Yukonomist: Prescribing a major health care shake up

Yukonomist Keith Halliday

The Yukon’s health system is a key part of our quality of life, even if film crews prefer to put moose and mountains in the territory’s promotional videos rather than healthcare professionals.

Compared to Alaska, universal care makes our system much fairer. Compared to the big provinces, the transfer payment allows better service in many areas. For example, according to the Canadian Institute for Health Information (CIHI), the average emergency department waiting time in the Yukon is less than half the national average.

But as several government reports since 2017 have found, all is not well with the system and the territorial government is planning a big shake up. It’s good to see action coming from these reports. Well done, this could enable our system to be the best in the country. However, without the right leadership and project management skills, it could prove a costly bureaucratic distraction.

For context, let’s run through a few areas where our system is strong and weak. There are multiple areas where the Yukon’s system outperforms those of our neighbours in British Columbia and Alberta, including emergency wait times and falls in the last 30 days by residents of long-term care homes. However, CIHI says our score for “potentially inappropriate medication prescribed to seniors” is 47.3 per cent, higher than the national average and rising. Our “In-hospital sepsis” (infection) rate is more than double that in B.C. and Alberta. And only 78.8 per cent of Yukoners have a regular health care provider compared to 82.0 per cent in B.C. and 83.7 percent in Alberta.

For all the talk of health care systems, it is ultimately the people on the front line who make the difference. In a 2018 survey of the Department of Health and Social Services, the department’s staff scored high on engagement. For example, 70 per cent said they were “inspired to give my best.” However, only 50 per cent said they thought the department was headed in the right direction and a worryingly low 45 per cent had confidence in their senior leadership.

After what I have heard about overwork and employee attrition from a couple of Yukon nurses over the last year or two, I would be very interested in seeing the employee survey data from front line workers in particular.

On the cost side, our health system has some major challenges. In 2017 the premier’s Financial Advisory Panel flagged rising health care costs as one of our top financial issues, noting that health spending had been rising faster than “one would have expected from Yukon’s demographics and per-capita growth observed elsewhere.”

From 2018 to 2020, another panel worked on the Putting People First report. Its updated analysis confirms the cost issue. The cost of a standard hospital stay in the Yukon was $8,387, for example, versus a national average of $6,349. Adjusting for inflation back to a base year of 1997, the report indicates that per person spending in the Yukon was about $7,500 in 2019, versus $4,500 across Canada.

Our spending has also been growing steadily faster than the national average. Health grew from 27.8 per cent of the territorial budget in 2014-15 to 30.1 per cent in 2018-19.

This happened during a period when the Yukon’s population was much younger on average than Canada’s. Younger people cost the system much less on average, but our population is expected to age substantially over the coming decade. If health costs accelerate and, say, federal transfer payment growth slows down as the feds deal with the post-COVID national debt, the territorial government will be caught in a nasty vise. This is not good news for other departments competing for funding, such as education or highways.

The Putting People First report makes a number of major recommendations. Some of them stand out starkly. Rather acidly for a sober public report, the report’s authors call on the Yukon government to “implement an evidence-based approach to system planning and decision-making.” You have to wonder what they think previous ministers and senior officials in the Silver and Pasloski governments were basing their decisions on, if not evidence.

The first three recommendations of the report call for a major restructuring. This includes changing the ways doctors are paid, and creating a new health authority called Wellness Yukon to provide “integrated” care across the health and social systems. This new super agency will manage the Yukon’s hospitals, primacy care facilities and long-term care homes.

From one point of view, this sounds sensible. Who could be in favour of un-integrated health care? It will be tidier on government org charts if there is one agency managing the many different touchpoints where Yukoners connect with the system, from doctors’ offices to vaccine clinics to the hospital.

However, organizational change is much more difficult to make work than just changing the names of agencies and who reports to whom. The premier’s Financial Advisory Panel, in fact, advised caution on this front, noting that “institutional reorganization can take many forms from moving around senior civil servants and reorganizing departmental mandates to consolidating [and then decentralizing] stakeholder boards in areas such as healthcare and education. This is the easiest change to undertake and the least likely to increase efficiency or effectiveness in the operations of government … this is otherwise referred to as ‘rearranging the deck chairs.’”

Indeed, we already have an agency that manages all our touchpoints: the Department of Health. There is nothing stopping the various Assistant Deputy Ministers and hospital bosses from cooperating today to deliver more integrated care. The Yukon is such a small jurisdiction that you could fit all the key decision makers around a single meeting table.

The designers of the new agency will need to be hard-headed about mandates, decision rights, budgets and incentives to make the new agency work effectively. Otherwise, they are just adding another layer to an already top-heavy system.

CIHI reports that the Yukon health system’s “corporate services expense ratio” — that’s overhead to you and me — is triple, yes triple, the level in B.C. and Alberta. The people designing the new system should cap the number of senior officials, communications and policy analysts. If we end up with a new agency with a CEO, chief of staff, head of strategy and communications department in addition to what we have now, that will be a very public insult to overworked nurses and doctors.

Caution is also required when changing how doctors are paid. Our fee-for-service system has well-known flaws, but it will be self-harm if the Yukon government changes it in a way that makes being a doctor in the Yukon less attractive than Canmore or Nelson.

It has now been four years of studies since the Financial Advisory Panel recommendations on the health system came out. It’s that moment when you have the hood up on the truck, the owner’s manual open to the right page, and are about to start disconnecting wires and unbolting things. The government has decided on action. The mandate letter for the current minister of health instructs her to “initiate the creation” of Wellness Yukon. What our health care leaders do next, and how well they do it, will be a legacy-defining moment we will all have to live with for years to come.

Keith Halliday is a Yukon economist, author of the Aurore of the Yukon youth adventure novels and co-host of the Klondike Gold Rush History podcast. He is a Ma Murray award-winner for best columnist.