Chapter 10. a The Role of the Minister of Health and Manitoba Health INTRODUCTION

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1 REPORT OF THE REVIEW AND IMPLEMENTATION COMMITTEE FOR THE REPORT OF THE MANITOBA PEDIATRIC CARDIAC SURGERY INQUEST Chapter 10 a The Role of the Minister of Health and Manitoba Health INTRODUCTION It is a fact of political life that nearly all developments within Manitoba s complex and dispersed health care system can potentially be brought back to the doorstep of the office of the Minister of Health. Arguably, the job of Health Minister is the most challenging and politically sensitive of all the positions within the provincial cabinet, with the possible exception of the position of Premier. Given our system of cabinet-parliamentary government, authority over policy and spending is concentrated in the hands of the Premier, the Cabinet and individual ministers. Yet the refinement and implementation of broad provincial policies and the actual expenditure of funds is done to a large extent by semiindependent bodies like municipalities, schools, colleges and universities, health care institutions and Crown corporations. Despite this diffusion of responsibility, the political process operating through the adversarial and partisan forum of the Manitoba Legislature, obliges individual ministers to be answerable for all that transpires within their portfolios of departmental and non-departmental organizations. In Chapter Two, where we provided an overview of the different types of accountability operating within Manitoba health care system, we cautioned against an insistence on too strict an interpretation of the principles of individual ministerial responsibility. It is appropriate that the Minister of Health be obliged to explain, and at times defend, actions within the health care system that lead to unpopular and/or unfortunate outcomes. In this role the Minister serves as a focal point for the achievement of ultimate accountability to the public. Answerability, however, should not be confused with the automatic obligation to resign their portfolio. Health Ministers should not be expected to resign their cabinet positions every time something goes wrong in the health system, especially if they were not involved in the matter and did not approve of what was done. It is unrealistic to make the minister absolutely accountable for everything. There are enormous demands on the time and energies of the minister. Only a small per centage of the thousands of decisions made daily within the health field are 117

2 C H A P T E R 1 0 THE ROLE OF THE MINISTER OF HEALTH AND MANITOBA HEALTH ever brought to his/her attention. Health spending represents nearly 40 per cent of the provincial budget and over 60 per cent of that spending is done through somewhat arms-length institutions and individuals who do not fall directly under the management control of the Minister and the Department of Health. ACCOUNTABILITY AND THE REGIONAL HEALTH AUTHORITIES The process of regionalization was begun in 1997 with the passage of the Regional Health Authorities Act. The Act has been amended several times since In general terms, the Act and its regulations give RHAs responsibility and authority to plan and coordinate the delivery of all health services within the 12 regions where they operate. There are also other statutes, such as the Hospitals Act and the Mental Health Act, that prescribe more specific responsibilities for institutions operating within the RHA framework. Regionalization has significant implications for the role of the Minister and of the Department of Health. This is not the place to review the progress to date in terms of putting the regional structure in place and developing the shared understandings and norms of behavior necessary to make it work as intended. The concern here is with the role of the Minister and the Department of Health in terms of the clear assignment of responsibility and accountability. To uphold the principle of ministerial responsibility, the Regional Health Authorities Act assigns important authority to the Minister of Health in relation to the Regional Health Authorities (RHAs). The Minister has responsibility and authority to establish the expectations related to the Minister s delegation of responsibility and authority to the RHAs and to ensure that those expectations are effectively communicated to all RHAs. (Manitoba Health, Achieving Accountability, 1999). The Act provides the Minister with a number of prerogatives to fulfill his/her responsibilities: authority to issue directives to RHAs authority to withhold funding authority to appoint and remove directors from boards of RHAs authority to approve board bylaws authority to enter into agreements with RHAs authority to require additional information from RHAs authority to place a facility under outside management. These powers give the Minister of Health clear authority to intervene in the operation of the RHAs. However, in the spirit of devolved decision-making and community responsiveness that is at the heart of the regional health care delivery model, such interventions should be the exception and occur infrequently. A persistent pattern of adverse outcomes in a surgical or other medical program would be a situation where a Minister of Health might feel obliged to intervene. 118

