An “evisceration.” A “sense of trepidation.” A “world of uncertainty.” Those are the words that Alberta’s health-care professionals are using to describe what is happening to Alberta’s health-care system.

Though the exact details have yet to be spelled out, the province announced on Nov. 8 that it would be transitioning away from its largely centralized provincial health-care system and establish four new “pillars” of health care – mental health and addictions, primary care, acute care and continuing care. Each pillar is to become a separate organization headed by its own executives, administrative board and budget.

The announcement was followed by Premier Danielle Smith’s dismissal of the Alberta Health Services’ (AHS) Chief Executive Officer and the firing of the AHS board. In February, Alberta released estimates that dismantling AHS would cost the province $85 million over the next two years.

Smith has said that she intends for AHS, currently the largest employer in the province, to focus primarily on delivering acute care. The province also has proposed to do away with the existing 15 regional authorities to create 12 regional advisory councils and an Indigenous Advisory Council.

The details of exactly how these different pillars will run and coordinate care between one another are still murky. But the province says that these changes will deal with a number of frontline problems, including emergency department wait-times and improved access to health-care providers and continuing care.

On April 2, the province unveiled plans for its mental health and addictions pillar. A new organization, Recovery Alberta, will be responsible for delivering all mental health and addictions services currently delivered by AHS. Recovery Alberta is expected to be fully operational by the summer and will have an annual budget of $1.13 billion.

The government will also establish the Canadian Centre of Recovery Excellence (CoRE) to “support Alberta’s government in building recovery-oriented systems of care” by “researching best practices for recovery.”

However, the scarcity of details have left many health-care leaders with more questions than answers.

How employee contracts will be handled, how operations between pillars will be coordinated, and how patients will be carried over between providers who are now employed under different systems are just some of the many concerns raised.

In the midst of a transition period with limited clarity, Healthy Debate asked health-care leaders what they foresee the impact the restructuring will have.

The short answer is, we don’t know what’s going to happen. But rather than calling it a “restructuring,” it would be better to call it an evisceration.

The province announced in November that it would create four organizations, and only now are some of those details beginning to play out. The first organization to be unveiled is completely opposite to what the Minister of Health (Adriana LaGrange) indicated would happen when we met her in mid-November. The four unions representing the employees of AHS were told that these organizations would not be an employer. And yet when the first organization for mental health and addictions was officially unveiled, it is in fact Recovery Alberta that is now the employer.

For context, this Recovery Alberta announcement will impact about 10,000 employees, 3,200 of whom are employees under the United Nurses of Alberta; the remaining are employees under the Alberta Union of Provincial Employees and Health Sciences Association of Alberta.

The impact on mental health nursing is going to be very disruptive and scattered. For example, we have nursing units at various larger hospitals across the province dedicated to mental health services like the Royal Alexandra Hospital and the University Hospital in Edmonton. The employer there will no longer be the AHS, it’s going to be Recovery Alberta.

Although this is supposed to be a gathering together of all the mental health, addictions and corrections, we won’t have a single-focus entity employer. Nurses who work on mental health units at the Grey Nuns Community Hospital, Misericordia Hospital as well as the third largest stand-alone mental health facility in the province, Villa Caritas, will not become employees of Recovery Alberta; they will remain employees of their current employer, Covenant Health.

How and what it is being done just leads to more questions in terms of how this is going to function down the road. There has been no clarity provided regarding the other three areas: primary care, acute care and continuing care.

The main message I received from the meeting with the minister was that Alberta Health gets $27 billion dollars in the annual budget, $18 billion of which currently goes to AHS. The new acute care organization will get whatever is determined for acute care and AHS just becomes one of the smaller contractors of acute care, much in the way that Covenant is under the current system. We have known that Covenant and the long-term care providers have never liked having AHS oversight. If you go back to November, you have Covenant Health and long-term care providers supporting this decision. [Covenant health “politely declined” a request for an interview.]

We don’t know what this is going to mean in terms of the rest of the AHS in continuing care. AHS provides many continuing care beds, many as part of acute care rural hospitals, for instance. They are the sole owner of two huge public entities, one in Edmonton, Capital Care, one in Calgary, Care West. These are multiple long-term care facilities owned by AHS. There have been rumors about the government wanting AHS to sell them off.

Does this mean that we’re looking at more movement into private, for-profit hands for continuing care beds? And what happens if home care also becomes part of continuing care. Currently the AHS is responsible for the provision of all home care, most of which is provided by nurses who are employees of AHS.

The same concerns are there with primary care; there have been rumors that public health services could also be eviscerated out of AHS. Really, is the refocusing anything other than an attempt to put a different face on an ideological desire for massive privatization for publicly funded services?

