First Nations Management & Leadership · Arcus perspective
Designing Shared Clinical and Administrative Services Across Multiple First Nations
Shared capacity needs a service promise
A shared service can make expertise available where a single health organization cannot sustain a full position or specialist system. It can also move work away from local teams without removing their responsibility for the outcome. A health director may still have to correct payroll inputs, chase an unanswered request or explain why a visiting professional did not arrive. The shared organization’s lower cost per transaction would then tell only part of the story.
Arcus’s management proposition is that a shared service succeeds when participating Nations can rely on a defined result at an understood total cost. The design starts with a service unit—such as a completed payroll cycle, an accepted procurement request or a delivered clinical session—and the obligations needed to produce it. Centralizing staff is an organizational choice; reliable delivery is the test.
Clinical and administrative services require different safeguards. A payroll deadline can be specified through a processing agreement. A clinical service also needs professional accountability, appropriate supervision, referral and escalation arrangements, and continuity when a practitioner is unavailable. A single generic service agreement cannot safely express all those requirements.
Use evidence to challenge the savings narrative
Ontario’s legislative committee report on the 2021 PPE audit describes procurement coordination involving shared-service organizations, but also inadequate inventory information and distribution delays during the pandemic. It illustrates why purchasing scale must be supported by demand information, stock management and delivery capacity. It is evidence from an exceptional provincial emergency, not a savings benchmark or a direct evaluation of First Nations shared services.1
A 2021 practitioner paper by Plexxus authors examines the difficulty of connecting procurement with outcomes across funding and delivery boundaries. Its perspective is valuable because it comes from shared-service practice, but it is not an independent comparative trial.2 The implication for a local business case is to specify where a claimed benefit occurs and who can actually realize it.
The FNHA’s 2019/20–2023/24 evaluation also identifies coordination and role-clarity challenges as regional functions develop.3 Together, these sources justify testing the interfaces around a shared service. None establishes that creating a new shared organization will automatically reduce costs or improve access. Those claims require local evidence.
Choose functions by their coordination burden
Begin with a service inventory and examine demand, standardization, specialist scarcity and the need for local relationships. A predictable administrative task with comparable rules may be a useful early candidate. A service requiring frequent interpretation of community priorities may need local leadership even when specialist support is pooled. Clinical services with small local demand may justify sharing, but their travel, continuity and professional requirements can make them expensive to coordinate.
Assess whether the apparent problem is insufficient scale, a poorly designed process or an external dependency. If invoices wait because purchasing approval is unclear, a shared accounts-payable team may simply inherit the queue. If local staff enter the same data repeatedly for different funders, a common reporting service needs compatible definitions and permissions before software can help. Redesigning the process may deliver much of the benefit without changing the employer.
Use a readiness test for each candidate: can the partners define the work consistently, provide accurate inputs, assign an authorized decision-maker and identify the recipient of the completed result? Defer functions that cannot pass that test until the missing agreements are addressed. This is sequencing, not a judgment that the function should remain permanently local.
Compare delivery arrangements before creating a new entity
Reciprocal support allows existing teams to cover defined gaps through an agreement. It can be appropriate for occasional needs, but spare capacity should not be assumed. Both the home service and the receiving service need protection when demand rises at the same time.
A host-Nation arrangement places a team within one participating organization that serves others under agreed terms. It can use existing infrastructure and avoid some establishment costs. Its credibility depends on transparent allocation, clear separation of host and shared costs, and a way for other Nations to challenge service decisions. Informal goodwill is a weak substitute for these provisions.
A jointly governed service organization may suit a larger, stable portfolio where partners want a dedicated employer and common systems. It introduces its own board, management, financial and technology costs. A purchased external service can be a fourth option for a tightly specified requirement, with attention to data control, continuity, vendor dependence and local capability development.
Evaluate each arrangement against the same demand and service requirements. Consider staged participation if Nations have different readiness or needs. Avoid promising universal participation to justify an optimistic unit cost before the Nations have authorized their commitments.
Write the agreement around completed work
A usable service catalogue defines eligibility, request channels, required inputs, operating hours, response and completion expectations, exclusions and escalation. Identify the local contact and shared-service owner, including who can authorize an exception. Distinguish acknowledging a request from completing it; a rapid automated reply provides little reassurance if the underlying work remains unresolved.
For a shared clinical team, specify referral acceptance, scheduling, local preparation, clinical documentation, follow-up ownership and cancellation arrangements with appropriate professional input. Clarify who tells the patient when plans change and who resolves the next step. The agreement should not leave the local health director responsible for decisions that only the regional clinical lead can make.
Include a capacity rule. When demand exceeds available sessions or processing capacity, partners need an agreed way to prioritize and an escalation route for urgent needs. A first-come queue may reward organizations with stronger administrative capacity. A negotiated approach can protect minimum access and allocate remaining capacity using service-relevant criteria approved by the partners.
Consider a hypothetical shared therapist who has ten available visits but requests for fifteen. An equal division may ignore need; allocation by request volume may disadvantage a Nation with less referral support. The answer requires an agreed prioritization process and a route for professional judgment. It cannot be resolved by the booking system alone. This is an illustrative design problem, not clinical advice or a client result.
