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 communiqués 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

Cancer Care Ontario Releases Action Plan for Improving Provincial Cancer Services

Cancer services better today, action needed to meet a 40 per cent increase in cancer patients in next 10 years

Toronto (March 20, 2008) – Cancer Care Ontario today released the 2008-2011 Ontario Cancer Plan, an action plan designed to boost cancer screening rates, improve access to diagnostic and treatment services, make cancer services better and safer, and put new cancer research into practice, faster.

"More people are surviving cancer and cancer services are better today than ever because of actions that have been taken in recent years," says Terrence Sullivan, President and CEO, Cancer Care Ontario.

"We cannot afford to be complacent because 40 per cent more people will be living with cancer in the next decade. By working with our partners to take the steps set out in the Ontario Cancer Plan, fewer people will get cancer and more will survive a diagnosis and receive better services, every step of the way."

The 2008-2011 Ontario Cancer Plan is a three-year road map for the province’s cancer system. It sets out the actions that need to be taken to control cancer and improve patient care. This is the second Ontario Cancer Plan. The first plan was released in 2004.

"We have made huge gains in the fight against cancer since the first Ontario Cancer Plan," said George Smitherman, Deputy Premier and Minister of Health and Long-Term Care. "In the last five years our government has added more quality services for patients suffering with cancer. This has reduced wait times significantly and has allowed patients to get quality cancer care closer to home. We will continue to work side by side with Cancer Care Ontario and health providers on the front lines to lessen the toll of cancer."

The 2008-2011 Ontario Cancer Plan has six goals and highlights four key actions that will have the greatest impact on cancer in the next three years:

1. Boosting cancer screening rates through aggressive education about screening, providing tools to help primary care providers and patients participate in screening, including using IT to send invitations, reminders and prompts about screening. Cancer Care Ontario will work with our partners to reach under-screened groups including low income earners, new Canadians, people without a family physician and Aboriginals.
2. Improving the time to diagnosis by beginning to measure and set targets for the wait time between a referral from a family physician to when the patient sees a specialist for tests.
3. Raising the quality of regional cancer services through implementing improvements including; providing better access to chemotherapy in community hospitals, closer to home; making highly complex chemotherapy and lung surgery safer; and making intensity modulated radiation therapy (IMRT) the gold standard radiation therapy.
4. Ensuring the high quality and safe introduction of tests that can predict people’s response to treatment and cancer risks, and enable individualized therapy – referred to as molecular medicine.

Significant progress has been made since the first Ontario Cancer Plan. Wait times for radiation and cancer surgery have been steadily going down; regional cancer services and centres have greatly expanded; there are fewer smokers because of Smoke-Free Ontario Act; and the colorectal cancer screening and HPV vaccination programs will save lives.

Growing Number of People with Cancer, Need for Services

• Close to half of all people will develop cancer in their lifetime: 44 per cent of men and 39 per cent of women.
• Sixty per cent of cancer patients survive 5-years or more after a cancer diagnosis, up from less than half two decades ago. Almost all prostate cancer patients and 90 per cent of breast patients live more than five years after a diagnosis.
• In 2007 the province spent $176 million on 27,000 intravenous chemotherapy treatments. In 2011-2012, it is projected that Ontario could spend an estimated $446 million on 49,000 chemotherapy treatments. Cancer Care Ontario continually improves cancer services so that fewer people get cancer and patients receive better care.

• Ontario Cancer Plan Backgrounder
• Cancer Care Ontario Backgrounder

Disparities in Healthcare Access and Use: Yackety-yack, Yackety-yack

Healthcare Policy / Politiques de Santé, 3(2) 2007: 10-18

Despite change, uncertainty and disarray in Canada's healthcare system(s), some observations about Canadian medicare still seem beyond challenge:

access to healthcare based solely on need is the core value that gave rise to and sustains medicare; the advent, through medicare, of universal, publicly funded physician and hospital services substantially reduced disparities in access to, and outcomes of, healthcare based on socio-economic status (Enterline et al. 1973; James et al. 2007); despite those gains, disparities remain - factors other than need continue to influence access to and use of services. The last point deserves elaboration. A growing body of research evidence indicates that use of hospital services in Canada is generally consistent with relative need across income groups (e.g., Manga et al. 1987; van Doorslaer and Masseria 2004; Allin 2006). Some studies (van Doorslaer and Masseria 2004; Allin 2006) show greater use of hospital services by those with lower income after controlling for healthcare need - perhaps calling into question the adequacy of existing measures of need. On the other hand, studies of specialist services have demonstrated a direct relationship between use and income, education or both (McIsaac et al. 1993, 1997; Roos and Mustard 1997; Dunlop et al. 2000; Finkelstein 2001; van Doorslaer et al. 2006; Allin 2006) - wealthier and better-educated Canadians use more specialist services independent of need. The picture with respect to primary care physicians' services is less clear. Some studies show an equitable (i.e., needs-based) distribution across education and income groups (McIsaac et al. 1993, 1997; Roos and Mustard 1997; Dunlop et al. 2000), while others do not. For example, Birch et al. (1993) found the use of family physician services to be positively associated with level of education (and extent of contact with friends and relatives). Based on data from the 2001 Canadian Community Health Survey (CCHS), van Doorslaer et al. (2006) found that, after standardizing for healthcare need, higher income was associated with a greater likelihood of seeing a primary care physician but a lower number of visits. Using 2003 CCHS data and a similar methodology, Allin (2006) observed a pro-rich inequity in the probability of visiting a family physician, a finding that was inconsistent among the provinces and territories. In the 2002/03 Joint Canada/US Survey of Health, Canadians with low income were less likely to have a regular doctor and more likely to report unmet healthcare needs than those with high income (Lasser et al. 2006). In an earlier international population survey, Canadian respondents with below-average income were more likely than those with above-average income to report having difficulty getting needed care (Shoen et al. 2000). Data from the 1994/95 National Population Health Survey showed that the likelihood of women in the appropriate age groups having either a Pap smear or a mammogram was associated with higher education level and being born in Canada (Gentleman and Lee 1997; Lee et al. 1998). Income level was also independently associated with having a Pap test (Lee et al. 1998). In the 2005 CCHS, respondents in the highest two (of four) income categories were more likely than those in the lowest income category to report having a flu shot in the previous 12 months (Kwong et al. 2007). Ontario-based studies have shown a positive association between income and access to coronary angiography and revascularization (Alter et al. 1999) and to in-hospital occupational therapy, physiotherapy and speech pathology following a stroke (Kapral et al. 2002). Patients from the lowest-income neighbourhoods waited much longer for coronary angiography (Alter et al. 1999) and carotid artery surgery (Kapral et al. 2002) than those from the highest-income neighbourhoods. Recently published studies in Healthcare Policy/Politiques de Santé point to inequities in access to radiation therapy for breast cancer based on income level (Fortin et al. 2006) and to mental health services for anxiety or depression provided by both family physicians and psychiatrists based on education level (Steele et al. 2007). This summary, reflecting a brief and unsystematic scan of the literature, describes only the tip of a much larger evidence iceberg. Clearly, Canadian medicare has failed to achieve healthcare access (and use) based on need, even for those services within the purview of the Canada Health Act: hospital and physicians' services. Being poor, poorly educated or both impairs access to specialist and (probably) family physician services, to preventive care (e.g., Pap tests, mammograms and flu shots) and to services for specific health problems (e.g., cardiovascular and mental health). But income and education are not only associated with access to services; they are themselves determinants of health, and often cluster together with other determinants such as Aboriginal status, early life experiences, employment and working conditions, food security, housing, social exclusion, social safety net, unemployment and employment security (Raphael 2004). The very people who need care the most are the least likely to get the care they need. Evidence of the continuing relationship between socio-economic characteristics and access to health services under medicare is abundant, long-standing and persistent. This evidence is without doubt well known (at least in part) to health system decision-makers. Why, then, is there so little sign of concerted heath policy or health system design and management initiatives at the federal or provincial/territorial levels to address this violation of the fundamental rationale for Canadian medicare? It may be more than coincidence that those on the receiving end of inequitable access are among the least politically and economically powerful members of Canadian society. Although many Canadians are passionately committed to the principle that access to essential health services should be based only on need, they may, given a lack of media and political attention to the issue, assume that the elimination through medicare of (most) financial barriers to obtaining hospital and physicians' services has solved the access problem. Under these circumstances, politicians and governments at the federal and provincial/territorial levels are under little or no pressure to mount a response. As a result, current policy complacency seems likely to continue unless equity of access emerges as a public issue that resonates with Canadians who support the core principles of medicare and mobilizes civil society. Now, there's a challenge for knowledge translation. Meanwhile, there will undoubtedly be lots of talk (research on access inequities and acknowledgment - out of public view - of their existence), but little policy action.