Devolving authority for health care in Canada's provinces: 3. Motivations, attitudes and approaches of board members
Jonathan Lomas, MA; Gerry Veenstra, MA; John Woods, BSc
CMAJ 1997;156:669-76
[ résumé ]
Mr. Lomas is Professor in the Department of Clinical Epidemiology and Biostatistics and the Centre for Health Economics and Policy Analysis, McMaster University; Mr. Veenstra is in the Department of Sociology and the Centre for Health Economics and Policy Analysis, McMaster University; and Mr. Woods was with the United Kingdom National Health Service and is now with the Education Centre for Aging and Health, McMaster University, Hamilton, Ont.
This article has been peer reviewed.
This is the third article in a four-part series on Devolving authority for health care in Canada's provinces.
Paper reprints may be obtained from: Jonathan Lomas, Centre for Health Economics and Policy Analysis, McMaster University, 1200 Main St. W, Rm. HSC-3H28, Hamilton ON L8N 3Z5; fax 905 546-5211
© 1997 Canadian Medical Association (text and abstract/résumé)
Abstract
Objective: To obtain information from the members of the boards of devolved health care authorities on their motivations, attitudes and approaches, to evaluate their relative orientations to the expectations of provincial governments, local providers and community members, and to evaluate the influence of members' being employees in health care or social services and being willing to stand for election.
Design: Mail survey conducted in cooperation with the devolved authorities during the summer of 1995.
Setting: Three provinces (Alberta, Saskatchewan and Prince Edward Island) with established boards and 2 provinces (British Columbia and Nova Scotia) with immature boards.
Participants: All 791 members of the boards of devolved authorities in the 5 provinces, of whom 514 (65%) responded.
Outcome measures: Respondents' declared motivations, levels of confidence in board performance and attitudes toward accountability; differences between members who were willing to run for election to boards and others and differences between members who were employees in health care or social services and others.
Results: The main motivations of board members were an interest in health care and a desire to be part of decision-making, and their main concern was inadequacy of data for decision-making. Almost all (93%) felt that they made good decisions, and 69% thought that they made better decisions than those previously made by the provincial government. Most (72%) felt that they were accountable to all of the local citizens, although nearly 30% stated that they represented the interests of a specific geographic area or group. Attitudes toward their provincial governments were polarized, with half agreeing and half disagreeing that provincial rules restrict the board members. The board members who were employed in health care and social services and those who were willing to stand for election did not differ substantially from their counterparts, although potential electoral candidates were less likely than others to feel accountable to provincial-level constituencies (such as taxpayers and the minister of health) and more likely to represent the interests of a specific geographic area or group. Only a modest number of differences were found among members from different provinces.
Conclusions: Board members' strong feelings of accountability to and representation of local citizens could counteract the structural influences leading board members to favour the interests of provincial governments and providers.
Résumé
Objectif : Obtenir des membres des conseils d'administration des organismes auxquels on a cédé des pouvoirs dans le domaine des soins de santé des renseignements sur leur motivation, leurs aptitudes et leurs approches, évaluer leurs orientations relatives par rapport aux attentes des gouvernements provinciaux, des fournisseurs locaux et des membres de la communauté, et évaluer l'influence du fait que des membres sont des employés de services de soins de santé ou de services sociaux ou sont disposés à poser leur candidature.
Conception : Sondage postal effectué au cours de l'été 1995 en collaboration avec les organismes auxquels on a cédé des pouvoirs.
Contexte : Trois provinces (Alberta, Saskatchewan et Île-du-Prince-Édouard) dotées de conseils établis et 2 provinces (Colombie-Britannique et Nouvelle-Écosse) où les conseils étaient en devenir.
Participants : Les 791 membres des conseils d'administration des organismes auxquels on a cédé des pouvoirs dans les 5 provinces, dont 514 (65 %) ont répondu.
Mesures des résultats : Motivations déclarées par les répondants, niveaux de confiance à l'égard du rendement du conseil et attitudes face à l'imputabilité; différences entre les membres disposés à poser leur candidature aux conseils et les autres, et différences entre les membres qui étaient des employés de services de soins de santé ou de services sociaux et les autres.
