A Sick System: An Outsider’s Guide To Who’s Responsible and What Must Change
A Discussion About the Incredible, Unstoppable, Change Coming to Health Care in Nova Scotia
WARNING: This is a bit much, even for THE BEE, and I’ve gotten some complaints. Going forward, I’ll try to break things like this up into more manageable and succinct bite-size essays.
This is the first multi-part overview entry of an essay series exploring outsiders’ views of Nova Scotia’s failing healthcare system.
If you are an outsider or insider, or have just spent too many hours in the waiting room in between, I’d encourage you to list or write about the changes you think are necessary based on your experience here to contribute to a larger document we can share with our elected representatives.
PART I - The current situation and a path to improvement
PART II - Applicable management ideas from the best in history
PART III - An Index of Nova Scotia Healthcare Facts and Figures
PART IV - Where do we start?
PART V - A change is coming
A Moment of Tragedy, A Larger Crisis
Like everyone, I am deeply saddened and troubled by the violent incident at the QEII emergency department on January 29th. My heart goes out to the victims, their families, and the frontline staff who face the unimaginable in a place meant for care and healing.
I would like to say this is an outlier, a shocking and isolated event. But every report from the frontlines says otherwise. The emergency room isn’t just overwhelmed—it’s on the verge of this kind of crisis 24/7, with patients, families, and staff all at the breaking point.
This will not make it any easier to get what we need - more people on the front lines of healthcare.
Nothing will change if we continue to focus on the wrong things. The trauma debriefs, union negotiations, and compensation will come, and more money will be thrown at the bloated system, but that won’t address the core issue: the hospital environment is what those in charge allow it to be.
It should be clear to us all by now: neither we, the citizens, nor our elected representative government are truly in charge, or even in control of this system. We've created a monster with our wealth and caring. We hand over nearly half our provincial budget to it, and in return, we get a fortress fiefdom that is fundamentally unaccountable, disconnected from the people it serves, and resistant to real change. The farthest thing from a democratic institution imaginable.
The solution isn’t more money. The system already has far more than enough—it just isn’t reaching the front lines. And it sure isn't reaching the people we intended to help. We must rein in the bureaucratic empire we have, with our own tax dollars and natural empathetic care for one another, allowed to cancerously grow unchecked.
More resources must go directly to frontline care, where they actually make a difference, rather than disappearing into layers of administration that protect themselves first and serve the public second at best.
This isn’t just a tragedy. It’s a wake-up call. Will someone finally act?
So, who is responsible?
Responsibility cannot be diffused. If no one can be pointed to as the responsible party, then no one has ever truly been responsible. If more than one person is responsible for a task then no one is responsible. The very structure of Nova Scotia’s healthcare system—where responsibility is spread across citizens, elected representatives, hospital management, and bureaucracy—practically guarantees a lack of real accountability. That’s exactly how we’ve ended up with a bloated, inefficient, and unresponsive system.
The Citizens
In a democracy, responsibility ultimately rests with the people. If citizens don’t demand change, question government spending, or hold leaders accountable, the system continues unchecked. We get the systems we’ll put up with.
However, while citizens have influence through elections every few years, they are not in operational control.
Representative Government (Premier, Health Minister, Legislature)
This group should be responsible. They control the funding, set policy, and appoint leadership. But ultimately they must delegate responsibility to management, staff, and health professionals, they’ve hired. This is right, but is also where the potential for problems begins.
Politicians could force change, but most avoid fights they don’t have to take on. Healthcare is a politically dangerous issue—voters fear cuts, they want more frontline healthcare, unions resist reforms, few workers want to be on the frontline any more than a WWI soldier wanted to be in the trenches, and bureaucrats bury change in process.
The Hospital’s Arms-Length Management (Nova Scotia Health Authority Leadership)
On paper, the NSHA is responsible for the actual operation of the system. They oversee hospitals, emergency rooms, organizational charts, and hiring.
