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Globe and Mail (Jan 10 2017): The real health-care change we need? Strong leadership

ANDRÉ PICARD

Saskatchewan has announced that it will scrap its 12 health regions and create a single health authority. It is the latest province to abandon the once-popular approach of regionalization in favour of more centralized control.

Prince Edward Island, Nova Scotia and Alberta all have a single administrative body for health care; British Columbia has gone from 20 regions to five; Manitoba from 11 to five; New Brunswick from eight to five, and so on.

The only holdouts are Quebec, which has 18 regional health and social-services agencies, and Ontario, which has 14 local health integration networks (and 76 sub-LHINs).

While there is a lot of rhetoric about the horrors of bureaucracy and the benefits of consolidation, we don’t really have any idea what the best management structure is for a health system, and for patients.

The theory is that regional bodies are more responsive to local needs, while centralized ones allow for more cohesiveness. Ideally, of course, we should strive for both.

The most remarkable aspect about the radical changes that provinces have implemented is that they are evidence-free and there have been virtually no follow-up studies to examine whether there have been benefits, financial or otherwise.

Too often, it is change for the sake of change – or to give the illusion of reform – and it amounts to little more than shifting the position of the deck chairs on a listing ship.

Alberta kicked off the regionalization trend in 1994 with a wildly disruptive move: It scrapped 128 hospital boards, 25 public-health boards and 40 long-term-care boards overseen (barely) by the Ministry of Health and created 17 regional health authorities. In 2003 that number was reduced to nine. Along the way, Alberta created what was broadly considered to be Canada’s best health system, not because it was visionary but because, for the first time, there was modicum of management and organization.

But health regions were independent and powerful and that didn’t sit well with the political masters. So, in 2008, regional health authorities were scrapped in favour of a single authority, Alberta Health Services. The AHS became a viper’s nest, controlled by political toadies and rife with internal feuds, to the point where the government vowed to “re-decentralize” (which has to be the most Canadian word ever conceived).

Saskatchewan has vowed to not repeat Alberta’s mistakes. Yet it is trotting out the same arguments: We want better, more integrated, patient-centred care at a lower cost. How that will be achieved by fiddling with bureaucratic structures – in essence, changing the names on the plaques on administrators’ doors – is not clear.

Saskatchewan Health Minister Jim Reiter said consolidation will reduce duplication and save money, though, when pressed, he admitted that “cost savings are not the primary driver.” (The exercise is expected to save about $7.5-million on a provincial health budget of $5.7-billion.)

One of the most popular rhetorical phrases in Canadian health care is that “we need to spend more on front-line care and less on bureaucracy.”

The reality is that we have very little idea how much we spend on bureaucracy. According to the Canadian Institute for Health Information, 3 per cent of the $228-billion in annual health spending goes to administration, or about $7-billion. But that is the cost of running ministries of health and health authorities; it doesn’t include, for example, the administration of hospitals or nursing homes.

The problem with Canadian health care is not too many or too few health regions; it is that no one is ultimately in charge, or accountable. There are no clear lines of authority. And even where there is a boss, decisions are too often overruled by ministers of health, who micromanage for political reasons.

Further, the single biggest expense – payments to physicians, nurses and other health workers, which account for about 60 per cent of all health spending – are centrally negotiated and out of the control of managers. In many provincial health structures, hospitals (or some hospitals) are also exempt from control by the regional health authority.

Complex health systems do not run themselves, and our current loosey-goosey collection of leaderless, milquetoast administrative bodies is not doing the job.

If you want a well-managed, efficient health system that provides value for money, you need to hire good managers, pay them decently, empower them and hold them accountable.

Until we do so, the number of health regions won’t matter, and the quality of health care will not improve appreciably.

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Health Canadacihr logo1This initiative has been generously funded by grants from Health Canada and the Canadian Institutes of Health Research. The views expressed here do not necessarily reflect those of the funders.