Résultats : Les principaux facteurs de motivation des membres des conseils étaient l'intérêt porté aux soins de santé et le désir de participer à la prise de décisions, et leur principale préoccupation portait sur l'insuffisance des données nécessaires à la prise de décisions. Presque tous (93 %) pensaient prendre de bonnes décisions, et 69 % pensaient prendre de meilleures décisions que celles que prenait auparavant le gouvernement de la province. La plupart (72 %) étaient d'avis qu'ils devaient rendre compte à l'ensemble de la population locale, même si presque 30 % ont affirmé qu'ils représentaient les intérêts d'un secteur géographique ou d'un groupe en particulier. Les attitudes des répondants à
l'égard du gouvernement de leur province étaient polarisées : la moitié d'entre eux ont constaté que les règles provinciales entravent les membres des conseils. L'autre moitié n'était pas d'accord à ce sujet. Les membres de conseils qui étaient des employés de services de soins de santé ou de services sociaux et ceux qui étaient disposés à poser leur candidature n'étaient pas différents pour la peine de leurs homologues, même si les candidats éventuels à une élection étaient moins susceptibles que les autres de penser qu'ils devaient rendre des comptes à l'échelon provincial (contribuables et ministre de la santé, par exemple) et plus susceptibles de représenter les intérêts d'un secteur géographique ou d'un groupe en particulier. On a constaté peu de différences entre les membres de provinces différentes.
Conclusions : Les membres de conseils étaient convaincus qu'ils devaient rendre des comptes à la population locale et la représenter, ce qui pourrait contrer les influences structurelles qui incitent les membres de conseils à pencher en faveur des intérêts des gouvernements provinciaux et des fournisseurs.
In the 2 previous articles in this series (CMAJ 1997;156:371-7 [full text/résumé] and 513-20 [abstract/résumé]) we highlighted the dual elements of decentralization and centralization that characterize the devolution of authority for health care from 9 of Canada's provincial governments to regional or district boards. Although some formal powers such as resource allocation have been delegated down, other initiatives, such as disbanding individual hospital boards, have moved powers up to the devolved authorities. In addition, the devolution restructuring was accompanied by declarations of the need to increase local citizen input and control over health care services. This has placed each devolved authority at the nexus between the provincial government's expectations, the providers' interests and the citizenry's needs, wants and preferences.
From the results of our 1995 survey of members of the 62 boards that agreed to participate (out of a total of 76 boards) in British Columbia, Alberta, Saskatchewan, Nova Scotia and Prince Edward Island, we reviewed how the backgrounds, resources and activities of these board members could influence the resolution of inevitable tensions between provincial government objectives, providers' interests and citizens' expectations in our second article in this series. (Details of the survey and the response rate are found in the first article.) We concluded that these structural characteristics -- board members' backgrounds, the resources available to them and the activities expected of them -- were likely to lead members toward meeting the expectations of the provincial government that created the authorities. However, we hypothesized that, in some provinces, this bias would be tempered with the expectations of the local providers, who were represented by employees in health care and social services, but that the expectations and needs of members of the local community appeared less likely to be incorporated into decisions.
In this article we review the survey results concerning the cognitive rather than structural elements affecting the members of the boards of the devolved authorities. We analyse board members' declared motivations, attitudes and approaches, not only to see how they may influence the resolution of the tensions discussed earlier but also to see whether the members are comfortable with the process on the boards and whether some of their characteristics, such as employee status or willingness to stand for election, influence their motivations, attitudes and approaches. Where relevant, we quote from some of the responses given in a section of the survey for comments, which was completed by 40% of the 514 respondents.
Results
Motivations for and concerns about participating
I am serving on this board because I believe the principle of regionalizing and rationalizing health care is correct and will result in better services to citizens at less cost.
I would not have committed myself to this process, and the difficulties that come with it, if I did not believe that restructuring was absolutely necessary and that efficient and effective health services can be delivered.
During the period of our survey (the summer of 1995) all board members were appointed. With the exception of Saskatchewan, where two-thirds of board members were directly elected as of October 1995, all provinces continue to have appointed boards, although most plan to move to at least partially elected boards by the end of the decade. Thus, our data on the motivations and concerns of appointees may not be generalizable to future elected board members.
