Canada

Danielle Smith believes she’s found the org chart that saves health care

If there was a health-care system structure that guaranteed better patient care, lower surgical wait times, and impartial and accountable decision-making, then it would be in place everywhere.

But it’s not.

British Columbia has five regional health authorities. Québec has 18. Ontario? It’s somewhat complicated.

In 2008, the Alberta government dispensed with years of frustration with the Calgary Health Region’s leadership and other tensions by smooshing everything together into Alberta Health Services, which always sounded on its face like the U.K.’s National Health Service, except that regionalization and decentralization have been Brits’ watchwords for ages.

AHS was a sufficiently effective and/or non-disastrous model that Nova Scotia and Saskatchewan followed suit with their own amalgamations in the last decade.

It’s arguable whether the promised cost savings and efficiencies of innovation ever materialized from this bigger-is-best approach. But now the province that started the centralization trend is embarking on a major disassembling, promising “patient-centred” outcomes, which is somehow different from 2008’s pledge to put the “patient first.”

Is this the organizational chart that finally cures the strains and aches of Alberta health care?

In the pre-AHS times, continuing care, mental health and hospital/acute care were all integrated within regions (with a specific agency for addictions treatment, for those who remember AADAC). In the new era Premier Danielle Smith is ushering in, Alberta’s monolithic superagency is broken into separate organizations by function.

“We believe that by creating specialized organizations within one provincial system, we will enable each organization to look after one area of health care only and avoid the scattered and unco-ordinated approach of the more rigid centralized structure that exists now,” the premier said at this week’s announcement.

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Of course, one person’s “scattered” and “rigid” is another person’s seamless — just as the UCP premier’s emphasis on focus sounds like a new bureaucratic mess to her NDP predecessor.

“This backward-looking UCP plan will stuff patients and providers back into ineffective silos,” NDP Leader Rachel Notley said. “Imagine a senior living in a continuing care facility who has to be taken to hospital because of a mental health condition. Under this plan, that poor senior is being tossed between at least three different government agencies.”

The New Democrats warn this latest system shakeup will pave the way for health privatization, the warning they tend to give in most months with vowels in their names. While it should be stated that any change may open the door for more for-profit providers, it should also be stated that Smith and Health Minister Adriana LaGrange say that’s not afoot in their plans, and their latest federal funding binds them further yet to the Canada Health Act provisions.

Reducing AHS to minor-player status

True as well: a government can surely overhaul health systems without bundling in privatization, just as a government can privatize without overhauling health systems.

While the premier has long shown past interest in private models and user pay, during the election and her premiership she’s shied away from those. But she hasn’t much shied away from her animus toward AHS, which appeared to harden in the pandemic; consider that the mass ouster of the agency’s board was one of this premier’s first actions. 

Smith’s reforms not only strip from AHS the responsibility for everything except acute care and hospitals, but also reduce AHS to being a minor player even within that subsector. One of its four pillar/silo/column organizations will oversee acute care, overseeing AHS as an equal alongside Catholic hospital manager Covenant Health and private surgical clinics — a reversal from present practice, in which Covenant and private firms were AHS’ contractors. (Smith’s team has developed the novel argument that AHS has a conflict of interest in the current system, which overlooks the fact that the former regional authorities also centrally coordinated a zone’s care as not-for-profit public entities, without the public screaming governance blue murder).

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Former premier Ed Stelmach may have criticized AHS for having taken over much of government’s decision-making on budget, infrastructure and policy in the years since he created the mega-organization 15 years ago. But he also was speaking at Smith’s press conference as Covenant’s chairperson, an organization that will be newly empowered under the UCP’s shakeup.

A woman address the media from behind a podium as another woman looks on.
Alberta Health Minister Adriana LaGrange speaks as Premier Danielle Smith looks on during a news conference on Nov. 8, where structural changes to Alberta Health Services were announced. (Jason Franson/The Canadian Press)

With LaGrange’s Health Ministry assuming new oversight of infrastructure projects and facility planning, is it no longer a given that AHS will run a new Red Deer hospital? A future Airdrie or north-Calgary facility? A standalone children’s hospital in Edmonton? So much, it appears, will be up to how the Smith government sorts out its new health-world order.

While it’s being termed a decentralization, much power is now consolidated within Smith’s own government and ministries. Provincial deputy ministers constitute half the board members chosen for AHS as it’s being disassembled, and the chair is former provincial minister Lyle Oberg, a former doctor and longtime Smith ally.

Politicians and bureaucrats will be at the heart of the “integration council” tasked with figuring out how the process of dismantling works without creating silos. Ministries of Health and Mental Health and Addiction will absorb many duties, including procurement — one of the centralizing functions that was always deemed one of the main perks of starting AHS in the first place.

According to leaked cabinet documents the NDP publicized, the Health Ministry will also eventually take over AHS’ public health and restaurant inspections operations, after they were so front and centre and scrutinized during the E. coli outbreak at a series of linked daycares this fall (and a year after chief medical officer of health Dr. Deena Hinshaw’s (first) termination sent shockwaves through public health).

In this vein, this reform is at the same time a decentralization and a recentralization in the ministries of LaGrange, Mental Health and Addictions Minister Dan Williams — and, ultimately, the premier’s office.

Dismantling the piñata

On one hand, it will end the recurring disempowered spectator status of successive Alberta health ministers as the mighty superboard did something disagreeable. “If something goes wrong with AHS and the government pays the price for it politically, you can see why that’s a bad bargain,” health systems expert Steven Lewis told CBC colleague Janet French.

But it also means the politicians will have to own more of the decision-making, without AHS to scapegoat, hide behind, or arm-wrestle with. They rejig it, they own it.

Lewis also expects this ambitious overhaul is “a concession to the rural base, which always used AHS as the piñata,” he said.

But as many ironies and quirks of this new era of integration/disintegration unfold in coming years, here’s one to watch out for.

As much as a government wishes to carve up the doctors’ clinics, mental health facilities, the senior homes and the hospitals into separate entities, so often in AHS-averse rural Alberta they’re all one facility — the hospital. In fact, the leaked cabinet briefing suggests that “AHS may operate some continuing care and primary care in rural hospitals, where appropriate.”

In other words, in some areas where the desire to defang AHS is strongest, the old agency will still loom large.

At least, that is, until another government comes along and decides it knows just the right org chart that will fix patient care.

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