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UBC Theses and Dissertations

Strategies for regional health planning in British Columbia Ryan, Patricia 1982

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STRATEGIES FOR REGIONAL HEALTH PLANNING IN BRITISH COLUMBIA by PATRICIA RYAN B.P.T., McGILL UNIVERSITY, 1972 A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE i n THE FACULTY OF GRADUATE STUDIES DEPARTMENT OF HEALTH CARE AND EPIDEMIOLOGY We accept t h i s t h e s i s as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA September, 1982 <£> P a t r i c i a Ryan, 1982 In presenting t h i s thesis i n p a r t i a l f u l f i l m e n t of the requirements for an advanced degree at the University of B r i t i s h Columbia, I agree that the Library s h a l l make i t f r e e l y available for reference and study. I further agree that permission for extensive copying of t h i s thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It i s understood that copying or publication of t h i s thesis for f i n a n c i a l gain s h a l l not be allowed without my written permission. Department of The University of B r i t i s h Columbia 1956 Main Mall Vancouver, Canada V6T 1Y3 Date i i Abstract In 1981/82 there was renewed interest in the concept of a regionalized form of health service delivery in B r i t i s h Columbia. A discussion paper which outlined a proposal for regionalizing those services funded d i r e c t l y by the Ministry of Health was cir c u l a t e d to the senior managers in the Ministry in August of that year. In this paper i t was suggested that regionalization would encourage the integration and co-ordination of health services at a regional l e v e l , thereby increasing the ef f i c i e n c y and effectiveness of the health delivery system. This study considers strategies for planning health service delivery at this regional l e v e l , with the model of regionalization outlined in the 1981 proposal used as a basis for discussion. Every e f f o r t has been made to develop an approach to planning that is feasible, given the context within which health policy decisions are made in B r i t i s h Columbia in 1982. To do this the changing trends in health care management in B.C. have been considered, and relevant planning and organization theory reviewed. Evaluations of regional planning systems in three other j u r i s d i c t i o n s are also described. The potential d i f f i c u l t i e s a Regional Manager might face in developing an integrated approach to regional planning are i d e n t i f i e d , and strategies to deal with these possible c o n f l i c t s outlined. It would seem from t h i s analysis that the degree to which authority is decentralized to the region is central to any decision about planning at the regional l e v e l . A model based on normative c e n t r a l i z a t i o n , and operational decentralization is suggested, with needs assessments, and p r i o r i z a t i o n of needs taking place at the region. Support for integrated regional health planning by both the government and the provider groups seems to be necessary i f good regional plans are to be developed, and if implementation of the plans and p o l i c i e s that evolve from the process are to be successful. It is suggested that introducing the structures and processes for planning at the regional level should involve two stages. During the f i r s t , the administrative functions for direct services would be decentralized, and a general review of health services and health care in the region undertaken. The development of a regional identity and l i a i s o n among the many subgroups operating in the region would be an important aspect of this f i r s t stage. The second stage, which would be implemented after one year, would see the development of a Regional Advisory Council and m u l t i d i s c i p l i n a r y , multiagency, Service Development Committees formed along service or functional l i n e s . More authority would be transferred to the Regional Manager during t h i s time in the areas of hospital budget review, and physician manpower planning. This i s the most important stage as i t has the potential i v to make the h e a l t h care system more e f f i c i e n t and e f f e c t i v e . In t h i s model support i s b u i l t i n t o the s t r u c t u r e f o r planning and there are r e g i o n a l wide co-o r d i n a t i n g and i n t e g r a t i n g mechanisms. V TABLE OF CONTENTS B#ge ABSTRACT i i TABLE OF CONTENTS v LIST OF FIGURES v i i i ACKNOWLEDGEMENTS i x CHAPTER I. BACKGROUND AND FRAME OF REFERENCE 1 I n t r o d u c t i o n 1 Major Assumptions 3 Boundaries to the Study 6 O u t l i n e of the Study 6 Methodology 7 Changing Trends i n Health Care Management i n B.C. . 8 S o c i a l C r e d i t P o l i c i e s 9 W i t h i n the M i n i s t r y of Health 10 R e g i o n a l i z a t i o n i n B r i t i s h Columbia 13 D e f i n i t i o n s ' 13 Rat i o n a l e f o r R e g i o n a l i z a t i o n 14 Implementation Problems 16 The B r i t i s h Columbia Model 19 I m p l i c a t i o n s f o r Regional Planning 24 I I . POTENTIAL DIFFICULTIES IN DEVELOPING AND IMPLEMENTING A REGIONAL HEALTH PLAN 26 I n t r o d u c t i o n 26 Organ i z a t i o n Design Theory 28 Achieving I n t e g r a t i o n and Co-ordination of Health Services 29 The P o t e n t i a l f o r C o n f l i c t at the Region 45 Sources of C o n f l i c t 45 S h i f t s W i t h i n the Cu l t u r e of the Org a n i z a t i o n ... 48 I m p l i c a t i o n s f o r Regional Planning 51 I I I . ORGANIZATIONAL STRATEGIES FOR ADDRESSING POTENTIAL PROBLEMS AT THE REGION 52 L i a i s o n Devices as I n t e g r a t i n g Mechanisms 52 Information Processing 56 Managing the C o n f l i c t 57 The New Role of the Manager 59 E v a l u a t i o n of the Manager 61 I m p l i c a t i o n s f o r Regional Planning 63 v i CHAPTER IV. DYNAMICS OF REGIONAL HEALTH PLANNING IN BRITISH COLUMBIA 66 Introduction 66 Support f o r Planning i n the 1980's 66 Levels or Stages of Planning 73 Approaches to Planning 75 Implementation Issues 78 Implications f o r Regional Planning 80 V. CENTRAL VERSUS REGIONAL PLANNING 82 Central (P r o v i n c i a l ) Health Planning 83 Standards as a Means of Planning 84 A l l o c a t i v e Planning 86 Role and Function of Central (Pr o v i n c i a l ) Health Planning 88 Summary 89 Regional Health Planning 89 A S h i f t i n R e s p o n s i b i l i t y 93 Role and Function of Regional Health Planning 94 VI. PLANS AND PLANNING 96 Introduction 96 Plan Oriented Planning 97 Process Oriented Planning 98 P a r t i c i p a t i o n 100 Provider P a r t i c i p a t i o n 100 Pu b l i c P a r t i c i p a t i o n 103 Implications for Regional Planning 106 VII. PLANNING SYSTEMS IN OTHER JURISDICTIONS 109 Introduction 109 New Zealand: A Provider Model 110 Service Development Groups 112 Structure • 113 The Process 113 Analysis of the Planning System 115 Summary 116 Ontario: A Consumer Based Planning Model 117 Structure 118 Planning Process 120 Analysis of the Planning System 121 Summary 122 B r i t a i n : A Bureaucratic Planning Model 123 Structure 123 Planning Within the National Health Service 125 Consumer/Provider Representation i n Planning 127 Analysis of the Planning System 128 Summary ••• 130 Implications f o r Regional Planning 131 v i i CHAPTER V I I I . CONCLUSIONS AND RECOMMENDATIONS 133 A. Summary 133 P o t e n t i a l D i f f i c u l t i e s 135 S t r a t e g i e s f o r S u c c e s s f u l Regional Planning 138 Support 139 L i a i s o n Devices 143 Plans and Planning 146 A l t e r n a t e S t r u c t u r e s f o r Planning 148 Recommendations 153 I.. Stage One - S e t t i n g the Stage 154 I I . Stage Two - The Development of an Integrated Planning Model 155 I I I . Stage Three - Increased Regional Autonomy 159 Conclusions 160 v i i i LIST OF FIGURES FIGURE PAGE 1. Proposed Health Regions f o r B r i t i s h Columbia 4 2. M i n i s t r y of Health Organization Chart 12 3. Factors A f f e c t i n g the Degree of D i f f i c u l t y i n Achieving Integration 30 4. Co-ordination Within the M i n i s t r y , Central/Regional ... 31 5. Co-ordination Within the M i n i s t r y , R e g i o n a l / D i s t r i c t .. 32 6. L i a i s o n Within the Health System 33 7. L i a i s o n With External Groups 34 8. Machine Bureaucracy 39 9. P r o f e s s i o n a l Bureaucracy 40 10. Factors A f f e c t i n g the Degree of D i f f i c u l t y i n Achieving Integration (11) 44 11. Integrating Mechanisms and the Environment 53 12. The P o l i t i c a l Manager 61 13. Rational vs Incremental Planning 76 14. The Planning Process 79 15. Developing a Planning Structure 82 16. Needs Assessment Model S3 17. Decision Tree 103 18. P a r t i c i p a t i o n i n Planning i n Other J u r i s d i c t i o n s 104 19. C i t i z e n P a r t i c i p a t i o n Matrix 106 20. Planning Structure i n New Zealand 112 21. SDG Planning Process 114 22. Ontario Regional Structure 118 23. The Regional Structure of B r i t a i n 123 24. The Flow of Guidelines and Plans i n the NHS 126 25. Percentage of GNP Spent on Health Services 130 26. Environmental Model of Health Planning 136 27. Bureaucratic Model — 148 28. D i s t r i c t Model 150 29. Service Development Committee Model 151 30. Regional Advisory Council Model 152 i x ACKNOWLEDGEMENTS This study has involved the e f f o r t s of many people. I would l i k e to extend my thanks to a l l those who have offered t h e i r support, and assistance during the time i t took me to complete t h i s work. In p a r t i c u l a r , I wish to express my appreciation and thanks to Dr. Anne. Crichton of the Department of Health Care and Epidemiology, U.B.C, for her guidance, encouragement, and her continued commitment to her students. I am also most g r a t e f u l to my other committee members, Mr. Paul Pa l l a n , M i n i s t r y of Health, f o r h i s valuable advice, and f o r reminding me of the many p r a c t i c a l issues involved i n planning health service d e l i v e r y , and Dr. Peter Frost, Department of Commerce, U.B.C, f o r h i s encouragement and assistance. F i n a l l y , to my fellow students, f r i e n d s , and family who have l i v e d through t h i s experience with me, my thanks f o r t h e i r continued support and good humour. 1 I. CHAPTER ONE: BACKGROUND AND FRAME OF REFERENCE INTRODUCTION In January 1981 there was a change of both the Minister and the Deputy Minister of Health in B r i t i s h Columbia. This precipitated a major reorganization of the Ministry with the result that there was a new reporting structure, extensive changes in personnel, and a s i g n i f i c a n t s h i f t in the strategies for control and administration of our health care system. Under discussion at the present time i s an extension of t h i s reorganization -- a proposal for r e g i o n a l i z i n g the delivery of those services such as Mental Health, Public Health, and Alcohol and Drug programs that are funded d i r e c t l y by the Ministry of Health. In t h i s study strategies for planning health services at the B.C. regional l e v e l w i l l be discussed and a design for planning that incorporates both t h e o r e t i c a l and p r a c t i c a l aspects of regional health planning presented. The rationale and objectives of B r i t i s h Columbia's regionalization proposal w i l l be outlined l a t e r in some d e t a i l . However, i t i s clear that the senior managers in the Health Ministry are being pressured to contain and control their spending. By integrating and co-ordinating services in a regional structure, they might make the health delivery system more e f f i c i e n t and e f f e c t i v e - i f there were good planning. But, there are 2 problems in doing t h i s . The onus of developing t h i s more e f f i c i e n t and e f f e c t i v e health delivery system w i l l be shifted to the new Regional Manager. This person must attempt to co-ordinate not only those services provided d i r e c t l y by the ministry, but also a l l those Quasi Autonomous Non Governmental Organizations (called QUANGO'S) such as hospitals and voluntary s o c i e t i e s which also provide services in the region. And while most of these organizations would agree that planning i s important, there are s t i l l serious misgivings about their support for integrated planning, and of the f e a s i b i l i t y of implementing the plans and p o l i c i e s that evolve from the process. Ginsberg (1.976), a health policy analyst in the U. S. suggests, "The burdens and pressures involved in implementation of regionalization f a l l on the bureaucracy ... there i s no constituency interested in i t , but there are powerful opposing groups." (226) Given these issues, which w i l l be developed more f u l l y in later chapters, i t i s clear that i f improved co-ordination and integration i s one of the main objectives of regionalization, then questions of strategy in developing a structure and process for planning at t h i s l e v e l are important, and should be addressed prior to implementation of regionalization in B r i t i s h Columbia. In t h i s study, four areas w i l l be considered: 1) The context within which health policy decisions 3 are made in B r i t i s h Columbia, 2) Organizational dynamics that should be considered in developing a strategy for planning at the region. 3) The role and function of planning at the regional l e v e l , and 4) Regional planning systems in other j u r i s d i c t i o n s C r i t i c a l factors a r i s i n g from these discussions w i l l be examined in developing a strategy for regional planning in B r i t i s h Columbia. MAJOR ASSUMPTIONS Any topic such as t h i s , which attempts to consider proposals s t i l l under discussion, must be based on certain assumptions. A major one in t h i s study is that regionalization w i l l procede as outlined in an internal draft document c i r c u l a t e d to senior managers in Health in August 1981, t i t l e d "Regionalizion of Health Care in B r i t i s h Columbia." In thi s proposal, seven regions were outlined, see figure 1. Each region is to have a manager who would be responsible for program delivery within that geographic area. The role of the region as outlined in thi s document i s as follows: 5 A. Services d i r e c t l y operated by the Ministry of Health 1. Overall regional planning for such services. 2. Overall budget development, a l l o c a t i o n , and monitoring. 3. Development of regional p o l i c i e s (to be consistent with p r o v i n c i a l p o l i c i e s ) and having input to p r o v i n c i a l p o l i c i e s . 4. Implementation and interpretation of province wide p o l i c i e s . 5. Provision of regional support services, including personnel, finance, planning and administration. 6. Overall need determination for the region. 7. Development of program structure to f i t regional needs. 8. Monitoring of program effectiveness, e f f i c i e n c y , and equity - based on p o l i c i e s and minimum standards that are developed by Program ADM's. B. Services funded through the Ministry of Health but  provided through some non-government agency (e. q~. Hospitals, Long Term Care f a c i l i t i e s , private health providers.) The role of the region in t h i s case includes: 1. Direct planning of services where no planning c a p a b i l i t y currently exists and l i a i s o n and co-ordination with existing planning bodies. 2. L i a i s i n g with such agencies in order to improve the co-ordination between government services and non-government services. 3. Monitoring compliance with o v e r a l l p r o v i n c i a l standards related to service delivery, management and programs. (1981,13) There was no mention in t h i s document of how a 6 Regional Manager was to go about achieving these goals, or what the structure and processes for planning would be. BOUNDARIES TO THE STUDY In the following chapters only the strategies for planning health services in a non metropolitan region w i l l be considered. H i s t o r i c a l l y , in B r i t i s h Columbia, the fiv e health units in the metropolitan areas of Greater Vancouver and V i c t o r i a have had a di f f e r e n t method of funding for health services. They have been separated as two regions - "Vancouver" and "Capital Regional D i s t r i c t " in t h i s proposal. I n i t i a l l y , at least, they w i l l have di f f e r e n t issues to consider in developing planning strategies. These w i l l not be addressed in thi s work. OUTLINE OF THE STUDY In following sections of thi s chapter, which i s concerned primarily with giving a background and frame of reference for this study, the reorganization of the Ministry of Health w i l l be outlined, as w i l l the rationale and objectives of B r i t i s h Columbia's regionalization proposal. In the next chapter t i t l e d , 'Organizational Dynamics at the Region', organizational design theory w i l l be reviewed and problems a manager must consider before developing a strategy for planning at that l e v e l discussed. Mechanisms for addressing these problems w i l l be suggested. Following t h i s , the role and function of planning at the region w i l l be developed, approaches to, 7 and mechanisms for planning w i l l be discussed-. A number of strategies for planning at t h i s l e v e l w i l l then be outlined in Chapter Four and examples of regional health planning in three other j u r i s d i c t i o n s examined. In the las t chapter, structures and processes for planning which seem to f i t the environment, the people, and the task in B.C. w i l l be proposed. A paradigm used to discuss and analyze these prospective models is one developed by Hall et a l . , in Change, Choice, and C o n f l i c t in Social Policy, (1975). They contend that issues gain p r i o r i t y for implementation according to three general c r i t e r i a . These are legitimacy, f e a s i b i l i t y , and support. According to Hall et a l . , issues (and by extrapolation, planning strategies) with high levels of these c r i t e r i a w i l l usually be more successful.(1975,475) METHODOLOGY The material for t h i s study has been gathered through a review of the l i t e r a t u r e , and by di r e c t interviews. (i) Literature Review Extensive review of l i t e r a t u r e on regionalization, regional plannning, and organizational theory has been done. Relevant theory w i l l be outlined in the f i r s t three chapters. 8 (i i) Direct Interviews In order to understand some of the implications of the 1981 reorganization for planning and policy making within the ministry, interviews were conducted with senior f o f f i c i a l s in the Ministry of Health. Information about the history of health care in B r i t i s h Columbia, and the history of planning for health delivery was gathered through discussions with many people. Of par t i c u l a r help were Dr. A. Crichton, Acting Program Director, U.B.C, Health Services Planning; Mr. Paul Pallan, Director, Policy Analysis, Policy, Planning and L e g i s l a t i o n , Ministry of Health; and Dr. C. Key, former Deputy Minister of Health. Information about regional health planning in other j u r i s d i c t i o n s was gathered through discussions with Mr.Bob N i c h o l l s , and Mr. D. Nichol, Area Health Co-ordinators in the United Kingdom; Dr. L. Malcolm, Regional Health Planner in New Zealand; and Mr. C. Roy, Assistant to Executive Director, Thames Valley D i s t r i c t Health Council in Ontario. CHANGING TRENDS IN HEALTH CARE MANAGEMENT IN B.C. Before going on to discuss regionalization, i t is important to establish the context in which these changes are being proposed. 9 SOCIAL CREDIT POLICIES The Social Credit party was returned to power in B r i t i s h Columbia in 1975 with a commitment to balancing the budget and stimulating long term investment in energy resources and industry. These goals became d i f f i c u l t to accomplish as changes in thet economy caused a decrease in revenue from natural resources ( p a r t i c u l a r l y in the forest industry). At the same time, expenditures in the s o c i a l services were increasing at a rapid rate. This was partly a carryover from the programs developed by the N.D.P. when they were in power, but was also a r e f l e c t i o n of a developing recession. The government compensated for the loss of revenue in 1980/81 by increasing taxation and putting more emphasis on 'good management' within the c i v i l service. Cabinet consolidated f i n a n c i a l control within the Ministry of Finance in 1980, increasing the power of Treasury Board. By doing t h i s , i t gained more contol over other m i n i s t r i e s , such as Health. This trend towards c e n t r a l i z i n g control was also evident with the release of a discussion paper "A New Financial Administration Act" (1980). In t h i s paper, which attempted to update and r a t i o n a l i z e the existing l e g i s l a t i o n r e l a t i n g to f i s c a l p o l i c y , d i r e c t f i n a n c i a l control by government over a l l public bodies was proposed. This section was subsequently removed afte r strong opposition from many groups, 10 including hospitals, who were wary of government interference. However, the inclusion of this section in the report indicated government's intention to increase i t s f i n a n c i a l control and accountability mechanisms. Premier Bennett's announcement, almost two years l a t e r , of a wage and spending restraint program designed to apply to a l l public bodies spending public monies might be seen as a reincarnation of this idea. This time, despite pressure from the same groups i t does not appear that government w i l l back down. What are the implications of these trends for the Ministry of Health? And why would government consider decentralizing health services delivery at a time when they appear to be c e n t r a l i z i n g control? WITHIN THE MINISTRY OF HEALTH As the largest spender of p r o v i n c i a l monies (31% of the budget in 1981), the Ministry of Health i s understandably under close scrutiny from the Cabinet. Despite e f f o r t s to control spending, annual expenditures have increased from $337 m i l l i o n in 1971 to more than $2 b i l l i o n in 1981. Analysts of health care policy in B.C. (UBC Health Policy Study Group,1982), suggest that i t was t h i s rapid increase in expenditure at a time when p r o v i n c i a l revenues were decreasing that precipitated the recent major reorganization of the Ministry of Health in 1981. 11 As we stated e a r l i e r , in January 1981 a new Minister was brought into the Ministry. With him came a Deputy known for his tough administrative s t y l e . During the next year there was a complete change in the senior health personnel, from those with a c l i n i c a l professional and program orientation to those with professional administrative, organization, and f i n a n c i a l management s k i l l s . The new managers' commitment to cost control and . an increase in accountability was evident with the release of a new organization chart (figure 2) in October 1981. It can be seen that with t h i s new structure f i n a n c i a l and managerial control i s centralized under the Senior Assistant Deputy Minister (ADM) of Management Operations. A l l major support staff report to him. In addition, in the regionalization proposal (1981) i t was suggested that an ADM Service Delivery (responsible for regionalization) would also be accountable to him. This would leave the the Program Assistant Deputy Ministers, i . e . ADM Prevention, ADM Care, and ADM I n s t i t u t i o n a l Services responsible primarily for policy development, program planning, and standards. By removing r e s p o n s i b i l i t y for implementing service delivery, much of their control and power would be taken away. The outcome of the reorganization of the Ministry of Health i s that i t i s now headed by a Minister and senior managers who share Treasury Board and Cabinet's DEPUTY MINISTER 3 Med tea) AdvUory CommUto! Pollcy & Ratource Allocation Committee Figure 2. Minlitry of Haalth OraanUallon Chart (Sept. 1981) Director Inform (lion Sanrloai 1 Executive Senior Atiiitint Deputy Minuter Director lcv*l Service* L»ee. Director Finjnoel Service! ' Director Administration Director P tr»onnel Service* E»ec Director Mjojgemcnl Into. Sritemi (proposed i n Reg. D i s c u s s i o n paper) Anliumt DAI, Community Ce/a Service* Atilttant DM. Imtltutionol Sorvloei Director Management, Service* 1 I Exec. Director Planning Policy] & legislation Exec. Olrector |Mtdic4l Servltei Plan Exec. Director Management Practice* and Aud'» E«ec. Director Emergency Health Servient r Assist. D.M. Service! Delivery I Director Policy & Planning |_|Exec. Director Mental Health Aailttcnt DM. H O J P I U I P r o g r e m i Exec. Director Alcohol end Drug Comm. txec. Director Foronjic Piycluat/lo Comminion 1 Director Policy and Plant) ing AintUnt DM. Pravtnthra Service* X Provincial Health Olhctr 1 Aiustant OM. Long Tarm/Homa but AitUtant OM. Vancouver Bureau Director Policy and Planning Director Public Health Inspection Director Dental Health Services Director Occupational Health Director Nutrition & Health Ed. Director Public Health Nursing Director Epidemiology Director Speech and Hearing Regional Managers 13 strong cost control and containment ideology. But, within the Ministry of Health i t s e l f , and c e r t a i n l y in the i n s t i t u t i o n s , agencies, and services which i t funds, but does not control d i r e c t l y , an opposing ideology which champions further spending, more service, greater a c c e s s i b i l i t y , and more autonomy p e r s i s t s . The tension between these two opposing forces w i l l create serious problems for managers and decisionmakers in the health system, and w i l l be p a r t i c u l a r l y evident at a regional l e v e l . In the next section we w i l l look at regionalization, i t s p r i n c i p l e s , and the model that i s proposed for B.C. REGIONALIZATION IN BRITISH COLUMBIA DEFINITIONS Regionalization has been defined in many ways and means something d i f f e r e n t to health planners, p o l i t i c i a n s , and providers. Some of the more common de f i n i t i o n s suggest: It i s a scheme for the geographic deployment of health care resources in an organized and h i e r a r c h i a l arrangement so that the maximum amount possible i s done at the lowest service l e v e l , and services of progressively greater levels of intensity are provided appropriately according to the needs of the individual patients. (Rhode Island,1977,2) It i s a way to allow for the provision of care to the right patient, at the right time, in the 1 4 right place, and for the right reason. (McDermit, 1979,11) Regionalization of health services is the v i s u a l i z a t i o n of integrated planning of a system of care with multiple but co-ordinated functions serving a geographical area demarked not by r i g i d p o l i t i c a l boundaries but according to c r i t e r i a based on people's consumption patterns with respect to care, and technical factors determining the optimum dimensions of the d i f f e r e n t types of services. (Task Force,1970,19) In analyzing these and other d e f i n i t i o n s , one sees that most would agree the term denotes a structure within a given boundary or geographic area for the deployment of services, and involves the p r i n c i p l e s of r a t i o n a l i z i n g , and optimizing the a l l o c a t i o n of