Health reform is stalling because we keep firing deputy ministers

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One day after new Nova Scotia Premier Stephen McNeil was sworn in, he fired three deputy ministers and shuffled six others.

One of those who got the axe was Kevin McNamara, until then the country's longest serving deputy minister of health – federal, provincial or territorial. He had a mere four-and-a-half years under his belt.

Mr. McNamara is one of the most knowledgeable people in Canadian healthcare – professional and well-respected. He was not given a reason for his dismissal. And he's too classy to make a fuss.

If you want to know why there are so many sensible proposals for reforming the health system but so little concrete action, look no further for an explanation.

Mindless change for the sake of change has become the norm.

You cannot make progress – in business, in government or in the not-for-profit sector – without sound, stable management, without vision.

Yet, in the upper echelons of Canada's healthcare system – and government in general – there is constant churn.

The Public Policy Forum studied this issue a few years back and found that the average lifespan of a federal deputy minister is 19.4 months.

By contrast, National Hockey League coaches – who, the saying goes, are "hired to be fired" – have an average tenure of 32.5 months. And CEOs of FP500 corporations – which suggests they are the best managed – keep their jobs for an average of 121 months, or just over a decade.

These numbers confirm something we know anecdotally: In Canadian public policy circles, there are no well-established leaders and, hence, no real leadership.

While ministers of health have the high profile, it's deputy ministers who do the heavy lifting, who command the army of public policy people in the bureaucracy.

Health is a complex file. Conventional wisdom is that it takes about two years for a minister and/or deputy minister to really be comfortable in the job. But few actually last that long.

Does is really benefit the Canadian public to have senior policy makers who wallow in ignorance and who never have a real opportunity to implement change?

It's certainly costly. Given the current dynamic – no knowledge of the ministry apparatus and no time – ministers and their deputies have to turn to outside consultants at great expense. These consultancies, ironically, are dominated by ex-mandarins, who recycle the plans they had when they were in office.

Then the deputy and the minister are shuffled again, and the cycle begins anew. To everything there is a season, churn, churn, churn.

The longest serving minister of health is Ontario's Deb Matthews, who has held the position since October 2009. It's no coincidence that, in the last couple of years, the province has made tremendous headway in a number of areas, ranging from pricing of generic drugs through to the implementation of significant reform in primary care.

A minister like Ms. Matthews is constantly bombarded with demands from interest groups and individual constituents and it takes a while for anyone to be able to sort the wheat from the chaff. It also takes some time to gain confidence and build trust among deputies and their underlings.

The tendency in Canada, at least in recent years, has been for new governments to clean house when they take power, to toss out or shuffle deputy ministers.

This "to the winner go the spoils" philosophy is counter-productive. Constantly shifting senior management means there is no institutional memory, no consistency and, most of all, no vision.

Having political toadies at the helm unnecessarily politicizes the bureaucracy. It also encourages mediocrity in management: The only deputies who keep their jobs tend to the blindly partisan or the Caspar Milquetoast types.

Employees of departments and ministries of health understand this dynamic and, in turn, they quickly learn that the safest approach is to never rock the boat to stay quiet.

If ideas don't rise up and ideas don't trickle down, you get stagnation, and stagnation (read: status quo) is what we tend to have in Canadian health policy.

Governments and the ministers of health in those governments usually take power with a few ideas in mind for fixing healthcare.

So why do those promises largely go nowhere? Why does reform tend to consist of changing the names on programs and little else?

Because politicians tend to be afflicted with the delusional notion that public policy can be changed with a snap of the finger or a wave of the magic wand.

The reality is that there is – like it or not – a process. If you want to work a system, you have to know the system – in government as in business.

Seasoned senior bureaucrats know that the real secret to implementing change is having strong relationships. A modern deputy minister of health needs to be on a first-name basis with the CEOs of regional health authorities, with the leaders of provincial nursing and physician groups, and with hospital bosses.

With Ottawa having largely abdicated its role in creating a semblance of a national health system, it has fallen to provincial and territorial health ministers and their deputies to do so.

They can't do so if they come and go as if in a revolving door.

Deputy ministers need to be able to speak truth to power – to the health minister and to the premier. To do so they need tenure and stability; they need to be leaders, not caretakers.

Only then will we get meaningful change.

André Picard is The Globe's health columnist.