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Saturday, November 27, 2010

Do We Need the AHS Super Board?

The media report on the “fracturing” of the Alberta Health Services Super Board is focused on the current and possible future resignations of board members.  This is fallout from the Dr. Duckett contract decision is a crisis of confidence about the AHS Board and by the Board itself I expect.  That crisis in confidence cuts both ways and is partly due to a failure of effective governance.  There needs to be clarity of roles and responsibilities of the various boards the Government of Alberta and the AHS Super Board in particular.

Ron Liepert is being blamed by the public for much of this current crisis of confidence in our health care system.  He was the political push to unilaterally and hastily disband the regional governance model in favour of a single Super Board system.  The goal was cost savings but a lot of good work and service capacity was lost in the process, especially in the Capital Region.  There was another political goal, the solving of the chronic overspending of the Calgary regional board. 

So rather than solving the “Calgary problem” and risk looking like Stelmach was punishing or picking on Calgary, the Ministry “leadership” changed to Ron Liepert, a Calgarian to solve the problem.  Overnight, without warning, consultation or concern for greater consequences, Liepert unilaterally changed the entire provincial health care governance structure.  The dismantling of the regional governance structure into one centralized appointed governance model delegated to deliver health care was established. That was the planted seed that has lead us to the current health care governance, emergency room crisis and overall systemic disarray that is now province wide.

So let’s look at the current Super Board situation in context.  Liepert created this centralized governance structure, selected and recommended the appointees to the new Super Board.  Once it was established Dr. Duckett, a health economist, was hired by the AHS Super Board with a clear mandate to get spending and costs under control.  What is particularly interesting is the composition of the Super Board…it is predominantly people with business experience – not public policy or health care experiences.  So decisions would more likely be business based before public policy based. 

These are all good people with valuable experience and who are undoubtedly trying to use their skills to make a difference and improve the health care system in Alberta.  The problem is they may only have part of the skill sets necessary to do this very complex and critically important job of overseeing the design, development and deployment of an effective health care system in Alberta.  They have the management discipline and a corporate governance experience. My question is do they understand there is a difference in dealing with public sector governance, public policy development, public sector accountability in a care giving system not a marketplace model of delivery?  Are they analytical as well as design oriented?  Are they sensitive to the human dynamics inherent in a health care delivery system at the patient, service provider and taxpayer levels?  Are they insightful enough about the political culture and context of their relationship with the Minister and the government while serving on such a board?  Can they effectively determine and articulate truth to the political power structure that is ultimately responsible and entrusted to provide health care to Alberta?  Finally do they have the benefit of a mutual two-way trust with the political powers and administrative machinery of government?

The recent resignations from the Super Board are reported to be largely based on the principle of board independence.  Political interference has to be resisted if a board is going to be effective.  However when a board is mandated to execute government policy there are public policy and political realities that may have to trump the presumption of arms length independence. Those overarching realities are the ultimate responsibility of the elected Minister to represent the public interest.  Provided the communications between the elected Minister and the appointed Board is done openly and transparently then it is not necessarily inappropriate interference with the independence of the appointed board.  A board can choose to ignore the advice or even direction of the Minister.  Unless the Board can convince the Minister that he is wrong or the suggested action is ill-advised, the natural consequences of non-compliance would be that the board would be replaced with others who would execute their roles consistent with the Minister’s interpretation of government policy.  That is as it should be in a public policy governance model so long as this is all open and public information so we citizens can judge if there is improper political interference or there is a board that is not fulfilling its responsibilities appropriately.

So what about the current AHS board status in light of current events?   I don’t conclude that Minister Zwozdesky insisting that the AHS board make the Duckett contract decision immediately instead of waiting two weeks is improper interference.  I am only basing this conclusion on media reports of the communications but none of the parties have suggested they are in accurate so far as I know.  The Board could have declined to comply with the Minister’s request for an immediate decision and if they believed that was the right thing to do in the public interest.   That is moot because the Board did make an immediate decision.  The question now is where this all goes from here!

