Transcript Regionalization: Does It Matter? - Association of Local Public Health

Regionalization:
Does it matter?
Denise Kouri
HEALNet Regionalization Research Centre
Centre de recherche sur la régionalisation Relais
June 2001
http://www.regionalization.org
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Regionalization Research Centre
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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
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Does regionalization matter?
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Overview of regionalization
Results of regionalization
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Potential for public health?
Key informant survey
Issues and discussion
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Problems with existing system:
Documented in late 1980s
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Fragmentation:
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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
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Year of Regionalization
94
96
94
97
92
93
89
92
Earliest year
96
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What is a regional health
authority (in theory)?
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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.
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# of regional health authorities
9
11
+
4+
17
12
32
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18
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Note: Comparability not strict
?
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Features: Authority & Structure
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Regional, subprovincial boards (+)
Devolution of authority from province
(selective)
Centralization and amalgamation of
local institutions
Affiliation agreements with independent
agencies
Transfer of provincial programs
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Features: Services & Programs
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Single authority responsible for wider range
of programs
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Attention to serving people in a more
coherent way
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Acute care; long-term care; public health;
community health; mental health
Avoiding duplication and multiple entries
More follow up and information
Toward community-based programs
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Breadth of Scope by Province
Institutions
(hospitals and/or nursing homes)
Newfoundland
New Brunswick
Health care
(above, plus services such as home care,
public health and addiction services)
British Columbia
Alberta
Saskatchewan
Manitoba
Nova Scotia
Health and social services
(above, plus community support services
and social assistance)
Quebec
Human services
(above, plus public housing and welfare
services)
Prince Edward
Island
Source: Lomas, 1999
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Relationship to Population health
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Within/for a specific geographic region
Focus on health status as outcome
Attention to social and economic
environments
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Short and long term determinants
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What is the appropriate, coherent region?
Collaboration with non-health agencies
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Whose responsibility is it?
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Problem of authority
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Provincial government speaks “for” RHAs
Targeting of funds by the provincial
government; ad hoc interventions
Reactive deficit solving
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Creation of perverse incentives
“Health boards are legally responsible for things over
which they have insufficient control.”
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Political vulnerability
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Who is more vulnerable to public
pressure:
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Province or RHAs?
Is political interference a fact of life?
Should devolution be complete?
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Getting closer to “the people”
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Boards as authorities
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Saskatchewan and Quebec board members
are elected
Elsewhere, board members are appointed
Issues of representation and
accountability
Public participation
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Quality vs quantity
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Problem of Provider Relationships
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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
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Key Informant Survey, May 2001
Inuvik
Van. North Shore
Saskatoon
Outaouais
Capital (Halifax)
North Okanagan
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Summary: What do you feel are the
positive effects of regionalization?
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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
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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.”
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Outaouais:
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improved the services to population;
improved the integration and coordination of
the services; and
shifted the focus from specific clients to
population.
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E.g. Mental health services
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Now front-line and specialists work together:
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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
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Some specialists did not like change and left.
Now looking at doing this with other groups such
as youth and elderly.
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Public health/promotion?
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Public Health Department was separate before, but
now it is integrated into the RHA.
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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
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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.
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Saskatoon:
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From patient perspective, more
emphasis on
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continuity of care and
being patient-centered.
More awareness throughout the system
of the various parts.
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More inclusive and holistic now
But still missing doctors.
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E.g. Public Health
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Used to be island:
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reported to municipal government
now under health board.
Over time, more joint programs :
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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
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Public health/promotion?
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Taken on physical activity as SDH corporate
activity
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New $ to Community Development
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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.
(hired 3 FTE CD workers)
No new money to public health, but they
have not had cuts, as most other areas
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Vancouver North Shore:
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Integration of services and continuity of
care
Reduced duplication in admin and mgt
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Fewer management positions
Community consultations very positive
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Public health/promotion?
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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.
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Always more to do, but we’ve started. Too
early to say definitively.
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North Okanagan:
Ability to:
 break down barriers between sectors,
services, and programs
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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
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although acute continues to gobble
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Public health/promotion?
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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
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no longer just accountable to prov govt
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Inuvik:
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Allowed for much more planning and a planned
approach to services within a local area.
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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.
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E.g. co-location and multi-disc.
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Community services are co-located with
multiple disciplines and
Regional services are provided by
interdisciplinary teams.
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Public health/promotion?
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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
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e.g., with FAS, doctor decided and steered a
preventive focus. Integrated approach to care
helped with this.
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Halifax:
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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
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“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.”
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Does RHA define its own health goals or
use provincial goals?
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Typically set their own goals with some
consideration of provincial goals
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How do you measure the health impacts or
outcomes of your programs?
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Are evaluating
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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
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Saskatoon and Vancouver using Balanced
Scorecard approach
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Where are we at?
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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?
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Issues:
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Clarity and commitment about authority
Systematic outcomes evaluation
Funding matched to goals
Predictable funding and stability in the
system
Physicians integrated
Organized primary care
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Selected Questions:
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What is the appropriate division of authority?
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What is the trade-off between institutional
integrity and integration of services?
More clarity about what a region is?
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Federal/provincial/regional
What is essence of a region?
Different strategies for rural and urban regions?
What is the relationship between
regionalization and “social capital”?
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