Vol. 16 • No. 1 • 2016
HealthcarePapers New Models for the New Healthcare
Regionalization: What Have We Learned? Gregory P. Marchildon
Commentary from Yves Bergevin, Gwyn Bevan, Yvonne Boyer, Adalsteinn D. Brown, Jean-Louis Denis, Stephen Duckett, Keesa Elicksen-Jensen, Katherine Fierlbeck, Bettina Habib, Derek Kornelsenand, Josée G. Lavoie, C. David Naylor, Peter W. T. Pisters, Jean Rochon, Denis Roy, Stephen Samis, Tim Tenbensel, Karsten Vrangbaek and Lloy Wylie
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HealthcarePapers New Models for the New Healthcare • Vol. 16 No. 1 • 2016
IN THIS ISSUE
INTRODUCTION 4 Regionalization Does Not Equal Integration Adalsteinn D. Brown, Peter W. T. Pisters and C. David Naylor The contributions to this issue of Healthcare Papers provide a clear picture of the strengths and weaknesses of regionalization efforts. The guest editor for this issue summarizes the current environment well when he states that, for want of something better, “regionalization remains the most viable means” to the improvement of healthcare system performance in Canada.
INVITED ESSAY 8 Regionalization: What Have We Learned? Gregory P. Marchildon Regionalization is arguably the most significant health reform in Canada since medicare. However, primary care has not been integrated into any provincial regionalization model. This factor has severely constrained the performance of regional health authorities and their ability to meet their respective legislative mandates. The lack of research on regionalization has also meant that provincial governments are working from an extremely limited evidence base on which to make critical decisions on the structuring of health systems in Canada.
COMMENTARIES 16 What Can We Learn from the UK’s “Natural Experiments” of the Benefits of Regions? Gwyn Bevan The author argues that changes in the National Health Service in the UK in the 1990s and 2000s offer three “natural experiments,” in terms of funding, organization and models of governance, that give evidence of the impacts of stable regions in the UK. He also considers the lessons of this evidence for Canada. 21 Regionalization Lessons from Denmark Karsten Vrangbaek In spite of the difference in size and historical traditions there are also many similarities between Canada and Denmark, particularly in terms of health and social policy goals and aspirations, and in terms of the commitment to a comprehensive, universal healthcare system. These similarities provide interesting opportunities for comparison.
1 HealthcarePapers New Models for the New Healthcare • Vol. 16 No. 1 • 2016
27 Health System Regionalization – the New Zealand Experience Tim Tenbensel New Zealand’s health system has many similarities with Canada, and also has significant experience with regionalization of healthcare services. Since 2001 the most significant change has been the development of regional primary healthcare organizations funded according to population characteristics. This significant change has created the potential for a more integrated health system. 34 Transforming Regions into High-Performing Health Systems Toward the Triple Aim of Better Health, Better Care and Better Value for Canadians Yves Bergevin, Bettina Habib, Keesa Elicksen-Jensen, Stephen Samis, Jean Rochon, Jean-Louis Denis and Denis Roy A study on the impact of regionalization across Canada in 2015 identified significant findings that involved: underperformance in some areas compared to other countries; movement towards a two-level system; the optimum size; and weak citizen and physician engagement. The authors present a realistic and attainable vision for high-performing regional health systems together with a way forward, including seven areas for improvement. 53 Regionalization as One Manifestation of the Pursuit of the Holy Grail Stephen Duckett Alberta’s implementation of a centralized structure for healthcare delivery had some strengths: economies of scale and expertise; opportunities for province-wide learning; internalization of geographic politics; and improved geographic equity. It also had weaknesses: diseconomies of scale, remoteness from communities and politicization. In any implementation of regionalization, policy makers should attempt to realize the benefits of alternative paths not travelled and minimize the weaknesses of the chosen structure. 58 The Politics of Regionalization Katherine Fierlbeck Regardless of their policy outcomes, strategies of regionalization are prevalent because they are politically useful. Yet, it is difficult to determine with any certainty what the specific outcomes of regionalization are. To mitigate the utilization of regionalization for politically advantageous reasons, it is useful not only to catalogue the outcomes of policies of regionalization, but also to identify whose interests are furthered, and whose are hindered. 63 Lost in Maps: Regionalization and Indigenous Health Services Josée G. Lavoie, Derek Kornelsen, Yvonne Boyer and Lloy Wylie The settlement of Canada meant the erasure of Indigenous place-names, and understandings of territory and associated obligations. The Canadian map reflects boundaries that continue to fragment Indigenous nations and traditional lands. Each fragment adds institutional requirements and organizational complexities that Indigenous nations must engage with, when attempting to realize the benefits taken for granted under the Canadian social contract.
THE AUTHOR RESPONDS 75 Where Are We Going from Here? Gregory P. Marchildon Most expert observers agree that regionalization is merely a vehicle to achieve a number of concurrent health system objectives. Yet, regionalization cannot be an end in itself. Moreover, there is likely no optimal degree of decentralization or centralization that will produce better health system performance. At the same time, regional health authorities in Canada are not likely to be capable of improving health system performance until they have adequate control of key missing pieces – the most important of which is primary care.
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INTRODUCTION
Adalsteinn D. Brown, DPhil Editor-in-Chief, Healthcare Papers Director, Institute of Health Policy, Management and Evaluation University of Toronto Toronto, ON
Peter W. T. Pisters, MD President and CEO, University Heath Network Toronto, ON
C. David Naylor, OC, FRCPC, FRSC Toronto, ON u
The contributions to this issue of (e.g., Quebec), redrawn regional boundaries Healthcare Papers provide a clear picture of (e.g., Alberta) or restated the accountabilities the strengths and weaknesses of regionaliza- of regions (most provinces). Even Ontario – tion efforts. The guest editor for this issue for a long time the control group for Canadian – Professor Greg Marchildon – summarizes experiments in regionalization – created the the current environment well when he states local health integration networks (LHINs). that, for want of something better, “region- Ten years later, Ontario is considering even alization remains the most viable means” more sweeping consolidation of healthcare to the improvement of healthcare system providers and powers under the LHINs. performance in Canada. To justify regionalization, policy makers It seems that governments agree with this commonly cite a greater focus on public health summary. The last decade has seen a spate of and health promotion, cost-saving consolida- efforts to rework the architecture of Canada’s tion of administrative processes and the prom- healthcare systems. Provinces have regrouped ise that health services will finally reflect how the sets of providers included under regions patients receive care from different providers as
4 Introduction they move through the system. Unfortunately, receive sophisticated and comprehensive policy makers sometimes conflate region- healthcare services from multiple provid- alization – the lumping of providers under ers. Better-coordinated care will result in regional governance – with integration or the improved quality, enhanced patient experi- organization of care around patient needs. Like ence and lower societal costs. A rapid way regionalization, integration may sound like forward is for provinces to encourage and jargon. However, many, if not most, patients in financially support new consortia of insti- Canada still experience the healthcare system tutions and other local care providers that as a series of disconnected siloes. Providers too grow from coalitions of providers focused on are frustrated when lack of integration under- meeting community needs. These networks cuts the ideal of coordinated and continuing of providers will thrive if they are big enough care for the changing health needs of individual to provide comprehensive care and achieve patients. When care providers work together economies of scale, and if the right incentives in a way that aligns their professional practices, are put in place. information systems, incentives and cultures, That brings us to reinvestment for perfor- they can provide health services faster, more mance. Each year that a network improves care reliably and with better outcomes. For the for patients in a meaningful way, it should be patient, that means fewer tests and unnecessary able to reinvest these savings back into further visits, better communication and a lower risk system improvements. However, to ensure that for medical errors. the improvements are real and corners aren’t Regionalization can support integra- being cut, ministries, regions and providers tion, but it is neither sufficient nor necessary must collaborate to generate detailed public to improve integration and health system scorecards for each network – scorecards that performance. In this issue, Yves Bergevin and focus on outcomes like health status, patient colleagues provide a comprehensive review experience and safe care. Making quality of global experiences in regionalization and improvement the first job of regions is a key conclude with seven lessons that talk about lesson from the US experience with accounta- how regionalization turns into integration and ble care organizations (ACOs) that is too often a clearer focus on the patient. These lessons neglected when we try to simultaneously juggle emphasize that the best regionalized systems cost control and quality in Canada. do more than bring budgets together. They These changes would go a long way to also change the way monies flow, creating rewarding achievement and creating a more incentives for integrated care, opportunities innovative and dynamic culture within our for reinvesting based on measured perfor- provincial healthcare systems. They play to the mance and a necessity for stronger clinical best side of Canada’s doctors, nurses and other leadership. They also point, somewhat pain- healthcare professionals by recognizing and fully, to the fact that we need a second phase rewarding better care rather than just volumes of regionalization reforms that go well beyond and costs of services. And, if these changes current debates about who controls whom and focus more attention upstream on popula- who gets to hold the money. tion health status, then health promotion and Here is what that second phase of reform maintenance in turn may get greater attention. might ideally involve: The third step is also crucial. Healthcare First, real integration needs to occur. systems across the country urgently That’s especially true when so many patients need to strengthen what is often called
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“clinical governance.” In top-performing Moving from regionalization to inte- health systems, doctors, nurses and other gration is tough sledding at a time when health professionals are constantly and closely most ministries of health face dramatic and engaged in leading efforts to improve care. continuing financial pressures. More than a They receive training, have access to data few provinces are at loggerheads with their on care and are supported in improvement doctors as they try to change the organiza- efforts, so that quality improvement is seen tion of care and limit physician expenditure. as part of the clinicians’ jobs, not just an extra Creating new structures may be part of task to be pursued when the last patient has the necessary reforms to our system, but it been seen. These systems also invest in lead- should not be the only part. The faster we ership development, so that more doctors, can get to that next phase of reform with its nurses and other providers can take a big possibilities of better integration, smart rein- picture view, use data wisely, embrace innova- vestment and reporting, and stronger clinical tions in healthcare and generate and test their governance, the faster Canada can regain its own ideas for improving the system. leadership in healthcare.
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6 invited essay HealthcarePapers
7 Regionalization: What Have We Learned?
INVITED ESSAY
Gregory P. Marchildon, PhD Ontario Research Chair in Health Policy and System Design Institute of Health Policy, Management and Evaluation University of Toronto Toronto, ON u
ABSTRACT Regionalization is arguably the most significant health reform in Canada since medicare. Although a majority of provinces continue to have regionalized systems in Canada, the policy is more contested today than it was a decade ago. Since Ontario’s implementation of local health integration networks (LHINs) in 2006 and Alberta’s elimination of regional health authorities (RHAs) in favour of Alberta Health Services in 2008, Canada has had differing approaches to regionalization. However, due to the centralization of physician budgets in provincial health ministries, primary care has not been integrated into any regionalization model in Canada. This factor has severely constrained the performance of RHAs and their ability to meet their respective legislative mandates. Moreover, the lack of research on regionalization has meant that provincial governments are working from an extremely limited evidence base on which to make critical decisions on the structuring of health systems in Canada.
Over a decade ago, this journal devoted an optimism about the future from “a promising issue to the Canadian experience with region- heritage to build on” (Denis et al. 2004) and alization (Lewis and Kouri 2004). The titles “an opportunity for improving management” of the articles not only reflected consensus on (Levine 2004) to imploring the political class the merits of regionalization but also great to “let regionalization continue to evolve”
8 Regionalization: What Have We Learned?
(Davis 2004) and bring the full “continuum abrupt decision to replace its health regions of care” (Ward and Bedford 2004) under the with a single health authority and the chaos control of health regions. that ensued for a year or two afterward. The In 2004, regionalization was in its ascend- reasons for the change were never clearly ancy as a pan-Canadian policy. Every prov- articulated and Alberta Health Services would ince except for Ontario had restructured have to evolve without the benefit of a detailed its health system into geographically-based implementation plan (Donaldson 2011). organizations, which had been delegated by What the future holds is anyone’s guess, their respective governments to organize and but we can no longer assume that a devolved manage the provision of a broad range of health RHA structure will be an identifying feature services and programs. Two years later, as if to of health systems within Canada. In fact, the emphasize the consensus, Ontario joined the only thing we can be sure of is that we are rest through its own version of regionalization likely to experience even more structural and with the implementation of what it would call organizational change in the next few years, local health integration networks, or LHINs as governments cope with fiscal pressures in (MacLeod 2015). The structural change a low economic growth environment and the made by the introduction of regional health promise that integration can improve quality authorities (RHAs) seemed to have become and reduce cost at the same time. a permanent part of the Canadian landscape. This issue is motivated by twin objec- What a difference a little more than a tives. The first is to determine what we have decade can make. Since that first issue, three learned more recently from regionalization, provincial governments – Prince Edward in particular the impact of regionalization on Island (2005)1, Alberta (2008) and Nova health system performance and outcomes as Scotia (2015) – eliminated RHAs in favour well as the health of the population served of a single, centralized delivery agent for by RHAs. The second objective is to address the entire province. New Brunswick (2008) some outstanding questions by examining and Manitoba (2012) dramatically reduced analogies within Canada or the experience the number of RHAs, while other provin- with regionalized structures in other coun- cial governments established or extended tries. This introductory essay sets the stage by province-wide services and infrastructure in summarizing the evolution of regionalization, an effort to gain greater economies of scale the original policy goals of the reform and the and scope. In Quebec, the provincial govern- challenges posed by regionalization. ment recently removed the second layer of its two-tier regionalized system in order to shift Evolution and Objectives resources from administration to front-line of Regionalization delivery. In all jurisdictions, the efficacy of Policy experts had been urging provincial regionalization is being questioned on multi- governments to consider establishing regionalized ple fronts by governments, the media and the structures for the administration and delivery general public (Marchildon 2015). of healthcare for decades before the 1990s. As The most interesting aspect of this change early as 1944, for example, Professor Henry is the extent to which major decisions on the Sigerist of Johns Hopkins University deliv- reorganizing of health systems have apparently ered a report to a newly-elected social demo- been made on minimal evidence. The prime cratic government in Saskatchewan, where example of this was the Alberta government’s he recommended dividing the province into
9 HealthcarePapers Vol. 16 No. 1 health regions in order to organize and deliver bodies responsible for managing the health a broad range of health services to 840,000 budgets for a population within a defined residents, two-thirds of whom lived in medi- geographic area was perceived to be the most cally underserviced rural areas (Sigerist 1947). effective way to exert some budgetary control Although it would take another half century and facilitate more integrated service deliv- for the Saskatchewan government to inte- ery in order to enhance the quality of health grate hospital and medical services into health services. In the words of the federal Minister regions, the government did create geographic of Health, regionalization would achieve on health regions with defined populations in behalf of all governments in Canada “the the province for the delivery of public health common goal of restraining the rate of increase (Marchildon 2005; Johnson 2004). The one in health service costs while maintaining and major exception was the Swift Current Health improving the quality of care” (Conference of District, which served as a “pilot project for Ministers of Health 1969: 1). universal coverage of hospital, medical, and Although five provincial governments dental care” from 1946 until the introduc- (Ontario, Quebec, British Columbia, Nova tion of universal medical care insurance in the Scotia and Manitoba) called for public studies 1960s (Duffin and Falk 1996, p. 676; Houston concerning the potential of regionalization in and Massie 2013). their respective provinces by the early 1970s, it would take 20 more years for regionaliza- tion to be introduced in Canada. The onset The initial years were marked by of a deep recession in the early 1990s coming after decades of deficit financing put most some false starts in terms of the provincial governments into a precarious quality of RHA leadership and fiscal position. As part of a broad program of senior management. public expenditure cuts, almost all provincial governments introduced regionalized health In the mid-1960s, the Royal Commission systems. They did so in order to exert some on Health Services chaired by Justice Emmett cost controls, reduce excess capacity in terms Hall recommended a mild form of regionali- of hospitals and human resources and bend zation through local health planning councils the cost curve by shifting the emphasis from (Canada 1965). This was followed by a more acute and institutional care to primary care, full-blooded recommendation in favour of health prevention and the more upstream regionalization by the Conference of Ministers determinants of health. of Health (1969). Driven by concerns about The initial years were marked by some managing the cost of universal medical care false starts in terms of the quality of RHA then being introduced throughout Canada, leadership and senior management. The skills federal and provincial health ministers required to govern and administer health concluded that regional authorities were systems as opposed to single healthcare organ- required to address the inefficiencies produced izations had to be developed and, at first, the by uncoordinated health organizations and lack of such skills was apparent. Governments providers. With universal medical care in place, added to the problem by providing insufficient provincial governments had to pay the hospital clarification on the roles and responsibili- and medical care bills without any effective ties of RHAs relative to ministries of health, managerial control. The creation of public and by continuing, at times, to micromanage
10 Regionalization: What Have We Learned?
RHAs rather than providing strategic goals lack of research interest in Canada in assessing and direction. In the language of the new what has been a remarkable natural experi- public management, ministries of health were ment in structural reform across jurisdic- to steer and the RHAs to row, but there were tions. Indeed, judging by publication output, too many instances of ministry “interference” there has actually been a decline in research in the daily operations of RHAs – often in the on regionalization during the past 15 years midst of crises where ministers of health had relative to the research that was done on the to face questions and demands from the media subject when regionalization was first planned and opposition members in the legislature. and implemented (Bergevin et al. 2016). Based on public releases at the time RHAs By the end of the 1990s, the managerial (if were first introduced, provincial governments not leadership) challenges experienced when were attempting to achieve at least seven regionalization was first implemented had distinct objectives through regionalization: diminished and governments began to revise the structures they had built. Some provincial 1. Integrate and coordinate a broad range ministries concluded that further economies of of health services (vertical integration). scale and scope could be achieved and admin- 2. Consolidate and rationalize hospi- istrative overhead lessened by consolidating tal services in order to reduce costs RHAs. As can be seen in Table 1, there has (horizontal integration). been a distinct trend to greater centralization. 3. Shift emphasis and resources to illness prevention and health promotion Regionalization Models (population health). Before embarking on a detailed discussion 4. Decrease variation and improve service of regionalization in Canada in the follow- quality through evidence-based practice. ing essays, it is worth determining where 5. Decentralize resources to facilitate better Canadian approaches to regionalization fit match with population needs. in terms of the three principal models of 6. Decentralize decision-making to increase regionalization we see in other higher-income public participation and input. countries. As can be seen in Table 2, region- 7. Increase accountability by having an alization in Canada has been administrative administrative body (RHA provider) report rather than political in nature. on performance and outcomes to the health In no case have provincial governments system funder and steward (provincial delegated authority and responsibility for government through health ministry). healthcare administration and delivery to local governments, nor have they created regional These objectives are almost identical to democratic structures to achieve this purpose. the objectives identified over a decade ago In one sense, this is understandable. Canada by Lewis and Kouri (2004). While it may be already is a decentralized political federation almost impossible to determine the relative with most of the authority and responsibil- weight put on these objectives by individual ity for healthcare residing with provincial provincial governments at the time, these governments. In contrast, local governments in objectives provide at least a starting point for Canada have no constitutional status and, rela- determining the criteria against which we tive to other OECD countries, are limited in would assess the success or failure of region- terms of revenue generation and responsibility alization. What is even more fascinating is the for health programs and services.
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Table 1. Regionalization in Canada, 2015
Name used for geographic- Population, based RHAs or Number Year 2015, Q3 province-wide of RHAs* Prior RHAs first Legislative Region (000s) health authority in 2015 number introduced authority
Health Authorities British Columbia 4,683 Health authorities 5+ 52 1997 Act
Alberta Health Regional Health Alberta 4,196 1 9/17 1994 Services Authorities Act
Regional Health Saskatchewan 1,134 Health regions 13 33 1992 Services Act
Regional health Regional Health Manitoba 1,293 5 11/12 1997 authorities Authorities Act
Local health Local Health Ontario 13,742 integration 14 – 2006 System Integration networks Act
Act Respecting Regional health Quebec 8,264 18 18 1989 Health and Social agencies Services
Regional health Regional Health New Brunswick 754 2 8 1992 authorities Authorities Act
Nova Scotia Health Authorities Nova Scotia 943 1 9/4 1996 Health Authority Act
Prince Edward Island 146 Health PEI 1 5/6 1993 Health Services Act
Newfoundland and Regional Health 528 Health regions 4+ 4a 1994 Labrador Authorities Act
Hospital Insurance Health and social Northwest Territories 44 6+ 6 1997 and Soc. Serv. service authorities Admin. Act
Yukon 37 – – – – –
Nunavut 37 – – – – –
*Refers to the addition of non-geographically based RHAs providing centralized service (e.g., tertiary care) to all provincial residents. Source: various provincial and territorial government websites and Statistics Canada for population estimates in third quarter of 2015. The Canadian approach may have been since these plans, at least historically, did unique in one respect. Coverage in Canada not involve a service or facility component. is divided between universal coverage for However, what was illogical – even if under- hospitals and physician care, and extended standable from a political perspective – was health benefits for community and long-term the omission of primary care. care – what the Europeans call social care. Although primary healthcare was made Regionalization provided a potential part of the legislative mandates of RHAs, vehicle to coordinate services across these not one government created a mechanism two very different coverage regimes with the for RHAs to coordinate, much less inte- exception of the provincial prescription drug grate, primary care into the new managerial plans. This was an understandable exception, system. As the main deliverers of primary care,
12 Regionalization: What Have We Learned?
Table 2. Three structural models of regionalization in high-income jurisdictions
Structural model Features Jurisdictions
Political and administrative decentralization: Sweden (counties), Denmark regionalized units are also democratically elected bodies (regions), Italy (regions) Democratic decentralization with responsibilities that extend beyond healthcare. and Spain (autonomous Health services administered, regulated, coordinated communities) and delivered by regional or local governments.
