09/22/2014 02:16 EDT | Updated 06/16/2017 01:03 EDT

Mandel to Play Giant Game of Health 'Whack-A-Mole'


Stephen Mandel is already tempering public expectations in his new role as Alberta's new Health Minister.

There will be no massive reforms and he says he'll work within the current system, save perhaps that he says it's likely that he will kill Alison Redford's ill-conceived campaign promise to create 140 so-called "Family Care Clinics" -- more fallout from Premier Jim Prentice's larger purge of the Redford legacy.

As for Question Period when the House resumes, "I'll get killed probably," Mandel said. "I don't know, I'll do my best. They will ask questions and I will try to answer. I can only do so much. I am learning and reading those wonderful [briefing] books that are so interesting and trying to learn as we go through the process."

So what will Mandel learn from those "wonderful books"?

He'll learn, if he follows the money, that two thirds of health dollars spent are public dollars, yet two thirds of health dollars consumed are by private health providers, which includes specialists and family physicians operating their own private practices. This means he isn't so much the commander of a "health system" as he is at the apex of a "health industry". In short, the secret to really getting things done is: incentives, incentives, incentives.

He'll learn that nothing gets done without getting the physicians on board. When they are, it is possible to move the ball substantially. When I worked for the ministry, I worked with physicians to substantially reduce waiting times and implement the electronic health record. Mandel needs to know that physicians have time on their side; they can wait out premiers and ministers of Health and reform fads as they come and go. Primary Care Networks in Alberta have seen success because of physician engagement in their development; Family Care Clinics for some reason never got traction and withered. That reason: physicians were disintermediated from the model.

He'll learn, with every turn of the screw, each successive minister moves health care to a "franchise model". To streamline delivery (and to reduce unproductive internal power conflicts), Alberta went from 17 regional health authorities to 9 and then to a single health authority under Alberta Health Services. People are demanding "health outlets" with consistent base-level services across the province.

He'll learn that health care is not immune from the rising expectations of our increasingly consumer-driven society. While health care insiders are loathe to equate patients with consumers, people are asking (rightfully) why they get near-instant service from other industries and not from health care? Patients are now global consumers and they have a global view of their own health services. Why wait in line in Canada when I can get my hip replaced in two weeks at reputable clinic in Bangalore? Canadians detest queue-jumping locally but gladly do it globally. Ironic? Nope. Just a fact.

He'll hear questions about sustainability of the health system and he will (hopefully) have to ask himself, "What is it we want to sustain?" This is an important public conversation as the health budget hits its ceiling. The health budget, paradoxically, is crowding out the social determinants of good health: education, housing, policing, and social services.

He'll learn that an ounce of prevention really is worth a pound of cure. The acute care system, with all its wonderful and spectacular treatments, is crowding out public health. Clean water, a safe food supply, immunization, and good sewage have done more to prolong the human life span in the last century than have acute care interventions.

And finally, he'll learn, as I did as a health care executive, the true game theory of the health portfolio. Individually, he will valiantly try to reduce the death rates from cancer, death rates from heart disease, death rates from accidents, and so forth. The reality is that even if cancer were cured tomorrow, the mortality and morbidity rates of other diseases would just shoot up. Why? Like it or not, you have to die of something. Collectively, managing a health system is a giant game of Whack-A-Mole.

Mandel has a reputation from his time as Mayor of Edmonton for cutting though large bureaucracies and getting things done. This is his real test. I'll try to lower my expectations, but as an Edmontonian, I have come to expect great things from him.