Here comes another restructuring
As we’ve heard for months now, the province is in the midst of restructuring health care on a sectoral basis with acute care, primary care, continuing care and mental health care and addictions as major components. Few details have been announced, but a price tag of 85 million dollars and a two-year time horizon have been mentioned.
Alberta Health Services, the mammoth and overarching agency that has been responsible for most health care over decades, will continue its responsibilities for acute health care (probably renamed as Alberta Hospital Services) while primary care, continuing care and mental health care will be co-equal partners.
Government has recently passed enabling legislation: the Health Statutes Amendment Act. Recovery Alberta is the name of the new organization that will provide mental health and addiction services and will evidently become operational this fall.
There’s not much news so far, at least publicly, and it’s likely that these are early days. There is, however, much anticipation, particularly in the wake of some job losses involving senior executives throughout the system. We’ve been through this sort of thing before, as waves of regionalization and centralization were attempted by earlier regimes. Old hands in the system (of whom it must be said there are few!) warn us we’re in for a tumultuous ride. They are almost certainly right; however well it’s handled, change of the magnitude that the government projects will be traumatic for all involved, and the ripples – and even the tsunamis – of change will go on much longer than anticipated.
We could have seen this coming
Changing things is the hallmark of political manoeuvring and a re-elected United Conservative Party was eager to break with the past. The thinking behind the new organization is not immediately obvious. Better patient care and improved access to care and caregivers are trotted out as the proximate impetus for change, but so too is the tired promise of money savings through more efficient practice. The sceptics among us (most certainly those who’ve been this way before) will note that savings in health care are usually notional and intangible – if they exist at all.
The major issue that has prompted tinkering or taking a broad axe to the organization of health in the province likely relates to the overall success and the autonomy of Alberta Health Services that developed over many years. It had become so large and so comprehensive an undertaking that the Ministry of Health and the broader government had little choice but to accommodate its activities and funding needs. I expect this was more than an irritant to the newly elected political eminences who resolved to set things right.
However the decision was made, it’s a big one and it won’t be a cake walk
Let me quote an organizational expert/political theorist from 16th century Florence, Italy, still highly relevant: “And one ought to consider that there is nothing more difficult to pull off, chancier to succeed in, or more dangerous to manage, than the introduction of a new order of things.” (Nicolo Machiavelli, The Prince).
So we are in search of a new order. Seemingly unaddressed by a revamped organization chart, however, are the staffing issues in health care and the unconscionable delays in service that effectively ration care.
Given the looming workforce issues, we must acknowledge that the success – such as it was! – dealing with COVID short months ago relates to the tireless effort of overworked docs, nurses and allied workers who ponied up, again and again, over many months. Kudos to the workers, and let me say it: “Thank you.”
The goodwill and amity that got us through the pandemic are the most valuable resources available to the health system. Heaven forbid that we lose an enviable orientation to patient-focused service. In spite of revamping the enterprise, but mindful of the access issues identified in the four newly identified sectors through the pandemic, it’s evident that the system, large as it is and however reconstituted, is going to need more funding.
Some suggest that now is the time to reintroduce further privatization in the system. As attractive as this may be to would-be entrepreneurs, I believe this is wrong-headed and has nowhere been demonstrated to save money when rigorous accounting is possible.
We’re back to change and making sense of restructuring. Volumes have been written about the processes needed to enact change and to overcome resistance to it. We’re in high-resistance territory now, post COVID. The world has gone topsy-turvy with the pandemic and its accompanying economic disruption. We’re playing catch up on a personal basis for a long list of disruptions in our lives. High prices for goods and services, fraught relationships in many families, and free-wheeling anxiety are the legacy of our troubling responses to recent events. This may be the very worst time to try to win new battles.
Though resistance to change is commonly derided by folk interested in putting their ideas into action, human biology doesn’t crave constant change either. As Harvard physiologist Walter Cannon pointed out nearly a hundred years ago, we need to narrowly maintain a constellation of intracellular and extracellular processes without change. We call this homeostasis. Our general resistance to perturbation in our lives may be considered an extension of this, as we attempt to keep our boats afloat and on an even keel.
On a more positive note, improved health care remains attractive to workers in health care who are oriented to help people and who are likely to support change that is reasonable and likely to benefit patients. The task then becomes a major process of communication and common sense. Leadership is called for as well as managerial competence, interpreting the future in ways that make sense.
To workers in the system, however, the spectre of organizational change becomes personal and presents the possibility and even the probability of loss – loss in predictability, status, responsibility and group membership. The unknown looms large. Anxiety accompanies the change process, and it’s easy to recognize that a turbulent health care environment invites poorer care. To visit human physiology again – cortisol levels rise with stress; cortisol in turn suppresses empathy, which can be problematic when we look to help others.
I haven’t heard much yet about “that vision thing,” as one of the American presidents put it. We need to have significant detail regarding just how the new organization will work. This in turn must be amplified by an army of people who know what they’re doing, who must listen as well as move forward.
Over the past few decades, organizational experts have become fond of saying that measuring or gauging progress is key; if you can't measure it, you can't manage it. This belief has led to an enthusiasm for performance indicators. I’d like to see an ongoing basket of indicators – ones that are reasonable and look to follow the effects of change on patient care – and I’d like to see these made public and on a regular basis. What a brave and helpful undertaking this would be! – it probably doesn’t have a chance.
We’re in for a long haul, I’m afraid.
Toughen up. Perhaps we’ll get there.
Wherever “there” is.
Editor’s note: The views, perspectives and opinions in this article are solely the author’s and do not necessarily represent those of the AMA.
Banner image credit: Marvin Polis