Essays February 2016

Comments re: Patients First: A Proposal to Strengthen Patient-Centered Health Care in Ontario – A Discussion Paper

Duncan G. Sinclair

With substitution of the word “people” for “patients,” I agree heartily with the objectives of:

  1. putting people (including patients) where they belong – at the very center of every interaction with a health/healthcare provider, be it an individual, institution, or organization, and
  2. integrating the functions of the disparate elements in Ontario of what we like to refer to as a “system.”[1]

If the overarching goal is to optimize the health of the population, which I believe it is and should be, it is important to focus primarily on people’s health, recognizing also the necessity of providing them with assistance in restoring their health if and when they become patients.

As far back as 1982 Tommy Douglas reminded us[2] that it is essential to integrate the work of the providers of healthcare services:

“When we began to plan Medicare, we pointed out that it would be in two phases. The first phase would be to remove the financial barrier between those giving the service and those receiving it. The second phase would be to reorganize and revamp the delivery system – and, of course, that’s the big item. It’s the big thing we haven’t done yet.” (emphasis added)

It’s 2016 and we still haven’t done it! Several governments, including Ontario’s, have tried quite a bit of reorganizing over the years but little or no revamping, the disruptive innovation needed to forge a real delivery system.

I agree strongly with strengthening LHINs, giving them more responsibility for integrating the health and healthcare services provided by elements of the “system” in their regions. Having read the discussion paper very carefully, however, I remain most unsure of what the Ministry/government intends by the word “strengthening” – just what it constitutes in the hard, cold terms of giving the LHINs more power and authority. Specifically, it is not clear what policy-making powers are to be devolved to the LHINs from the Ministry/government, with its responsibility for province-wide governance. The paper implies each will be provided subsidiary authority for governance of the way health/healthcare services are integrated in its region as well as responsibility for planning for what the providers of those services do and holding them accountable for how well they do it. That, in my opinion, is the way it should be. But the only time the word “governance,” defined as leadership – the power to direct – is used in the discussion paper is when the LHINs are described as being given new responsibility for governance over the functions of the to-be-defunct CCACs. Regional planning is referred to frequently but it and regional governance, the power to make the what’s to be done decisions, while related, are not the same.

The issue is an important one. It is fair to say that to this point in their development, LHINs are perceived to be not much more than regional agents of the MOHLTC with very little independent power or authority. I regret to say that the vagueness in the discussion paper on this point takes me back to the era of District Health Councils that too were touted as important regional planning bodies but in the end were disbanded as not very helpful either regionally or centrally in moving the “system” toward greater coordination/integration. That they were not was largely because they were never given any real power or authority, nor did the Ministry/government exercise its power centrally to require the deliverers of healthcare services, primarily hospitals in those days, to implement the plans developed by the DHCs. That was left to the Health Services Restructuring Commission some 15 years ago.

To address directly the questions related to the first proposal in the discussion paper:

  • How do we support care providers in a more integrated care environment?
    • This is a question best answered by each LHIN, given the differences among their regions throughout Ontario. One size won’t fit all!
  • What do LHINs need to succeed in their expanded role?
    • They will need members with more experience in the challenges of governing and of avoiding the temptations to meddle in the management of the care providers, institutions, and organizations in their regions (the how to do it decisions). They will also need less  ‘second-guessing’ by and ‘end-running’ to Queen’s Park. They will also need more analytical staff and, above all, data derived from a much more highly developed, universally applied, province-wide, comprehensive health information management system; Queen’s Park should focus its attention on the latter’s development and implementation.
  • What other local organizations can be engaged to ensure patients are receiving the care they need when they need it? What role should they play?
    • Public health units and municipal social service agencies should be closely involved with the LHINs in developing policies, planning, and evaluating on-going needs within their regions.
  • What other opportunities for bundling or integrating funding between hospitals, community care, primary care and possibly other sectors should be explored?
    • First the funding derived from the MOHLTC for all elements in a particular region should be combined into a single “bundle” to be allocated by each LHIN in accordance with its plan for integration of those elements into a genuine regional system. Subsequently explore with the Ministry of Community and Social Services the potential of combining the two funding sources.
  • What areas of performance should be highlighted through public reporting to drive improvement in the system?
    • Using a comprehensive health information system, there are many performance statistics that could be used to compare one LHIN region (and their sub-regions) with another and to drive improvements, the most important being:
      • Health status (self- and provider-reported)
      • Patient and family satisfaction with the range, quality, and accessibility of the services received
      • Outcomes of services provided
  • Should LHINs be renamed? If so what should they be called? Should their boundaries be redrawn?
    • Yes. They should be Regional Health Integration Boards. The boundaries should remain as they are unless there is compelling evidence that they need to be changed; begin by building on what is in place, imperfect as that foundation may be.

