Regionalization: Does it matter?

1. Regionalization:Does it matter? Denise Kouri HEALNet Regionalization Research Centre Centre de recherche sur la régionalisation Relais June 2001 http://www.regionalization.org

2. Regionalization Research Centre • Funded by HEALNet/RELAIS (NCE) • National focus – based in Saskatoon • Study and act as a resource centre for regionalization topics • Work with decision makers in regional health authorities to enhance decision making

3. Does regionalization matter? • Overview of regionalization • Results of regionalization • Potential for public health? • Key informant survey • Issues and discussion

4. Problems with existing system:Documented in late 1980s • Fragmentation: • many separate local institutions • provincial government silos • duplication and multiple entries • Focus on services and institutions • Focus on disease and treatment • Population not involved • Political rigidity • Expensive

5. 94 96 97 93 94 89 92 96 92 Year of Regionalization Earliest year

6. What is a regional health authority (in theory)? • Autonomous health care organization with responsibility for health administration within a defined geographic region within a province or territory. • Has appointed or elected boards of governance. • Is responsible for funding and delivering community and institutional health services within its regions.

7. 9 4+ 11+ 12 5 17 18 32 ? 8 # of regional health authorities Note: Comparability not strict

8. Features: Authority & Structure • Regional, subprovincial boards (+) • Devolution of authority from province (selective) • Centralization and amalgamation of local institutions • Affiliation agreements with independent agencies • Transfer of provincial programs

9. Features: Services & Programs • Single authority responsible for wider range of programs • Acute care; long-term care; public health; community health; mental health • Attention to serving people in a more coherent way • Avoiding duplication and multiple entries • More follow up and information • Toward community-based programs

10. Breadth of Scope by Province Source: Lomas, 1999

11. Relationship to Population health • Within/for a specific geographic region • Focus on health status as outcome • Attention to social and economic environments • Short and long term determinants • What is the appropriate, coherent region? • Collaboration with non-health agencies • Whose responsibility is it?

12. Problem of authority • Provincial government speaks “for” RHAs • Targeting of funds by the provincial government; ad hoc interventions • Reactive deficit solving • Creation of perverse incentives “Health boards are legally responsible for things over which they have insufficient control.”

13. Political vulnerability • Who is more vulnerable to public pressure: • Province or RHAs? • Is political interference a fact of life? • Should devolution be complete?

14. Getting closer to “the people” • Boards as authorities • Saskatchewan and Quebec board members are elected • Elsewhere, board members are appointed • Issues of representation and accountability • Public participation • Quality vs quantity

15. Problem of Provider Relationships • No physicians under regional authority • Many different service agreements and organizations had to be made coherent • Much instability and change • Providers left out of picture • Demoralization • Primary care still problematic

16. Key Informant Survey, May 2001 Inuvik Outaouais Saskatoon Van. North Shore Capital (Halifax) North Okanagan

17. Summary: What do you feel are the positive effects of regionalization? • Enhanced local relevance of services / programs and services delivered in appropriate location • Reduced duplication / increased consolidation • Increased standardization • Improved efficiency and coordination • Reduced barriers • Increased cross-sectoral planning • Shifted focus from specific clients to population

18. Accomplished without regionalization? “Theoretically, we could have accomplished in other ways, but I don’t know how.” “Although in theory it should be possible in other ways, it wasn’t happening.” “Guess you could have accomplished this without RHAs, but it would be difficult.” “Possible, but difficult. Needed to break down the territoriality and this did it.” “Can only go so far through collaboration and horizontal integration (e.g., through one service or one hospital integrating within). You need one governance structure to force it to a higher level.” “With the province in charge and funding services, focus remains on individuals. Cannot focus on the health of a region when you are looking at the provincial level.”

19. Outaouais: • improved the services to population; • improved the integration and coordination of the services; and • shifted the focus from specific clients to population.

20. E.g. Mental health services • Now front-line and specialists work together: • Instead of clients going directly to specialists or hospitals for care, now go to primary care worker who refers, case managers, etc. • Family physicians now (with the support of specialists), provide the front line care. • Approach seems to be working • Some specialists did not like change and left. • Now looking at doing this with other groups such as youth and elderly.

