elements for a proposed cpha policy statement on regionalization

ELEMENTS FOR A PROPOSED CPHA POLICY STATEMENT ON REGIONALIZATIONSource: Canadian Journal of Public Health / Revue Canadienne de Sante'e Publique, Vol. 64, No.1 (January/February 1973), pp. 101-104Published by: Canadian Public Health AssociationStable URL: http://www.jstor.org/stable/41987116 .

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ELEMENTS FOR A PROPOSED CPHA POLICY STATEMENT ON REGIONALIZATION

The Health Services Division of CPHA pro- poses that CPHA go on record as: 1 . Re-emphasizing its endorsement of the

Hastings Report. 2. Recommending the above principles to the

provincial and federal governments of Ca- nada.

3. Urging all health care institutions, providers of service, professional organizations, community groups, and the public in general to play positive and constructive roles in implementation of this form of regional health development;

4. Urging the federal government, in consul- tation with provincial governments, to re- vise the present cost sharing systems for Medical Care Insurance, Hospital Insur- ance, Canada Assistance Plan, and other federal-provincial programs to promote maximum flexibility and innovative potential for the provinces and their districts in developing comprehensive health systems on a regional basis;

5. Urging the federal government to assist the provinces financially in extending health service coverage to nursing home care, dental care, prescription drugs, pros- thetics, and - most importantly - home care and preventive health services as essential components of a regional system.

6. Urging all public health workers, and organizations, to play an active and constructive role in helping to evolve a new, more effective and more humane health care system for all Canadians.

Introduction There is a growing consensus among plan-

ners, and providers of service, on many as- pects of planning relating to future patterns of health service organization. One such area of apparent consensus is in the need for "regionalization" of health services, although in-

terpretations vary as to how this need can be met.

The problem then is to define regionalization. The term has come to be understood as an intermediate level of either administration or, more commonly, co-ordinative function (advisory planning, etc.) between the provincial level, and the local service delivery unit level.

The earliest enunciation of the concept of regionalization in connection with health services is generally attributed to the British Ministry of Reconstruction after World War I which led to the establishment of the Min- istry of Health in 1919. Among many basic principles of general policy, the following guideline was set forth: "When a special function is to be undertaken, it be undertaken by one governing body for the whole community requiring the service, and not for different sections of the community by several bodies." In 1920, the Lord Dawson Re- port recommended an integrated network of health centers around intermediary and central base hospitals. "The regional organization was defined as a two-way communi- cation system between the periphery and the center for purposes of services, training of personnel and continuing education (1).

In Canada, a more restricted view of regionalization was developed around hospital services, as illustrated by the following ex- cerpts from the Task Force Reports on the Cost of Health Services in Canada:

". . . that a regional hospital board have the power to decide, first of all, whether a special service were necessary, and if it were, the board would be empowered to allocate it to the hospital or hospitals best suited to undertake this responsibility. Again it might be that a service already established in one hospital should be moved to another hospital for reasons of efficiency and economy. This also, the regional board should be empowered to undertake." (2)

January/February 1973 Policy Statements 101



The Report goes on to refer to the role of regional boards in reducing duplication of ac- tivities such as the administration of education and training programs, and the review of individual hospital budgets and service programs, as well as shared purchasing and other areas of joint action. The report recommends :

"That as a first step toward eventual regional organization of all health services, there be a Regional Hospital Board with executive authority. The Board would be composed of representatives of each hospital, doctors, municipal authorities, the public, and others as appropriate. The Board would decide the role of each hospital, i.e. the service that each hospital would provide, with power to re-locate services, if necessary. It would ad- minister the regional budget." (2) This has been the major model of region-

alism in health care in recent years - a mechanism for getting hospitals to reduce waste and duplication caused by unproduc- tive competitiveness.

Regionalization Patterns in Canada Different approaches to regionalization

have appeared in several Canadian provinces. The concept of regionalization embodied in the Castonguay - Nepveu Commission of Inquiry into Health & Social Services, which was later introduced into the Quebec House of Assembly in Bill 65, looked at integration of a whole spectrum of health and social service programs on a regional basis. The fi- nal form of Bill 65, as passed by the Quebec House of Assembly in December 1971, provided for regional councils and for local community service centers (CLSC's), as well as hospital centers, social service centers, and reception centers. The twelve regional councils which were established in Quebec under the regulations of Bill 65 are based on community (consumer) participation, and serve basically as advisory units, and not as administrative structures. Some 31 hospitals in the province are being given responsibility for public health services, and the development of a number of CLSC's is in progress.

The neighbouring province of Ontario released its new Ministry of Health organization plan in August 1972. A major thrust towards regionalization occurred in the for- mation of new District Health Councils. It is envisaged that:

"Various health agencies will continue to function under management boards, with financial and technical assistance from government. However, it is intended that local agencies and services will become ac- countable to the people they serve through strong representation on District Health Councils concerned with the total spectrum of health services. Boards of health, hospital boards, and other management boards will be responsible for agency administration and quality of service provided. Special interest groups, such as hospital councils and mental health councils, will have an important planning and co-or- dinating function as subcommittees of Dis- trict Health Councils. The link between government and District Health Councils will be provided by area co- ordinators appointed by government to co- ordinate health care delivery throughout Ontario." (3)

At present, the District Health Councils are not established as administrative structures, but rather as advisory and co-ordinative units. Herein lies the rub.

