Healthcare reform in Saskatchewan in the 1990s: Lessons from the Minister of Health

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Canadian Masterclass on Managing a Health System through an Economic Downturn …

Canadian Masterclass on Managing a Health System through an Economic Downturn
(Louise Simard)

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  • necessary health services no longer rationed on ability to pay
  • intended to make access to insured hospital and physician services reasonably equal across the country reduced federal cost-sharing, rising expenditures, recession, mismanagement by government the province was virtually bankrupt, huge public deficit (around $15 billion)
  • cuts to services, incl. healthcare health system revamp, with focus on broader determinants of health  Wellness Model: cost containment, maintenance of standards, improving population health, integration, continuity of care
  • social determinants lens (SES, education, housing, sewer and water quality, etc.) focus was on deficit reduction, not necessarily health reform (e.g. changes to drug plan, cuts to chiropractic services) hospital conversions became negative symbol of health reform
  • Importance of community development building awareness of health reform a powerful way to bring public along with change population health approach required buy-in from many partners: district boards, governments (local and provincial), educational programs, health care professionals, individuals, communities and families
  • -reform needs a champion - the individual minister needs to be interested and motivated; -the stage needs to be set so that there is a readiness amongst the general public and stakeholders to accept change (fiscal situation - set the stage); -reform needs to be launched early in a government’s mandate; -there needs to be a body of research that supports the change (many commissions had discussed the need for reform); -a vision and the goals must be clearly defined, and compelling; -the vision needs to offer hope in order to make the tough measures that will be required more palatable; -stakeholders (including unions) should be involved in the development of the vision and goals, and in the development of the strategic plan for implementation; -once defined, the vision needs to be communicated to a larger audience - the public; -steps for implementation need to be set out with clear deadlines for accomplishing the various steps. It was also helpful to have materials advising and guiding the implementers through the various steps of implementation; -if significant change is required the strategic implementation must be bold and go beyond small steps of no real significance in themselves; -public opinion leaders need to be part of the process - they should be encouraged to hop on the bus; -the plan needs to be flexible - if changed is required - it is a two-way process. The government needs to be open to advice and willing to nurture non-threatening dialogue to explore options with those who would be affected by change and to implement their suggestions where appropriate; -there needs to be critical management of issues as they arise or preferably issues should be anticipated and dealt with before they become an issue; -the consistency of the message needs to be maintained.
  • Numbers of general practitioners/family physicians and specialists increased in SK between 1996 and 2000 Supply of GPs/FPs in SK is under the Canadian rate (91 per 100,000 population compared to 94). SK has significantly fewer specialists (62 versus 93 per 100,000 population)

Transcript

  • 1. HEALTHCARE REFORM IN SASKATCHEWAN IN THE 1990s: LESSONS FROM THE MINISTER OF HEALTH Louise Simard Minister of Health, Saskatchewan (1991 – 1995)
  • 2. THE CONTEXT
    • 1962: Saskatchewan birthplace of medicare in Canada
      • publicly funded/administered, universal access
  • 3. THE CONTEXT
    • Federal government was financing about 55% of healthcare costs; contributions reduced in late 70s/early 80s
    • 1984: Canada Health Act
    • 1991: A perfect storm for Saskatchewan
  • 4. THE CONTEXT
    • First priority: get deficit under control
    • Second priority: revamp healthcare
      • Stakeholders recognized need
      • Many commissions (e.g. Murray Commission)
        • Wellness Model
  • 5. FORMING GOVERNMENT
    • Oct. 1991: Social democrats form government
      • dramatic action taken, reverberates through province
      • large “umbrella boards” in Saskatoon and Regina
  • 6. MANAGING REFORM
    • Over 400 boards collapsed into 30
    • Strategic approach to community involvement
      • public consultation and stakeholder buy-in essential
    • Social determinants lens
    • Provincial Health Council, Utilization Commission established
  • 7. MANAGING REFORM
    • Two competing goals
      • deficit reduction, not reform per se
      • focus on revamping healthcare system and population health
    • Announcements of hospital conversions and cuts to services posed political challenges
  • 8. TWO STAGES OF THE REFORM PROCESS
    • Reorganization of the governance and delivery structures of the health system
    • Reform of service, program and delivery methods
      • long term and evolutionary in nature
      • primary health care, population health goals
      • community involvement, control over system
      • increased coordination, integration of services
  • 9. CUTS TO SERVICES
    • Early 1992: provincial government set stage for significant cuts, 3.3%
      • community-based services spared
      • hospital, physician, optometric, chiropractic and prescription drug funding decreased
    • 3.3% cut felt more like a 10% cut, since growth in healthcare spending had been escalating annually by at least 7%
  • 10. HOSPITAL CONVERSIONS
    • 1993: Government sought further savings
      • closure (conversion) of acute care beds in 52 rural hospitals
        • converted to health centres, which would deliver more appropriate services
        • even after conversions, beds per capita higher than in most provinces
  • 11. HOSPITAL CONVERSIONS
    • public outcry and disapproval of new policies
      • Important to
        • face the people and explain policies
        • set deadlines
        • develop strategy to cope
      • Implementation of guidelines, first-responder system, labour adjustment strategy, rural initiatives fund, trial runs
  • 12. DISTRICTS
    • Aug. 1993: deadline to establish District and set requirements
      • “ A Guide to Core Services for Saskatchewan Health Districts”
        • outlined basic services expected to be provide in the short term, and services that would eventually be transferred from government
      • all 30 districts established and rural hospitals converted as planned
        • day of conversions, non-issue in media
        • lower mortality
  • 13. MORE REFORM INITIATIVES
    • Over the next two years more and more initiatives were undertaken to accommodate health reform
  • 14. HEALTH HUMAN RESOURCES
    • Restructured provincial health sector bargaining units (The Dorsey Commission)
      • 500 bargaining units and 21 collective agreements in health sector prior to reform
      • 35 bargaining units and 6 collective agreements in health sector after reform
    • Labour reorganization removed the final barrier to integrated health services delivery
  • 15. REFLECTIONS
    • Ingredients for successful change management
  • 16. REFLECTIONS
    • 30 years later, reform structure in place, but still evolving
    • Review of the reform (the Fyke Commission)
      • less health regions,
      • another round of restructuring
    • Population health focus
      • improved, but much more to be done
  • 17. REFLECTIONS
    • Patient First Review (the Dagnone Commission)
      • focus on patient- and family-centred care
  • 18. HEALTH OUTCOMES
    • Perceived very good or excellent health status of SK people stable from 1994 to 2007
    • Infant mortality rates declined in SK and Canada from 1991 to 2007
    • Life expectancy at birth and at age 65 have been steadily increasing in SK
      • Rates are similar in SK and Canada, with slightly higher rates in Canada
  • 19. RESOURCE USE
    • While the number of physician visits dropped by 17% between 1991-92 and 2000-02, the number of prescriptions filled increased by 31%
    • In 1999, health spending in SK below national average ($2,907 versus $2936)
      • spent less on hospitals, drugs, doctors and other professionals, but more on long-term care and other health expenditures
  • 20. QUESTIONS?