Statutory administrative delegation to organizations New Zealand, Australia Fiscal and administrative operating at limited arm’s length from government. (NSW and SA), England delegation Health services administered, coordinated and, in some and Canada (BC, SK, MB, cases, delivered by delegated health authorities. ON, QC, NB, NL and NT)
Administrative decentralization Bureaucratic deconcentration from ministry to Ireland and Canada (AB, NS with centralized policy and centralized delivery authority with some members of and PEI) fiscal control staff located in geographic zones.
Source: author. physicians retained their status as independ- integration and coordination is required for ent practitioners paid mainly on a fee-for- regionalization to achieve its purpose. The truth service basis through contracts negotiated by is that there is so little study of this phenom- medical associations and provincial govern- enon that we hardly know in any objective sense ments. Organized medicine throughout what regionalization has changed in terms of Canada made it clear that it would never coordination and integration. support a change in which its members would At the same time, I would disagree with be made accountable to RHAs through those who have drawn what I think is a false contract or employment arrangements. The dichotomy between integration on the one end result was that RHAs were unable to hand and regionalization on the other. Over manage perhaps the most crucial piece in the 15 years ago, it was argued in this journal that continuum of health (Marchildon 2015). the characteristics posited in the ideal model The one conundrum posed by regionali- of integrated delivery systems developed by zation wherever it has been implemented is Shortell et al. (1993, 1994) in the US differed its linkage with integration. It is true that the substantially from the characteristics of the reform has suffered from the naïve assump- then current model of RHAs in Canada tion that regionalization would automatically (Leatt et al. 2000). However, the integrated increase health system integration and health delivery system characteristics put forward service coordination. Indeed, the reform was by these authors were based on an ideal of conceived as the organizational means to coordinated healthcare as developed on an achieve precisely those ends. In reality, RHAs ideal consumer-based model of managed care have had tremendous difficulty in replacing in the US, while the RHA characteristics were health service silos with a seamless continuum based on the reality of early regionalization of care; indeed, some RHAs seem to replicate in very different institutional environments. the very organizational and service silos that What we really need is a study of the had existed prior to regionalization. The real common characteristics of integrated delivery question is whether the service user experi- systems across countries that share reason- ence has been altered by regionalization. Some ably similar institutional environments, and analyses (e.g., Bergevin et al. 2016) suggest that then compare these to regionalized systems it has, but only to a degree; that much more in Canada to determine to what extent and
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Canada. 1965. Royal Commission on Health Services, with what results regionalization can lead to Volume II. Ottawa: Queen’s Printer. integration. My hope is that, over the coming Conference of Ministers of Health. 1969. Task Force Reports years, we will see an increase in scholarly on the Cost of Health Services in Canada, Volume 1. Ottawa, research, as well as more rigorous evalua- ON: Department of National Health and Welfare. tion within and outside governments of the Davis, J. 2004. “Let Regionalization Continue continuing experiment with regionalization to Evolve.” Healthcare Papers 5(1): 50–54. in Canada. As Table 2 illustrates, we have Denis, J.-L., D. Contandriopoulos and at least two models of regionalization that M.-D. Beaulieu. 2004. “Regionalization in Canada: a Promising Heritage to Build On.” Healthcare Papers could be compared in terms of performance 5(1): 40–45. and outcomes. These studies would provide Duffin, J. and L.A. Falk. 1996. “Sigerist in Saskatchewan: the basis for future policy change that is the Quest for Balance in Social and Technical Medicine.” more evidence-informed than what we see Bulletin of the History of Medicine 70(4): 658–83. at present. Donaldson, C. 2011. “Fire, Aim … Ready? Alberta’s We can no longer afford to be so parochial Big Bang Approach to Healthcare Disintegration.” in our thinking about regionalization. The Healthcare Policy 6(1): 22–31. Canadian experience is simply too limited, Houston, C.S. and M. Massie. 2013. 36 Steps on the Road to Medicare: How Saskatchewan Led the Way. both in terms of scope and time. For this Montreal: McGill-Queen’s University Press. reason, the first group of authors in this issue Johnson, A.W. 2004. Dream No Little Dreams: a was given a mandate to describe some relevant Biography of the Douglas Government of Saskatchewan, experiences with regionalization outside 1944–1961. Toronto, ON: University of Toronto Press. Canada and the possible lessons these may Levine, D. 2004. “Regionalization: an Opportunity for hold for provincial governments here. The Improving Management.” Healthcare Papers 5(1): 46–69. second set of authors was asked to provide Lewis, S. and D. Kouri. 2004. “Regionalization: Making Sense of the Canadian Experience.” their observations on the recent Canadian Healthcare Papers 5(1): 12–31. experience, while a third group was asked to MacLeod, H. 2015. “Local Health Integration speculate on how regionalization might be Networks: Build on Their Purpose.” Healthcare reshaped in order to deliver on its original Management Forum 28(6): 242–46. promise. I hope that these respective reflec- Marchildon, G.P. 2005. “Regionalization and Health tions on regionalization will be the start of a Services Restructuring in Saskatchewan.” In C. Beach, R.C. Chaykowski, S. Shortt, F. St-Hilaire and major new initiative to study the impact of A. Sweetman, eds., Health Services Restructuring in regionalization on healthcare in Canada. Canada: New Evidence and New Directions. Kingston, ON: McGill-Queen’s University Press for the John Notes Deutsch Institute. 1. The government of Prince Edward Island Marchildon, G.P. 2015. “The Crisis of Regionalization.” Healthcare Management Forum 28 (6): 236–38. eliminated RHAs in 2005, but did not Sigerist, H.E. 1947. Saskatchewan Health Services create Health PEI until 2010. Survey Commission: Report of the Commissioner Presented to the Minister of Public Health, October 4th, References 1944. Regina: King’s Printer. Bergevin, Y., B. Habib, K. Elicksen-Jensen, Ward, T. and L. Bedford. 2004. “Continuum of Care S. Samis, J. Rochon, J.L. Denis and D. Roy. 2016. Must Be under Region’s Control.” Healthcare Papers “Transforming Regions into High-Performing Health 5(1): 55–59. Systems Toward the Triple Aim of Better Health, Better Care and Better Value for Canadians.” Healthcare Papers 16(1): 34–52. doi:10.12927/hcpap.2016.24767.
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15 What Can We Learn from the UK’s “Natural Experiments” of the Benefits of Regions?
COMMENTARY
Gwyn Bevan, PhD Professor of Policy Analysis Department of Management London School of Economics & Political Science London, UK u
ABSTRACT Marchildon highlights the lack of evidence on policies of regionalization in Canada: with regionalization being in favour in the 2000s followed by disillusion and the abolition of regions by some provincial governments. This paper looks at evidence from the UK’s single-payer system of the impacts of regions on the performance of the delivery of healthcare. In England, regions were an important part of the hierarchical structure of the National Health Service (NHS) from its beginning, in 1948, to the introduction of provider competition, in the 1990s. Since then, in England, govern- ments have understood that the NHS cannot be run from Whitehall and have tried to replace hierarchical control by provider competition. The consequence was that regions in England were subjected to frequent reorganizations from the mid-1990s with their abolition being announced in 2010. In contrast, the devolved countries of the UK have always been organized as “regions” in the form of their historic national boundaries. This paper argues that changes in the NHS in the UK in the 1990s and 2000s offer three “natural experiments,” in terms of funding, organization and models of governance, that give evidence of the impacts of stable regions in the UK. It also considers the lessons of this evidence for Canada.
16 What Can We Learn from the UK’s “Natural Experiments” of the Benefits of Regions?
Introduction Regions in England and the Devolved According to my reading of Marchildon’s Countries (2016) account of policies on the introduc- It seems that the predilection of politicians tion of regional health authorities (RHAs) in Canada to impose top-down structural in Canadian provinces in the 2000s, it was reforms in the absence of evidence to justify hoped they would better enable the provinces them, as described by Marchildon (2016), is to make many kinds of improvements in an even more serious problem in England. the delivery of healthcare: better integration Indeed, Timmins (2013: 6) suggests that and coordination of a broad range of health the “disease” of the English NHS might be services; more redistribution of resources from described as “organisation, reorganisation and acute hospital services to illness prevention; redisorganisation.” So, if Jane Austen were greater use of evidence-based medicine to to chronicle the recent story of the NHS in reduce unwarranted variations and improve England, she might well begin by saying: quality of care; better allocation of resources “It is a truth universally acknowledged that to the needs of populations; greater participa- a Secretary of State for Health in possession tion in decision-making and accountability of the English NHS is in want of a top- for performance. If these were indeed what down reorganisation.” This “truth” was put to provinces were hoping for, then it is under- the test when the Conservative and Liberal standable that they would be disappointed parties, in forming the Coalition Government with the failure of regions to resolve abid- after the 2010 elections, agreed and published ing problems of all healthcare systems. This their program for the government of May paper argues that the National Health Service 2010, stating their second priority for the (NHS) in the different countries of the UK NHS in England to be: “We will stop the top- offer an intriguing “natural experiment” as to down reorganisations of the NHS that have the impacts of a stable region under different got in the way of patient care” (Cabinet Office models of governance. In the English NHS, 2010: 24). But this public commitment by if we define regions as the next level below the Coalition Government did not deter the that of the nation, then, from the mid-1990s, new Secretary of State for Health in England, the English NHS has tried to deliver health- Andrew Lansley, whose white paper, Equity care to a population of over 50 million with- and Excellence: Liberating the NHS (State out a stable region. But in each of the UK’s for Health 2010) published in July 2010, three devolved “countries” – Scotland, Wales “launched arguably the biggest restructuring and Ireland – each NHS has a stable region in it (the NHS) had seen in its 63-year history” the form of their historic national boundaries (Timmins 2012: 3). The Chief Executive of (with populations of 5 million, 3 million and the NHS famously described this organiza- nearly 2 million, respectively). tional change as so big “you could probably The following sections explain the see it from space” (Nicholson 2010). nature of three natural experiments between From the start of the NHS in 1948 to the England and the devolved countries that 1974 reorganization, there was, however, mini- enable comparisons to be made from having mal organizational change. The 1974 reorgani- stable regions, summarize evidence from zation was justified in aiming to remedy flaws studies of these experiments and discuss the in the original organization design of the NHS implications of that evidence for the debate in England and Wales, as created in 1948, about regionalization. in which providers were divided into four
17 HealthcarePapers Vol. 16 No. 1 organizational silos (and these divisions were of the UK for the following decade: First, it mirrored in Scotland and Northern Ireland) abolished the idea of provider competition, for: teaching hospitals, non-teaching hospitals, but maintained the purchaser/provider split in general practitioners (GPs) and community England and Wales. Second, it enacted devolu- health services. The 1974 reorganization tion to Scotland, Wales and Northern Ireland created organizations defined by populations, so each country’s government could decide its not providers across the countries of the UK. own policies for its NHS. Third, it increased In England, undergraduate teaching hospitals NHS spending in England in real terms by were moved into the regional structure of 14 five per cent a year, which fed through (by the RHAs, and three sub-regional organizations Barnett formula) to increased spending on each were defined for the same geographical areas country’s NHS. Fourth, it introduced into the in the hope that this would better enable a English NHS the system of annual perfor- basis for the close working between hospi- mance (star) ratings with sanctions for failure tal and community health services, primary and rewards for success. Scotland led the way healthcare, and social services. However, those for the devolved countries in abandoning the geographical identities were lost by the 1982 purchaser/provider and going back to a hier- reorganization of hospital and community archical system in which their Health Boards health services (Levitt and Wall 1984). ran providers. From 2006, the government The destabilization of regions in England reintroduced provider competition into the followed the introduction of the “internal English NHS, and the Lansley reforms sought market” in 1991. This changed the NHS in to entrench that policy in primary legislation each country from a hierarchical structure to (Bevan 2014; Timmins 2012). a market, with “purchasers” that contracted with, rather than ran, “providers” (Secretaries of State for Health, Wales, Northern Ireland and Scotland 1989). In England, RHAs, were abol- The destabilization of regions in ished in 1996 and replaced by eight regional England followed the introduction offices (Ham 2000: 1); which in turn, in the of the “internal market” in 1991. 2000s, were succeeded by four regional directo- rates of health and social care, then 28 and later Three Different Natural Experiments in 10 Strategic Health Authorities (SHA) (Audit the Health Systems of the UK Commission and Healthcare Commission This section explains how the period from 2008: 16). The Lansley reforms proposed in 1996 to 2012 offers three different kinds 2010 aimed to empower GPs as purchasers to of natural experiments for examining the choose between any qualified provider subject impacts of regions. These three periods were to national regulators. These reforms saw no as follows: role for any regional presence in its organiza- 1. 1991 to 1996: before devolution. In this tional chart for its new system of governance period, the English NHS was admin- (Secretary of State for Health 2010: 29). In istered by RHAs and all countries had contrast to England, each devolved country had implemented the policies of the inter- a stable region defined by national boundaries. nal market. The natural experiment The (New) Labour government elected was in differences in per capita spend- in 1997 made four major policy decisions that ing on the NHS, which was markedly had a profound influence on the health systems higher in Scotland (by 25%) and Wales
18 What Can We Learn from the UK’s “Natural Experiments” of the Benefits of Regions?
(by 18%) than in England (Dixon The Outcomes of the Three Natural et al. 1999). Experiments 2. 2000 to 2006: immediately after devolution. Dixon et al (1999), using data from 1995/96, In this period, no government sought to examined the first natural experiment and improve performance by provider compe- found that crude productivity of doctors tition. Although England still had lower and nurses in terms of patients seen and per capita spending on healthcare than the treated were lower for doctors and nurses in devolved countries, the more interesting Scotland and Wales than in England. Hence, natural experiment was in the governance the higher levels of funding in Scotland and of performance against targets. England Wales appear to have resulted in an easier was the odd man out in two ways: First, working life for producers than more care its regions lacked stability; second, only for patients. in England was failure by providers to Alvarez-Roseté et al. (2005), using data achieve government targets for quicker from 2002/03 and Connolly et al. (2011), access to health services penalized using data from 2006/07, examined the through public reporting and performance second natural experiment. Both studies management (in what became the regime found that providers in the English NHS of annual “star ratings”) (Secretary of State still appeared to have higher rates of crude for Health 2000). In the devolved coun- productivity. And there had been dramatic tries, such failure was widely perceived to improvements in England in reducing long be rewarded with extra funding (Bevan et waiting times for access to the NHS and al. 2014). quicker response times by ambulance services 3. 2006 to 2012: when devolution has become to potentially life-threatening emergencies well established. In this period, levels (Category A calls), which was not matched of per capita funding in the northeast by the devolved countries. region of England were by 2011/12 Bevan et al. (2013), using time series similar to that of Scotland and the most of data, mostly up to 2011/12, for the interesting natural experiment was third natural experiment, found a marked between different models of govern- improvement in Scotland’s performance, so ance that had developed in England that it broadly matched England’s for hospi- and Scotland. In England, the policy tal waiting times and ambulance response emphasis for improving performance times to Category A calls. The performance was on provider competition without in Wales and Northern Ireland on those a stable region (Secretary of State for measures still lagged behind England and Health 2002). In Scotland, the govern- Scotland. There was little evidence that the ment emphasized a “tougher and more effort expended in England on provider sophisticated approach to performance competition had delivered improvements in management” in which performance was performance. The third natural experiment systematically monitored with support suggests that when the regional government and intervention when necessary (Steel in Scotland did operate a system with sanc- and Cylus 2012: 113-114). In Wales tions for failure and rewards for success, this and Northern Ireland, there was no had the potential to outperform a system evidence of similar regional governance in England based on provider competition of performance (Bevan 2014). without a stable region.
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Discussion Cabinet Office. 2010. The Coalition: Our Programme for Government. Retrieved August 19, 2016.
20 Regionalization Lessons from Denmark
COMMENTARY
Karsten Vrangbaek, PhD Professor, Departments of Political Science and Public Health Director of Center for Health Economics and Policy (CHEP) University of Copenhagen Copenhagen, Denmark u
ABSTRACT Denmark is a small Northern European country with an extensive welfare state and a strong commitment to maintaining a universal healthcare system. Like the other countries in the Nordic region, Denmark has a long tradition of democratically governed local and regional governments with extensive responsibilities in organizing welfare state services. The Danish healthcare system has demonstrated an ability to increase productivity, while at the same time maintaining a high level of patient satisfaction. Ongoing reforms have contributed to these results, as well as a firm commitment to innovation and coordination. Regions and municipalities in Denmark are governed by directly elected democratic councils. The Danish case is thus an example of democratic decentralization, but within a framework of national coordination and fiscal control. In spite of the difference in size and historical traditions there are also many similari- ties between Canada and Denmark, particularly in terms of health and social policy goals and aspirations, and in terms of the commitment to a comprehensive, universal healthcare system. These similarities provide interesting opportunities for comparison.
Introduction: Is the Danish Case Denmark has a long tradition of democrati- Relevant for Canadians? cally governed local and regional governments Denmark is a small Northern European with extensive responsibilities for organizing country with a population of 5.6 million. welfare state services. A major reform in 2007 Like the other countries in the Nordic region, created larger regions and municipalities in
21 HealthcarePapers Vol. 16 No. 1 order to strengthen quality and economic and a successful transition of many services efficiency. Regions and municipalities in from inpatient to ambulatory care. This Denmark are governed by directly elected has contributed to remarkable productivity democratic councils. The Danish case is thus increases in Danish hospitals of 4–5% annu- an example of democratic decentralization, ally from 2009 to 2013. but within a framework of national coordi- The regions are currently managing a nation and fiscal control as explained below rationalization and redesign of the system, (Vrangbaek 2015, Olejaz et al 2012). establishing a number of new centralized Local governments in Denmark are hospitals and the closing of smaller hospi- responsible for social services, home care tals. General quality indicators show posi- services, elderly care, primary education and tive trends, and Denmark is at par with other employment. Regional authorities manage similar European countries on most health specialized healthcare in the form of region- outcomes. Finally, the regional structure and ally owned hospitals and privately owned the reconfigured municipalities have imple- general and specialist practitioner clinics mented a number of initiatives to strengthen (Olejaz et al 2012). The governance structure coordination and integration of care. Not all are of Danish healthcare underwent a substan- successful, but a major benefit of the regional- tial reform in 2007, where the previous 278 ized structure in Denmark is that it allows for municipalities were amalgamated into 98 new experiments and learning across units. and larger municipalities. The aim was that In spite of the significant difference all municipalities should have at least 30,000 in size, there may be relevant lessons for inhabitants. In practice, most ended up being Canadian health policy from the Danish considerably larger, and the average is now case. In particular, it may be relevant to look 55,000 inhabitants. At the same time, the at Danish policy instruments for handling previous 13 counties were replaced by 5 new multilevel governance and coordination across and larger regions, with population sizes rang- administrative levels. Similarly, both Denmark ing from 1.6 million (Greater Copenhagen) and Canada are facing aging populations and, to 600,000 (Northern Jutland). The regions therefore, need to provide better integrated assumed responsibility for specialized health- services to deal with the growing number of care from the previous counties, while the citizens with chronic care needs. Finally, the municipalities gained responsibility for many Danish case may provide inspiration in regard other tasks, including a stronger responsibil- to the difficult issues of how to decide and ity for rehabilitation, prevention and health implement a major reform of the governance promotion in addition to the traditional system. public, infant, home care and school health tasks. The evaluation of the regional govern- The Structural Reform of 2007 ance structure for healthcare in Denmark The 2007 “Structural Reform” has been since 2007 is generally positive. The region- labelled “unthinkable” by several policy ally based system has managed to contain analysts (Bundgaard and Vrangbaek 2007; costs and to adjust to external contingencies, Christiansen and Klitgaard 2008, 2010). The such as the economic downturn following the reason is that such reform attempts histori- global financial crisis in 2009. The regions cally have mobilized resistance from power- have also been the key actors in a major ful stakeholders within the major parties and redesign of the Danish hospital infrastructure more broadly. There has historically been
22 Regionalization Lessons from Denmark a strong commitment to local and regional was argued that this reform was necessary to democratic structures as the locus for organi- prepare for the demographic transition with zation of welfare services, and many politi- a growing number of elderly, chronic care cians have started their careers in municipal patients often suffering from multiple diseases. and regional politics. Furthermore, adminis- The demographic transition also poses long- trative reforms tend to alienate a large number term challenges for financing of the welfare of public employees, that fear disruptions state. Although such arguments are enviable, and changes in the wake of the reform, and a reform was still expected to generate opposi- in the case of centralization reforms, many tion, not least since the previous structure had citizens fear that larger units and longer been performing rather well in terms of cost distances to politicians and to service provid- containment and quality. This meant that there ers (e.g., hospitals) reduces their power to was no clear “burning platform” for change. engage in decision-making. So how did the So what facilitated the process? 2007 structural reform come about? What were the main arguments and which politi- cal constellation made it possible? The main … the politicians behind the answer from policy analyses of the reform has been that the reform was a result of a rare proposal wanted to eliminate “window of opportunity” due to the combina- “grey zones” of overlapping tion of reform-minded, central-level politi- responsibilities … cians, de facto majority government, weak internal and external opposition and reduced In the political arena, there was a unique support for decentralist ideas. Furthermore, parliamentary situation, where the govern- key government actors seized the opportunity ment was in an unusually strong position. and skillfully managed the policy process to Although it was a minority government, it overcome resistance from important stake- could count on support from one of the major holders and build a strong coalition behind opposition parties, which had been a long- the reform (Bundgaard and Vrangbaek 2007; time supporter of administrative reform. At Christiansen and Klitgaard 2008, 2010). the same time, the other main opposition The main political arguments behind the parties were rather weak and did not have a reform were that larger municipalities and unified stance concerning the reform. Another regions would enable more expertise and more political factor was a change in the internal financially robust administration of welfare power balance within the major govern- services. Higher volume was expected to lead ment party, which meant that the voices to better quality and more efficient adminis- favoring decentralization and localism had tration. Furthermore, the politicians behind become weaker compared to the reformist the proposal wanted to eliminate “grey zones” and centralist wing. of overlapping responsibilities and create a At the same time, a strong advocacy coali- unified entry point for citizens through a tion group was formed with members from clearer division of labor and better coordina- the industry association (“Danish Industry”), tion. There was a strong belief in “benefits of the association of municipalities (“Local scale” in specialized healthcare and there were Government Denmark”) and key ministers and concerns about quality and economic “sustain- ministries (Finance, Economics and Interior), ability” in smaller municipalities. Finally, it while no major opposing coalition appeared.
