Beware health-care ‘super-agencies,’ experts say
Experience of other provinces suggests patients may suffer, efficiencies are not assured
Before proceeding with the creation of a health-care “super-agency,” Ontario would be wise to look closely at the experiences of other provinces that have gone down that bumpy road, health policy experts and leaders warn.
Nova Scotia, British Columbia and Alberta have undertaken similar reforms and found them to be more difficult, disruptive and distracting than anticipated, they caution.
“Everybody is thinking about the restructuring (while) the actual provision of services sort of gets ignored,” charged Katherine Fierlbeck, a political science professor at Dalhousie University, recounting Nova Scotia’s experience.
Nine regional health authorities were merged into the Nova Scotia Health Authority in 2015 with the aim of saving money and creating efficiencies.
But Fierlbeck argues there is no evidence to show that either goal was attained.
“There is this idea that money will be saved, but there is no evidence that happened in Nova Scotia. I have been tracking the budget over time and the short answer is you can’t tell,” she said.
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The Star reported in January that Ontario is eyeing the creation of a “super-agency” that would absorb more than 20 smaller agencies including Cancer Care Ontario, the Trillium Gift of Life Network, eHealth and 14 local health integration networks.
The provincial government has yet to confirm it intends to create a super-agency, but the idea is being openly discussed in the broader public sector. The provincial New Democrats have released numerous leaked government documents on health restructuring, including draft legislation to enable creation of a super-agency.
Meantime, the Star has confirmed through a public record search with the Ministry of Government Services that the province incorporated, just over two weeks ago, an entity named Health Program Initiatives. The new entity and superagency are one and the same, said a source close to government who spoke on condition of anonymity in order to discuss the restructuring plan.
Asked if she had any advice for Ontario, Fierlbeck responded: “Don’t do it.”
Nova Scotia created a “huge monster agency” through the merger of smaller health agencies, she said, adding there was much inefficiency in decision making. Officials were unsure whether to get permission to make certain moves. There was a reluctance to make big decisions and a belief those should come down from on high.
An informal, blue-ribbon panel of Nova Scotia physicians, including a former deputy health minister, issued a report two years ago in which they wrote that the merged organization “has quickly become a bureaucratic non-system which cannot respond quickly on behalf of dying or very ill people.”
Fierlbeck said primary care services in the province continue to be “a mess,” long-term care lacks planning and mental health services are improving but still not where they should be. Thirteen years after healthcare services in British Columbia were overhauled, the province’s cancer system continued to struggle, Dr. Don Carlow, a former head of the B.C. Cancer Agency, wrote in a 2014 opinion piece in the Vancouver Sun.
The restructuring saw the board of the cancer agency disbanded. The agency was then taken over by the Provincial Health Services Authority, which had competing priorities.
Before the overhaul, the cancer agency reported directly to government. But after the changes, it reported to the authority, which in turn reported to government.
The cancer agency, which once had an international reputation for excellence and attracted top talent, had difficulty recruiting professionals and suffered from poor morale under the new structure, lamented Carlow, former president of the Ontario Cancer Institute/ Princess Margaret Hospital and former executive director of the Canadian Association of Provincial Cancer Agencies.
Reached by phone, Carlow said Cancer Care Ontario is the envy of cancer systems around the world and he would hate to see it suffer a similar fate:
“This is an anachronism. You’ve got a good system and other people are looking at it and writing about it and praising it and copying it, and now they want to take it down? Oh no, I think that would be a mistake.”
Carlow pointed to a 2011 analysis by the Organization for Economic Co-operation and Development, which compared cancer systems in OECD countries. The best ones had good governance and leadership and took a systemic approach to cancer control through a lead organization like Cancer Care Ontario, he said.
Ontario’s former deputy minister of health, Dr. Bob Bell, said he is worried for the future of cancer care and organ donation in Ontario if both are moved under the umbrella of the super agency. “Ontarians have enjoyed a system that continually improves without radical chaotic changes in structure,” said Bell, former president of the University Health Network and a former cancer surgeon.
“Incremental solutions are at hand to improve our current problems. Incremental change is not resisting innovation, it is introducing change in a responsible, safe manner that does not put patients at risk,” Bell added.
Alberta’s health system experienced much publicized disruption after it was centralized in 2008. Alberta Health Services was created out of 12 smaller health entities.
Opposition politicians and unions denounced the merger and called for AHS to be dismantled, charging health services were suffering.
Its first CEO, Stephen Duckett, lasted only 18 months, eventually returning to his native Australia. At the same time, some board members resigned.
Reached by email, Duckett described the restructuring this way:
“In my view it was handled badly but I think the outcome was good. There was unhealthy competition between the predecessor authorities which was not in the public interest. I do not think though that the merger process impacted adversely on patient care.”
“Incremental change is not resisting innovation, it is introducing change in a responsible, safe manner that does not put patients at risk.” DR. BOB BELL FORMER DEPUTY MINISTER OF HEALTH