I also agree strongly with the second objective of the discussion paper, that of ensuring that every Ontarion, patient or not, has a “primary healthcare home,” to paraphrase, but broaden the language of the Ontario Medical Association. The idea of making primary care the integrating ‘pivot’ for all other forms of care, institutional, community, acute, chronic, therapeutic, preventative, urban, rural, etc., is a good one. That being said, I do have a major concern that accomplishing this objective may prove impossible given the government’s commitment to continue unamended central bargaining with the OMA of physicians’ recompense, the Medicare ‘basket’ of services, and all those matters that relate to the responsibilities and distribution of physicians throughout the province. The discussion paper does refer to giving the LHINs responsibility for “health human resources planning” in primary care but it is far from clear to me how that might apply to physicians (or to nurses and others such as the coordinators of community care services) given the maintenance of the status quo in central bargaining. Again, it is highly unlikely in such a large and diverse jurisdiction as Ontario that one size will fit all; it certainly will not do so comfortably!

As for the LHINs’ establishment of sub-regional nodes, I believe this too to be a very good idea. I suggest, however, that the concept would be strengthened substantially by defining those nodes as sub-regional clusters of each region’s primary care teams. This would be consistent with achieving the very desirable objective that each person in each region and throughout Ontario have a primary care home and also that the provision of primary care services should be done by multi-professional teams, applying the principle of “one-stop shopping” for people seeking a range of primary health and healthcare care services.

I do have two serious reservations about the wisdom of transferring to the LHINs operational responsibility for the current functions of the CCACs. The first is drawn from the experience with Regional Health Authorities in other provinces where it has become abundantly clear that mixing governance and resource allocation responsibilities with operational functions resulted in a) favoured status for the ‘in house’ operational functions over those in the hands of other bodies and b) a dangerous shift of focus from the longer range governance functions of the RHA boards and managers to the more immediate operational ones. To refer again to my point on governance, I presume (hope) that the intention of the Ministry and government is to strengthen the LHINs so that they can provide effective regional governance (within the limits of and subservient to the governance/policy direction provided to Ontario as a whole by the government) to the whole range of providers, organizations, and institutions that provide health and healthcare services in their regions. If this is the goal, at this point in their development LHINs should not have to deal with the operational responsibilities of CCACs. It would be far better to transfer those employees and responsibilities to sub-regional clusters of primary care teams or, failing that, to the Public Health Units that already have well-developed operational units and considerable experience in the provision of services directly to the public.

To address the specific questions asked in this section of the discussion paper:

  • How can we identify, engage and support primary care clinician leaders?
    • This too is a question best addressed to each LHIN dealing directly with those clinician leaders on the ground.
  • What is most important for Ontarions when it comes to primary care?
    • To answer this question I would have ICES conduct a survey of Ontarions and report on the results. I suspect that having same-day access 24/7 to his or her primary care provider (or a colleague) whether in person or by e-mail or telephone would be most important.
  • How can we support primary care providers in navigating and linking with other parts of the system?
    • Primary care teams should be the focal point for all care, the locus of community care coordinators, and of maintaining the health (including medical) record of each person registered with them. Their members can best be supported by teamwork among all their members.
  • How should data collected from patients about their primary care experience be used? What data and information should be collected and publicly reported?
    • Data on patient care experience should be entered into the personal health record by the person receiving the care. It should be aggregated and used for reporting purposes and also as the basis for the allocation of significant bonus payments to the best performing primary care teams and other providers on a quarterly basis. Obviously, all patient and performance data and information should be “anonymized,” aggregated, and reported publicly.

I have commented above on Proposal #3 to transfer direct responsibility for service management and delivery from CCACs to the LHINs. I think this is a bad idea that will weaken the LHINs, primarily by diverting their attention from their central and most important function of providing regional governance, policy direction, leadership, and planning to the providers of health and healthcare services in their regions. To repeat, I advocate strongly locating the CCACs employees with sub-regional clusters of primary care teams or, failing that, with Public Health Units.

To respond directly to the questions asked in this section:

  • How can home care delivery be more effective and consistent?
    • First, the provision of community-based services will require more people and funding; both will have to be shifted out of the currently much more richly funded acute care sector, region by region. Second, I believe this question can best be answered by sub-regional clusters of primary health teams and other providers who are familiar with local geographic and other constraints; that is the primary reason to locate community care coordinators there.
  • How can home care be better integrated with primary care and acute care while not creating an additional layer of bureaucracy?
    • This is best done, as I have suggested, by making primary care teams the locus for the CCAC’s care coordinators and the focus of the provision of care generally to the people registered/rostered with the primary care teams.
  • How can we bring the focus on quality into clients’ homes?
    • This can best be done by regularly surveying those being provided services and their families and by integrating home/community care into the functions of all providers of primary care, beginning with primary care teams.