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The “Association of County Councils” obvi- The government also benefited from the ously had strong interests in maintaining status publication of a research report showing that quo, but was too late and not sufficiently strong “local democracy” would not suffer. This in mobilizing support. On the contrary, within had been a main concern in previous reform Local Government Denmark, there was a discussions, as there is a strong emphasis on feeling that the reduction in the number of local level democratic participation in the local governments (and mayor-ships) would administration of the Danish welfare state. be outweighed by gaining a stronger position Summing up, it appears that there are and more responsibility for welfare tasks. This general lessons about advocacy coalitions, meant that the government could benefit from management of the policy process and fram- playing the municipalities against the counties, ing of the political discussions in the Danish thus securing support from a major part of the case of the Structural Reform from 2007. decentralized political forces. Some of the key arguments concerned benefits Other important elements in the manage- of scale, and the need to create better struc- ment of the policy process include a tight tures for coordination of care. The following government control of the Commission, section presents some of the instruments used which was established to investigate alterna- to coordinate the multilevel governance of tive options. The mandate for the Commission healthcare in Denmark after the reform. was relatively narrow, and the Commission was dominated by representatives of central govern- Instruments for Multilevel Governance ment ministries. The Commission presented a of Healthcare in Denmark report that emphasized expected future chal- The Danish healthcare system can be lenges to the health and social care systems described as a multilevel governance struc- and framed the different policy options. In ture consisting of the state (ministries and the following political negotiation process, agencies), the regions and the municipalities. the government cleverly did not reveal its true All three levels have democratic assemblies intentions until it was too late for the opposi- elected in direct elections. There are inter- tion to mobilize resistance. Furthermore, the est organizations for both the municipalities government guaranteed all county and munici- (“Local Government Denmark”) and the pal employees, that they would retain their jobs regions (“Danish Regions”) and, although in the new structure, thus disarming much of they are not a formal part of the governance the critique from this major voter group. system, over time, they have assumed a role as The government also created a process of key negotiation partners for the government “voluntary” amalgamations in the municipali- and as mediators and facilitators of policy ties. This turned the local level debate into a development and implementation at the discussion about which other municipality to regional and municipal levels. The two organ- join, rather than a debate about the reform izations are also partners in annual “economic itself. To reinforce the process, the govern- agreements” with the government. These ment created economic disincentives for agreements establish targets for the economy municipalities that considered not joining of the regions and municipalities and serve as with other municipalities. Finally, a “liaison forums for discussing new policy initiatives. group” negotiated solutions in municipalities These agreements are since 2014 entered where “voluntary” amalgamation agreements in the context of a national “Budget Law,” could not be found. whereby the national parliament establishes
24 Regionalization Lessons from Denmark boundaries for expenditures at all levels The third generation of health agree- of government, including the regions and ments cover the period of 2015–2018. They municipalities. Budget overruns are punished include detailed agreements about a set of by withholding state grants. The budget law mandatory topics (prevention, admission and the economic agreements mean that the and discharge procedures, training and reha- fiscal autonomy of municipalities has been bilitation, health IT and work processes). The reduced considerably, although they, unlike detailed agreements must address the general the regions, still have the ability to raise taxes. issues of division of labour between regions and In addition to this economic coordination municipalities and different groups of health mechanism, there is a long-standing tradition professionals, knowledge sharing and train- for involving regions and municipalities in policy ing, coordination of capacity, involvement of development committees, working groups, patients and relatives, equity, documentation, etc. This means that most policy initiatives are research, quality development and patient safety. negotiated across the levels when they are being The framework of national and regional/ developed and/or in the implementation phase. municipal agreements backed by legislation The municipalities and regions have a strong (and threats of intervention) has created a incentive to participate in these processes in flexible and relatively successful structure for order to influence the decisions. More broadly, coordination across governance levels. The it is important for them to continue to appear as historical tendency has been for the state to valuable and legitimate policy partners to avoid gradually take a stronger hand in the steering the threat of legislative intervention, and ulti- processes, although many policy details and mately, to secure their survival. implementation choices are still left to the In addition to the overall state-municipal/ regions and municipalities. The benefits of this regional economic agreements, the reform in system is to allow for flexible adjustments to 2007 also introduced new mandatory health regional and local conditions, while at the same agreements between municipalities and time maintaining budget control and a high regions. The intention of these agreements is degree of equity across the decentralized units. to promote coordination across municipal care services, primary care and hospital care. These agreements include a number of mandatory topics related to admission and discharge from The intention of these agreements hospitals, rehabilitation, prevention, psychiatric is to promote coordination across care and IT support systems. Formal targets municipal care services, primary for progress are agreed among the partners care and hospital care. and also subject to national level monitoring. The agreements are formalized at least once Coordination of Care in each four-year election term for municipal Based on the health agreements and other national and regional councils, and must be approved by level initiatives, the regions and municipalities have the Danish Health and Medicines Authority. implemented a number of coordination initiatives. A structure of joint committees and working These include patient pathway programs groups were set up to facilitate the negotiation (descriptions), and standards to support the regions and implementation of the agreements, and and municipalities in developing more inte- national guidelines, standards and indicators grated services for chronic care patients. Pathway for monitoring progress have been developed. programs have been developed for a number of
25 HealthcarePapers Vol. 16 No. 1 chronic conditions, including heart conditions, The coordination efforts in the Danish diabetes II, chronic obstructive pulmonary disease health sector are supported by the develop- (COPD), chronic back pain etc. ment of national standards for ICT solutions, The regions and municipalities have also which enable providers to access electronic implemented organizational measures to patient records and communicate electroni- promote integration of care. Examples include cally in regard to admissions and discharges. the use of outreach teams from hospitals doing Prescriptions are also handled electronically follow-up visits in patients’ homes after discharge, and a national electronic “medical card” with training programs provided by the regions for prescription information is currently being municipal nursing and care staff, establish- implemented. Patients have access to their ing municipal units located within hospitals own health records via a national e-health to facilitate communication, particularly in portal called “Sundhed.dk.” The same plat- regard to discharge, and the use of “GP practice form is used for communication and as an coordinators” to facilitate communication. entry point for health professionals to patient More and more practices employ specialized information, quality data, etc. nurses, and several municipalities and regions have Many similar coordination initiatives provided financial support to set up multi-specialty have been taken in the Canadian provinces. facilities, commonly called “health houses.” The However, the difficulty often lies in the detailed models vary across the country, but often include design and implementation. Experiences from GPs, practicing specialists, physiotherapists other health systems, including Denmark, can and others. Medical homes are encouraged in provide inspiration for these processes. the sense that GPs are intended to function as coordinators of care for patients and to develop References a comprehensive view of their patients’ individual Christiansen, P.M. and Klitgaard, M.B. 2008. Den utænkelige reform. Strukturreformens tilblivelse needs in terms of both prevention and care. This 2002–2005. Odense, DK: Syddansk Universitetsforlag. principle is commonly accepted and is supported Christiansen, P.M. and Klitgaard, M.B. 2010. “Behind by the general national-level agreements between the Veil of Vagueness: Success and Failure in Institutional GPs and the regions. GPs participate in various Reforms.” Journal of Public Policy 30(2): 183–200. formal and informal network structures, and are Bundgaard, U. and Vrangbæk, K. 2007. included in the health service agreements made “Reform by Coincidence? Explaining the Policy between the regions and the municipalities to Process of Structural Reform in Denmark.” facilitate cooperation and improve patient path- Scandinavian Political Studies 30: 491–520. doi: 10.1111/j.1467-9477.2007.00190.x ways; although, as in many other countries, there are concerns about the practical integration of GPs Marchildon, G.P. 2016. “Regionalization: What Have We Learned?” Healthcare Papers 16(1): 8–14. due to their workload and the incentive structures doi:10.12927/hcpap.2016.24766. inherent in their status as private providers. Such Vrangbaek, K. in Mossialos, E., M. Wenzl, R. Osborn issues are further complicated by the difficulties in and D. Sarnak (eds). 2015. International Profiles of recruiting new GPs in some areas of the country Health Care Systems. (pp 39–42) Commonwealth Fund. and by the fact that many older GPs still operate Retrieved May 2016.
26 Health System Regionalization – the New Zealand Experience
COMMENTARY
Tim Tenbensel, PhD Health Systems, School of Population Health University of Auckland Auckland, New Zealand u
ABSTRACT New Zealand’s health system has many similarities with Canada, and also has long- standing experience with regionalization of healthcare services. Since 2001, the most important change has been the development of regional primary healthcare organi- zations funded according to population characteristics. This significant change has created the potential for a more integrated health system. However, barriers remain in realizing this potential. The key challenges include dealing with inter-organizational complexity and finding the right balance between hierarchical and collaborative rela- tionships between the state and non-government providers. Although New Zealand governments have greater capacity to make changes to organizational and policy changes, professional interests retain considerable capacity to shape policy outcomes through implementation.
Introduction New Zealand’s health system shares many healthcare services. New Zealand’s type of characteristics with Canadian health systems. health system architecture (fiscal and admin- Healthcare is predominantly funded from istrative delegation) reflects the most common taxation; both countries have political insti- Canadian model (Marchildon 2016). As tutions of Westminster-style parliamentary such, New Zealand has also had considerable democracy with comparatively clear chan- experience with regionalization (although this nels of accountability for health policy and term is not used in New Zealand).
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Notwithstanding these broad similarities, New Zealand’s Regionalization History there are some important historical and insti- On the face of it, New Zealand has followed a tutional differences. Unlike Canada, primary very similar trajectory to Canadian provinces. medical in New Zealand is not (and never The period 1983–2001 has close parallels has been) fully funded by the government. to the Canadian story from the 1990s. Prior New Zealand was one of the first countries to to the 1980s, New Zealand’s health system attempt universal coverage of health services consisted of hospitals that were publicly in the late 1930s (Ashton 2013; Gauld 2013). owned and funded, and governed by demo- However, in primary care, this ambition was cratically-elected boards, whilst primary care successfully resisted by organized medicine, services were provided by independent medi- which fought to retain the right of family cal practitioners in small business. Over the doctors to charge co-payments (Hay 1989). course of the 1980s, there was organizational Even so, the public share of health spending is restructuring and consolidation from dozens considerably higher in New Zealand (consist- of hospital boards to 14 Area Health Boards ently around 80%) than in Canada, because (AHBs), which were responsible for hospital pharmaceuticals and many non-medical and community-based health services, but not services are predominantly publicly funded. primary care. In the “Big Bang” reforms of the early 1990s, the AHBs were abolished (including the structure of democratic representation) … the most significant difference and replaced by a system of clear demarca- between New Zealand and tion between four regional health authorities Canada is the development of … (RHAs) as purchasers, and providers (includ- regionalized primary healthcare. ing hospitals and publicly funded commu- nity-based services) (Gauld 2001). In 1997, While New Zealand and Canada share the four RHAs were merged into a single a history of colonialism, New Zealand’s purchaser, the Health Funding Authority indigenous peoples (Māori) comprise over (HFA). Primary care arrangements were 15% of the population. The Treaty relation- largely unaffected by these changes. ship between Māori and non-Māori, and After a change of government, the HFA the persistence of significant disparities in was abolished and a new system of District health outcomes have stimulated significant Health Boards (DHBs) was introduced in developments in health policy and service 2000. DHBs marked a return to admin- provision. Another significant difference istrative decentralization, integration of is that New Zealand has a long history purchasing and provision and democratic of democratically-elected hospital/health representation. DHBs have a strong resem- boards dating back to the 1870s (Laugesen blance to the AHBs of the 1980s, but an and Gauld 2012). important difference is that the 20 DHBs are As of 2016, the most significant differ- required to plan and deliver services based on ence between New Zealand and Canada is the the needs of their population (Tenbensel et al. development of what could be termed region- 2008). DHBs are accountable to the central alized primary healthcare. The story behind government, which is clearly laid out in the this, and the experience and consequences of New Zealand Public Health and Disability it, are the focus of this commentary. Act (2001). As of 2016, New Zealand’s
28 Health System Regionalization – the New Zealand Experience structure is more decentralized than most 1998) in health systems, the principles of Canadian provinces. The rationale for this Alma-Ata and its emphasis on primary number of DHBs is primarily pragmatic, as healthcare as something much broader than it was close to the number of major hospitals, family doctor services and a shifting of the which provided the administrative homes of locus of control from practitioners to the the new DHB organizations (Gauld 2001). broader community. During the 1983–2001 period, the The PHCS introduced a shift in the overarching rationales for structural change way the government funded its contribution ranged from consolidation, rationalization and to primary care from fee-for-service (FFS) improved accountability (AHBs of the 1980s), reimbursement to capitation based on the efficiency, (purchaser–provider split of the characteristics of enrolled population. This 1990s) to population health, public participa- new capitation model was more generously tion and service integration (DHBs of the funded than the old FFS-based system (Mays 2000s). In common with Canada, there has and Cumming 2004). However, to receive been limited research conducted on whether the benefit of this increased funding, family each round of restructuring led to desired physicians – known as general practitioners improvements. (GPs) in New Zealand – were required to There is certainly no consensus among become part of a new type of organization commentators that the current arrangement in primary care, known as Primary Health is optimal (Gauld 2009). Even so, structural Organisations (PHOs). PHOs were estab- reform has been off the agenda since the lished by the government as a type of non- 2000 reforms, because both major political profit organization, with a statutory set of parties were cognizant of structural reform minimum requirements for those who wanted fatigue and electoral backlash. Attention has to join. shifted to other policy instruments designed PHOs were built on important develop- to encourage integration through the fostering ments in the organization of primary care of inter-organizational networks. in the 1990s. In response to the govern- ment’s introduction of competitive contract- Integrating Primary Care into Health ing models to the health sector, primary System Governance care doctors had formed new organiza- Since 2001, the New Zealand regionaliza- tions, known as Independent Practitioner tion story has taken quite a different turn. Associations (IPAs), that formed in order to Governments have prioritized the integra- collectively bid for funding from purchasers tion of primary care into broader health (RHAs) (McAvoy and Coster 2005). This system governance. The Primary Health environment also stimulated the develop- Care Strategy (PHCS) introduced in 2001 ment of third-sector primary care – non-profit was framed in terms of endemic problems of organizations that served a low-income and primary care access and inequality in New high needs clientele (similar to Ontario’s Zealand and the consequences for demand Community Health Centres, but non-govern- for hospital services (King 2001). These ment owned), and the development of Māori problems were largely attributable to the high health providers (Crampton et al. 2005). level of patient co-payments in primary care. In the 2002–2004 period of implemen- The PHCS was informed by Starfield’s work tation of the PHCS, many of the 80 or so on the centrality of primary care (Starfield PHOs that formed were based on existing
29 HealthcarePapers Vol. 16 No. 1 organizations (IPAs, third sector and Māori providers), and the vast majority of GPs One key policy instrument for inte- joined PHOs. Around 95% of the New Zealand population are enrolled in PHOs gration has been the extensive use of (Ministry of Health 2016a). performance measures and targets. The relationship between government agencies (DHBs) and PHOs is primar- Emergent Issues in New Zealand ily governed through the PHO Services Health System Governance Agreement – a contract for services, which is The changes since 2000 have embedded a nationally consistent, but administered at the system-wide focus on population health, even local level by DHBs. Through this mecha- if DHBs and PHOs often have difficulty nism, the primary care sector has contractual in developing specific initiatives aimed at and, therefore, accountability relationships improving population health outcomes and with government. reducing inequities (Tenbensel et al. 2008). PHOs have been regarded as having the New Zealand’s relatively low proportion potential to be a driving force for the integra- of sole-practice GPs (Royal New Zealand tion of primary health services with other College of General Practitioners 2015) and parts of the health system (Gauld 2009). The high uptake of electronic health records government led by the National Party has (Protti and Bowden 2010) can be plausibly sought to stimulate the development of alli- attributed in part to the changes outlined ances between public sector DHBs and non- above, as PHOs enable and often take on government PHOs to plan, fund and deliver themselves the aggregation of some primary services at the local level. Governments have care data management functions. also attempted a number of mechanisms of However, it is important to note some encouraging collaboration in specific service significant limitations and barriers to the areas, with mixed success (Mays 2013). effectiveness of this “regionalization of One key policy instrument for integration primary care,” and the integration of health- has been the extensive use of performance care services. Firstly, there has always been measures and targets. While some of these something of a mismatch between DHBs have been focused solely on hospitals, these and PHOs in terms of scale and relation- are increasingly being used as ways to engi- ships. Back in 2008, Gauld argued that neer greater collaboration between DHBs little policy consideration was given to the and PHOs. For example, in order to reach the interaction between the DHBs and PHOs target of 95% of all two-year-olds fully immu- (Gauld 2008). Many PHOs traverse DHB nized by July 2012, significant cooperation boundaries, and many are not defined by was required between GPs, PHOs and DHBs, geographic boundaries at all. There are all of which were linked in a chain of account- some good reasons for this. Some PHOs are ability (Willing 2014). From July 2016, DHB focused on specific populations. For exam- and PHO alliances will be jointly responsible ple, one PHO is a federation of many Māori for performance against new “system level health providers, while another focuses measures” (SLMs), including ambulatory- on Pacific Island populations (Pasifika) sensitive hospitalization for those 0–4 years across greater Auckland. It is also fairly old and rates of amenable mortality (New easy (and common) for dissatisfied GPs Zealand Ministry of Health 2016). to switch PHOs.
30 Health System Regionalization – the New Zealand Experience
Although the number of PHOs had Zealand public sector routines involving rela- reduced to around 30 by 2012 (Cumming tions between government funders and non- 2014), these different logics still create a government providers (Ryan 2011). The PHO complex inter-organizational environment. Services Agreement and the system of targets While DHBs and PHOs have contiguous attest to these strong lines of hierarchical boundaries and stable “one-to-one” rela- accountability. tionships in some parts of the country, the However, governments are also cognizant complexity of inter-organizational relations of the limitations of hierarchical approaches, increases in the larger urban centres, particu- partly due to the tacit power of health profes- larly New Zealand’s largest city, Auckland sionals to divert policy through implemen- (Tenbensel et al. 2014). tation. The emphasis on collaboration and This adds further complexity to a relation- inter-organizational networks represents an ship between PHOs and DHBs that is char- attempt to develop a more integrated health acterized by a number of structural tensions. system through softer, more “organic” means. The first tension is between a population Some localities have clearly responded focus and a clinically-defined focus. Most to this. The Canterbury district (based in the PHOs, despite the aspirations of community- city of Christchurch) has been highlighted governed primary healthcare, are effectively as an international exemplar of integration controlled by GPs. Progress toward a popu- by the influential UK think tank, the King’s lation-based focus in PHOs has been slow, Fund (Timmins and Ham 2013). Innovative because the vast majority of capitated fund- approaches include the pooling of DHB and ing flows to GPs with little headroom left for PHO budgets regarding areas of service. initiatives to reduce barriers to access. The DHB has clearly stepped back from A second tension, familiar to Canadians, using a command-and-control approach is between the prerogatives of the state as and instead, emphasized its partnership with funder, and primary care providers still rooted non-government-based primary care provision. in a private small-business model. DHBs have had difficulty enforcing their contrac- tual authority in this environment – an … governments are also cognizant example being the early failure of many GPs of the limitations of hierarchical and PHOs to meet requirements for care on evenings and weekends without sanction approaches … (Controller and Auditor-General 2010). GPs Lessons for Canada from the New have the additional “safety valve” of being Zealand Experience able to raise co-payments – a right that is New Zealand’s experience over the past 15 effectively enshrined and that has survived years may be instructive for Canadian prov- repeated governmental challenges (Croxson inces, although there are always limits in what et al. 2009). can be learnt (and possibly transferred) from Against this backdrop, the third and one jurisdiction to another. This is pertinent perhaps most significant tension concerns the at a time in which some Canadian provincial relative emphasis on hierarchical and collabo- governments are considering the possibility rative relationships between DHBs and of more regionalized primary care structures PHOs. Hierarchical, principal-agent relation- in order to foster a more integrated health ships are hard-wired more generally into New system (Price et al. 2015).
