2023-09-17 09:00:00
(Edmonton and Ottawa) Alberta embarked on creating a centralized health agency like ripping off a bandage. Suddenly.
“Everything happened literally overnight,” recalls federal MP Ron Liepert, who led this major reform in 2008. He was then the Minister of Health of this western Canadian province led by a government progressive conservative. No bill was needed to eliminate the nine regional health agencies and three provincial organizations responsible for treating addictions and cancers and providing mental health care. Alberta legislation gave him the power to proceed by ministerial order.
“I had a press conference at 9am in the morning and, meanwhile, senior officials at the Ministry were contacting 200 administrators to fire them and 12 CEOs to tell them they were losing their roles. »
The government replaced them with a single board of directors and a new president and CEO, both interim. Their mandate was to define the structure of this new organization.
At the time, there were numerous problems plaguing Alberta’s health care system. Hospitals competed fiercely for resources and the quality of care was uneven across regions. The rivalry between establishments in the cities of Edmonton and Calgary was such that it hampered access to medical treatment. Patients were even transferred more than 500 km to Saskatchewan or the American state of Montana to obtain certain advanced services instead of being directed to a hospital closer to the “enemy” city. The proportion of administrative costs for the health system “was close to 10% and it was still not enough,” recalls Ron Liepert.
Pumping more money into a system that was not working properly anyway was not an option for me.
Ron Liepert, former Minister of Health of Alberta
Today, Alberta is the province that pays the least in the entire country. According to the Canadian Institute for Health Information, its ratio for spending on organizational services (administration, finance, human resources, communications, etc.) is 2.7%, well below the Canadian average of 4. 3%. For comparison, Quebec’s ratio is 4%. However, the cost of an average hospital stay remains the highest in the country, in particular because of the high salaries paid to doctors and nurses.
Alberta Health Services (AHS) is the largest employer in the province, with 112,300 employees, and remains, for now, the largest health agency in the country. It has a budget of 17.5 billion1 in order to serve a population of 4.4 million people. However, it will be dethroned by Santé Québec following the adoption of Bill 15.
But the Quebec reform is not a copy and paste of that carried out in Alberta, warns Antoine de la Durantaye, press secretary to the Minister of Health, Christian Dubé. “We made our own diagnosis,” he points out. With reports from the Clair Commission, the Commissioner of Health and Well-being and Deputy Minister Dominique Savoie. It was following the fact that Quebec realized that its reform had similarities with that of the oil-producing province. In the minister’s office, we especially do not want to repeat the mistakes of Alberta, which rushed in without preparing. This is why a transition committee will be set up for a period of two years.
PHOTO JEFF MCINTOSH, CANADIAN PRESS ARCHIVES
Over time, the reform helped reduce administrative costs and improve the treatment of certain illnesses in Alberta.
A long transition
When it was created, the role of this centralized health agency was to execute the major directions formulated by the Minister of Health and his officials. The government, for its part, had to keep a healthy distance.
“If you want to adopt a policy stating that the wait for surgical procedures should not exceed three months, you work with the new board of directors and the CEO to determine the funding required,” cites Ron Liepert as an example. Then you invest the funds to make it work and you leave the implementation to the agency. If it doesn’t work, then you step in. »
This is what happened in Quebec during the pandemic. Public Health was developing its vaccination policy and Daniel Paré, who directed the campaign, took care of all the logistics. A sharing of tasks considered much more effective.
If, over time, the reform made it possible to reduce administrative costs and improve the treatment of certain illnesses in Alberta, the first years of its implementation were particularly stormy.
Stephen Duckett, the first CEO of AHS recruited as far away as Australia, now believes he was given “a mission impossible”.
“We had 30 different payroll systems for a long time,” he says from his home in Melbourne. We didn’t know how many employees we had. »
A “dysfunctional and desperate” situation made worse by budget cuts. “It was very difficult to manage while absorbing 1 billion cuts,” admits the septuagenarian. His short tenure ended in controversy.
Eight years passed following centralization before the administration was well oiled, including four to set up the single payroll system. “It was a big change not only for Albertans, but also for health-care workers,” says Verna Yiu, who led the agency for six years until she was fired by the United Conservative government. by Jason Kenney in 2022. She is now the interim vice-president of studies at the University of Alberta, where she agreed to grant us her very first interview since her dismissal. By the time she became president and CEO of the agency, most of the reform was in place. “It was really in 2016 that we were able to make major improvements in the quality of care while maintaining the financial viability of the health system,” indicates the pediatrician specializing in nephrology.
PHOTO JEFF MCINTOSH, CANADIAN PRESS ARCHIVES
In Alberta, the cost of an average hospital stay remains the highest in the country, in part because of the high salaries paid to doctors and nurses.
An Achilles heel
The idea of letting a large health agency take care of the entire operational side of the network worked initially. But the situation deteriorated following a ministerial reshuffle less than two years later.
The father of reform, Ron Liepert, avoided interfering in the agency’s affairs, but his successor took the opposite approach.
My replacement liked to meddle in matters and there is no doubt that this is what triggered the political interference.
