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Recovering backpacker, Cornwallite at heart, political enthusiast, catalyst, writer, husband, father, community volunteer, unabashedly proud Canadian. Every hyperlink connects to something related directly or thematically to that which is highlighted.

Thursday 13 February 2014

Teaching to Fish vs Making Sausage in a Healthy Ontario

Dear Bob Hepburn,

All press is political, I guess, and this could just be Hepburn trying to prove a point.  Or, he could believe his own rhetoric - I generally tend to assume people take the time to think through the complexities of a given situation, whatever they choose to communicate - but I've been wrong before.

So let's outline some problems with this post.  This is the sort of advice you could pay a high-priced Government Relations consultant $700 an hour for - if you did, you would be taking copious notes.  Which means probably no one will read it.  We don't respect what we don't pay for, right?

1)  Nobody can pick up the phone and immediately get the Minister.

Her number is (416) 327-4300.  Give it a try, see what happens.  But of course that's not her direct line, which is a less-shared number.  It's not her cell which should be even more exclusive.  Even her staff won't be able to reach her their 24/7, or even 9-5 (which in politics is more like 8 to 8).

Ministers tend not to answer their phones while they're in Question Period.  They shouldn't be answering their phones while they're in meetings - with stakeholders, getting briefed by Ministry staff or their own political aides or constituents (because they are MPPs, too).  If they're giving a speech or taking a tour somewhere, they should have their cells on mute.  Interrupting people in front of you because someone one the phone "outranks" them is elitist, exclusionary and discriminatory - not a good way to lead.

If you want to speak to a Minister, you need to schedule something in advance.  It's as simple as that.  

Yet the execution is far more complex.  Ministers will agree to meetings and calls all the time, delegating to their staff to sort out the details - my people will call your people, etc.  They have dedicated schedulers who try to make everything work, with everything including the demands of the constituency office, time demands from the Premier's Office, Legislative responsibilities, committees, time asks from fellow MPPs of both Parties, individuals with significant health challenges, advocacy groups, agencies, hospitals, pharmaceutical companies, doctor associations, front-line worker unions, interest groups like seniors health, diabetes, cancer, mental health, so on and so forth.

They call it "drinking from the firehose" - there's no way on earth one person can successfully manage every demand, every nuance, every crack in a system that's bigger than most jurisdictions in Ontario.  

Which is why delegating to Executives is so important.

2) On that "Culture of Fear" 

Boo-hoo, you might say.  If you can't take the heat, get out of the fire.  A tough leader has no issues with prioritizing and skipping past the less-necessary issues and stakeholders.  Same goes for funding - if a program fails to deliver tangible, measurable results, kill it.  It wasn't necessary in the first place.  Staff that waffle?  They simply need a firm hand to keep them in line.

It doesn't matter that the issues on the table range from ridiculously costly drugs that can save the lives of a marginal few, hospitals to serve increased need at present or preventative measures to address avoidable costs, like the kind that come from Diabetes Type II (we'll get back to this later), Smoking-related lung cancer or workplace mental health initiatives.  Tough leaders are ruthless, right?  Focused on the money.   Efficiences.  That kind of thing.

The smart thing to do for tough-minded Ministers to find tough-minded Executives who aren't afraid to bust some heads and make some ruthless cuts to make the beast financially sound.  Who, pray tell, are these aggressive, money-focused individuals?  How do you tell them from others in a crowd?  

Generally, they will have a record of being tough and making cuts, but they also demand to be paid for their labours - which they'll be sure to tell you about over golf.

3) If you reached the Minister, what would you say?

Let's say Bob Hepburn manages to get Deb Matthews on the phone, for a health-related issue; maybe he's got a relative dying of some rare and treatable disease whose cure costs as much as ten MRI machines desperately needed in Northern Ontario.  What would he say?

"Hey, Minister, my mom's dying of empathitis, why aren't you treating it?  Why are you letting my mother die?"

The Minister knows that Bob has some political savvy - that, and access to a whole lot of ink.  He may or may not understand or care about the complex funding landscape that is health; if he's being aggressive, like those Executives who get what they want, he could very well be exaggerating his mother's condition so as to elicit a response.  That's how Question Period works, after all.

Knowing Matthews, who suffers from a bit of empathitis herself, she would probably say "that's terrible, let me look into it and get back to you."  But what happens next?  Does she pull a twenty out of her taxpayer-dollar wallet and walk Bob's mom to the nearest clinic?

Of course not.  Like in a hospital, especially one in a state of emergency, the ask gets triaged among all the other asks that come in to the Minister, her staff, the Ministry staff, the agencies, other Members, so on and so forth.  Somewhere within and between thousands of players, decisions get made.  

