Monday, 9 June 2014
Megaregions and the future of Canadian health care services
The era of the Megaregions and ‘Big Health’ has arrived.
The first health regions in Saskatchewan had as few as a few thousand people and clearly were not viable. Over time the number of regions has gradually diminished as the balance between geography and trying to reflect community needs has been juggled by a handful of individuals sitting in provincial capitals.
This week Nova Scotia announced the dismantling of the district health boards through an eloquent legal slight of hand. While effectively maintaining the districts, their boards were all dismissed and replaced a single administrator responsible for all health districts. Nova Scotia health boards dismissed.
Alberta dissolved health regions into a single megaregion and have yet to recover or develop an effective operating modality. With BC now at five regional authorities, Saskatchewan at 12, Manitoba 5 (reduced from 11 late last year), Ontario with 14 LHINs, Quebec at 18, New Brunswick 2, Newfoundland at 4, (PEI, Yukon, Nunavut also have single boards, NWT has 8) the number of 67 has gradually diminished over the last decade with a starting position in the hundreds nationally.
While some provinces also have tertiary level services combined into a provincial health authority or equivalent, even these are getting rolled into the megaregions as politicians recognize the high costs of tertiary services can be mitigated by better primary and secondary services.
Somewhere someone should be asking two questions
1. What is the ideal set of size parameters for a health region?
2. Who is making these decisions on amalgamation and why?
On the first question, New Zealand argued in the 90’s that the ideal population was in the one million mark, and based on performance of many health boards they may have been close in their number. Given Nova Scotia is just shy of the 1 Million mark perhaps the recent decision makes sense.
The bigger questions is why? Yes there is a small amount of money to be gleamed by reducing boards and by marginally reducing administrations (although this is questionable). The developing question is how the health regions now interact with the Ministries of Health. Or, what exactly are the Ministries of Health now doing?
As the trend continues we can expect Health regions is be limited to implementation and delivery of services and the buffer between the consumer and the politician, Ministries of Health will not just monitor quality but also increasingly be responsible for program development. By controlling the size and function of the Health regions, Ministers of Health effectively are distanced from the problems at the patient bed or clinic room, but fully in control of what is happening. It is all about limiting the political liability of health as there is limited political currency to be gained in health.
Communities are merely been given lip service, non-government organizations are used to fill in on the fringe activities that are politically unpalatable, and the family is being left behind in standardized protocols. Big “H” health has arrived, driven by the triple bottom lines that include finances, quality and effectiveness of care, and supposed concern about employees.
Through this the need to modernize public health remains. Vested in tradition and seeking long term benefits the current public health models lack comparability against waiting times, complication rates, and payback value of less than four years.
The elephant in all this is the future of primary health care and delivery of physician services. One can expect these to begin to be rolled into the Megaregions in order to have an even better grasp on the continuum of health services. This despite the active resistance to such change by the medical community.
Fasten your seatbelts, the rapidity of change will be increasing, with those not strapped in will be left standing in the sidelines and left behind and unable to influence the direction of the future health system.