Political scientists studying interest group politics often start with an assumption that the “top of the food chain” in interest group politics has to be the Ontario Medical Association.

The initial assumption is that this rich and powerful lobby group runs circles around the government. However, the actual record over the past twenty years indicates that the OMA does not have a “winning track record” in their relations with government.

The truth is doctors tend to be politically naive about the cut and thrust of political dynamics. To start with, physicians are not even aligned as a group. So it has been hard for the OMA to be the “single voice of doctors”, when they are often fragmented.

The problem is: we will never successfully transform our healthcare system, until and unless our doctors are happy.

Nevertheless, it is hard to generate any sympathy for physicians among the other healthcare interest groups. Indeed, there have been a number of cases where government has gained the “upper hand” when the Ontario Hospital Association has publically opposed the OMA — and urged the government to undertake measures the doctors oppose.

While we’ve had many examples of “divide & conquer” politics among healthcare interest groups, these incidents become embedded in our culture, and in weakening relationships.

If our goal is to transform the system, we need these vested interest groups to collaborate and partner with one another. However, the challenge — following the expected election this Spring or next Fall — will be transforming our healthcare delivery system, with fewer financial resources.

Because our doctors are very well paid following the significant increases they negotiated with the McGuinty Government, the assumption is: they are the “big winners” in the resource allocation game.

Most people remember the series of generous increases over the past 10 years — forgetting the virtual wage freeze that lasted for much of the ’90’s. In the last set of negotiations, the result — on average — was that most doctors have experienced at least a 5% reduction in their income. It could have been, and still might get worse, once the election has been settled.

The top strategist for the OMA today is former Deputy Minister of MOHLTC, Ron Sapsford. While Ron certainly sees the “big picture” from his comprehensive perspective, his mandate is to represent the narrow interests of the doctors — who have experienced higher than average wage increases for over a decade, but who still feel undervalued, unfairly treated, and poorly paid.  

Indeed, “physician unhappiness” has become a major impediment to healthcare transformation throughout our healthcare system. “What are we going to do about our grumpy doctors”, is all too common a question/concern expressed right across the province.

We talk about the need to be honest and open with patients about tough issues like end-of-life planning. Well, we also need to talk to our doctors about what’s at stake over the next few years for the very survival of our public healthcare system. The system cannot be successfully transformed without the full involvement of physicians in the design, planning and implementation phases of health system transformation.

What we know from past experience is that “more money” does not make physicians happy. We’ve tried significant annual increases every year for the past ten years, and it does not work. More money has never solved our “physician unhappiness” problems.

Given that the government does not have any more money anyway, perhaps now is the time to address the underlying reasons for such widespread grumpiness on the part of the medical profession.

As everyone on the ground-floor of healthcare service delivery knows, physician behavior and attitude has a huge impact on both the quality of health service delivery, and on the level of job satisfaction for the rest of the health services team. We need “happy doctors” to produce an environment where the whole healthcare team can collaborate to achieve the great care, and good service, that taxpayers believe they have already paid for over many years.

As the system transforms over the next three to five years, nurses and other health professions will no doubt see jobs shift to the community sector — perhaps at lower pay. Physicians ought to understand that rather than “more money” for OHIP fees, we really need to save as many RN and allied health care jobs as possible.

How about some empathy from physicians for our non-medical health professionals!

Our anxiety-ridden service delivery system really can’t afford to have the OMA and the government at logger heads again over money for increased physician payments — we know how that nasty fight ends. It won’t be pretty.

Given that there is no money, can we stop the mean spiritedness, and switch to the “Happiness Agenda” for doctors; to the “Better Experience & Quality Agenda” for patients; and to the Determinants Of Health & Equity Agenda for the high-cost, at-risk populations?

The fact is, we need physician brain-power fully engaged in the on-going design and planning of our local health service delivery systems, at the Health Link operations level; and at the LHIN planning level; and, at the provincial policy level. We will never run a good healthcare system without meaningful physician engagement in the overall planning operations and policy process. We need physician brainpower — and we need positive and collaborative attitudes.