resources. RATIONALE FOR REGIONALIZATION Regionalization has been described as the panacea of every health care planner since Dawson f i r s t recommended i t in 1920. (Bice, 1976, 90) It i s brought out again and again in health care l i t e r a t u r e by those discussing health care p o l i c y , and health care organization, as the method of choice for delivery of services. The major reports written for each province in Canada since 1968 have a l l recommended the establishment of regions. Although they vary in their recommendations regarding the size of the regions, boundaries, and 1 5 administrative structures, the basic concept of the planning, co-ordination, and integration of health services for lower costs and the continuity of care remains constant. A report of the Task Force on the Cost of Health Services in Canada (1970) made a firm proposal for regionalization on f i n a n c i a l grounds. The need i s so evident, the economics and improvements so s i g n i f i c a n t , that regional planning should proceed immediately (20) The Hall Commission, 1964, and the Hastings Report 1971 also made recommendations along these l i n e s . Regionalization attempts to strik e a balance between the centralized need to maintain a given l e v e l of quali t y throughout the system.and the decentralization required to e l i c i t community involvement at a l o c a l l e v e l . Therefore i t i s seen as the l o g i c a l and desirable middle l e v e l for the planning and administration of health services. (Arbon & Ramirez de Arellaro,1978,6) Regionalization has proceeded or been proposed in many countries in the world, from s o c i a l i s t Cuba and Russia, to p l u r a l i s t , democratic countries such as the United States. Both developing and developed countries have t r i e d i t , primarily because most governments now, regardless of their p o l i t i c a l ideology or state of their economy, are the ones responsible for the delivery of health care. There are increasing pressures on a l l governments to ra t i o n a l i z e the expensive resources involved in health. The problems tend to be s i m i l a r : 1) increasing percentages of the GNP going to health 2) increasing rate of resource consumption 3) increasing demands for high technology 4) increasing demands for equity In the developing countries regionalization i s proposed as the best method to use the few resources ava i l a b l e . In developed countries i t is seen as a more palatable instrument of cost containment and sensible cost con t r o l . This would appear to be the reason for B.C. proposing i t at t h i s time. IMPLEMENTATION PROBLEMS Why, i f regionalization i s seenby most people to be the most rational and e f f e c t i v e way to deliver health services has i t not been implemented more often and more successfully? There are several reasons. One of the most important i s described by Arbon and Ramirez de Arellaro, health planners in the World Health Organization. Participants in any regionalization e f f o r t are not only disparate but may, indeed, c o n f l i c t with the o v e r a l l goals of the organization. Local o f f i c i a l s resent relinquishing any of their power to regional a u t h o r i t i e s , central o f f i c i a l s are also reluctant to delegate. Professional r i g i d i t y cannot be underestimated, and people accustomed to working in established patterns don't l i k e change. Private organizations i . e . medical associations also 17 r e s i s t . Regionalization therefore, equals negotiating, bargaining, and compromise. (1978,77) Although they talk about a developing country, many of the same problems exist in attempting to implement regionalization anywhere. If one is to make our health care system more e f f i c i e n t and e f f e c t i v e i t may well involve the elimination or r e s t r i c t i o n of superfluous or dysfunctional structures. This has been proven many times to be exceedingly d i f f i c u l t . These then are some of the general d i f f i c u l t i e s which w i l l be explored in greater d e t a i l in r e l a t i o n to implementation problems in B.C. Ken Charron (1977,142) discussed the Canadian experience with regionalization and suggested that i t had not progressed more in Canada because of the t r a d i t i o n a l lack of public interest in health care structures, lack of knowledge of how to go about i t , p o l i t i c a l i n e r t i a , and a 'don't rock the boat' atti t u d e . These factors are apparent in B.C., but also in our polarized p o l i t i c a l system regionalization is associated with the more s o c i a l i s t N.D.P. philosophies and platforms. Regionalization was f i r s t proposed for B.C. but with a much d i f f e r e n t structure by R.G. Foulkes in 1974. His model, which tended to be more a proposal for decentralization than regionalization stressed community p a r t i c i p a t i o n . This present proposal does not. It i s clear there are bound to be many 18 d i f f i c u l t i e s in introducing regionalization in B.C. If the government i s to ensure successful implementation th i s author suggests that i t must not only be aware of the potential d i f f i c u l t i e s , but must also c a r e f u l l y plan the structure and the implementation process in order to minimize c o n f l i c t and gain support for the p o l i c i e s and plans that follow. B.C. REGIONALIZATION OBJECTIVES The objectives of regionalization as stated in the B.C. Regionalization proposal are as follows: 1) To improve the e f f i c i e n c y and effectiveness of the health care system. 2) To improve accountability of the health care system at a l l l e v e l s . 3) To improve equity within the health care system. 4) To maintain and improve the quality of health services. (1981,11) These objectives r e f l e c t the present philosophy of the senior managers in health, which are cost containment ( e f f i c i e n c y , and effectiveness) and cost control (accountability). 19 THE BRITISH COLUMBIA MODEL There are several d i f f e r e n t models of regionalization which can be analyzed according to five main factors. These are: 1) the rationale behind boundary formation 2) the number of services covered 3) the methods of implementation 4) the r e l a t i v e degree of autonomy at the region 5) the extent to which p a r t i c i p a t i o n i s allowed by consumer and provider groups The B.C. model w i l l be described in r e l a t i o n to these fiv e points and w i l l be b r i e f l y compared with other models of regionalization presently operating in Canada. i . Boundaries The c r i t e r i a or methodology for mapping regions depends on the reasons for r e g i o n a l i z i n g . Rationale could depend on: a) a technological base - i . e . a Regional Medical Centre as a t e r t i a r y hospital and a corresponding area that has primary and secondary i n s t i t u t i o n s b) p o l i t i c a l boundaries - respecting existing municipal or county boundaries c) s p a t i a l (natural) approach - in which regions are derived from usage, patterns of service within an area 20 d) demographic - boundaries developed taking into account population figures In Quebec, boundaries have been determined on a technological base, while Ontario used p o l i t i c a l boundaries for i t s D i s t r i c t s , and a modified technological base for i t s Regions. In B r i t i s h Columbia, a combination of (b) and (c) was used in developing the preferred option for the boundaries. Existing boundaries of Regional Hospital D i s t r i c t s , and Public Health Unit Boundaries were recognized, and every attempt made not to s p l i t them. There was also an attempt to recognize the r e a l i t i e s of geography, transportation, service u t i l i z a t i o n , and patterns of movement of the population. (B.C. Regionalization Proposal,1981,16) i i . The Number Of Services Covered Regionalization can involve one department or several m i n i s t r i e s . In Quebec, and i n i t i a l l y in Manitoba, health and s o c i a l services were regionalized together because i t was f e l t that so many of the problems were related. (Manitoba separated the two after a short time.) In B.C., at least as a f i r s t stage, only those services d i r e c t l y provided by the Ministry of Health w i l l be regionalized. 21 i i i . The Methods Of Implementation Regionalization could be introduced into one region at a time as a demonstration or p i l o t project, or implemented a l l at once. It could be done v o l u n t a r i l y by Regional councils, or l e g i s l a t e d by the government. In Canada there have been d i f f e r e n t approaches. Quebec and Manitoba forced the pace of regionalization by taking fixed positions, and introducing l e g i s l a t i o n that demanded compliance. (Charron,1977,42) Subsequently they had to modify their positions. Ontario developed i t s proposals over a number of years and succeeded in gaining substantial support. It transferred the i n i t a t i v e s for D i s t r i c t Health Councils to the people in the d i s t r i c t . In B r i t i s h Columbia, i t i s not clear at t h i s stage how the government w i l l introduce the regionalization of health service delivery to the province. i v . The Relative Degree Of Autonomy At The Region On the c e n t r a l i z a t i o n / d e c e n t r a l i z a t i o n continuum, there are many alte r n a t i v e s , and the choice for any p a r t i c u l a r decision making structure depends on the p r i o r i t y given to control versus p a r t i c i p a t i o n , and to uniformity versus d i f f e r e n t i a t i o n . Martins, in "Concepts and Practices for Regional Administration" 1975, suggests three models for the 22 purposes of analysis: 1) Complete Autonomy - not r e a l l y feasible, t h i s would be l i k e a state within a state. It would have a high degree of self s u f f iciency and legal authority. 2) Relative Autonomy - these are most common. They tend to leave open considerable areas of disc r e t i o n in the application of basic p r i n c i p l e s of decentralization to a variety of areas. 3) Close Supervision model This approach would have a regional administration under close supervision of central a u t h o r i t i e s , with only a small measure of l o c a l d i s c r e t i o n . Most of these operate more l i k e branches than regional administations. In Canada, for the most part, regionalization has been implemented with a model of r e l a t i v e autonomy. If we consider this on a continuum, Manitoba and Quebec undoubtedly are closest to a model of regional autonomy, while Ontario has a r e l a t i v e degree of autonomy. We would expect, given the trends outlined e a r l i e r , that B.C. would implement in the name of e f f i c i e n c y and effectiveness, and with an underlying goal of cost containment, a model of regionalization based on close supervision. Implications of thi s w i l l be discussed in later sections. v. P a r t i c i p a t i o n How are citizens,consumers and providers to be involved in the planning and administration of health services? Again, this w i l l be considered in more d e t a i l l a t e r , but b r i e f l y , in Quebec p a r t i c i p a t i o n and control 23 by both these groups was b u i l t into the system. In Ontario D i s t r i c t Health Councils act in an advisory capacity to the pr o v i n c i a l health ministry. In B.C., no provision for p a r t i c i p a t i o n in the planning or administration of the health services by either the provider or consumer groups has been suggested. v i . Summary We see, then, i f B.C.'s proposed model of regionalization i s analyzed according to these five points that there is every indication that i t would r e f l e c t the present p r o v i n c i a l government's p o l i c i e s of maintaining strong central control and increasing accountability mechanisms. The objectives outlined e a r l i e r suggest t h i s , as does the fact there has been no involvement as yet in the planning by people in the f i e l d . , Neither has there been any suggestion for p a r t i c i p a t i o n by the providers or consumers in either the planning or administration of health services at the region. Increased equity and improved a c c e s s i b i l i t y to services appear to be of secondary importance in t h i s time of recession and f i s c a l constraint. Whether or not t h i s p a r t i c u l a r model of regionalization i s the best approach to contain costs and get 'value for money' remains to be seen. Another underlying reason for the government to introduce regionalization at t h i s time i s that a regional o f f i c e would act as a buffer between V i c t o r i a and the 24 interest groups in the region. This mechanism has been used before by government in bargaining (HLRA), and could be an e f f e c t i v e mechanism to contain costs. IMPLICATIONS FOR REGIONAL PLANNING The purpose of t h i s chapter was to give the background and frame of reference for planning at the regional l e v e l . It has been suggested that the reorganization of the Ministry of Health (with a complete change of senior managers), indicates a strong desire by the present government to increase centralized control and strengthen accountability mechanisms at a l l l e v e l s . The proposal for regionalization i s a natural evolution of t h i s p o l i c y . Any regionalization scheme has many implementation problems, with the most serious tending to revolve around the fears of interest groups at the regional l e v e l about the loss of autonomy. With increased control and accountability as clear objectives of t h i s B.C. model, i t can be anticipated that problems w i l l a r i s e quickly in^B.C. - the extent depending primarily on how these groups perceive t h i s proposal as a real or potential threat to their self i nterest. This w i l l place the new regional manager in a d i f f i c u l t p o s i t i on. In t h i s f i r s t year he or she w i l l 25 have direct authority ( f i s c a l , managerial) only over those services d i r e c t l y operated by the Ministry. But, i f the goals of increased e f f i c i e n c y and effectiveness are to be reached the Regional Manager w i l l need the support of the big spenders in health - the hospitals, and physicians - 1 in developing an integrated Regional Health Plan. These issues w i l l be expanded in later chapters. At this point, i t i s s u f f i c i e n t to say that these dynamics and the potential for c o n f l i c t at this l e v e l have important implications for the manager who w i l l be developing structures and processes for planning. In the next chapter organizational dynamics relevant to t h i s discussion w i l l be outlined. 1 Hospital Programs took 53%, MSP 23% of the Prov. Health Budget, Government Estimates, 1981/1982. 26 II. CHAPTER TWO: POTENTIAL DIFFICULTIES IN DEVELOPING AND  IMPLEMENTING A REGIONAL HEALTH PLAN INTRODUCTION In an organization as complex as the B.C. health care system, a proposal for the decentralization of administrative functions, regionalization, and the introduction of a new layer in the bureaucracy invites a great deal of speculation as to the l i k e l i h o o d of success of the venture, the appropriateness of the structure, and possible implementation problems. But although these questions are interesting, they are not in themselves central to the problem addressed in this study - stategies for planning at the region. Because of t h i s , only those organizational dynamics important to the development of structures and processes for e f f e c t i v e planning w i l l be discussed. Planning in and for an organization can take many forms. In a small, or simple structure in a stable environment, long range planning i s primarily a manager's r e s p o n s i b i l i t y . It is often done in an ad hoc or 'laissez f a i r e ' manner. Success depends to a large extent on the manager's personal s t y l e , leadership a b i l i t y , and foresight. As an organization becomes more complex, and the environment more unstable, the role and function of planning changes. The planning process tends to become more formalized and the stategies for successful planning 27 more c r i t i c a l . In a complex p o l i t i c a l organization such as the health care system i t is p a r t i c u l a r l y important to design structures and processes for planning that are not overly dependent on the style or a b i l i t i e s of any one person. It has been shown only too c l e a r l y in the past year with the 'resignations' of the fi v e top managers in the Health Ministry, that when there i s unrest, or external pressure for change, managers can be s a c r i f i c e d . This gives the appearance at least, that those in charge are attempting to solve the problem. Pfeffer talks about the symbolic role of the manager as one of control and personal causation. (1978, 263) This i s what leads people to believe that when things go wrong, f i r i n g the manager w i l l help. It does not seem unreasonable to suggest, given the p o l i t i c a l nature of the health care organization, and the potential for c o n f l i c t at the regional l e v e l , that Regional Managers might be replaced r e l a t i v e l y quickly. We have said that one of the functions of planning at thi s l e v e l i s to co-ordinate, and integrate services. Therefore, i t would be important to have mechanisms which link the many subgroups at the region b u i l t into the design for planning, and not have their co-ordination l e f t e n t i r e l y to the manager's d i s c r e t i o n . It was because of thi s premise that organization design theory has been chosen as a theoretical base for 28 developing a planning strategy at th i s l e v e l . ORGANIZATION DESIGN THEORY Those who study organization design try to iden t i f y the structures and processes that f i t the type of people and the kind of task the organization faces. (McCaskey,1980,73) The approach that w i l l be taken here to consider an organizational design for planning at the region is one based on " s i t u a t i o n a l " theory. Lorsch in discussing t h i s idea states that the term " s i t u a t i o n a l " in t h i s context implies that appropriate behavior patterns in an organization are dependent on the environment that confronts i t , and on the perso n a l i t i e s of i t s members. (1980,273) Analysis by s i t u a t i o n a l theory, he says, "provides managers with a way to think about organization design in re l a t i o n to these two factors and can help them to understand some of the complex problems that they face." (1980,276) It i s clear that one of the more obvious roles of planning at th i s l e v e l i s to encourage better integration and co-ordination of services (which would make a more e f f i c i e n t and e f f e c t i v e health delivery system). This was i l l u s t r a t e d in the la s t chapter when the proposed role of the B.C. health region was outlined. In t h i s section, a region w i l l be considered in .29 re l a t i o n to i t s environment, and to i t s sub groups. D i f f i c u l t i e s of planning the co-ordination and integration of services w i l l be reviewed and mechanisms or devices to promote or aid i t w i l l be outlined. ACHIEVING INTEGRATION AND CO-ORDINATION OF HEALTH SERVICES Lorsch (1979,1980), Lawrence and Lorsch (1979), and Pfeffer (1978) have written extenively on the d i f f i c u l t i e s in achieving integration and co-ordination between subunits in an organization. A chart proposed by Lorsch (1979,107) to measure the degree of d i f f i c u l t y in t h i s has been adapted and expanded, and w i l l be used to examine the B.C. Regional organization. (See Figure 3) FIG. 3 FACTORS AFFECTING THE DEGREE OF DIFFICULTY IN ACHIEVING INTEGRATION DIFFICULTY FACTOR LOW > HIGH 1. Dependence on, and r e l a t i o n s h i p to the environment low high 2. Number of units requiring i n t e g r a t i o n small many 3. Degree of d i f f e r e n t i a t i o n among units small large 4. Complexity and degree of uncertainty of the information simple and highly c e r t a i n highly complex and uncertain 5. Importance of i n t e g r a t i o n to the organization n-.^ f g i n a l c r i t i c a l (adapted from Lorsh,1979,107) 31 i . Dependence On And Relationship To The Environment Regional health planning involves many organizations and many departments. Some of the complex int e r r e l a t i o n s h i p s for planning at the region w i l l be i l l u s t r a t e d in the following figures (see Figures 4-7). These are diagramatic and should be looked at in conjunction with the organization chart (figure 2). Figure 4. Co-ordination Within the Ministry, Central/Regional SENIOR A.D.M. A.D.M. SERVICE DELIVERY ( f i s c a l and managerial p o l i c i e s ) PROGRAM A.D.M.'s (standards, program p o l i c i e s , p r i o r i t i e s ) REGIONAL MANAGER Program planning and policy making in these dir e c t service areas such as Long Term Care, Mental Health, and Public Health w i l l be done by the Program ADM's (Prevention, Care, and Institutions) in V i c t o r i a . This means that planning and p o l i c y making is to a large extent separated from the implementation and control function which w i l l be the r e s p o n s i b i l i t y of the ADM Service Delivery, and the Regional Manager. This leads to a complicated quasi matrix structure. Some mechanism for feedback between these groups i s necessary. 32 Figure 5. Co-ordination Within the Ministry -Regional/District A.D.M. SERVICE DELIVERY DIRECTOR PLAN/POLICY REGIONAL MANAGER REGIONAL MANAGER PLAN/POL. DISTRICT DISTRICT A. B. PUBLIC HEALTH LONG TERM CARE ALCOHOL & DRUG MENTAL HEALTH The Regional Manager has f i s c a l and administrative r e s p o n s i b i l i t y for di r e c t services offered by the Ministry. There would have to be planning to co-ordiniate these services within the region. As each region w i l l have more than one d i s t r i c t , there w i l l have to be some mechanism for these D i s t r i c t Directors and program managers to co-ordinate and plan at this l e v e l . 33 Figure 6. Liaison Within the Health System Regional H o s p i t a l D i s t r i c t Boards Long Term Care k \ Hospitals (Medical Admin., Hosp. Admin.,, Department Heads) Union Bd. of Health REGIONAL PLANNING Mental Health Services Emergency Services) Voluntary Organizations Physicians External to thi s organization, but c r i t i c a l to any e f f o r t by a Regional Manager to co-ordinate and integrate and therefore better plan for services at this l e v e l are Othe QUANGO'S such as hospitals, and voluntary organizations, and 2) those other boards such as Regional Hospital Boards or Union Boards of Health who are already in existence. Some mechanism for involving these groups in regional planning i s necessary both from a rati o n a l standpoint (to avoid duplication) and a p o l i t i c a l standpoint (support, and therefore f e a s i b i l i t y ) . 34 Figure. 7. Liaison With External Groups Interest Groups iF.Tnrf rnnmenta 1 Crniips M i n i s t r y of Human Resources Mi n i s t r y of Education Municipal Councils REGIONAL PLANNING Worker's Comp. Min i s t r y of Transport: Changes in health status of a population have been shown in recent years to be influenced only marginally by the application of more health services. Lalonde, in "A New Perspective on the Health of Canadians", 1974 states that, major causes of death now are l i f e s t y l e related. Reports coming out of England, following attempts to r a t i o n a l i z e the a l l o c a t i o n process for health services, seem to indicate that health status is far more related to sociodemographic factors than access to health f a c i l i t i e s and health services. (Martini et a l . , 1977, 293-309) Therefore, any regional planning model must allow input to and feedback from other m i n i s t r i e s , agencies, and departments. This must be considered when developing a stategy for planning at the region. 35 As we see, t h i s regional organization is only a small part of a big system, and in fact most analysts of health organizations take an open systems approach to discussions of health care. We see that the relationships between a l l the various organizations which play a part in our health care delivery system are both complex and c r i t i c a l . " This makes the region very dependent on i t s environment for successful operation. Lorsch, discusses a n a l y t i c a l techniques for gauging t h i s l e v e l of dependence (1979,102). He contends one must consider the number of forces and the i n s t i t u t i o n s outside the organization which must be dealt with in order to achieve the organization's purpose. If we assume that one of the reasons for regionalizing i s to co-ordinate and integrate services at this l e v e l then the many interrelationships described above indicate that the regional organization i s indeed very dependent on i t s environment and therefore w i l l be d i f f i c u l t to co-ordinate . i i . Number Of Units To Be Integrated As we have said, the large number of units to be integrated at the regional l e v e l contributes to the d i f f i c u l t y in co-ordination. 