The Decibel - What’s behind the shakeup of Alberta’s health care system

Episode Date: November 22, 2023

The Alberta government has been announcing several changes coming to the province’s health care – including dismantling the health authority, and putting more decision-making and responsibility into the hands of government.Today, The Globe’s health columnist Andre Picard explains what changes are being proposed, and why he thinks they might not fix the longstanding issues in Alberta’s health care – and could lead to other problems for the province.Questions? Comments? Ideas? Email us at [e-mail]

Welcome to a new day for health care in Alberta. From the very beginning of our government's mandate, improving health care at every level has been the top of our list of priorities. And with delays affecting the whole system, the urgency of the challenge can't be overstated. Alberta's Premier Danielle Smith has been announcing a slew of changes her government wants to make to the province's health care. The current health system in our province limits government's ability to provide system-wide

oversight on behalf of the people of Alberta. The current Alberta health care system is one that has forgotten who should be at the centre of its existence, patients and the health care experts who look after them. A common theme among the changes would put more power and responsibility into the hands of politicians and away from public health officials. This has been an issue for Premier Smith since the days of mask mandates and vaccine requirements during the pandemic. So today, we're talking to Andre Picard, the Globe's health columnist. He'll explain what changes the Alberta government is proposing and why he thinks they might not fix the issues in the province's health care, and in fact could lead to other problems for Alberta and the rest of Canada.

I'm Mainika Raman-Wilms and this is The Decibel from the Globe and Mail. Andre, thank you so much for being here. Thank you for having me. I think before we talk about what's being done in Alberta, Andre, let's actually talk about why this is happening. So why has the Alberta government said it is making or wanting to make these changes around health care? I think there's two reasons. One is governments are all struggling with health care. It's in big trouble.

Nobody has a doctor. The ERs are overcrowded, et cetera. So everybody wants to do something. And the easy thing to do is to restructure. We have a tradition of doing this in Canada. Everybody restructures all the time rather than deal with fundamental issues. So that's number one. And number two, I think, is more political. It's sort of a revenge factor.

You know, Premier Danielle Smith has made no secret of the fact that she doesn't like Alberta health services for a whole number of reasons. And this is her opportunity to dismantle it and put her mark on the health system. And we're definitely going to get into the political stuff. But I guess let's talk about this idea of restructuring. And that comes from issues in health care. So what are the issues specifically that Alberta has been facing here? Alberta has the same problems as everyone. We have a real problem hanging on to workers.

There's an inadequate number of doctors, nurses, et cetera, or maybe not an inadequate number, but they don't have the time. They're burned out. So it's a real severe labor shortage. That's the number one issue in healthcare everywhere today, and Alberta's no exception. The other big problem is access. So Canadians have, you know, so-called free healthcare, but we really have access problems. 6.5 million Canadians without a doctor, very long wait times for emergency services, a lot of ERs closing, really long waits for surgery, for access to things like

mental health, it can literally be years to access. So access, access, access is the big, big problem in Canada today. What about the province's health authority? So Alberta Health Services, which we mentioned already, what are some of the problems with Alberta Health Services as it exists now, even before the proposed changes that the government is putting on the table? Well, first I'll say there's no perfect health system. Every health system has its problems. So we go through this notion of should we be regionalized, should we be centralized? So AHS is centralized.

So when you have a big centralized institution, you know, that has problems. It has a lot of employees, it's bureaucratic, it's slow, a lot of people feel ignored, especially in the regions. And that's who votes for the UCP, they're really heavy on the rural and remote. So they don't like AHS, they feel it's sort of in the capital, it ignores them, etc. So it has sort of all the normal problems of a big business. And then some, because it has the politics of healthcare. So yeah, so it sounds like so Alberta has one agency for the entire province, whereas it's

