On March 11, 2019, the new directors of the super agency Ontario Health held their first meeting. The boards that governed 14 regional authorities called LHINs and six other Ontario health agencies were terminated at the same time, leaving Ontario Health in charge.
This transition from a decentralized system to a centralized model (and occasionally back again) has been a recurring theme across Canadian healthcare over the past few years. Newly elected governments tend to pursue structural change as the Ford government in Ontario is currently doing. In evaluating this churn in our 13 provincial/territorial health systems, it is pertinent to consider how agencies contribute to healthcare performance.
First some categorization – there are four classes of agencies recognizable in Canadian healthcare.
The first and most recent class is the provincial super agency – i.e. – Ontario Health, Alberta Health Services (AHS) and Nova Scotia Health Authority (NSHA). The super agency takes accountability for provincial health outcomes away from the minister of health and ministry and gives it to the agency CEO and board. Generally, responsibility for physician compensation and public health remains with the ministry whereas the rest of provincial clinical responsibility moves to the agency.
The second class is the regional agency or authority. Ontario had 14 regional agencies called LHINs, but it appears regional health is consigned to the dustbin of history in this province. With the regional agency model in most provinces, the ministry oversees provincial planning and performance and relies on the regional agencies to both advise on and implement programs in the regions.
The third class of agency is functionally rather than clinically focused – for example eHealth agencies, procurement services or HR recruitment agencies – and likely should be characterized as “back office”.
Class four agencies are disease or condition specific agencies including cancer care in some provinces and the Provincial Health Services Authority in BC which includes cancer, mental health, children, maternal and emergency services.
In examining the value of the various agency models, the super agency has been most contentious. The NSHA and the AHS certainly created well documented turbulence at their initiation. The long period of inertia while the super agency takes shape and determines strategy is often counterproductive to the continuous incremental health care improvement that we rely on for quality care.
The remarkable breadth of responsibility attached to the CEO of the agency may be problematic. Will the CEO of a super agency be able to focus and move forward all clinical elements within the agency’s hierarchical structure?
The next two or three years will determine whether CEOs of super agencies can lead provincial health systems better than ministers and ministries. Progress in Ontario will be watched carefully by other provinces to evaluate success of this enormous new super agency.
Many provinces including Newfoundland and Labrador, New Brunswick, Quebec, Manitoba and BC remain committed to Class 2 regional health agencies although proposed legislation in Manitoba may change regional responsibilities. In a country as diverse and geographically immense as Canada, it seems sensible to develop a methodology that would engage regional voices in planning and implementing care delivery. Regional health agencies could work within a super agency or within a ministry-led system.
Again, the super agency experience in Ontario without regional engagement will be carefully examined. If the health of nearly 14 million Ontarians living in locations as diverse as Kenora and Kitchener can be effectively managed from central Toronto without need for regional input, the centralized super agency concept will seem increasingly attractive.
Class 3 functional “back office” agencies may be organized in a variety of ways. Health procurement is a central government function in BC and Alberta and may be part of the super agency in Ontario. In Alberta, Netcare is a provincial information management entity within the ministry. In Ontario, the previously independent eHealth agency is now part of the super agency.
Class 4 disease or condition specific agencies are rapidly disappearing across the country. With the termination of Cancer Care Ontario (CCO), Saskatchewan and Manitoba are the only remaining provinces with independent cancer agencies. As mentioned, BC groups five conditions including cancer into the PHSA. In the rest of the provinces and territories cancer care is one of many services provided by the ministry or the super agency.
As a cancer surgeon, it is difficult to understand why Canada is turning its back on programmatic management of cancer.
International comparisons of cancer outcomes have documented the world leading cancer survival of Canadian patients (patients actually drawn mainly from BC, Manitoba and Ontario since these are the provinces with comprehensive data from cancer registries).
Providing citizens with a modern cancer program is challenging in 2019 and it is remarkable that governments are turning their backs on independent cancer programmatic planning.
From encouraging behavioural changes that reduce the risk of getting cancer, to complex screening programs for early cancer detection, cancer treatment in an environment where best practices evolve extremely quickly, survivorship and palliative care- the range of services provided by an excellent cancer program is extensive and ever expanding.
It would seem logical that when developing this complexity of service, a dedicated agency with experts advising programmatic direction and strategy would be sensible. The Ontario model went one step further and authorized the cancer agency to distribute the funds that paid for cancer services across the health system. Cancer Care Ontario would then distribute those funds with an emphasis on improving cancer care delivery (volumes and wait times) as well as quality.
Enhancing cancer quality of care by funding cancer centers of excellence for complex cancer care was one method used by CCO. Another method was to insist on reporting and publication of metrics (cancer surgery margins of resection and numbers of lymph nodes resected, for example) as part of the requirement to receive provincial cancer funding.
Removing this independence of planning, funding and quality improvement likely hurt the BC Cancer Agency when it moved inside the limited provincial super agency PHSA.
Cancer is an expensive disease and new treatments emerge constantly that increase the cost of care. The new fields of genomic oncology, personalized cancer care and immunotherapy will make it increasingly difficult to keep “up to date” with best practices and stay on budget. Having an independent cancer agency constantly engaged in evaluating the best practices that can be achieved within a limited cancer budget kept Ontario cancer care both leading edge and cost effective.
Can a complex program like cancer care receive the attention necessary within a super agency model? Experience in British Columbia suggests that recruiting and retaining effective leadership has been difficult under the limited BC super agency. All eyes will be focused on Ontario to determine whether that province’s internationally leading cancer program will maintain its leadership capacity when it is one of many clinical priorities in Ontario Health.
In summary there are four classes of health agency models: super agencies that take over responsibility from ministers and ministries; regional agencies that reflect local planning and implementation; functional agencies that provide “back office” services; and clinical agencies that focus on diseases and/or conditions. The current trend in Canada seems to be greater focus on super agencies, decreased emphasis on regional agencies, consolidation of functional elements and elimination of disease focused agencies.
These changes will clearly influence the way that care is delivered in our provinces and careful evaluation of these changes is essential.
Image Credit: ©frender – Can Stock Photo Inc.