36 i i i . D i f f e r e n t i a t i o n Of Units Involved In Planning The degree and nature of the differences between the many subunits involved in deli v e r i n g health care at a regional l e v e l are important to consider before developing a strategy for planning. When there i s a great deal of d i f f e r e n t i a t i o n , integration and co-ordination of services becomes more d i f f i c u l t , because each group tends to see problems from i t s p a r t i c u l a r point of view. McCaskey (1980,73-80) states that with a greater degree of d i f f e r e n t i a t i o n there i s also a heavier burden on information processing, and upon decision making within the organization. In health care in general, and at thi s regional l e v e l in p a r t i c u l a r , several factors lead to an extreme degree of d i f f e r e n t i a t i o n between groups. These groups d i f f e r not only in the nature of their work, but also in their history, ideology, and perceptions. An in depth analysis of the nature of the differences between a l l the subgroups involved in health care in B.C. i s far too big a task for t h i s section. That there are differences histor i c a l l y and id e o l o g i c a l l y i s c l e ar. Several factors which contribute to thi s w i l l be outlined b r i e f l y . It was not u n t i l 1974-5 that the Ministry of Health f u l l y amalgamated Hospitals, Public Health, Mental Health and the Medical Service Commission under one Deputy 37 Minister. Prior to that they had been under four Deputies, and in the not too distant past the health care organization as we know i t had been under d i f f e r e n t ministries e n t i r e l y . New funding mechanisms were introduced by the Federal Government when the Hospital Insurance and Diagnostic Services Act was passed by the Federal Government in 1958. This provided for 50/50 cost sharing by the federal government for those programs operating out of hospitals, and led to both a d i f f e r e n t orientation to health care, and d i f f e r e n t mechanisms for contr o l . Hospitals and hospital administrators in the technological era following the second world war tended to become very entrepreneurial. Their emphasis was on advanced high technology and cure rather than low technology and prevention. Although Public Health, Mental Health, the Medical Services Commission, and I n s t i t u t i o n a l Services were s t r u c t u r a l l y amalgamated in 1974-5 there i s l i t t l e evidence even now to suggest that there has been much functional integration between these very d i f f e r e n t organizations. An i l l u s t r a t i o n of t h i s i s the fact that when thi s regional structure was f i r s t proposed and work begun on determining boundaries i t was discovered that there were eight separate regional boundary systems already in existence in the Ministry of Health. Attempting to integrate organizations responsible for such varied tasks as administering 38 Insurance, and providing Mental Health services, Public Health Inspection,and Primary Health Care - who have varied s t a f f , and sometimes c o n f l i c t i n g goals, becomes extremely d i f f i c u l t . Mintzberg in "Organizational Design, Fashion or F i t " (1981) discusses the problem of f i t between the structure of an organization and the kind of work that is done. He suggests that inappropriate designs can lead to disharmony. In analyzing organizational structures, he came up with fiv e clear configurations to describe structures that f i t the type of work done and the environment encountered. These are: 1) simple structure 2) machine bureaucracy 3) d i v i s i o n a l i z e d form 4) professional bureaucracy 5) adhocracy If we consider t h i s amalgamation of the Ministry of Health, two of these designs seem p a r t i c u l a r l y relevant. a) Machine Bureaucracy Here the emphasis i s on standardization of work. A large hierarchy emerges in the middle l i n e to oversee the specialized work of the operating core (Figure 8). It tends to ce n t r a l i z e power at the top. Mintzberg says that because external controls encourage bureaucracy and c e n t r a l i z a t i o n , t h i s configuration i s often assumed by organizations l i k e governments, or agencies that are subject to many external Figure 8. Machine Bureaucracy 39 controls. '(1891,108) In health, the c l e r i c a l l y oriented Medical Service Commission, Hospital Insurance Programs, and Personnel Services would tend to operate well with t h i s machine bureaucracy structure. In their case, standardization of work processes would tend to be demanded. However, th i s would work less well with the predominantly professional groups such as those working in Mental Health and Public Health. Some reasons are outlined below, b) Professional Bureaucracy This bureaucratic configuration r e l i e s on the standardization of s k i l l s more than work processes or outputs for co-ordination. Professionals are given 40 c o n s i d e r a b l e c o n t r o l over t h e i r work and i n t h i s s t r u c t u r e the o r g a n i z a t i o n s u r r e n d e r s a good d e a l of power not o n l y t o the p r o f e s s i o n a l s t hemselves but a l s o t o the a s s o c i a t i o n s and i n s t i t u t i o n s t h a t s e l e c t and t r a i n them i n the f i r s t p l a c e . ( M i n t z b e r g , 1 9 8 1 , 1 0 9 ) In a p r o f e s s i o n a l b u r e a u c r a c y the s t r u c t u r e t h a t emerges tends t o be d e c e n t r a l i z e d , w i t h power f l o w i n g a l l the way down the h i e r a r c h y t o the p r o f e s s i o n a l s i n the o p e r a t i n g c o r e . ( f i g u r e 9) F i g u r e 9. P r o f e s s i o n a l B u r e a u c r a c y T h i s i s , of c o u r s e , a s i m p l i f i c a t i o n of the i s s u e , as a h e a l t h c a r e o r g a n i z a t i o n a t a l l l e v e l s c o n t a i n s a mix of t h e s e and o t h e r s t r u c t u r e s . But i n g e n e r a l , the problem i s c l e a r . Not a l l groups can be managed or c o n t r o l l e d i n the same way. W i t h the t r e n d i n government t o i n c r e a s e c e n t r a l c o n t r o l one might expect 41 problems of ' f i t ' , p a r t i c u l a r l y with the professional groups. Even within what we might c a l l the professional side of the organization there are inherent and deep rooted differences between groups. Increasing s p e c i a l i z a t i o n and competition for scarce resources encourages t h i s . In recent years there has been more c o n f l i c t between those who support the 'medical model' of health care ( i . e . doctors in charge) and those who dispute i t . This has arisen partly from movements in the late 1960's and early 1970's in the United States. Some areas, such as Mental Health, tend to be p a r t i c u l a r l y susceptable to thi s type of confrontation. This has been exacerbated by non medical professionals such as pychologists and s o c i a l workers who have been encouraged to take a great deal of r e s p o n s i b i l i t y in those geographical areas where there have been no p s y c h i a t r i s t s to deal with psychological disorders ( i . e . outside the Lower Mainland). With increasingly scarce resources and pressures to r a t i o n a l i z e the money that i s spent in health care delivery, t h i s argument continues. The concept of substitution between groups may become more important, and the 'medical model' challenged more seriously in the future. The subgroups at the region.are also d i f f e r e n t i a t e d in their method of funding. Some, such as 42 voluntary organizations, are supported through grants, others such as the hospitals, have an 'arm's length' funding relationship with the government, and some are d i r e c t l y funded. This implies d i f f e r e n t reporting mechanisms and d i f f e r e n t methods of control. We can see that the various subgroups h i s t o r i c a l l y , i d e o l o g i c a l l y , and by the nature of their work are very d i f f e r e n t . Not only does th i s lead to d i f f i c u l t y in the co-ordination and integration of services but can also lead to c o n f l i c t between them. iv. Complexity And Degree Of Uncertainty Of Information Lorsch states that the more uncertain or complex the information the more time must be spent to sort out, understand, and resolve the c o n f l i c t i n g points of view between groups. This makes integration and co-ordination more difficult.(1980,283) The type and quantity of information needed for planning, p r i o r i z i n g needs, and making decisions about resource a l l o c a t i o n at the region has been the subject of considerable debate. Zimmer reviews the subject in depth in the paper "Data Needs for Regionalization." (1976). He says that f i v e basic types of data are needed when a health system i s regionalized. These are; population data, morbidity and mortality data, manpower 43 data, f i s c a l data, including cash flow, and an inventory of available services. There i s controversy over which i s the best way to get t h i s information, but even i f accurate data could be gathered, decisions about resource a l l o c a t i o n based on t h i s information are s t i l l d i f f i c u l t . Some health planners, such as those in the United Kingdom, propose an epidemiological approach to making decisions about resource a l l o c a t i o n . Others use u t i l i z a t i o n data in conjunction with various other sources of information. Most want some input from citizen/consumer/provider groups. It would seem the degree of uncertainty about the best approach to use in deciding how to allocate resources is high. Information processing i s also a very important and d i f f i c u l t area, even in t h i s age of computers. A huge amount of information i s generated d a i l y , but the d i f f i c u l t y in making sense out of i t , or getting i t to the people who need i t in an understandable manner, i s tremendous. Much work w i l l have to be done in t h i s area. In addition there i s also the technical nature of the information which tends to isolate, groups. Judgments about the necessity of acquiring pieces of equipment, or programs become d i f f i c u l t because of the degree of s p e c i a l i z a t i o n of the information. .Any planning model must consider information processing and information dissemination as a major issue. 44 v. Importance Of Integration To The Organization The health service system i s an aggregate of in t e r r e l a t e d health services, arranged to function (id e a l l y ) as a complex whole. However, due to the reasons c i t e d e a r l i e r ( d i f f e r i n g h i s t o r i e s , values, goals) t h i s i s in fact a very d i f f i c u l t thing to accomplish. Communication d i f f i c u l t i e s , competition over scarce resources, and self interest lead to fragmentation, duplication, and gaps in service. The Manitoba White Paper on Health Pol icy,(1974) the Foulkes Report, (1974) and the Task Force on the Cost of Health Services in Canada (1970), a l l c i t e d i f f i c u l t i e s with integration as one of the contributing factors to i n e f f i c i e n t and therefore more costly services. Since governments everywhere are concerned about s p i r a l i n g health care costs, i t would appear that t h i s i s a very important issue for any health care organization. v i . Summary To go back to our chart (figure 10), i t becomes clear that when these factors (dependence on the environment, the number of units to be integrated, the differences between the subunits, the complexity and degree of uncertainty of the information, and the importance of integration to the organization) are considered for the B.C. Regional Health Organization, that the regional manager w i l l have a very d i f f i c u l t time FIG. 10 FACTORS AFFECTING THE DEGREE OF DIFFICULTY IN ACHIEVING INTEGRATION DIFFICULTY FACTOR LOW — » HIGH 1. Dependence on, and re l a t i o n s h i p to the environment low X high 2. Number of units requiring i n t e g r a t i o n small X many 3. Degree of d i f f e r e n t i a t i o n among units small X large 4. Complexity and degree of uncertainty of the information simple and highly certain X highly complex and uncertain 5. Importance of in t e g r a t i o n to the organization n-^rginal X c r i t i c a l (adapted from Lorsh,1979,107) 46 integrating and co-ordinating health services for the area. This same chart, and much of the same analysis can also be used to identif y the potential for c o n f l i c t in developing an integrated and co-ordinated approach to health care delivery. With the change in philosophy at the centre, and with this new layer added to the bureaucracy i t seems clear that many of the inevitable 'battles' over money, power, and control that w i l l take place over the next few years in health could well take place at the region. The next section w i l l consider issues r e l a t i n g to t h i s . THE POTENTIAL FOR CONFLICT AT THE REGION SOURCES OF CONFLICT Tushman and Nadler (1980) state that c o n f l i c t arises in organizations when interdependent subunits: 1) have inconsistent goals 2) have d i f f e r i n g perceptions on how to reach commonly held goals 3) must share scarce resources (180-182) Miles, in "Organizational C o n f l i c t , and i t s Management" (1979)identifies other areas. In reviewing the l i t e r a t u r e he came up with eight sources of organizational c o n f l i c t . These are: 1 ) task int-erdependencies 2) status inconsistencies 3) j u r i s d i c t i o n a l ambiguities 47 4) communication obstacles 5) dependencies on common resource pools 6) differences in performance c r i t e r i a and reward systems 7) differences in unit orientations and structures 8) s k i l l s and t r a i t s of personnel (1979,204-228) If we refer back to the main points made in the las t section regarding the d i f f i c u l t i e s in integrating subgroups in a regional health care organization, the following conclusions can be drawn: A) Because the subgroups are so di f f e r e n t there would tend to be: a) inconsistent goals and d i f f e r i n g perceptions on how to reach commonly held goals b) differences in performance c r i t e r i a and reward systems c) differences in unit organization and structure d) communication obstacles B) The complexity of the information would lead to communication obstacles C) The complex relationship and dependence on the environment would lead to: a) dependence on a common resource pool (money, personnel) b) task interdependencies c) j u r i s d i c t i o n a l ambiguities We see that many of the sources of c o n f l i c t l i s t e d by Miles, Tushman, and Nadler are present at the regional l e v e l . Central to much of thi s i s the competition for shared, scarce, resources. Underlying i t are issues of power, p o l i t i c s , and c o n f l i c t i n g c u l t u r a l values. 48 SHIFTS WITHIN THE CULTURE OF THE ORGANIZATION There seems to be a renewed interest in attempting to measure the culture of organizations as one important factor to consider in analyzing the potential for c o n f l i c t and d i s s a t i s f a c t i o n within the organization. Swartz and Davis in their a r t i c l e , "Matching Corporate^ Culture and Business Strategy (1981), discuss the relationship between structures and designs of organizations, and their culture. They have developed a method of measuring organizational culture, and use i t to indicate the potential for problems within an organization. Although th i s i s an issue that a f f e c t s the whole organization i t has important implications for planning at the regional l e v e l . The culture of an organization i s d i f f e r e n t from i t s climate. Culture, they say, i s a pattern of b e l i e f s and expectations shared by the organization's members. These b e l i e f s and expectations produce norms that shape the behaviors of individuals and groups in the organization. "Whereas culture i s concerned with the nature of the expectations of the people at work, climate measures whether these expectations are being met" (Swartz and Davies, 1981,33). During a process of change ( i . e . a recession) climate can be poor i f the employees do not adopt the new values. The authors also state that culture i s "rooted in deeply held b e l i e f s and values, and r e f l e c t s what has 49 worked in the past", and that consequently, i t i s d i f f i c u l t to change. (1981,34) This has important implications for implementation, as they state: a lack of f i t between culture and planned changes in other aspects of organizations may result in the f a i l u r e of a new measure to work. (1981,34) Thus i t could be concluded that implementation problems and poor morale are indications of dysfunction between strategies and the culture of the organization. In the present recession the new management group i s attempting to change the focus and goals of the organization from ones based on attempts to increase equity and a c c e s s i b i l i t i y (more equals better care), to ones rooted in cost containment and accountability ( e f f i c i e n c y , effectiveness). The reorganization of the Ministry of Health, and the regionalization proposal, both indicate a move in that d i r e c t i o n . The paper by Campbell, A. et a l . (1981) i l l u s t r a t e d t h i s when they described the s h i f t from management by professionals to professional management in the B.C. Health Ministry in 1981. In t h i s type of service organization t h i s s h i f t indicates a major attempt at changing the culture of the organization to meet the new environment (recession bringing about scarce resources, with pressure from Treasury Board to contain c o s t s ) . • But the values and b e l i e f s of 'care' are deep rooted in the provider groups, therefore, d i f f i A W i t n implementation of change are inevitable. 50 Added to th i s d i f f i c u l t y with f i t between the people in the organization and the new s t r a t e g i s t s are ones inherent in any regionalization proposal. It was stated e a r l i e r that regionalization meant d i f f e r e n t things to providers, planners, and p o l i t i c i a n s . To many, p a r t i c u l a r l y the providers, i t has the connotation of increased services, more p a r t i c i p a t i o n , and improved a c c e s s i b i l i t y . This i s , no doubt l e f t over from the rather i d e a l i s t i c proposals of the early 70's such as the Castonguay Nepreu/Report in Quebec, and the White Paper on Health Policy, in Manitoba. In B r i t i s h Columbia, in 1982, those proposing regionalization seem to see i t more as a palatable method of cost control, and as a buffer between V i c t o r i a and the interest groups at the regional l e v e l . E a r l i e r we talked about the differences between subgroups within the health care system, and how the nature of their differences can lead to d i f f e r e n t goals and perspectives. Part of the reason for th i s i s that these groups have d i f f e r i n g subcultures. Care may be a c u l t u r a l value of some, but not others. This may lead to misunderstandings, and more d i f f i c u l t i e s in implementation. In r e l a t i o n to problems in organization culture i t seems that the human resource perspective must be integrated into the strategy formulation process, and that stategic plan reviews should include an assessment of implementation problems. 51 The Regional Manager, as a bureaucrat, in the middle between the providers and government policy makers, w i l l be in a c r i t i c a l position to manage these potential problems. An appropriate planning strategy could help. IMPLICATIONS FOR REGIONAL PLANNING Organization design theory i d e n t i f i e s three essential aspects which need to be considered before developing a design. These are the task, the environment, and the people. In a B.C. Regional Health organization, after considering these three aspects, several problems have been i d e n t i f i e d : 1) Integration and co-ordination between the various subgroups w i l l be very d i f f i c u l t . 2) The potential for c o n f l i c t at the region is very high 3) Because of the s h i f t within the culture of the of the organization i t can be expected that the climate w i l l be poor, and therefore implementation of any change w i l l be d i f f i c u l t . 4) Information processing and dissemination w i l l be important i f sound decisions are to be made. In the next chapter strategies to address these problems w i l l be outlined. 52 III. CHAPTER THREE: ORGANIZATIONAL STRATEGIES FOR  ADDRESSING POTENTIAL PROBLEMS AT THE REGION In t h i s chapter t h e o r e t i c a l responses to the problems mentioned in the last sections w i l l be outlined. Some are devices that can be included in the structure for planning, others are processes which involve a new role for the manager at this l e v e l . LIAISON DEVICES AS INTEGRATING MECHANISMS Some writers have explored mechanisms for improving integration between subunits in an organization. Mintzberg suggested that there are four basic ways to do t h i s : 1) d i r e c t supervision 2) standardization of s k i l l s 3) standardization of work processes 4) mutual adjustment and that these are appropriate in d i f f e r e n t types of environment (1979,286-288). He then l i s t e d four aspects of the environment (simple, complex, stable, and dynamic), and developed a matrix which indicated that as environments become more dynamic and more complex, one should move from using d i r e c t supervision as a mechanism of integration, to the standardization of s k i l l s and work processes. Eventually, i t i s suggested that co-ordination can only be achieved with mutual adjustment. (See figure 11) 53 Figure. 11. Integration Mechanisms and the Environment stable dynamic simple - decentralized^ bureaucratic - standardization of s k i l l s - decentralized, organic - mutual adjustment - centralized, bureaucratic - standardization of work processes • 1 - c e n t r a l i z e d , organic - d i r e c t supervision (Mintzberg,1979,286) B.C.'s health care organization has been shown to be made up of many small organizations. The environment of each is s l i g h t l y d i f f e r e n t , but for the most part they would tend to be considered both complex and dynamic. Therefore, one could presume, i f Mintzberg's analysis i s correct, that there would have to be a considerable amount of mutual adjustment at the operational l e v e l . This i s suggested by his statement: when a dynamic environment i s complex, the organization must decentralize to managers and s p e c i a l i s t s who can comprehend the issues yet allow them to interact f l e x i b l y in an organic structure so that they can respond to unpredictable changes. (1979,286) In health care in B.C., the environment has been shown to be both dynamic and complex. Mintzberg's analysis suggests that there needs to be more than d i r e c t supervision, or standardization of s k i l l s or work at the regional l e v e l , and that the structure should allow for 54 the f l e x i b i l i t y of mutual adjustment. This has important implications for control - for example, how s t r i c t l y guidelines and standards whould have to be followed by the Regional Managers. Mintzberg suggests that there are devices that can be incorporated into the structure that w i l l promote integration. These are l i a i s o n devices, such as task forces, standing committees, integrating managers, and matrix organizations. (1979,161) Galbraith, (1979,80-87) agrees with Mintzberg, but develops more e x p l i c i t l y this idea that as the organization and environment become more complex, there i s a progression of devices for integration and co-ordination of services.. The following are mechanisms he suggests are in use: 1) Rules or Programs - for predictable tasks where there is no need for communication. 2) Hierarchy - on an exceptional basis, the problem can be referred up to a l e v e l where there is a global perspective. The problem with t h i s i s that as uncertainty increases the number of exceptions increase. This leads to overloading. 3) Setting Targets and Goals - instead of specifying s p e c i f i c behaviors. This involves a certain l e v e l of planning. 4) Committees, teams, and task forces. 5) Integrating Positions 6) Integrating Departments. (One device he did not mention i s integrating systems, such as a budgeting approach which requires progressive objective setting.) He surveyed three separate industries -55 P l a s t i c s , Food, and Containers (1979,86), and used as a measure of uncertainty the percentage of new products developed in the last ten years. He then looked at the number of integrating mechanisms the company had. Predictably, the P l a s t i c s industry, with 35% new products used far more integrating mechanisms. Mintzberg says that these devices represent the most s i g n i f i c a n t contemporary development in organizations in recent years. (1979,177) He goes on to say Liaison devices are tools primarily of organic structures and are generally used where the work i s at the same time 1) horizontally specialized, 2) complex, and 3) highly interdependent, and since specialized complex tasks are primarily professional ones, then one tends to find a r e l a t i o n s h i p between professionals and the use of l i a i s o n devices. (Mintzberg, 1979,178) It seems from t h i s discussion that l i a i s o n devices should play an important role in the planning and administration of health services at the regional l e v e l . The organization is complex, horiz o n t a l l y specialized, and highly interdependent, and most of the people providing the services are professionals. From his analysis he suggested that, "In general, given the nature of the work of the middle manager, we would expect l i a i s o n devices to be the single most important design parameter at the middle l e v e l " (1979,177). A Regional Manager i s at t h i s middle l e v e l . In the B.C. proposal, regionalization i t s e l f is an integrating structure, and the regional manager has 56 been given an integrating role.. But i t is a role that w i l l be d i f f i c u l t to carry out. There is no mechanism suggested at this time for integrating the many subgroups over which the manager has no di r e c t control. It would seem that i f any serious attempt i s to be made to rat i o n a l i z e the delivery of services at that l e v e l , that there w i l l have to be a s i g n i f i c a n t degree of f l e x i b i l i t y given to the manager at the operational l e v e l , and l i a i s o n devices such as committees, teams, and task forces would have to be used. INFORMATION PROCESSING As organizations become more complex, information processing becomes more d i f f i c u l t . In our health care organization this seems p a r t i c u l a r l y troublesome. Galbraith suggests that there are two ways to improve the s i t u a t i o n . One is to decrease the need for information by 1) creating slack resources, or relaxing the targets, or 2) by creating self contained tasks. In a time of recession, creating slack resources i s very d i f f i c u l t , and in an organization as interdependent as the health care system creating self contained tasks may not be possible. Secondly, he suggests mechanisms to improve the a b i l i t y to process information. These are 1) investing in 57 a v e r t i c a l information system, and 2) creating l a t e r a l relationships that cut across l i n e s of authority ( l i a i s o n roles, task forces, teams, integrating roles, managerial li n k i n g roles, and matrix structures). (1979,81) There have been attempts to improve the v e r t i c a l information systems by the introduction of Zero Based Budgeting. This system has been complemented by the rapid advance of computer technology. The second solution, creating l a t e r a l relationships, are the same mechanisms used to promote integration between departments. It would appear that both would be important, but that some form of l i a i s o n at this l e v e l would be c r i t i c a l in that i t would serve several other functions such as helping with information processing and encouraging integration of services. In the next section approaches to handle the c o n f l i c t that i s inevitable in such a system w i l l be discussed. MANAGING THE CONFLICT Many approaches taken to understand organizational behavior build i m p l i c i t l y on a ra t i o n a l model of behavior. From th i s point of view, the organization i s seen as a system within which individuals and groups act in an in t e r n a l l y consistent way, and therefore organizational structures and processes are 58 deliberately planned and co-ordinated to best reach organization objectives. (Tushman and Nadler, 1980,178) This 'rational actor' model views change as the rational adaption by the organization to feedback from i t s environment. Following from t h i s , the role of the manager is seen as planning, organizing, co-ordinating, and c o n t r o l l i n g , based on c l e a r l y a r t i c u l a t e d goals and objectives. Some health planning systems, such as Br i t a i n ' s Nation Health Service (in the 70's), developed out of t h i s 'rational actor' model. Problems with t h i s approach w i l l be discussed l a t e r . On the other hand-, the p o l i t i c a l approach to analyzing an organization considers i t as a system characterized by c o n f l i c t , value dissensus, and bargaining. This would seem more appropriate in our case. Bacharach and Lawler, in Power and P o l i t i c s in  the Organization (1980,1-9), r e f l e c t t h i s approach when they state: organizations are not the r a t i o n a l , harmonious e n t i t i e s of managerial theory, nor the arenas of apocalyptic class c o n f l i c t projected by Marxists, but rather p o l i t i c a l l y negotiated orders. They assert further on in their work that interest groups and c o a l i t i o n s dominate p o l i t i c s in an organization, and that each interest group attempts to maximize i t s own goals and p r i o r i t i e s by having i t s views represented in policy decisions. Strauss (1978), discusses the importance of 59 building co-operative structures, and suggests that in situations l i k e t h i s , when respective parties share some aims, but not others, that negotiation i s important. Negotiation, he states " i s getting things accomplished when parties need to deal with each other to get things done... with the implication that s o c i a l orders are in some sense always negotiated orders".