Change for the sake of change? A look at what’s behind the choice to reorganize Alberta’s entire health system

In response to pressing health policy challenges, such as the many Albertans without a primary care provider and long waits in hospitals, the province recently announced plans to embark on a transformative reorganization of its healthcare system. Although change is needed, it is unclear why the government opted against evidence-based reforms that are carefully designed to address the most significant issues faced by patients in favour of destabilizing the system in a manner that risks making things worse. Over the past several decades, health systems around the world have moved towards more integrated delivery models to achieve economies of scale, eliminate duplication, and improve patient care. Alberta embraced integrated delivery in the 1990s by replacing individual hospital governance structures with 17 regional health authorities, later reducing that number and finally consolidating them into a single organization, Alberta Health Services (AHS), in 2008. Although AHS is not without its challenges, many experts regard it as a high performing model, citing Alberta’s province-wide health record and the lowest administrative costs in the country as examples. Under Alberta’s new reforms, the role of AHS will be significantly narrowed and some of its current policy-making and funding activities will be centralized in the hands of the provincial government. AHS will become one of several entities that deliver acute care services and are accountable to a newly created acute care organization. It appears that politics played a role in the dismantlement of AHS, given the government’s repeated scapegoating of the organization for problems of its own making. For example, Premiers Jason Kenney and Danielle Smith blamed AHS for surge capacity issues during COVID-19—at a time when the government refused to do their part to curb demand for beds by implementing public health measures that were in effect in other provinces. Premier Smith’s election campaign included criticisms of AHS and, in November 2022, she replaced its entire board with a single administrator. In addition to the creation of an entity to oversee acute care, the reforms will result in three new organizations that will each be responsible for one part of the health system: primary care, continuing care, and mental health and addictions. It is not yet clear how these organizations will work together on areas of overlap: for example, with both the acute care and mental health organizations potentially having responsibility for in-patient mental health services. We also don’t yet know how policy-makers will mitigate the risk of patients falling through the cracks between the four silos of care. The new primary care organization will work towards ensuring every Albertan has access to a provider and will coordinate and oversee primary care. Considering the many Albertans who are struggling to access primary care today, focusing on this issue may be one of the bright spots of the new reforms, depending on how it is operationalized. One potential point of contention is the fact that all publicly funded providers and clinics will now be accountable to the new primary care organization. It is unclear what this accountability will look like and how its oversight will overlap with or complement that of the College of Physicians and Surgeons of Alberta. Other significant primary care reforms already underway include an expanded role for pharmacists and nurse practitioners being permitted to practice independently and bill the government directly. The new continuing care organization will work towards developing services and supports for home and community care, improving existing facilities, and exploring options for Albertans. And finally, the new mental health and addictions organization will be tasked with implementing the government’s recovery-based model, which has been criticized for minimizing the importance of harm reduction. Notably absent from the government’s announcement was any reference to evidence from Canada or abroad demonstrating that these silos of service delivery will address any of our current health system challenges. In fact, this reform comes at a time when several other provinces are moving towards more integrated models more like Alberta’s. One might have argued, as Alberta’s Auditor General did in 2017, that instead of disaggregating AHS, the government ought to have further leaned into integration, for example by better coordinating primary care with acute care. Other new entities created by the reforms include a procurement and system optimization secretariat within government, an Indigenous advisory council, and an integration council. Existing AHS advisory councils will be replaced by 12 new local advisory councils, which will represent regional perspectives and priorities. The creation of so many new administrative structures is puzzling in light of the government’s enthusiasm for red tape reduction and Premier Smith’s criticism of AHS as having too many managers. When pressed on how much this system transformation will cost, the government did not provide specific numbers and instead made vague references to the cost of the last reorganization, which involved the creation of AHS in 2008. Given the substantial cost that is likely to be associated with a system overhaul, it is problematic that government either lacks clear cost projections or is unwilling to be transparent with the public on these numbers. Apart from their potential cost and the risks associated with destabilizing an already struggling system, these reforms may exacerbate rather than fix some of the most significant challenges, such as the recruitment and retention of staff. With high demand for health professionals across the country, why would someone choose to come to a province with a system that may soon be in organizational disarray over a jurisdiction with more stability and predictability? Health professionals may be deterred from working in a system that requires them to spend considerable time navigating uncertain system changes rather than spending that time providing patient care. Health professionals may also gravitate away from a province that is moving towards a centralization of government power, particularly given their strained relationship with elected officials over the past several years, as exemplified by the fraught contractual negotiations between physicians and the province. Although the government has paid lip service to the importance of working with health professionals on the new reforms, it is telling that entities like the Alberta Medical Association and the United Nurses of Alberta were not consulted on the changes prior to their announcement. Contrary to Premier Smith’s insistence otherwise, much of this sweeping reorganization appears to be change for the sake of change, given the lack of evidence in support of these reforms. There are concerns that the changes will add chaos to an already struggling system and that they fail to address the province’s most significant health policy challenges. In fact, unless they are carefully operationalized, these reforms risk worsening issues such as recruitment and retention of health professionals and patient access to care. Lorian Hardcastle is an associate professor in the Faculty of Law and Cumming School of Medicine at the University of Calgary.

Change for the sake of change? A look at what’s behind the choice to reorganize Alberta’s entire health system

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