However, they operate like an insulated fiefdom, shielded from political and public accountability by the very government that should be holding them to account. Such is the power of a too-big bureaucracy in a place filled with too polite citizens. They have all the money, all the power, and a kind of moral superiority over us. They answer primarily to themselves, rewarding administrative expansion over frontline efficiency.
The Hospital Bureaucracy (Administrators, Middle Management, Unionized Staff Behind the Frontlines of Care)
Here lies the mechanical force of dysfunction: an unmovable administrative army that thrives on complexity, regulation, and hierarchy.
Most people inside the system feel powerless—whether it’s doctors, nurses, or even hospital managers—but the bureaucratic machine itself is responsible for inertia and inefficiency.
So How Does This Play Out?
Everyone must do the part they are responsible for.
CITIZENS
Citizens, with energetic activist optimism, must insist their representative government fundamentally change the organization, management team, culture, and structure of health care.
GOVERNMENT
Representative government has the authority to fix the system.
We must maintain and improve the delivery of those services Nova Scotians, indeed all Canadians, value most. Necessity demands that we eliminate, or fundamentally alter, the remainder. In Nova Scotia, an uncompromising review of every aspect of Healthcare must again be undertaken, but with new possibilities for change, and new goals in mind.
We need management audits in every major department. These must be undertaken by people with no vested interests but direct accountability to the public for success. The process will, we know, uncover a maze of inefficiency, needless red tape, isolated bureaucratic empires, high stress, low morale, and dismal productivity--in short, broken system, and an inefficient, rule-driven bureaucracy that is completely ill-adapted to respond to the demands of a province and healthcare system in transition.
The solutions include cutting out layers of bureaucracy; wholesale elimination of departments, consultants, managers, and divisions; pushing frontline responsibilities to the frontline, decentralized decision-making; new management ideas, and radically altered attitudes. It won't be easy.
Establishing working structures and systems to replace stifling bureaucratic controls is only half the equation--the easy half. Changing attitudes, altering the very culture of the healthcare system will be more difficult. The days of guaranteed job security, regardless of performance are gone. Productivity, creativity, and flexibility will be requirements for success in the hospital, just as they are in private business. Only the most successful frontline workers truly matter. Everyone else is either not needed or can be replaced. We should hire more senior managers on short-term contracts; bringing the best people in from the private sector to do a specific job and keep them only to the degree to which they are verifiably successful. This would allow constant renewal, new ideas, new styles, a more vibrant workplace. Changes of this magnitude are frightening, there is no question. But they are also a source of new hope.
Head coaches in the NHL last an average of 2-4 years before being fired or moving on. Assistant coaches tend to have slightly longer tenures but still rotate regularly, especially when head coaches are replaced. If a team underperforms, coaches are often the first to go rather than gutting the roster. We can learn from high-performance teams in high-stakes situations like this. It should be the same in Healthcare.
This is a War
The U.S. Army, despite being a massive organization, operates with a surprisingly flat command structure compared to traditional bureaucracies, especially in high-stakes combat situations. In general, the degrees of separation between a frontline soldier and the highest-ranking military leadership (e.g., the Chief of Staff of the Army or the Chairman of the Joint Chiefs of Staff) is around five to six levels—sometimes even fewer in direct combat units.
We’re in Mortal Combat and it’s the Stanley Cup Final Game every day
The benchmark goal: No one in Nova Scotian healthcare should be more than six degrees of separation (six rungs on the organizational charts) away from an elected official who can be held accountable for the performance of the job. And if a senior manager, whose name and responsibility should be well known to the public, is in a position more than 4 years without achieving newsworthy and significant change and improvement, the system is not working correctly.
HEALTHCARE MANAGEMENT
We must believe in many things to make our system of government work, among them we must believe in the power of individual accountability within organizations. That means the Minister of Health should be able to name the exact person responsible for failures in emergency care, patient flow, and bureaucratic bloat. If they can’t, then no one is truly in charge—and that’s unacceptable. A red flag indicator that the system is not working.
