Provincial Health Human Resource Plans

• Abstract
• Purpose of health policy or idea
• Characteristics of this policy
• Political and economic background
• Purpose and process analysis
• Expected outcome
• References

Featured in half-yearly report: Health Policy Developments 7/8

Abstract

Pursuant to the 2004 intergovernmental accord on health care, provinces were to release health human resource action plans by December 2005. Eight provinces and territories met the deadline, but six jurisdictions (including the federal government) are still to release their action plans.

Purpose of health policy or idea

As part of the 2004 10-Year Plan to Strengthen Health Care the ten provincial, three territorial and the federal governments were to release detailed Health Human Resource (HHR) action plans by December 2005.  The plans were meant to be comprehensive action plans dealing with, among other things, shortages of health care professionals, plans for alternative payment schemes, changes to scopes of practice, moves towards interprofessional education and practice and population needs-based funding. The purpose was to demonstrate a commitment to move HHR planning from its past focus on single professions towards an integrated multi-professional approach rooted in making HHR planning a key component of other health care reforms.

Main points

Main objectives

The objective of the plans was to begin to move HHR planning in Canada in a different direction. In the past HHR planning tended to be profession-specific and employed models rooted in past HR needs to forecast future needs. The plans released in December were intended to be multi-professional and to provide a framework for future planning based on making progress on other reform objetives such as primary health care reform and team based practices employing a wider range of professions, including "new" professions such as nurse-practitioners and mid wives.

Type of incentives

The incentives vary considerably within each of the provincial and territorial plans released to date. There are some provisions for financial incentives in some jurisdictions to prompt the creation of multi-disciplinary primary health care teams and for physicians to move away from fee for service practices.  Some of the provinces have also committed funds for educational institutions to create more training seats for some professions and for regional health authorities to develop retention strategies for health professionals. 

Most of the provincial plans have given more attention to non-financial incentives (e.g. reform of workplace practices or scopes of practice) to encourage the participation of stakeholder groups, including professional associations and regulatory bodies.

Groups affected

Health care providers, regional health authorities, educational Institutions

Degree of Innovation	traditional		innovative
Degree of Controversy	consensual		highly controversial
Structural or Systemic Impact	marginal		fundamental
Public Visibility	very low		very high
Transferability	strongly system-dependent		system-neutral

Overall the development of the provincial action plans marks an important first step in developing better HHR planning processes within the provinces and territories. It remains to be seen whether this will translate into better coordination and a reduction in interprovincial competition for scarce resources between provinces and territories.

Political and economic background

Health human resource issues have been a key concern in the Canadian health care system for well over a decade. Decisions made in the early 1990s saw a significant decrease in the number of training seats available in Canadian medical schools and has contributed to the shortage and maldistribution of doctors across the country. 

Large urban centres have significant shortages of family physicians and long wait times for access to specialists. Immigrants in these areas are particularly hard pressed for access to services because of language and cultural barriers. 

Rural communities have trouble attracting and retaining family physicians and can have to travel large distances to access specialist services.  Provinces have in recent years also relied heavily on foreign trained physicians (esp. from Asia and southern Africa) to fill these gaps but are under increasing domestic and international pressure to stop this recruitment from developing countries.

Although there is no shortage of applicants to nursing programs in Canada, there is a real problem with the retention of trained nurses. Citing problems with job stress, poor working conditions and an over reliance on part time and casual work large numbers of nurses leave the profession well before retirement age. The current work force is aging and there are real shortages of experienced nurses in all jurisdictions.

Past attempts to rectify these issues with financial and other incentives have not substantially remedied the problems. And at the same time there was increasing evidence of interprovincial competition between provinces  financial incentives were used to attract health professionals from elsewhere in the country. This naturally put less well off parts of the country (esp. Atlantic Canada and parts of western Canada) in even more difficult circumstances when it comes to retaining their health providers. 

Two national sector studies on physicians and nurses has indicated the need to move toward a more integrated pan-Canadian approach to HHR planning that is both multi professional and forward looking rather than based on forecasts based on past needs.

Change of government

Although the plans were released in the midst of the recent federal election, the change of government at the federal level is not expected to impact the intergovernmental process signficantly

Change based on an overall national health policy statement

10 Year Plan to Strengthen Health Care -- an intergovernmental political agreement signed in 2004

Purpose and process analysis

Current Process Stages

	Idea	Pilot	Policy Paper	Legislation	Implementation	Evaluation	Change
Implemented in this survey?

Origins of health policy idea

Calls for a more rational and forward looking approach to HHR planning in the provinces go back well over a decade. Of particular importance has been the ongoing work conducted on the physician and nursing sectors that has pointed out the need for more coordinated planning processes. These sector studies were undertaken by coalitions of professional associations, regulatory bodies and unions and funded by the federal government. In addition, attempts to deal with other health reform issues such as wait times for some services indicated the extent to which key reform objectives were being hampered by health human resource challenges.