We asked respondents why they agreed to sit on the board and what their concerns about the board were (Table 1). Although only 18% of respondents were employed in health care or social services, interest in health care issues was a major motivation for nearly three-quarters of respondents. More than half were motivated by a desire to take part in decision-making, and one-third were interested in changing the way things are done, although in Saskatchewan and Prince Edward Island personal desire to change things was a much less important motivation than in the other provinces. One in 5 respondents considered the role a civic responsibility.
Members appeared to have no single overriding concern about sitting on the board, although nearly half were worried that they did not have the data to make decisions. As a British Columbia respondent stated, "One of the biggest problems we face is the reluctance of bureaucrats to devolve information along with responsibility." This concern contrasted somewhat with the response to another question on the overall experience of board members, 67% of whom felt they had enough information to make good decisions.
Board performance and group process
I find this a very interesting and fulfilling board to be on and am confident that we can make a difference in the delivery of health care.
We have been very lucky to have a good board chairperson and a board of open-minded people who have remained "apolitical" and therefore effective.
Despite concerns about the potential ineffectiveness of the boards, members appeared to have positive views of their actual performance and of the group decision-making process (Table 2). In all 5 of the provinces, respondents were confident that their board made good decisions and, in fact, better decisions than those previously made by the provincial government. Although the respondents overwhelmingly felt that they influenced their board, they valued the consensus of the board over their personal opinion.
We also related positive and negative views of the decision-making process to characteristics of the individual respondents. We created an index of each respondent's comfort with the board process by assigning values to 2 areas of responses: we scored the responses to the first 3 statements in Table 2 on a scale from 5 for "strongly agree" to 1 for "strongly disagree," and we scored the extent to which the respondent's 2 most desired activities matched the actual activities being undertaken by his or her board (5 for 2 matches, 3 for 1 match and 1 for no matches; see Table 6 of the second article). The index had a minimum value of 4 (least comfortable) and a maximum value of 20 (most comfortable). The mean score for all respondents was 14.2, but there were significant differences among provinces (p < 0.001, 4 and 458 degrees of freedom), with members of the immature boards in British Columbia and Nova Scotia scoring lower, on average (mean 13.4 in each province), than those of the more established boards in Alberta (14.8), Saskatchewan (14.6) and Prince Edward Island (14.9). This result suggests that, as board members gain experience, their comfort level with the decision-making process increases. Thus, experience helps. Finally, the members most comfortable with the board process tended to have somewhat less education than their peers and were more likely to have previous experience as an appointee to a board.
Accountability and representation
The most important aspect of the regional governance of health care is a rationalization of special interests and a return of responsibility and accountability for the system to the public.
We take pride in truly representing the interests of our communities.
While I represent my local area on the District Board, all members are working to ensure the best health care possible for the District as a whole.
In our second article, we showed that the way the boards were structured, the activities that were their focus and the types of information readily available to them could lead them to favour provincial government objectives and, in some provinces, provider interests. Was this orientation also reflected in board members' views of whom they represented and to whom they were accountable? Apparently not.
Attitudes of board members were very clearly focused on the representation of and accountability to the citizens of their local or regional community (Table 3). Almost three-quarters of respondents chose "all of the local citizens" as the group to whom they felt most accountable for their decisions. Few board members felt most accountable to either the provincial government or the local health providers and institutions. There were few provincial differences; however, board members in Alberta felt somewhat more accountable to the minister of health than did those in other provinces.
When asked whom they felt they represented, more than 70% of board members again responded that they represented everyone in their locality. This was the only open-ended question in the survey, and it allowed us to code responses given in the words of the board members (Table 3). Again, very few members claimed that they represented the provincial government or health care providers, but nearly 1 in 5 claimed they represented interests of specific groups such as women or aboriginal people. More than 1 in 10 gave an answer that suggested that they represented a geographic interest in the locality (e.g., "rural areas" or "my town"). These patterns of stated representation varied little among provinces. Nevertheless, a large percentage of board members agreed that if they thought their views were right, then their views should prevail over those of the community. This response suggests a limit on the extent to which board members would directly represent the view of their communities.
Relationship to the provincial government
I feel the changes being implemented by the ministry of health could have been done under the old health care system without going through the process of setting up all the boards. Things will be very little different from the excellent services offered prior to the reform.
