THE CANADIAN PRESS/John Woods
A version of this commentary appeared in the Hill Times, Ottawa Life and the Winnipeg Free Press
The use of management consultants to design reforms for Canada’s health systems has become increasingly popular by both provincial and federal governments over the past several decades – but it’s not always been good value for money spent. So why do we do it?
In my home province of Manitoba, the newly installed Conservative government of Premier Brian Pallister hired the consulting firm KPMG in 2016 to conduct the Health System Sustainability and Innovation Review. The firm was paid $750, 000 for producing two reports which the government only released to the public reluctantly, and then, only with some sections blacked out.
Many critics are blaming KPMG for the sweeping scope and forced pace of the transformational changes currently underway in the Manitoba health system, with more to come.
This recent example leads me to ask two questions: Why has reliance on consultants become so popular by governments? And to what extent can consultants contribute to the redesign of our health systems in ways that will introduce efficiencies, improve service delivery and also meet the test of political feasibility?
In other words, should we really be relying on consultant to solve our health care woes?
Governments need to be smart buyers when they look for outside help to overhaul our health systems. Consultants can contribute importantly on narrow operational matters such as project management and IT systems. However, when it comes to the “big decisions” such as how much of the provincial budget should be spent on healthcare or how many regional health authorities there should be, the advice of consultants will be of limited value.
Why? Because health policy is personal, value laden, complex, risky and highly politically sensitive.
When it comes to a redesign of the health system, it is not enough for governments to make the “right” decision based on management theory, they must also ensure the support of stakeholders within the system and communicate effectively to gain the support of the public. None of us, not even health officials, has full knowledge of the sprawling, complicated health system so we either generalize from our own experiences and that of others we know, or we base our opinions on the kaleidoscopic images of supposed system breakdowns presented in the media. This makes the politics of health reform particularly difficult.
There are three main reasons why governments turn to consultants for help. First, they often believe that the leadership of health organizations will be unwilling to deliver budgetary restraint and innovation because they want to protect the status and budgets of their organizations. Consultants are seen to provide independent and objective advice.
Second, there is often the related belief that health organizations lack the expertise to design and deliver bold changes. Healthcare bureaucracies are perceived to be poor learning organizations that avoid risky innovations.
Finally, governments sometimes use consultants to send the symbolic message that they are serious about reform. Consultants’ reports can provide “political cover” for changes they always intended to make.
But too many healthcare consultants follow a Sherlock Holmes approach: “It’s elementary Dr. Watson.” Their diagnoses of the “ailments” of the health system are typically dire. Their prescriptions for a “cure” are accordingly radical. Often governments ask consultants to work under tight deadlines, which means they are forced to rely heavily on the knowledge and data that already exists within the system.
But that’s not to say consultants bring nothing to the game.
Typically, consultants work in multi-disciplinary teams that combine expertise in fields as accounting, budgeting, human resources management, IT and broad health policy issues. Often they have experience studying health system issues in a number of jurisdictions. Their advice does not come cheap, but the cost must be kept in the perspective of the overall cost of the health system.
But one danger with consultants is their tendency to apply the same template regardless of which health system they are examining. Their reports tend to follow a similar format. They are dominated by the ascendant management ideas (so-called best practices) and laden with buzzwords. Bold strategies are prescribed, but the challenges of translating such strategies into action typically receive short shrift. Bullet points, extensive use of graphs and diagrams and lists of dos and don’ts are meant to simplify the complexities of the health system for the benefit of the busy decision-maker. Recommendations are made forcefully and confidently.
Consultants typically criticize health systems for serious shortcomings in relation to planning, coordination, performance measurement, evidence-based accountability and a lack of innovation. And they are often right. Such advice reflects managerial rationality that typically involves a search for greater efficiency and effectiveness.
Politicians follow their own type of rationality that consists of avoiding a backlash, the loss of public support and potential defeat at the next election.
Here’s the crux: Consultant reports aren’t simply summarizing “symptoms” in our health system that can be cured by an application of the latest “managerial fixes.” They are actually detailing “chronic conditions” of health systems in which the supply of services will never fully meet demand. This fundamental reality leads to perennial political debates about how much healthcare we can afford and how best to pay for it.
Unaided politicians cannot transform health system. They need the specialized knowledge and advice of experts in the field. Too often they assume that the leaders of health organizations are unwilling and unable to bring about bold reforms. This assumption ignores the fact that such officials have intimate knowledge of the strengths and weaknesses of the system, most desire to see it improved and those same officials will ultimately have to carry out the elaborate plans proposed by consultants.
There is a place for consultants in the change process but consultants should also be kept in their place.
Dr. Paul G. Thomas, PhD, OM, is Professor Emeritus of Political Studies, University of Manitoba and an Expert Advisor with EvidenceNetwork.ca. He has formerly worked on patient safety issues on the national and provincial level and has studied the change process in health systems.
This work is licensed under a Creative Commons Attribution 4.0 International License.