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1
Regionalization:Does it matter?
Denise KouriHEALNet Regionalization Research CentreCentre de recherche sur la régionalisation
RelaisJune 2001
http://www.regionalization.org
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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
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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
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8992
92
93
94
94
96
96
97
Year of Regionalization
Earliest year
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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.
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321817
11+ 12
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5
4+
?
9
# of regional health authorities
Note: Comparability not strict
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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
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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
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Breadth of Scope by ProvinceInstitutions(hospitals and/or nursing homes)
NewfoundlandNew Brunswick
Health care(above, plus services such as home care,public health and addiction services)
British ColumbiaAlbertaSaskatchewanManitobaNova Scotia
Health and social services(above, plus community support servicesand social assistance)
Quebec
Human services(above, plus public housing and welfareservices)
Prince EdwardIsland
Source: Lomas, 1999
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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?
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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
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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
InuvikInuvik
Van. North ShoreVan. North Shore
North OkanaganNorth Okanagan
SaskatoonSaskatoonCapital (Halifax)Capital (Halifax)
OutaouaisOutaouais
Key Informant Survey, May 2001
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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
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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.”
19
Outaouais:
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 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.
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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
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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
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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”?