I am disappointed that much of what we do is directed by the Department of Health. Through their funding allocations they are forcing us to move in the direction they want. We don't have as much local autonomy as they make us believe we have.
The government tells you what you can do, and you take the blame from the community if it is not a popular decision.
I feel as if we are constantly being second guessed by bureaucrats, who are willing to acknowledge our decision-making power only as long as we make the decisions they want, even on relatively minor issues. It would be easier if they told us in advance what our decisions must be.
There appeared to be a polarization in attitudes toward provincial governments (Table 4). When asked to agree or disagree with the statement "We're very restricted by rules laid down by the provincial government," almost half of board members agreed and just over half disagreed. The members of the more established boards in Alberta and Saskatchewan appeared to feel most restricted. This result was not explained, however, by the fact that the established boards had had more time to encounter restrictions from the provincial government. The other established boards -- those in Prince Edward Island -- felt the least restricted by their provincial government.
A similar but less dramatic polarization was evidenced in the responses to the statement "The main reason that the government has provided us with local authority is because now there are tough budget decisions to be made." In any event, as shown in Table 2, more than two-thirds of board members were convinced that they would make better decisions than those previously made by the provincial government.
Finally, 2 concerns often voiced about devolving authority from provincial governments -- that budget pressures would prevent long-term planning and that equity among communities would be compromised -- did not appear to trouble board members.
Did board members who were employees in health care or social services differ from the others in their characteristics and attitudes?
I really find that having employees on our board has greatly assisted our District. We are trying to work together as a board, and having individuals who have been involved in health care has certainly helped us.
Personally I don't believe that employees should be board members. Meetings and board work will take a lot of time out of their workplace (shift work, etc).
Most provincial governments have at least discouraged employees in health care from serving as members of the boards, if not disallowed their participation. This trend is reflected in the fact that only 18% of survey respondents (from 6% to 36% of respondents in each province) were employees in health care or social services. Provincial governments were presumably concerned that such employees would be in a conflict of interest and would express views and attitudes more in line with the interests of providers than with the community at large.
In Table 5 the characteristics and attitudes of board members who were employees in health care and social services are contrasted with those of other members. The table includes only the areas in which significant differences were found. Compared with their peers, the employees in health care and social services were proportionately more likely to be inexperienced in serving on a board, middle-aged, university educated, members of an ethnic minority and women. The only differences in attitudes were that, compared with their peers, a larger percentage of employees felt restricted by the provincial government, willing to vote on the basis of their own views rather than the community's views and compromised in their ability to make long-term plans by reduced budgets.
The areas in which there were no differences are perhaps more interesting. Board members employed in health care or social services were no more likely than other members to see themselves as accountable to health care providers and institutions. Indeed, none of the board members employed in health care or social services, but 3% of the others, declared that they were accountable to health care providers and institutions. Almost three-quarters of both groups felt accountable to all of the local citizens.
Did board members willing to stand for election differ from the others in their characteristics
and attitudes?
If the government decides to only elect board members we will lose some very effective people who would never run for office; this is a tough, thankless task and it is better that you are responsible to the public rather than beholden to an electorate with certain agendas.
I feel it will be better once we have elected boards. Our accountability will be clear then, and we can do a better job for our community and our province's people.
Most provincial governments have declared their intention to move toward elected devolved authorities by the end of the decade. The controversy surrounding this move is exemplified by the contradictory views from 2 survey respondents quoted above. There appeared to be uncertainty about whether elected board members would feel more accountable to specific interests in the community than to the community at large and whether board members with political (geographic or interest-group) constituencies would be willing to make the expected tough choices.
Because none of the board members were elected at the time of our survey, we cannot compare elected and appointed board members directly. We can, however, compare appointees who stated that they would stand for election with those who did not. Of the 502 members who responded to this question, 207 (41%) said that they would stand as a candidate, 100 (20%) said that they would not and 195 (39%) were unsure. Prince Edward Island had the largest proportion willing to stand for election (50%) and Saskatchewan the lowest (35%).
