from a luxury to being a commonplace. Brings in the Mainstream.

·        By having the main alternative, the train, taken away at a point in time when the new auto system could replace it. Brings in the Reluctant.


This story of the auto on PEI is in reality the DNA for all technology driven mindsets. As such we will use this pattern deliberately when we come to offer an alternative view of health and healthcare. This is why setting out to create an alternative delivery system is potentially so powerful.


We know how to change powerfully held mindsets about institutional delivery systems and we know how to shift the consumer from an ignorant dependency on the provider to an informed person who takes charge of their own situation. 25 years ago if we wanted to do any banking transaction from the simplest, like cashing a cheque, to the most complex such as arranging a mortgage we turned up in person at a branch during banking hours. Often we were part of a long line up to see the gatekeeper of the bank, the manager. Today 90 % of retail banking transactions occur outside of the branch and take place 24 hours a day 7 days a week.


What is the DNA of Canadian Banks’ success in creating an alternative delivery system?

·        By connecting their own individual alternative systems to a common network

·        By focusing initially on a high demand, high cost area – cash

·        By creating in the new company a completely new workplace culture quite separate from the command and control home culture of each partner

·        By differentiating the complexity of the transactions and building separate channels to deal with each higher level of complexity

·        By differentiating customers by their psycho-social profile and not simple demography

·        By finding out the cost per transaction and the cost per segment and ensuring that there was a product and a channel that met all profiles.

·        By using pricing to alter behaviour.

·        By building on success – moving from cash to debit cards, from ABMs to Call Centres and from Call Centres to the Internet

·        By training the customer to take responsibility for their own banking and financial management


The new alternative healthcare delivery system will contain many of these elements and will have a similar trajectory and life cycle.


We know how to look at new technology and  create breakthroughs in application that change all society. Substantial breakthroughs in technology that change how we live occur in two major ways. They are the result of either a process called “Rotation” or “Integration”. If we can understand these processes we can extract a breakthrough from the technology that we see before us already.


“Rotation” is the process where the innovator gives an established technology a new and more powerful use by shifting the context,. Example: the first wheel was a pottery wheel. The “Rotation” was to shift its axis and attach it to a cart. The result, western civilization!. Integration extends this process by adding new components. Example the steam engine. The Rotation was to re-perceive a stationary water pump in a mine operating on the vertical plane to a dynamic source of traction to pull coal wagons on the horizontal plane. The integration elements included the new steel making technology that enabled rails to be made and cylinder boring techniques that were derived from making cannons which enabled high pressures.


The key understanding is that the big breakthroughs come by not from one new idea or one new item but from a sensitive examination of the current portfolio of technology and the assembly of seemingly disparate parts into a new whole.


When we come to look at the technology that we need to make the breakthrough in the healthcare interface, we will need to use these processes of Rotation and Integration. The solutions selection will suggest some interesting areas.



We know how to build the research foundation to give a new idea the support that it needs to become accepted as a national political priority. All parents knew intuitively that the early years were important. What has decisively shifted the policy framework and the political agenda has been a focused research agenda that has gone beyond intuition and provided us with a factual understanding of why this is true.


It will be essential to  build a framework of research that does the same for adult and seniors wellness. Where could we productively research?


·        We intuitively “Know” that our health as adults and as seniors is powerfully influenced by our sense of purpose, our sense of being valued, our support system and the circumstances of where we live. Just as research into the Early years has had a powerful impact on policy and expectations, so research into “Purpose”  and “Role” is needed to shift the stereotype of age = illness and dependency. Why are so many Seniors well might be a good start to this work.


·        We know that major cultures, like crime in New York, can be changed by making small but well placed changes to the environment. Where and how seniors live will have a large impact on their health. We know so little about this and see institutionalization as the destination. We need to build up a body of knowledge to support changes in housing and social policy.


·        We know that workplace environments have a powerful effect on the health and mortality of employees based on their rank in the hierarchy. Other than the Whitehall study, we have little evidence to support this intuitive feel. Much of the improvement in population health  in the 19th century came from improvement in the physical conditions of the workplace. The initial research suggests that a look at the sociology of the modern workplace will yield good results and shift us off the pure medical model for risk factors. Have a look again at the Whitehall slide. See again how minor the medical risk factors are.


For the executives, there is almost no incidence of CHD. For those at the bottom most of the factors are not known. Factors such as smoking and cholesterol are minor



If we think that this may not really apply let’s look at the DVA sickness leave pattern.


You see a perfect gradient in sick leave at DVA. The higher up in the hierarchy, the more control and the more control the less stress and the less damage to the immune system. There is a tremendous research opportunity here for Prince Edward Island to take a lead on researching adult wellness and looking at the systemic causes of illness such as rank in a hierarchy.



[1] 2001 report of internal demography to the Deputy

© Copyright 2003 Robert Paterson. Click here to send an email to the editor of this weblog.
Last update: 05/01/2003; 3:19:46 PM.