Nothing compares to Alberta

In an incredible workaround to avoid accountability, Alberta is moving to "hospital-based leadership".

In a pre-recorded address to avoid media scrutiny, Alberta’s premier announced the next phase of the UCP’s avoidance of accountability in healthcare: moving to “hospital-based leadership.”

“It’s costing time, and it’s costing patients’ time, and it’s costing Albertans the care they deserve,” she said.

“Soon, each facility will have an empowered leadership team supporting our sites, responsible for hiring, managing resources, and solving problems. Sites will have the ability to direct dollars to the greatest need and access local decision-making because when people closest to the problem have the power to fix it, things get better.”

On the one hand, this may mean relocating current AHS staff from larger centres to smaller ones. Or maybe it means firing them all and hiring “common sense” conservatives, I mean “employees”, locally. It’s hard to guess-timate how “soon” these leadership teams can be built in rural hospitals that probably don’t have any office space available to house them, from a non-existent talent pool in regions of the province where there was no employment opportunity previously.

“In business, you can’t afford delay. A grocer doesn’t wait months for approval to cover a staff member on leave; they hire someone and keep the shelves stocked. A contractor doesn’t sit on a broken tool waiting for permission, they replace it and keep building. That’s how things work when you trust the people on the ground.”

Well, no, it’s not about “trust” — Ms. Smith is actually talking about unlimited resources. Finding a stock person to cover maternity leave ought to be a far easier task than finding someone with a nursing degree or M.D., especially in rural. Again, we’re comparing apples and lightbulbs. Alberta (like every other province, country, and continent) has limited resources of nurses, doctors, x-ray techs, lab techs, diagnosticians, anesthesiologists and every other specialized role in a hospital. A siloed hospital leadership team will not have access to a provincial database of employees to try and cover maternity leave.

The ability to just “replace” a broken tool is reliant on a well-padded budget. If we’re talking about a hammer, that’s an expense that can probably be quickly replaced, but it is not the same as replacing an MRI machine for $250k-$500k. One of my local cafes had a broken espresso machine for four months because the replacement cost was $15,000.

I’m almost certain that Ms. Smith has no intention of providing individual facilities with unlimited budgets.

We cannot compare replacing a stock person at a grocery store with trying to replace an Emergency Room Physician, and we cannot compare the cost of a hammer with an MRI machine. Unless this government plans on simply paying the bills without requiring set budgets, funding resources will continue to be limited, no matter who is placing the orders.

It’s also fair to point out that there was a fiscal justification for moving to centralized purchasing; cost reduction. Yes, it may take more time to get six chairs replaced since central has to put out a call to all facilities to see how many of them could also use replacement chairs, but they do it because it reduces the cost per chair. I mean, it did reduce costs before AHS procurement started outsourcing their job to their side hustle.

And now we’re going to have 177 procurement departments available so some enterprising Albertans can install their friends all over the province and continue ripping off the government without worrying about one CEO doggedly following the paper trail. Could this government be any more inclined to protect their crooks and cronies? Frick. Moving on.

“Hospital-based leadership gives each facility the flexibility to respond, the freedom to adapt, and the authority to act, because one-size fits all doesn’t work in healthcare, and it never will,” she said with all the authority of someone who compared the ease with which a grocery store can replace a stock person with a hospital replacing medical professionals.

“Let me be clear; Alberta Health Services will still play a vital role as a provider of hospital-based services (what?); they will have a renewed focus on priorities like improving wait times and providing high quality hospital care for patients across Alberta. (AHS) will continue to set boundaries, track performance, and hold leadership accountable but from now on, local leaders will have more authority to make the right call, and more accountability to deliver results.”

Good to know we’re going to install leadership teams locally to “respond, adapt, and act” on everything but wait times and providing high quality hospital care because those aren’t nearly as important as getting chairs delivered faster.

From apples, to coffee cups, and elephants

“We’re not the first to make these moves. Countries like Norway, the Netherlands, and parts of Australia have already made the shift to hospital-based leadership and they’ve seen faster service, better patient outcomes, and stronger staff retention; all while staying accountable. When you trust the front lines, results follow,” she said.

There’s so very much to unpack there. Let’s start with the fact we’re comparing apples to coffee cups, and elephants. Alberta may have jurisdiction over healthcare, but we are not like the country of Norway (remember; that’s the excuse for not having a trillion saved in the Heritage Fund), and we are not comparable to the continent of Australia for reasons that should be obvious, but admittedly not to me until some point during my second cup of coffee this morning.

Alberta spends $4,436 per capita on health (6% of GDP), Norway spends $11,313 CAD (9.9% of GDP), the Netherlands spends $9,815 CAD (11.3% of GDP), and Australia is a continent.