different in a province like BC, right? So they have regional agencies. So like Vancouver Coastal, Fraser Health, those are different kind of regional agencies. Yeah, they've gone the regionalization route. So, you know, BC is quite clear. Each region has its authority, health authority. They have an independent agency for Indigenous health, which is unique to BC, which is very successful. So yeah, the lines are very clear in a province like BC or New Brunswick, etc. It's all about geography. It's not about services, which is the way Alberta is going. Let's actually talk about some of the changes that are being proposed now in Alberta. Let's start with the restructuring of Alberta Health Services. What exactly is the Alberta

government proposing here? Well, it's doing something very different. As I said, we've gone to regionalization, deregionalization in every province for years, they're doing something completely different. They're breaking it down into four pieces. So acute care, continuing care, primary care, and mental health and addictions. So it's going to be by service rather than region. So that's interesting. And then those four sections or networks, whatever they're going to call them, are going to report to an integration council, which is sort of the centralized bureaucracy, the decision making, but it's going to rest with the health minister and the premier. It's not going to be independent. So these are big, big changes, very different from what any other region has done. What does that mean for the average person in Alberta? Like, what would it be like getting

a family doctor? If you need to see a psychologist, go to the hospital? What would change? I think the short answer is we don't know. I don't think ultimately structure matters a lot to people. You don't notice. This is a lot of changing of the plaques on the doors when you regionalize and deregionalize, and people don't notice that.

What will make a difference is, for example, if the primary care network, the premier promised that every Albertan is going to have a family doctor. So if the primary care network can do that, patients will see the difference. But that promise gets made every election by every politician, and we don't follow through on it. So I'm not sure that changing the structure will automatically tackle those big issues. Now, the concern with this, breaking it by service, is what happens to complex patients? And there's a lot of them.

What happens if you have an acute care problem? So you fall down in your home, you're an elderly woman, you fall down in your home, but you actually have mental health problems, and maybe you're suffering from dementia. That's why you fell and you live in a nursing home. So you're in these four sections. Who's going to take care of you? Now, the government says nothing will change. You know, patients will still get the continuum of care, but how will they split it up?

And the other question about the four networks is how are you going to have less bureaucracy if you have four times as many structures as you have now? So that's, again, an unanswered question. Yeah. I mean, this sounds like a pretty major change for the province. And of course, when we talk about health care, the cost of things is always front and center. So do we have any sense of how much these kind of changes would cost the province? Well, the government has budgeted $85 million, which is, you know, really peanuts. But, you know, it depends on what you say costs money. So the last time they did one of these big overhauls, 2008, they said that cost $87 million. But it didn't cost $87 million, it cost billions of dollars because the entire province's health system was rejigged. The last time was quite a dramatic one in 2008. They

essentially told everyone they had to reapply for their jobs. So just that structure, the HR investment in that was millions and millions of dollars. So it depends, you know, if it's just strictly on the moving of furniture and making new plaques, maybe it'll cost $85 million. All right, let's talk about some of the politics here. We'll come back to kind of the structure ideas in a bit, but I really want to touch on the second point that you made off the top, Andre. So the Alberta government has proposed putting more decision-making around health care policy into the hands of government.

So what exactly have we seen there? Well, it's really this integration council. It's about giving power to politicians to have the final say. And this is quite related to COVID. This is all about politicians. The UCP in particular felt that they just didn't have enough say, that public health was too vocal, that they had too much power. This is about the emasculation of health leadership. We wanted to have a political, politicians to have the final say. So that's what this is about ultimately. I guess what powers does the health authority have now that would potentially maybe be in the hands of government if this proposal were to go through?

