Nobody's responsible

The provincial health system is designed to obscure accountability. As a result, fixing problems takes longer

by Andrea Reimer

If I was a cynic, I might look at the high-profile firing of Fraser Health Authority CEO Bob Smith this past week as an attempt by the BC Liberals to prevent a political bleed out in advance of the May 17 election. Consider the facts.

The problem-plagued Fraser Health Authority (FHA) manages the delivery of health care to 1.47 million British Columbians or, put another way, one-third of the province's voters. And not just any voters: the FHA includes a whopping 25 provincial electoral districts in the all-important eastern suburbs of the Lower Mainland. In an election that may be decided by a handful of seats, political pundits have singled out this region as the one to watch.

What we've been watching instead is a steady stream of FHA missteps that range from the outrageous (you can bet how New Westminster will be voting after finding out that $400,000 was spent at Playland for FHA employees and their families at the same time plywood was being nailed over the windows at moth-balled St. Mary's Hospital) to the downright tragic.

The death of Baljit Singh Bains earlier this month after being sent home prematurely from the Surrey Memorial Hospital was one such tragedy but it is sadly not the first. A recently released coroner's report placed partial blame on the same hospital for the 2003 death of Frank Brander. Close to a half dozen deaths at other FHA hospitals have also raised public concerns in the past few years.

In addition, public outrage has been underlined by weekly front page headlines in community newspapers from Delta to Hope featuring bed closures, ambulance shortages, filthy beds, multi-day waits in ERs and “re-therm” food that's enough to make you sick.

All of these are probably pretty good reasons for saying soyanara to the CEO, but personally I'm not that interested in why Smith himself was fired. His status as the third FHA boss in three years speaks to a much larger problem with governance and management. If we really want to fix the FHA, and the province's four other regional health authorities who all have troubles of their own, we'd do a lot better to look at who fired Smith.

But let's start with who didn't fire Smith. It wasn't Health Services Minister Shirley Bond, who correctly pointed out, in an oft-parroted refrain from MLAs whenever a problem arises with health care delivery anywhere in the province, that the statutory body responsible is the board of directors for the Health Authority itself. But while you can blame the directors, you sure can't hold them accountable. Why? Because they're not elected: they're appointed by (drum roll please) those very same MLAs who claim they have nothing to do with any of the problems with health care delivery.

Before you think this is an anti-Liberal rant, note that I was pretty careful in the last paragraph not to say Liberal MLAs. During most of their two terms in government, NDP MLAs had a very similar habit of downloading responsibility for health care failings on to regional boards too.

In fact, it was the NDP that started the process of regionalization, first with the precursor Community Health Councils in 1993 and formally with the establishment of the province's first regional health boards in 1997. Dwindling federal transfer payments to all the provinces in the 1990s meant less money for provincial expenditures, including health care. Regionalization, and most particularly the regional boards that could be pointed to as the bad guys when cuts were made, became a trend across the country with every single province establishing regional health boards by decade's end.

To be fair, the NDP were in part responding to the 1991 BC Royal Commission on Health Care and Costs which recommended a move to local health care governance. The impetus for the Commission's recommendations, however, came out of a desire to “engage communities and individuals in the design, delivery and accountability of the health system.” These are laudable goals that I and others, like the BC Medical Association, very much support, but clearly they've been difficult to achieve via appointed directors who hold so many closed-door meetings that even their MLA appointers have expressed frustration.

Creating elected, locally accountable boards that decide how tax dollars are spent on the provision of public services is not a newfangled idea. The province's school boards have been doing it in some cases since before there was a province. Like regional health boards, legislation from the province provides broad standards within which school boards can make policy decisions and prioritize spending to meet local needs.

The difference is that if a school board experiences the kind of catastrophic failure we've seen from some health authorities, voters have recourse during school board elections. This provides a strong imperative for school trustees to engage the community on impending decisions, both so that trustees better understand what community priorities are and so that the community understands why trustees make the decisions they do.

The result is that school boards adapt relatively quickly to meet the unique needs of their community. Vancouver, for example, pioneered English as a Second Language instruction, multi-lingual home to school support for parents, and anti-homophobia and inner city school programs. The Victoria school board, on the other hand, has put considerable energy into developing a successful community schools model. As their respective districts grow, boards have been able to trade innovations that have been perfected at the local level for relatively low expense to provincial taxpayers as a whole.

Given the staggering proportion of the provincial budget consumed by health care, having accountable local governance seems even more important now than it was in 1991 when the Royal Commission made it's recommendation to move in this direction. But for precisely the same reason, getting the province to move away from the current zero-accountability model will likely take a few more causalities of the kind we've seen this past month.

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