(234,1978) It was shown e a r l i e r that our health care organization is a myriad of interdependent subsystems. In a situation l i k e t h i s , one would think that some form of negotiation i s ess e n t i a l , and i t should be recognized as such. Given this view of the organization, the role of the manager in managing c o n f l i c t and c o a l i t i o n s must be examined. THE NEW ROLE OF THE MANAGER In the past, l i t e r a t u r e on the role of the manager focused mainly on the manager/subordinate relationship. But, in t h i s model of regionalization, where integration and co-ordination between subunits appears to be one of the primary tasks of the manager one would expect external relationships to be much more important. Pfeffer (1978,36), contends that management of organizational c o a l i t i o n s , including the resolution of the 60 various c o n f l i c t s amongst interest groups, may be one of the most appropriate conceptualizations of management. Lawrence and Lorsch, (1980,222-223) say much the same thing when they talk about the new role of management being an integrator "to achieve unity of e f f o r t among the major s p e c i a l i s t s in the business, and to resolve interdepartmental c o n f l i c t s " . Mintzberg discusses the role of the " P o l i t i c a l Manager" whose key role would be as spokesperson and negot i a t o r : "A good deal of time i s spent with outsiders. This person i s caught in a complex managerial position where he/she i s required to reconcile a great many diverse p o l i t i c a l forces acting on the organization. They spend a good deal of time in formal a c t i v i t i e s , meeting, negotiating with pressure groups and explaining the actions of the organization to special interest groups. This i s t y p i c a l of managers at the top of most governments, hospitals, and i n s t i t u t i o n s . " (Mintzberg, 1979,127) It i s clear from e a r l i e r discussions that the manager at the region w i l l have to be very much a p o l i t i c a l manager. A model by Mintzberg seems to accurately project the role that t h i s person w i l l play, (figure 12)' 61 Figure 12. The P o l i t i c a l Manager MANAGER AS A MONITOR (external) MANAGER AS A MONITOR (internal) l i a i s o n leader MANAGER AS A NERVE CENTRE I MANAGER AS A DISSEMINATOR MANAGER AS A SPOKESPERSON MANAGER AS A , STRATEGY MAKER i (Mintzberg, 1979,72) EVALUATION OF THE MANAGER The Regional Managers, in a p o l i t i c a l organization such as a health care organization, w i l l be judged to a large extent on.how well they manage c o n f l i c t ( i . e . by the lack of p u b l i c i t y and 'end runs'). If the objectives of regionalization are any indicat i o n , they w i l l also be judged on the c r i t e r i a of e f f i c i e n c y , and effectiveness. P f e f f e r (1978,1-19) discusses these two terms. Organization E f f i c i e n c y he suggests, i s an internal standard of performance, with the only question being whether the job i s being done well. E f f i c i e n c y i s not concerned with whether or not the job should be done in the f i r s t place, and i s therefore a r e l a t i v e l y value free term. Managers have t r a d i t i o n a l l y been evaluated on t h i s 62 c r i t e r i o n . Organizational Effectiveness i s a far more complex term. Pfeffer suggests that i t is an external standard, and that i t measures how well the organization is meeting the demands of the various groups and organizations that are concerned with i t s a c t i v i t i e s . Acceptability, he says, i s judged by outsiders - the interest groups, individuals and organizations that come in contact with i t . Since each group has i t s own individual set of c r i t e r i a for evaluating t h i s , "effectiveness" depends on which group i s doing the judging, and i t s criteria.(1978,32) He contends we are moving from a concern with organizational e f f i c i e n c y , to organizational effectiveness, and therefore that negotiation, p o l i t i c a l strategy formulation, and bargaining are becoming more important. This may be true for a l l organizations, but i t seems that t h i s analysis i s p a r t i c u l a r l y appropriate for a p o l i t i c a l organization such as a health region, in a province where there are only two closely matched p o l i t i c a l p arties. It would seem that the Regional Manager would have to be concerned with t h i s image of effectiveness, otherwise, as a symbolic gesture, he or she might well be f i r e d . Since t h i s manager has no formal power over the big spenders (hospitals and doctors), these l i a i s o n mechanisms become very important, and negotiation and bargaining become key s k i l l s . Strategies mentioned to improve co-ordination 63 and information processing are one method to manage the inevitable c o n f l i c t that w i l l a r i s e at the region. Through these mechanisms, support and linki n g relationships can be structured into the design for planning. However, the manager w i l l have to take on a new role as well. He or she must act as a spokesperson, must monitor the situation c a r e f u l l y , and must be w i l l i n g to negotiate and bargain with the interest groups. Liaison with external groups would seem to be p a r t i c u l a r l y important. IMPLICATIONS FOR REGIONAL PLANNING When this organization i s considered in rel a t i o n to i t s environment, the many subgroups, and the task, several problems or issues are c l e a r : 1) there w i l l be great d i f f i c u l t y in co-ordinating and integrating services at the region 2) the potential for c o n f l i c t between those providing services and the government i s very high 3) methods of improving information processing w i l l be important i f sound decisions are to be made. To meet the objectives of e f f i c i e n c y and effectiveness, the regional manager w i l l have to be aware of, and manage these problems. Two mechanisms have been outlined to deal with the issues. The f i r s t i s to build l i a i s o n devices and mechanisms into the design for 64 planning. The second i s to change the t r a d i t i o n a l role of the manager to one based on Mintzberg's concept of the p o l i t i c a l manager where bargaining and negotiation are recognized as key roles.(1979,127) But, i f as expected, B r i t i s h Columbia regionalizes health services with a model based on close supervision, the regional manager as a bureaucrat would be able to bargain and negotiate only on certain issues with much of the job being to administer to guidelines and p o l i c i e s set down by V i c t o r i a . John Child (1972), in a c r i t i q u e of organizational design theory, suggests that often those analyzing organizations forget or play down the role of what he c a l l s 'strategic choice'. By t h i s , he means that those in power in organizations, can and do af f e c t the environment. Organization design, he suggests, must take th i s group, the managers, into account. The role and management style suggested here for a regional manager varies greatly from the management style of the senior administrators in the health ministry outlined e a r l i e r . In addition, from our analysis, i t would seem that p a r t i c i p a t i o n in the planning process by those involved in implementation would also be important. This too might be contrary to the philosophy or culture of thi s group. These potential d i f f i c u l t i e s are indications of the difference between the control demanded by central 65 government, and the f l e x i b i l i t y which seems to be indicated by the organizational dynamics for health care planning at the region. If regional planning i s to succeed, the problems mentioned here w i l l have to be addressed. In a l a t e r section, a pragmatic approach to the c e n t r a l i z a t i o n / decentralization issue w i l l be outlined. 66 IV. CHAPTER FOUR: DYNAMICS OF REGIONAL HEALTH PLANNING IN B.C. INTRODUCTION Given these d i f f i c u l t i e s , or at least the potential for d i f f i c u l t i e s in planning health services at the regional l e v e l , what can we learn from planning theory that can help us in designing structures and processes for successful planning at thi s level? Is there support for planning? From whom? And what i s the role of planning at the region as opposed to planning in Vic t o r i a ? SUPPORT FOR PLANNING IN THE 1980'S Planning for the organization and delivery of health services in the 80's w i l l be very d i f f e r e n t from the planning that took place in the twenty or t h i r t y years following the Second World War. The issues dominating that time were primarily those of equitable d i s t r i b u t i o n (geographic and income), and a c c e s s i b i l i t y . This i s i l l u s t r a t e d by the fact that the Federal Government between 1949 and 1968 i n i t i a t e d a series of matching grants for the following programs: (a) National Health Grants, 1949, which included Hospital Construction Grants (b) Hospital Insurance and Diagnostic Services Act, 1957 for hospital operating expenses (c) Health Resources Fund, 1966, for construction of buildings for educating health professionals (d) Medical Care Insurance, 1966-67, for payment 67 of physicians' services These grants served as a means of r e d i s t r i b u t i n g wealth across the country, precipitated the building of a great number of hospitals, and encouraged the expansion of many health education programs. The size and complexity of health care organizations developed rapidly during this period. There were great technological advances and the power and number of professional groups grew. The bureaucratization of health delivery increased as the p r o v i n c i a l government took on more and more r e s p o n s i b i l i t y for health. During this time the philosophy of health care changed from one based purely on sickness r e l i e f and cure, to one based also on support and care, causing the boundaries between health and s o c i a l services to blur. Funding was also shifted in this d i r e c t i o n . Planning in t h i s era was fragmented. In an e a r l i e r section i t was mentioned that u n t i l the early 70's there were four separate ministries looking after the health needs of B r i t i s h Columbians. Each department carried on a form of planning ( i . e . Hospital Programs had a Planning Group, as did Mental Health) but for the most part, planning tended to be informal with the focus entrepreneurial or advocacy. Each agency or i n s t i t u t i o n planned primarily for expansion of i t s own services. There was also a certain degree of implementation planning, but l i t t l e integrated planning across sections. Hospitals in p a r t i c u l a r , were developed as ' l o c a l 68 autonomous units', with each one attempting to increase quality and scope of service to i t s residents. The Task Force report on the Cost of Health Services for Canadians (1970) signalled the beginning of a new era. The Federal Government had become alarmed at the open ended nature of i t s 50/50 cost sharing agreement with the provinces and wanted a new mechanism for funding. This Task Force suggested a restructuring of the funding system and recommended that health care services be more systematically integrated in order to increase e f f i c i e n c y and avoid gaps and duplication of service. (1970,19) Foulkes(1974) c l e a r l y i d e n t i f i e d the lack of integrated or co-ordinated planning as one of the more serious problems in B r i t i s h Columbia's health system. There is no single group within the Department of Health that plans health services or car r i e s out research... such research that does exist i s not co-ordinated. In addition, the projects r e f l e c t a single purpose function and are usually r e s t r i c t e d to f i r e f i g h t i n g . (1974,iv-A-9-2) As mentioned e a r l i e r , he also suggested a regionalized and decentralized system of health care delivery based on the concept of community resource centres. But his report was a 'Green Paper', not a government policy paper, and with the defeat of the N.D.P. in 1975 t h i s regionalization proposal was shelved. The Ministry of Health under.the Social Credit leadership did make an attempt to develop a more co-ordinated approach to 69 health care delivery. This became more c r i t i c a l after the Established Programs Financing Act (EPFA) was introduced in 1977. It shifted the r e s p o n s i b i l i t y for determining how health care would be financed to the provinces, and put pressure on them to watch their funding p o l i c i e s more c a r e f u l l y . After t h i s , co-ordinated planning within the Ministry of Health was seen to be more important, and in 1977, a central planning unit c a l l e d Planning and Development Divis i o n , was formed. Coming out of the 'Development Group', i t s main focus was on long range planning, although i t was also to co-ordinate and di r e c t planning a c t i v i t e s within the Ministry. E f f o r t s to increase r a t i o n a l decisionmaking continued, and in May 1978 a major i n i t i a t i v e 'The Hospital Role Study' was begun. Its purpose was to attempt to establish a l o g i c a l government strategy for guiding c a p i t a l and operational development of acute hos p i t a l s . This study i s presently at the stage of tr a n s i t i o n from planning to implementation, and is an example of an attempt by government to negotiate change. E f f o r t s were also made around t h i s time to have each department develop goals and objectives which would f i t in with the o v e r a l l Ministry objectives. Planning, during the 70's was seen by the bureaucratic planners as a necessary move towards a more rat i o n a l approach to decision making. This was 70 precipitated by a change in the economy, the increased complexity of the system, and the general perception that health care costs were s p i r a l l i n g . Blum, summarizes th i s trend in the U.S. which led to the p r o l i f e r a t i o n of planning bodies there: The slow moving, p l u r a l i s t i c a l l y operative, unaided p o l i t i c a l resolution of differences and advancement of commonalities i s now seen as inadequate to carry us forward under the impact of fast moving, di s j o i n t e d technological changes which d r a s t i c a l l y and unevenly a l t e r perceptions of time, distance, place, and desirable goals. (1974,386) In Canada there were at least s t r u c t u r a l moves towards increasing r a t i o n a l i t y in planning during the 1970's. F i r s t there was the increase in the number and v i s i b i l i t y of planning/policy units in most government departments (Chenier and Prince,1980), and secondly, there were the many proposals for regionalization in the major health studies written for the provinces in the early 70's. But although there were these structural moves, with integrated planning gaining a certain l e v e l of legitimacy during t h i s time, and some support from the bureaucrats, there was generally less support from the providers and the p o l i t i c i a n s . There i s a fundamental difference in perspective between government^bureaucrats, the r e l a t i v e l y autonomous service providers,and the p o l i t i c i a n s . The bureaucrats, i d e a l l y , should take a u n i v e r s a l i s t i c perspective, and consider the e f f e c t of 71 decisions on the whole province or region. Costs, both c a p i t a l and operating, and tradeoffs between d i f f e r e n t parts of the system should be considered. This might be c a l l e d a systems perspective. The providers who tend not to think in terms of cost, but in giving service take a more p a r t i c u l a r i s t i c approach, while the p o l i t i c i a n s act largely in a reactive way in response to pressure, or to p a r t i c u l a r issues. Although t h i s i s a generalization, i t can, perhaps, help us to understand how d i f f e r e n t perceptions can lead to d i f f e r e n t goals, which in turn can lead to d i f f i c u l t y in developing support for co-ordinated and integrated planning. As expected, integrative planning ( i . e . a systems approach to planning) did not get much support from the provider groups or the p o l i t i c i a n s during the late 60's and early 70's. The providers tended to see any centralized planning attempts as bureaucratic, slow, and unnecessary. Detwiller elaborates on t h i s point in an a r t i c l e describing the d i f f i c u l t i e s in developing Regional Hospital D i s t r i c t s in B.C (1972, 20) He stated that although Regional Hospital D i s t r i c t s (RHD) had been suggested in 1952 the d i s t r i c t s were not formed u n t i l the government l e g i s l a t e d the act in 1967. He suggested that the d i f f i c u l t i e s lay in the fact that.the concept of co-ordinated planning i s "contrary to the forces underlying the h i s t o r i c a l development of not only our medical and hospital systems, but our free enterprise competitive 72 system as well." To what extent w i l l the d i f f i c u l t i e s that B.C. now faces, (with regard to health care costs), force these two groups (providers and p o l i t i c i a n s ) to increase their support for integrated planning? One might hypothesize that while integrative planning gained a certain l e v e l of legitimacy during the 70's, that i t i s not u n t i l the 80's, with a perceived f i s c a l c r i s i s , that this type of planning w i l l get the support necessary to make any extensive change possible. As we move through the 80's the emphasis, in planning continues to s h i f t . It i s not enough now to aim merely for better co-ordination and integration of services - planning in the 80's w i l l to a large extent be planning for r e d i s t r i b u t i o n and even cessation of services. This i s fundamentally d i f f e r e n t than planning for new programs, new hospitals, and new services, and the strategies involved must change. 'Value for money', 'more bang for the buck' are more appropriate mottos for the day, and both monitoring and evaluation of existing and new services must play a more important r o l e . In t h i s environment one might expect there to be a s i g n i f i c a n t degree of support for integrated planning at the regional l e v e l . The manager, even without d i r e c t powers over those groups who spend the most in health care w i l l have a certain degree of influence over them. He or she w i l l undoubtedly act in an advisory capacity to the 73 senior bureaucrats who make decisions about the amount and d i s t r i b u t i o n of resources to the regions. It can be expected that with the p r o v i n c i a l government wanting to increase control, and with i t threatening indiscriminant cutbacks and freezes, that the many disparate groups operating at the regional level would be more than w i l l i n g to p a r t i c i p a t e in e f f o r t s to co-ordinate regional services. It is suggested therefore that support for integrative planning by the providers and the i n s t i t u t i o n s w i l l grow in the 80's. With regionalization, a structure is provided that makes thi s more feasible and p o t e n t i a l l y more e f f e c t i v e . Whether or not the B.C. government w i l l either recognize or want to take advantage of t h i s opportunity i s not yet known. LEVELS OR STAGES OF PLANNING Planning has been defined in many di f f e r e n t ways. Most suggest that i t i s concerned with change -i.e.. Friedman who states that planning "guides change within a s o c i a l system". (1973,346) Another d e f i n i t i o n that r e f l e c t s the r e d i s t r i b u t i v e aspect of planning i s stated by the National Health Service (NHS) planning department: "(planning is) deciding how the future pattern of a c t i v i t i e s should d i f f e r from the present, i d e n t i f y i n g the changes necessary to accomplish t h i s , and specifying how these changes should be brought about." (1976,4) 74 Planning within s o c i a l systems then, would seem to be concerned with guiding change r a t i o n a l l y , and is not necessarily oriented to providing new services. To accomplish this in a health care setting several types of planning a c t i v i t i e s are required. Crichton discusses stages in the process of tra n s l a t i n g s o c i a l philosophies into s o c i a l services. She suggests that philosophy and ideology influence s o c i a l policymaking. The progression she i d e n t i f i e s i s : -philosophy -ideology -government policy planning -administrative planning -program planning -service planning ( i . e . rationing by providers) (Crichton,1981) In a health care organization these planning a c t i v i t i e s tend to take place at di f f e r e n t l e v e l s in the organization. The ov e r a l l philosophy and ideology important to much of government policy making i s largely p o l i t i c a l and therefore more the domain of the p r o v i n c i a l cabinet (with input from the senior managers in health). The importance of these value positions i s c l e a r l y shown when governments change. One would expect the Ministry of Health in V i c t o r i a to be concerned with government policy planning and administrative planning, while the region would be more involved with operational and administrative planning. . The l i n e managers and the d i s t r i c t s would tend to do most of the service and project planning. 75 Although this i s a s i m p l i f i c a t i o n of the process, as, at di f f e r e n t times, and with d i f f e r e n t issues, i t w i l l vary, there are d e f i n i t e l y stages in planning, and they do tend to take place at d i f f e r e n t levels in the bureaucracy. From th i s i t is suggested that the type of planning one would see at the regional level would be administative and operational planning. APPROACHES TO PLANNING Two very d i f f e r e n t approaches to planning have been widely debated in the l i t e r a t u r e (Donnison,1972, Lindblom,1973, Faludi,l973, Etzioni,1973, Blum,1974). One is the 'Rational Comprehensive' approach to planning and the other i s the 'Incremental' approach. Lindblom is well known as an exponent of this second type which has also been c a l l e d 'Muddling Through'. (Lindblom,1973) The main points are l i s t e d in figure 13. In the s o c i a l policy f i e l d , with the p o l i t i c a l pressures, lack of information, time constraints, etc., i t would appear that Lindblom's model i s v a l i d , and perhaps even as he suggests, the method of choice for planning in t h i s environment. However, since his'publication of t h i s work in 1959 a number of authors have questioned the appropriateness of his approach, p a r t i c u l a r l y as the method of choice. Donnison (1972) states that underlying apparent incremental growth must be an i m p l i c i t master plan which Figure 1 3 . Rational vs. Incremental Planning RATIONAL COMPREHENSIVE (ROOT) l a . C l a r i f i c a t i o n of values or objectives d i s t i n c t from and usually prerequisite to empir-i c a l analysis of a l t e r n a t i v e p o l i c i e s . 2a. Policy-formulation i s there-fore approached through means-end a n a l y s i s : f i r s t the ends are i s o l a t e d , then the means to achieve them are sought. 3a. The test of a "good" p o l i c y i s that i t can be shown to be the most appropriate means to desired ends. 4a. Analysis i s comprehensive; every important relevant factor i s taken into account. 5a. Theory i s often heavily r e l i e d upon. SUCCESSIVE LIMITED COMPARISONS (BRANCH) l b . S e lection of value goals and empir-i c a l analysis of the needed action are not d i s t i n c t from one another but are c l o s e l y intertwined. 2b. Since means and ends are not d i s t i n c t , means-end analysis i s often inappropriate or l i m i t e d . 3b. The test of a "good" p o l i c y i s t y p i c a l l y that various analysts f i n d themselves d i r e c t l y agreeing on a p o l i c y (without t h e i r agreeing that i t i s the most appropriate means to an agreed objective). 4b. Analysis i s d r a s t i c a l l y l i m i t e d : (i ) important possible outcomes are neglected ( i i ) important a l t e r n a t i v e p o t e n t i a l p o l i c i e s are neglected ( i i i ) important affected values are neglected 5b. A succession of comparisons greatly reduces or eliminates r e l i a n c e on theory. (Lindblom,1973,125) determines choice among incremental a l t e r n a t i v e s . While 'master plan' seems too strong, i t i s similar to Crichton's model which suggests that government policy planning i s guided by philosophy and ideology. An example of thi s in Canada i s that in the apparent incremental development of our health care system there was the underlying l i b e r a l ideology that access to health care was a right of a l l Canadians. This fundamental decision guided much of the incremental decisions that followed. . 