(In Norway) the health system is partly de-centralized. The Ministry of Health and Care Services, along with its subordinate agencies, is responsible for planning, regulating and supervising the healthcare system. Four regional health authorities (RHAs) are in charge of specialist care, which is provided in hospital trusts owned by the RHAs, including in polyclinics within hospital outpatient departments. The vast majority of Norwegian patients are treated in publicly funded hospitals. Since January 2023, patient choice of hospitals has been limited to public providers and private providers with a public tender agreement (Saunes, 2023a). Municipalities are responsible for the organisation of primary care, which is primarily delivered by independent general practitioners (GPs) who perform a gatekeeping function to specialist care.

Country Health Profile, Norway, 2023, page 9

The Netherlands “has among the lowest unmet needs in the EU, with only 0.3% of the population reporting unmet needs for medical care due to cost, travel distance or waiting times in 2023” (page 15/23). The Netherlands model seems more like what the UCP would prefer to move to, aside from the not-for-profit, higher spending, employer insurance coverage, and more fulsome early childhood and preventative care.

In 2006, a major reform introduced managed competition to the Dutch health system, changing the government’s role from direct control of volumes and prices to rule setting and oversight. Health care is delivered by private providers and operated by private health insurers.

The Ministry of Health, Welfare and Sport (MoH) oversees the stewardship, planning and regulation of the health system, although it does not have a hierarchical relationship with payers or providers and has limited ability to act autonomously. The Netherlands typically approaches policy development through cross-sector initiatives, bringing together stakeholders from different areas, including the MoH, health workers, and patient organizations.

The MoH holds the primary responsibility for high level planning of health and health care, although the municipalities also share responsibility especially for social care and mental health care for children. The Dutch government sets the benefits package and budget, but planning for health services largely operates at the individual provider and payer level. Negotiations between providers and health insurers determine the price, volume and quality of services available to patients, within the boundaries of the nationally set regulations and benefits package. Providers are responsible for infrastructure investments and both payers and providers maintain financial reserves (page 2).

Municipalities hold most responsibility for providing public health services. The Public Health Act, in force since 2008, specifies the services covered, which include preventive health care for children, screenings and vaccinations. Children up to 4 years of age receive preventive care and vaccinations at municipal child health centres staffed by specialized physicians and nurses. These child health centres also provide medical and parenting advice, and refer children to other primary health care providers, mostly GPs, when treatment is needed. Older children receive preventative check ups from school doctors.

A range of providers operate at the primary care level, including physiotherapists, dentists, midwives, remedial therapists and primary care psychologists. However, GPs are the main point of contact and central figures in the Dutch health care system, acting as gatekeepers to most secondary care (page 9).

Country Health Profile, the Netherlands, 2023

Australia is aiming for less duplication of services, more regional coordination, and multi-jurisdictional collaboration between the federal, states/territories, and local governments. Essentially, Australia appears to be moving in the opposite direction that the UCP is heading. I realize she said “parts of” the continent, but I’m not going to try and figure out which ones she may have been referring to. In any case, Australia has been focused on national health reform and is still trying to get to a place that moves away from “more siloed decision-making”.

The illusion of distance

Another reason Alberta Health Services was created was to be an arm’s length entity where healthcare would be free from political influence; something we know continued to be an issue throughout.

Justice Centre for Constitutional Freedoms co-founder John Carpay, an influential UCP supporter and regular guest on Ms. Smith’s radio show, initially called Jason Kenney to account in 2020 for his decision to empower his Cabinet with the ability to amend or introduce legislation unilaterally. I argued then that Bill 10 was about Jason Kenney giving Cabinet power to intervene if Dr. Hinshaw attempted to use the sweeping powers afforded to the Chief Medical Officer of Health in the event of a public health emergency.

Mr. Carpay argued often that decisions should not be made by unelected bureaucrats who could not be held to account. Danielle Smith obviously agreed because her first target was Dr. Deena Hinshaw, followed by the AHS board, and then AHS itself.

In 2023, an Alberta judge ruled that political interference with the Chief Medical Officer of Health’s recommendations was a violation of the Public Health Act, which prompted Danielle Smith’s UCP to table Bill 55 in May to legally allow elected officials with no medical background, let alone an interest in public health, to decide which medical advice they will accept.

Moving AHS back into fragmented structures, under the direct management of individual Ministers, however, is a level of accountability Danielle Smith has proven unwilling to hold herself, or her Ministers to.

Enter “hospital-based leadership”, and the “vital role” AHS will still play in managing things Albertans care about to create a nice buffer zone between what Albertans have to deal with and who can be sacrificed in the name of “renewal” before an election if Albertans aren’t happy.

Once again, I have to admit that when it comes to dodging accountability, nothing compares to the depths Danielle Smith will go.

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