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The major challenge is working out how “first-dollar coverage” entrenches the corpo- to blend hierarchical and collaborative styles of ratist dynamic, whereas New Zealand’s has inter-organizational relationships (Tenbensel enhanced governmental autonomy in health et al. 2011). The strengths and shortcomings of system reform (Tenbensel 2008). both approaches are readily apparent in New If this analysis is correct, then Canadian Zealand. Collaboration can produce innova- provinces may need to develop their own tive developments, but not – it appears – across paths to health service and system integration, the board, and not in a way that fundamentally without the same capacity of New Zealand changes the balance of power between state governments to set the agenda and drive and profession. Hierarchical governance can change more unilaterally. and does change this balance, but is rarely effective at changing the hearts and minds of References those delivering primary care services. Ashton, T. 2013. “The New Zealand Health System after 75 Years: Let’s Stop and Smell the Roses.” New One important consideration is that some Zealand Medical Journal 126(1380): 6–8. New Zealand developments are not easily transferrable to Canada, because of the differ- Ashton, T. and T. Tenbensel. 2010. “Reform and Re-reform of the New Zealand System.” In K. Okma ent nature of government/interest group and L. Crivelli, Six Countries, Six Reform Models – the relationships in primary care. New Zealand Healthcare Reform Experiences of Israel, the Netherlands, governments have frequently been able to New Zealand, Singapore, Switzerland and Taiwan (pp. 83–110). Singapore: World Scientific Publishing. introduce changes in primary care without the prior agreement of medical interest groups Controller and Auditor-General. 2010. District Health Boards: Availability and Accessibility of After-Hours (Ashton and Tenbensel 2010). Although Services. Performance Audit Report. Wellington, NZ: these policies are usually transformed when Office of the Auditor-General. implemented, governments can and do have Crampton, P., P. Davis and R. Lay-Yee. 2005. considerable autonomy in devising new “Primary Care Teams: New Zealand’s Experience with arrangements. Canadian provincial health Community-Governed Non-Profit Primary Care.” policy, by contrast, is strongly corporatist Health Policy 72(2): 233–43. – built on bilateral negotiating and bargain- Croxson, B., J. Smith and J. Cumming. 2009. Patient ing relationships between provincial govern- Fees as a Metaphor for So Much More in New Zealand’s Primary Health Care System. Wellington, NZ: Health ments and medical associations. Arguably, the Services Research Centre. PHCS and the introduction of PHOs would not have survived a corporatist process of Cumming, J., J. McDonald, C. Barr, G.Martin, Z. Gerring and J. Daubé. 2014. New Zealand Health policy formulation and decision-making. System Review. World Health Organisation and Asia It is quite possible that key differences in Pacific Observatory on Health Systems and Policies. the “accidental logics” (Tuohy 1999) of health Retrieved August 11, 2016.
32 Health System Regionalization – the New Zealand Experience
Gauld, R. 2013. “Questions about New Zealand’s Royal New Zealand College of General Health System in 2013, Its 75th anniversary year.” Practitioners. 2015 Workforce Survey. Retrieved New Zealand Medical Journal 126(1380): 68–74. July 19, 2016.
33 Transforming Regions into High- Performing Health Systems Toward the Triple Aim of Better Health, Better Care and Better Value for Canadians
COMMENTARY
Yves Bergevin, MD, MSc, CCFP, FRCPC, FCFP Medical Advisor, Clinical Governance Institut national d’excellence en santé et en services sociaux (INESSS) Director of Global Health Programs, Department of Family Medicine, McGill University Montréal, QC
Bettina Habib, MSc, MScPH Clinical Research Assistant, Centre for Clinical Epidemiology Lady Davis Institute, Jewish General Hospital Montréal, QC
Keesa Elicksen-Jensen, MA Improvement Analyst Canadian Foundation for Healthcare Improvement Ottawa, ON
Stephen Samis, MA Vice-President Canadian Foundation for Healthcare Improvement Ottawa, ON
34 Transforming Regions into High-Performing Health Systems
Jean Rochon, MD, LL.L, DrPH Medical Advisor, Institut national de santé publique du Québec (INSPQ) Emeritus Professor, Université Laval Associate Professor, Université de Montréal Montréal, QC
Jean-Louis Denis, PhD Professor, Canada Research Chair in Health Systems Governance and Transformation École nationale d’administration publique (ENAP) Montréal, QC
Denis Roy, MD, MPH, MSc, FRCPC Vice-President - Science and Clinical Governance Institut national d’excellence en santé et en services sociaux (INESSS) President of the Canadian Association of Health Services and Policy Research (CAHSPR) Clinical assistant professor, École de santé publique de l’Université de Montréal Associate professor, Université de Sherbrooke and McGill University Montréal, QC u
ABSTRACT A study on the impact of regionalization on the Triple Aim of Better Health, Better Care and Better Value across Canada in 2015 identified major findings including: (a) with regard to the Triple Aim, the Canadian situation is better than before but variable and partial, and Canada continues to underperform compared with other industrialized coun- tries, especially in primary healthcare where it matters most; (b) provinces are converging toward a two-level health system (provincial/regional); (c) optimal size of regions is prob- ably around 350,000–500,000 population; d) citizen and physician engagement remains weak. A realistic and attainable vision for high-performing regional health systems is presented together with a way forward, including seven areas for improvement: 1. Manage the integrated regionalized health systems as results-driven health programs; 2. Strengthen wellness promotion, public health and intersectoral action for health; 3. Ensure timely access to personalized primary healthcare/family health and to proximity services; 4. Involve physicians in clinical governance and leadership, and partner with them in accountability for results including the required changes in physician remuneration; 5. Engage citizens in shaping their own health destiny and their health system; 6. Strengthen health information systems, accelerate the deployment of electronic health records and ensure their interoperabil- ity with health information systems; 7. Foster a culture of excellence and continuous quality improvement. We propose a turning point for Canada, from Paradigm Freeze to Paradigm Shift: from hospital-centric episodic care toward evidence-informed population-based primary and community care with modern family health teams, ensuring integrated and coordinated care along the continuum, especially for high users. We suggest goals and targets for 2020 and time-bound federal/provincial/regional working groups toward reaching the identified goals and targets and placing Canada on a rapid path toward the Triple Aim.
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Regionalization constitutes de facto one Interest in the healthcare services sector of the main organizing strategies of health has recently shifted to managing for results systems across provinces and territories in and to continuous quality improvement. Canada, beyond the five founding principles This is perhaps best exemplified by the of the Canada Health Act (public admin- high-performing healthcare organizations istration, comprehensiveness, universality, (accountable care organizations [ACOs]) portability and accessibility) (Government in the US and the recent decision of the US of Canada 1985). Government to transform Medicare physician Over the past 20 years, there has been re-imbursement from fee-for-service to pay- much experimentation with regionalization for-performance (Kaiser Permanente 2015; across Canadian provinces. The short-lived Steinhauer and Pear 2015). Canadian Observatory on Regionalization There have been recent announcements reviewed these natural experiments, highlight- and undertakings of healthcare governance ing certain elements of regionalization with reform across Canada, such as the centraliza- regard to the performance of provincial health tion of regional health authorities (RHAs) systems (Lewis and Kouri 2004). in Alberta, Nova Scotia and Prince Edward Since 2004, however, as pointed out by Island into one provincial health author- Marchildon (2016) in his introductory essay ity and Quebec’s recent shift to a two-level of this issue, there has been little systematic regional system as of April 1, 2015. These evaluation of the impact of the regionali- ongoing changes underpin the timeliness zation of health in Canada. As one of the and importance of examining the impact several contributions to this issue on region- of regionalization. alization, this paper attempts to address We conducted a study of regionalization what have been the realizations – the impact across Canada in 2015. A detailed report is – of regionalization across Canada toward available (Bergevin et al. 2016). We will thus the Triple Aim of Better Health, Better Care present here the salient features of the report, and Better Value (Institute for Healthcare reflect on how one might implement in the Improvement 2016). near term the vision and way forward recom- mended and suggest what might be useful processes at federal, provincial/territorial and Interest in the healthcare services regional levels to reach specific time-bound sector has recently shifted to health goals and targets, thus accelerating the progress toward the Triple Aim. managing for results and to This study used a rapid evidence-based continuous quality improvement. approach, which included in-depth structured interviews of 30 senior Canadian health leaders The regionalization of health services has from every province and 2 territories. The study progressed at different rates across provinces. participants included deputy ministers, assistant Québec was an early adopter, implementing deputy ministers, two former ministers, CEOs regionalization together with universal health of RHAs, academics (including one dean) and insurance in the early seventies. Ontario, on leaders from Canadian health organizations. We the other hand, has only recently pursued assured the respondents of the anonymity of partial regionalization through its Local their responses, which allowed them to express Health Integration Networks (LHINs). themselves frankly and freely.
36 Transforming Regions into High-Performing Health Systems
and lacks quantitative evidence; and the lack of a true comparison group, although some Several factors made it difficult would argue that Ontario, not having formally to tease out cause-and-effect regionalized, could act as a comparator.
relationships … Major Findings In addition to the interviews, we Origins of modern district health conducted a scoping review of the literature systems/regionalization on regionalization in Canada over the past Following the Declaration of Alma-Ata decade, as well as a rapid review of the char- on Primary Health Care in 1978, national acteristics of some high-performing health governments sought to implement primary systems in other countries. healthcare for their populations (World The study identified major findings. Based Health Organization 1978). This has led to a on these, the study team then developed a body of work on district health systems with vision and a way forward with seven areas for ministries of health appointing district health improvement toward transforming regions into management teams for each health district high-performing systems. covering a population of around half a million This study presents several strengths: the (World Health Organization 2016). The senior positions, expertise and experience emergence of “regions” across Canada gener- of the interviewed health leaders together ally corresponds to the WHO’s definition of with their very high response rate (94%); the “districts,” which is the usual international consistency of the findings across Canada; terminology for such health structures. the convergence of the findings from the As Marchildon attests, all provinces interviews with those from the literature; and except Ontario have undergone some degree the systematic validation of the findings by of centralization of local health structures to study participants when the draft report was RHAs, thus moving to a two-level system circulated for validation and feedback. consisting of ministries of health and RHAs. Several factors made it difficult to tease This has been achieved by dissolving the boards out cause-and-effect relationships and to of local health institutions and placing these isolate the contribution of regionalization to institutions under the RHAs (Marchildon overall improvements in health and health- 2013). Over time, many provinces have care: the lack of relevant healthcare perfor- also reduced the number of regions. A brief mance data disaggregated at the regional description of regional health systems in each level and the weakness of current information province/territory is presented in the report. systems; the absence of formal evaluations of regionalization across Canada and in many Regionalization in context cases the lack of meaningful annual reporting Although life expectancy in Canada has on performance; the multiple changes in the increased from 78 to 81 years of age over structure, functions and numbers of regions the past 7 years (Organisation for Economic that have occurred since the beginning of Cooperation and Development 2011) regionalization across provinces, thus preclud- – it is now only 2 years behind that of ing an observation period sufficient to draw Japan – “Canadian healthcare continues to satisfactory conclusions; the fact that much of be an underachiever” (Lewis 2015). Table 1 the literature is in the form of expert opinion presents data for Canada, France (a high
37 HealthcarePapers Vol. 16 No. 1 performer) and the United States (our neigh- American organizations; key points included: bour) on four important performance meas- ures of the health system from a patient’s • access to client-centred care, clients taking perspective. Nine percent of Canadian senior charge of their own health destiny and citizens spent over $2,000 out-of-pocket in health and wellness promotion; the previous year compared to 0% in France. • coordination and integration of services; Only 45% could get a same- or next-day • support of electronic health records appointment with a doctor or nurse when and integrated information systems, needed (83% in France). Only 41% could together with mobile applications for access after-hours care (compared with 69% patients/clients; in France). And 39% of older Canadians had • integration of physicians into the to use the emergency department in the past accountability of care with performance- two years compared with only 15% in France based funding and relevant modes of (Osborn et al. 2014). remuneration; and Table 1. Four health system performance measures • inclusion of financial coverage of essential from a patient’s perspective drugs, particularly in the ambulatory and home care settings. Issue France Canada US
Spent $2,000 or more Towards a two-level system out-of-pocket in the past 0% 9% 21% year In recognition of the usefulness of regions, there has been a convergence of regionaliza- Could get same- or next- day appointment with tion models across Canada with most prov- 83% 45% 57% doctor or nurse when sick inces moving toward a two-level system, in or needed care which the ministry of health provides policy, Access to after-hours 69% 41% 55% financing and overall governance and over- care sight, and in which RHAs are responsible for Emergency department 15% 39% 39% regional governance (in line with provincial use in the past two years policies), management and service delivery Source: Commonwealth Fund 2014. International Health Policy Survey for a given territory and population. Ontario’s of Older Adults in Eleven Countries (Osborn et al. 2014). system is structured between a two-level and Under the Affordable Care Act (ACA), a three-level system: the province has main- the United States is making rapid progress in tained local hospital boards, has a strong focus reforming its health system. Population cover- on access and quality and has instituted Local age is expanding and the growth in America’s Health Integration Networks (LHINs), which healthcare spending is slowing. Increasingly, carry out certain integration and coordination ACOs are emerging and offering more inte- functions but are not regions in the true sense grated and coordinated care at lower costs of the word. The two-level system has proven (The Economist 2015a, 2015b; Townsend very functional in several provinces, includ- 2013). High-performing health organizations ing British Columbia. As of April 1, 2015, such as Kaiser Permanente and Intermountain Québec also moved to a two-level system; Healthcare provide many useful lessons for its 34 RHAs are called Centres intégrés healthcare across Canada. Many of the senior de santé et de services sociaux (CISSS), leaders participating in the study raised the nine of which are designated as university need to learn from such high-performing affiliated (CIUSSS).
38 Transforming Regions into High-Performing Health Systems
Optimal size Regionalization has contributed to Several study participants expressed the improved care through enhanced knowledge view that the size of regions is relevant to of the needs of communities and populations; their functioning. A population size between an evidence-based approach to the provi- 350,000 and 500,000 was deemed opti- sion of care; the development of needs-based mal, with travel times within the region not regional service delivery plans; the regrouping exceeding three to four hours. This is consist- of services for better quality, improved results ent with the approach recommended by and lower unit costs; and enhanced govern- the WHO and other multilateral agencies ance and managerial capacity. Our study has (Tarimo 1991; World Bank 1993). Different revealed a more integrated and coordinated services are optimally organized and deliv- approach to care with a better allocation ered on different scales, and thus for different of resources toward community, home and population sizes: local for primary healthcare, long-term care. Regional service delivery regional for secondary care and provincial for plans, specialist outreach and telehealth have tertiary care. additionally improved access to specialized services in the rural areas of regions. The Better health, care and value: Better than results across Canada and within provinces are before but variable and partial variable and there is still considerable room There was a strong consensus among study for improvement. participants that regionalization has contrib- As regionalization has often been imple- uted positively – albeit variably – to improving mented in the context of budgetary constraints, the health status of Canadians through an it is not evident that regionalization per se has enhanced population health approach with contributed to reducing costs. It can be said better care, strengthened public health and an though that regionalization has contributed intersectoral approach to address the deter- to enhancing the efficiency of the health- minants of health. Regions act as integra- care system. Examples include: rational and tors toward health improvement (Figure 1). evidence-based regional service delivery plans However, the potential contribution of better responding to the needs of communi- regionalization to better health has not been ties; the re-allocation of resources toward the fully realized. community, ambulatory and long-term care;
Figure 1. Regions as integrators toward health improvement
Better value • Relevance of services • Priorities • Optimal allocation and use of resources • Cost-effectiveness
Better health Regions as integrators • Public health • Population health approach Better care • Intersectional action to • Equity – effectiveness • Integration and coordination address health determinants • Citizen engagement • Quality/safety • Services responsive to • Physician engagement • Clinical governance/networks community needs • Information systems/knowledge management • Enhanced capacity • Cost-effectiveness • Adaptive capacity/learning and improvement
39 HealthcarePapers Vol. 16 No. 1 the regrouping of clinical services toward managed without the essential elements of a enhanced expertise, quality (reduced complica- quality program approach: goals and objec- tions) and lower unit costs; the strengthening tives are often vague or absent, as are targets of primary healthcare including, in some cases, and baselines; monitoring systems are weak; through the move away from fee-for-service theories of change and logical frameworks are physician remuneration; the reduction in incomplete; and emphasis on evidence-based management costs in some areas; and a long- interventions is variable. term reduction in the pressure on emergency departments and hospitals arising, on the one Engagement of physicians: Improving but hand, from stronger primary and community variable and weak care, and on the other hand, from the improv- Although there has been important progress ing health status of the population through in the engagement of physicians as leaders, in better care, enhanced public health and inter- clinical governance and in clinical networks, sectoral action. Here again, there is consid- our study revealed very weak engagement of erable room for improved efficiency while physician clinicians with regard to the health improving effectiveness and quality of care. system, and regionalization in particular. Many study participants commented that Citizen engagement: Both pluses the budget envelopes for physician services and minuses and for drugs – two very large components The impact of regionalization on citizen of health budgets and important drivers of engagement was reported to be mixed and the costs of the system – are not within the at times more negative than positive. On the budget envelopes of RHAs. Most mentioned positive side, the enhanced population health the need for far greater accountability of and intersectoral approaches have increased physicians for individual patient outcomes, attention to the needs of communities and service utilization and system performance; facilitated dialogue with elected municipal in this context, many referred to the high- officials and community representatives. performing healthcare systems, to the emerg- Specifically, efforts have been made to engage ing results from ACOs in the United States indigenous peoples in the governance of and to examples from other countries. The their health systems, particularly in British modes of engagement, contracting and remu- Columbia and Quebec. On the negative side, neration of physicians were recognized by the dissolution of hundreds of local hospital, study participants as one of the major obsta- health centre and other institutional boards cles to improving the performance of regional through their consolidation into one RHA has health systems across Canada. greatly diminished the involvement of citizens in the governance of their health institutions. Patient-centred primary healthcare: Variable across Canada and weak relative Incomplete results-driven program to other countries approach, with unclear goals, targets and There was consensus among the majority of weak monitoring systems study participants that access to timely, qual- Despite health expenditures of the order of ity primary care is one of the major issues $200 billion in 2014 (>$6,000 per Canadian, facing regional health systems across prov- 11% of GDP) (Canadian Institute for Health inces and regionalization in particular. This Information 2015), healthcare is often was highlighted by the Commonwealth Fund
40 Transforming Regions into High-Performing Health System
2014 survey, which showed that only 45% Links to foster more coordinated and inte- of Canadian seniors could obtain a same- or grated care (Ministry of Health and Long- next-day appointment with a doctor or nurse term Care 2015). While there has been when needed, compared with 83% in France. progress in Ontario, much remains to be done Similarly, 39% of Canadian seniors used the to ensure integrated and coordinated care, emergency department in the past two years given that many patients still end up in the compared with only 15% in France (Table 1), hospital emergency department needlessly. evidence of failure of the health system to Other provinces are also actively working decrease the recourse to hospital-based care to strengthen access to primary healthcare, (Osborn et al. 2014; Tannenbaum 2014; the cornerstone and standard point of entry Marshall 2015). to healthcare across Canada (The Conference One of the goals of health systems should Board of Canada 2014). be to enable people to remain autonomous Building on a strong history of general in their homes and communities. The access practice, Canada is at the forefront of the of Quebecers to family physicians has been development of family medicine educa- particularly problematic; this problem has tion. The College of Family Physicians of been identified as urgent and important by the Canada (CFPC) promotes competencies provincial government and has given rise to through accredited residency programs and major legislative reform and negotiations by the the Certification Examination in Family government in 2015. As these changes have yet Medicine (CCFP). It has also promoted to be fully implemented at the time of writing, “Timely Access to Appointments in Family the jury is still out as to their effectiveness. Practice: Same-Day/Advanced Access Scheduling” and “A Vision for Canada: Family Practice – the Patient’s Medical … Canada is at the forefront Home” (College of Family Physicians of of the development of family Canada 2011, 2012) Passing the Certification medicine education. Examination in Family Medicine has become a pre-requisite for family practice in some Ontario has focused on access to primary provinces. A number of provinces have begun healthcare with family health teams (FHTs), moving – albeit slowly – toward FHTs and community health centres and more adapted local health centres/family medicine centres modes of contracting and remunerating (patients’ medical homes). family physicians. Building on Ontario’s work to strengthen primary care, the Minister of Slow and variable progress on information Health and Long-Term Care in Ontario systems and electronic health records released Patients First: Action Plan for Health Regional health executives have to lead and Care in February 2015 (Government of manage their RHAs on a daily basis much in Ontario 2015). It is to be noted that 94% the same way a pilot might have to fly a plane of Ontarians already have a primary care with a partial instrument panel, an infrequent provider. Furthermore, for those 5% of emergency requiring urgent action. It was noted patients with multiple and complex condi- that there exist multiple health information tions, and who account for nearly two- systems, with major difficulties in exchang- thirds of healthcare costs, the government ing relevant information between them. There of Ontario has created Community Health is also an important variation in the rate of