77 Another example is ref l e c t e d in the difference between the development of the National Health Service system in B r i t a i n and our health care system in Canada. B r i t a i n based i t s development on Bevin's view that as much health care as possible would be given, but within resources available. Canada on the other hand has a system that was developed on the philosophy of the 'Father of Medicare' - Justice Emmett Hall - who did not set those l i m i t s , but instead, wanted a health care system based on the i l l - d e f i n e d p r i n c i p l e s of un i v e r s a l i t y , a c c e s s i b i l i t y , comprehensiveness, and p o r t a b i l i t y . As a consequence, Canada now facing d i f f i c u l t decisions around rationing health services, i s having a d i f f i c u l t time with the public and the providers who have come to expect almost unlimited resources. Etz i o n i argues in a similar vein, that incrementalists f a i l to acknowledge the importance of the fundamental decisions which occur in the system,(1973,221). He also states that "although incremental decisions greatly outnumber fundamental ones, that the l a t t e r ' s significance for 'societal decision-making' i s not commensurate with their number" and that often i t i s they that set the context for numerous incremental decisions. This i s one of the reasons why so much time was spent o u t l i n i n g the context within which health policy decisions are made here. Blum developed and defended a model for planning 78 which is s i m i l a r . His i s based on normative planning plus "ar t i c u l a t e d and guided incremental ism"(1974,67-68). A l l three planners suggest that overa l l goals and objectives are important, and that basic decisions need to be made that guide short run decisions. They also suggest that there is no need for the time consuming, expensive, and impractical comprehensive approach to planning advocated by some, nor that one must, alternately, succumb to ad hoc incrementalism. Their approach, which combines certain aspects of each, i s perhaps the more p r a c t i c a l way to think of planning in times when resources are scarce and the environment so dynamic. IMPLEMENTATION ISSUES Planning within a bureaucracy has many constraints - lack of adequate information, time pressures, and p o l i t i c a l pressures. Figure (14) i l l u s t r a t e s what th i s author considers some of the influences in the p o l i t i c a l planning process. Thomas Hall in 1972 pointed out that the p o l i t i c a l process in planning i s often of decisive importance in determining the outcomes of plans and planning and that there i s no e f f e c t i v e way of i s o l a t i n g planning from i t . It is unlikely that this w i l l be of less influence in the 80's. He suggests then, that the planner should attempt to incorporate into planning, Figure 14. The Planning Process 79 Inputs Our p u V a support aeeds demand potiVfca\ \ planning/ prooessesX poua-j / decisions rational / £pd planning / actions enu\ronrrv e n i * measures that w i l l ensure eventual acceptance. This i s s t i l l true today. E a r l i e r in t h i s study i t was suggested that, in developing a strategy for planning at the regional l e v e l , i f possible, i t should include mechanisms that structure support into the planning system. This raises the questions of implementation strategies. Planning must take implementation issues into account. Taylor (1972) in fact, l i s t s implementation as one of the seven planning steps. Friedman (1973,359) agrees and 'states that the kind of implementing mechanism adopted w i l l i t s e l f influence the character of the plan and the way i t i s formulated. The extent to which one must be aware of problems of implementation varies with the type of government. There is a rel a t i o n s h i p between the amount of government control and planning. In t o t a l i t a r i a n s o c i e t i e s which are c e n t r a l i s t and do not rely on consensus, much more reliance can be placed on 'plans and 80 planning* (Russia with i t s 5 year plans i s an example of t h i s ) , unlike democracies which f i r s t seek to build up a consensus, and then proceed "often doing less than necessary, later than necessary." (Etzioni,1973,229) Although i t has been suggested that there is a trend towards increased control by central agencies of the B.C. government, ours is s t i l l a democratic system, and governments must recognize and react to the demands and concerns of the public. Presently this government i s challenging this with i t s s t r i c t wage and spending res t r a i n t programs. In response, considerable pressure i s presently being put on i t to change i t s p o l i c i e s of cutbacks in health and other s o c i a l programs. It w i l l be interesting to see to what extent the government w i l l risk-public displeasure in order to continue these p o l i c i e s in i t s e f f o r t to keep costs under control. IMPLICATIONS FOR REGIONAL PLANNING From th i s largely theoretical discussion i t i s suggested that, in a p o l i t i c a l organization such as our health care system, there are l i m i t s to r a t i o n a l i t y in planning. Friedman(1973) c a l l s this 'bounded r a t i o n a l i t y ' . This refers to rational decisionmaking within the constraints of the situation, or attempts to be as rati o n a l as possible given the existence of interest groups, p o l i t i c a l opposition, the economic systems, the 81 information systems, etc. It was postulated in an e a r l i e r section of t h i s study that as we move through the 80's there w i l l be more support for r a t i o n a l i t y in health care planning by the health providers, and the p o l i t i c i a n s . We would expect decisions to rely far less on t r a d i t i o n and i n t u i t i o n , as managers at a l l levels are made more accountable for their decisions. The approach to planning that i s proposed i s one suggested by Blum and Etzioni - where ov e r a l l goals and objectives are set, some fundamental decisions made, and a 'guided incrementalist' approach to implementation taken. It i s suggested that implementation strategies are important to consider prior to the development of the planning system. In the next section the potential role of planning at the central and regional levels w i l l be considered. 82 V. CHAPTER FIVE: CENTRAL VS REGIONAL PLANNING INTRODUCTION Blum, (1974) suggests that the best way to develop an e f f e c t i v e structure for planning i s , to f i r s t e s t ablish the goal of planning, and then to consider the potential role and function of planning at that l e v e l . This in turn demands a certain type of structure. Figure 15 i l l u s t r a t e s t h i s . Figure 15. Developing, a Planning Structure (1974,400) Once a structure i s conceived in t h i s way, he suggests the p r o b a b i l i t i e s are greater that the desired functions w i l l be performed. This contributes to role success and leads to the f u l f i l l m e n t of the purpose. While there i s no guarantee that by following t h i s formula in developing a structure for planning that the purpose w i l l necessarily be accomplished, (planning in 83 th i s context is after a l l dynamic, and fraught with unforseeable d i f f i c u l t i e s ) but i t i s the most ra t i o n a l approach, and the one that w i l l be followed in thi s study. There are d i f f i c u l t i e s however, in that there can be no ove r a l l agreement on the goal of planning at any l e v e l , since the providers, the bureaucrats, and the p o l i t i c i a n s have d i f f e r e n t perceptions. But i t is suggested that despite t h i s , there can be a pragmatic approach to developing the role of planning at each of these l e v e l s . CENTRAL PLANNING Regionalization in B.C., as outlined in Chapter One, appears to be based on normative c e n t r a l i z a t i o n and operational decentralization. Arbon (1978,6) suggests that in t h i s model the centre would retain authority for setting goals, standards and targets, and the intermediate and l o c a l l e v e l s would have the r e s p o n s i b i l i t y for managing within established guidelines. This i s a model of r e l a t i v e autonomy and i s one that i s most widely adopted in the western i n d u s t r i a l i z e d world. Within t h i s model there are many variations, and questions of the degree of autonomy and f l e x i b i l i t y permitted at the regional l e v e l , and the extent to which differences are allowed between regions needs to be addressed before any decision i s made about the structure 84 or process for planning. Bice and Kerwin,(1976,100), suggest that t h i s c e n t r a l i z a t i o n / decentralization issue is one of the key decisions facing policymakers in health: ...because regional health care systems w i l l encompass r e l a t i v e l y small populations and large numbers of d i f f e r e n t i a t e d suppliers, l o c a l i z e d planning is suggested, but imperatives of e f f i c i e n t management and equitable a l l o c a t i o n of resources require that regulation of the industry be based on more universal standards. (1976,100) STANDARDS AS A MEANS OF PLANNING With the type of regional structure proposed, i t is generally agreed that the centre would provide guidelines, p o l i c i e s and standards. This sounds much l i k e the type of planning suggested e a r l i e r . However., i t i s possible that V i c t o r i a , working within a control model would want to use standards (or guidelines) as a substitute for planning, with l i t t l e f l e x i b i l i t y allowed at the regional l e v e l . But B r i t i s h Columbia is a large, multilingual and m u l t i c u l t u r a l province, with a great deal of environmental and demographic var i a t i o n s . Just as the population i s unevenly d i s t r i b u t e d , with most people concentrated within 50 miles of the U.S. border, so too are the major health care resources unevenly d i s t r i b u t e d . In addition the seven regions outlined in Chapter One (figure 1) vary greatly in size, population d i s t r i b u t i o n , 85 geography, and transportation systems, suggesting that f l e x i b i l i t y in planning for p r i o r i z a t i o n of needs would be necessary. For example, the problems of the North (transportation, retention of s t a f f , access to s p e c i a l i s t s , sudden growth of resource towns) are very d i f f e r e n t than the problems faced in the Lower Mainland, and the solutions to problems must vary. Blum (1974,387) in discussing t h i s issue distinguishes between "indigenous, planning derived c r i t e r i a " which-would help to c l a r i f y when goals were reached, and general "promulgated standards". The difference, he suggests, i s that with the former, standards are derived which suit the s p e c i f i c community condition for which the planning body is responsible. He does not disagree with using widely accepted standards to describe large goals - i . e . length of l i f e , freedom from d i s a b i l i t y l e v e l s etc.- because these can become goals which stimulate planning, d i r e c t i t , and can also provide a means to measure i t s success. But, he does not f i n d useful standards to describe means of achieving goals - i . e . number of beds, physicians/population, etc., as these are means which do not necessarily describe ends. To be useful he says "they must vary with l o c a l needs as well as with l o c a l capacities to use s p e c i f i e d input"(1974,388). Although perhaps a b i t i d e a l i s t i c , as th i s approach would necessitate a great deal of planning c a p a b i l i t y at the regional l e v e l , as well as established 86 information systems, he makes a very good point. The degree of variation among the seven regions in B.C. i s perhaps unrivaled anywhere and the approach to health care delivery must vary tremendously i f goals of 'effectiveness and e f f i c i e n c y ' are to be reached. Too s t r i c t l y enforced standards could be dangerous, or at least counterproductive, and defeat the purpose of planning. Standards, however, can be useful as checks and balances. The development of minimum and optimum standards has been suggested as one approach (Pallan,1981) and i s , perhaps, an appropriate solution for the present government. Minimum standards guarantee a certain degree of equity within and between regions, while optimum standards may provide some guidelines for planning. However, given the wide differences between regions and the inadequate information systems in place, the regional manager must have the f l e x i b i l i t y and authority to develop the optimal standards which can be negotiated for his or her p a r t i c u l a r region. ALLOCATIVE PLANNING Another major role that V i c t o r i a w i l l play i s planning for the a l l o c a t i o n of resources. Friedman (1972,357-359) talks about a l l o c a t i v e planning as one of the more important and recognized forms of planning. This w i l l take place at both the Central and Regional l e v e l but w i l l play a more important role in V i c t o r i a . 87 He describes a l l o c a t i v e planning as needing to be comprehensive, and concern i t s e l f with: (a) the interdependence among a l l the e x p l i c i t l y stated objectives of the system or subsystem. (b) the interdependence in the use of a l l available resources of the system (c) the influence of the external environment (1973,357) This is related to the concept of s o c i a l r e s p o n s i b i l i t y , or public interest, and r e f l e c t s the di f f e r e n t , u n i v e r s a l i s t i c perspective that bureaucrats must, or should take, as opposed to the p a r t i c u l a r i s t i c view of many interest groups, Al l o c a t i v e planners, he states, w i l l often defend a set of value propositions essential to the survival of the system, and must consider system wide balances and equilibrium. The central organization w i l l also have the re s p o n s i b i l i t y of c o l l e c t i n g information about the whole province, monitoring trends, s i f t i n g and sorting information, and d i s t r i b u t i n g i t appropriately. With the resources available in V i c t o r i a (computers, speci a l i z e d s t a f f ) information processing w i l l be an important aspect of any central planning function. It i s clear that the central government w i l l remain responsible for c o l l e c t i v e bargaining. In the past 88 the government has used the Health Labor Relations Association as a buffer between i t s e l f and the bargaining associations. Although t h i s w i l l no doubt continue, there is a trend for government to take back some control in this area. The wage and spending r e s t r a i n t program i s an indication of t h i s . It i s possible, that i f health services are regionalized, V i c t o r i a would be less concerned with the operation of direct services. This would make the government more a policymaking and funding agency, and would leave the operation of di r e c t services to the region. ROLE AND FUNCTION OF CENTRAL (PROVINCIAL) HEALTH  PLANNING Given the above discussion, tentative suggestions for the role of planning in V i c t o r i a i s : 1) To provide o v e r a l l d i r e c t i o n for the Ministry of Health. (This involves under-standing the s h i f t s in ov e r a l l government p r i o r i t i e s , and where the Ministry stands in relation to them.) 2) To develop a long range or strategic plan for health care in B.C. 3) To develop guidelines, p o l i c i e s , and minimum standards for health care in B.C. and to as s i s t in developing optimum standards for the regions 4) To integrate and co-ordinate p r o v i n c i a l health care services 5) To plan for a l l o c a t i o n of resources between regions 89 6) To c o l l e c t and analyse data and monitor trends in health care and health care status in the province 7) To conduct medical manpower planning 8) To l i a i s e with external groups ( i . e . those external to health care such as Human Resources, as well as health planning groups from other j u r i s d i c t i o n s ) • 9) To undertake r e s p o n s i b i l i t y for c o l l e c t i v e bargaining SUMMARY The role of planning in V i c t o r i a w i l l primarily be long range strategic planning, policy planning, and a l l o c a t i v e planning. There w i l l be a tendency for planning at t h i s l e v e l to be proactive, and i t must, of necessity, be closely t i e d to the p o l i t i c a l processes from which the philosophies and ideologies that influence policy decisions a r i s e . REGIONAL HEALTH PLANNING Planning at the regional l e v e l must be intensely concerned with f e a s i b i l i t y issues. The type of planning would tend to be operational or administrative planning (concerned more with implementation), and the time frame would be shorter than the strategic or corporate planning done in V i c t o r i a . From the discussion to t h i s point i t would appear that most would agree that the goal of regional 90 planning would be: 1) to increase the e f f i c i e n c y and effectiveness of health service delivery at that l e v e l , and 2) to increase the a c c e s s i b i l i t y of health services to the population of the region The underlying but largely unstated goals of government would be to contain and control costs, and of • providers to increase their autonomy. The role and function of regional planning can be developed out of the material reviewed in e a r l i e r sections. It was suggested that to reach the above general goals, one would have to promote the co-ordination and integration of the many subgroups providing health and related services in the region (only some of which are controlled d i r e c t l y by the Regional Manager). This i s necessary in order to eliminate some of the duplication and i n e f f i c i e n c i e s within the system, and to encourage more e f f e c t i v e health care delivery. It was shown in Chapter Two that the nature of the organization (dynamic, dependent on external groups, complex) would make co-ordination and co-operation among these groups d i f f i c u l t . C o n f l i c t would l i k e l y a r i s e , p a r t i c u l a r l y when resources become more scarce, and the general climate could deteriorate. These factors would increase the d i f f i c u l t y in implementing an integrated regional health plan. Information processing was also i d e n t i f i e d as an 91 important consideration in thi s type of organization. Central p o l i c i e s and guidelines must be disseminated to appropriate groups (not only those funded d i r e c t l y by the Ministry), along with information about cost constraints. Epidemiological data about health status and trends should move from the centre, where the epidemiological expertise i s , to the regions where the groups who can use the information are located. Communication between a l l the various subgroups would also be c r i t i c a l i f co-ordination and elimination of duplication i s to be achieved. This would also serve to decrease the c o n f l i c t . E a r l i e r , work done by Pfeffer (1978,1-19) on organization e f f i c i e n c y and effectiveness was reviewed. He suggested that organizations are s h i f t i n g from measuring e f f i c i e n c y to measuring effectiveness, and that effectiveness i s largely shown by how well the organization meets the demands of the various subgroups. If one of the reasons that regionalization was proposed was for i t to act as a buffer between V i c t o r i a and the many subgroups who provide service, then one of the roles of planning would be to provide a mechanism for those groups to voice their demands. For the regional organization to be 'effective' t h i s mechanism must work, i. e . the Regional Manager must have enough authority to make appropriate decisions and be able to negotiate 'packages' with these groups. 92 There are other more obvious roles of regional planning. One would be to plan the best way to allocate the resources for which the Regional Manager i s d i r e c t l y responsible. If the old incremental approach i s to be avoided,, then health services needs' assessment becomes very important. Some say that t h i s is the data area most central and germinal to the regional planning and monitoring process.(Zimmer,1976,136) However, th i s task of assessing needs, i s both complex and d i f f i c u l t . Chambers and Woodward, (1979) have developed one approach which i d e n t i f i e s most of the p r i n c i p l e components that must be considered in developing a regional health plan. This i s i l l u s t r a t e d in Figure 16. While determining the supply side i s quite straightforward (although i t requires a good information system), assessing demand is far more d i f f i c u l t . Epidemiological approaches have proven to be unreliable with small populations in England (Martini,1977); u t i l i z a t i o n rates tend to r e f l e c t the status quo and are d i f f i c u l t to compare between di f f e r e n t population groups; measurements such as waiting l i s t s can be e a s i l y manipulated and are therefore not a good indication of need; and oral responses and b r i e f s often represent only the more vocal or p o l i t i c a l l y active interest groups. The approach described by Chambers and Woodward, which i s a combination of these, would seem most appropriate. How one then goes about p r i o r i z i n g these Figure 16. . Needs Assessment Model 93 DEMAND UTILIZ-H ATION EPID. BASED NEEDS ASSESS, ORAL RESPONSES AND BRIEFS TOTAL NEEDS PRIORIZATION > PLANS SUPPLY SERVICES MANPOWER 1 T FACILITIES TYPE X DISTRIB TYPE! =1 I RETENTION! ~1 TYPE zxz DISTRIB (Chambers and Woodward,1979) needs i s another matter. Some discussion of t h i s w i l l take place in a later section. A SHIFT IN RESPONSIBILITY There has been a tendency, since the Task Force Report on the Costs of Health Services for Canadians in 1970, for the Federal Government to s h i f t r e s p o n s i b i l i t y for health care back to the provinces. The change to block funding with the Established Programs Financing Act in 1977 which resulted from th i s report is an example. At the same time, since the Lalonde report in 1974 there has been more emphasis on individuals taking more 94 r e s p o n s i b i l i t y for their health status ( i . e . the P a r t i c i P a c t i o n campaign). Both Federal e f f o r t s have been r e l a t i v e l y successful. The provinces are c e r t a i n l y attempting to bring health care costs under control, and Canadians in general seem to be running, swimming, hiking, and exercising more. Regionalization within a province i s in keeping with t h i s , as i t helps to s h i f t r e s p o n s i b i l i t y for health care back to the community. One role of planning then, would be to educate, and therefore increase the awareness of both consumers and providers about costs of health care. Providers, as the rationers of service, must be encouraged to think of t o t a l costs of services, tests, h o s p i t a l i z a t i o n etc. The p r o v i n c i a l government's expressed p o l i c i e s of s h i f t i n g emphasis towards health promotion, so d i f f i c u l t to operationalize in the present structure, might find f r u i t i o n in a new approach involving public p a r t i c i p a t i o n . ROLE AND FUNCTION OF REGIONAL HEALTH PLANNING Given the above discussion, a potential role and function of regional health planning might be: 1. to assess regional health needs and i d e n t i f y regional problems 2. to indicate p r i o r i t i e s for health care spending given the regional needs, and p r o v i n c i a l p r i o r i t i e s 95 3. to develop a regional health plan which would address these needs 4. to act as a mechanism for information processing: (i) from V i c t o r i a to the Region, (guidelines, data analysis) ( i i ) from the Region to V i c t o r i a (concerns, effectiveness) ( i i i ) to promote communication between various regional subgroups 5. to increase community awareness about health care costs and health promotion techniques 6. to improve the co-ordination of services within the region 7. to review and monitor regional health plans In the next section we w i l l consider what is perhaps even more important - the structures and processes for planning at the regional l e v e l . 96 VI. CHAPTER SIX: PLANS AND PLANNING  INTRODUCTION Now that a potential role and function of regional health planning has been discussed, questions r e l a t i n g to the structure and process of planning can be addressed. Two areas seem of pa r t i c u l a r importance given the present situation in B r i t i s h Columbia and w i l l be considered in this chapter. Both are related to one of the basic dilemmas facing health care policymakers today -the c o n f l i c t between demands for f l e x i b i l i t y in the management of our health care system (by the nature of the organization and i t s environment) and the demands by the Central agencies of government for more centralized control and managerial accountability at a l l l e v e l s . Fundamental decisions w i l l have to be made by those developing a strategy for planning at the regional l e v e l about the extent planning w i l l be 'plan oriented' as opposed to the more f l e x i b l e 'process oriented'; and second, to what degree p a r t i c i p a t i o n by the providers and/or the public can be encouraged or allowed in th i s environment. While i t might appear that t h i s government, given the present trends, would encourage a type of planning that i s 'plan oriented' - that involved l i t t l e or no p a r t i c i p a t i o n , i t i s suggested that the implications of th i s decision should be considered, and the lessons 97 learned in other j u r i s d i c t i o n s heeded. It was mentioned above that planning can be 'plan oriented' or 'process oriented'. Each invites a par t i c u l a r type of structure. PLAN ORIENTED PLANNING With this type of planning, a plan ( i . e . a blueprint) i s developed, usually by bureaucratic planners, and i s regarded as a serious, long term commitment. This tends to be the 'Rational Comprehensive' approach to planning discussed e a r l i e r . Changes can be made, but are not made e a s i l y . To encourage implementation the government can use a strong approach such as 'command planning' where sanctions are applied "to compel adherence to c l e a r l y formulated objectives". (Friedman,1973,36) The plan i t s e l f would have legal force. Friedman states that I t a l y i s using t h i s approach in health care, in an attempt to d r a s t i c a l l y cut i t s health care costs. More t o t a l i t a r i a n states such as Russia use this as well. A weaker form of command planning attempts to get compliance to a plan through 'inducement', such as tax exemptions, subsidies etc. Our Federal Government used t h i s with the provinces to develop universal health insurance in Canada. The inducement was money - cost sharing agreements, the five hundred m i l l i o n d o l l a r s in the Health Resources Fund, etc. Friedman suggests that when performance of subsystems i s important for the attainment of system wide 98 goals (and in B.C. the co-operation from the QUANGOS is important to permit integration and co-ordination of services), or when the imposition of even indirect controls i s impractical, planning should stress process over the development of a r i g i d plan. The government of B.C. can and does impose indirec t controls, but because of the large number of d i f f e r e n t i a t e d actors, with d i f f e r e n t goals and di f f e r e n t perceptions of the problems, and because the government i s unable to compel such things as co-operation and information sharing, process oriented planning i s recommended, even i f the goal is cost c o n t r o l . This i s p a r t i c u l a r l y true because those who spend the most in our health care system are only i n d i r e c t l y controlled by government. The lack of good information processing systems and the nature of the organization, as was outlined e a r l i e r , also supports t h i s . PROCESS ORIENTED PLANNING With t h i s form of planning, the p a r t i c i p a t i o n of a l l the p r i n c i p a l interests should be en l i s t e d in the formation of the plan. A strong form makes extensive use of negotiation, bargaining, and compromise. A weaker form depends for i t s implementation on nothing more persuasive than the p a r t i c i p a t i o n of key actors ( i . e . those who w i l l be involved in implementation) in the planning process. Here the plan i s less important than the possible benefits 99 of joint consideration of targets, p o l i c i e s , and the formalization of communication between d i f f e r e n t agencies. This type of planning increases awareness, creates a common information base, and decreases uncertainty. Friedman suggests that there i s often a mix of the two -so that a plan is formally developed, but the process encourages implementation. It would seem that i f we follow Friedman's analysis, then B.C., with i t s many subsystems should use a planning approach which i s a mix of the two, but more process than plan oriented. This implies a consultive approach to planning. It also seems that in our. rapidly changing world, long range planning with too s t r i c t an adherence to formally developed plans would not be p r a c t i c a l . Any plan that i s developed now should probably not be more than a 3 year plan, and should be greatly concerned with implementation. By involving those in charge of implementation in the joi n t consideration of targets, and p o l i c i e s , and by encouraging dialogue between contending sectors, one would go a long way towards f u l f i l l i n g many of the roles outlined for regional planning in Chapter 5. 