Monday, November 10, 2008

Patient First Review: Gov’t short on details; regional health authority restructuring, job cuts and privatization of some services seem inevitable

“The Saskatchewan Party wants an audit of the entire health care system to ensure money is being used properly,” McMorris said. “We also want to establish a single provincial health authority to replace the 13 health regions.”

“This would reduce administration, direct precious health care dollars to front line care, and encourage hospitals to work together on solving waiting list problems.”
Don McMorris, Saskatchewan Party Health Critic, June 9, 2005
The official launch of the Saskatchewan Party government’s “patient first” independent review on Nov. 5, 2008, was short on specifics and judging from comments made by Premier Brad Wall since then indicate that the review might not be as independent as people think.

According to the government news release, Tony Dagnone, the former head of Saskatoon’s Royal University Hospital, has been appointed as the commissioner to lead the review, which will have two parts.

The first part of the review will focus on issues and challenges in the health care system from the perspective of patients, their family members, and advocates, based on their experiences with the system. Front-line health care providers will be asked to provide advice and insight on possible recommendations for change, to directly address the issues and concerns raised by patients and their families.

The second part of the independent review will examine administration in health care and identify efficiencies, constraints and opportunities for improvement in the regional health authorities, their affiliates and the Saskatchewan Association of Health Organizations. Areas of specific examination will be general administration (executive offices, board costs, planning and development), finance, human resources, system support (including information technology) and communications.

Dagnone will work with independent consulting firm KPMG to assist with consultations, analyzing results and drafting recommendations for the patient experience review. He will work with Deloitte Inc. on the administrative review. Details on opportunities to participate in the consultation process will be announced in the coming weeks. Dagnone plans to present the minister with his report by mid-2009.

Health Minister Don McMorris said at a news conference that privatizing health-care services isn’t the goal of the review.

“Right now we have some private delivery within the public system,” said McMorris.

“Our goal and our commitment still will be to a publicly funded, publicly administered health-care system.”

Nor is centralizing all of the health regions under one single health authority “in the cards at all right now,” McMorris said.

“As a matter of fact, I’m working on reappointing and renaming the boards of the 12 health regions that we have in the province and that will hopefully be done in the next two to three weeks,” he added. [Patients have a voice (Leader-Post, Nov. 6, 2008)]

McMorris’s comments don’t exactly square with what he has said in the past. And as for board members of the health regions they are appointed by the Lieutenant Governor in Council and serve at pleasure.

In its Oct. 2007 election platform the Saskatchewan Party said the province “requires more accountability in the health care system, so that health care dollars are directed away from bureaucracy, red tape and unnecessary duplication and into improving front-line care for patients and health care providers.”

“To ensure greater efficiency and accountability in health care spending and improve front line care, a Saskatchewan Party government will undertake a Patient First Review of the health care system.”

The key words to remember seem to be bureaucracy, duplication and efficiency.

Following the Throne Speech on Dec. 10, 2007, McMorris said he had already talked to the Ministry of Health about the patient-first health review and planned to start the review as soon as possible.

“What we want to do is have a look at the whole system and find efficiencies so we can push more money to the front lines, doctors and nurses,” McMorris said.

“We certainly realize that there (are) administration costs to run a system as big as this, but do we have the right mix?” [Health system under microsope (Leader-Post, Dec. 11, 2007)]

On Apr. 21, 2008, McMorris told the legislature’s human services committee that his ministry has “allocated 1.75 million to begin work on a patient-first review of our health care system and patient exit surveys.”

At the May 5, 2008, human services committee meeting, during consideration of the health ministry’s estimates, NDP MLA Cam Broten asked Minister McMorris if he foresaw a public tour around the province or individual meetings with stakeholders, if an interest or stakeholder group wanted to have a role in the patient first review, is there a process that they can follow to be included?

“I would expect we’d see probably all of the above,” McMorris said. “You know, I don’t see why we would be limiting or eliminating anybody.”

“Will members of the public be able to have their say?” Broten asked.

“Yes, I can’t see why not,” McMorris replied.

“RHAs have their meetings open to the public, you know, so there’s certainly avenues for public to input,” he said.

“I will say that the few that I was at, I was surprised at how few public showed up to these. But I guess it usually takes a burning issue in a community — or a community being large like Regina or a smaller community — that creates interest. And I guess if none of the public are showing up, maybe those issues aren’t quite as burning.”

It remains to be seen just how much input the public will have and the quality of that consultation. It wouldn’t be at all surprising if the government tried to limit this to letters, emails or online forms through a special website.

Broten’s questions then turned to the structure of the regional authorities.

