By Ron Liepert
Each Canadian province has created somewhat different structures to manage health service delivery. Through the 1990s, most adopted some form of regionalization and devolved a certain amount of responsibility for identifying and meeting health care needs to these regional structures. But in 2008-2009, two provinces took sharp turns away from regional models. Minister of Health Ron Liepert explains why Alberta did away with its regional structures altogether. —Report from a presentation at the 2009 conference of the MUHC-ISAI
Alberta and New Brunswick have experienced the most profound changes in the country over the past few years, and I dare say other provinces are watching to see whether we are going to be successful or not. In essence, Alberta dissolved nine regional health authorities, the Cancer Board, the Mental Health Board and the Alcohol and Drug Abuse Commission, and rolled them into one entity called Alberta Health Services, a province-wide health delivery system that is charged with delivering equitable services to Albertans no matter where they live in the province.
Many reasons for this particular decision have been cited, but in my view the purpose was to reverse the siloed and fragmented approach to the delivery of health care that had developed in Alberta — not by any devious means, but by evolution. This created barriers to the good care that various entities had originally been created to provide. These silos did not just develop between cancer, mental health and other areas, but also between regions. Initially, the desire was to promote healthy competition between regions in their coordination of the delivery of acute care, public health and continuing care. And individual regions did become leaders in certain fields of delivery. But what struck me in taking over this portfolio some 18 months ago was the reluctance to adopt winning strategies developed in other regions.
The competition was not constructive and did not promote patient access to care. One flagrant example was in neonatal care, an area that relies on constant cooperation between facilities. In Alberta, the Calgary and Capital (around Edmonton) regions accounted for about three-quarters of the population and housed the major university health centres. Over time, the relationship between these two regions deteriorated to the point where Capital’s first call for neonatal assistance was not Calgary but rather Saskatoon. And Calgary’s first call was not Edmonton, but Montana. As a result, two years ago, we had a Calgary mother deliver quadruplets in Montana when she could have been accommodated in Edmonton. While perhaps the most flagrant, this was certainly not the only example of how much cooperation between Alberta’s Regional Health Authorities had deteriorated.
The regional structure also put board members in a very difficult position. These boards were created as a governance model on behalf of Alberta taxpayers; however, each board member resided in a certain community and had, on a daily basis, to face neighbours on Main Street. It was difficult for board members not to advocate on behalf of their community, even when this was to the detriment of taxpayers. We took a bold step in the spring of 2008, and abolished these regional boards altogether.
The Alberta Health Services (AHS) merger is the largest in Canadian history. It involves an $8 billion operation with some 90,000 employees, along with physicians and other providers whose work is dependent on this system functioning smoothly. We appointed a board of directors that more closely reflects a board that should run an $8 billion operation. There has been criticism that this board should include more health practitioners, but I believe that what health providers do best is diagnose and treat patients. Board members need to know how to run $8 billion corporations.
The management team at AHS is now in place. We took the best from the old Regional Health Authorities. We recruited an international CEO from Australia, Stephen Duckett, a CFO from British Columbia, and we are in the process of recruiting a Vice President of Strategy from outside the country. The governance and administrative structures are now in place. We have also transferred our emergency medical services (EMS) from municipalities to AHS, and these are now an integrated part of our system. Now it is time to deliver more effective and efficient patient care, and improve access — in a manner that is cost effective. Alberta spends more on health care per capita than any other province except Newfoundland, some $30 million per day in total; we should expect more from that investment. We need to improve access, we need to move the patient from the bottom of the organizational chart to the top. Too often, providers claim to advocate on behalf of the patient, but whenever an attempt is made to move that patient up the organizational chart, a profession, union or special interest group will oppose it.
Time for change
Changes are often opposed just because a practice has been in place for 40 or 50 years. We need to address professional attitudes toward change, as well as a professional culture that encourages the public to think that they cannot get treated unless they are in a hospital, where the only person who can take care of them is an MD or an RN. The pace of cultural change in health care is not keeping up with patient demand, or with new medical advances, drugs and technology. Provider behaviour is also encumbered by administrative structures or boundaries that are often put into place by professional colleges. These too must change.
I am often asked by Albertans why we do not pattern ourselves after some of the more successful countries such as New Zealand, the UK, the Netherlands or Sweden when it comes to sustainable health care delivery. My answer is very simple: We are not a country. We must conform to the Canada Health Act (CHA), which I believe is an outdated piece of legislation that needs changing. It is an act that really defines very little but creates a myth in the public mind that acts as a barrier to change. The CHA implies that health care is only about hospitals and physicians.
We need to engage in real discussion, not political rhetoric, to enable Canadians to understand the prospect of obesity rates doubling by generation, and of a demographic shift in which one in five Canadians will be over the age of 65 by 2020. These are real issues for the next generation to pay for. We need to break down barriers and work with professions and unions to re-examine scope of practice. We need teams of professionals dealing with patients, practising team care and not just referring patients from one profession to another. It is time to develop and pioneer health care innovations to improve the quality of care for patients within a publicly-funded system. Because if we do not, the result will be an ever more inefficient system with constant shortages of staff at all levels, longer wait times, unsustainable costs and patients at the bottom of the organizational chart instead of at the top.