This may be the biggest and most fundamental change required.
The Nova Scotia Health Authority is an example of what happens when responsibility is diluted:
Too many decision-makers
No real consequence for failure
Endless studies and committees rather than decisive action
We must have:
A Single, Accountable Leader: One person (not a board or committee) should be personally responsible for healthcare outcomes.
No Excuses, No Bureaucratic Deflections: If emergency care is failing, someone must be removed. If hospital budgets are bloated with admin costs, someone must be fired.
Radical Simplification: Bureaucracies sustain themselves by making things unnecessarily complicated. We must cut through this and streamline decision-making to get resources directly to the front lines.
This is Going to Sting
"If what I say now seems to be very reasonable, then I will have failed completely. Only if what I tell you appears absolutely unreasonable have we any chance of visualizing the future as it really will happen."
Arthur C. Clarke, author of 2001: A Space Odyssey, speaking about A Vision Of The Future in 1960
If the ideas in this Substack don't seem strange, if they don't make you uncomfortable, uneasy, and cause you to wonder how all this would work and how the pieces fit together then I've failed.
Stop me if you’ve heard this one before…
If an idea here doesn't scare you; if it doesn't freak you out a little; If an doesn’t cause a little trouble... then pass it by. This is not intended to win wide head-nodding agreement. If an idea doesn’t get some pushback - especially from those in authority and power, it’s probably not a big idea, and it’s probably old, and it probably won’t work. Change comes ‘in spite of…’.
None of these ideas will be quick fix, easy-way shortcuts, though a fair number are simply different ways of looking at the problems of the day. None of them are ingenuous policy solutions, funding shifts, or simple tactical changes. None are easy. And none are truly new either - Healthcare is a big world and there is nothing new under the sun.
My hope is that you will find the way I present these ideas somewhat outside the mainstream and thought-provoking. The change required is well known, but it’s been held out of bounds until now.
What I will try to do is offer constructive, specific ideas. Where I resort simply to criticism, my hope is that it is specific and concrete enough that it adds constructively to the discussion by giving a new way to talk about a problem and indicating where we might turn to find the new answers that I'm sure are out there and coming at us… we’re not the only ones working on this problem.
Strategic vs. Tactical
Change in Healthcare Reform
Understanding the difference between strategic and tactical change is crucial for reforming healthcare in Nova Scotia (or anywhere else). Both are necessary, but they serve different purposes and operate on different timelines.
Strategic Change (Big-Picture, System-Level Reform)
Definition: Strategic change focuses on long-term, structural transformation of the healthcare system. It addresses the root causes of inefficiencies, misaligned incentives, and systemic dysfunction.
Characteristics of Strategic Change in Healthcare:
Timeframe: Long-term (years, even decades).
Scope: Broad, system-wide changes affecting governance, funding models, and accountability structures.
Goal: To fundamentally improve how healthcare is structured, managed, and delivered.
Who Drives It: Political leaders, policymakers, system architects.
Example in Healthcare:
Overhauling Nova Scotia’s Health Authority – Reducing administrative layers, breaking up unaccountable bureaucracies, and decentralizing decision-making to hospitals and frontline workers.
Changing Funding Models – Shifting from top-down budget allocations to performance-based or direct funding to frontline care.
Flattening the Organizational Structure – Adopting a military-style chain of command where decisions move quickly from frontline staff to leadership without excessive bureaucracy.
Privatization or Mixed Delivery Models – Introducing private-sector partnerships for non-critical services while keeping core emergency and essential care under public control.
Successful Strategic Change
Accountability Must Be Clear – If healthcare reform is strategic, there must be a single accountable person for each part of the change.
No Bureaucratic Evasion – A strategic plan should not allow for "diffused" responsibility. Someone must own the failure or success.