But are all of these players after the same thing?

4) Ontario doesn't really have a healthcare system.

System: a set of connected things or parts forming a complex whole.

The only thing tying Ontario's multiplicity of services, agencies, divisions and stakeholders together is, frankly, money - not public health and certainly not structural sustainability.

What we think of as a carefully integrated system of services is actually a feudal empire with lots of little lords guarding coveted ground.  Executive get where they are because they're willing to fight for what they want and have more than a little ambition.  That's the way the system works; that's how rank is rewarded.

It is true that our feudal healthcare non-system is largely funded by public dollars; there's some metrics in place to show something akin to ROI but as is the case with any system based on financial rewards, to the squeaky wheel goes the grease.

Of course, smart, tough, fiscally-focused Executives play to win and build their teams accordingly.  

Knowing the pressures on healthcare and recognizing the necessity of making strong cases/using inside channels to make them to, these Executive earn their salary by ensuring the saliency of their organizations - by hiring GR experts.

5) Lobbyists are part of the non-system.

GR, Government Relations - lobbying.  It's considered a dirty, corrupt industry, full of self-serving conivers using inside connections to score wins for their clients, regardless of big-picture consequence.

That's by and large true, but such is the case in any industry - much like Executives, it's the people who demand more who get more and earn respect for doing so.  Do you know how many high-priced lobbyists (and some don't list themselves as lobbyists, but are lawyers) are heavily involved in Political Parties, to the point where they get called upon for consulting duties?  A lot.  They have strategically networked their way into positions of influence and profit both themselves and their clients from those connections.

After all, half of work is networking, right?  If we are telling our kids out of school they have to hustle, make the right connections and aggressively promote their interests to get ahead, is it in anyway fair to get mad at professionals who've made successful careers doing the same thing?

Along these same lines, government tends to fund in buckets (which we'll get back to with Diabetes Type II) - a problem gets identified, money is allocated by Finance to a Ministry who then allocates money to agencies.  Those agencies put out Requests For Proposals which service providers will compete for.  

To simplify that - service providers have to compete with each other over money that goes to serving Ontarians.  If they don't get money, what happens to their operations?  

Just as Political Parties spend ridiculous amounts of money competing for votes, service providers have to spend money competing for dollars.  That means knowing the mind of Ministers and grant proposal reviewers and, often as not, figuring out how to undermine opponents so as to ensure they don't get what you need.

And when has survival of the fittest ever been about curing the weak or ill?

6) Lobbyists are necessary

Get mad at lobbyists all you want.  Yes, they trade on the fact that they're golfing buddies with Chiefs of Staff or cut their teeth campaigning on by-elections with the former-staff, now PA to whatever.  The best lobbyists have spent time in government which yes, means they have buddies, but more than that they understand government.

If you don't understand government, you can't get position yourself to get funding.  You certainly can't shape the process that leads to funding, which is where the real wins are to be found.

There's a big difference between government - the sustainable institutions, the bureaucracy - and Parliament, which serves as government's Board of Directors.  Cabinet is the Executive Committee and the Premier is the Chair.  None of these elected officials necessarily have the professional competency in any of the fields they may end up being Minister for.  

You can argue this as a good thing or a bad thing, but either way, it means Ministers need to do a lot of on-the-job learning, which comes in the form of briefings, consultations and visits.  Who schedules these meetings, consultations and visits?  Political staff, who always have one eye towards delivering wins and avoiding faceplants for their boss and their Party.

But who decides the content and direction of these meetings, consultations and visits?  How do they pitch the importance of their particular ask to the Minister/the Minister's staff?

Most briefings are done internally, by bureaucrats who inherently bring their own biases, intentional or unintentional, to the table.  Just like anyone else, when they present options for solutions to the Minister, they're going to frame the positions in a way that nudges in the direction they think is best.  

This process is rife with filters.  Even when it's the Minister looking for information down the chain, Executives, managers and front line folk want to sell themselves positively and possibly present issues in frames that serve to protect their self-interests; especially true in a climate where cuts loom and jobs are on the line.

The only way that Ministers can get sufficient opinions and perspectives to make balanced decisions is to get outside points-of-view directly from agencies, stakeholders and even individuals.  But again, how do you squish everything in to a busy schedule and a cluttered brain?

Lobbyists (at least the good ones) are more than backroom buddies; they are translators, simplifiers, analysts.  They do their homework, get to know the Minister, her/his inner circle of decision influencers and understand the bigger political picture that decisions are being made in.  Like a guide, they lead their clients through the bureaucratic wilderness and across the political chasm, touching just the right benchmarks along the way.

