Is Danielle Smith’s overhaul of Alberta health care restructuring or revenge?

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Drawn and quartered was a medieval form of execution in which the victim was hanged, cut into four pieces, and the parts scattered.

Last week, Premier Danielle Smith dispatched Alberta Health Services, the quasi-independent agency that oversees the delivery of health care in the province, to the gallows. In its stead will be four chopped-up pieces, responsible for acute care, continuing care, primary care, and mental health and addictions.

The drawing and quartering – or “de-aggregation” as the Premier called it – was necessary, she said, because AHS had become too big for its britches. It not only delivered health services, but formulated policy, and allocated the lion’s share of health funding in the province.

But the real impetus for change seems to be revenge. Ms. Smith objected strenuously to the actions of AHS during the COVID-19 pandemic, notably the temporary imposition of mask mandates and vaccine passports.

In her campaign to be leader of the United Conservative Party, she lashed out repeatedly at Dr. Deena Hinshaw, Alberta’s Chief Medical Officer of Health. When Ms. Smith became Premier, she sacked Dr. Hinshaw and fired the entire board of directors of Alberta Health Services, replacing them with a single overseer.

Public health officials can only be effective if they are independent and can speak and act freely, and are able to take actions that are not necessarily popular. Similarly, the very reason for an agency like AHS to exist is to operate at arm’s length from the government, so it can make decisions that are not politically motivated.

One of the principal reasons Canada’s health system is crumbling is that it is micromanaged by politicians whose visions don’t extend beyond their noses. The partisanship and second-guessing are poisonous.

Yet, the changes Alberta is making will centralize power in the offices of the health minister and premier.

To be clear, AHS was not without its flaws. It had indeed become bloated and haughty, and dismissive of rural health concerns in particular. Worse yet, it has not been particularly effective at tackling the two most pressing problems in health care today: the lack of access to primary care, and overflowing emergency rooms.

But nothing suggests the rejigged structure will do anything to resolve those problems. If anything, action will be delayed while bureaucrats busy themselves with shifting the deck chairs.

Alberta has made a habit of this over the decades.

In 1994, the province had 128 hospital boards, 25 public health boards and 40 long-term care boards that were consolidated into 17 regions. Brutal but fairly effective. In 2004, the number of regional boards was reduced to nine, and then in 2008, the AHS was created as a single governing authority.

Most other provinces have followed Alberta’s lead, creating integrated systems, most with a small number of geographic regions. Centralized systems should help create a seamless patient experience, and reduce bureaucracy.

The latest iteration of Alberta’s health system throws regionalization out the window. Instead, AHS will be divided into four organizations: primary care, acute care, continuing care, and mental health and addictions. They would be connected by an “integration council,” a board that reports to the health minister.

What’s unclear is what happens to a patient who doesn’t fit neatly into one of the boxes. Opposition leader Rachel Notley cited the example of a senior in long-term care who is hospitalized with a mental health issue. Who takes charge of this complex patient?

There are some good elements in Premier Smith’s new strategy, notably a vow that every Albertan will have a primary care provider – either a family doctor or nurse practitioner. But was it really necessary to create a Primary Care Organization to implement this plan? Couldn’t AHS have simply made it a priority?

Missing from the announcement was any commitment to additional funding or staffing. The government said it has budgeted $85-million, which is a laughable amount given the size of the task. The province spends almost $42-billion on health care annually.

The AHS has 112,300 employees. It oversees 11,069 registered physicians, 106 hospitals, and five psychiatric facilities. It has 8,523 acute care bed, 28,300 continuing care beds, and 3,077 addiction and mental health spaces – not to mention an ambulance service, public health, and more.

The organizational chart is dizzying and will become even more so when it’s drawn and quartered.

The most fundamental error, however, seems to be that the government has diagnosed a structural problem when, in fact, it has a capacity and access problem.

As Heather Smith, president of United Nurses of Alberta, says: “The wrong diagnosis always creates the wrong treatment.”