It Must be Radically Practical – Bureaucrats love complexity; we must demand simplicity and efficiency. A strategic shift should cut bureaucracy, not add to it.
Tactical Change (Operational, Immediate Fixes)
Definition: Tactical change focuses on short-term, operational improvements that can be implemented quickly to address specific problems in the healthcare system. These are "boots on the ground" changes rather than sweeping reforms.
Characteristics of Tactical Change in Healthcare:
Timeframe: Short-term (weeks to months).
Scope: Specific fixes at the hospital, department, or frontline level.
Goal: To solve immediate problems without requiring structural change.
Who Drives It: Hospital administrators, department heads, frontline medical staff.
Example in Healthcare:
ER Process Improvements – Our first and foremost priority. Increase safety. Reducing wait times by reorganizing triage protocols, adding more paramedics, or deploying more nurse practitioners.
Technology Upgrades – Implementing better patient management software to speed up communication between doctors and nurses.
Eliminating Redundant Admin Tasks – Cutting paperwork that doesn’t directly contribute to patient care, freeing up time for doctors and nurses.
Better Shift Scheduling – Preventing staff burnout by improving work-hour distribution and ensuring better use of available personnel.
Successful Tactical Change
"No Problem is Too Small to Fix." Small inefficiencies, when ignored, create system-wide failures. A failing ER doesn’t need a committee—it needs someone empowered to make immediate changes. It needs more people on the frontline.
Immediate Action is Key. Tactical change should be executable today, not someday. Bureaucracy loves "studies" and "future initiatives"—we need to believe in fixing what’s broken right now.
Authority Must be Given to Frontline Leaders. Just like a military squad leader doesn’t wait for a general’s permission in a firefight, hospital department heads should be able to fix local inefficiencies without waiting for provincial or management approval.
How Strategic and Tactical Change Work Together
Strategic change sets the vision (e.g., moving resources to the frontline, decentralizing hospital decision-making, eliminating layers of bloated bureaucracy and unaccountable senior management).
Tactical change implements the fixes needed today (e.g., safety, more staff, allowing ER nurses more autonomy in triage).
If you only focus on tactical change, you get short-term band-aids without fixing the root cause of the problem.
If you only focus on strategic change, you risk paralysis—massive reforms take years, and people suffer in the meantime.
Healthcare Reform Needs Both
Right now, Nova Scotia is failing at both levels:
Tactically: The ERs are imploding, frontline workers are burning out, and the system is slow to react to crises.
Strategically: We keep pouring money into the same broken structure without changing the fundamentals of how healthcare is run.
Citizens must demand immediate tactical fixes to stabilize the system while strategically flattening bureaucracy and making leadership personally accountable for real, long-term reform.
PART II
A Series of Ideas On Management
Any one detail, followed through to its source, will usually reveal the general state of readiness of the whole organization. Pull on any one thread and you can unravel the whole blanket.
The Devil is in the details, but so is salvation.
The person in charge must concern themself with details. If she does not consider them important, neither will her subordinates. Yet “the devil is in the details.” It is hard and monotonous to pay attention to seemingly minor matters. In my work, I probably spend about ninety-nine percent of my time on what others may call petty details. Most managers would rather focus on lofty policy matters. But when the details are ignored, the project fails. No infusion of policy or lofty ideals can then correct the situation.
In Greek mythology, Antaeus was a giant who was strong as long as he had contact with the earth. When he was lifted from the earth he lost strength. So it is with doctors. They must not become isolated from the real world...
Sit down before fact with an open mind. Be prepared to give up every preconceived notion. Follow humbly wherever and to whatever abyss Nature leads, or you learn nothing. Don't push out figures when facts are going in the opposite direction.
More than ambition, more than ability, it is rules that limit contribution; rules are the lowest common denominator of human behavior. They are a substitute for rational thought.
Administration is, or ought to be, a necessary overhead to aid production, and should at all times be kept as low as possible.
