Saturday, May 24, 2008

De-Regionalizing Alberta

The Road to Reform or Collateral Political Damage?
And then there was one.


by Steven Lewis

Last Wednesday (May 14, 2008), 12 boards governed Alberta’s 9 health regions, and the province’s mental health, cancer, and alcohol and addictions programs. A day later they were all replaced by the Alberta Health Services Board (AHSB). Alberta is the second province to eliminate RHA boards – PEI (population 140,000) was the first. New Brunswick is down to two. The Alberta solution is nothing if not Canadian: when in doubt, restructure.

Why this, and why now? Recent Alberta politics explain the timing. Premier Ed Stelmach was the surprise winner in the Conservative leadership race last year over heir apparent (and previous Calgary RHA Board Chair) Jim Dinning. Widely expected to suffer serious electoral losses in the recent election, Stelmach won a massive majority. This conferred a license to make a clear and dramatic statement as a means
of putting a new face on government and bidding a final adieu to the Klein-Calgary era.

The why is more interesting. Regionalization as originally conceived was intended to devolve authority from the provincial level while consolidating it at the local level. In no province was devolution as thoroughgoing as envisioned. Political accountability proved difficult to devolve, so governments continued to have to answer for alleged regional missteps. Over the years most provinces have repatriated authority from the regions, retaining control over major decisions such as facility closures and earmarking funds for specific purposes. But RHA boards do experiment and innovate, reach out across sectors, have mechanisms for responding to local concerns and preferences, and advocate for their regions.

So what, in the government’s view, is the trouble with regionalization? In April Health & Wellness Minister Ron Liepert said that a new governance model was needed to improve management. Perhaps the new regime sees the regions as vocal irritants always clamouring for money. Perhaps it was an accumulation of perceived sins, from the instrument sterilization cock-ups in East Central to the very public complaints of underfunding by the Calgary RHA leadership prior to and after the election. Structural reform does not guarantee improved access, better quality, or greater efficiency. Moreover, restructuring takes its toll on leadership and creates anxiety among the troops. It succeeds only when it is part of a coordinated, substantive plan to change the system’s culture, incentives, and accountability.

The creation of the AHSB is the first of a promised three stages of changes to be announced by December 15, 2008. The most concrete commitments thus far are to train more doctors, extend the ban on trans fats in restaurants and get rid of junk food in schools. Whatever the merits of these measures, they are hardly transformational, and none requires taking regionalization apart.

That leaves de-regionalization and its prospects for success. The key questions are:
• Will the promised Community Health Councils be acceptable substitutes for the RHA boards or dismissed as toothless imitations of the real deal? They are to be appointed by the AHSB, raising obvious questions about their independence and capacity to advocate and criticize. British Columbia had a two-tier system in the 1990s, with local community councils mandated to advise the RHA boards. The public had more connection to and confidence in the community councils than the RHA. The government eliminated the tension by getting rid of the community councils.
• What will become of the population health agenda? Reducing health disparities is intersectoral work that takes place at the neighbourhood and community level. One of the unsung triumphs of regionalization has been the education of boards about the non-medical determinants of health and the importance of addressing the root causes of ill health. Can a single provincial board even begin to understand and pursue a population health agenda in the face of the predictable preoccupation with access, wait times, drugs and technologies? Will the system stake its future on a highly
medicalized, technology-focused view of health? Who will champion prevention and health promotion, and back up rhetoric with dollars?
• How will the voices of the marginalized be heard? It’s daunting enough to get the attention of an RHA board, let alone a single provincial authority working out of Edmonton.
• If the model retains regions as administrative units, how much authority and flexibility will accrue to the executives? To what extent will they be able to reallocate funds and experiment with new approaches? Existing CEOs, several of whom have national and international reputations, have been given until April 2009 to find other work. Will this capacity find meaningful roles in the new era or will the province find itself with a severe executive talent shortage?
• The new board reports directly to the Minister. Will the Minister (and the ministry) set out a broad set of expectations and accountabilities and let the board operate with considerable autonomy – almost like a Crown Corporation – or will the leash be short? Will the power lie with the AHSB or with the Minister and Deputy?

All should clarify in the coming months. The first move shows no lack of courage: poking a stick in the eye of 125 politically well-connected board members and the communities they represent is a calculated act of disharmony. If there is leftover boldness to apply to the substantive issues, there are some intriguing possibilities. Imagine the AHSB with a mandate to achieve:
• A fully functional, interoperable, standardized electronic medical record within 2 years.
• A health human resources plan that optimizes the roles of all providers, with expanded roles for nurses, pharmacists, and therapists.
• The full integration of physicians into the system with a focus on primary health care.
• The removal of all of the perverse incentives in the system that drive up costs and stand in the way of equitable, high quality care.
• A brave, evidence-based, cost-effective approach to drug purchasing and prescribing.
• A real reduction in health disparities between the well-off and the disadvantaged.

In a jurisdiction truly committed to reform, the restructuring would be the warmup act to a genuine transformation agenda. Alberta’s health regions have arguably been leaders in quality improvement, health information technology adoption, and primary health care renewal. With the stroke of a pen a great deal of innovation capacity and experience has been cast aside. Nothing in the public communiqu├ęs to date suggests that anyone has thought very deeply about the risks and consequences of the dismantling. The challenge for the government and the AHSB is to get out of the gate with some creative policies and progressive decisions.

Without some early and tangible wins, the memory of May 15, 2008 may linger longer and deeper in the public consciousness than its architects ever imagined.
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Steven Lewis is President, Access Consulting Ltd., Saskatoon, Adjunct Professor of Health Policy, University of Calgary & Simon Fraser University and a member of the editorial advisory board for the journal Healthcare Papers | Steven.Lewis@shaw.ca