A comparison of those willing to stand as candidates with the other members (i.e., those unwilling to run and those unsure about running) revealed no differences in characteristics or attitudes. However, a comparison of those willing to stand for election with those clearly unwilling showed that potential electoral candidates were less likely to have a university education or a household income of more than $50 000. Also, fewer of the prospective candidates thought that the local authority would lead to different standards of health care among communities. Finally, fewer of those willing to stand for election than those unwilling to stand (14% v. 26%) felt accountable to the provincial level (minister, ministry or provincial taxpayers).
Discussion
With the exceptions that board members from Prince Edward Island feel less restricted by their provincial government than do the members in other provinces, and that members of immature boards are slightly less likely than those of mature boards to let their views override those of the community, we found few differences in attitudes among the boards in different provinces. This congruence in attitudes was observed despite the fact that there are some structural differences among the devolved authorities in different provinces, mainly involving the scope of services for which they are responsible. As we hypothesized in our first article, the main approaches and attitudes of board members appear to be determined by something other than the particular devolved authority structure put in place by the provincial government. This finding may be of concern to provincial governments or a comfort to them, depending on their confidence in the ability of their chosen design for devolved authority to achieve the objectives they have in mind.
Board members stated that their boards were functioning very well in the group decision-making process; two-thirds thought that they were doing better than previous provincial performance. This strong positive regard for the functioning of their own board suggests that survey respondents' attitudes and approaches may have been determined more by local influences than by provincial design. A likely candidate for this influence, the commitment to representation of the local citizenry, is discussed later.
If we are to be guided by their self-reported attitudes, then the attitudes of board members who were health care and social service employees did not appear to differ substantially from those of other members, even in the degree to which they felt accountable to health care providers and institutions. Although one should be cautious in extrapolating from these self-reported attitudes and behaviours to actual behaviour, there is other evidence that the providers in a health care system can adopt the broader community view.
The respondents who were clearly willing to stand for election were less likely than those unwilling to run to feel accountable to provincial-level authorities such as the minister or ministry of health. A move to elected boards could, therefore, shift feelings of accountability even further toward the local citizens and away from the provincial governments. Already, 30% of board members feel that they represent a specific population or geographic interest rather than the entire region. The election of boards may increase this tendency because those willing to run are twice as likely as those unwilling to stand for election to feel most accountable to "local citizens from the group I represent" (9% v. 4%).
We recognize, however, that the views of appointees who stated a willingness to stand for election are only a rough approximation of the views of actual elected board members. A comparison of today's elected board members in Saskatchewan with the appointed members from Saskatchewan we contacted in our survey would give a better measure of this tendency. We also recognize that considerations other than stronger local accountability would contribute to the decision to proceed with elections of board members. These considerations will be discussed in the last article in this series.
Contrary to the implication from the analysis of structural variables in our second article -- that these variables would lead board members to favour meeting the provincial governments' objectives and, in some provinces, health care providers' expectations -- our evaluation of board members' attitudes and perceived accountabilities indicates an overwhelming tendency to favour the community's voice and expectations. Board members reported feeling largely accountable to and representative of all of the citizens in their jurisdiction. Their self-declared intention was to represent unambiguously the interests of local citizens in making the health care system more effective and efficient.
Indeed, the potential structural bias toward the interests of the provincial government appeared to be actively resisted by about half of the board members, who saw provincial rules as restricting their freedom and provincial motivation for devolving authority as diffusing blame for tough choices to local areas. Feelings of accountability to the local providers, even among employees in health care and social services, were very rare (expressed by only about 2% of respondents).
These findings appear to hold true in all of the provinces, suggesting that feelings of commitment to local or regional communities can dominate commitment to the province or that board members actively counteract any structural biases in favour of the provincial government and providers by strongly advocating the interests of their local citizenry. It is clear, nevertheless, that the boards are grappling with the sometimes conflicting pressures of political motives from their provincial government, professional views from their providers and personal expectations from their citizens. As a board member stated, "The greatest challenge is to coordinate and manage many different personal, professional and political agendas for the good of the people."
The survey reported in this series was funded by the Ontario Premier's Council and the HealthGain program of Glaxo Wellcome Canada. Mr. Woods' contribution was provided by the UK National Health Service Trainee Program. The Centre for Health Economics and Policy Analysis receives partial funding from the Ontario Ministry of Health.
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