Heather Smith

For the most part, nothing’s really changed so far in terms of the immediate physician or patient experience. But there are broad concerns shared by a lot of us and that has really paralyzed a lot of decision makers. The AHS can’t really function right now because no one knows what the landscape is going to look like and nobody is feeling comfortable making decisions.

We’re all very concerned about ensuring that these four pillars the province is creating are all connected and that the health-care worker, patient interactions and journey through them are as seamless as it can be. The last thing we need is more silo-ing and barriers between these areas of care.

But it’s all very uncertain. We’re feeling a sense of trepidation because the system’s kind of in disarray to a degree already, the access block is massive. We have so many Albertans that have no access to a family physician, and the current funding model for family medicine is completely nonviable. But how do we reconcile that with the uncertainty of what things will look like when a new primary care pillar gets set up? How is that going to look in a system where many physicians work in many or all aspects of the health-care system? For example, many family physicians work in mental health and addictions care as well as in continuing care facilities, some of them also work in hospitals. How are we going to get their patients through this new system when we’re dealing with four separate organizations?

When we really push at high levels and ask the government what their plan is, it’s very clear that there aren’t a lot of specific, thought-out details over how it’s going to look and interact.

As an emergency physician, I can tell you that there are tons of concerns we have about how patients are going to move through acute care and long-term care. Our hospitals are currently overflowing with alternative level of care (ALC) patients. In some hospitals, we have 20 to 30 per cent of our beds occupied by ALC patients. It’s not safe for them to go home but they have to get discharged somewhere. But how are we going to be able to transfer ALC patients if there are separate continuing care and acute care organizations? How are these organizations going to interact with each other? Or are more of our emergency departments just going to get blocked by ALC patients that can’t get into continuing care. How do we break that log jam?

Prior to this decision, it’s fair to say we weren’t doing as good of a job as we should have to integrate community care in hospitals and long-term care, for example. The AHS was trying to get involved in bigger parts of that. But it’s really concerning that by creating four separate orgs that are going to have four different CEOs, four different management teams and four different administrative arms, it’s just going to create way more bureaucracy and red tape with no real oversight.

If the province doesn’t get frontline input from the experts that actually deliver the care, this is going to be a disaster and it’ll likely just make things worse for patients.

Paul Parks

Being a surgeon, none of this has really hit the ground yet. We’re just living in a world of complete uncertainty.

How will these changes affect acute care and, in particular, surgery? There are a number of potential downsides, and I don’t see a whole lot of upsides.

Though a lot of changes won’t impact surgery, I do suspect there will be more contracting out as the acute care part of AHS shrinks and it may not be able to carry on with all of the activities it did before.

One of the concerns for us will involve the flow of patients. A big problem for surgery is that when patients are operated on, they then recover in hospital and sometimes have to go to continuing care. Patients that needed long-term care beds were always easily coordinated because AHS controls long-term care, extended care and hospital beds. But there’s really no plan for how that ongoing coordination will happen in the future.

Another issue is cost. AHS has a very big profile and is able to negotiate things like volume discounts on medical devices, drugs and everything else. It’s not clear how the budget is going to be broken up.

We can also expect a bigger bureaucracy. Part of the idea behind creating the AHS was to decrease bureaucracy. Although bureaucracy will always exist in some capacity, creating four separate portfolios is likely to encumber it further.

The biggest problem over the next couple of years is the complete uncertainty over how this is going to happen. This plan was clearly drawn up by the Premier and the health minister on the back of a napkin, then handed to administrators saying, “We think this is the best way to restructure health care and we want you to do it with $65 million in the next two years.”

When AHS was created in 2009, things didn’t stabilize until about 2016. We’re going to see a giant period of instability, increased costs, certainly no benefits to the acute care system, and significant concerns regarding blocking of beds by patients who can’t get into the continuing care system.

There are lots of situations where governments have centralized health care and that has its own problems. But there aren’t currently many examples where they’ve torn it apart.

There’s so much uncertainty. If you look on alberta.ca about this, no information has been updated since they made the announcement six months ago. All it says is that continuing care plans would be underway happening in the spring of 2024.

The only possible benefit I see is that there is the potential for things to become more regional. It could be an opportunity to address regional disparities in different areas of the province, but we don’t know if that’s actually something that will be a part of this.

The biggest thing that has been bothersome is that the Alberta Association of General Surgeons and the Alberta Medical Association (AMA) just haven’t been consulted at all about how this should be structured. You’d like to help them to at least continue to provide the services that people need, but there’s been no engagement. No one from the government has asked the people who actually work in the system.

Tony Gomes