The provocateur’s prescription

Hired to fix Alberta’s ailing health system Duckett opts for ‘shock’ treatment

Back in February Heather Smith was ready to like Stephen Duckett.

Alberta’s recently created health superboard had just poached Duckett an Australian health economist from his government job in the state of Queensland. Smith president of the United Nurses of Alberta heard good things about the man who was about to become Alberta Health Services’ new president and CEO — that he was smart educated and based his decisions on evidence: “A man of learning” recalls Smith. The nurses union in Queensland gave him a good review. “The message we got back was generally ‘We’re sorry to see him go’” says Smith. “I was the one here in our office saying ‘He may not be bad. Let’s see.’”

Eight months later Smith has a different view. The nurses have filed a complaint with Alberta Health Services accusing Duckett of “bullying” spreading “mistruths” and causing “serious morale issues” in the health system. This after Duckett told media that much “of what a nurse does in a hospital ward could be done by someone else” and made other remarks about disparaging nurses’ coffee breaks. “We have been disappointed” says Smith.

Liked or not Duckett has an immense — or as he puts it on his blog “incredibly difficult” — job ahead of him. Last year Health Minister Ron Liepert suddenly scrapped the province’s health regions (along with their CEOs) to centralize the system under the Alberta Health Services’ (AHS) banner. Neither the public nor health staff were consulted.

The department which employs about 90000 faces a whopping billion-dollar deficit.

Duckett is tasked with making the new behemoth work and building staff and public confidence in the superboard. At the same time he’s also being asked to cut hospital wait times improve accessibility create new health advisory councils and more — all while hacking down the deficit.

If he succeeds he rakes in $144000 on top of his annual $575000 salary. The size of his potential bonus is directly tied to 10 specific goals ranging from cutting emergency wait times for complex cases (from an existing 16.1 hours to 14 hours) to increasing seniors flu immunization rates (from 58 per cent to 63 per cent). “We have a single hired gun with a promise of a bonus if he does it well” says Smith.


Duckett hasn’t wasted any time making his mark on Alberta’s system. As soon as he was on the job in March he started furiously restructuring AHS departments. Managers had to reapply for their existing jobs; some were laid off. Staff describe an uncertain and demoralizing work environment.

“The general sense at the staff level is that this has been terribly mishandled and it appears as though those in charge have no idea what they are doing” says one AHS employee. (Staff are forbidden from openly speaking their minds to media as a new code of conduct was written up shortly before Duckett started.)

So far Duckett has been provocative in his approach — much like the health minister. Duckett has slowed hiring (nurses call it a “freeze”; Duckett calls it putting the “brakes on external recruitment”) shut down hospital helipads for a week based on bad information cast doubt on the quality of research being done at Alberta universities and announced plans to cut some 300 acute care beds and 250 mental health beds.

He has yet to win over both his own staff and the public. “He burned through a lot of credibility very quickly” says David Eggen executive director of Friends of Medicare and a former NDP MLA. Eggen also refers to Duckett as a “hired gun” — he believes that the AHS board hired someone out of country so “he can execute the dirty work and then you can blame him” once he’s gone. “He definitely is not here to win friends and influence people so far as I can tell.”

(Duckett wasn’t interviewed for this story despite repeated requests over several weeks for an interview. AHS communications staff said he was too busy and declined to set up an interview with other health officials saying Duckett “is the best guy for your interview.”)

Duckett writes on his blog that he’s not here to cut and run and that he’s been “amazed by the continuing xenophobia associated with my appointment.” His contract is for an “indefinite term.” He writes: “Why would I have left a good job in Queensland uprooted my family and bought a house in Edmonton for a job that might only last 12 months? To put the record straight I have a long-term contract with Alberta Health Services.”


Duckett hails from a country that has a mix of public and private hospitals; about 40 per cent of Australians use private health insurance for routine procedures like eye and joint surgery. This begs the inevitable question: under Duckett will Alberta see more private care?

Albertans have traditionally been suspicious of Conservative efforts to reform health care. Former premier Ralph Klein’s infamous Third Way a plan that would have paved the way for more privatization hit a wall of public backlash. Now Liepert talks about “finding efficiencies” in the system — in other words cutting inefficiencies.

“There’s no one magic bullet that’s going to fix the problem” says Liepert. “There’s going to be 100 different bullets and hopefully if we fire 100 different bullets in the same direction we’re going to start to see a different alignment of health care.” Critics like Eggen say that Liepert’s vaguely worded “different alignment” involves more privatization.

Duckett is the man responsible for firing Liepert’s bullets. Both his supporters and detractors say he’s got a brilliant mind; as an economist he loves working with numbers and finding ways to make health systems more efficient. But is the Aussie bent on privatization? “No” says Vivian Lin a a former colleague of Duckett’s and the chair of public health at La Trobe University in Melbourne. In fact she says the opposite is true. “A lot of people would see him as a very committed person to Labour Party values — so socialist left…. He has quite publicly opposed attempts to privatize elements of the Australian health system.”

Former colleagues say Duckett is a strong supporter of the public system though not an ideological supporter. “Basically Stephen’s view is that the public system is more efficient and more equitable than the private” says Hal Swerissen dean of health sciences at La Trobe — a position Duckett himself held until 2006. “It solves the big problems better. It’s not an ideological position in the sense of ‘Public is better no matter what’…. He would be interested in what is going to be efficient.”

In Alberta Duckett has much more power than he had in Australia where state and federal governments share responsibility for health provision (he worked on both levels and in the mid-’90s was the equivalent of deputy minister in the federal government). “Whether you’re at the federal level or the state level you don’t actually have the levers of the whole health system because each level only has responsibility for one part” says Lin.

