The single most important person in Canadian health care today is someone you have likely never heard of: Stephen Duckett, the new chief executive officer of Alberta Health Services.
In the 12 weeks he has been on the job, there has been a shakeup the likes of which we have never seen in the country. By all accounts, he has only just begun, having set out to fundamentally restructure health-care delivery.
If Mr. Duckett succeeds, the centralized corporatist model he is trying to introduce in Alberta will likely be copied across Canada; if he fails, it will likely take decades for the province to recover.
Either way, medicare will likely never be the same.
Alberta has, in the past decade or so, created the best, most innovative health system in Canada. Regionalization allowed health authorities to shape services to local needs, created better continuity of care, made the health system more responsive, improved public health and led to strong alliances between university researchers and health regions.
But regionalization also created powerful, independent health leaders like Sheila Weatherill of Edmonton and Jack Davis of Calgary, who used their influence to push for massive infrastructure investment, new research funding and ever-larger health budgets.
Slightly more than a year ago, Premier Ed Stelmach blew up the structure and replaced the regional health authorities with a single "superboard" to oversee all health-care services in the province.
The move was motivated principally by petty politics. Mr. Davis and Ms. Weatherill had become so powerful that they were perceived as threats, not to mention that their politics did not align perfectly with those of Mr. Stelmach's rural conservatism.
The change was extolled with feel-good utterances about a "new governance model" that will "clarify the roles and responsibilities" and create a "21st-century" health-care system that will be "more effective and efficient."
But the sad truth is that there was no plan other than to purge perceived enemies and get power back in the hands of the political inner circle.
The year since the regions were dismantled has been a disaster. The Alberta system has been adrift. The supposedly lean and mean superboard has bumbled its way to overspending $1.2-billion and access and quality of care has deteriorated markedly.
Yet, Alberta Health Minister Ron Liepert insists things are going swimmingly. He describes the restructuring of health care in the province as the "biggest merger in Canadian history" and an important "rebranding" of health; he dismisses the complaints as the whining of vested interests and media elites.
Enter Mr. Duckett, recruited from Australia as the plain-spoken captain who must right the ship in stormy economic times.
One of his first moves was to release a new organizational structure to give people a sense of "where they fit." The chart stretches a mind-numbing 86 pages, but it soon became apparent that a lot of current employees didn't fit. Middle managers were forced to reapply for their jobs. Dozens - maybe hundreds, it's not clear - were singled out for elimination.
Infrastructure spending is on hold. There is a hiring freeze. Every single hire (or rehiring) must be approved by Mr. Duckett personally. Alberta's aggressive hiring of nurses, domestically and abroad, has ground to a halt. The nursing shortage has suddenly evaporated - budget-balancing oblige. Clearly, Mr. Duckett's No. 1 role and goal is to cut spending. The drop in oil prices has left Alberta with a severe budget shortfall. Bringing health spending under control is a laudable and necessary goal. But, despite the rhetoric, there is no evidence that eliminating regionalization is the way to do so.
It is up to Mr. Duckett to prove otherwise - and the other provinces (where regionalization is the norm) are watching.
He is being paid $575,000, a modest amount for a CEO of a "corporation" with 8,000 employees and a $13-billion annual budget. But he will also get a 25-per-cent bonus ($143,750) for meeting his budget goal.
There are hints emerging of how savings will be achieved. Mr. Duckett likes to talk about the non-nurse work done by nurses, which suggests replacing registered nurses with less qualified practical nurses and support staff.
He speaks of physicians primarily delivering front-line care, which suggests that Alberta's alternative payment plans that encourage balancing research, teaching and patient care are in the crosshairs. He wants to fund only research with "measurable results" - presumably immediately. Other provinces must be licking their chops at the prospect of wooing back all the research stars they lost to Alberta in recent years.
That Mr. Duckett comes from a country where there is a lot of private and for-profit health care also has health-care professionals worried, but to date he has dismissed suggestions he plans to go the politically risky privatization route to trim public spending.
The reality is that there is still no obvious plan other than tough talk and belt-tightening.
A year after a successful regional model of health delivery was trashed, there is no clear vision of what should and will replace it.
And for all the turmoil and bluster surrounding Alberta's restructuring of health care, the single most important question remains unanswered: How is this better for patients?
The answer to that question will be Mr. Duckett's legacy.