The 10 Year Plan to Strengthen Health Care was signed in 2004 by the Prime Minister and the ten provincial and three territorial Premiers and included increases in transfers to the provinces and territories, the funding of provincial wait list management strategies, a commitment to benchmarking wait times for key services and the development of integrated HHR plans by all governments. These plans were to be publicly released by December 2005.

Saskatchewan, Ontario, Quebec, Nova Scotia, New Brunswick, Prince Edward Island, Nunavut and the Northwest Territories released HHR actions plans by the deadline. British Columbia, Alberta, Manitoba, Newfoundland and Labrador, Yukon and the federal government did not meet the deadline.

Initiators of idea/main actors

• Government

• Providers

• Scientific Community

• Others

Approach of idea

The approach of the idea is described as:
new:

Stakeholder positions

It is difficult to assess the overall position of the major stakeholder groups as there are significant variations in both the details of the plans and in the extent of consultation/engagement undertaken by governments in the development of the plans.

Only the province of Saskatchewan (with the assistance of CPRN) engaged in a major multi-stakeholder consultation initiative (see Further Reading for a link to the report) as part of the development of its action plan. Stakeholder organizations in Saskatchewan were generally supportive of the action plans key directions (especially around primary health care reform and work place practices) when the report was released in December 2005. Other provinces reported some level of one on one consultations with key stakeholders in the health sector but no province undertook any significant public consultation. 

The major national stakeholder groups (especially the Canadian Nurses Association, the Canadian Medical Association and the Health Action Lobby [which includes physicians, nurses and allied health professionals]) have all been supportive of initiatives designed to create more integrated and coordinated planning. These national organizations have been particularly interested in the development of pan-Canadian frameworks for HHR planning, though this is more controversial with some provincial and territorial governments who see such frameworks as limitations on their own ability to make decisions within their own jurisdiction. 

Though, as noted above, there has been a draft pan-Canadian framework developed by a federal-provincial-territorial intergovernmental committee that is currently being circulated for comment and comparison with the individual provincial plans.

Actors and positions

Government
Federal Government	very supportive		strongly opposed
Provincial Governments	very supportive		strongly opposed
Providers
Physicians	very supportive		strongly opposed
Nurses	very supportive		strongly opposed
Other Health Professions	very supportive		strongly opposed
Scientific Community
Researchers	very supportive		strongly opposed
Health Council of Canada
Health Council of Canada	very supportive		strongly opposed

Influences in policy making and legislation

The implementation of most of the commitments made by the provincial and territorial governments can likely be achieved without resort to major legislative change. Funding incentives for providers, educational institutions and regional health authorities will come through upcoming budget measures in each of the provinces and other changes are at the level of policy rather than legislation. The one exception may be the need to amend current or introduce new legislation to provide for the regulation of "new" professions such as nurse practitioners and mid-wives, although most provinces already have such legislation in place even when there are very few of those kinds of providers in the province.

Legislative outcome

n/a

Actors and influence

Government
Federal Government	very strong		none
Provincial Governments	very strong		none
Providers
Physicians	very strong		none
Nurses	very strong		none
Other Health Professions	very strong		none
Scientific Community
Researchers	very strong		none
Health Council of Canada
Health Council of Canada	very strong		none

Positions and Influences at a glance

Adoption and implementation

The implementation process will undoubtedly be led by the individual departments of health and education in each of the provinces.  Implementation will require ongoing negotiation and consultation with the key health care stakeholders such as the professional associations, the regulatory bodies and unions.  Indeed, many of the financial incentives for providers will likely be made part of the next rounds of collective bargaining with doctors, nurses and allied health professions and this is where the successful implementation of the goals of the action plans will be first tested.

In addition, the development of recruitment and retention strategies by the regional health authorities (in those provinces that have a regionalized delivery structure) will be a matter of negotiation and consultation between the regional authorities and their respective provincial governments. 

The key barriers to implementation will be resistence from those stakeholder organizations (or elements within those organizations) who fear some loss of autonomy in terms of their role within the health care system. There are also significant differences between the stakeholder organizations over the direction of things like primary health care reform and changes to the scopes of practice of health providers. These differences will make it difficult for governments to proceed quickly in these areas and will require a great deal of negotiation (mediated by the provincial government) between these groups in each of the provinces.

As the plans have only been in the public domain for a few months it is difficult to assess the extent of resistence to their implementation.

Monitoring and evaluation

As the action plans and the intergovernmental agreement that gave rise to them are really "political" commitments by each of the governments, there is no formal process for monitoring progress on implementation or for evaluating the success of that implementation. 

The federal government has not placed any conditions (e.g. financial penalties) on provinces or territories that either fail to produce HHR action plans (though all have committed to eventually releasing plans) or which fail to carry through on the commitments contained in them. In addition the plans do not have much in the way of specific numerical targets at this point that can be easily measured in terms of success or failure.

However, the province of Saskatchewan has informally committed itself to continuing the process of stakeholder engagement it used in developing the plan to assess progress at regular intervals. 

Monitoring and compliance will happen -- if it happens at all -- through political channels and through the actions of various health policy and health lobbying organizations. For instance the Health Council of Canada -- an intergovernmental body designed to report to the public on health care issues and reform initiatives -- has provided an initial assessment of the action plans that were released as of December 2005. The results of that assessment is provided below.