“Are you satisfied with the RHA structure, or is this an area where you see changes occurring over the coming years?” he asked McMorris.

“You know, we don’t have any immediate plans to change the RHAs. Maybe if, you know, after the patient-first review comes back and, you know, they talk about whether there does need to be some structural change, we can have a look at that,” McMorris replied.

“I do know that — and not that this is, you know, this is not a warning to any of the RHAs at all — but every time I look at the map and I see, you know, the different jets and extensions of how the RHAs are formed, it doesn’t make a whole lot of sense as far as transportation patterns.”

McMorris went on to say “I’m not saying that’s what the patient-first review will change that. I’m just kind of musing out loud, when you look at the map there are some, you know, oddities to it. That doesn’t mean that we need to change the number of RHAs or anything else. It’s just a comment that certainly the patient-first review will maybe come back and say we should even just change the way the borders look for better flow. Yes, just for better flow.”

It should be noted that at its annual convention in Feb. 2005, Saskatchewan Party delegates passed a resolution stating a Saskatchewan Party government would create “a single health care agency for the entire province that would fully utilize the province’s health facilities and human resources.”

This was reaffirmed in a June 9, 2005, news release when McMorris, who was then the party’s health critic, said “The Saskatchewan Party wants an audit of the entire health care system to ensure money is being used properly…We also want to establish a single provincial health authority to replace the 13 health regions.

“This would reduce administration, direct precious health care dollars to front line care, and encourage hospitals to work together on solving waiting list problems.”

The Wall government can say it doesn’t have any “immediate plans” to change the RHAs, but that doesn’t mean things won’t change after Dagnone’s final report is released. When asked by CBC reporter Geoff Leo on Oct. 1, 2007, a week before the provincial election, if he would legislate essential service agreements, McMorris said no.

“I don’t think we need to get to legislation, I don’t think we need to go there at all,” he said.

Within a month of winning the election, however, the Saskatchewan Party government turned around and introduced essential services legislation even though it wasn’t in its election platform.

Tossing around words like “unnecessary duplication” “finding efficiencies” “bureaucracy” and “red tape” points to the existence a plan. The Wall government seems convinced there is considerable fat to be trimmed in the health regions.

At its 2008 Annual General Meeting the Saskatchewan Chamber of Commerce passed a resolution urging the provincial government to implement a funding mechanism for health care delivery based on outputs rather than inputs; promote the establishment of a competitive environment for the provision of health care in Saskatchewan; and to fully review recommendations provided by the Saskatchewan Chamber of Commerce with the intent to establish a strategy to develop health care economic opportunities in the province.

It appears a copy of the resolution was sent to Health Minister Don McMorris in a letter dated May 15, 2008.

In his June 27, 2008, response to Saskatchewan Chamber of Commerce president Dale Lemke, McMorris said his government is “prepared to look carefully at a variety of options” and that “The private sector can and does deliver health services effectively within a publicly funded system. This is clearly the case with respect to ambulance and medical laboratory services. We will continue to examine whether there are benefits to further private delivery in publicly funded, publicly administered health services.”

In the article Review for health system (StarPhoenix, July 12, 2008) reporter James Wood revealed for the first time that Tony Gagnone, the former president of Royal University Hospital, was hired to help set the terms of reference for the report in conjunction with consulting firm Deloitte and Touche at a cost the government says it expects to be under $200,000.

In an interview from London, Ont., where he served with the London Health Sciences Centre from 1992 until his retirement in 2005, Dagnone said looking at the heath region structure is not a starting point for the review but if the focus on the patient requires looking at the region model, it will be done.

When asked about private involvement of health support services, Dagnone said the duty of any government is to consider ways to get the best value for its health dollars.

“If there’s a support service out there that one can demonstrate can be delivered differently, why not? Because to me, the core competency of health care is looking after that patient,” he said, adding just because an area is studied doesn't mean changes would necessarily take place.

Dagnone said no decision has been made about whether the review should look at private delivery of direct health-care services, but downplayed the possibility and stressed the government's commitment to medicare.

Dagnone also said the review will look at “high-impact areas” that affect the provision of quality health care.

“That will include looking at some solutions around improving the access to the systems, looking at rejuvenating and building some capacity, looking at new models of care, looking at how best to improve the workplace and we can’t forget looking at some efficiencies,”

According to Wood, “Dagnone expects to make his recommendations on the study’s framework to Health Minister Don McMorris within the next few weeks” and that “He may or may not have a role in the review when it is then launched.”

“The review will include consultation with community leaders, patients and health-care providers. It will likely involve focus groups rather than public meetings.”

