(Edmonton and Ottawa) Alberta began creating a centralized health authority like ripping off a bandage. Suddenly.
Posted at 5:00 am.
“It all happened literally overnight,” recalls MP Ron Liepert, who led this major reform in 2008. At the time, he was health minister in this western Canadian province, which was led by a Progressive Conservative government. No legislation was needed to abolish the nine regional health authorities and three provincial organizations responsible for treating addiction and cancer and providing mental health care. Alberta legislation gave him the authority to act by ministerial order.
“I had a press conference at 9 a.m. and in the meantime, senior ministry officials contacted 200 administrators to fire them and 12 CEOs to tell them they would lose their roles. »
The government replaced them with a single board of directors and a new president and CEO, both on an interim basis. Their mission was to determine the structure of this new organization.
There were numerous problems with Alberta’s health care system at the time. Hospitals competed fiercely for resources and the quality of care varied regionally. The rivalry between facilities in the cities of Edmonton and Calgary was so great that it made access to medical treatment difficult. Patients were even moved over 500 km to Saskatchewan or the American state of Montana to receive certain advanced services instead of being sent to a hospital closer to the “enemy” city. The share of administrative costs for the health system “was just under 10% and was still not sufficient,” remembers Ron Liepert.
Pumping more money into a system that wasn’t working properly was not an option for me.
Ron Liepert, former Alberta Health Minister
Today, Alberta is the lowest-paying province in the country. According to the Canadian Institute for Health Information, the share of spending on organizational services (administrative, finance, human resources, communications, etc.) is 2.7%, well below the Canadian average of 4.3%. For comparison: Quebec’s rate is 4%. However, the cost of an average hospital stay remains the highest in the country, particularly due to the high salaries of doctors and nurses.
Alberta Health Services (AHS) is the largest employer in the province with 112,300 employees and remains the largest health authority in the country for now. It has a budget of 17.5 billion1 to serve a population of 4.4 million people. However, it will be dethroned by Santé Québec following the passage of Bill 15.
But the reform in Quebec is not a copy of the reform implemented in Alberta, warns Antoine de la Durantaye, press secretary for Health Minister Christian Dubé. “We made our own diagnosis,” he emphasizes. With reports from the Clair Commission, the Commissioner for Health and Wellbeing and the Deputy Minister Dominique Savoie. Only in retrospect did Quebec realize that its reform bore similarities to that of the oil-producing province. Above all, in the Minister’s Office, we don’t want to repeat the mistakes of Alberta, which rushed in without preparation. For this reason, a transition committee will be set up for a period of two years.
PHOTO JEFF MCINTOSH, CANADIAN PRESS ARCHIVE
Over time, the reform helped reduce administrative costs and improve treatment of certain diseases in Alberta.
A long transition
When established, the role of this centralized health authority was to implement the key directives formulated by the Minister of Health and his officials. The government, for its part, had to maintain a healthy distance.
“If you want to adopt a policy that says the wait time for surgery should not exceed three months, work with the new board and CEO to determine the necessary funding,” Ron Liepert gives as an example. Then you invest the resources to make it work and leave the implementation to the agency. If it doesn’t work, jump in. »
This happened in Quebec during the pandemic. Public Health developed its vaccination policy and Daniel Paré, who led the campaign, took care of all the logistics. A division of tasks is considered to be significantly more effective.
While the reform allowed for reductions in administrative costs and improvements in the treatment of certain diseases in Alberta over time, the first years of its implementation were particularly stormy.
Stephen Duckett, the first CEO of AHS who was recruited from as far away as Australia, now believes he has been given “an impossible mission”.
“For a long time we had 30 different payroll systems,” 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 cope with a billion cuts,” admits the septuagenarian. His short term ended in controversy.
After centralization, it took eight years for the administration to become well-oiled, including four years to establish the unified payroll system. “It was a big change not only for Albertans but for health care workers,” says Verna Yiu, who led the agency for six years until she was fired by Jason Kenney’s United Conservative government in 2022. That’s 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 had already been implemented. “It was only in 2016 that we were able to significantly improve the quality of care while maintaining the financial viability of the health system,” says the pediatrician who specializes in nephrology.
PHOTO JEFF MCINTOSH, CANADIAN PRESS ARCHIVE
In Alberta, the cost of an average hospital stay remains the highest in the country, due in part to the high salaries of doctors and nurses.
An Achilles heel
The idea of leaving the entire operational side of the network to a large health authority initially worked. But after a ministerial reshuffle less than two years later, the situation worsened.