41 HealthcarePapers Vol. 16 No. 1 implementation of electronic health records, the need for oversight by an elected govern- and the lack of interoperability between these ment. Most felt that the system performed and information systems precludes any real- best when the government remained at time management of the health system. Several arm’s length from service delivery with clear participants placed the Canadian situation in communications between levels. sharp contrast with that of Kaiser Permanente in the US with fully interoperable integrated Inadequate financial coverage of essential information systems, allowing for real-time drugs in ambulatory/home settings management of individual patients and of the RHAs are mandated to ensure the provision of system, not to mention the mobile applications client-centred care within communities and to for patients who become partners in shaping promote the autonomy of clients, making the their health destiny. recourse to hospital care necessary only when other approaches have failed. The inadequate The frequent re-organization of the financial coverage of essential drugs in ambulatory healthcare delivery architecture and care settings is a major roadblock to maintain- of regional structures and functions ing people in the community and to the optimal within provinces use of non-hospital services, thus contributing to Several provincial and territorial govern- the overutilization of hospital services and driv- ments have implemented changes to regional ing healthcare costs up. Reimbursing the cost of structures and functions every few years. essential drugs in all settings would, in all likeli- While noting that some of these changes were hood, pay for itself, especially in the context of necessary to improve function, these frequent bulk negotiating and purchasing by provinces and changes – and poorly executed change territories. This would greatly facilitate the ability management – have caused major disruptions of RHAs to progress toward ambulatory, home to the system, taking precious time away from and community care. client-focused improvements in health service In summary, Canadians enjoy one of delivery in order to manage the changes. This the highest life expectancies in the world. has also prevented meaningful formal evalu- Regionalization has most likely contributed ations of regionalization. Several respondents to this better health through better care, appreciated the fact that most provinces have stronger public health and increasing inter- now moved to a two-level system and that sectoral action to address the determinants of provincial healthcare delivery systems are now health. Regionalization has also most likely reaching a stage of stability and maturity. contributed to better value for money in health. However, we must not shy away from taking Insufficient clarity in roles and responsibilities note of the serious problems confronting of governments/ministries of health and healthcare in Canada. Access to family physi- of regional health authorities cians and to primary care is a major issue across Over the past decade, functions have been Canada; wait times for specific procedures are devolved to RHAs without a commensurate very long in some provinces and go well beyond readjustment within ministries of health established benchmarks (Canadian Institute (absence of business process reengineering), for Health Information 2014). Value for money often leading to duplications of function and could be improved considerably, especially to a tendency by ministries to micromanage when one compares Canada’s performance regions. All study participants appreciated with that of other countries. Canada faces real
42 Transforming Regions into High-Performing Health Systems
challenges in measuring its performance in Figure 2. Distribution of roles between provincial health and acting on results despite the exist- and regional levels ence of excellent knowledge organizations and Provincial population health policy framework • Whole-of-government approach to better health with prevention academic institutions. of non-communicable diseases and injuries Given the very solid base in Canada’s • Health poicy/financing/oversight • Provincial public health health system development – including the • Tertiary care/academic authorities major contributions from regionalization Accountability Clarity of roles – and the well-circumscribed nature of the framework issues facing healthcare across the provinces Regional health authority • Local/proximity primary healthcare/family health and territories, significant progress should be • Secondary care • Coordinated and integrated care across the continuum attainable within a few years by addressing a • Regional public health limited number of “system” issues. • Regional/municipal intersectional action We asked the study participants to iden- tify what it might take to further enhance the of communities and characteristics of regions, performance of regions toward better health, as well as to meet the realistic expectations of better care and better value. These views have key stakeholder groups. Regional governance been summarized in a “way forward,” to iden- is also necessary for the regions’ success in their tify a vision for regionalization and to posit efforts to engage and involve citizens and elected seven areas for improvement. officials in health-related issues. Two major streams of work are Way Forward recommended: A vision for regionalized high-performing health systems in canada 1. A much greater focus on population health Regions can provide the opportunity to achieve (including population-based planning and two aims: a high-performing health system service delivery; and public health and and a territory to achieve population health intersectoral action to strengthen wellness improvement. By using a population health and address the social determinants of health). approach, regions can be powerful integrators 2. A renewed focus on the local level and of efforts to improve health and healthcare. proximity services with integrated and On the care side, integration and coordination coordinated primary healthcare provided by can best be achieved at the regional level, while highly accessible multidisciplinary family simultaneously maintaining focus on specific health teams/health centres. local needs within the region. A vision thus emerges for high-performing Three strategies would underpin these regionalized health systems and for territories areas of greater focus: where healthy public policies can be implemented. The realization of this vision rests on re-estab- 1. Visionary executive leadership, which lishing and respecting the clarity of the respective advances a population health approach. roles and functions of provinces/territories and 2. Stronger physician leadership, engagement regions, and on ensuring the accountability of the and accountability for clinical and health health system’s various players (Figure 2). system outcomes. The governance function of regions is partic- 3. Stronger patient, citizen and community ularly important to ensure an optimal adaptation engagement and leadership. of programs and resources to the specific needs
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Such an approach would be supported by Seven areas for improvement a knowledge function through an enhanced Stemming from the recommendations of the evidence-based approach, information study participants and from further synthesis systems and an adaptive capacity to ensure by the study team, the following are seven areas continuous learning and quality improvement. for improvement which, if implemented, would Information would flow in real time through contribute importantly to achieving this vision the system with interoperable electronic and lead to major, rapid progress toward the Triple health records feeding into the population- Aim. While these seven areas for improvement are based health information system. Physicians, each necessary for regions to achieve better health, managers and executives would be held better care and better value, several will require accountable for results. system changes beyond regionalization (Table 2). Financial coverage of essential drugs would be provided in ambulatory and home Table 2. Seven areas for improvement settings, thus further decreasing the recourse Manage the integrated regionalized health systems to hospital care. 1 as results-driven health programs, transforming Organizing services in this manner under them into high-performing health systems one RHA enables the reallocation of resources Strengthen wellness promotion, public health and 2 intersectoral action for health to better address the between acute care, long-term care and primary social determinants of health care/home care/social services, thus ensuring Ensure timely access to personalized primary that the system is well prepared to meet the 3 healthcare/family health teams (FHTs) and to care challenges of the future (Figure 3). proximity services
While such a vision may a priori appear Involve physicians in clinical governance and unreachable or utopian, it is to be noted that leadership, partner with them in accountability for 4 high-performing healthcare organizations results and engage them in the required changes in physician contracting and remuneration in the US, such as Kaiser Permanente and Engage citizens in shaping their own health destiny Intermountain and those in other countries, are 5 and their health system approaching such a vision, at least on the care side. Furthermore, if one were to combine the best Strengthen health information systems, accelerate the 6 deployment of electronic health records and ensure characteristics of health regions across Canada, their interoperability with health information systems one would likely achieve such a vision. Such a Foster a culture of excellence, learning, innovation vision is, therefore, realistic in the near term for 7 and research and encourage adaptive capacity Canadian provinces and territories. towards continuous quality improvement
Figure 3. Regions as integrators toward health improvement
Executive leadership
Regional health authority
Regional-level secondary care/access to tertiary care
Excellence, continuous learning and research, adaptive capacity towards Community/local level Information flow continuous quality improvement Primary healthcare Proximity services Home care/long-term care/ social services
Citizen leadership Intersectoral action Professional/physician leadership
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1. Manage the integrated, regionalized health systems or federally. Intersectoral action for health as results-driven health programs, transforming at local, municipal, regional, provincial them into high-performing health systems and federal levels should simultane- In order to achieve high performance, ously be strengthened using approaches regionalized health systems will need to be that are best suited for the issues at hand managed as results-driven health programs and through the engagement of elected with clear goals, targets, baselines, bench- officials, community representatives and marks and milestones, as well as a strong- ordinary citizens. performance monitoring system with clear Recurrent funding for this investment indicators and support from solid real-time in wellness will need to be increased. In the information systems. spirit of Better Value of the Triple Aim and the These systems should be characterized recurrent cost-savings approach of the report, by robust accountabilities and metrics: physi- these additional costs should be covered by cians, managers and executives of RHAs the highly effective and revenue-generating should be held accountable for the health interventions of increased tobacco and new outcomes, utilization and value for money of sugary drink taxation. their respective clienteles/populations. Furthermore, regions should have multi- 3. Ensure timely access to personalized primary year strategic/business plans that include healthcare/FHTs and to proximity services regional service delivery plans (with medical Building on Canada’s strong tradition and staffing plans), public health and intersectoral excellence in family medicine education, every action. They should also be held accountable Canadian should be ensured access to timely, for their implementation and monitoring appropriate, comprehensive and high quality of results. primary care. We should continue to encour- age interprofessional family practice teams 2. Strengthen wellness promotion, public health comprising nurse practitioners, family physi- and intersectoral action for health to better cians and other health professionals with a address the social determinants of health responsive appointment system, after-hours Every opportunity to engage patients and coverage, home care/visits as needed and citizens in shaping their own health destiny coordinated and integrated care, especially for should be taken. This should be achieved in those who need it most (Spitzer et al. 1974). partnership with health professionals and by These FHTs should ensure continuity of care encouraging population health strategies and and foster attachment. the adoption of healthy behaviours, preventing Learning from high-performing organi- to the greatest extent possible chronic condi- zations and from other countries, fund- tions and injuries, and promoting healthy ing for these family health teams/health living and aging. centres should be results-based and not Population and public health should simply fee-for-service (Atun 2015; Burwell be strengthened at regional, provincial and 2015; Marshall 2015). Regions will need to federal levels, while differentiating which re-focus their attention to the local level by actions are best conducted locally (and way of proximity services (soins de proximité), often in partnership with municipalities enhanced citizen engagement and local and community groups), and those which intersectoral action in collaboration with are better conducted regionally, provincially municipalities and community groups.
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4. Involve physicians in clinical governance and Medicare in the US and other countries (Bras leadership, partner with them in accountability for and Duhamel 2008; Pear 2015). results and engage them in the required changes In this context, a strong argument can in physician contracting and remuneration be made to regionalize budget envelopes for Building on recent progress in clinical the remuneration of physicians, whether it is governance, physicians should be much more for family physicians operating within family involved as leads for clinical services and be health teams/centres, for family practice and held accountable for the results of the clini- specialist services in hospitals or for other cal services they lead. Clinical governance, in specialized ambulatory services. Integrating this case, is optimally achieved by physician physicians within regionalized structures leads /co-leads, who display strong leadership and functions in this manner will ensure that and who foster motivation and teamwork. integration reflects the notion of the produc- Strengthening the quality of care and clini- tion process within an organization – a key, cal excellence would also require the further but often neglected management principle development of strategic clinical networks (Coase 1937). that connect individual clinical services within and across regions. 5. Engage citizens in shaping their own health Beyond that, individual clinicians should destiny and their health system be held accountable for their patients’ As Eric Topol suggests in his book The Patient outcomes and co-accountable for the perfor- Will See You Now, we need to ensure that mance of the health system. Modalities of citizens are much more engaged in shaping contracting and remuneration will need to their own health destiny in partnership with reflect this new reality. While provincial medi- their health professional (Topol 2015). Their cal associations have resisted such approaches engagement in the governance of their local in the past, there is an evolution toward remu- and regional health system should likewise neration models other than simply fee-for- be fostered; they should also have the oppor- service, such as capitation as part of blended tunity to participate in local citizen/patient remuneration. It is to be noted that physicians committees linked with their community in organizations, such as Kaiser Permanente, health teams/centres, as well as in intersec- and in other jurisdictions achieve a high level toral action for wellness and the prevention of professional satisfaction and remuneration of non-communicable diseases and injuries. commensurate with their expertise and work- RHAs should also further strengthen patient load under performance-based funding. advocacy and representation mechanisms at Remuneration should be adapted to the all levels of the system and further strengthen diversity of functions: patient care including the dialogue with elected municipal officials on-call coverage, management, teaching and and other community representatives. research. One is reminded of the wisdom of Sidney Lee’s The Three-Layered Cake, which 6. Strengthen health information systems, describes a remuneration scheme consisting accelerate the deployment of electronic health of three layers: basic compensation, personal records and ensure their interoperability with incentives and system incentives (Lee SS health information systems 1974, 1975). We would do well to learn from In order to provide client-centred, integrated experiences across provinces and from recent and coordinated care and improve the perfor- changes in the reimbursement system for mance of the health system, electronic health
46 Transforming Regions into High-Performing Health Systems records that feed into a real-time population- of health facilities and FHTs participating in based health information system should be collaborative CQI and accredited. fully deployed, as is currently being done in As knowledge is global, we should learn high-performing healthcare organizations, from the best of each system, both within with the principle of one person – one record Canada and internationally, and address the (electronic medical record, health information priority issues and areas for improvement system including financial data). discussed here. It will be important to empha- While this will require additional funding size increased interregional and interprovincial during the deployment and upgrade phase, learning and the implementation of innova- such a system should greatly improve the tions and best practices with rigorous evalua- efficiency of health service delivery through tions and evidence of improved effectiveness clinical analytics, prevent duplication and and efficiency. The recently published Naylor unnecessary procedures, avert potentially Report emphasizes the need for meaningful dangerous drug interactions and support the change, the importance of innovation toward a maintenance at home and in the community better performing health system and the impor- of individuals, who might otherwise end up tance of well-documented experimentation in the emergency room and require hospi- (Government of Canada 2015). talization. All this should lead to recurrent We should strengthen research cost savings, which should ultimately recover programs that can contribute to improv- the deployment and upgrade costs of a fully ing the Canadian health systems. This can integrated electronic health records and be achieved through a coordinated effort of information system. the Canadian Institutes of Health Research (CIHR), provincial research funds, academia 7. Foster a culture of excellence, learning, and provincial ministries of health/regions innovation and research and encourage adaptive with a view to addressing the issues and areas capacity towards continuous quality improvement for improvement presented. We will need In order to foster excellence, the passion greater emphasis on and more investment for care needs to be rekindled by involv- in implementation research closer to the ing and motivating health professionals and delivery of services, as well as in population their professional bodies, and by fostering health interventions, fostering a culture of an approach of continuous quality improve- learning systems. ment in all health service delivery and public Furthermore, high-performing ACOs in health institutions. This will require effec- the United States and elsewhere should be tive leadership of ministries of health, RHAs studied with the specific objective of learn- and other health organizations, as well as ing what could realistically be applied to the nurturing a partnership with physicians in the Canadian healthcare context to bring about context of enhanced accountability for results major improvements. for their patients and the populations they serve. Accreditation mechanisms and continu- ous quality improvement (CQI) strategies As knowledge is global, we can contribute significantly to this effort. Provincial ministries of health should hold should learn from the best of each regions accountable for these results, including system, both within Canada and use of performance-based systems, proportion internationally …
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Towards a Paradigm Shift Physicians of Canada 2011, 2012; McGill The recent book Paradigm Freeze: Why It Is So University Department of Family Medicine Hard to Reform Health-Care Policy in Canada 2016). These FHTs should ensure inte- leaves us with the impression that change grated care trajectories along the continuum in Canada’s healthcare will be very difficult with strong patient and family engage- (Lazar et al. 2013). ment, together with the relevant specialty This study provides a different conclu- programs, and social and community sion. The health of Canadians is one of the services when needed. best in the world, and Canadian provinces Such an approach, characterized by and territories are each pursuing a path to realistic and practical clinical excellence, improve their healthcare systems. The vision should contribute to maintaining people at and areas for improvement identified in this home and in their community and decrease paper are straightforward and could lead to the recourse to emergency department and to significant progress toward better health, hospital use (Reid RJ 2013) and, in the long better care and better value in only a few run, lead to costs savings. It should better years, at modest one-time costs recuperated prepare us to meet the needs of Canada’s with recurrent cost savings. Money, therefore, aging population. should not be a roadblock to change. Realizing all at once the vision and way Furthermore, there is a growing energy forward with its seven areas for improvement for change. Among others, three recent may appear daunting; focusing on primary events demonstrate this phenomenon: healthcare is likely to be a good entry point to a Policy Forum on Advancing Quality begin realizing this vision and to bring high Through Regional Clinical Governance held returns in a few years. in Toronto in March 2016 and, in May 2016, a Symposium des leaders en santé organ- How could we stimulate the change ized by the Order of Nurses of Quebec and required for this paradigm shift? a McGill Primary Care Policy Symposium First, to focus the mind, we might wish (CAHSPR et al. 2016; McGill University to set some goals and targets for the near Department of Family Medicine 2016; term. The following goals and targets are Order of Nurses of Quebec 2016). These presented as examples, to begin a conversa- three recent events each brought together tion, and are not meant to be prescriptive several hundred participants and shared or exhaustive. the theme of clinical excellence and quality We suggest, to begin a discussion, the through integrated, coordinated care along following goals and internationally comparable patient trajectories, with strong executive, targets for December 2020: professional and patient engagement. We are proposing a turning point for 1. Ensure that >90% of Canadians have Canada, from Paradigm Freeze to Paradigm access to a FHT Shift: from hospital-centric, episodic care • As measured by FHT rosters toward evidence-informed population- • Could get same- or next-day appoint- based primary and community care deliv- ment with doctor or nurse when sick ered and coordinated by FHTs (including or needed care those within community health centres • Access to after-hours care as the case may be) (College of Family
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2. Ensure coordinated and integrated care the 2000 Clair Commission, which recom- for >90% of high users mended Family Medicine Groups for Quebec • Decrease in emergency department use (Groupes de médecine familiale or GMF) • Decrease in rates of hospital admissions put forward the idea of GMF 3.0. Similarly, • Decrease in median number of Robert Reid presented the concept of Medical prescription drugs Home v 2.0 (Gouvernement du Québec 2000; McGill University Department of Family A pluralist approach to continuous quality Medicine 2016). Can we work further to improvement supported by shared goals better refine these concepts with the best and metrics evidence on the essential elements of an We need to consider evidence-informed optimal FHT? Based on these, should we approaches to management of change, contin- develop a formal process of accreditation of uous quality improvement, diffusion of inno- FHTs much as we do for other healthcare vation and scale-up, especially in the context institutions? of organizations with highly-educated self- driven professionals for whom professional Addressing the management of change satisfaction is highly valued. simultaneously at the three levels While some would argue for a bottom-up of the system approach and others for a top-down approach In order to effect a paradigm shift and the to change management, success may lie in an required rapid change, significant momentum approach that fosters working together with needs to be garnered by executive, professional common goals and practical, measurable, and patient champions at the three levels of the achievable and realistic targets. system: federal, provincial/territorial and regional. It may well be worth remembering the Following Canada’s federal election in wisdom of the 1970 Quebec Castonguay- October 2015 and the election of a new Liberal Nepveu Commission, which recommended government, the Prime Minister of Canada a pluralist approach to primary healthcare instructed the Minister of Health through her for Quebec; local health centres could stem Minister of Health Mandate Letter to: from, but not be limited to, a public corpora- tion originating from a group of citizens joined “Engage provinces and territories in the by a health team; a public corporation devel- development of a new multi-year Health oped under the initiative of a group of health Accord. This accord should include professionals with public representation; a a long-term funding agreement …” private corporation composed of health profes- (Trudeau 2015) sionals with consultative community input (Gouvernement du Québec 1970). Ontario, with A renewed health accord is a unique its different models of FHTs and its community opportunity to strive for the Triple Aim and health centres, is a good example of an evolving to be innovation-driven and performance- pluralist approach with a focus on collaborative based. Canada’s new federal Minister of continuous quality improvement with support Health has already indicated that, throughout from Health Quality Ontario (Ontario College her career, she has been led by the Triple Aim of Family Physicians 2015a, 2015b). of Better Health, Better Care and Better Value At the recent McGill Primary Care and has expressed a desire to advance these Policy Symposium, Michel Clair, Chair of goals for all Canadians (Philpott 2016).