In recent years, the OMA has invested in a rigorous leadership development program which is beginning to produce a new generation of physician leaders at the local health care service delivery level. As the Health Links are being set up, there are numerous examples of young, smart doctors taking an active role in shaping our primary care system.

Dr. Jonathan Kerr of Belleville Ontario, is one such emerging community physician leader who graduated from the OMA’s leadership development program. The South East LHIN brought Jonathan on as their Primary Care Physician Lead. “He has got great listening skills and he builds trust and commitment among each of the people he works with”, says one observer.

Dr. Brent Elsey with the Barrie Family Health Team is another “next generation physician leader” who is really exciting physicians and connecting to everyone on teams throughout the North Simcoe Muskoka LHIN about the benefits of more integrated approaches to primary care.

In the Central West LHIN, Dr. Frank Martino is the Primary Care Lead. He is the current President of the Ontario College of Family Physicians. Observers say Frank is another “emerging physician leader” who really connects with other physicians — as well as with everyone else on the multidisciplinary partner’s team.

While the next generation is “getting ready” to provide enlightened and visionary local leadership for primary care reform and health system transformation, physicians as a group are too often chronically unhappy. But poking sticks at them in the fee negotiations is not a particularly smart strategy. Engagement and meaningful involvement is the very best strategy. The challenge is the “level of cynicism” that exists on both sides.

While everyone pays attention to the issue of physician incomes, the fact is organized medicine invests considerable efforts to improve health, and improve the healthcare system. Doctors have to work in this system, so they want to make it better too.

Currently the OMA is working closely with the Ontario Quality Council to develop quality-based procedures. They are active partners on the “Choosing Wisely Campaign” which encourages physicians to think about the value of tests which are of lower value, or, perhaps unnecessary for some patients — potentially saving hundreds of millions of dollars. The OMA is also placing priority on the electronic medical records with their aggressive e-agenda — which has now resulted in over 9,000 physicians with electronic records.

If we’re looking for insights that will determine the design of Ontario’s emerging system, the OMA certainly has compelling insights that must be considered when primary care — rather than acute care — is the centre of the system.

While it is true that many physicians still demand no further reductions in income, the fact is that many understand the province’s financial realities and are supporting the OMA to help create a better health system for everyone.

Hopefully the OMA Board and Council will be able to convince rank-and-file physicians that it is in their very best medium and long-term interests to help create a better healthcare delivery system — rather than just fight for an even richer pay packet for doctors — which can only end in what economists call, “The Tragedy Of The Commons“.

The “Tragedy of the Commons” is a systems thinking archetype that illustrates one of the common mistakes in designing complex adaptive systems: combining perverse incentives for individuals or silos in systems — where system health and survival actually requires cooperation and coordination of effort.

The archetype is named after an essay by ecologist Garret Hardin that explains how a tragedy occurs over the use of a “common pasture” — where the villagers of a community graze their livestock, and where the incentive structure is designed to reward everyone for increasing the size of their livestock herds. In such environments, greed is the normal response.

Over time, the common pasture is bare dirt, all the livestock die, and the villagers starve-to-death. That’s what we are heading for right now in Ontario: another “Tragedy Of The Commons“.

Prime Minister Paul Martin Jr’s $40 billion, 10-year, 6 percent annual increases “Fixed-For-A-Generation Health Sector Reform Fund”, was almost all spent on wage increases for healthcare professionals. While some of the money went to improved services, most went to improved wages for healthcare professionals.  

The Canadian Institute For Health Information reports that half of the money from the six percent annual increases went to physician fee increases — which went up an average of 3.6 percent each year, for ten years. Unionized nurses and hospital staff improved their wages by an average of 3.4 percent per year — “way better” than anyone else did over that same period.

So all that money — which was to be spent on changes that would “fix healthcare for a generation” — just turned into greatly improved wages and gold-plated pensions for health professionals. Not higher quality services. Not services that are more “patient-centred”, or even “safer” care. Just better wages and pensions.

Now we’re broke, and the healthcare system still needs to be “fixed“!

Let’s hope that our doctors roll up their sleeves and press on with the work they have started — and let’s hope that government and the delivery system meaningfully engages our doctors in efforts to truly transform our healthcare services delivery system.

Next week I’ll address the emerging Patients’ Lobby.