Well, you know, the AHS theoretically is an agency that runs the health system. So they can decide we're going to have more harm reduction services. We're going to have more psychiatric hospitals. We're going to close hospitals in rural areas. These are all things that are unpopular with some people. And the politicians could override that. Now, today, they can actually do it. But it's a little more uncomfortable because it's kind of stepping on people's toes. It's going over the authority. Now it's going to be formalized. It's going to be,

oh, we have the final say. There's not going to make a decision before us. So it's a subtle shift, but I think an important one. And there was also another change announced that the cabinet would now have the final say in emergency orders. This is a proposed change, right? Can you explain what that would be, Andre? Yeah, so ultimately governments have to have the final say, but public health has to be able to act quickly. You know, the so-called lockdowns, you know, we order that all restaurants close, that schools will be closed for X number of weeks,

those kind of orders. But they're not just about infectious disease. There could be a flood. You can order the evacuation of a town if there's a fire. But there's been some litigation about this. Do governments have to sign the final order, et cetera? So this is a bit up in the air, but I think it's about centralizing power with government again. The government, again, wants to have the final say on everything. Okay. Yeah. In addition to these changes being proposed by the government, there's also this recent report that Alberta was looking at, basically how the Alberta government handled

things during the pandemic and what should change maybe in the future. So this was headed by former politician Preston Manning. He's a big name out there. He used to be the leader of the Reform Party. So can you just walk me through some of the recommendations and comments in this report, Andre? Well, you know, a lot of this is just a review of how things like emergency orders were handled. It's sort of a pretty dense report. But I think what's important about it is the overall philosophy, this philosophy of individual rights are paramount, collective rights are not so important. It says that we should operate on this notion that everyone's constitutional rights are going to be infringed if government does anything. So it's

kind of an anti-government document, which again fits into that philosophy. But I think that's kind of disturbing, this notion that we should do nothing. That's what I take from the report. Hmm. Yeah. There's also a really interesting part of that report that I know stuck out to us when we were reading it about how government should consider, quote, alternative scientific narratives. I guess, can you speak to that as well? Because that sounds like a big deal. Yeah. So that's another one. You know, the report is saying we shouldn't just listen to, you know, expert scientists.

Everybody should have a say. So it's, again, back to individualism because freedom is paramount. So we've talked about a whole bunch of things here, Andre, I guess, how likely are these changes to fix the issues that we've seen in Alberta's healthcare? I don't think there's no magical fix, whether it's in Alberta or Ontario, nobody has a magical fix to our big problem, which is the labor issue. I think we have to give them, to a certain extent, the benefit of the doubt. They're trying something different. I'm not sure that this dramatic change is necessary or useful at this point. Take primary care, for example.

Everybody getting a doctor, that's really important. That should be a priority. But as I wrote in my column, why didn't we just tell the AHS to do that? The government can say, make this a priority. Do it. Do you have to create a whole new network and agency to give them that job? You know, Alberta has a lot of great things. It probably has the best infrastructure of any province.

It has fabulous institutions, hospitals. It has the best pay. It has tremendous IT, much better than any province. It does a lot of things really well. And why aren't you bolstering that while you're just fiddling around with the structure? We'll be back in a lot of these things. I guess, what are the issues that you see, Andrei, with politicians being involved in health care in that way? Yeah, I think it's the biggest problem we have today is this micromanagement by politicians. The best health systems in the

world, which are in the European countries, Nordic countries, they have this independence. So the politicians set the philosophy. I always come back to this. Everyone should have a family doctor. So that's a philosophy that it should be a government policy. But then you let the experts do it. That's how healthcare should operate. It should operate essentially like a business. And I don't mean that as a profit-making business, but it should just be doing, it should have tasks and it should carry them out. But in Canada, we have this continuous meddling by politicians. There's a story on the front page of the Globe about a kid who can't get a drug. Well, the minister is all over that. And the minister shouldn't be all over that. The minister should say that's the job of the health system. Alberta's getting a lot of attention, again, because the politics are a bit different, but everyone's

doing this to varying degrees. Alberta's a good example. They had an independent AHS. The Alberta Health Services was technically an independent agency. But then the government, when it doesn't like what AHS is doing, it fires the board. Yeah, which they did last year, right? They fired the board of the AHS. Yeah, last year they fired the whole board. Last week they fired the senior executives of AHS. So it's a falsehood.

You pretend it's independent and you interfere. So in Canada, that's how the health system runs, unfortunately. So it's a falsehood. You know, you pretend it's independent and you interfere. So in Canada, that's how the health system runs, unfortunately. The main role of a health minister is to make sure that the government doesn't look bad on the news. I use the example of a fire. You have to evacuate a town. You want to do it immediately. That's what the public health office says.