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We propose a small, time-bound federal Better Value for Canadians, one should not working group/task force composed of, at forget the fourth component of what is now minimum, the federal Ministry of Health, the referred to as the Quadruple Aim: profes- CFPC, the Canadian Medical Association sional satisfaction and happiness in the work- (CMA), the Canadian Nurses Association place. Until recently, Canada may not have (CNA) and academic and patient representa- paid sufficient attention to this fundamental tives. These various members should commit component (Sikka R 2015). Improving organ- to this paradigm shift and consider how best izations and systems that foster professional to support this pan-Canadian change, in the satisfaction and happiness, in part by reaching context of the development of the new accord. practical clinical excellence, will benefit both Each province/territory might also wish to health professionals and the people they serve. consider creating a similar time-bound work- In order to succeed with this paradigm ing group composed of the provincial/territo- shift and its related management of change, we rial Ministry of Health, RHAs and provincial/ will need executive, professional and patient territorial chapters of the CFPC, CMA, champions with strong leadership skills. How CNA, faculties of health sciences, patient can we harness the leadership and identify the representatives and other key stakeholders champions in each province and territory to with a view to rapidly addressing the above transform our regions into high-performing goals and targets. health systems toward the Triple Aim of Within regions, RHAs might set up Better Health, Better Care and Better Value for time-bound working groups with FHTs and Canadians? Can we envision Canada becom- CHCs, patient representatives, representa- ing a world leader in primary healthcare? We tives of medical specialties most involved believe that we must seize the moment. in care trajectories, public health to foster a population-based approach, long-term facili- Acknowledgements ties and other relevant key stakeholders. These This study would not have been possible working groups would rapidly address the without the outstanding participation of the above goals and targets, keeping in mind both 30 senior health leaders from across Canada. population and geographic coverage, as well as A sincere thank you to each of them for addressing the needs of aboriginal communi- taking time out of their extremely busy sched- ties and other groups with specific needs. ule and for their effort. Deep appreciation for RHAs will need to be given the tools by their thoughtfulness in analyzing the major provincial ministries of health to exercise greater issues confronting health and healthcare leadership and governance as related to primary across Canada, in contributing to identify- healthcare: a clear mandate, the budget enve- ing potential areas for improvement and in lopes including for physician payment and full reviewing the draft report to validate the responsibility for management and oversight. robustness of the findings. Communication between levels would foster Sincere thanks to the staff of the Canadian the rapid resolution of bottlenecks. Strong Foundation for Healthcare Improvement clinical analytics would help measure progress. and, in particular, to Colby Williams for her Knowledge from good, well-measured practices tremendous coordination and follow-up and would be disseminated for everyone’s benefit. Diane Hull for all her support. While this paper attempts to address the The study received financial support from Triple Aim of Better Health, Better Care and the Initiative sur le partage des connaissances
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College of Family Physicians of Canada. 2012. Best et le développement des compétences Advice: Timely Access to Appointments in Family Practice. (IPCDC) and the Canadian Foundation for Ottawa, ON: Author. Healthcare Improvement (CFHI). Gouvernement du Québec. 1970. Castonguay-Nepveu A warm thank you to the staff of the Commission. Québec, QC: L’éditeur officiel du Québec. Canadian Association for Health Services Gouvernement du Québec. 2000. Commission and Policy Research (CAHSPR) for making d’étude sur les services de santé et les services sociaux possible the presentation of the study at the (Commission Clair). Retrieved August 25, 2016. Closing Plenary for the CAHSPR Annual
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McGill University Department of Family Medicine. Steinhauer, J. and R. Pear. 2015, “House Approves 2016. McGill Primary Care Policy Symposium. Bill on Changes to Medicare.” New York Times. Retrieved June 10, 2016.
52 Regionalization as One Manifestation of the Pursuit of the Holy Grail
COMMENTARY
Stephen Duckett, PhD, DSc, FASSA, FAHMS Director, Health Program Grattan Institute Victoria, Australia u
ABSTRACT Regionalization has strengths and weaknesses. The balance of the two will vary over time, differing in different contexts and with different implementations. Alberta’s implementation of a centralized structure had some strengths: economies of scale and expertise; opportunities for province-wide learning; internalization of geographic politics; and improved geographic equity. It also had weaknesses: diseconomies of scale, remoteness from communities and politicization. In any implementation of regionalization, policy makers should attempt to real- ize the benefits of alternative paths not travelled and minimise the weaknesses of the chosen structure.
As Marchildon (2016) notes, health system The hope of regionalization was that it reform has multiple objectives, some overt, would achieve allocative (or social) efficiency some less so. Typically, regionalization has two by facilitating the right mix of investments interrelated components: across various models of care (e.g., hospitals vs residential aged care). That this hope has 1. aggregation of the governance of disparate not been realized has not stopped advocates health sector entities into an organization of regionalization from continuing to spruik defined geographically; and its (supposed) merits. It was also hoped to 2. delegation of responsibility to the improve continuity of care – a strategy also geographic entity. now being pursued by other means, e.g., US
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Accountable Care Organizations (ACOs) and of the executives of three of the authorities – Ontario’s Quality-Based Procedures (QBPs). Capital, Calgary and Cancer Board – merged Alberta was an early adopter of the into Alberta Health Services (AHS) had a total regionalization project, consolidating 195 remuneration greater than that of the chief organizations into 20 in 1994, down to 12 in executive of the combined authority (Duckett 2003 and finally, 1 in 2009 (see Table 1). 2011). The Board office of AHS had the same As with other provinces, none of these staffing (both in terms of number of staff and models involved complete regionalization – people) as that of the previous Calgary RHA. responsibility for design or implementation Economies of scale went beyond the of fee-for-service payments to physicians was immediate governance roles. AHS back office not assigned to regional authorities under functions were about half to two-thirds the any model. size of the combined human resource, finance Most recently, Alberta was a front-runner and information technology functions of the in the single authority model – the first previous combined authorities. province that has a regional health author- Another area where amalgamation allowed ity (RHA), which covers the whole province achievement of scale economies was in (Duckett 2010). The creation of the author- procurement. Significant savings were achieved ity was hasty, with the justification for the from standardization, volume discounts and change lost in the entrails of the politics of elimination of questionable procurement prac- the day (Donaldson 2010). What can be tices. An example of the latter was one pros- observed today are some of the strengths thesis supplier made a regular modest donation and weaknesses of this approach. to a surgical research fund, which appeared to affect the ability of the predecessor health authority to conduct a transparent evalua- Aggregation … into a single tion of products. Centralization of purchasing authority allows consolidation resulted in the loss of donation, but this was more than offset by better prices. of back office functions. A second and related benefit was shar- Strengths of a Single Authority ing of expertise from the two larger previous There are four main (potential) strengths authorities, Capital and Calgary especially. of a single authority compared to multiple Those authorities had a number of corporate regional authorities, at least as implemented staff who had developed expertise in their areas in Alberta: economies of scale and expertise; of responsibility (e.g., food services and labo- opportunities for province-wide learning; ratory medicine were some examples). Some internalization of geographic politics; and of the smaller authorities had also developed improved geographic equity. expertise in aspects of health management Aggregation of multiple authorities into a (e.g., Chinook in using Lean Techniques). single authority allows consolidation of back Following the merger, this expertise office functions. In Alberta, each previous became available across the province, result- authority had a governance infrastructure of ing either in savings or improved services or boards (members were paid), chief executive and both. The merger also allowed standardiza- corporate governance support. Larger RHAs tion of accounting practices and definitions, had a larger infrastructure. Chief executive which had precluded effective interregional officers were generously remunerated. Each comparisons in the past.
54 Regionalization as One Manifestation of the Pursuit of the Holy Grail
Table 1. Alberta’s shrinking reporting points 1988+
Long- Public Regional Total (not Hospital term care health Central health health including Era Ministries boards boards boards service boards authorities ministries)
2: Hospitals and Medical Care 2: Cancer and Pre-1988 128 40 25 0 195 and Community Mental Health Health
1988–1994 Alberta Health 128 40 25 2 0 195
3: Cancer, Alberta Health Mental Health 1994–2003 – – – 17 20 and Wellness and Alcohol and Drug Abuse
Alberta Health 2003–2008 – – – 3 9 12 and Wellness
1: Alberta Alberta Health 2008– – – – – Health 1 and Wellness Services
The initial AHS formal structure incor- Creation of AHS internalized these porated many province-wide leadership tensions and allowed a new priority-setting roles, including having major hospitals in process, which ranked all policy propos- Edmonton and Calgary accountable to the als against each other. The initial formal same executives, and all regional hospitals structure of AHS gave each member of the (Red Deer, Lethbridge, etc.) accountable to executive responsibility for both line manage- the same person. This structure facilitated ment and province-wide policy or operations. internal benchmarking of previously sepa- This strengthened mutual accountability and rately governed services. A single authority reduced parochial pleas. also enabled consistent implementation of best Intraprovincial rivalry continued, of practices, including improving patient flow to course, but in some cases was able to be reduce long waits in emergency departments harnessed for good. For example, following (Duckett and Nijssen-Jordan 2012) media advocacy about the need for additional As a province, Alberta has been character- radiation oncology capacity (linear accelera- ized and cursed with a high degree of intrapro- tors) in Calgary, I requested information on vincial rivalry between Edmonton and Calgary. the current efficiency of existing machines Each previous health authority saw its respon- in Calgary and Edmonton (treatments per sibility as pursuing a medical arms race with its machine per annum). This comparative infor- rival(s), with the result health system planning mation had not been previously collected. was dominated by political calculations rather There was a significant difference between than (relatively) technocratic assessment of the two cities in radiation oncology effi- population health needs. Partly as a result of ciency with Calgary being less efficient than this unhealthy competition, Alberta was a Edmonton. A “Lean” process was initiated in relatively expensive province in terms of health Calgary, which significantly improved effi- expenditure per head of population (Duckett ciency and generated additional treatment et al. 2012, Duckett 2015). capacity. Not to be outdone, a similar process
55 HealthcarePapers Vol. 16 No. 1 was also initiated in Edmonton, which led to all the disadvantages that entails. The first further efficiency improvements there, creat- full year of AHS was plagued by address- ing a virtuous improvement cycle. ing significant budget challenges, which Different predecessor authorities in involved very tight budget control. In Alberta pursued different policies and the second full year, with a better budget approaches in many areas; naturally so, since outcome, significant changes to formal “regional responsiveness” is claimed as one of delegations were approved. However, the the strengths of authorities covering smaller consistency with which these were imple- geographic areas. The inevitable conse- mented varied across the organization with quence was differential access to services. some middle managers requiring “consulta- In Alberta, this resulted in quite different tion” on decisions when formal delegations levels of provision (and hence access to) allocated decision rights further down the residential aged care and home care. In two chain. Centralization also created delays parts of the province, some mental health in decision-making. inpatient services were still provided in A second disadvantage of centralization isolated, stand-alone facilities – a model not is the removal of top decision-makers from consistent with contemporary service system many local communities. Although the AHS design internationally. Board met at least annually in each of the Creation of AHS allowed “best prac- seven major cities in the province, and senior tice” experience to be implemented across leaders (including myself ) regularly visited the province (with mental health reform in towns and cities across the province, an annual Edmonton being a standout example of failed foray, or even regular visits, does not provide policy implementation). Best practice roll-out the same access for local elites to the Board involved developing standardized measure- and executives as local residence. ment tools and access metrics, implementing RHAs covering smaller geographic areas province-wide funding formulae, and favouring had a range of informal mechanisms for poor-access areas in a budget priority setting. tapping into the views of local communities. This created a perception (often realized) of Weaknesses of a Single Authority local responsiveness. In contrast, AHS took There were three main weaknesses of the almost two years to establish any form of local Alberta model of implementation of a single engagement (through community advisory province-wide authority compared to multi- committees), resulting in a real loss of under- ple regional authorities: diseconomies of scale, standing of local issues and priorities. remoteness from communities and politicization. The structure of AHS, with many local Although the creation of a single prov- functions (e.g., catering and security) report- ince-wide authority allows economies of scale, ing through province-wide services also it also creates the potential for diseconomies disrupted local coordination. Furthermore, of scale. AHS is a very large organization, province-wide priorities to reduce expendi- now with more than 100,000 employees – it is ture and improve efficiency often conflicted probably the fifth-largest employer in Canada with local employment goals or supporting and more than three times the size of any local suppliers. other health service. Together, this created the impression of An organization of this size inevitably AHS as an out-of-touch lumbering giant involves multiple layers of reporting with disregarding local needs and aspirations.
56 Regionalization as One Manifestation of the Pursuit of the Holy Grail
A final weakness of a single consolidated Alberta experience so far is that, despite a authority is the enhanced potential for politi- change in government – a once in a genera- cization, particularly in a province character- tion experience in the province – AHS has ized by clientelism (Duckett 2015). Where not been unwound, suggesting that the new multiple (competing) regional authorities administration has recognized the benefits exist, there is a clear and obvious separation of of the consolidation and is seeking to miti- the regional authority from government, even gate the weaknesses through strategies other though the authority may have very strong than starting afresh. This, in turn, suggests political links to the governing party. With that other provinces may be able to watch only one authority in the province, there is the the Alberta experience to assess the benefits risk that the authority will lose the percep- of consolidation after the turbulent imple- tion of independence. This risk is particu- mentation phase has passed and at least one larly strong with a micro-managing minister. organizational leader has remained in place This then constrains the autonomy of the for a consolidating period. organization and increases the risk of political decision-making. References Donaldson, C. 2010. “Fire, Aim… Ready? Alberta’s Big Bang Approach to Healthcare Disintegration.” The Balance of Strengths and Healthcare Policy 6(1): 22–31. Weaknesses Duckett, S. 2010. “Second Wave Reform in Alberta.” Johnson (1996) identified that critical deci- Healthcare Management Forum 23(4): 156–8. sions often have no right answer – that each Duckett, S. 2011. “Getting the Foundations Right: choice, in this case, a single authority or Alberta’s Approach to Health-Care Reform.” multiple – has strengths and weaknesses. Healthcare Policy 6(3): 22–26. His solution (“polarity management”) was Duckett, S. 2015. “Alberta: Health Spending in a Land to make the choice, having first identified of Plenty.” In G.P. Marchildon and L. Di Matteo, eds., Bending the Cost Curve in Health Care (pp. 297–326). those strengths and weaknesses, and then take Toronto, ON: University of Toronto Press. action to minimize the expected weaknesses Duckett, S. and C. Nijssen-Jordan. 2012. “Using of the chosen path and try to obtain some of Quality Improvement Methods at the System the strengths of the alternate path. For exam- Level to Improve Hospital Emergency Department ple, the community involvement weakness of Treatment Times.” Quality Management in Healthcare 21(1): 29–33. a centralized organization could, in part, be Duckett, S., G. Kramer and L. Sarnecki. 2012. mitigated through advisory committees. The “Alberta’s Health Spending Challenge: a Policy- economies of scale strength of a centralized Oriented Analysis of Inter- and Intra-Provincial organization could potentially be available to Differences in Health Expenditure.” in D. Ryan, Ed., Boom and Bust Again: Policy Challenges for multiple separate authorities through agreed a Commodity-Based Economy. Edmonton, AB: centralized purchasing. University of Alberta Press. Schön (1971) identified polarities in Johnson, B. 1996. Polarity Management: Identifying organization design face both centripetal and and Managing Unsolvable Problems. Amhert, MA: centrifugal forces and that, in some period, HRD Press. one form (centralization vs decentralization) Marchildon, G.P. 2016. “Regionalization: What Have We Learned?” Healthcare Papers 16(1): 8–14. is emphasised over the other, with organiza- doi:10.12927/hcpap.2016.24766. tional design often swinging like a pendu- Schön, D.A. 1971. Beyond the Stable State: Public and lum from centralized to decentralized and Private Learning in a Changing Society. London, UK: back again. What is interesting about the Temple-Smith.
57 The Politics of Regionalization
COMMENTARY
Katherine Fierlbeck, PhD Professor, Department of Political Science Dalhousie University Halifax, NS u
ABSTRACT Regardless of their policy outcomes, strategies of regionalization are prevalent because they are politically useful. They permit governments to be seen addressing serious systemic problems in the healthcare system without fundamentally upsetting the face- to-face relationship between physicians and patients. They shift the responsibility for unpopular policies, including the consolidation of services, away from provincial governments. They can be part of a larger process of decentralizing power that is undertaken for larger, non-health-related reasons. They can also serve as a strategy of disruption that destabilizes the bases of influence enjoyed by specific stakeholder groups. For epistemological reasons, it is difficult to determine with any certainty what the specific outcomes of regionalization are. Thus, to mitigate the utilization of regionalization for politically advantageous reasons, it is useful not only to catalogue the outcomes of policies of regionalization, but also to identify whose interests are furthered, and whose are hindered, within a strategy of regionalization.
Why is it, in this age of evidence-based consolidation) are politically useful regardless medicine, that so many jurisdictions over of their policy outcomes. the past two decades have regionalized (or Implementing (or modifying) regional consolidated) their healthcare systems, despite structures of governance can, in the first the considerable lack of evidence regarding place, present a way for governments to be the effectiveness of these policies? One answer seen responding to public pressure to address is: because strategies of regionalization (or serious systemic difficulties within healthcare,
58 The Politics of Regionalization without alienating those using healthcare to be made to regional health authorities services. Healthcare reforms that occur at the (RHAs). Some administrations, such as Ralph point of contact between healthcare providers Klein’s Conservative government in Alberta, and patients tend, as Lazar et al. (2013) have were able to survive the widespread closure of noted, to be highly unpopular. By contrast, rural hospitals; others were not. Employing reforms that focus upon the higher echelons RHAs to deflect public discontent from of healthcare administration are more invis- provincial governments, however, conflicted ible to healthcare consumers and are tolerated with the aspiration expressed in reports much more comfortably. The political rhetoric tabled in some provinces (including British of regionalization is simple and intuitively Columbia, Saskatchewan and Nova Scotia) plausible even without a solid body of empiri- that regionalization could be a concrete means cal evidence to support it. Because of this, it is of accommodating a broader base of citizen also well-suited for incorporation into elec- engagement in governance and policy making toral campaigns. This is important, as electoral (Bickerton 1999). As a policy construct campaigns serve as a process of legitimation informed by New Public Management, supporting the reform process once a party is the underlying principle of regionalization in office (ibid.). The concept of regionaliza- was that administrative decision-making tion is inchoate enough to endorse a wide in routine policy areas was more effectively variety of outcomes: it is quite coherent, for performed at levels closer to the community example, either to argue that decentralizing (balanced by departments of health retaining administrative authority can “result in effec- responsibility for the overarching coordina- tive and efficient use of existing capital,” or to tion of policy design and implementation). hold that centralizing administrative authority The main instrument of citizen engagement can produce a less fragmented and, therefore, was to be elected and accountable community more efficient healthcare system (as Nova health boards, and some reports even saw Scotia did, respectively, in 1989 and 2015). these community health boards as the focal point of a regionalized system, with RHAs merely acting as a coordinating mechanism between active community boards and the Some administrations … were able provincial health department (Nova Scotia to survive the widespread closure 1994). But regionalization as an instrument of of rural hospitals; others were not. democratization was an idea that never came to fruition in any jurisdiction. With healthcare The implementation of several regional- budgets constituting close to half of public ized healthcare systems in Canada occurred sector spending in many provinces, govern- during the early- to mid-1990s – a period of ments were loath to sanction decision-making economic contraction in which unpopular mechanisms that could potentially expand decisions to consolidate healthcare services demand rather than contain it. The emphasis had to be made. Acutely aware both that a upon regional decision-making bodies became plethora of rural hospitals was hugely ineffi- less about encouraging the broad participation cient, and that rural constituencies were quite of local stakeholders and more about requiring protective of these hospitals, for example, health authorities to make politically unpopu- provincial governments shifted the burden of lar decisions in order to remain within strictly determining precisely how cost savings were defined budgets.
