The Winnipeg Regional Health Authority was established in the mid-1990s and it has grown into a massive, complex bureaucracy.
Its budget is approaching $3 billion. Its many activities range from operating a central laundry to establishing standards while operating a multitude of regional programs, funding all hospitals, and operating some hospitals (including the Health Sciences Centre). The regional concept is not unique to Winnipeg nor Manitoba, although the form it takes and the role it plays can be very different in different places.
The WRHA has changed dramatically since its inception and the question is: is the form it has evolved into the most effective model for delivering health-care services? In the case of Winnipeg’s hospitals, some devolved, meaning they are both funded and operated by the WRHA while some (such as St. Boniface and Concordia) are just funded by the WRHA. In the case of regional programs, these are specific programs funded and operated by WRHA but, in many instances, are delivered through the hospitals or other health-care institutions.
In the case of devolved hospitals, there is perceived and/or real conflict of interest in a number of areas, including transparency, responsibility, and accountability. For example, are both the devolved and non-devolved hospitals treated the same in terms of resource allocation and are initiatives proposed by the administration of a devolved hospital treated the same as those proposed by a non-devolved hospital? We have no experience indicating they are treated differently, however, this model is structurally unsound and contains the potential for ethical and financial conflict.
Many WRHA programs are delivered through the hospitals and other institutions. This matrix structure results in the WRHA personnel responsible for delivering the programs being embedded in the hospital or other institution. For example, a person in charge of a regional program in a hospital is not an employee of the hospital but rather an employee of the WRHA. Once again, this presents a potential for conflict and puts the individual and the hospital in a difficult position when there are differences between the program goals of the WRHA and the goals, operating procedures, budget constraints, and accountability framework of the hospital.
Our concern for these issues is not without independent corroboration. In 2013, the WRHA commissioned the University of Ottawa Heart Institute to conduct an evaluation of the WRHA’s cardiac science program.
The report (released in December 2014) comments extensively on the governance of the program: “The cardiac science program operates within a complex and multisystem level, decision-making structure… This unique governance structure presents a certain number of challenges… The cardiac science program seems to be integrated in a complex matrix, i.e. being accountable at several levels… The governance structure leads to dysfunctional lines of authority and accountability.”
We believe these criticisms apply to most, if not all WRHA programs, as they are all structured similarly to the cardiac science program.
How can the WRHA be restructured or what other models offer a means of improving health-care delivery?
We believe that in order to create incentives for hospital administrators to strive for continuous improvement and focus on patient outcomes, some fundamental changes need to be made.
The first would be to adopt activity-based funding (ABF), eliminating the current global funding model. The activity-based funding model is successful in Europe. Under ABF, funding is based on the type, volume and quality of the service provided.
The second step, which should be implemented in conjunction with the first, would be to separate the purchaser and the regulator (the WRHA and the government), from the service providers (hospitals, programs, and other health-care institutions). The WRHA would not operate any hospitals or programs. Think of the WRHA performing a role similar to the Manitoba Public Insurance Corp. — purchasing health-care services from arm’s-length providers on a contract basis. This purchaser/provider split has worked well in many European countries, which spend less but have better patient outcomes than Manitoba does.
We believe it is time to gore the sacred cow and look at these and other models to improve health-care delivery, make it more sustainable and improve patient outcomes. Manitobans deserve it.
Originally published in the Winnipeg Free Press, April 13, 2016
Wayne Anderson is chair of the Frontier Centre for Public Policy. He is past chairman of the board of St. Boniface General Hospital. He wrote this in co-operation with Dal McCloy, past chairman of Riverview Health Centre, and Judith Scanlan, R.N., PhD, past secretary of St. Boniface hospital’s board.