100 PARTICIPATION To what extent should there be representation by the providers and/or the public in the planning process? These concepts w i l l be considered separately in the following sections. PROVIDER PARTICIPATION It has already been suggested that the physicians, hospitals, and, no doubt, other health professions would be w i l l i n g to p a r t i c i p a t e in health services planning. Should they? Vroom and Yetton (1973), management theo r i s t s , suggest that there are fiv e ways that managers can make decisions. These vary from an autocratic approach, to management by consensus. This author suggests that planning decisions can be made in much the same way. The five ways they suggest follow: 5 Modes of Decison-making 1. You solve the problem or make the decision yourself, using information available to you at that time. 2. You obtain the necessary information from your subordinate(s) then decide on the solution to the problem yourself. You may or may not t e l l your subordinates what the problem i s in getting the information from them. The role played by your subordinates in making the decision is c l e a r l y one of providing the necessary information to you, rather than generating or evaluating alternative solutions. 3. You share the problem with relevant subordinates i n d i v i d u a l l y , getting their ideas and suggestions without bringing them together as a group. Then you 101 make the decision that may or may not r e f l e c t your subordinates' influence. 4. You share the problem with your subordinates as a group, c o l l e c t i v e l y obtaining their ideas and suggestions. Then you make a decision that may or may not r e f l e c t your subordinates' influence. 5. You share a problem with your subordinates as a group. Together you generate and evaluate alternatives and attempt to reach agreement (consensus) on a solution. Your role is much l i k e that of a chairman. You do not try to influence the group to adopt "your" solution, and you are w i l l i n g to accept and implement any solution that has the support of the entire group. (Vroom,1973,69) . To est a b l i s h the best approach to use in any given s i t u a t i o n , these authors suggest the use of their decision making tree (Figure 17). If t h i s process i s worked through for regional planning, given the frame of reference developed e a r l i e r , i t would seem that to ensure implementation of the plan, either s t y l e 4 or 5 would work best. These models are ba s i c a l l y consultive models of decision making and planning, and would tend to be time consuming. This i s l i a b l e to be unpopular with t h i s government which seems to be under some pressure to reach decisions quickly. The l i t e r a t u r e reviewed e a r l i e r on organization theory also suggested that consultation by those involved in implementation would be important. Less clear in these arguments are questions re l a t i n g to public p a r t i c i p a t i o n in planning. Whereas pa r t i c i p a t i o n by.those in charge of implementing plans is pragmatic and can be supported e a s i l y with organizational Is there a q u a l i t y r e q u i -rement such that one s o l -ution i s l i k e l y to be more r a t i o n a l than another? Do I have s u f f i c i e n t imf ormation to make a high qualityj decision? Is the problem structured? Do| we know what information we need and where to get i t ? Is acceptance of decison by subordinates c r i t i c a l to e f f e c t i v e imple-mentation? If I were to make the dec-i s i o n by myself i s i t reasonably c e r t a i n that It would be accented! by my subordin-ates? Do subord-inates share the organ-i z a t i o n a l p.oals to be obtained i n solving this problem. Is c o n f l i c t among sub-ordinates l i k e l y i n preferred solutions? (Vroom,1973,69 103 and planning theory, public p a r t i c i p a t i o n is a more d i f f i c u l t issue, in that i t i s based to such a large extent on underlying values. PUBLIC PARTICIPATION IN PLANNING With movements in the U.S. in the 60's stressing community development, there was a growth in c i t i z e n p a r t i c i p a t i o n in both federal and state policy making, and p a r t i c u l a r l y in policy making in s o c i a l issues. This philosophy developed a l i t t l e more slowly in Canada, but was evident in the regionalization proposals developed in Quebec, Manitoba, and Ontario in the early 70's. A review of regional health planning today (Figure 18) reveals that public p a r t i c i p a t i o n i s s t i l l a dominant c h a r a c t e r i s t i c of most regional planning systems. Is t h i s just a carry over from the 60's, or i s public p a r t i c i p a t i o n useful in t h i s era of cutbacks, r e s t r a i n t , and a necessity for increased accountability? Public p a r t i c i p a t i o n can take many forms and can perform many functions. Rosener, reviews this subject and suggests that although there i s no formula for success, that i t i s possible to design p a r t i c i p a t i o n strategies which w i l l s a t i s f y the needs of p o l i t i c i a n s , administrators, and c i t i z e n s a l i k e . (1975,16) She developed a matrix which l i s t s the possible functions of p a r t i c i p a t i o n down one side and techniques of p a r t i c i p a t i o n on the other. One i s able to gather from 104 Figure 18. P a r t i c i p a t i o n in Planning in Other J u r i s d i c t i o n s Provider Consumer Joi n t Prov/Cons. Advisory Executive "'Duties Ontario Quebec U.S. U.K. N.Z. >/ J t h i s which technique performs which function. This has been adapted (figure 19), to r e f l e c t potential functions i in c i t i z e n p a r t i c i p a t i o n of regional health planning in B.C., and some of the more commonly suggested techniques. (The functions l i s t e d are those which this author feels might be useful for any government making s o c i a l p o l i c y decisions.) From t h i s , one sees that the techniques which produce the most functions which seem useful to governments are c i t i z e n advisory committees, and c i t i z e n representation on policy making boards. Task forces and the Dephi technique are also be b e n e f i c i a l in some cases. With the present trends in government suggesting a move to increase central government's control i t may not seem reasonable to suggest public p a r t i c i p a t i o n in planning, at least in the i n i t i a l stages. One would Figure 19. C i t i z e n P a r t i c i p a t i o n M a t r i x 105 o vt ? f A . <A I 0 ?r £ * °< * 0 0 £ +^  s * ? s r O f * i ' W ST 5" 9 ! S »H / 3" / l / r \ •Mr \ \ \ \ rr*-- \ \ \ \ » f ' 1 \ \ •\1 i \ m 106 expect government to move, in the name of e f f i c i e n c y and effectiveness, with an underlying goal of cost control, to a model of regionalization that would have regions under close supervision. Bureaucrats, too, might object to c i t i z e n p a r t i c i p a t i o n in the planning or administration of health services, on the grounds that p a r t i c i p a t i o n slows down, and complicates, decisions that in the end s t i l l have to be taken by those who are responsible for them. Also, they suggest that c i t i z e n advisors are rarely unbiased, as many people w i l l only get involved in a committee i f they can understand the eventual benefits they may get from.it. (Bregha,4-8) Nevertheless, t h i s author suggests that the advantages far outweigh the disadvantages. Appropriate c i t i z e n involvement has the potential to provide real benefit to those in power, p a r t i c u l a r l y at a time when governments everywhere are faced with making unpopular decisions with regards to health care services. In a lat e r chapter the effectiveness of c i t i z e n p a r t i c i p a t i o n in regional health planning in other j u r i s d i c t i o n s w i l l be discussed. IMPLICATIONS FOR REGIONAL PLANNING It i s suggested from t h i s review of organizational and planning theory that i f the Regional Manager i s to achieve the goals of e f f i c i e n c y and effectiveness, and perform the role and function of 107 regional planning as outlined in the l a s t chapter that: 1. the structure for planning must involve l i a i s o n and co-ordinating mechanisms such as committees and task forces, and 2. the process must allow for a large degree of f l e x i b i l i t y in developing optimal regional standards for the region. Consultation with at least those who deliver the services at the regional l e v e l seems c r i t i c a l , and while there is only i n d i r e c t evidence at present, i t would seem from Figure 19 that in a time of serious cost cuts that p a r t i c i p a t i o n by the public in planning would serve several important functions. It i s also clear that planning should be 'process' more than the more formal'plan' oriented. Neither the structure nor the process suggested is congruent with the present government's policy of increasing centralized control, and i t i s suggested that t h i s dilemma w i l l cause problems for a regional manager who i s faced with a task ( i . e . to improve e f f i c i e n c y and effectiveness) without the authority or f l e x i b i l t y to achieve i t . In the next section regional planning structures of three j u r i s d i c t i o n s (Ontario, B r i t a i n , and New Zealand) w i l l be discussed. Each of these areas has had regional service delivery for some time. By considering their 108 systems, plus any evaluation or changes that have been made, i t i s hoped that we can learn something of value for developing a strategy for B.C. 109 VII. CHAPTER SEVEN: PLANNING SYSTEMS IN OTHER JURISDICTIONS INTRODUCTION While i t is beyond the scope of t h i s study to do an in depth analysis of the planning systems of each of these three areas, we are fortunate in that, for various reasons, others have been evaluating the success, impact, and d i f f i c u l t i e s faced by these groups. New Zealand did a formal evaluation of both outcome and process of i t s regional planning p i l o t projects before deciding to regionalize throughout the country. Ontario, due to increasing pressure from D i s t r i c t Health Councils (DHC's) to decentralize f i s c a l authority to them, has been attempting to evaluate the success of these groups. Although no formal evaluation has been completed there have been several a r t i c l e s written, and a conference held on the subject. B r i t a i n i s now in the midst of another costly reorganization of i t s health system. Again, several authors have attempted to analyse the problems of the previous system which led government to make these changes. As background, the basic structure of each system w i l l be outlined, with an attempt to i l l u s t r a t e the pa r t i c u l a r areas of interest in t h i s study - the authority given to the region, the extent and mandate of any citizen/provider committees or council, and the approach 110 taken to regional planning. By reviewing these systems i t is hoped that we can more c l e a r l y identify approaches or strategies for regional health planning that w i l l gain the support necessary for ef f e c t i v e implementation in B.C. NEW ZEALAND: A PROVIDER MODEL New Zealand is in the early stages of developing a regional approach to the planning and organization of health services. The problems that led to thi s reform are similar to those faced by most of the i n d u s t r i a l i z e d western world: 1) growth in health expenditures 2) surplus of medical manpower 3) uncertainty about the scope and nature of professional accountability 4) in e q u a l i t i e s in the d i s t r i b u t i o n and balance of health services, between geographic areas as well as between high and low status services, and between i n s t i t u t i o n a l and community care 5) fragmentation and lack of co-ordination of care (accentuated and perpetuated by i n s t i t u t i o n a l and h i e r a r c h i c a l systems of management, with each agency competing both for resources and the provision of services.) 6) lack of e f f e c t i v e community involvement (although many current problems are l i f e s t y l e r e lated). (Malcolm,1981 .5) Malcolm, a health planner in New Zealand, 111 suggests that many of these problems arise because the history of health policy development has focused upon s t r u c t u r a l , organizational and f i n a n c i a l issues. (1981,18) He contends that for this reason, issues such as qu a l i t y and balance of care; the professional influence over, and accountability for, the use of resources; and matching professionally provided services to the health status and needs of a community, have been overlooked. The approach he suggests for dealing with many of these problems l i e s in securing changes in behavior of health professionals. In New Zealand government has attempted to do this by following a democratic, p a r t i c i p a t i v e model for regional planning which stresses process more than structure. Planners in New Zealand i n i t i a t e d a new approach to regional health planning through the use of 'Service Development Groups' (SDG'S). They were f i r s t started in Christchurch in 1972, and more recently in two p i l o t projects in Northland (1978), and Wellington (1979). (Malcolm,1981,3) There have been two evaluations of t h i s system, (Wright,1981, and Malcolm et a l . , 1981), both suggesting that, although minor changes should be made, the approach i s largely successful. The concept w i l l be described in the following section. 1 1 2 SERVICE DEVELOPMENT GROUPS These are m u l t i d i s c i p l i n a r y , multiagency groups organized along service l i n e s - i . e . g e r i a t r i c s , mental health, primary care. They cut across the t r a d i t i o n a l boundaries of institutions/voluntary s o c i e t i e s / p u b l i c health units, and provide a mechanism where professionals with common s p e c i a l t i e s or interests can develop p o l i c i e s , plan, and organize together. The degree of consumer representation varies with the committee. STRUCTURE In both evaluations i t i s suggested that SDG'S report to Area Health Boards, which would in turn report to the Department of Health. The proposed structure i s i l l u s t r a t e d in Figure 20. Figure 20. Planning Structure in New Zealand DEPARTMENT OF HEALTH AREA HEALTH BOARD l \ > \ SDG' S \ AREA MANAGEMENT TEAM Service Development Groups - formed mostly of 1 13 professionals, act as an advisory body to the area management team. THE PROCESS The mandate of a Service Development Group i s : 1) to develop service planning procedures, including the proposal of strategies and future programs 2) to review and monitor plans 3) to develop l i a i s o n or di v i s i o n s of r e s p o n s i b i l i t i e s with other service groups and relevant agencies 4) to consult with and/or involve consumers. (Wright,1981) The following chart (figure 21) shows how one SDG, a Mental Health Group, could p a r t i c i p a t e in the planning process. These groups have been told that their function is to consider community needs, set p r i o r i t i e s , propose co-ordinating strategies, and develop proposals. Early in the development of these groups i t was made clear that t h e i r s was a re a l l o c a t i v e and r e d i s t r i b u t i v e role, and that no new funds could be a l l o t t e d . They receive information and s e c r e t a r i a l assistance from the area planning and research group. 114 FIGURE 21. SERVICE DEVELOPMENT GROUP PLANNING PROCESS STAGES OF THE PLANNING PROCESS PROCESS .OUTCOMES -> DEFINING GOALS 1 IDENTIFYING PROBLEMS •—— -Seeking opinions -Promoting discussions -Commissioning research -Reviewing services -Identifying unmet needs and inefficiencies. [—} SETTING PRIORITIES WITHIN . THE MENTAL HEALTH SERVICE AREA -Exploring problem areas -Consulting those affected -Clarifying and defining objectives -Setting priorit ies •PROPOSING CO-ORDINATED STRATEGIES OF APPROACH -Involving agencies, mental health workers, and commun-ity groups -Promoting ideas -Proposing co-ordinated approaches and compre-hensive strategies. ^DEVELOPING PROPOSALS--Putting forward well researched proposals for comment -From this comment, assessing the feasi-b i l i t y and acceptability of the proposal -Proposing action U*_MONITORING -Monitoring the achieve-ment of objectives -Reviewing objectives and schemes in terms of changing social conditions COMMUNICATING information on the needs of the comm-unity to the Area Health Board -i HIGHLIGHTING problem areas inequalities and ineff ic-iencies Increase AWARENESS of mental health issues ACTION taken by agencies in response to this information and advocacy. ADVOCATING for the needs of SUPPORT given to commun-certain population or ity groups and voluntary problem groups. agencies by the Mental Health SDG. _^ RECOMMENDING objectives-and priorit ies to the Area Health Board tADVISING the Health Board on mental health policy • PRIORITIES amended or ratified by the Health Board; RESOURCES alloc-ated in terms of these priorit ies BRINGING AGENCIES — TOGETHER to consider particular problems PROMOTING multi-agency-planning by making planning and infor-mation resources avail-able to agencies. Improved COMMUNICATION and CO-ORDINATION between mental health and re-lated agencies —) The development of systematic PLANNING within agencies. RECOMMENDING action to the-)Proposals accepted or Area Health Board and modified by the Health agencies. Board or its Executives; resulting plan event-ually IMPLEMENTED REPORTING to -the Area Health Board -agencies -the public (Malcolm et a l . , 1981) 115 ANALYSIS OF THE PLANNING SYSTEM In New Zealand, the regional structure i s based on a model of r e l a t i v e autonomy. The central government issues guidelines and p r i o r i t i e s to (at th i s time) an Area Hospital Board, which has a considerable degree of f l e x i b i l i t y and autonomy. The planning model, which uses p a r t i c i p a t i o n by providers who serve on committees developed along functional l i n e s , has been evaluated in 1980 by Smith, an outside consultant (Malcolm et a l . , 1981). She used a survey approach to id e n t i f y as objectively as possible the needs problems, achievements, and f r u s t r a t i o n of the SDG's. Smith looked for both process and substantive outcomes of the system. Process outcomes included improved communication and relationships between members (and members' agencies), commitment of the members to the group, acceptance of the group by others, etc. Substantive outcomes were divided into three sections: (i) information/education outcomes, ( i i ) consensus/policy outcomes, and ( i i i ) improved service outcomes. (Malcolm et a l . , 1981,71) The results showed that for the large majority of the participants the most important outcomes seemed to be those c l a s s i f i e d as process and educational. Learning, understanding, communication, improved information, and 1 16 better relationships, were f e l t to be key descriptors of those outcomes. Specific services funded under the Community Health Care Programme were also perceived to be important outcomes as were consensus/policy decisions, such as agreement on standards and objectives. (Malcolm et a l . , 1981,74) While cost savings were not looked at d i r e c t l y , one would assume that service delivery would become much more e f f i c i e n t ( i . e . by improving r e f e r r a l p o l i c i e s , understanding each other's roles) and more e f f e c t i v e ( i . e . by having those close to the problem identi f y needs and p r i o r i t i e s ) . SUMMARY The advantages of such an approach seem to be that i t i d e n t i f i e s groups with common problems and interests ( i . e . care of the aged), and brings representatives together in a formalized system of communication and partnership. This fact alone should help to promote accountability, and decrease duplication and i n e f f i c i e n c i e s in the system. This system seems to be working well, except for the fact that at the present time there i s some fru s t r a t i o n over a lack of clear reporting mechanisms. As such, i t provides us with some insights into developing a strategy for regional planning in B r i t i s h Columbia. A disadvantage i s that these groups, which are composed largely of providers, would be influenced in any 1 1 7 planning a c t i v i t y by their provider bias. Providers have d i f f e r e n t perceptions of problems because of their t r a d i t i o n a l roles, history, and power. They might not consider more radic a l or unusual alternatives to problems, and may also place more emphasis on their own needs, as opposed to community needs. It would seem, therefore, that a mix of providers and consumers on a committee or council might provide better advice to a regional manager. ONTARIO: A CONSUMER BASED PLANNING MODEL Ontario, another viable system, has a d i f f e r e n t structure for regional planning. The Ministry of Health was reorganized in 1974 with a view to decentralizing the planning and administration of health services. This was in response to recommendations made by the 'Health Planning Task Force' (1974) that stated among other things that Ontario should have "a decentralized, co-ordinated, integrated, and p l u r a l i s t i c health care system based on D i s t r i c t Health Councils which would operate within p r o v i n c i a l guidelines." (1974,xi) As a result of t h i s , D i s t r i c t Health Councils (DHC's) have gradually been set up in Ontario. They are formed in response to l o c a l i n i t i a t i v e , and the twenty-five now in operation cover most of the province. Each has a s p e c i f i c geographic area bounded by county, d i s t r i c t , or regional municipal l i n e s . They have been grouped by the Ministry into six 1 18 planning regions with an area planning co-ordinator at the Ministry for each region. With each region to have a health sciences complex i f possible, t h i s regional structure has both technological regional boundaries (with primary, secondary, and t e r t i a r y f a c i l i t i e s ) , and p o l i t i c a l d i s t r i c t boundaries. STRUCTURE In t h i s model, the d i s t r i c t s have a r e l a t i v e degree of autonomy. This i s shown with figure 22, the planning structure, and the mandate of the d i f f e r e n t l e v e l s . Figure 22. Ontario Regional Structure PROFESSIONAL ASSOCIATIONS AREA PLANNING CO-ORDINATOR i D.H.C. D.H.C. SECRETARIAT 119 The general role of each l e v e l i s as follows: Provincial Ministry of Health - o v e r a l l planning and guidance (policy and standards) - c o l l e c t i o n of data and analysis - maintenance of f i s c a l control Area Planning Co-ordinator (one per region) - act as l i a s i o n between council and ministry - co-ordinate services within the region D i s t r i c t Health Council - i d e n t i f y the d i s t r i b u t i o n of needs and consider alternative methods of meeting those needs that are consistent with p r o v i n c i a l guidelines - plan a comprehensive health care program and estab l i s h short term p r i o r i t i e s that are consistent with long term goals - co-ordinate a l l health a c t i v i t i e s and ensure a balanced e f f e c t i v e and economical service sat i s f a c t o r y to the people of the d i s t r i c t (Barnes, 1 980 , 1 4-.1 5) Membership in DHCs Members are appointed by Order in Council on the recommendation of the the Minister of Health. The 15 to 19 members have 3 year terms. Members include providers, consumer, and l o c a l government representatives. (The Planning Function of DHC, 1977) Committee Structure There is a variation in the subcommittee or subgroup structures selected by the councils to undertake the co-ordination and planning of services. The trend now is towards a model that looks at program or services, thereby cutting across i n s t i t u t i o n a l and agency boundaries. This i s much l i k e New Zealand's approach. 120 Authority By M i n i s t e r i a l d i r e c t i v e , a l l requests for funding by providers must go through the DHC for i t s comment before being reviewed by the Ministry. The DHC also has complete access to information, and the a b i l i t y ( i . e . resources) to conduct research. As such DHCs exert a s i g n i f i c a n t degree of influence and power within each d i s t r i c t . PLANNING PROCESS DHCs have a planning, advising, and review role, but because they are of di f f e r e n t sizes and ages, the type and effectiveness of their planning varies greatly amongst them. (Barnes,1981) In her analysis of DHCs, Barnes suggests that many are having a d i f f i c u l t time moving into the planning phase for two reasons: they are too busy f i r e f i g h t i n g , and they have not developed an organization structure or staff secretariat which enables them to perform the function well. She does state, however, that most are involved in needs assessment studies (done mostly by outside consultants). While health providers ( i . e . doctors) are allowed on Council, u n t i l 1981, hospital administrators were not. D i s t r i c t Health Councils are predominantly consumer based, c i t i z e n focused planning groups, which assess d i s t r i c t needs and p r i o r i t i e s . * 121 ANALYSIS D i s t r i c t Health Councils have been in operation up to eight years. Pressure is now building to decentralize real ( i . e . f i s c a l ) authority to them. Although the system is working well, there i s some fru s t r a t i o n over 'end runs', hospital administrators or board chairmen going d i r e c t l y to the Ministry of Health. (Roy,1981,Barnes,1981) In addition, with only one area planning co-ordinator (situated in Toronto at the Ministry) for each region, and no regional planning body, there appears to be some d i f f i c u l t y in co-ordinating health services within the larger regional area. Harman and Harman (1982) discuss t h i s problem in r e l a t i o n to an i n s t i t u t i o n such as a cancer c l i n i c going to one d i s t r i c t council with a request for a regional status. As these requests cut across d i s t r i c t boundaries a regional designation cannot be granted solely on the acceptance of one council. Thus the issue of regional units, services, and programs presents a dilemma to DHCs and those groups who make that request. (Harman and Harman,1982,51) They state that at th i s time no mechanism to address regional requests ex i s t s , and suggest either a regional planning body, and/or a regional manager situated in the region. 