The father of reform, Ron Liepert, avoided interfering in the agency’s affairs, but his successor took the opposite approach.
My successor liked to interfere in matters and there is no doubt that this was the trigger for the political interference.
Ron Liepert, former Alberta Health Minister
Since then, AHS has been the scene of great distress depending on the mood of elected officials.
The board was dissolved by the Progressive Conservatives in 2013, restored by the New Democrats in 2015, and dissolved again in 2022 by current Prime Minister Danielle Smith of the United Conservatives. He was therefore replaced twice by the same government-appointed sole administrator. A violation of the autonomy granted to the health department when it was founded. Danielle Smith now wants to go back and regionalize decision-making 15 years after centralization, despite the health authority’s good moves during the pandemic.
Eight months earlier, his predecessor, Jason Kenney, fired AHS CEO Verna Yiu, who had been in office for six years and was very popular. Its policy of mandatory vaccination of health workers during the pandemic was poorly received by the United Conservative government, influenced by the anti-vaccination movement.
“I took this job knowing that I could be fired the next day,” says Dr. Yiu, without wanting to go into more detail about the circumstances of her departure. “It’s the nature of this kind of higher employment. » She believes the game was still worth it.
PHOTO MYLÈNE CRÊTE, THE PRESS
Verna Yiu was 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 Quebec’s Ministry of Health for the founding of Santé Québec. “I basically explained to them what Alberta Health Services is and the benefits of a centralized health care system,” she says.
She believes that during her tenure at AHS, she was able to establish a governance discipline with long-term planning that allowed her to improve care. “No government will say no, I don’t want financial sustainability,” she states. She therefore suggests that the Government of Quebec and those responsible for Santé Québec keep in mind this objective and that of improving the health of the population.
1. AHS’s annual budget was nearly $15.5 billion in 2019-20, before the COVID-19 pandemic.
Centralization or decentralization?
Health Minister Christian Dubé has repeatedly pointed out that his reform aims to decentralize the health system. Certain powers are concentrated in his ministry and delegated to the network. But the reform also includes a centralization of governance with the creation of a single large health authority like in Alberta.
Five tips for Quebec
Beware of political interference
For health management expert Tom Noseworthy, there is no doubt that health care in Alberta could have been better without government intervention. “You will not improve patient outcomes unless you take the government and its departments out of the day-to-day running of health care,” he warns. The legislation must be specific enough to prevent the board and management from changing at the whim of the government. Santé Québec is subject to the Law on the Management of State Enterprises. A protective measure that would have been useful in Alberta. “Let the experts do their job as long as they get results,” emphasizes Verna Yiu, former CEO of Alberta Health Services. Trust the people at the top. » She believes that great discipline is required 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 care 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 a unified voice for local regions to influence the health system,” notes Tom Noseworthy, professor emeritus of health management and policy at the University of Calgary. After the territorial designation, Santé Québec retains the regional administrations. At the same time, the names CISSS and CIUSSS will be abandoned and replaced, for example, by Santé Québec-Estrie. Their boards of directors will be replaced by new boards of directors made up of elected local officials, academics, users, employees and people from the community.
Get doctors involved
“Doctors have to be part of the system, they are the ones who drive the system forward,” emphasizes Verna Yiu. In Alberta, the five regional zones are led by pairs of a doctor and a health administrator. Both are therefore jointly responsible for the household. “Doctors are generally not as interested in the budget as they are in the quality of care,” explains the pediatric nephrologist. But when you improve the quality of care, you also improve the budget. there is no doubt. »
Beware of bureaucracy
Alberta is not immune to the administrative variations caused by the centralization of its health care system. The nurses’ union points out that local managers sometimes have to contact their supervisors to hire staff and that authorization is required to purchase prune juice for constipation patients. The Alberta Medical Association notes that primary care physicians who are not part of the central authority face bureaucracy. “I practice in a small community,” explains its president, Fredrykka Rinaldi. I know all the orthopedic surgeons here. Why would I send a request to an empty mailbox somewhere when I can call them directly? »
Plan the transition well
A headlong move into centralizing care, as Alberta has done, risks leading to the same difficulties. “If you plan it well, it shouldn’t be that difficult,” says Dr. Yiu. In Alberta the decision was made very quickly and there wasn’t much opportunity to do any preliminary work. »
Learn more
5 Number of Canadian provinces that have centralized their healthcare 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, leaving only four.
Source: AL Berta Health Services