With respect to Proposal #4, I am all for establishing the links proposed between public health units and the LHINs. This makes good sense, even more if, in the long run, the geography of the Public Health Units and those of the LHINs were to be made the same.[3]Public Health Units have long-established links with municipalities and could constitute for LHINs (and for the MOHLTC) important regional-municipal ‘bridges’ to achieve better coordination of the social services that, together with health services, constitute the broad determinants of health.

With respect to the specific questions relating to Proposal #4:

  • How can public health be better integrated with the rest of the health system?
    • Again this is a question best answered on a regional basis by Public Health Units working with LHINs. To facilitate their working together I suggest that there be cross membership on the Boards of the Health Units and LHINs and regular meetings between each Medical Officer of Health and the Executive Director of the relevant LHIN.
  • What connections does public health in your community already have?
    • I do not have sufficient personal information to be able to answer this question.
  • What additional connections would be valuable?
    • I have suggested two in the response to section #1 (p3).
  • What should the role of the Medical Officers of Health be in informing or influencing decisions across the health system?
    • Ontario’s Medical Officers of Health should have far greater influence on the governance/policy making and planning of the “system” both regionally and provincially. By training and experience their focus on population health and all its determinants would be very beneficial as a counter to the persistent emphasis on ‘acute care’ since the start of Medicare and to rebalancing the system toward achieving the overarching goal of optimizing the health and productivity of Ontario’s (and Canada’s) population. The voice of public health in the governance of our “system” should be far more influential.

I commend the Minister and the Ministry of Health and Long-Term Care for its public, clear and unequivocal commitment to transform the focus of Ontario’s health/healthcare system, putting people (including patients) at its center in place of the providers of care. The latter and the services they provide are important but the well-being of every person who seeks those services is paramount.

The gaps in care, both those referred to at the outset of this discussion paper and others, are all too real. I also commend the MOHLTC and the government for its commitment to closing them. Those gaps do impede all who need help, but especially elderly people seeking assistance to sustain their health as well as patients from accessing the services they need to restore them to good health. But I question the view that those gaps can be eliminated solely by yet more structural changes bearing on “the disparate way(s) different health services are planned and managed.” I can do no better than return to the wise words of Tommy Douglas, spoken now some 35 years ago:

We must grasp the nettle and “ … reorganize and revamp the delivery system… the big thing we haven’t done yet.” It’s (over)time to do so!

About the Author

Duncan G. Sinclair, Professor emeritus and Fellow, School of Policy Studies, Queen’s University and Chair (1996-2000), Ontario’s Health Services Restructuring Commission

References

Click here to download the PDF of Patients First: A Proposal to Strengthen Patient-Centered Health Care in Ontario – A Discussion Paper 

Footnotes

[1] System. n. A group or set of related or associated material or immaterial things forming a unity or a complex whole. The New Shorter Oxford English Dictionary 4th ed. 1993
[2] T.C.Douglas. 1982. An interview as quoted in Alberta Roundtable Report, Government of Alberta, August, 1993, p. 17, from Decter, Michael B. 1994. Healing Medicare. McGilligan Books, p. 14

[3] But leave those boundaries (and those of the LHINs) as they are for now! We don’t need more disruptive reorganization while trying to achieve the objectives of this discussion paper. 

 


Comments

Hugh MacLeod wrote:

Posted 2016/10/02 at 05:24 PM EDT


I agree with the assessment and recommendations in this essay. The comments echo many of the observations found in a recent article by Professor Gregory Marchildron, titled" The Crisis of Regionalization"..Healthcare Management Forum, Nov 15/2015 Vol.28 No. 6 p236-238...A key passage follows:

"The LHINs offer the opportunity to experiment with performance measurement and payment incentives and disincentives to an extent not offered in other provinces.

By not owning and running any of the healthcare organizations within their boundaries, LHINs have to potential to use, in a dispassionate and objective manner, the power of the purse to shape behavior and encourage better performance. Using an approach developed in the United Kingdom, LHINs could negotiate agreements with healthcare organizations and groups of providers that set clear targets.9 Although controversial as a system of terror and targets using performance measures, the National Health Services has seen outcomes improve in numerous areas and has become the highest performing health system in the world according to a basket of indicators used by the Commonwealth Fund.10"

 

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