The goldilocks principle and Canadian health care system governance

Health care system governance is important. CEOs of health care organizations need to report to someone and health care boards fulfill this oversight role. Besides recruiting and hiring a CEO, boards also hold CEOs accountable for achieving outcomes, act as mentors and support CEOs when necessary in taking the heat from the unhappy segments of the community when contentious decisions are made. Local boards provide a mechanism for engaging people in the local community. And they develop connections and collaborative arrangements with boards from other sectors that have responsibility for matters such as housing and education that have an on impact population health. All these functions could be done by government itself, but the general view of those involved in health care is that that the role of government and its civil service should be limited to matters such as policy development and enabling implementation leaving the day-to-day running of the health care system to organizations that can operate at arm’s length.

Canada is generally not a country of extremes, but this is not so when it comes to how we govern our provincial health care systems. In this case, we clearly have extremes. At one end is Alberta which, at the moment, has essentially no institutional, regional or provincial boards for system governance. At the other is Ontario with 14 Local Health Integration Networks (LHINs), 14 Community Care Access Centres (CCACs), 150 hospital corporations and thousands of other community health services agencies all with their own governance structures. This raises the question regarding how much governance in health care is “just right” to obtain the best performance (aka the Goldilocks Principle)?

Measuring the impact of governance models on the performance of provincial health care systems is challenging at best given that numerous factors contribute to health care system performance. Based on spending alone, Alberta, with almost no governance structures, performs quite poorly compared to other provinces. Even though Alberta has a relatively young population, its cost per capita is the second highest of any province, only surpassed by Newfoundland which I think we would all agree has special geographic and population challenges. Although this relatively high level of spending has been occurring in Alberta for many years, there is no sign that recent trends towards less and less governance has brought Alberta’s high spending in line.

But cost performance is only one consideration. Good health outcomes, coordination and patient experience are also to be strived for. Local governance is intended to better engage people in designing solutions that address their needs effectively. Having too many boards increases complexity and can make cooperation and coordination difficult as individual boards often make decisions in the best interests of their own organization rather than the collective good of the population being served. Ontario is trying to address this issue with its Health Links (ultimately about 80 of them), which are intended to bring many service provider organizations together voluntarily at the local level to coordinate care for complex populations. Evaluation is currently underway to see how well this “non-board” structure works in minimizing the potentially negative impact of Ontario’s fragmented board structure.

In the 1980s, every hospital in Canada had its own board. There were hundreds of them; there were 400 in Saskatchewan alone. In the 1990s every province in Canada except Ontario did away with almost all of their hospital boards and transferred health care system decision making authority from the hospital boards to regional boards with only Ontario maintaining a significant number of hospital boards, reducing from around 225 to the current number of approximately 150. Finally in the early 2000s, Ontario created the CCAC and LHIN boards, devolving some Ministry authorities while still maintaining hospital boards. In most provinces, along with having many fewer boards, there are many fewer CEOs. Ontario remains the outlier with many CEOs reporting to many boards.

The number of regional governance structures in Canada has also declined. In 2001, Saskatchewan reduced regional boards from 30 to12 and BC from 52 to 6. Other provinces such as Manitoba and New Brunswick have more recently followed suit. And in the recent Nova Scotia election campaign the winning Liberals committed to reducing their regional boards from 10 to 2.

But the prize for minimizing the use of health care system boards goes to Alberta. After doing away with its hospital boards, Alberta moved to a structure of 17 regional boards. Then in 2008, Alberta did away with those authorities and their boards and moved to a single authority for its entire provincial population. This new organization, Alberta Health Services (AHS), is very large, utilizing approximately 104,000 employees and 17,600 volunteers and linking with 8,400 physicians. In mid 2013, because the AHS board refused the Alberta Health Minister’s request to withhold performance payments that were owed to their executives for the previous year, the Minister dismissed the board members and appointed a single person to supervise AHS. And recently, the Minister announced that the health Ministry is taking over the handling of new home care contracts with providers in Edmonton because he believes that the AHS has not provided the necessary oversight. With these changes, one wonders whether Alberta will have any health system boards in the future.

So back to the question regarding how much governance in health care is “just right” to obtain the best performance. I have worked in British Columbia within a regional board structure and in Ontario with its fragmented hospital, community agency, LHIN and CCAC boards. I also participated in a review of the regional health authority structure in Manitoba. I am not aware of any definitive studies which determine the best health care governance structure in Canada, but the trend is clear. There is a trend towards fewer and fewer health care governance boards. And I believe that this trend is likely to continue.

The political process is evolving to a situation where no matter what health care governance structure exists, the Minister is being held publically accountable. Historically, regional boards may have been used for political cover for unpopular decisions or poor performance, but this is changing. In these days of instant media with RSS feeds, Twitter, Facebook, YouTube and 24 hour news, the Minister’s accountability is more direct and in real time. It appears that Ministers are being driven by this new instant accountability to reduce the number of health care boards to enable them to have a more direct line-of-sight into the day-to-day running of the health care system. And with fewer boards, Ministers are getting more involved and becoming more directive. This may not be “just right” to achieve health care system performance that is best for Goldilocks. It is just the way it is.