Make the cost model auditable by every partner
Compare the total cost of completed service: the shared team and systems, retained local work, coordination, travel and logistics, quality oversight, and transition. Separately identify fixed readiness costs and costs that change with use. A low-volume Nation may require access to the service even when it submits few requests; a volume-only price may not cover that readiness fairly.
Consider a negotiated base contribution for availability plus a transparent variable component for use, with explicit funding for access costs such as remoteness. This is one option, not a universal formula. Test how each alternative affects a small remote Nation, a larger high-volume participant and a partner with substantial local capacity. Show who benefits and who pays under realistic demand changes.
An illustrative business case might avoid $120,000 of separately purchased services while adding $80,000 of shared delivery costs and $50,000 of local coordination and travel. On those hypothetical assumptions, annual costs rise by $10,000 before establishment spending. The arrangement could still be worthwhile if it creates dependable access, but presenting it as a $40,000 saving would exclude real costs.
Distinguish avoided spending, released staff capacity and better service. Do not add them together as cash savings. Record which budget holder can remove a cost, when an existing contract ends and whether local teams must retain backup. Include demand variation and transition overlap in the decision, rather than relying only on the expected steady-state year.
Protect information control and the ability to change course
Shared technology does not itself authorize shared access. FNIGC’s explanation of OCAP® emphasizes First Nations ownership, control, access and possession, while recognizing that application reflects each Nation’s decisions.4 Establish the relevant Nation-approved arrangements before consolidating information. Professional, privacy and contractual requirements also need appropriate review for the actual service.
Define who can access which information, for what purpose, where it is held, how incidents are handled and what happens when participation changes. Procurement data, employment records and clinical records have different purposes and access needs. A common platform should support those distinctions. Reporting across Nations requires an agreed purpose and authority; it should not become an automatic by-product of using one vendor.
Agree on a practicable exit and service-continuity process. Identify notice, outstanding commitments, record transfer, staff implications and the costs of separating systems. Exit terms should protect continuity and honour commitments without making a Nation dependent on an arrangement it cannot meaningfully review. These provisions require locally appropriate legal and professional advice.
Evaluate the service where work is received
Use measures that connect the shared team’s performance to the local experience: completed requests, recurring errors, cancelled sessions, time to resolution and local time spent obtaining the service. Review results by participating Nation, service and access conditions. A regional average can hide a recurring delivery problem for a small community.
Investigate competing explanations when performance changes. A shorter queue may reflect improved processing, fewer referrals or new barriers to submitting a request. More recorded incidents may reflect better reporting rather than deteriorating quality. Pair administrative measures with local feedback and examine the full path from request to result.
Expansion should depend on credible service performance, manageable local workload and an updated cost forecast. A pilot that meets central processing targets by pushing extra work into communities has not demonstrated a sustainable model. Resolve that imbalance before adding partners or services.
The Shared Service Commitment Framework
This original Arcus decision framework is a management aid for local adaptation. It is not a validated assessment instrument or a substitute for the Nation’s authority and relevant professional requirements.
Result
Question: What completed service can each Nation rely on?
Decision evidence: A service catalogue with recipients, completion standards and exclusions.
Responsibilities
Question: Who controls each dependency?
Decision evidence: Local and shared owners, professional oversight and escalation authority.
Capacity
Question: How is scarce availability allocated?
Decision evidence: An agreed minimum access offer, prioritization process and backup capacity.
Full cost
Question: What work and spending remain outside the shared team?
Decision evidence: Retained local effort, logistics, transition and cost-allocation scenarios.
Review
Question: Can Nations correct or change the arrangement?
Decision evidence: Community-level performance, data controls and continuity provisions.
Turn the design into an operating commitment
Start with one bounded service and establish the baseline before changing delivery. Map several real requests from start to finish, record local effort and agree on what a completed service means. Select a pilot that can reveal important coordination problems without placing continuity at avoidable risk.
Before launch, approve the service catalogue, responsibilities, allocation rules, information arrangements and full cost model through the participating Nations’ processes. Rehearse a missing input, staff absence, urgent request and system outage. Name the people authorized to resolve each situation and fund the backup.
Arcus can help participating Nations compare delivery options, build transparent costing and develop practical service agreements and review measures. The initial output should be a decision-ready service design with explicit commitments, so leaders can judge whether the proposed arrangement improves capability and remains accountable to the Nations it serves.
Sources and limits of the evidence
- Ontario Standing Committee on Public Accounts, PPE Supply report, February 2023. Reviews the 2021 audit and hearings; emergency supply-chain evidence, not a First Nations delivery benchmark.
- Bell and Chen, The Role of Shared Services in Supporting Ontario’s Move to Bundled Care, 2021. Practitioner-authored paper from a shared-services perspective; conclusions are not independent causal estimates.
- FNHA, Evaluation of the First Nations Health Authority, 2019/20–2023/24, June 2025. Printed pages 67–69 provide regionalization context, not a forecast of savings from a new shared service.
- FNIGC, The First Nations Principles of OCAP®. OCAP® is a registered trademark of the First Nations Information Governance Centre (FNIGC). Implementation requires each Nation’s applicable direction.
Research reviewed October 18, 2026. Decision frameworks, options and hypothetical illustrations are Arcus management synthesis. No client outcomes or universal staffing, savings or impact benchmarks are claimed.
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