Manitoba's approach to regionalization is, in many ways, a longer reach foward. In its White Paper on Health Policy released in July 1972, the Manitoba government moved the debate from a strict focus on community health centers to a broader view of the issue in terms of "District Health Systems". The District Health System is outlined as a local community board operating all local health and social services, with a single administrative authority, a single block budget (pre- sumably related to the number of persons for whom the program is responsible) and a "health team" approach to service delivery. The District Health System is seen as the ve- hicle to (1) correct deficiencies in the health care system such as inequities in distribution, access, and effectiveness of care; and (2) to relieve the pressure of rapid cost increases

102 Canadian Journal of Public Health Vol. 64



for existing hospital and medical services. It is also expected that, through the implementation of this system, some of the present gaps in service or coverage can be filled by more significant community voice and responsibility in health services. And herein lies one of the central issues, so little explored. The transfer of authority from the provincial level to a regional, and probably more rele- vant, a district level must involve the transfer not only of administrative rights, but also responsibilities for providing a broad range of health (and social service) care to a defined population group. The community or district board will then have to face up to de- cision making responsibilities. This new role of the community or district board will change negotiations with provincial government from the now traditional "more" request to discussions of how adequate standards of health care are best delivered.

The Community Health Center and Region - alization

The Hasting's Committee (Report of the Community Health Centre Project) was established in 1971 by a federal government grant, at the request of the 1970 federal-provincial Health Ministers' Conference to ex- plore the much-discussed community health center in the Canadian context. The Hastings Committee quickly realized that the major issues of health care could not be examined in isolation from each other, and that a strict focus on the community health center as a new entity without equal concern for its linkage or indeed its centrality to the whole of health services, would be at best short-sighted and at worst foolish.

As a result, the Hastings Report recommends :

"2. The immediate and purposeful re-organization and integration of all health services into a health services system to ensure basic health service standards for all Canadians and to assure a more economic and effective use of all health care resources."

This report recommends a redistribution of function and responsibility between provincial and district (or area) authorities. The province must retain responsibility and ulti- mate approval for the "planning, allocation of resources and evaluation". The province must, however, according to this view, delegate sufficient power and responsibility to the district authority for: health services (subject to basic guidelines); standards of province-wide equity; and a system of ac- countability. The province's responsibilities for overall planning are: to assure balance and equity; to introduce effective and innovative manpower policies: to provide ap- peal and grievance mechanisms; to supply funds for the achievement of system objec- tives; to organize province-wide communi- cation, maintenance of records, and data re- trieval; and to evaluate the service system and outcomes of care as a whole.

The District authority would be responsible for detailed planning; effective linkage of all local services; manpower recruitment and development; budget determination and allocation of funds to component programs and facilities. The range of services will vary according to the particular stage of implementation. However, the eventual goal must be the development of comprehensive health (and social service) programs under a local authority which, while being broadly repre- sentative of the community at large, will still provide a voice to the professionals of the community in determining service delivery patterns.

Issues in Implementing Regionalization The concept of regionalization is coming

almost as close to motherhood as the anti-pol- lution campaign. The problems are - what specifically is meant by regionalization, and how do we implement it?

Regionalization per se is no panacea to the ills of the health care system; its inter- pretation must be handled very carefully to prevent a Parkinson's Law situation from de-

January/ February 1973 Policy Statements 103



veloping. If regionalization is to mean merely the creation of a new administrative layer between the provincial authority and the service delivery level, it could actually result in greater rather than less resistance to change. It is imperative to avoid a situation whereby "reorganization makes change more difficult than it was before. Reorganization often re- sults in layering - the piling of administrative echelon upon administrative echelon in an unremitting quest for co-ordination, symmetry, logic, and comprehensive order."^)

The processes of pluralism and evolution are promising approaches to implementation. Clearly, different provinces will feel their way along differently. In the words of come- dian Flip Wilson - "Different strokes for different folks." Pragmatism is probably a useful modifier to a "cookie cutter" approach, because the pattern of regionalization really must evolve through experi- ence.

Yet, as the Hastings Report indicated, "the immediate and purposeful reorganization and integration of all health services into a health services system ..." is essential in order to deal with the serious inequities in our current health care system.

The underlying principles involved in implementing regionalization then, are: 1) the reorganization of all health (and so-

cial) services into an integrated health and social service system is both desirable and necessary;

2) provincial authorities should delegate to single district authorities the responsibility

for the broadest possible range of health (and social) services;

3) provinces must retain, and improve, their potential to assure province-wide; - balance and equity - guidelines and monitoring of standards of service programs, facilities, utilization, and health status of the people; - effective manpower training, education, distribution and effective practice; - communications, records, and data re- trieval; - funding; and equally important, - evaluation.

4) the district health authority should have responsibility for: - detailed planning; - effective integration of all local health services; - manpower recruitment and development; - budget and allocation of funds to component programs and facilities; and - service standards and effective use of resources.

5) community health (and social service) centers provide the logical and desirable focal point and means of integrating the broadest possible range of services into an effective health program for the people of a area, whether this be a rural district, or a district or neighbourhood of a large metropolitan area.

6) a "phasing in" or staging process is necessary; this is illustrated in the Hastings Report, Appendix B, Diagram 2.

REFERENCES ( 1 ) Consultative Council on Medical and Allied

Services, Ministry of Health, Great Britain: "Interim Report on the Future Provision of Medical and Allied Services". Her Majesty's Stationery Office, London, 1970.

(2) Task Force on the Costs of Health Services in Canada. Information Canada, Ottawa, 1970, p. 9.

(3) Statement by The Honourable Richard T. Potter, M.D. Minister of Health, Re-organi-

zation of the Ministry of Health, August 23, 1972.

(4) Community Health Centre in Canada, Re- port of the Community Health Centre project to the Conference of Health Ministers, Mimeograph 1972.

(5) Kaufman, Herbert: The Limits of Organi- zational Change , University of Alabama Press. 1971, pp. 76-77.

104 Canadian Journal of Public Health Vol. 64



elements for a proposed cpha policy statement on regionalization

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