1 2 2 SUMMARY Ontario then has a s l i g h t l y d i f f e r e n t approach to regional health planning than New Zealand. Here D i s t r i c t Health Councils are the main planning and co-ordinating bodies with subcommittees formed along service or program l i n e s . Like New Zealand, the approach i s process oriented but the emphasis on p a r t i c i p a t i o n stresses consumers and l o c a l governement more than providers. Guidelines and p o l i c i e s are c l e a r l y outlined by the central government and s e c r e t a r i a l and s t a f f support i s provided through the DHC se c r e t a r i a t . Unlike New Zealand's SDGs, the Councils have a s i g n i f i c a n t degree of influence because of their budget review and monitoring function. Again, although no formal outcome evaluation has been done, reports suggest that the system i s viable (Barnes,1982; Dixon,1981), with questions now r e l a t i n g to the p o l i t i c a l decision of whether to decentralize f i s c a l authority to these councils. By building up l o c a l support for planning and encouraging the responsiblity for the rationing of services to be s h i f t e d to the community, the Ontario government has gone a long way towards making i t s health care system more e f f e c t i v e . There i s some question now of a need for a stronger regional (as opposed to d i s t r i c t ) planning, as well as some method of preventing end runs. Both could be dealt with by strengthening the regional organization. 1 23 BRITAIN: A BUREAUCRATIC PLANNING MODEL England has taken quite a di f f e r e n t approach to regional planning. In 1973 a National Health Service (NHS) Reorganization Act was passed which provided for a regionalized approach to the administration and planning for health care delivery in B r i t a i n . There were problems with the system and in 1879 a Royal Commission was formed to examine i t . A number of recommendations "for s t r u c t u r a l changes were made and are currently being implemented.. STRUCTURE The system as i t was developed in 1973 appears as follows: (figure 23) Figure 23. The Regional Structure of B r i t a i n ) Pers. Soc.•Ser DHSS \ NHS J Soc. Security | RHA-J Reg. Prof. Adv. Ctte. Local Auth. 1 i Jnt. Cons. _ . AHA ;  •Area Prof. Adv. Ctte. ! Ctte. _ — — 1 CHC 1 — - - DMT Dist . Prof . Adv . Ctte. 1 24 Explanation of Acronyms (DHSS) Department of Health and Social Services This was created in 1968 from the merging of the Mi n i s t r i e s of Health and Social Security. The NHS part of this organization issues guidelines, decides central p r i o r i t e s , and allocates resources to the RHAs. (RHA) Regional Health Authority The Regional Health Authorities are responsible to the DHSS for strategic plans and p r i o r i t i e s for i t s region and for a l l o c a t i n g resources to and monitoring the performance of the Area Health Authorities in the region. (Stewart et a l . ,1980,202) (AHA) Area Health Authority The Area Health Authorities are responsible to the RHA for assessing needs and planning and managing services in an area. The RHAs allocate resources and establish p r i o r i t i e s within the guidelines l a i d down by DHSS and the RHA, thus combining both an operational and strategic role. The AHAs employ a secretariat to carry out their functions. In the new Reorganization Act (1980), i t was recommended that t h i s t i e r be removed. (DMT) D i s t r i c t Management Team There may be as few as one or as many as six d i s t r i c t s in an area. They prepare a three year 1 25 plan for submission to the AHA. The DMTs are composed of a small group of senior health service o f f i c i a l s and doctors. There i s an Executive O f f i c e r , Finance O f f i c e r , Nursing O f f i c e r , Community Medical O f f i c e r , a General Pr a c t i t i o n e r , and a representative of the S p e c i a l i s t s . They work by a consensus approach to management. (Levitt,1979) PLANNING WITHIN THE NHS During preparations for the 1974 reorganization i t was recognized that "new decision making processes and mechanisms would be needed to bring about the anticipated benefits of a regionalized health system".(Notes,1979,453) Thus a highly formalized and comprehensive NHS Planning System was developed to provide better mechanisms to help those with planning r e s p o n s i b i l i t i e s to plan better. The concept and philosophy behind the system and a suggested annual timetable of planning (as well as a proposed series of standardized forms) was released in 1976 in "The NHS Planning System". In this document the d i f f e r e n t roles of each t i e r in the system was i l l u s t r a t e d . (See figure 24) In this we see that regions and areas are generally responsible for strategic plans (3-10 year time frame), and d i s t r i c t s for operational plans ( r o l l i n g 3 year time frame). (NHS,1976,17) About the same time (1976) there was also a 126 Figure 24 THE FLOW OP OUIOELINIS AND PLANS IN THE N.H.S. NATIONAL D E S S I s R M S j g a l d e l i a a a on. : • R a t i o n a l F o l l o i o a •BeSOUTMS • T A l l f t b l * t e B U s • P r i o r i t i a a f o r B M o a r e e U t i l i s a t i o n I B S S B s r i a w a R a t i o n a l 8 t r a t a -g i a a A P r i o r i t i a a • n d B*r±aaa G u i d e l i a a a I E S S S a r i s v a B c g i a B f t l P l a n a • B d I d o n t i f i a a I u n i f a r R a t i o n a l A o t l o n IEGIONAL jHHA i n d l o a t a a t o ABAa |* £aSio<nal A a p l l f i o a t -l o n A I n t e r p r e t a t i o n o f R a t i o n a l Q o l d e -l l a s a L l k a l j S a a o o r o a A l l o o a t i i S S A o e a s l d a r a a n y iwe«SMxy a d j u a t a a a t a t o B a g i a a a l S t r a t a g i o P l a n !UU X a r l a v a ATM O p e r a t i o n a l P l a n a O p e r a t i o n a l P l a n a f o r B a g i e a a l l j ' J U m g o d S e r r i e a a ISHA P r a p a r a a [ K a g i o n a l P i s a V-| i H A I n d l o a t a a t o SKT AHA rttrnm o o P r i o r i t i e s l a l i * n t o f R a t i o n a l A l a g i o n a l O u l d a l i a a s • L i k a l y B e a o o r o a A l i o -o a t i o n a t o D l a t r l o t s otfTticr (ABA e o n a l d e r a u j l oeaaaxy a d j u a t -m t a t o ATM [ S t r a t a g i o P l a n IAEA S a r l e v a • D i s t r i c t O p e r a t i o n a l P l a n a • O p e r a t i o n a l P l a n a f o r A r * a KaaagoA ftarrloea 'AHA P r a p a r a a l A r a a P l * a |S I T ' P r a p a r a a O l e t r i o t O p e r a t i o n a l P l a n • C c n s l d e r e a n y A d j u s t a e n t a t o A n a B t r e t e g i o P l a n NHS- Planning S y s t e m , 1976, ( o 1 27 report of the Resource Alloca t i o n Working Party (RAWP) that recommended a new system for deciding f i n a n c i a l a l l o c a t i o n to health authorities (Hosp. Health Services Review, 1979, 455) The new method attempted to calculate the r e l a t i v e need for resources through an epidemiological, population based approach. Again t h i s i s a formalized, rational approach to planning, and since i t s inception there have been c r i t i c i s m s of i t , p a r t i c u l a r l y in i t s a p p l i c a b i l i t y to subregional a l l o c a t i o n s . (Martini,1977) CONSUMER/PROVIDER REPRESENTATION IN PLANNING Community Health Councils, and D i s t r i c t Professional Advisory Committees are supposed to act as consultants to the D i s t r i c t Management Teams and the Area Health Authorities in the planning process. There has been some d i f f i c u l t y with t h i s , and in the 1980 Reorganization Act there are recommendations that the role and mandate of at least the Community Health Councils be changed. (Barnes,1981,21) CHCs were set up by Parliament as independent bodies to evaluate the present standards in hospitals, health centres, c l i n i c s and the community health services. The Councils which were made up, primarily, of consumers' representatives, were created as a statutory body with authority to act as a counterweight to the highly managerial and professional set-up of teams at the d i s t r i c t l e v e l . (Barnes, 1981 ,23) They advise both health 1 28 care managers and the public. While they do assess community needs they have l i t t l e input into the planning process and are not involved in either implementation of plans or a l l o c a t i o n of resources. Some have been refused a right to comment by AHAs (Weiler,1977), or are consulted after the DMT has already formulated a view. With a small staff (maximum 2) they do not have the resources to do comprehensive or detailed needs assessments and are dependent on AHAs for information. While the future of CHCs i s uncertain after the upcoming reorganization, Barnes (1981,37) suggests that i t is clear that there w i l l be some mechanism for consumer representation b u i l t i n . They are an important opposition group. ANALYSIS The NHS planning system i s a formalized, bureaucratic, rational comprehensive approach to planning. It i s 'plan oriented' with great d e t a i l demanded, p a r t i c u l a r l y in the d i s t r i c t three year r o l l i n g operational plans. Planning in t h i s system is primarily a bureaucratic process with p a r t i c i p a t i o n by either providers or consumers (separated in this case into d i f f e r e n t committees), varying widely from d i s t r i c t to d i s t r i c t . There i s s t i l l strong centralized control, though there has been more decentralization in recent years. The fact that a Royal Commission was formed in 1.29 1979 to review the system indicates that there were serious problems with th i s approach. Barnard et a l . , received a grant from the DHSS to assess the planning system. They summarize their findings in "NHS Planning: An Assessment Concluded".(1980) In their analysis they make many of the observations that we would expect, given the theoreti c a l discussion presented in this study. Basic a l l y they suggest that this system did not take into account what we stated e a r l i e r was the basis of Organizational Design Theory - the environment, the task, and the people. They state "the act of planning does not guarantee a future... that in a complex human environment l i k e the NHS, i t would be unreasonable not to expect groups and individuals to have di f f e r e n t view, interests, and t e r r i t o r i e s to defend... and that b a s i c a l l y the NHS planning system made u n r e a l i s t i c assumptions about the free flow of information and the l e v e l of consensus between t i e r s " . They suggest a far less dogmatic approach to planning ( p a r t i c u l a r l y operational planning), and more ef f e c t i v e p a r t i c i p a t i o n by the providers and consumers. 1 30 • SUMMARY Again, no cost analysis of the B r i t i s h system was done, but recent reports suggest that B r i t a i n continues to spend a lower percentage of i t s GNP on health services than most other i n d u s t r i a l i z e d nations. Figure 25. Percentage of GNP spent on Health Services Year B r i t a i n U.S. Canada France 1977 5.1 8.9 7.1 7.9 1978 5.2 8.9 7. 1 8.2 1979 5.2 9.0 7.2 8.4 (Maxwell,1981,41) Nevertheless, the costly reorganization that B r i t a i n i s undergoing now indicates that t h i s approach (topdown, and heavily bureaucratic) i s so unpopular, that, despite i t s apparent success in c o n t r o l l i n g costs, a major restructuring w i l l none the less take place. It did not receive enough support from the physicians, the consumers, or the bureaucrats themselves who found i t too slow and i n f l e x i b l e . (Nichol and Nicholls,1981) IMPLICATIONS FOR REGIONAL PLANNING In this chapter various structures and processes for planning have been considered and the planning systems in three other j u r i s d i c t i o n s i l l u s t r a t e d . Planning models in Ontario with i t s consumer 131 oriented approach, and New Zealand with i t s provider oriented approach, both seem viable. From the New Zealand evaluation we learn that there needs to be a clear reporting structure.and an Area Health Board that has enough authority to respond to requests and reports of the Service Development Groups. Otherwise i t i s suggested, these groups become disenchanted and lose interest. In Ontario the D i s t r i c t Health Councils have a s i g n i f i c a n t degree of influence because they review hospital budgets and make recommendations to the Ministry of Health about these in r e l a t i o n to regional p r i o r i t i e s . Again there seems to be some indication that there needs to be more dire c t ( i . e . f i s c a l ) authority closer to the d i s t r i c t s in order for decisions to be made more quickly. Some suggest a regional manager, others that the DHCs be given more authority. (Harman, and Harman,l982) Both of these systems use l o c a l groups to assess l o c a l needs, and both build support for planning into the structure and process of planning. The B r i t i s h system with i t s far more elaborate planning process i s the one that i s in d i f f i c u l t y . Heavily bureaucratic, i t i s slow and i n f l e x i b l e , and does not use either consumer or provider groups e f f e c t i v e l y . Support for planning by either of these groups has not been b u i l t into the structure of planning and the assessment of l o c a l needs i s strongly influenced by the R.A.W.P. formula. 1 32 The New Zealand approach suggests that providers (doctors, nurses, s o c i a l workers, etc.) can work together e f f e c t i v e l y to r a t i o n a l i z e service delivery, and the Ontario approach suggests that d i s t r i c t s can assess and p r i o r i z e community needs. Both are process, more than plan oriented. Some combinatin of these approaches may work well in B r i t i s h Columbia. In the next chapter, a planning structure and process w i l l be outlined for B.C. 133 VIII. CHAPTER EIGHT: CONCLUSIONS AND RECOMMENDATIONS A SUMMARY In this f i n a l chapter some of the major issues for health care planning that have arisen from the material presented w i l l be reviewed and a strategy for regional health planning in B.C. proposed. It has been suggested that the goals of regional health planning are to: 1) increase e f f i c i e n c y ( i . e . decrease production costs for a given l e v e l of service) 2) increase effectiveness ( i . e . make sure what is being done needs to be done) 3) increase a c c e s s i b i l i t y (but without increasing the resources used) The underlying reasons for the p r o v i n c i a l government suggesting a regionalized approach to health care delivery at this time would seem to be that they want to increase accountability, introduce a palatable mechanism of cost control, and provide a buffer between government and the interest groups at the region. The Regional Manager w i l l not have an easy time achieving the goals of region a l i z a t i o n , p a r t i c u l a r l y given the present economic climate, and the apparent d i s t r u s t between government and the various provider groups. In the following pages, an approach to planning i s outlined which takes these d i f f i c u l t i e s and also the 134 management style of the present leaders in the Ministry of Health in B.C. into account. While any planning document must r e f l e c t the values of the writer, i t would seem u n r e a l i s t i c given the present environment to present a model for planning that is based e n t i r e l y on 'rational' planning, or to suggest an approach that i s completely at odds with the government's philosophy and therefore unlikely to be taken seriously ( i . e . decentralizing executive authority to a citizen/consumer group). E a r l i e r , i t was stated that regional health planning would be considered in r e l a t i o n to legitimacy, f e a s i b i l i t y , and support, with the assumption that s i g n i f i c a n t degrees of each are necessary to ensure successful implementation. It would seem that with the demands for increased e f f i c i e n c y , effectiveness, and 'value for money', by p o l i t i c i a n s , bureaucrats, and consumers, that the legitimacy of planning i s not in question, but as we have seen those of f e a s i b i l i t y and support are. Can a structure and process for planning at a regional l e v e l be developed that: 1) works ( w i l l help achieve the above goals), and 2) has the support of the groups necessary to ensure e f f e c t i v e implementation? In the next section we w i l l review some of the problems that a Regional Manager might be expected to face. 1 35 POTENTIAL DIFFICULTIES These have been discussed in some d e t a i l in the past chapters and w i l l be outlined only b r i e f l y here. Most f a l l under two broad catagories - the providers of service and the environment, a. The Providers Many of the potential problems facing a Regional Manager are due to the large number of subgroups involved in d e l i v e r i n g health care services in a region, and the fears of these groups over loss of autonomy, or loss of resources with which to provide services. The fact that the Regional Manager w i l l only have dire c t control over a small proportion of those providing services in a region makes attempts at co-ordinating and integrating services d i f f i c u l t . In addition, these various subgroups - because of their past, their roles, and their varying degree of influence and power - have d i f f e r e n t perspectives, interests and goals. This increases the potential for c o n f l i c t and makes attempts at integration of services even more d i f f i c u l t . Assumptions cannot be made about the free flow of information between these groups. It would seem that in order to develop a system of health care delivery within a region that i s e f f i c i e n t and more e f f e c t i v e than the present method of d e l i v e r i n g services, these groups must not only be involved in regional health planning ( i . e . be represented on 1 36 committees) but must also support integrated planning and be w i l l i n g , i f necessary, to change their attitudes and their behavior. This suggests that there would have to be some concrete (as opposed to a l t r u i s t i c ) reason for their being involved. b. The Environment It has been suggested that the environment within which a Regional Manager operates, and must plan is both dynamic and complex. Blum . (1974,125) uses an environmental model to discuss planning of health services. (Figure 26) Figure 26. Environmental Model of Health Planning Blum , (97^, i2s This indicates that many factors contribute to * 1 37 the health status of a population, and must be taken into account when developing a regional health planning model. In our resource based economy where boom towns can spring up and major lumber m i l l s close overnight i t would seem that the environment is even more dynamic than usual. Rapid changes in technology and new cures or methods of care for diseases can also change service needs quickly. Because of t h i s , long range planning, and in p a r t i c u l a r , detailed operational planning i s not recommended. In B.C. there i s a great variation between regions (demographics, population sizes, and geography) making an overdependence on fixed standards unwise. This, plus the fact that B r i t i s h Columbia does not have a well developed information system, makes the task of planning more d i f f i c u l t . Clearly part of the environment now i s the current recession which has a s i g n i f i c a n t impact on the resources available for health care services. The implication of the widespread cuts in s o c i a l services, bed closures in hospitals, and staff l a y o f f s are not yet known. Given the above, the task of co-ordinating and r a t i o n a l i z i n g service delivery at a regional l e v e l would not be simple. In the next section some mechanisms and approaches to planning which would increase the chances of the success of the venture w i l l be outlined. 138 STRATEGIES FOR SUCCESSFUL REGIONAL PLANNING Barnard et a l . (1980,302), in their analysis of the B r i t i s h planning system stated that there are three grounds for judging D i s t r i c t Plans: 1) they must make a serious attack on l o c a l health i ssues 2) they must demonstrate due consideration of f i n a n c i a l , l o g i s t i c , and other organizational r e a l i t i e s 3) they must respect regional ( i . e . provincial) p o l i c i e s and p r i o r i t i e s except where they can be demonstrated to be inappropriate These grounds are appropriate for B.C. and could be used for evaluating regional health plans here, but i t i s suggested that although they do show some concern with implementation, support in implementation might be added as a fourth c r i t e r i o n . To a s s i s t us in developing an approach to regional planning in B.C. three areas have been reviewed: - relevant organizational theory - relevant planning theory - planning systems in three other j u r i s d i c t i o n s . From this review we have found that the potential for increasing e f f i c i e n c y and effectiveness through good management alone i s limited, and that several external factors seem important for the development and successful implementation of regional health plans. 139 SUPPORT Most important in both the development of good plans and in the successful implementation of p o l i c i e s and recommendations that evolve from them are issues of support. To achieve the goals of e f f i c i e n c y and effectiveness i t seems that support must come not only from the groups who deliver service in the region but also from the government, a. Government An acceptance of the p r i n c i p l e of regional planning for health services r e a l l y means that the government must accept a certain degree of decentralization of the planning and control function. The c e n t r a l i z a t i o n / d e c e n t r a l i z a t i o n issue was discussed in some d e t a i l e a r l i e r . Most talk about i t in terms of potential c o n f l i c t , but Bice (1976,90-92) suggests that the problem l i e s in the confusion regarding the concepts of authority, c e n t r a l i z a t i o n and decentralization, and that, in government, a decentralized system can exist only when there i s a strong central government able to devolve powers. He suggests that delegation does not diminish a superior's authority, and that the appearance of strong regional governments with a broad base of discretionary power i s r e a l l y an indication of a strong central government. Although not everyone would support t h i s view, in t h i s study i t i s suggested that regions and the 1 40 central agency have complementary roles, and a pragmatic approach to the delegation of authority - one based on normative c e n t r a l i z a t i o n and operational decentralization (with regional planning to assess needs, id e n t i f y p r i o r i t i e s , etc.) can be developed. To plan.well, the Regional Manager must have planning staff based in the region - people who understand the needs of the region and the r e l a t i v e power and goals of the interest groups which may be lobbying for more services. It i s important for t h i s planner to be seen as someone who has a regional as well as a p r o v i n c i a l perspect ive. Government support for planning also means that i t can not allow 'end runs' by interest groups. In many ways this relates to the amount of authority the Regional Manager has. Although the manager must work as much as possible within the guidelines and p o l i c i e s set out by the province, i f these are inappropriate to l o c a l needs, he or she must have the f l e x i b i l i t y and authority to make recommendations and decisions that vary from the guidelines. In those cases where decisions have ongoing policy implications then the manager must s t i l l be seen as someone who has influence in the decision making process. F l e x i b i l i t y and authority to develop negotiation packages with those groups whom the manager i s attempting to co-ordinate would greatly increase his or her a b i l i t y to develop a better system of health care delivery. 141 Thus i t is suggested, that without adequate support from the central government for regional decision making in planning, any real change would be impossible. Co-ordination and integration of services at that l e v e l requires authority - and r e s p o n s i b i l i t y without authority would lead to frustration and the potential for f a i l u r e . By leaving the 'shaping' of health service delivery at the region to the manager, the Ministry of Health would be free to design an overall framework for health p o l i c y . Demonstrable support by government for the concept of regional planning would seem to be the most important c r i t e r i o n for i t s success, b. Support From Subgroups Most would agree that good regional health planning must involve extensive- collaboration. E a r l i e r in th i s study i t was suggested that, with the current economic sit u a t i o n and the hard l i n e that has been taken so far by government, the providers would be w i l l i n g to be part of an integrated planning process. Far better to be part of the process than to have ar b i t r a r y cuts imposed. At the same time, i t would seem important for the government to re a l i z e that without the support of the groups actually providing the services., any cost-effectiveness of regionalization would be impossible. It would be too easy for the many groups either c o l l e c t i v e l y ( c o a l i t i o n s ) or on their own ( i f they are powerful enough) to sabotage any e f f o r t s at co-ordination. One can not 142 command co-operation and information sharing - things necessary to increase e f f i c i e n c y and effectiveness in a system as complex as t h i s . We have stated that consultation i s important. Barnard (1980,303) suggests that i t i s equal to negotiation and would seem to be pragmatic, given the interdependencies between the various subgroups del i v e r i n g health services. He states that the objective of both consultation and collaboration i s to build up c o a l i t i o n s of support for real planning decisions, but that to reach any mutually accepted solutions, both organizations must have something to negotiate with, and some reason to negotiate. Strauss (1978,234) suggests that s o c i a l orders are in some sense always negotiated orders, and that i f long l a s t i n g (durable) co-operative structures are required then the process involves: 1) hammering out the negotiation machinery 2) progressive building of agreement 3) the ironing out of residual disagreements. To accomplish t h i s , (1) implies that the structure must allow a mechanism for discussion between various groups, (2) suggests a need for incentives, and (3) implies that the regional manager would have to have a reasonable amount of authority and f l e x i b i l i t y . 