I have suggested previously in this Blog the AHS Board and many others, like in areas of Children Services and PDD for example, are not effective in providing good governance for the province.   They are ostensibly there to provide local input and intelligence to the Minister and Ministry but they end up being a buffer and a barrier between the politicians and the public.   The system is unworkable in this kind of political culture where partisan politics replace good public policy.  This default to partisan politics driving decisions was obvious in health care under Minister Liepert.  Just look at the fact he decided unilaterally to change the health care governance structures for pure political purposes.  He did that without warning, consultation or concern for consequences to the public or the professionals just trying to do their jobs.

If these various appointed boards are in reality mere buffers designed to protect politicians from accountability to the public they should be disbanded.  Given the many Ministerial reversals of AHS Board and CEO decisions since Zwozdesky took over the Ministry, those still on the AHS Board should ask themselves if they still have the confidence of the Minister.  I think the evidence is pretty clear the answer is no. 

Zwozdesky is not the kind of Minister who wants to hide from the public in doing his policy and political duty.  He and his department are the ones who are ultimately responsible for the outcomes of health care and they know it.  The appointed and virtually anonymous Super Board, like many others in the province, are ineffectual in serving the public interest, especially if there is political interference and a lack of clear mandated authority.  Under these circumstances I think the AHS Board should all resign and return the clear and direct lines of accountability and responsibility for design and delivery of health care to the government.  This need not be in protest or seen in any way as a failure to perform by the AHS Board.  Rather it would put the responsibility for health care policy clearly back on the Minister and Ministry where it belongs.  It would set an example for the other Boards too who are mostly being used as mere buffers between the public and the politicians

The expertise in the health care system would not be lost and can be more effective at bring truth to power - directly – as the Emergency Room Docs are doing now.  The bureaucracy can also do its job better in providing analysis and suggesting policy options for our elected representatives to consider when making public policy decisions on our behalf.

I have great respect for any citizen who comes forward to serve on government agencies, boards and commissions.  I have done so many times myself.  There is always a question about roles, responsibilities and relationships between these boards and the government, the Minister and the public interest.  The wisdom and judgement of all those involved are always required in keeping these realities in context.  My conclusion is the AHS board was set up by the previous Minister primarily for political reasons.  If the current Board members come to the same conclusion then they need to return the legal responsibility to provide for health care in Alberta back to the elected officials.  That is just part of the task of fixing the governance model as well as the resolving of the health care crisis that we are seeing unfold these days. 

CLARIFICATIONS REQUIRED:
There is a news story in the Edmonton Journal today on the status of the Super Board quoting me that need clarification and correction.  By way of clarification there is an implication in remarks attributed to me that Minister Zwozdesky threatened to remove the AHS Board if they did not comply with his request.  I don’t know if that happened or not in the discussion between the Minister and the Board Chair.  It appears that I am quoting the Minister in that regard.  I was not. 

My point is that is within the power of the Minister to replace the Board, and that is as it should be.  It appears in the news story that I am saying the Minister made such a comment to the Chair.    I did not say or imply that comment was made at all.  I only suggested that removing the Board is a natural and appropriate consequence of not a Board not complying with a proper direction of the Minister....the key here is was the Ministerial direction proper and not just political.  In my mind Minister Zwozdesky was acting appropriately and not politically in his comments on the preferred outcome from the AHS Board on the Duckett situation.

I DON’T SPEAK FOR THE ALBERTA PARTY!
The other point of clarification that is needed is the headline on the continuation of the story on page B12 that says “Alberta Party wants mass resignation.”  This headline is totally inaccurate and misleading.  While I am a member of the Alberta Party I do not speak for the Alberta Party.  I know the headlines are not written by the same person who writes the story.  The reporter here is doing a very good job at informing the public about some very important governance, policy and political events impacting our health care system.  Unfortunately newspapers don’t have the reporters write the headlines for their own stories to ensure they accurately represent the content and intent of the articles they write.  This is unfortunate.  Please be assured I do not speak not do I intend to speak for the Alberta Party on any matter of its policy.  That is the job of the Leader Sue Huff and the President Chris LaBossiere.  

Let's let Minister Zwozdesky, Parliamentary Assistant Fred Horne and now Independent MLA Raj Sherman plus the rest of our elected representatives in the Alberta Legislature do their jobs in fixing the crisis in our health care system - just as we elected them to do.