Most Albertans — including Eggen and Liepert — aren’t familiar with Duckett’s previous work. “That’s the job of the headhunter to do that work” says Liepert when asked what specifically Duckett did in Australia. (Duckett was selected by a search firm; Liepert interviewed Duckett and impressed by his “no-nonsense style” OK’d the choice.)

Before he moved to Edmonton earlier this year Duckett was in charge of Queensland’s Centre for Health Care Improvement which was tasked with implementing the state Labour government’s plan to improve patient safety and the “organizational culture” of the health department. Queensland Australia’s second-largest state has about four million people. Duckett was about three years into the job when Alberta wooed him away.

Before that in the ’80s and early ’90s he worked for the health department in the state of Victoria where as director of acute health he introduced case-mix or activity-based funding — a system whereby hospitals are paid for each procedure they do instead of being given a lump sum.

Duckett plans to introduce activity-based funding in Alberta and has said it will save tens of millions of dollars. In a May speech he said the activity-based system ensures hospitals receive “fair” funding and live within their means. Switching over “would mean that arguments about overfunding unfair treatment favourites etc. would be wiped away and would also reduce the likelihood of service reductions of a budget strategy” he said.

Eggen is wary of the plan. “I think it’s to open the door to more private contracting and also to as they say create this idea of competiton between hospitals which is patently absurd as far as I’m concerned.”

Liberal leader David Swann — a doctor — says activity-based funding has advantages and disadvantages. “It means that where people are doing good work efficient work they get rewarded. The disadvantage is if they just push through people more quickly it may not be the best work. It may be the fastest work. So giving them more money because they push people through more quickly isn’t exactly what’s needed.”

Swann is unimpressed with the government’s approach to health care. “They’re making ad hoc decisions based on the pressures they’re getting and the indicators of either human suffering or professional outrage or public anxiety.”


Swann might not be too far off. Swerissen who worked with Duckett in Australia for about 10 years says his former colleague intentionally riles up people. “One of the techniques that he uses is to basically shock people a little bit by pointing out the obvious” says Swerissen. “If you have a situation where one group of professionals is really doing things which are irrational and inefficient he’s quite likely to say so and then see what reactions he gets.”

It’s done not for the mere sake of provocation says Swerissen but with a goal in mind: “He does that a bit to destabilize a situation and then see what emerges and then he will adapt to the set of circumstances. He uses that as a strategy to get some movement in the system. It’s quite a pragmatic approach that he usually has.”

Unsurprisingly not everyone in Australia appreciated this. “I think if there was one group that didn’t like him it was the AMA — the Australian Medical Association” says Lin. “They think he doesn’t like doctors.” (Contacted by Fast Forward Weekly a spokesperson with AMA Queensland said: “We don’t comment on Stephen Duckett. We don’t have anyone who’s worked with him directly.”)

Alberta doctors have been wary about the new superboard arrangement and impending cuts. In a June letter former Alberta Medical Association president Noel Grisdale warned Liepert that trying to “achieve too many savings too soon” might do more harm than good putting AHS in a position where it “may become identified with reduced access and reduced quality before having a chance to prove itself.”

Current Alberta Medical Association president Chip Doig is diplomatic when asked about Duckett saying it would be “a little bit unfair” to grade Duckett’s performance so early. Doig is hopeful that cuts won’t hurt either doctors or patients. “We have every expectation from what’s been communicated to us… that cost savings will primarily be achieved through not a reduction in health services but in other efficiencies.”


So what’s next for Duckett and Alberta health care? Critics — including some within AHS — say there’s no clear plan. “They’re feeling it out as they go along” says Swann.

Liepert disagrees. “We have the plan called Vision 2020” says the minister referring to a broad health road map put out by the province last December. The plan which aims for a “patient-focused co-ordinated and efficient” system lists five strategic goals including providing services “in the right place and at the right time” and “matching workforce supply to demand for services.” Part of that includes expanding pharmacists’ and dietitians’ roles as a way of freeing up doctors’ time.

Vision 2020 says it’s “not about the private delivery of health services” but a “stronger more efficient and sustainable publicly funded health system.”

Liepert says “For anybody to say there is no plan they’re not looking at what’s out there.”

But he doesn’t rule out more private options. “Are we going to the U.S. system? Absolutely not…. Are we going to be selling off our hospitals for profit? No. But we have for-profit provision of seniors care. Doctors are in it for profit. Doctors they’re not part of the United Way. So there’s all kinds of for-profit health care today.”

As for Duckett he’s reaching out to AHS staff by asking for their input on ways to save money. Those who come up with the best suggestions will get prizes including two weekend getaway packages and two $500 gift cards — rewards Duckett is pledging will come from his own pocket. “I see part of my job as a leader as being to liberate you to think and act creatively” Duckett wrote on his blog earlier this month. “And I now want to put my money where my mouth is.”

He’s also asking AHS board members to take a pay cut but has made it clear that he won’t give up his bonus.

Under Duckett AHS is also revisiting the much-maligned code of conduct that forbids staff from publicly sharing their opinions. “They seem to be reaching out for at least the impression of consultation now… [to] give a sense of legitimacy to what’s happening” says Swann.

Meanwhile health advocates are mobilizing to show their support for Alberta’s public system. Rallies were recently held in Calgary and Red Deer and more are planned for the coming weeks. “There’s a concern that we’re going to be cutting more services and people will be able to access less” says Bonnie Malach of Alberta Better Care Calgary a newly formed coalition of health advocates.

The province Liepert says is currently working on next year’s budget. “I don’t know what our funding increase is going to be for health care but let’s say as an example instead of 10 per cent or even six per cent our increase next year is only three per cent. Well by golly there’s going to be some tough decisions around that.”

“What they are time will tell.”