3 REPORT OF THE REVIEW AND IMPLEMENTATION COMMITTEE FOR THE REPORT OF THE MANITOBA PEDIATRIC CARDIAC SURGERY INQUEST For the Minister to provide policy leadership and scrutiny of the operation of the health care system, he/she requires timely information on the actions and performance of the RHAs. The Regional Health Authorities Act imposes several reporting responsibilities on the RHAs: required to report in the time and form specified by the minister on a health plan for the region; required to provide any reports and statistical information that the minister may require; required to submit within six months after the fiscal year an annual report; and a requirement that the Council of Board Chairs for RHAs report regularly to the Minister. In addition to the information which flows from the RHAs, the Minister and the Department use the research services of the Manitoba Centre for Health Policy and Evaluation (MCHPE). The MCHPE is an internationally recognized group of researchers from different disciplines. The Department of Health negotiates annually with MCHPE to produce five or six studies that can provide an independent evaluation of population health as it relates to programs and services provided by RHAs and hospitals. THE TRANSFORMATION OF MANITOBA HEALTH The regional model assumes that Manitoba Health will provide policy frameworks, set health care standards and monitor the performance of health institutions. The Mission Statement for Manitoba Health states that the department is: To provide leadership and support to protect, preserve and promote the health of all Manitobans. This mission is accomplished through a structure of comprehensive envelopes encompassing program, policy and fiscal accountability; by the development of health public policy; and by the provision of appropriate, effective and efficient health and health care services (Manitoba Health, Annual Report, ). In a companion vision statement, the Department talks about leading the way to quality care, empowering Manitobans with knowledge and choices, building partnerships for healthy communities and fostering innovation. These are sweeping and ambitious objectives. However, the Review Committee has serious doubts about whether Manitoba Health with its present organizational design and analytical capacity is capable of fulfilling its mission and vision. As the regionalization process proceeds, Manitoba Health will be placed more and more in the position of having to steer the complex and dispersed health care system by remote control. Manitoba Health is already less involved with the direct delivery of health programs than in the past. It cannot rely as much on command and control as it once did. Today, and increasingly into the future, Manitoba Health personnel will have to provide policy and managerial leadership across organizational boundaries rather than within the framework of an integrated department. New structures, new kinds of knowledge and new skills will be required within Manitoba Health for it to serve the Minister effectively, to set the parameters of health care delivery, and to hold the health institutions operating with delegated authority accountable for their performance. 119

4 C H A P T E R 1 0 THE ROLE OF THE MINISTER OF HEALTH AND MANITOBA HEALTH We describe the core future roles of Manitoba Health as follows: to provide policy planning and advice to the Minister and the government; to provide province-wide medium to long-range planning; to ensure that budgetary allocations reflect long-term plans and current government priorities; to prescribe health care services that must be provided and to ensure compliance with health care standards; to monitor performance and to conduct periodic, in-depth evaluations of selected programs; to develop information reporting and information management approaches to ensure program and financial accountability. At present, Manitoba Health has too little capacity to perform these roles. The senior leadership of the Department recognizes this and they have put forward proposals within government to restructure the Department and to expand its capacity in crucial areas. If changes are not made within Manitoba Health there is a significant risk that the health care system will be reactive rather than anticipatory, further problems will develop, weaknesses in programs and delivery systems will not be detected, and program and financial accountability will be weak. The above discussion should not be read as a criticism of the current personnel in Manitoba Health. The problems involve system shortcomings, far more than individual shortcomings. Redefining and changing the operations of Manitoba Health represents a major challenge. There will be financial costs involved in creating the organizational and analytical capacity to enable the Department to fulfill its changed role. Current employees will have to be supported through education and training to acquire the knowledge and skills required to work with a variety of outside organizations. The Minister of Health and the Executive Management Committee recognize the need to transform the Department. Since there has been a reduction in staff from approximately 2,500 down to approximately 1,100 in In part, this reduction reflects the withdrawal of the Department from the direct management of service delivery. More of the transactional work of dealing directly with health institutions now takes place at the RHA level. There has been a significant migration of department staff to work at the RHAs, especially at the WRHA. This has been due to a number of factors: an opportunity to make more of a difference, a more dynamic and creative organizational culture and enhanced remuneration. As part of this movement, managerial talent with experience, knowledge and skills has been lost from the Department. New personnel with the requisite competencies have not been added. The result is that the Department now has limited capacity to: develop coherent policy directions for health care, including within the context of federal-provincial relations; engage in long-term system-wide planning conduct research, especially that which is relevant to standards setting and managerial improvement; ensure that quality assurance and risk management activity is taking place within the system; 120