We're getting out in three hours. Everybody has to go. What if a politician has to make that decision? Oh, how's this going to affect my reelection? What about so-and-so's business? Who's my buddy who contributed to my campaign? All this other junk comes in and interferes with tough decisions. I want to ask you about the other side of this, though, Andre, because is because is there maybe an argument here that politicians should be the final voice on these big decisions, like whether to close schools during a pandemic or requirement for vaccination? Because, of course, these are people who are elected and are accountable to the public, whereas public health officials are not. So is there an argument there? There's definitely an argument. You know,

politicians shouldn't be entirely on the sidelines, especially with political issues like shutdowns, you know, emergency measures. But I think the issue for me is you have to be able to take advice from experts and you have to be able to say, I don't know everything. You know, the cabinet of the Alberta government does not have expertise in public health, in managing a pandemic. I don't think anyone is saying politicians have no say. They have to have the ultimate say. But I think it's the differences between setting policy, saying what the values are you want implemented. That's very different from meddling in day-to-day operations.

And that's what we don't want. We don't want them deciding, you know, what vaccine you should be getting, for example. That's not their lane. So set policy, absolutely, have the final say, but don't meddle in the day-to-day. Throughout the pandemic, and particularly in Alberta, I can say, I think, we've seen public health officials really bear the brunt of decisions around masking, vaccines, lockdowns. Many of them received, you know, a lot of criticism and frankly, a lot of hate too, right? So what are the consequences of these health officials taking the blame for public health measures like that? Yeah, it's very hard on them, you know, and it wasn't just in Alberta. Alberta was particularly vocal, I think. And the government played into it was a problem, right? They were critical of the chief medical health officer, Dina Hinshaw, she was fired eventually, you know, she got blamed for everything. But you know, when you undermine someone whose job is essentially to look out

for the collectivity rather than individuals, you know, when you undermine that, I think it harms the entire society. So we've talked a lot about Alberta. Could we see this type of shift happening elsewhere in Canada too? Oh, I think so. I think, you know, this is a viewpoint, a worldview of conservative governments, not progressive conservative governments as we've traditionally had in Canada, but sort of the UCP type. Pierre Poliev has very much this dialogue about, you know, individual rights, freedom. You know, the irony is they say, get government out of your life, but they want to give government more power. They want to give politicians more power and not

government. Before I let you go, Andre, we've talked about a lot of things here, but I guess, what does this all mean for public health in Canada? You know, especially if another health crisis happens. Well, you know, public health lives this eternal paradox. Public health is invisible when it's working. And it's always unpopular because it restricts people, right? It's about restrictions for the greater good. And eventually everybody gets tired of that. So this is a perpetual, centuries-long issue with public health.

And it'll survive. It'll have some tough years. I think there are some dark years ahead for public health, but then something bad is going to happen. We're going to see its value. You know, we see this cycle continually. We had SARS in 2004. It was an economic disaster. We've understood the value of public health.

Then things were going tickety-boo for a long time. So what do we do? Well, we stopped funding public health. We've understood the value of public health. Then things were going tickety-boo for a long time. So what do we do? Well, we stopped funding public health. We forgot them. Then COVID came along. We put a massive amount of money, emergency money into public health. They did great work. The pandemic's more or less over in the public's mind. Well, so let's toss public health out. We don't need them anymore. It's sort of an eternal cycle. So I think it'll be back. I just hope we don't have to pay

too big a price for their return. Andre, thank you so much for taking the time to speak with me today. Thank you. That's it for today. I'm Mainika Raman-Wells. Our producers are Madeline White, Cheryl Sutherland,

and Rachel Levy-McLaughlin. David Crosby edits the show. Adrian Chung is our senior producer, and Angela Pachenza is our executive editor. Thanks so much for listening, and I'll talk to you tomorrow.