What it takes to do a job will not be learned from management courses. It is principally a matter of experience, the proper attitude, and common sense — none of which can be taught in a classroom... Human experience shows that people, not organizations or management systems, get things done.
To doubt one's own first principles is the mark of a civilized person. Don't defend past actions; what is right today may be wrong tomorrow. Don't be consistent; consistency is the refuge of fools.
Free discussion requires an atmosphere unembarrassed by any suggestion of authority or even respect. If a subordinate always agrees with his superior he is a useless part of the organization. In this connection there is a story of Admiral Sims when he was on duty in London in World War I. He called a conscientious hard-working officer in to him to explain why he was dissatisfied with the officer's work. The officer blushed and stammered when Sims pointed out that in all the time they had been working together the officer had never once disagreed with Sims.
Avoid over-coordination. We have all observed months-long delays caused by an effort to bring all activities into complete agreement with a proposed policy or procedure. While the coordinating machinery is slowly grinding away, the original purpose is often lost. The essence of the proposals is being worn down as the persons most concerned impatiently await the decision. The process has been aptly called coordinating to death.
A system under which it takes three men to check what one is doing is not control; it is systematic strangulation.
I believe it is the duty of each of us to act as if the fate of the world depended on him. Admittedly, one man by himself cannot do the job. However, one man can make a difference... We must live for the future of the human race, and not for our own comfort or success.
When doing a job — any job — one must feel that he owns it, and act as though he will remain in that job forever. He must look after his work just as conscientiously, as though it were his own business and his own money. If he feels he is only a temporary custodian, or that the job is just a stepping stone to a higher position, his actions will not take into account the long-term interests of the organization. His lack of commitment to the present job will be perceived by those who work for him, and they, likewise, will tend not to care. Too many spend their entire working lives looking for the next job. When one feels he owns his present job and acts that way, he need have no concern about his next job.
One must create the ability in his staff to generate clear, forceful arguments for opposing viewpoints as well as for their own. Open discussions and disagreements must be encouraged, so that all sides of an issue are fully explored.
Do not regard loyalty as a personal matter. A greater loyalty is one to the Navy or to the Country. When you know you are absolutely right, and when you are unable to do anything about it, complete military subordination to rules becomes a form of cowardice.
It is a human inclination to hope things will work out, despite evidence or doubt to the contrary. A successful manager must resist this temptation. This is particularly hard if one has invested much time and energy on a project and thus has come to feel possessive about it. Although it is not easy to admit what a person once thought correct now appears to be wrong, one must discipline himself to face the facts objectively and make the necessary changes — regardless of the consequences to himself. The man in charge must personally set the example in this respect. He must be able, in effect, to "kill his own child" if necessary and must require his subordinates to do likewise.
One must permit his people the freedom to seek added work and greater responsibility. In my organization, there are no formal job descriptions or organization charts. Responsibilities are defined in a general way, so that people are not circumscribed. All are permitted to do as they think best and to go to anyone and anywhere for help. Each person is then limited only by his own ability.
As subordinates develop, work should be constantly added so that no one can finish his job. This serves as a prod and a challenge. It brings out their capabilities and frees the manager to assume added responsibilities. As members of the organization become capable of assuming new and more difficult duties, they develop pride in doing the job well. This attitude soon permeates the entire organization.
Responsibility is a unique concept... You may share it with others, but your portion is not diminished. You may delegate it, but it is still with you... If responsibility is rightfully yours, no evasion, or ignorance or passing the blame can shift the burden to someone else. Unless you can point your finger at the man who is responsible when something goes wrong, then you have never had anyone really responsible.