When the best lobbyists do their work, it's the Minister's inner circle who communicate the interests of their client.  When mediocre lobbyists do their job, they simply put clients in front of the Minister and charge for the access.  The worst ones, however, will bully Ministers through attack ads, planted stories in the news and the like.  

By worst, of course, I mean ethically.  As is the case with politicians, executives or journalists, it's the ones who shout the loudest and compete the fiercest who get ahead, at the expense of the system.

Know, though, that some of these lobbyists are brilliant.  I've seen complex problems reduced to connect-the-dots solutions and bureaucratic nightmares streamlined into cogent decision trees in about five hours of meeting time.

But again, we don't pay for talent, we pay for brand and competitiveness.  A quote from one of these detail-oriented, ridiculously wealthy problem solvers: "I don't think about anything unless I'm paid to."

To sum up:

If we want to spend less and want government to lead by example, we're going to have fewer Ministers responsible for bigger Ministries.

- Those Ministers will, in the name of efficiency, promote tough, aggressive Executives to manage their agencies.  Those Executives don't work for cheap; you have to pay big bucks to get ruthless.

- If you demand a lot, you're going to defend a lot.  Which is why we have such an inefficient, feudal system in the first place.

- Cut money to Executives, you get less aggressive Executives, which mead to less aggressive agencies, which means less funding - and less service.

- Smart Executives (who make money) understand the value of twisting government's arm or whispering in their ear and hire the best (i.e., wealthiest and best self-promoting) lobbyists to ensure their issues are heard and responded to.

- In a consumer-based, sales-oriented health system, the focus is on the Executives, sales agents and the service - not on the health and well-being of the people.

Get mad at Deb Matthews all you want, but tell me - what would you do to fix this systematic, structural problem?

Here's a case study to show you just how messed up the system is, and not just in healthcare:

Diabetes Type II: A Case Study

Diabetes sucks.  It sucks for the individual who has it, but it also sucks billions of dollars out of Ontario's economy via healthcare and other costs.  By 2020, that suckage is expected to be over $6.9 billion.  That's a lot of money that could go to other health services, or to infrastructure, or even to tax cuts.

Diabetes Type II is preventable.  It is catalyzed by things like diet and exercise.  You know all that oppressive, socialist health promotion stuff people get mad at?  Taking pop out of schools and whatnot?  The point of that campaign is to reduce children's exposure to heavily-marketed, unhealthy products that will hurt them down the line, meaning more money out of your pocket and fewer healthy bodies to pay taxes over all down the road.

Better than denying something to someone, of course, is educating them about the risks and nurturing the self-regulation required to make healthier, more sustainable choices.  But we don't see self-regulation as a health thing; it belongs in another silo, education, if it belongs in the purview of government at all.

Educating around health, though - that counts as healthcare, right?  Just not in the school, it's more of an agency thing.  So, Ontario has put some cash together and handed it to municipal health agencies to provide peer-training opportunities.  Service providers can take a course, learn about Diabetes Type II and it's prevention and then go forth into their communities and tell people how to do their lives a bit differently and save themselves some long-term pain.

It's all very noble and sounds great on paper, but.

Service providers less successful at getting money directly are applying for whatever money they can find so as not to have to close their doors, leaving both their staff and clients on the street.  All kinds of groups have lined up for the money, agreeing to whatever terms to get it.  They will take the course - which is brief, and has no follow-up testing or consistency metrics - and will do what's required, providing the scant paper-trail of evidence required to show they'd done what they got money to do.

Will any actual community behaviours be changed?  I highly doubt it.  But we'll never know, because there's no metrics to record this.  

Put the right aggressive, cost-oriented Executive in place, though, they'll solve this problem by cutting the program.  Problem solved, right?  Only no problem has been solved - Diabetes Type II remains prevalent.

You can overall focus on a leaner, meaner government and more competitive work environment, as Tim Hudak would do, but not everyone is good at being competitive.  They tend not to get ahead.  They also tend to fall into behaviours detrimental to their health and overall, the health of the province.

But it's because of reduced funding for agencies across the board that these providers are turning into service thrift shops, providing whatever it is that will sell.  Whatever it takes to survive, right?  Consumers get competing thrift shops to buy at, but the structural problems go completely addressed.

Feudalism doesn't work.  Competition isn't systematic; if anything, it impedes structural ingratiation, which is why our healthcare system is in the mess it is.

There are shared solutions to these structural problems available, but you aren't going to hear about them from the tough-minded, self-promoting lobbyists or Executives.  They're in the job of increasing their own value, after all, not of solving problems.

So who gets the big bucks to promote cross-pollination, empower individuals - teaching to fish, as it were - and essentially put themselves out of work?


You get what you pay for, I guess.

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