Results of evaluation

An informal assessment of the contents of the action plans was produced by the Health Council of Canada as a supplement to its annual report released in February 2006. The results of that assessment is summarized below:

• Saskatchewan's plan provides an indepth analysis of population health needs link to HHR planning and includes a number of objectives but provides no specific numerical targets for elements of the plan such as increasing the number of clinical placements.
• Ontario developed more of a progress report than an action plan which focuses on past initiatives rather than future ones. There is a detailed plan for developing better collaboration in policy development with regard to HHR between government departments.
• Quebec did not develop a stand alone action plan but rather a progress report on an agreement signed during September 2004 First Minister's Meeting. Their report focuses mostly on physicians but includes important elements regarding shortages, changing scopes of practice and retention of rural health professionals.
• Nova Scotia explicitly linked its action plan to the F/P/T pan-Canadian framework and to joint HHR planning efforts in the Atlantic region (including New Brunswick, P.E.I. and Newfoundland and Labrador). Plans include changes to scopes of practice and the integration of internationally trained health professionals.
• New Brunswick developed a comprehensive plan in 2002 which runs until 2009 and the 2005 action plan reports on progress of that plan and notes that most of the targets it set out have been met. The current action plan's key elements include increasing enrollments, retention strategies and some changes to scopes of practice.
• Prince Edward Island's plan focuses on planning based on population health needs and ongoing collaboration between provinces in Atlantic Canada. Many of the strategies are future oriented but the plan does not provide specific targets or timelines.
• Nunavut's plan focuses specifically on the challenges facing a large northern territory with a small population. Of particular concern is a strategy to attract a larger number of Aboriginal students into health profession training (which they will have to take elsewhere in the country as the territory has little training capacity of its own) and the incentives needed to insure their return to practice in the territory.
• The plan provided by the Northwest Territories has a similar focus on the difficulties of recruiting and retaining health professionals in Canada's far north. Plans include promotion of health careers to their own population, improving succession planning within health care workplaces and providing opportunities for ongoing professional development for existing and future health professionals in the territory.
• The federal government, British Columbia, Alberta, Manitoba, Newfoundland and Labrador and the Yukon territory did not release plans by the December 2005 deadline.

Expected outcome

For all the limitations in both the process that led to the plans development and in the lack of specific targets and measurable indicators of success within the plans themselves, there is reason to be cautiously optimistic about the future direction of HHR planning both in individual provinces and intergovernmentally. The political commitment made by the fourteen governments to produce integrated HHR plans and to begin a process of HHR planning that is multi-professional and forward-looking and which is linked to planning models rooted in population health needs and other key health reform objectives marks a significant break with past practice in Canada.

The release of the action plans and the recent tabling of a draft pan-Canadian framework document for HHR planning by a federal-provincial-territorial committee is indicative of a change of attitude in the way provinces and territories approach HHR planning. The failure of profession specific planning models and the negative impacts of ad hoc decisions made for the sake of 'labour peace' or other considerations have made it clear to provincial governments that HHR planning needs to be approached differently. At the same time, the seemingly intractable problems of wait list management and primary health care reform have served to underscore how important HHR planning is to the other elements of the provinces' health care reform agendas.

The key challenge for the governments concerned will be maintaining the momentum that led to the action plans development in the first place.  Provinces are likely to proceed slowly on some of the new initiatives for fear of disrupting the system too significantly and other areas (esp. those linked to changing scopes of practice) will require large investments of time and energy in order to bring key stakeholders along in the process. If fully implemented there is reason to be optimistic that some of the reforms proposed will result in better health outcomes for the population, better working conditions for health professionals and improved access to the system for citizens.

Impact of this policy

Quality of Health Care Services	marginal		fundamental
Level of Equity	system less equitable		system more equitable
Cost Efficiency	very low		very high

To date the release of the provincial action plans and the intergovernmental framework for pan-Canadian HHR planning have not had an impact on the system's operations. The potential impact in terms of improving equity within the system, improving the quality of services and the overall cost effectiveness of the system is quite high, but it will depend on the successful implementation of these plans in coming months and years.

References

Sources of Information

Health Council of Canada. 2006. "Progress Update: Wait Times and Health Human Resources" a supplement to Health Care Renewal In Canada: Annual Report to Canadians, 2005. Ottawa: Health Council of Canada.

Tom McIntosh and Renee Torgerson. 2006. Setting Priorities and Getting Direction: Conference Report (Consultation Conference on Health Human REsource Planning).  Ottawa: Canadian Policy Research Networks. 

Information from the federal government (including links to provincial health departments where individual action plans can be downloaded) can be found at www.hc-sc.gc.ca/hcs-sss/hhr-rhs/strateg/plan/index_e.html

Author/s and/or contributors to this survey

Tom McIntosh

Suggested citation for this online article

Tom McIntosh. "Provincial Health Human Resource Plans". Health Policy Monitor, April 2006. Available at http://www.hpm.org/survey/ca/b7/2