Corporate Healthcare: Amalgamating Health Regions

By Gerrit Van Wyk.

T. Rex healthcare.

The Tyrannosaurus Rex was a large dinosaur living in North America about 60 million years ago, after which it went extinct because it couldn’t adapt. The fossil of Scotty, reportedly the largest T. Rex found, was discovered in Saskatchewan, Canada, in 1991.

About seven years ago, one of the provinces in Canada appointed a panel with the mandate, or requirement, to report on reducing the number of its health regions, to improve patient care make administration more efficient, consolidate clinical and support services, review legislation to re-establish the role of Boards, and identify ways to manage information to improve the management of healthcare performance. The province wanted Scotty to come to healthcare.

To Goffman, human social activity is like drama productions; dramas are scripted, and performed by actors, to an audience, with a lot of preparation going on offstage behind the scenes. The panel was part of such a drama performed for the general public, who couldn’t know who wrote the script, and about the conversations and history in the background leading up to the drama. Note the province decided ahead of time on the script, or what it wanted to change, the role of the panel was to tell them how to do it, not question the decision, and to perform it in such a way the story is plausible to the audience, or voters. The actors were chosen carefully, and, ironically, two were Board members, metaphorically turkeys voting for Thanksgiving.

Kurt Vonnegut showed most stories follow a few story-lines, and in this case the melodrama was according to the lines of: more change was needed in healthcare, shortly after a previous convulsion of change petered out, the esteemed panel would surprise us with their answer, after which our health system will be saved, and we’ll live happily ever after.

When someone, in this case the government, says what it wants, what it doesn’t want lurks behind it. In this case the problem, according to government, was administration of the health regions was inefficient and patient care was terrible, the Boards appointed by the government refused to march to its orders and had to go, and healthcare performed poorly. The solution was a single Board directly accountable to the Minister of Health, giving orders to a single CEO, and the Minister giving orders to the Ministry of Health on how to plan for and structure the Scotty. In short, politically it was about control.

The health regionalization craze emerged from Canada’s financial crisis in the 1990’s. In theory, following economic dogma, it would help contain healthcare costs and make healthcare delivery more effective by using economies of scale, but in practice it was implemented only partially, and predictably failed in its lofty aspirations. According to governments, it failed because it was a bad idea, not because governments miserably failed to implement it properly, hence what was needed is more of the same, but bigger and better. Which will fail for the same reasons smaller failed.

The first and biggest problem is the emphasis is on cost, with efficiency and quality tacked on by enthusiasts of that genre. Healthcare demand is infinite, hence containing costs to fix a leaky bucket will always fail; you need to look at solving the cost issue differently. Economically, healthcare in Canada is a monopoly with no competitors, competition, including amongst healthcare workers, is prevented by law, and the only product substitute is unregulated alternative care. To think under these conditions economic principles will work to drive down cost is not credible.

The efficiency, quality, and evidence-based management ideologies came to healthcare via industry, and triggered vast armies of experts, consultants, managers, etc., with plans to implement and drive it. More than 20 years later there is no evidence it made any difference.

In most armies, orders come from the top of a command pyramid following strict lines of communication to give the generals control, which eliminates creativity and innovation on the ground. As Kipling wrote, yours is not to wonder why, yours is just to do or die. Many such armies shine brilliantly on march-by parades, but often fail during the first moments of battle, because its ability to adapt is gutted. The T. Rex health region is designed according to similar principles, and its first test was the COVID-19 pandemic. Before it finished, several senior leaders quit without giving reasons, or, perhaps, were ordered not to. It’s not difficult to connect the dots. Like failed battles, it left casualties on the battlefield.

A second and equally big problem is politicians, in keeping with the unstated Western mindset that reality and our social world can be controlled by brilliance and force of mind, are divorced from a reality that is complex, and therefore difficult to impossible to control. Politicians don’t think up big ideas, they are influenced by people selling simplistic solutions to complex problems, and they are petrified of the uncertain and unknown. Until we change our thinking and approach, we’ll keep flitting like butterflies from one pretty flower to the next.

Which bleeds into the next problem; humans are social beings at a staggering level of complexity, and if you don’t understand and manage that complexity, you are bound to repeatedly fail, a lesson politicians, bureaucrats, and planners seem incapable of learning. An army capable of innovating and adapting on the fly is more likely to succeed in the field than one centrally controlled. Healthcare could learn much from that. The role of leadership is not micromanaging, it is to empower people and give them the resources to get on with things.

The reason previous health regions floundered is not because it was a bad idea, it was because governments never trusted them to democratically govern themselves. Instead, Boards were political appointments, with budgets and providers managed centrally, which was a recipe for disaster. The fearsome T. Rex became extinct because it couldn’t adapt. The nimble small mammals who could respond and adapt to change did. Centralizing health regions for more control is a bad idea, and will one day be on display in the museum next to Scotty.

Postscript. The poster child for transforming into a single health region was another province, who recently announced it will go in the opposite direction. The report mentions the costs savings and efficiencies the T. Rex model was supposed to bring about, predictably, never materialized. The catastrophe is not the failure and disassembly of this model, it is in how it is to be done. Instead of acknowledging healthcare and healthcare practice looks like a complex interrelated system, the province will break up the T. Rex system into new silos with more political oversight. That model is another dinosaur skeleton in a museum, and doomed to fail as well. Instead of rummaging around the bones in museums for lessons and failures of the past, we need to boldly go where no-one went before; healthcare and healthcare practice is a complex interrelated system, accept that and change accordingly.