21. Public health/promotion? • Public Health Department was separate before, but now it is integrated into the RHA. • Director of Public Health is on management team. • Whenever we develop new models or programs, health promotion is integrated right from the start. • But RHA does not always have the money to cover this service • We had an objective to increase funding by 20% for promotion and prevention, and we didn’t achieve it. • But it’s there as a priority area, and as soon as there is money, it will address the priorities.

22. Saskatoon: • From patient perspective, more emphasis on • continuity of care and • being patient-centered. • More awareness throughout the system of the various parts. • More inclusive and holistic now • But still missing doctors.

23. E.g. Public Health • Used to be island: • reported to municipal government • now under health board. • Over time, more joint programs : • Influenza - in past, public health would just offer immunizations, now, they feed the numbers back to the acute care sector to help them plan for outbreak

24. Public health/promotion? • Taken on physical activity as SDH corporate activity • not just one sub step in a strategic goal, or an issue relegated to a sector • SDH promotes via media and ads, work with pilot schools to id activities, get kids involved, and work with special or at-risk groups. • New $ to Community Development • (hired 3 FTE CD workers) • No new money to public health, but they have not had cuts, as most other areas

25. Vancouver North Shore: • Integration of services and continuity of care • Reduced duplication in admin and mgt • Fewer management positions • Community consultations very positive

26. Public health/promotion? • Increased awareness of Public Health issues • Now people from the Health promotion sector at the management table. • Public health more integrated with other parts. No longer a stand alone. • Always more to do, but we’ve started. Too early to say definitively.

27. North Okanagan: Ability to: • break down barriers between sectors, services, and programs • Facility staff know about community services and vice versa. • reconfigure services so to address client needs not just service needs • shift funds to where needed • although acute continues to gobble

28. Public health/promotion? • Plan together across continuum to address public health • E.g. concern in acute care re admissions for asthma - traced to air quality issues. Work with industry to try and influence their policies on open burning, etc. • Public health has an increased accountability to community • no longer just accountable to prov govt

29. Inuvik: • Allowed for much more planning and a planned approach to services within a local area. • Look at the larger jurisdiction and then streamline it for the local area. • People planning are from the local area and therefore it is more informed planning. • People feel more a part of the system when it is local, and they see how it all fits together. • There is a greater chance to educate the public.

30. E.g. co-location and multi-disc. • Community services are co-located with multiple disciplines and • Regional services are provided by interdisciplinary teams.

31. Public health/promotion? • Public health has fared very well. Seen as critical piece of health system. • Public health folks now work with others as part of the team. • Because of team work, people now start to think prevention and promotion • e.g., with FAS, doctor decided and steered a preventive focus. Integrated approach to care helped with this.

32. Halifax: • eliminating duplication of services and infrastructure, reducing multiple directors and managers and services and • enhancing standard practices and systems (e.g., I.T.) • Note: Region is new

33. “See different people around the table and it is easier to work across lines. The lines between departments and sectors are starting to meld.” • “Attending meeting tonight that involves public health, acute care, dept of health, etc, whereas before, we worked more in silos and wouldn’t think so much about players or departments.”

34. Does RHA define its own health goals or use provincial goals? • Typically set their own goals with some consideration of provincial goals

35. How do you measure the health impacts or outcomes of your programs? • Are evaluating • but few evaluate health outcomes • seem to be still heavily focused on process and interim outcomes • although they all seem to aspire in the direction of assessing health outcomes • Saskatoon and Vancouver using Balanced Scorecard approach

36. Where are we at? • Integrated, more coherent services? • Wider range of services and programs? • More client focus? • More coordination? • Population health? • Health outcomes for evaluation? • More population participation? • Reduce/stabilize expenditures?

37. Issues: • Clarity and commitment about authority • Systematic outcomes evaluation • Funding matched to goals • Predictable funding and stability in the system • Physicians integrated • Organized primary care

38. Selected Questions: • What is the appropriate division of authority? • Federal/provincial/regional • What is the trade-off between institutional integrity and integration of services? • More clarity about what a region is? • What is essence of a region? • Different strategies for rural and urban regions? • What is the relationship between regionalization and “social capital”?