Streamlining the Health Organisation
Healthcare in BC
Why is healthcare to the west of Boundary Road different from that to the east? It’s different because British Columbia has geographic-based health authorities. With a 2023-24 budget of $28B, healthcare in British Columbia is delivered by five geography-based Health Authorities (Fraser, Vancouver Coastal, Vancouver Island, Interior, Northern), a faith-based Health Authority (Providence), a Provincial Health Services Authority, and a Health Authority in a different order of government (First Nations). Healthcare systems and practices in Fraser Health on the east side of Boundary Road are different from those in Vancouver Coastal Health on the west side.
“Unnecessary implementation variation: the same thing done differently by different parts of the same enterprise”
Unnecessary variation in processes within an enterprise is unnecessarily complex and costly. First, more resources are required for redundant policy and standards units. Second, it takes subject matter experts away from client-facing services in order to develop, maintain, and reconcile standards. Capital investments are higher and returns on investment are lower. In our case, we pay extra for Health Authorities to develop different versions of the same thing, pay more to maintain them, and pay yet again to put them together when we need a province-wide, health system view or when healthcare workers or patients move between health authorities. The latter could mean crossing Boundary Road, or crossing over the Granville Street Bridge. The health system spends more and gets less.
Patients deserve the same high standard of care consistent with location and type of facility across the province, and healthcare workers shouldn’t have to know more systems or processes than necessary. A small hospital in Northern BC should offer the same level of care as one in Southern BC. Burnaby General Hospital (Fraser Health) should deliver patient care using the same processes and information system as Lions Gate Hospital (Vancouver Coastal Health). St. Paul’s Hospital (Providence Health) should have the same patient care policies as Vancouver General (Vancouver Coastal Health).
Standardising practices by service and facility size across the health system would improve continuity of patient care across facilities, reduce errors, reduce patient-facing resources required to develop standards, enable staff to move between facilities, and reduce infrastructure costs (purchase, maintenance). Simple is better than complex; one set of processes is better than six. Practice standards would be developed by each service for small, medium, and large acute care facilities. Not all specialised services would be offered in all facilities. Standard practices for an enterprise are like a playbook for a sport, e.g. soccer. Teams with more expertise and better equipment (e.g. 18 yo rep league) run more sophisticated plays from the playbook than those that have less expertise and less equipment (e.g. 12 yo Silver B).
“If you have twice as many managers as required, you receive half the management.” – Law of Bureaucracy Management
“If you have twice as many managers as required, you pay twice as much as necessary.” – Corollary to Law of Bureaucracy Management (Well, duh)
Consolidating provincial health authorities would not only make healthcare more efficient, it would improve and reduce the cost of executive direction, and reduce the cost of support services. Ontario consolidated its health system to create Ontario Health. In BC, this would mean eliminating an unnecessary management layer. Let’s look at the numbers. The ratio of healthcare workforce to total workforce in BC (11%) is in line with that in Ontario (12%). Although BC’s healthcare workforce is about 1/3 that in Ontario, health system executive salary in BC is 4 times that in Ontario.
In 2021, there were 286k healthcare workers in British Columbia comprising about 11% of all employees, and in 2022, there were 929k healthcare workers in Ontario comprising about 12% of all employees (jobbank.gc.ca, 7-Jun-24).
In 2021, total salary for executive leadership in 6 Health Authorities and PHSA in BC was $21.6M (Vancouver Sun Public Sector Salary database, accessed1-Jun-24)
In 2023, total executive salary for Ontario Health was $5.4M (Ontario Sunshine List 2023, accessed 1-Jun-24).
BC has too many executives and too little leadership. Applying the Law of Bureaucracy Management and using Ontario as a benchmark, we’re paying about 12x what we should and receiving 1/12th the management. Ouch! Before we go all Red Wedding (Game of Thrones on HBO) on the executive suite, we’ll need this extra capacity to manage transformation of BC’s health system. As transformation proceeds, we can reduce the executive cadre through retirement, reassignment and attrition, not bloodshed. As resources are freed up, they can be redirected to patient-facing services.
Consolidation makes better use of support services, information, and expertise. We can reduce operating costs and increase return on capital investment by consolidating Finance, Human Resources, IM/IT, and Real Property.
A single organization eliminates information and expertise silos. It is faster to react to novel situations (e.g. pandemics), and faster to adopt new, best practices.
Reorganisation of the health system in BC doesn’t mean upending healthcare services. My experience with reorganisations in the federal government is that consolidation primarily affects executive and senior management. Staff, supervisors and mid-level management are largely unaffected. They continue to report and work as before. The big difference is they spend more time delivering patient care in an efficient, integrated team and less time trying to make things work. More satisfaction and less frustration improves recruitment and retention. Smart people don’t want to work in a stupid system.
Our health system is like a leaky racing shell with 6 coxswains. Rowers spend as much time bailing water as they do rowing, all in different directions, and all with different oars. Adding more rowers helps with the bailing but the boat is still directionless. Athletes train to row, not to bail. Let’s appoint one coxswain (disembark the rest), fix the leak, give them standard oars, have all the rowers pull in one direction, and go for Gold.
We now know where we are. The next post will describe where we want to be, and a roadmap to get there. Consolidating the provincial health authorities is key to transformation. Moving forward with one organisation is faster and easier than moving forward with eight, which is like herding cats. Our transformation project has the following elements, including one quick win for primary care:
Performance Measures and Improved Accountability to Patients and Healthcare Workers
Improving Primary Care with improved Information Management
A New Day in Primary Care (story)
Streamlining the Health Organisation
Putting the Pieces Together (story)
greg
Enterprise Coach