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Healthcare systems can also adopt regional health authorities notwithstanding the fact structures incidentally, as the answer to a polit- that administrative authority over the provi- ical problem that has nothing at all to do with sion of basic services provided by primary care healthcare. In some states, such as Spain (in physicians would seem to constitute “govern- 1978), Brazil (in 1988) and Russia (in 1993), ing, managing, and providing health services” political decentralization was the response to (rowing) rather than “setting strategic policy a history of authoritarian rule. The reorgani- direction” (steering). A province with several zation of healthcare in these states was not a health authorities could conceivably argue considered re-thinking of healthcare govern- that a provincial presence was necessary to ance per se, but rather part of a larger move coordinate certain functions (such as physician toward the institutionalization of the dispersal contracts) across all health authorities. Yet of power on a regional basis (Chubarova and even in provinces that have amalgamated all Grigorieva 2015; Lobato and Senna 2015; health authorities into one entity, departments Pérez Durán 2015). The historical context of of health have been unwilling to transfer these states is especially important, because it responsibility for physicians to the provin- imposes potential limitations on subsequent cial health authority, despite the resulting reforms. States that have adopted regional administrative bifurcation between primary governance mechanisms due to a suspicion and acute healthcare services. This would of the un-salutary aspects of centralized seem to suggest that the desire to govern power will, like Spain, be much more wary health systems according to a clear distinction of attempting to reconsolidate structures of between rowing and steering is subordinate to healthcare governance at a national level than the provinces’ desire to maintain direct control states without similar experiences. over a powerful stakeholder group. It also Another phenomenon that has not been raises important questions about the provin- scrutinized in any depth is the disruptive cial governments’ willingness to microman- impact of strategies of regionalization and age administrative issues when they become the way in which they can be used to desta- highly political. bilize the influence of major stakeholders. If employed strategically, governance reforms can potentially diminish the influence of groups that exercise influence over particular … departments of health have aspects of the health system. The first itera- been unwilling to transfer tion of regionalization across Canada, for responsibility for physicians to example, focused not only upon the delegation the provincial health authority … of administrative responsibility down from departments of health to RHAs but also up But physicians are not the only healthcare from local hospital boards and providers to providers who have been strategically affected RHAs. The influence of local providers at a by shifting governance structures. During the community level was significantly diminished recent process consolidating Nova Scotia’s through this process (Black and Fierlbeck nine health authorities into one, for example, 2006). Concern by provincial governments the provincial government endeavoured to use over the influence of providers is currently the process to sideline a nurses’ union with a evident in the refusal of departments of health history of achieving high-wage settlements to cede authority over physician services to (which consequently served as benchmarks
60 The Politics of Regionalization for the rest of the public sector). An impor- system may have the provision of healthcare at tant aspect of health authority amalgamation its core but, like most policy areas, it is also a in Nova Scotia was the consolidation of over mechanism through which to elicit sufficient 50 healthcare bargaining units into 4. Rather political support to maintain the governing than permitting run-off votes to determine party in power. which bargaining agent would represent work- ers in any category represented by more than one union prior to restructuring, the province Is it possible to limit the way in appointed a mediator–arbitrator to distribute which regionalization is used healthcare workers into each of four catego- ries and to assign a bargaining agent for each strategically for political purposes? of them. The mediator–arbitrator, however, Notwithstanding any real policy declared that the principle of majoritarianism outcomes, strategies of regionalization are was a fundamental prerequisite for legitimate useful politically. The concept of regionaliza- representation and that allocation to bargain- tion is amorphous enough to serve a range of ing units would only be done on that basis. political ends; it contains simple and credible When the mediator–arbitrator assigned two causal claims; and there is little irrefutable of the four bargaining units to the very union evidence to either support or negate the merit that had successfully negotiated high-wage of these claims. Is it possible to limit the way settlements in the past, the Minister of Health in which regionalization is used strategically and Wellness declared that the mediator– for political purposes? One could, perhaps, arbitrator had “failed to fulfill his mandate,” subject them to the same scrutiny given to and that the province itself would introduce therapeutic treatments. To use the metaphor legislation to determine which union would of evidence-based medicine, the utility of represent what bargaining units. When it regionalization as prescribed treatment would became apparent that this move would likely then depend upon being clear about what the precipitate a challenge under section 2(d) of ailment is (what is it, precisely, that region- the Canadian Charter of Rights and Freedoms, alization is expected to improve?); what the the province backed down and ultimately treatment is expected to do; what the evidence negotiated a system of multilevel “Councils” base is; what the precise causal pathways are; comprised of discrete unions. and what the harms as well as benefits of It is disingenuous to suggest that health treatment are. policies at any level can be extricated from The problem, of course, is that health the political context within which they are policies, and especially wide-ranging ones designed and implemented. Governments such as regionalization, are qualitatively are responsible to patients, but they are also distinct from therapeutic drugs or medical responsible to voters and taxpayers, and it is procedures. An “evidence-based” approach to fatuous to suggest that the political calcula- comprehensive policies like regionalization tions made by governments could or should be will always face significant epistemological eliminated. For better or worse, policy making limitations. It is, in the first place, difficult is embedded in a larger context of democratic to isolate clear causal relationships simply governance; and democracy at its rawest is because there are so many potential confound- about the ability of those in power to win or ers that may be relevant in such wide-ranging maintain the support of the citizenry. A health initiatives. It would, for example, be extremely
61 HealthcarePapers Vol. 16 No. 1 difficult to determine whether the consolida- References tion of health authorities across a province Bickerton, J. 1999. “Reforming Health Care Governance: the Case of Nova Scotia.” Journal of was itself responsible for a decline in adminis- Canadian Studies 34(2): 159–90. trative costs, as a multitude of other variables Black, M and K. Fierlbeck. 2006. “Whatever (such as the implementation of new health IT Happened to Regionalization? The Curious Case of systems) might also have had a causal impact. Nova Scotia.” Canadian Public Administration 49(4): Replication, another foundational principle 50626. of evidence-based medicine, is impossible for Chubarova, T. and N. Grigorieva. 2015. “The Russian the same reason. Regionalization strategies Federation.” In K. Fierlbeck and H. Paley, eds., Comparative Health Care Federalism (pp. 195–211). fall into a category that Pawson (2006: 25) Farnham, UK: Ashgate. calls “complex systems thrust amidst complex Godlee, F. 2016. “Is “DevoManc” Devolution, Delegation, systems;” and it is highly unlikely that one or Dismantling of the NHS?” BMJ 352: i1668. could ever articulate a generalizable theory Lazar, H, J. Lavis, P.G. Forest and J. Church. 2013. about how policies of regionalization, or any Paradigm Freeze: Why Is It So Hard to Reform Health- other complex sociopolitical interventions, Care Policy in Canada? Montreal, QC, and Kingston, consistently and predictably work (Marchal ON: Institute of Intergovernmental Relations and McGill-Queen’s University Press. et al. 2013). This is not to say that one should not Lobato, L. and M. Senna. 2015. “Brazil.” In K. Fierlbeck and H. Paley, eds., Comparative Health collect and scrutinize the performance of Care Federalism (pp. 178-93). Farnham, UK: Ashgate. healthcare systems as they implement and Marchal, B., G., Westhorp, G. Wong, S. Van Belle, T. revise various permutations of regionaliza- Greenhalgh, G. Kegels et al. 2013. “Realist RCTs of tion; even “N of one” studies can be quite Complex Interventions – an Oxymoron.” Social Science informative. But in answering the question, and Medicine 94: 124–28. “why do polities choose to adopt (or modify) Marchildon, G.P. 2016. “Regionalization: What strategies of regionalization?,” the epidemiolo- Have We Learned?” Healthcare Papers 16(1): 8–14. doi:10.12927/hcpap.2016.24766. gists’ concentration upon outcome measures is usefully complemented by the politi- Nova Scotia. 1994. Minister’s Action Committee on Health System Reform. Halifax, NS: Author. cal scientists’ focus upon identifying whose interests are furthered and whose are impeded, Pawson, R. 2006. Evidence-Based Policy: A Realist Perspective. London, UK: Sage. by specific policy choices. Regionalization seems to have a remarkably enduring quality: Pérez Durán, I. 2015. “Spain.” In K. Fierlbeck and H. Paley, eds., Comparative Health Care Federalism it has been said that cockroaches and RHAs (pp. 47-61). Farnham, UK: Ashgate. are the only two things that will survive a nuclear holocaust (Godlee 2016). Given the absence of convincing evidence demonstrating its capacity to achieve specific outcomes, the appeal of regionalization must rest at least in part with its political utility.
62 Lost in Maps: Regionalization and Indigenous Health Services
COMMENTARY
Josée G. Lavoie, PhD MFN-Centre for Aboriginal Health Research University of Manitoba Winnipeg, MB
Derek Kornelsen, PhD MFN-Centre for Aboriginal Health Research University of Manitoba Winnipeg, MB
Yvonne Boyer, PhD Brandon University Brandon, MB
Lloy Wylie, PhD Western Centre for Public Health and Family Medicine Western University London, ON u
ABSTRACT The settlement of the land now known as Canada meant the erasure – sometimes from ignorance, often purposeful – of Indigenous place-names, and understandings of territory and associated obligations. The Canadian map with its three territories and ten provinces, electoral boundaries and districts, reflects boundaries that continue to fragment Indigenous nations and traditional lands. Each fragment adds institutional requirements and organizational complexities that Indigenous nations must engage with when attempting to realize the benefits taken for granted under the Canadian social contract.
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This paper discusses how the implementa- boundaries on Indigenous communities, and tion of regionalized forms of health system the imposition of healthcare systems. governance at the provincial level continues to The British North America Act (renamed perpetuate state-centric territorial administra- the Constitution Act) of 1867 created a tion and control of Indigenous peoples and jurisdictional divide that remains to this day. Indigenous health and well-being, imposing Under section 91(24), “Indians and lands new boundaries on Indigenous territories, reserved for Indians” were allocated as a fragmenting and marginalizing Indigenous federal responsibility under federal jurisdic- communities and perspectives and further tion, whereas the responsibility for health- splitting service delivery across a prolifera- care was allocated to the provinces, leaving tion of jurisdictions. The argument is organ- Indigenous health in this jurisdictional ized along three main themes. The first gap. The current jurisdictional map counts discusses the colonial imposition of territo- fourteen healthcare systems. The thir- rial boundaries and the resulting impacts on teen provincial and territorial governments Indigenous health and well-being. The second are responsible for the delivery of a range distinguishes concepts of colonial territorial- of health services, defined by the Canada ity from Indigenous land-based reciprocity, Health Act 1984. The Act mandates publicly examining the impact of the colonial territo- provided hospital and physician services, rial paradigm on treaty-making, land claims leaving room for regional variation of ensured and health governance and delivery. A final services based on provincial priorities, such as section explores issues of Indigenous represen- Pharmacare or long-term care. tation on health authorities (HA)/boards as a The fourteenth, and often forgotten counter to imposed territorial paradigms. We healthcare system, is provided by the First conclude with key lessons. Nations and Inuit Health Branch (FNIHB) of Health Canada, which funds and, to a lesser extent, delivers healthcare services to First This system does not, at the moment, Nations living on-reserve (all provinces and provide services to Métis … in the Yukon) and Inuit (in Newfoundland and Labrador only). The federal government Colonization: Imposing Federal and has the prime responsibility for a comple- Provincial Control over Health Services ment of prevention and primary care health Prior to colonization, Indigenous peoples services provided to “Status Indians”1 living living in what is now known as Canada, on reserve and to Inuit living in their tradi- existed within their own jurisdictions and tional territories in Québec and Labrador. governed themselves according to their This system does not, at the moment, provide own legal, social and political systems. As a services to Métis, who only recently have result, Indigenous nations were responsible become acknowledged as eligible to federal for the health and well-being of their people programs as defined under the Indian Act and enjoyed a measure of well-being much (2015 Daniels v Canada). At the time of writ- higher than is currently observed in a major- ing, Métis are still awaiting the final decision ity of Indigenous communities across Canada of the Supreme Court of Canada. However, it (Boyer 2014). Colonization and the establish- appears unlikely that FNIHB, which has been ment of Canada entailed a unilateral imposi- actively engaged in transferring its role as the tion of federal and provincial jurisdictional provider of health services to First Nations for
64 Lost in Maps: Regionalization and Indigenous Health Services three decades (Lavoie et al. 2009: 18), and in communities that are defined and underwritten off-loading responsibilities to provincial juris- relationally, by developing respectful/reflexive dictions (Lavoie and Forget 2006), might step relations of reciprocity (Asch 2014; Simpson forward to extend health services to Métis. and McDonald 2011) as expressed in tradi- Federal and provincial policies move at tional practices of treaty-making. The colonial different paces and follow different priorities, project is continuously focused on displacing sometimes closing jurisdictional gaps, though Indigenous concepts of land and stewardship, often opening new ones. Given this combination in favour of a static notion, aligned with the of multi-jurisdictional boundaries and service concept of private property and its mutually variation, services provided to First Nations, exclusive use of land set by static boundaries. Métis and Inuit peoples2 are often the subject of This territorial paradigm framed the jurisdictional disputes (Lavoie et al. 2015; The establishment of the Canadian federation Jordan’s Principle Working Group 2015). as well as the very practice of treaty-making in colonial contexts (historically and in the present) in ways that not only directly contra- The colonial project is continuously dict Indigenous rights to self-determination focused on displacing Indigenous but also continue to have significant deleteri- ous effects on Indigenous health and well- concepts of land and stewardship … being. Indigenous rights are entrenched in the Territoriality, Treaties and the Royal Proclamation of 1763 (King George Governance of Health 1763) – a document issued to clarify the The paradigm that underpins jurisdictional rights of the French and Indigenous minori- boundaries is based on the concept of terri- ties following the conquest of New France toriality or the exclusive control of bounded by Britain. This document states that the geographic space and the contents, including Indigenous population is not conquered; people, within those boundaries (Sack 1986). they retain title over their ancestral territory The colonial imposition of territorially defined and encroachment must be negotiated and authority imposes forms of spatial organiza- settled by Treaty. As can be seen in Table 1, tion and conceptions of geographic space that the signing of Treaties (1871–1921) and land predetermine the kinds of relationships between claims agreements (1975 to present) were people, places, things and authorities that are and are intended to “settle” issues of terri- possible within a given jurisdiction (Kornelsen toriality and federal obligations, based on 2015). The colonial state, then, is taxed with this concept of exclusive use. The result is a developing putatively just forms of the distribu- patchwork of territorially defined jurisdictions tion of resources (including healthcare) across of exclusive control, perpetuating disagree- those living within these fixed boundaries. This ment between federal or provincial authori- concept of territoriality is at odds with many ties on who is responsible for the “contents,” Indigenous epistemologies that understand as well as pitting Indigenous communities jurisdictions and just distributions in relational against each other as they vie for federal/ terms – that is, that land is not something to provincial resources. The imposition of new be arbitrarily divided and controlled but some- territorial boundaries on Indigenous nations, thing to build relationships with. This paradigm which arbitrarily fragmented some nations extends to the just distribution of “resources” or across different jurisdictions, also resulted in a obligations between individuals and between constellation of small discrete communities.
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Table 1. Treaties and self-government activities in relation to Indigenous health
Relationship to Health
Agreement Signed YK NWT NU BC AB SK MB ON QC NB NS PEI NFLD Some control over health services Input into policy/ regulations Commitment for specific services
Treaty No. 1 (Canada 1871) 1871
Treaty No. 2 (Canada 1871) 1871 Implied Treaty No. 3 (Canada 1873) 1873 commitments Treaty No. 4 (Canada 1874) 1874
Treaty No. 5 (Canada 1875) 1875
Medicine Treaty No. 6 (Canada 1876) 1876 Chest clause
Treaty No. 7 (Canada 1877) 1877
Treaty No. 8 (Canada 1899) 1899 Verbal 1905 commitments, Treaty No. 9 (Canada 1929) –06 none included in Treaty No. 10 (Canada 1906 the text of 1906) the Treaty Treaty No. 11 (Canada 1921 1921)
James Bay and Northern Quebec Agreement 1975 (Canada 1974)
Northeastern Quebec 1978 Agreement (Canada 1984)
Inuvialuit Final Agreement (Canada & Committee 1984 for Original Peoples’ Entitlement 1984)
Sechelt Indian Band Self- Government Act (Canada 1986 & Sechelt Indian Band 1986)
Métis Settlements Act (Alberta & Metis 1989 Settlements General Council 1990)
Gwich’in Comprehensive Land Claim Agreement 1992 (Indian and Northern Affairs Canada 1992)
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Relationship to Health
Agreement Signed YK NWT NU BC AB SK MB ON QC NB NS PEI NFLD Some control over health services Input into policy/ regulations Commitment for specific services
The Umbrella Final Agreement (Canada & 1993 Council for Yukon Indians 1993)
Sahtu Dene & Métis Comprehensive Land Claim 1993 Agreement (Canada & Sahtu Tribal Council 1994)
Nunavut Land Claim Agreement (Canada & 1993 Nunavut Tapariit Kanatami 1993)
Manitoba Framework Agreement (Manitoba 1994 1997)
Indian Self-Government Enabling Act (British 1996 Columbia 1996b)
Indian Advisory Act (British 1996 Columbia 1996a)
The Nisga’a Final Agreement (Canada & 1999 Nisga'a Tribal Council 1999)
The Métis Act 2001 (Saskatchewan 2001)
Tlicho Agreement (Canada, Government of the 2003 Northwest Territories & The Tlicho 2003)
Carcross/Tagish First Nations Programs and Services Agreement Respecting the Indian and Inuit Affairs Program and the First Nations and 2003 Inuit Health Branch of the Government of Canada (Carcross/Tagish First Nation, Canada, & Yukon 2003)
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Treaties and land claims agreements make is responsible for providing health services for varying healthcare-related commitments to First Nations people living on reserve, primar- signatories. Of the historical Treaties (the ily through contribution agreements to the numbered Treaties, signed between 1871 and bands to run these health services. Band-run 1921), Treaty 6, which includes over 50 First programs are only provided funding for Status Nations in central Alberta and Saskatchewan, First Nations who live on their home reserve, is the only one to make a healthcare-related leaving nearly half of Canada’s First Nations commitment in writing. The Medicine Chest people who live off reserve without funded clause charges the federal government with access to on-reserve services. This limits the the responsibility to protect First Nations access that First Nations peoples living off people from pestilence and famine and to reserve have to culturally appropriate services provide a “medicine chest” in the house of as they are forced to access mainstream each Indian agent (Backwell 1981). While systems for their healthcare needs. In addition, First Nations representatives view these when there are gaps in coverage in on-reserve provisions as the basis for a full federal obliga- services, First Nations people living on the tion for health, the federal government has reserve do not necessarily get access to provin- adopted the position that the provision of cial services to address their unmet needs medical care is a matter of policy and not of (The Jordan’s Principle Working Group right (Boyer 2004). This position is based on 2015). This jurisdictional boundary leads to the 1966 Supreme Court of Saskatchewan, significant inequities and gaps in continu- known as the Johnston appeal, which stated ity of care, given that on-reserve services do that “the [medicine chest] clause itself does not have the same funding resources as the not give to the Indians the unrestricted right provincially run programs (i.e., availability of to the use and benefit of the ‘medicine chest’ after-hours care). Small communities are also but such rights as are given are subject to the expected to compete for program funding for direction of the Indian agent.” Therefore, health and other services. according to this interpretation, the federal government determines the legitimacy of Indians’ request for healthcare and to allocate … the federal government has it free of charge or at a cost (Canada 1966). adopted the position that the Since 1974, some lands claim agreements have included health-specific provisions. The provision of medical care is a James Bay and Northern Quebec Agreement matter of policy and not of right … (1975) and the Nisga’a Final Agreement (1999), give signatories some level of control Indigenous Participation as a Counter to over policy and health service delivery. The Overlapping Maps and Jurisdictional Gaps majority of these agreements, however, focus Trends in self-government have provided on input into policies and regulations over improved opportunities for First Nations services to be provided by the province or and Inuit participation in service delivery. territory. See details in Table 1. Agreements between federal and/or provincial The consequences of this jurisdictional health ministries/departments/HAs and First uncertainty regarding health has been Nations and Inuit communities have multi- significant for First Nations, Inuit and Métis plied. Self-government agreements have their peoples in Canada. The federal government own geographic boundaries.
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Meanwhile, most provinces (with the established in every regional health author- exception of Prince Edward Island and ity (RHA) in BC, although the scope has more recently, Alberta and Nova Scotia) focused on Indigenous-specific services, as well as the Northwest Territories have rather than the full range of health services adopted decentralized models of health- that Indigenous people use. This innovation care delivery, which entails a transfer of is unprecedented and unique to BC. authority from the Department of Health to regional authorities. Decentralization Discussion and Conclusion is intended to increase opportunities for While commitments to self-determination citizen engagement in local priority setting, create opportunities for some level of given that these regional authorities are Indigenous control over selected health tasked with priority setting and the alloca- services, the entire framework remains tion and management of health resources mired in territorial assumptions that legiti- (Saltman et al. 2007). The relationship mize imposed colonial boundaries and between Indigenous nations and HAs vary the kinds of competitive, control-based across the country. In effect, regionalization relationships that follow. As such, federal, has added yet another level of complex- provincial, regional and Indigenous authori- ity and variation in the complement of ties over health services remain frag- services accessible to all residents, including mented, and responsibilities debated. This Indigenous communities. is particularly the case for First Nations. Most decentralized provincial healthcare The creation of HAs in most provinces did systems have not entrenched mechanisms to not resolve these issues. While Ontario ensure Indigenous representation. Specific (with Indigenous advisory committees for provisions are listed in Table 2. Ontario the LHINs) and BC (with regional tables is the only province to have established a on First Nations health) have established council composed of Indigenous peoples these advisory bodies to recommend and to advise on regional priority setting in press for Indigenous priorities within the healthcare, which is provided through the HAs, these are not recognized as decision- LHINs, although this is simply an advisory making bodies within those authorities, but role. BC and Nova Scotia have had provi- rather to advise on Indigenous priorities. sions that stipulate that the make-up of the Therefore, legislation of provincial HAs has Board of Directors must reflect the popu- yet to guarantee Indigenous representation lation that the RHAs are set up to serve; on their boards. Indigenous peoples had not been specifically Although representation is important to mentioned. This changed in BC as a result advance the goals of Indigenous peoples in of the 2011 Tripartite Agreement on First Canada, the appointment of a First Nations, Nations Health Governance, which includes Métis or Inuit individual on a board, tasked explicit language to direct the HAs to work to represent all Indigenous peoples in the collaboratively with First Nations in the region, itself contradicts the principle of self- planning and delivery of health services determination. And while Aotearoa (New (Government of Canada, Government of Zealand) has engaged with this complexity BC and the First Nations Health Society and developed pathways (Lavoie et al. 2012), 2011). New tables for discussion and nego- Canadian provinces have yet to begin these tiation of First Nations priorities have been conversations.