Ron Liepert, former Minister of Health of Alberta
Since then, AHS has been the scene of great heartbreak depending on the mood of elected officials.
The board was dissolved in 2013 by the Progressive Conservatives, restored in 2015 by the New Democrats, then dissolved once more in 2022 by current Premier Danielle Smith of the United Conservatives. He was thus replaced twice by the same sole administrator appointed by the government. A breach of the autonomy that had been granted to the health agency when it was created. Danielle Smith now wants to go back and regionalize decision-making, 15 years following centralization, despite the health agency’s good moves during the pandemic.
Eight months earlier, his predecessor, Jason Kenney, had fired AHS CEO Verna Yiu, who had been on the job for six years and was well-liked. Its policy of compulsory vaccination of health care workers during the pandemic had gone down badly with the United Conservative government, influenced by the anti-vaccination movement.
“I accepted this position knowing that I might be fired the next day,” says the Dre Yiu without wanting to elaborate further on the circumstances of his departure. “It’s the nature of this type of higher employment. » She believes that the game was still worth the effort.
PHOTO MYLÈNE CRÊTE, THE PRESS
Verna Yiu served as president and CEO of Alberta Health Services before being fired by Jason Kenney’s government in 2022.
CEOs before me had ministers who called them four or five times a day. It was reactive management, crisis management.
Verna Yiu, former CEO of AHS
The former CEO was consulted by the Quebec Ministry of Health for the creation of Santé Québec. “I basically explained to them what Alberta Health Services is and the benefits of having a centralized health system,” she says.
She believes she was able to establish governance discipline with long-term planning during her tenure at AHS, which allowed her to improve care. “No government will say no, I don’t want financial sustainability,” she notes. She therefore suggests that the Government of Quebec and the managers of Santé Québec keep an eye on this objective and that of improving the health of the population.
1. AHS’s annual budget was just under $15.5 billion in 2019-20, before the COVID-19 pandemic.
Centralization or decentralization?
The Minister of Health, Christian Dubé, has indicated on several occasions that his reform aims to decentralize the health system. Certain powers are concentrated within his ministry and will be delegated to the network. But its reform also includes a centralization of governance with the creation of a single large health agency as in Alberta.
Five tips for Quebec
Beware of political interference
For health management expert Tom Noseworthy, there is no doubt that health services in Alberta might have been better without government interference. “You won’t improve patient outcomes if you don’t take government and its ministry out of the day-to-day business of managing health care,” he warns. The legislation must be specific enough to prevent the board of directors and management from being changed according to the moods of the government. Santé Québec will be subject to the State Corporation Governance Act. A safeguard that would have been useful in Alberta. “Let the experts do their job as long as they get results,” insists former CEO of Alberta Health Services Verna Yiu. Trust the people at the helm. » She believes that great discipline is needed on both sides so that everyone respects their role. “Everyone must have the ultimate goal in mind: healthier people and a sustainable system. »
Maintain local representation
The centralization of Alberta’s health system initially stifled regional voices. But a few years later, the government added five regional zones to ensure better representation. “The superstructure is necessary, but there needs to be some common voice for local regions to have influence over the health care system,” notes Tom Noseworthy, professor emeritus of health management and policy. at the University of Calgary. Santé Québec will retain the regional administrations following the territorial designation. At the same time, it will abandon the name CISSS and CIUSSS and replace it with Santé Québec-Estrie, for example. Their boards of directors will be replaced by new governing boards composed of municipal elected officials, academics, users, staff members and people from the community.
Involve doctors
“Doctors must be part of the system, they are the ones who drive the system,” underlines Verna Yiu. In Alberta, the five regional zones are led by pairs of a physician and a health administrator. Both are therefore jointly responsible for the budget. “Doctors are generally not very interested in the budget, but they are in the quality of care,” explains the pediatric nephrologist. But if you improve the quality of care, you will improve the budget. there is no doubt. »
Beware of bureaucracy
Alberta is not immune to the administrative aberrations caused by the centralization of its health system. The nurses’ union notes that local managers sometimes have to go through their superiors to hire staff and that permission is required to buy prune juice for constipated patients. The Alberta Medical Association notes that family doctors, who are not part of the centralized agency, are encountering bureaucracy. “I practice in a small community,” explains its president, Fredrykka Rinaldi. I know all the orthopedic surgeons here, why would I need to send a request to an empty box somewhere when I can phone them directly? »
Plan the transition well
Launching headlong into centralization of care as Alberta has done risks leading to the same type of difficulties. “If you plan it well, it shouldn’t be that difficult,” says the Dre Yiu. In Alberta, the decision was made very quickly and there was not much opportunity to do preparatory work. »
Learn more
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- 5
- Number of Canadian provinces that have centralized their health care system: Alberta, Saskatchewan, Nova Scotia, Prince Edward Island and Newfoundland and Labrador.
- 5
- Number of collective agreements within Alberta Health Services. Quebec wants to merge 136 collective agreements so that only 4 remain.
Source : ALBerta health services
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