1 43 LIAISON DEVICES The need for l i a i s o n mechanisms has been demonstrated repeatedly in this study. Two approaches seem p a r t i c u l a r l y appropriate in this setting: some form of committee structure, and a new role for the Regional Manager. Since they would serve d i f f e r e n t functions, both would be necessary, a. Committees Each of the three planning systems we looked at had committees of some type. The model used in New Zealand and the one that most D i s t r i c t Health Councils in Ontario seem to be moving towards, has committees formed along functional or service l i n e s . There are real advantages to thi s type of system, p a r t i c u l a r l y i f members are representives of di f f e r e n t agencies and professions. Since they cut across t r a d i t i o n a l boundaries ( i n s t i t u t i o n a l , public health, and voluntary organizations) they provide a mechanism where those with common interests (such as those employed in mental health) can discuss problems, plan, and organize together. It therefore provides an interface for the co-ordination of services and a forum for the exchange of ideas. Committee meetings would help to increase the awareness of others roles and problems. Many of the changes ( i . e . avoiding duplication of services,and improving r e f e r r a l systems) are not costly, but would go a long way towards making the 144 services for a group such as the mentally i l l more e f f i c i e n t and e f f e c t i v e . Clearly, providers should be involved in these m u l t i d i s c i p l i n a r y , multiagency committees, but should consumers? There seem to be d e f i n i t e advantages to involving the c i t i z e n / consumer on advisory committees. They can moderate the professional bias and represent the interests of consumer groups. If used wisely, i . e . in policy areas, needs assessments, and as a sounding board for p r o v i n c i a l p o l i c i e s (but not in implementation strategies) they can be very useful. Ontario's D i s t r i c t Health Councils work well in t h i s way. A committee structure which is formed along service or functional l i n e s , with some consumer/citizen representation is therefore recommended for the B.C. regional planning system. b. The Regional Manager As Liaison Having committees develop plans and assess needs, in i t s e l f w i l l not improve services. The individuals on the committees must have the support of their agencies. For example, the hospital representative to the Mental Health Committee must have the support of the hospital administrator to make changes. This person must not be a token representative, but be able to speak knowledgbly about the organization, and must also have access to the Administrator in order to have decisions 145 (such as a l t e r i n g the r e f e r r a l procedure, or changing follow up procedures) r a t i f i e d quickly. If members of committees do not have th i s support, then increased effectiveness and any increase in e f f i c i e n c y w i l l be minimal. One of the roles of the Regional Manager would be as a l i a i s o n between government and these various administrators. The importance of these committees has to be stressed to these groups. It is important for the Regional Manager to develop support within the region, as he or she w i l l be evaluated ( i f not e x p l i c i t l y , then i m p l i c i t l y ) on how e f f e c t i v e the regional organization i s , and not only on how e f f i c i e n t i t i s . As we stated e a r l i e r , measures of effectiveness tend to be external reactions. If the government i s lobbied a great deal, or receives a great many complaints from interest groups,or consumer groups then i t i s possible that as an indication of change, the manager would be replaced. In summary, the l i a i s o n role would seem to be very important for a manager at the regional l e v e l , but again, unless t h i s person i s seen as someone with a s i g n i f i c a n t degree of authority, e f f e c t i v e l i a i s o n w i l l be very d i f f i c u l t . 1 46 PLANS AND PLANNING Although most would agree that regional health plans are important, i t seems that the process should not be too formalized, or involve a great deal of operational d e t a i l . It should not, for example, be the r a t i o n a l comprehensive, blueprint planning popular in B r i t a i n . Some planners (Barnard, Friedman) suggest that plans should be more strategic than operational, to allow some f l e x i b i l i t y in methods of achieving ends. The process of planning ( i . e . getting various groups together to id e n t i f y problems, p r i o r i z e needs, etc.) i s almost as important as the plan that evolves, as t h i s process often sets the stage for implementation. Because of the wide variation between regions, planning should not be based too i n f l e x i b l y on government established standards. It i s suggested that minimum standards be developed c e n t r a l l y to ensure equity between regions, but that optimum standards for each region be developed j o i n t l y by the Region and the planning group in the Ministry. These would be based on regional needs and would take into account the p a r t i c u l a r problems of each region. The North, for example, with problems of s t a f f retention might have a d i f f e r e n t approach to delivery of services and therefore would have a d i f f e r e n t optimum standard in some areas. Control, through monitoring plans against an ov e r a l l strategy, would seem better than attempting to lay 1 down in elaborate d e t a i l the format and content of plans An approach to evaluation which stesses outcome rather than process i s also recommended. Clear d e f i n i t i o n s of boundaries and reporting mechanisms i s also important in any regional planning e f f o r t . 1 48 ALTERNATE STRUCTURES FOR PLANNING Several d i f f e r e n t structure are possible for planning in B.C. These w i l l be i l l u s t r a t e d and some advantages and disadvantages of each outlined. Figure 27. Bureaucratic Model REGIONAL MANAGER != ; 1 , 1 1 PL/POLICY i CONSULTANTS DISTRICT A. DISTRICT B. Here the Regional Manager with the aid of his/her st a f f and input from the Ministry of Health would develop a regional health plan. No permanent advisory body would be formed, although ad hoc committees could be set up. With th i s approach one would expect a dependence on c e n t r a l l y set standards. Advantages A regional plan could be developed quite quickly, (and some would say e f f i c i e n t l y ) . Disadvantages With l i t t l e or no involvement in the planning process by those who delive r the services the plan may not be the best ( i . e . address the real problems, or have the best answers). It would tend to be unpopular and may not have the support necessary for implementation. If the Regional Manager does not have a s i g n i f i c a n t degree of authority the most powerful groups (hospitals and doctors) would have no 1 49 reason to pay attention to recommendations that evolve from i t . It does not build into the structure the l i a i s o n mechanisms important for integration, and co-ordination of services. This means that the success is very dependent on the a b i l i t i e s of one person, the Regional Manager. This would make t r a n s i t i o n from one to another p a r t i c u l a r l y d i f f i c u l t . Given the rapid turnover of staff in many government positions, i t seems that support for planning should be b u i l t as much as possible into the planning structure. In addition, elected o f f i c i a l s such as chairmen of the Regional Hospital D i s t r i c t s may not want to report to a bureaucrat. Also, many might see this form of regionalization as too authoritarian. E a r l i e r i t was suggested that, with the extensive reorganization and the trends within, government to s h i f t the culture of the organization from one based on objectives stressing better care and more services, to ones stressing cost control and accountability, the potential for poor morale was high. Introducing a planning system that was seen as authoritarian and bureaucratic would contribute to t h i s problem. Since one of the biggest resources in a health system i s s t a f f , potential problems with morale should be taken into account. 1 50 Figure 28. D i s t r i c t Model REGIONAL MANAGER PL/POLICY CONSULTANTS DISTRICT A DISTRICT COUNCIL I SUB CTTE' 1 SUB CTTE Here, much l i k e the Ontario system, D i s t r i c t s would have D i s t r i c t Councils with subcommittees formed at that l e v e l along service l i n e s . Much of the planning could take place there. But, unlike the Ontario system , there would be a Regional Manager and st a f f situated in the region to be responsible for ov e r a l l co-ordination of the planning .function of the region. Advantages With the smaller size, i t would be easier to develop community awareness and community s p i r i t . Planning would take place closer to the community and therefore might more accurately address community needs. Pi sadvantages This model would tend to perpetuate the status quo. Since the boundaries would be formed on Public Health boundaries there would be no incentive for hospitals or physicians to get involved. Co-ordination and integration across service l i n e s would s t i l l be very d i f f i c u l t . In addition, there may even be competition between d i s t r i c t s for resources. This would increase d i f f i c u l t i e s with integration of services. 151 Figure 29. Service Development Committee Model REGIONAL MANAGER STAFF DIST. A. DIST . B. T -S.D.C El d e r l y ~ r i i ~I i 1 S.D.C. S.D.C. Primary Rehabil Care i t a t i o n With t h i s model, committes formed along service l i n e s would report d i r e c t l y to the Regional Manager. These committees would get input from the st a f f working at that o f f i c e . Advantages A l l the advantages l i s t e d e a r l i e r of having multiagency, m u l t i d i s c i p l i n a r y committees based on service l i n e s addressing regional needs would apply. The Regional Manager would also have the perspective necessary to do the o v e r a l l planning for the region. This model would have the support of some of the provider groups ( p a r t i c u l a r l y the smaller ones). Disadvantages Some problems would not f a l l neatly into one of these groups. Co-ordination may be d i f f i c u l t between them. These groups might lose interest or become frustrated i f the Regional Manager does not have enough authority to make decisions without r e f e r r i n g back to V i c t o r i a . If the Regional Manager i s very busy, or away, these groups may not get the feedback or attention that they require. This model may not get the support of the Regional Hospital D i s t r i c t s , or Union Boards of Health who also see themselves as planning bodies. 152 Figure 30. Regional Advisory Council Model REGIONAL MANAGER -STAFF T DIST. A., DIST. B. REGIONAL ADVISORY COUNCIL S.D.C. E l d e r l y S.D.C. Primary Care S.D.C. Rehabil-i t a t i o n With th i s model a Regional Council would be formed with some elected o f f i c i a l s , some consumers, and some providers. This body would act as an advisory/planning group to the Regional Manager. Subcommittees would be formed along service l i n e s as with the la s t model. Staff of the Regional Manager would act as secretariat to both the Regional Council and the Service Development Committees. Advantages This s h i f t s more responsiblity and accountability to the region for health care decisions and p o l i c i e s . Elected o f f i c i a l s ( i . e . chairmen of RHDs) could be on the Council and would therefore provide a mechanism for involving hospitals. This model would help the development of a regional ' s p i r i t ' or identity among the providers and c i t i z e n s . It also has a l l the advantages l i s t e d e a r l i e r of multiagency, m u l t i d i s c i p l i n a r y service groups. Because i t would be seen to be less authoritarian i t would get support from most groups and would be good for morale. Support for planning i s almost b u i l t into the structure and therefore the success of planning i s less dependent on the a b i l i t i e s of one person, such as the Regional Manager. This i s important during times of t r a n s i t i o n . Disadvantages It would be slow and d i f f i c u l t to set up. Regions would be new and people would not be used to rela t i n g - t o each 153 other within a regional context. L i t t l e planning would take place in the f i r s t few months as committees would take some time to become established, and would have to go through an i n i t i a l 'growing' period where roles are developed. In the early stages i t would also be d i f f i c u l t to know which committees to form or who to have on them. RECOMMENDATIONS The model for planning which would seem to have the most support for implementation, and which would also provide the best structure to develop a regional health plan that meets the c r i t e r i a outlined e a r l i e r , i s the model with a Regional Advisory Council, and Subcommittees formed along service l i n e s . It would be important within this structure, to give the Regional Manager a s i g n i f i c a n t degree of authority and f l e x i b i l i t y in methods of achieving goals. However, this would be a d i f f i c u l t model to implement a l l at once. Some reasons were outlined in the section on disadvantages to t h i s approach. For example, at f i r s t there would be no sense of regional iden t i t y , and i n i t i a l l y there might be c o n f l i c t among those on the committees. This would make any attempt at co-ordinated planning d i f f i c u l t . To increase the chances of success i t i s recommended that there be two or perhaps even three stages of implementation. It should be c l e a r l y stated that the f i r s t two stages follow each other, and that the second 1 54 one would be implemented at the end of the f i r s t year.. I. STAGE ONE - SETTING THE STAGE Goals 1) To set up the regional o f f i c e . 2) To undertake an overall review of the health services in the region. 3) To establish a 'regional i d e n t i t y ' . 4) To develop support for regional planning. In t h i s stage the planning model used would be the 'Bureaucratic' model outlined f i r s t . In the f i r s t year the manager would be setting up an o f f i c e , h i r i n g s t a f f , and developing a rapport with those services d i r e c t l y funded by the Ministry of Health. This in i t s e l f would be a d i f f i c u l t task as those provi-ding di r e c t services such as Mental Health services, may have some resistance to reporting to a Regional Manager rather than the Director of Mental Health Services in V i c t o r i a . During t h i s time an ov e r a l l 'supply side' review of services and programs operating in the region could be done, as well as some preliminary i d e n t i f i c a t i o n of health problems in the region. Information about the new structure and the plans for Stage Two would be di s t r i b u t e d , as well as an advertising campaign undertaken, to inform both the public and the providers about the new system. The Regional Manager would spend a s i g n i f i c a n t 1 55 amount of time in a l i a i s o n role developing support for the concept of integrated regional planning with the many other groups operating in the region. Ad hoc committees could be developed to help in the implementation process. These committees would be useful in that they would also be a mechanism whereby individuals suitable for the Regional Council could be i d e n t i f i e d . During t h i s time those individuals in the community who might be asked to s i t on the Regional Council would also be i d e n t i f i e d . I I . STAGE TWO - THE DEVELOPMENT OF AN INTEGRATED  REGIONAL PLANNING MODEL Goals 1) To develop a Regional Advisory Council. 2) To set up appropriate Service Development Committees. 3) To develop a 3 year Regional Health Plan. 4) To co-ordinate and integrate services in the region. In this second stage, a Regional Advisory Council would be formed. It would be made up of elected o f f i c i a l s (such as the chairman of the Regional Hospital D i s t r i c t s and the Union Boards of Health), consumers, and providers. Ontario's system which has 40% providers, 40% consumers, and 20% elected o f f i c i a l s might be a good mix. 156 These would predominantly be appointed members, recommended by the Regional Manager to the Minister for appointment. The mandate of this council would be to act in an advisory capacity to the Regional Manager, to a s s i s t in the assessment and p r i o r i z a t i o n of regional health needs, and to a s s i s t in the development of a 3 year Regional Health Plan. In conjunction with the Regional Manager, this body would review hospital budgets, and hospital c a p i t a l expenses. Requests for grants by Voluntary Organizations would also be reviewed by t h i s c o u n cil. It would have, as a se c r e t a r i a t , planning and consulting staff from the regional o f f i c e . This Council would also set up the Service Development Committees based on regional needs. These committees which would have a greater percentage of providers than the Advisory Council (perhaps 60% providers, 40% consumers) would contribute s i g n i f i c a n t l y to the planning process by: 1) defining goals 2) i d e n t i f y i n g problems 3) setting p r i o r i t i e s within the service area (respecting p r o v i n c i a l p o l i c i e s ) 4) proposing a co-ordinated strategy of approach 5) developing proposals 6) monitoring services for their area. 157 Community eductation would also be an important function of these groups. These Service Development Committees would also have access to regional planning staff who might act as secretariat to them. During this stage, s i g n i f i c a n t l y more authority would be delegated to the Regional Manager. If the manager is to negotiate change with the many groups operating within the region, he or she must have something to negotiate with, and a reason to negotiate. As we stated e a r l i e r , there are incentives for negotiating on both sides, but at t h i s stage the manager has l i t t l e power. Some suggestions to improve this follow. i . Voluntary Organizations It is recommeded that the Regional Manager review the grant requests of a l l Voluntary Organizations and make recommendations to the Ministry based on regional p r i o r i t i e s . i i . Physic ians T r a d i t i o n a l l y a very powerful group, physicians may not have any incentive to become involved in integrated regional planning. To encourage their involvement, i t i s recommended that the Regional Manager become the chairman of a regional manpower working group, 158 as well as belonging to the p r o v i n c i a l group that is concerned with physician manpower planning. This group would consider methods of increasing the numbers of physicians in some regions and decreasing them in others. In Quebec, the government i s taking a proactive stance is a l t e r i n g the fee schedules for new physicians s e t t l i n g in some areas (Montreal and Quebec 75% and the North 135%). Limiting the number of b i l l i n g numbers in a region, or recommending changes in admitting p r i v i l e g e s are other ways to control the practice of physicians in a region. Although the central agencies of government would retain authority fo.r c o l l e c t i v e bargaining with the physicians, the above measures would give the Regional Manager a s i g n i f i c a n t degree of influence over them, and would encourage the physicians to parti c i p a t e in the regional planning process. i i i . Hospitals While the Regional Manager would not have dire c t authority over hospitals, i t would be possible to increase negotiating powers by having the Regional Manager, in conjuntion with the Regional Advisory Council: 1) review hospital budgets (in rel a t i o n to regional p r i o r i t i e s and plans) 2) review plans for c a p i t a l expansion of hospitals (again in re l a t i o n to regional 159 p r i o r i t i e s ) I n i t i a l l y , the Regional Manager would act in an advisory role to the Regional Hospital D i s t r i c t in these matters. As the regional organization strengthened, however, more authority would be transferred to i t . These two steps seem legitimate, since there would be elected o f f i c i a l s , consumers, and providers on the Advisory Council. The Hospital Role Study which i s nearing implementation stage would f i t nicely with this approach. This second stage would see the formation then, of a Regional Advisory Council which would have Service Development Committees, developed because of regional needs, reporting to i t . A s i g n i f i c a n t degree of authority would be delegated to the Regional Manager during t h i s stage. This would seem to be the best approach for improving health service delivery to a region without increasing o v e r a l l costs. It would also tend to be popular and would have the support of most groups. An evaluation i s recommended after 3 to 5 years. At that time a decision could be made about whether to move to the next stage. 160 I I I . STAGE THREE - INCREASED REGIONAL AUTONOMY During a t h i r d stage, there would be a gradual devolution of power and authority to the Regional Advisory Council. This would s h i f t r e s p o n s i b i l i t y to the community for health services delivery. In this model some overall p r o v i n c i a l control would have to be maintained to ensure that d i s p a r i t i e s between regions did not develop. CONCLUSION In this study, strategies for regional health planning in B r i t i s h Columbia have been explored. An approach to planning was sought that would allow a Regional Health Plan to be developed that would: 1) seriously address the health care needs of a region 2) demonstrate due consideration of f i n a n c i a l , l o g i s t i c , and other organizational r e a l i t i e s 3) respect p r o v i n c i a l p o l i c i e s and p r i o r i t i e s , except where they can be demonstrated as inappropriate, and 4) have the support necessary for implementation. It is f e l t that the best approach to doing t h i s , given the current situation in B.C., would involve two stages. The f i r s t would be e s s e n t i a l l y a decentralization of the administrative functions for direct services, and a general review of health services and health care in the region. The development of a 161 regional identity and l i a i s o n among the many groups operating in the region would be important aspects of this f i r s t stage. The second stage would see the development of a Regional Advisory Council and Service Development Committees. More authority would be transferred to the Regional Manager during t h i s time, and health service delivery would be s t r u c t u r a l l y , and functionally integrated. This is the most important stage, as i t has the potential to make health care delivery in a region much more e f f e c t i v e and e f f i c i e n t . It builds into the structure support for planning, as well as developing regional wide co-ordinating and integrating mechanisms. By s h i f t i n g more r e s p o n s i b i l i t y to the people of the region i t would have a p o s i t i v e effect on morale. At the same time, i t would give the Regional Manager and Council a s i g n i f i c a n t degree of authority over the hospitals and physicians, a necessary step i f any real change i s to occur in our health care system. While drastic changes should not be expected to occur overnight with t h i s approach, i t does address most of the potential problems outlined in t h i s study and would seem to be the best method of dealing with the many d i f f i c u l i t i e s facing health care managers today. 1 62 REFERENCES Arbon, G., and Ramirez de A r e l l a r o , A. Regionalization of Health Services, The Puerto Rico  Experience. Oxford University Press, 1978. Bacharach, S. B., and Lawler, E.J. Power and  P o l i t i c s in Organizations. San Fancisco: Jossey-Bass Publishers, 1980. Barnard, K.; Lee, K.; M i l l s , A.; and Reynolds, J. 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Guidelines for the 70's, Volume 2, Social  Goods and Services. Winnipeg: Manitoba, 1973. Martins, J.M. Concepts and Practice of Regional  Administration. Health Commission of New South Wales, Sydney, A u s t r a l i a . A p r i l , 1975. 165 Maxwell, R.J. Health and Wealth, An International  Study of Health Care Spending. Toronto: Lexington Books, D.C., Heath and Co., 1981. Miles, R.H. "Conflict and Its Management". in Miles, R., and Randolph, W. A., (ed.) The  Organization Game. Santa Monica, Ca.: Goodyear Publ. Co., 1979. Miles, R.H., and Randolph, W. A. (ed.) The  Organization Game. Santa Monica, Ca.: Goodyear Publ. Co., 1979. Mintzberg, H. The Nature of Managerial Work. New York: Harper Row, 1973. Mintzberg, H. "Organization Design: Fashion or F i t ? " Harvard Business Review, 1981, Jan.-Feb. , 103-116. Mintzberg, H. The Structuring of Organizations . Englewood C l i f f s , N.J.: Prentice-Hall Inc., 1979. Mintzberg, H. "Patterns in Strategy Formation". in Miles, R. (ed.) Resource Book in Macro  Organizational Behavior. Santa Monica Ca.: Goodyear Publ., 1980, 343-359. Nadler, D.A., and Tushman, M.L. "A Congruence Model for Diagnosing Organization Behavior".. in Miles, R. (ed.), Resource Book on Macro Organizational Behavior Santa Monica, Ca.: Goodyear Publ. Co., 1980, 30-50. Nadler,D.A., and Tushman, M.L. "Implications of P o l i t i c a l Models of Organization". in Miles, R. (ed.) Resource Book on Macro Organizational Behavior, Santa Monica, Ca.: Goodyear Publ. Co., 1980, 177-191 . Noyce, L., et a l . "Regional Variations in the Allocation of Financial Resources to the Community Health Services." The Lancet, 1974, March 30, 535-557. Ontario. Report of the Health Planning Task Force. Toronto: Ontario Ministry of Health, 1974. Ontario Council of Health. The Planning Function of  the D i s t r i c t Health Council. Toronto, Ontario, 1977. 166 P f e f f e r , J. "Power and Resource Alloc a t i o n in Organizations". in Miles, R., and Randolph, W.A. (ed.) The Organization Game. Santa Monica Ca.: Goodyear Publ. Co., 1979, 87-102. Pfeffer, J., and Salaneik, G. The External Control  of Organizations. New York: Harper Row Publishers, 1 978. Randolph, W.A. "Technology and The Design of Organizational Units". in Miles, R. and Randolph, W.A. (ed.), The Organization Game, Santa Monica Ca: Goodyear Publ. Co., 1979, 87-102. Rhode Island Department of Health. Health Planning  and Resource Development. Technical Reports," No. 6., Providence, Rhode Island, February, 1977. Rosener, J.B. "A Cafeteria of° Techniques and Critiques". Public Management. 1975. December, 16-18. Saward, E. (ed.) The Regionalization of Personal  Health Services. New York: Prodist, 1976. Strauss, A. L. Negiotiations: V a r i e t i e s , Contexts,  Processes, and Social Order. San Francisco: Jossey-Bass, 1978. Stewart, R., Smith, P., Blake, J., and Pauline, W. The D i s t r i c t Administrator in the National Health  Service. London:Pitman Press, 1980. 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"Concepts in Planning of Regional Health Systems". Transcript of a speech given to the Alberta Hospital Association, December, 1976. Malcolm, L. "Towards More innovative Health Care", unpublished manuscript, Health Planning Research Unit, Christchurch, New Zealand, 1981. Malcolm, L., Wright, L., Smith, K. "Evaluation of Service Development in North Canterbury." unpublished paper, Health Planning Research Unit, Christchurch, New Zealand, 1981. Malcolm, L. Personal Communication about the New Zealand Planning Structure, September, 1981. Nicholls., B., and Nichol, D. , Personal Communication about Regional Health Planning in B r i t a i n , May, 1981. Regionalization of Health Services in B r i t i s h Columbia, Internal Report of the Ministry of Health, August, 1981. Roy, C , Personal Communication about Ontario D i s t r i c t Health Councils, June, 1981. Weiler, D. "Community Health Planning in the N.H.S.", unpublished paper, University of Birmingham, 1977. 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