Wood’s story is important for a number of reasons, one of which is transparency and the lack of details.

– Dagnone was hired to help the government so there is likely a contact and terms of reference for his services. The government has not released this information. Why?

– Dagnone submitted a report with recommendations on the study’s framework to Health Minister Don McMorris. Where is this report and why has it not been released to the public?

– The consultation process announced so far does not mention the general public. Will the public get to have its say in a meaningful way? If not, why? McMorris told the human services committee on May 5 that the public would be included.

– With the terms of reference for the review apparently complete why have they not been released in their entirety?

In a follow-up article by James Wood on July 26, 2008, McMorris confirmed “that the government is open to looking at an increased private role in health care as part of its “patient-first review” of the health system.”

“I don’t think we’re going to be opposed to them looking at, you know, areas we can find efficiencies in. And if it is around governance, if it is around contracting-out, I need to know that,” said McMorris, who noted that there are other factors that have to be considered beyond “pure dollars and cents.”

“I’m not afraid to have any review look at that kind of stuff. Then it would be up to government to see if we want to move in that direction. Certainly we’re looking for the best information to make the best system.”

When asked about whether the review will extend to looking at the potential of private delivery of actual health services, McMorris did not rule it out.

“The question is not whether there should be private delivery within the health system. There already is. It’s to what extent? There are arguments on both sides of that. In some areas, it makes sense and there are some efficiencies to be found. In other areas there aren’t,” said McMorris.

McMorris also said the government wants to “move as much money to front-line care and make sure we’re as administratively lean as possible.” [McMorris looks at more private care (Leader-Post, July 26, 2008)]

McMorris’s comments, past and present, seem to suggest that some privatization of services is a given and that arguments against it have already been dismissed; and that the restructuring of regional health authorities, including job loss, is inevitable.

It’s interesting to note that, at one time, Tony Dagnone was not a supporter of regional health authorities – at least not the kind in Saskatchewan.

On Apr. 18, 1997, Dagnone spoke at a lunch meeting of the North Saskatoon Business Association and indicated he was happy that Ontario’s Tory government had rejected the Saskatchewan model of regional, partially elected health boards.

According to StarPhoenix business editor Murray Lyons, Dagnone, president and chief executive officer of London Health Sciences Centre, left Saskatoon and his post as president of Royal University Hospital just as the NDP government was adopting the regional model.

Keeping hospital governance in the hands of volunteer boards gives communities direct influence in health care decisions, Dagnone told the audience.

“I do not believe that appointing people by government or electing people into those positions is necessarily the best solution,” he said, noting Ontario Premier Mike Harris had praised the volunteer boards running hospitals.

“Hospitals are very, very important community resources. They’re big, big businesses,” he said later in an interview. “To run big businesses, especially if it’s a business that has to do with looking after the health of the community, you need the very, very best people.”

Instead of regional health authorities, the province appointed a health services restructuring committee which is “the hammer” to force change in the communities.

Long before the announcement by the Harris government that hospitals would close, health administrators in London got together to merge hospitals and services.

Dagnone’s facility was created through the amalgamation of the university hospital and the two other hospitals. A merger negotiated in 30 days during 1995 put the three hospitals and two family practice sites under a single administration. [Ex.-Sask. health administrator lauds volunteer health boards (StarPhoenix, Apr. 19, 1997)]

Does Dagnone still hold these views? If so, should we expect his report to include it?

Recent comments by Premier Brad Wall suggest that Dagnone’s review might not be as independent as we think.

In a question and answer session with StarPhoenix reporter James Wood on Nov. 5, Wall was asked if his government had given any thought to including ambulance service with health-care coverage. At present it’s not covered and can be expensive, especially in rural areas.

Wall replied that the patient-first review is “going to look at ambulatory care.”

“There are some innovative things government can do on the ambulance side of things and we’re looking at those and, again, I think we will see more as a result of the patient-first review, more recommendations on that.” [Glad you asked: Premier Wall answers your questions (StarPhoenix, Nov. 8, 2008)]

So according to Wall it’s already been established that the study will include recommendations regarding ambulance service.

The Saskatchewan Party Policy Book, by the way, states that a Saskatchewan Party government will create “a centrally dispatched EMS system to coordinate the delivery of EMS services (air and ground) province-wide” and reorganize “provincial EMS to include emergency fixed and rotary wing service in partnership with the STARS program in Alberta.”

Whether these are good ideas or not isn’t the point. It’s the integrity of the review process that’s at stake. It’s barely started and already the outcome of several issues seems to have been pre-determined. If that’s the case then what else is there that the public hasn’t been told?

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