PART III
AN INDEX
Number of all doctors in Nova Scotia per thousand people: 3.4
In Canada: 2.7
World Health Organization minimum recommended number: 2.5
Amount doctors are paid less than the national average in Nova Scotia: $10,000-$100,000
Percent decline in the number of patients seen per year per doctor in Nova Scotia since 2000: 25%
Total number of nurses in Nova Scotia: 15,000
Percent of a graduating class of nurses who will take a job offered in Nova Scotia: 50%
Percent of nurses who will quit within the first five years: 50%
In the first year: 17%
Percentage of population self-reporting to be in poor health: 2.8%
OECD (Organization for Economic Co-operation and Development) average: 8.5%
Frequent fliers: Amount of healthcare resources used by top 5% of all users: 55%
Lowest 50% of all users: 4%
Percentage of all people aged 50 and older that DID NOT need hospitalization last year: 91.4%
Nova Scotia’s physicians spend approximately 1.36 million hours annually on administrative tasks, equating to the workload of 625 full-time physicians.
Canadian spending on healthcare last year: $300 Billion
As a percentage of GDP: 13%
Canada’s spending/ GDP position in world: 2nd highest
Nova Scotia’s healthcare spending: $9.5 Billion
As a percentage of GDP: 18.27%
Nova Scotia’s healthcare spending/GDP position in the world: Number 1
PART IV
WHERE DO WE START?
We start by having a historically popular premier whose government came into power with a mandate to do more and to go further than any premier before to make our healthcare system work better for Nova Scotians.
And we know a lot about what doesn’t work.
We know from the previous Liberal government that centralizing power and control in ever bigger bureaucracy does not work.
We know from the NDP government before them that simply spending more does not work.
We know from a generation of management that tinkering with this policy and that does not work.
And we know from three years of crisis management with the new government that racing to the scene of every fire is not solving the big problems.
Now we must stop and start again with new goals in mind, new systems of responsibility, and new accountability.
PART V
A CHANGE IS COMING
Of course Canada’s healthcare system is irreparably broken.
It’s an 80-year-old socialist idea conceived before the polio vaccine was even invented, let alone our expectations about modern healthcare. Like many of the 80-year-old hospital buildings where it is practiced, the current scheme cannot scale to the size, complexity, and pace of change happening in the modern world.
The notion that the current monopolistic, rigidly ruled, bureaucratically overwrought, centrally planned, system can be brought back to its prime is stupid because after some practical point optimism and stupidity are nearly synonymous.
Everyone is grieving.
No one is happy.
There is no quick fix, easy way.
There is an institutional resistance to change.
Government is perceived to have only one lever – more or less money – and that lever is not working.
Everyone wants more and better.
The myth of the Canadian universal eternal healthcare system, held in suspended animation by a misguided and jingoist nationalistic pride, is dead.
The only question remaining is how many Canadians will have to suffer and die before a Supreme Court Charter decision, a citizen uprising, or a practical and pragmatic government finally puts an end to this anachronistic socialist monopoly that is hurting all Canadians.
We could encourage the provinces to join together to genuinely decentralize healthcare; fighting to repatriate local control from the federal government to reform and reimagine a new system with new goals in mind. The Provincial government and other governing bodies must also be held to account and be willing to give up long-held, entrenched, and dogmatic positions and powers.
Long wait times, low worker productivity and dissatisfaction, out-of-control costs, public complaints, and resistance to change are symptoms that cannot be fixed with new policies, studies, money, and hope. We must, as a country of local communities, stop and start again with a new goal in mind.
Costs have gone out of control. Productivity has stalled. Doctors are seeing 25% fewer patients per year than they were 20 years ago. No one in a position of power is willing to state this or investigate why it is happening. The number of frontline workers per thousand people has actually declined in spite of massive overall budget increases. Meanwhile, healthcare and social assistance is by far the largest employment sector in Nova Scotia, growing to nearly ¼ of all jobs in the province with almost all that growth in administrative positions.
The fight is against bureaucracy. It is the enemy. Bureaucracy is a disease that infects large mature organizations, and government is the biggest in history. The larger the system, the more exponentially explosive the bureaucracy. The tentacles of bureaucracy need to be treated like the cancers they so much resemble.