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Table 2. Indigenous representation in regionalized models
Province/ Pop. 2015 % of pop. Number of Members Provisions entrenching Indigenous territory (000) Indigenous RHA in 2015 are participation
YT 37 25 Not regionalized N/A N/A
No specific provision to ensure Indigenous representation (Government NT 44 50 6+ Appointed of the Northwest Territories 1988, and amendments)
NU 37 85 Not regionalized N/A N/A
Article 7.6.4 states that “the membership of public sector boards should reflect the BC 4,683 5 5+ Appointed cultural and geographical makeup of the population” (The Board Resourcing and Development Office 2007)
AB 4,196 6 1 N/A N/A
No specific provision to ensure Indigenous SK 1,134 15 13 Appointed representation (Saskatchewan Health 2008)
No specific provision to ensure Indigenous MB 1,293 15 5 Appointed representation (Manitoba 2008)
According to the Principles Governing the Appointments Process, the “Persons selected to serve must reflect the true face of Ontario in terms of diversity and regional representation.” The Local Health System ON 13,742 2 14 Appointed Integration Act requires the creation of an Aboriginal and First Nations Health Council to advise the minister about health and health services related issues (Ontario Public Appointment Secretariat 2007)
No specific provision to ensure Indigenous QC 8,264 1 18 Appointed representation (Governement du Québec 2005)
Elected/ No specific provision to ensure Indigenous NB 754 2 2 Appointed representation (New Brunswick 2002)
According to the regulations, “the following are to be considered assets in the consideration of candidates for nomination: NS 943 3 1 Appointed population characteristics such as age, gender, ethnicity, geography or membership in a disadvantaged group” (Nova Scotia 2000)
PE 146 1 1 N/A N/A
No specific provision to ensure Indigenous NL 528 5 4+ Appointed representation (Government of Newfoundland and Labrador 2005)
Pop. = population.
A possible pathway is now being travelled agreement set to address health and other by the BC First Nations Health Authority inequities experienced by First Nations, BC (FNHA). Created as a result of a tripartite is witnessing a new era in Indigenous health.
70 Lost in Maps: Regionalization and Indigenous Health Services
Backwell, P. 1981. “The Medicine Chest Clause in This new era has enabled: forging a relationship Treaty No. 6.” Canadian Native Law Reporter 4: 1–23. between the FNHA and the BC Ministry of Boyer, Y. 2004. Discussion Paper Series on Aboriginal Health; facilitating partnerships between First Health, Legal issues: No. 3. The International Right to Nations and the HAs in all five BC regions; Health for Indigenous Peoples in Canada. Ottawa, ON: working toward greater policy and service inte- National Aboriginal Health Organization. gration throughout the province; and recognizing Boyer, Y. 2014. Moving Aboriginal health Forward: that Indigenous health is a joint responsibility Discarding Canada’s Legal Barriers. Saskatoon, SK: Purich Publishing Ltd. of all the partners. The impact of this shift has British Columbia. 1996a. Indian Advisory Act. not fully materialized, but it has brought key Victoria, BC: Queens Printer. health and First Nations leaders to the table to British Columbia. 1996b. Indian Self-Government collaboratively address the gaps in Indigenous Enabling Act. Retrieved August 25, 2016. health in ways not seen in other parts of Canada.
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Canada. 1906. Treaty No. 10 and Reports of Governement du Québec. 2005. Agences de Commissioners. Retrieved August 26, 2016.
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Marchildon, G.P. 2016. “Regionalization: What Saskatchewan. 2001. The Métis Act. Retrieved August Have We Learned?” Healthcare Papers 16(1): 8–14. 26, 2016.
HealthcarePolicy.net Health Services, management and policy research|
73 the author responds HealthcarePapers
74 Where Are We Going from Here?
THE AUTHOR RESPONDS
Gregory P. Marchildon u
Means to an End Bevan argues that improved performance As the authors in these essays emphasize, through greater coordination and integration regionalization is merely a means to achieve was the product of hierarchical planning and defined goals and objectives. It is not a goal in performance management accompanied by itself. As pointed out in their extensive review hard sanctions and tight regional governance of health regions in Canada, Yves Bergevin and monitoring of performance. and his colleagues (2016) correctly identify Similarly, Karsten Vrangbaek (2016) regionalization as “one of the main organ- provides a tantalizing list of Danish initia- izing strategies” of provincial health systems tives to improve coordination and integration in Canada in the last quarter century. But, orchestrated by the central government to as discussed in my introductory essay and support the five regions in the country respon- repeated in a number of the essays presented sible for hospital and physician care and the 98 here, regionalization itself is simply a vehicle to municipalities responsible for almost all other achieve a number of objectives all intended to healthcare services, including the following: improve health system performance, including the quality of care and patient responsiveness. • Patient pathway programs and standards Gwyn Bevan (2016) goes further. He to develop more integrated services for argues that the early regionalization of the various chronic conditions (e.g., diabetes). National Health Service (NHS) in the United • Hospital-based outreach teams conduct- Kingdom was not even necessary, much less ing post-discharge follow-up visits in sufficient, to achieve what he isolates as its patients’ homes. key administrative objective, to facilitate the • Creation of multi-disciplinary “health coordination and integration of care. Based on houses” and medical homes. the more recent natural experiment of de facto • Use of GP practice coordinators to facili- creation of health regions for Scotland, Wales tate communication across health service and Northern Ireland through devolution, organizations on behalf of patients.
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• Agreements between regions and GPs to (whether decentralized or centralized) for the increase responsibility and accountability political tier of government. Certainly, at least for coordination and integration. some political leaders hoped that the boards and CEOs of RHAs would wear at least some Stephen Duckett (2016) points to the of the difficult decisions in the initial stages resource allocation function of health regions of regionalization. While opposition parties and the presumption that more regionally- and the media made sure that did not happen, based organizations can be expected to be there was another political use of RHAs that more responsive to local needs in getting the was even more ubiquitous: focusing reforms at right mix of investment across various types of the higher administrative and structural health healthcare. Of course, if this task is not carried system levels because such reforms are less out properly, it can result in significant under- disruptive to voters and providers than service investment in certain types of care, thereby delivery reforms. impeding integration and coordination with Politically motivated structural health other services. system reform has been a regular part of the Canadian landscape since regionalization was introduced in the early to mid-1990s. Perhaps Politically motivated structural health the most infamous example is the Alberta system reform has been a regular part government’s decision to disband its RHAs in favour of a single delivery agent. Political of the Canadian landscape … concerns about CEO remuneration and the How this coordination and integration bureaucratic rivalry between the Calgary occurs is a significant question. As Bevan and Edmonton health regions and competi- (2016) and Tim Tebensel (2016) point out, tive vying for resources from the provincial it can occur through hierarchy or the market. government were likely the determining Most systems mix and match depending on the reasons for the change in direction. At the type of health services and providers involved. same time, there has been a noticeable trend Some arrangements are difficult to describe. toward greater centralization in regional- Canadian physicians, for example, are inde- ized systems inside and outside Canada in pendent contractors and many continue to recent years. be paid on a fee-for-service basis. Medicare evolved into a highly corporatist arrangement Centralization between provincial governments and organ- Regionalization has always involved a combina- ized medicine that has actually made top-down tion of centralization up from healthcare organi- reform at the provincial ministry or the regional zations to a regional body and a delegation of health authority (RHA) levels very difficult. resource allocation and managerial decision- This stands in sharp contrast to the top-down making from health ministries to regional reforms in New Zealand, Denmark and the bodies. As noted in the introductory essay UK discussed here. (Marchildon 2016), there has been a marked However, regionalization is not all about trend to more centralized structures, either in policy and administration. There are also terms of reducing the number of RHAs or significant political objectives. Katherine creating single province-wide health authorities. Fierlbeck (2016) describes the potential As Duckett (2016) points out in his political benefits of regionalized structures essay, the balance between decentralization
76 Where Are We Going from Here? and centralization changes over time and everywhere in Canada. This can be seen most the pendulum may once again shift back to readily when it comes to primary care. In the more decentralized structures in the future New Zealand case, Tebensel (2016) shows in Canada. In the meantime, it is important how GPs were required to become part of to understand that there are both costs and Primary Health Organizations (PHOs) with benefits to both decentralized and central- accountability requirements set by statute ized structures, and the enormous challenge and a direct linkage with the District Health faced by provincial governments in getting the Boards. This structure is very similar to what tension between the two just right. was recommended to the Ontario government While provincial governments are aware by the Primary Health Care Expert Advisory that healthcare is too complex and varied Committee in 2015. However, the Ontario to be entirely managed by a ministry, they Medical Association’s (OMA) opposition to want to be able to obtain economies of scale the recommendation will make it extremely and scope that seem to be easiest to achieve difficult for the government to adopt with- under a single delivery organization. However, out a major conflict with organized medicine bureaucratic overload often accompanies the (Marchildon and Hutchison 2016). multiple hierarchical levels of authority in Indeed, the relationship between physicians large organizations. Alberta Health Services and regionalized structures, particularly as it (AHS) has 100,000 employees and is one of affects primary care, has been identified as a the largest employers in Canada. It is, in fact, major impediment to improving health system a mini version of the NHS, one of the largest performance. In their major review of regional- employers in Europe. However, it is ques- ization in Canada, which has been summarized tionable whether the scale and scope advan- here, Yves Bergevin and his colleagues (2016) tages of such an enormous organization ever point to the lack of accountability between outweighed the inefficiencies associated with physicians and RHAs and the implications of such size, and the continual reforming of the this in terms of improving health services. The NHS since the early 1970s could be seen as an reality is that those countries, such as the UK effort to decentralize. and New Zealand, where major changes to Despite these lessons from other jurisdic- this accountability relationship have occurred, tions, it is unlikely that the trend to centrali- have experienced significantly better outcomes zation has run its course in Canada. Indeed, in terms of health system performance, at least there is little evidence of a counter-trend to as measured in the Commonwealth Fund’s increasing, rather than reducing, the number International Survey. of RHAs. We can only hope that the political The Truth and Reconciliation decisions taken in the near future will more Commission of Canada (2015) delivered its carefully weigh the advantages and disadvan- landmark report in December 2015. Since tages of centralization based on experiences in that time, there has been considerable discus- Canada and outside Canada. sion of how the country can get beyond its paternalistic foundation and racist settler- The missing pieces Aboriginal relationship, so that Canada’s In reviewing the experience with regionali- Indigenous peoples can be in greater control zation in other countries, it is difficult not of the decisions that affect their lives. Since to be struck by the extent to which physi- health and healthcare will be major factors cians work outside of regionalized structures in this reconfiguring of Canadian society,
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Josée Lavoie and her colleagues (2016) were the countries examined here. This will likely asked to examine the interface between continue to be the case when it comes to regionalization and Indigenous health doctors and it will certainly be true when it and healthcare. comes to the manner of involving and serv- At this time, only two provincial health ing Indigenous populations in Canada. At the systems have formal structures for Indigenous same time, this onus on governments makes input into regionalized structures. The it more difficult to orient policies, programs government of British Columbia requires and incentives to increase the integration public sector boards, including the govern- and coordination of health services through ment-appointed RHA boards, to reflect regionalized structures. The paradox is, the cultural and geographical make-up of however, that without this integration and the populations they serve. Ontario’s Local coordination within or outside regionalized Health System Integration Act requires an structures, it will be difficult to improve health Aboriginal and First Nations Health Council system performance. to advise the provincial Minister of Health on I will conclude by repeating (sometimes Indigenous health and health services issues. paraphrasing) the seven areas of improvement These requirements are limited to advisory identified by Yves Bergevin and his co-authors functions and do not go as far as involve- (2016), and then suggesting, in parentheses, ment of the Maori in health system deci- some potential concrete actions. sion-making in New Zealand, for example. However, the recently created First Nations • Managing RHAs as a results-driven Health Authority (FNHA) is intended to health system (provincial ministry of be a direct actor in determining health and health setting hard targets for RHAs with health services for Indigenous residents in explicit consequences for failure). British Columbia. It is difficult at this point • Strengthening wellness promotion and to see how the FNHA will work with the public health including intersectoral province’s five RHAs, but the experiment is actions and policies (encouraging RHAs being watched in other provinces to see if the to identify at least one public or popula- model can, and should, be adapted to other tion health intervention that requires environments. collaboration and policy synergy with local governments within its defined geographic boundaries). • Ensuring timely access to primary health- … only two provincial health systems care (require patient registration with have formal structures for Indigenous primary care practices and, simultaneously, input into regionalized structures. require primary care practices to provide full 24/7 coverage as part of remuneration Conclusion package). In Canada, due to the history of public • Involving physicians in clinical governance payment and private delivery (Naylor 1986), and leadership and have RHAs partner governments have had to collaborate more with them to improve accountability and with private actors – particularly the medical performance (either transfer physician profession – to achieve health system changes budgets to RHAs or create an inter- than has been the case with governments in mediary organization that would create
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Bevan, G. 2016. “What Can We Learn from the UK’s an accountability relationship between “Natural Experiments” of the Benefits of Regions?” physicians and RHAs with performance Healthcare Papers 16(1): 16–20. doi:10.12927/ requirements). hcpap.2016.24768. • Engaging citizens in shaping their own Duckett, S. 2016. “Regionalization as One health destiny and their respective health Manifestation of the Pursuit of the Holy Grail.” Healthcare Papers 16(1): 53–57. doi:10.12927/ systems (ensure greater transparency for hcpap.2016.24770. citizens at the RHA and ministry levels with Fierlbeck, K. 2016. “The Politics of Regionalization.” more regular public consultation and engage- Healthcare Papers 16(1): 58–62. doi:10.12927/ ment by RHAs and ministries with citizens hcpap.2016.24772. on long-term direction and priorities). Lavoie, J.G., D. Kornelsen, Y. Boyer and L. Wylie. • Strengthening health information systems, 2016. “Lost in Maps: Regionalization and Indigenous Health Services.” Healthcare Papers 16(1): 63–73. accelerating the deployment of electronic doi:10.12927/hcpap.2016.24773. health records and ensuring their interop- Marchildon, G.P. 2016. “Regionalization: What erability with health information systems Have We Learned?” Healthcare Papers 16(1): 8–14. (launch a federal–provincial–territorial doi:10.12927/hcpap.2016.24766. process with a definite deadline with the Marchildon, G.P. and B. Hutchison. 2016. “Primary objective of providing all Canadian citi- Care in Ontario, Canada: New Proposals after 15 zens with comprehensive electronic health Years of Reform.” Health Policy 120(7): 732–38. records that they can access and use at Naylor, C.D. 1986. Private Practice, Public Payment: Canadian Medicine and the Politics of Health Insurance, any time). 1911–1966. Montreal, QC: McGill-Queen’s • Fostering a culture of excellence (creat- University Press. ing a pan-Canadian forum that regularly Tenbensel, T. 2016. “Health System Regionalization showcases health organization and delivery – the New Zealand Experience.” Healthcare Papers 16(1): 27–33. doi:10.12927/hcpap.2016.24771. innovations and based on a juried assess- Truth and Reconciliation Commission of Canada. ment of international originality and target 2015. Honouring the Truth: Reconciling the Future. population impact). Winnipeg, MB: Author. Vrangbaek, K. 2016. “Regionalization Lessons These actions are not comprehensive. Nor from Denmark.” Healthcare Papers 16(1): 21–26. are they particularly simple or easy, given the doi:10.12927/hcpap.2016.24769. current governance and administrative arrange- ments and the power wielded by some interest groups. However, they are intended to begin a discussion about the actions needed to actu- ally improve what most agree is the suboptimal performance of most health systems in Canada, whether defined at the provincial or the regional healthcare level. Faute de mieux, regionalization remains the most viable means to achieve this end. … everywhere References Bergevin, Y., B. Habib, K. Elicksen-Jensen, S. Samis, J. Rochon, J.L. Denis and D. Roy. 2016. “Transforming Regions into High-Performing Health Systems Toward the Triple Aim of Better Health, Better Care and Better Value for Canadians.” Healthcare Papers Longwoods.com 16(1): 34–52. doi:10.12927/hcpap.2016.24767.
79 HealthcarePapers Volume 16 • Number 1 EDITOR-IN-CHIEF Adalsteinn D. Brown, Director, Institute of Health Policy, Management and Evaluation and Dalla Lana Chair in Public Health Policy, Dalla Lana School of Public Health, University of Toronto
EDITORIAL ADVISORY BOARD FOR HEALTHCAREPAPERS Mr. Torbjörn Pelow, Health Administrator & Consultant, Owen B. Adams, Director of Research, Policy and Planning, Gothenburg, Sweden Canadian Medical Association Dr. Bernardo Ramirez, Academy for Educational Development, Dr. Arif Bhimji, Magna Health, Aurura, Ontario Washington, DC Adalsteinn D. Brown, Director, Institute of Health Policy, Management Dr. Janet Thompson Reagan, Professor and Director, Health and Evaluation and Dalla Lana Chair in Public Health Policy, Administration Programs, California State University, Dalla Lana School of Public Health, University of Toronto Northridge, California Dr. Gordon D. Brown, Professor and Director, University of Missouri– Dr. Anne E. Rogers, Professor of the Sociology of Health Care, Columbia, Department of Health Management & Informatics National Primary Care Research and Development Centre, Mr. Tom Closson, Toronto, Ontario University of Manchester, England Mr. William Carter, Borden Ladner Gervais, Toronto, Ontario Dr. Judith Shamian, President, International Council of Nurses, Mr. Michael Decter, Toronto, Ontario Geneva, Switzerland Dr. Jeff Edelson, Executive VP, Research and Development & Ms. Tina Smith, Program Director, University of Toronto, Chief Medical Officer, Intranasal Therapeutics, Saddle Brook, NJ, Institute of Health Policy, Management and Evaluation, Principal, Aequanimitas Consulting, Berwyn, PA Toronto, Ontario Dr. Bruce J. Fried, Associate Professor and Director, University of Dr. Willem Wassenaar, President, Wellesley Therapeutics, North Carolina at Chapel Hill, North Carolina Toronto, Ontario Mr. Peter Goodhand, Markham, Ontario Dr. Ruth Wilson, Professor, Department of Family Medicine, Queen’s University, Kingston, Ontario Dr. Toby Gordon, Associate Professor and Director, The Johns Hopkins University, Department of Health Policy and Management, Dr. Howard S. Zuckerman, Professor Emeritus, Center for Baltimore, Maryland and Vice-President Planning & Marketing, Health Management Research, University of Washington, Johns Hopkins Medicine Seattle, Washington Dr. Carol Herbert, Professor Emeritus, UWO Schulich School of EDITORIAL ADVISORY BOARD FOR HEALTHCARE Medicine & Dentistry, London, Ontario QUARTERLY PUBLICATIONS Dr. Alan Hudson, Toronto, Ontario Dr. Charlyn Black, Director, Centre for Health Services and Policy Mr. Ron Kaczorowski, President & Managing Director, Prism Research, University of British Columbia Alliance Group (IBO), Toronto, Ontario Dr. Christopher Carruthers, President, Society of Physician Executives, Mr. John King, Healthcare Advisor, Toronto, Ontario Ottawa, Ontario Dr. Peggy Leatt, Founding Editor-in-Chief, Professor and Chair Emeritus, Sister Elizabeth M. Davis, Sisters of Mercy of Newfoundland & Labrador Department of Health Policy and Management, Gillings School of Global Dr. Jeff Edelson, Executive VP, Research and Development & Chief Public Health, University of North Carolina at Chapel Hill, NC Medical Officer, Intranasal Therapeutics, Saddle Brook, NJ Dr. Sandra Leggat, School of Public Health, LaTrobe University, Mr. Hy Eliasoph, Toronto, Ontario Bundoora, Victoria, Australia Mr. Ted Freedman, Toronto, ON Mr. Steven Lewis, President, Access Consulting Ltd., Saskatoon; Dr. Peggy Leatt, Founding Editor-in-Chief, Professor and Chair Adjunct Professor of Health Policy, University of Calgary and Simon Emeritus, Department of Health Policy and Management, Gillings Fraser University School of Global Public Health, University of North Carolina at Mr. Jonathan Lomas, Founding Executive Director, Canadian Health Chapel Hill, NC Services Research Foundation, Ottawa, Ontario Mr. Joseph Mapa, President and CEO, Mount Sinai Hospital, Dr. Noni MacDonald, Dalhousie Medical School, Toronto, Ontario Halifax, Nova Scotia Mr. James Saunders, President, J.L. Saunders and Associates Inc., Mr. Bruce S. MacLellan, President, Environics Communications Inc., Calgary, Alberta Toronto and New York Mr. Don Schurman, Sierra Systems, Edmonton, Alberta Mr. Joseph Mapa, President and CEO, Mount Sinai Hospital, Dr. Judith Shamian, President, International Council of Nurses, Toronto, Ontario Geneva, Switzerland Dr. Michael McGuigan, Medical Director, Long Island Regional Poison Control Center, New York CONSULTING EDITORS FOR HEALTHCARE QUARTERLY PUBLICATIONS Dr. Robert McMurtry, Professor of Surgery, University of Western Dr. Robert Filler, Founding Member and Chair, Ontario Ontario and Orthopedic Consultant, St. Joseph’s Health Care, Telehealth Network London, Ontario Dr. Michael Guerriere, Vice-President, Transformation Services and Dr. Eric Meslin, Director, Indiana University Center for Bioethics, Chief Medical Officer, TELUS Health Solutions Indianapolis, Indiana Mr. Ken Tremblay, Peterborough, ON Dr. Terrence J. Montague, Professor of Medicine and Director, Disease Management Research Group, University of Montreal, Montreal, Quebec Peel back the layers of health care and explore each one. Have heard of the Canadian Patient you Put our reports to work for you. Experiences Reporting System (CPERS)?
Launched in 2015, this new resource collects responses from the Canadian Patient Experiences Survey — Find out more. Inpatient Care (CPES-IC). This comprehensive and Visit www.cihi.ca comparative information can be used to develop or email [email protected]. benchmarks and drive quality improvement. CPERS is the country’s only tool that supports national comparisons of patient experience. And it’s available now for implementation across Canada.
www.cihi.ca At the heart of data