5 REPORT OF THE REVIEW AND IMPLEMENTATION COMMITTEE FOR THE REPORT OF THE MANITOBA PEDIATRIC CARDIAC SURGERY INQUEST develop performance measurement, performance reporting and evaluation frameworks and mechanisms; and conduct rigorous financial analysis and to develop financial management systems. Given the challenges facing the province in the health care field, it is not an exaggeration to state that the Department lacks many of the means to set sound new policy directions and to ensure the efficient, effective and accountable delivery of safe health care services. We would not call the situation a crisis, but there is a clear need to strengthen and revitalize the Department. A start in the direction of strengthening the Department was made in July, 2000 with the creation of the new position of Assistant Deputy Minister for Regional Affairs to lead the new Division of Regional Affairs. The Division groups a number of related units and activities to better coordinate the Department s overall approach and dealings with the RHAs. The Division includes: Regional Support Services, Financial Services, Capital Planning, Primary Care, Home Care, Long Term Care and Emergency Medical Services and Planning. The Department has also proposed to create another Assistant Deputy Minister position leading a Division responsible for Health Standards, Evaluation and Initiatives. Also proposed is a small Policy and Planning Secretariat covering planning and research, federal-provincial relations, risk management and communications. The Secretariat would report directly to the Deputy Minister. There are also proposals to strengthen the Division led by the Assistant Deputy Minister of Financial Control and Management Accountability. We recognize that government would be reluctant to spend scarce health dollars on administrative overhead, especially if there might be the perception that the new departmental functions duplicate what is done at the RHA level. However, it is our understanding that the new Divisions in Manitoba Health would be there to set policy and financial frameworks, to support and ensure consistency among the RHAs and to provide oversight of the system. In other words, the Department would not actually develop activities in the fields of standards settings, quality assurance, risk management, performance measurement and evaluation. However, it would possess sufficient in-house capacity or contract out for expertise to provide the government and Manitobans with the assurance that these activities are being conducted in a sound and consistent manner throughout the health care system. FUTURE DIRECTIONS The process of regionalization is incomplete, in part because Manitoba Health is still involved with operational matters. According to the Report on Health Care Financial Management and Accountability (the Webster Report), presented to the Government of Manitoba in April 2000, the duplication and overlap between the Department of Health and the RHAs must be eliminated to achieve cost savings and to clarify accountability. The Webster Report also pointed out the anomaly in the Winnipeg region where all but one of the Winnipeg hospitals retained their boards of directors, with their program managers reporting to the WRHA. A number of joint review committees involving all the relevant stakeholders were proposed in the Webster Report to drive the regionalization process forward. Mention is also made in the Webster Report of an initiative underway involving Manitoba Health and the Regional Health Authorities of Manitoba Inc. 121

6 C H A P T E R 1 0 THE ROLE OF THE MINISTER OF HEALTH AND MANITOBA HEALTH to refine the relationship between the Minister and the RHAs, to identify areas of exclusive and shared accountability and to develop agreed-upon mechanisms of accountability. A rigorous objective evidencebased approach to accountability is seen as the preferred route to follow. The identification of appropriate measurement criteria (of both a clinical and managerial nature) is one of the most challenging and critical functions to be performed by Manitoba Health in collaboration with the RHAs. A collaborative process between Manitoba Health and the RHAs should be developed to monitor performance based agreed criteria. To implement many of the recommendations of both the Sinclair and the Webster Reports will require a significant investment in sophisticated computer-based clinical and managerial information systems. A joint task force involving the RHAs and Manitoba Health is engaged currently with the development of a provincial IT strategy. Technological support at the level of individual institutions, at the RHA level and within Manitoba Health is clearly inadequate. Investments in information and communications technologies (ICTs) will pay-off in the long-term in greater efficiency, effectiveness and innovation in the health system. They will also contribute to better policy analysis, stronger managerial capacity, the provision of feedback information and early warning signals of emerging issues, and the strengthening of accountability at all levels. There is a particular application of ICTs in conjunction with the proposed Western Canadian Children s Heart Network, which is discussed in a separate chapter. RECOMMENDATIONS This chapter has emphasized that the Minister of Health is answerable for the overall performance of the health care system. The regional model adopted in 1997 delegates significant authority, resources and managerial direction of health care service to the 12 RHA Boards and the Chief Executive Officers who report to them. The Review Committee recommends that the regionalization process be completed to include all health facilities. There remain areas of overlap and duplication between the provincial policy determination, standards setting and monitoring role that reduce efficiency and blur accountability. An initiative is underway to more clearly align responsibilities within the provincial-rha relationship. The Review Committee urges the completion of this initiative to serve as the basis for clearer direction and sounder accountability framework within the regional health care model. Manitoba Health is in transition, moving away from a significant role in the direct management of service delivery and towards a new role that focuses on policy frameworks, provincial-wide planning, standards setting, performance measurement and evaluation as a basis for ensuring that all Manitobans have fair and consistent access to competent and safe health care. To perform in its new role, Manitoba Health needs to be reorganized and to develop new kinds of knowledge and skills among its employees. The Review Committee supports recent actions and further proposals for reform put forward to the Government of Manitoba by the Minister of Health and the Deputy Minister of the Department. 122

7 REPORT OF THE REVIEW AND IMPLEMENTATION COMMITTEE FOR THE REPORT OF THE MANITOBA PEDIATRIC CARDIAC SURGERY INQUEST Meaningful accountability in the complex and decentralized structure of regional health care requires the generation and flow of valid, reliable, timely and relevant health care data among stakeholders at all levels within the system. This requirement will involve significant investments in the creation of information technology infrastructure linking the various parts of the health system. It will also require a transformation of the culture of the health care system to ensure the greater utilization of data to guide decision-making, with less reliance being placed on political calculations, institutional rivalries and the use of crises to leverage additional resources. The Review Committee supports the work of the provincial taskforce developing a health information technology strategy as a basis for the creation of an information rich context for better informed policy-making, management and risk avoidance. 123

8 124 C H A P T E R 1 0 THE ROLE OF THE MINISTER OF HEALTH AND MANITOBA HEALTH

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