Longwoods Blog

by Ted Ball


Ontario is just now entering a critical phase of our provincial healthcare system’s history. The decisions we make right now—in the midst of the pandemic—about our future health system design could very well determine the medium-term wellbeing and, ultimately, the survival of our public health services over the next five or six years.

After the next election, just eighteen months from now, it is very possible that our existing, fairly well-performing, healthcare services delivery system could end up deteriorating significantly almost without our noticing it, leading us into “Boiling Frog” syndrome—lulled into relaxation by the ever-warming water, followed by sleep, and then, finally, being boiled to death.

So, what is the solution?

The challenge ahead will not be met by the “solution” suggested by all the vested self-interest groups in healthcare and the provincial premiers. In their own narrow self-interests, they are advocating for putting more money into their coffers.

Thank goodness Trudeau dodged the multibillion dollar investment that the premiers demanded for maintaining the status quo in healthcare—with its estimated 30 percent waste.

Despite the anxious voices of health system’s vested-interest-group lobbyists, our healthcare system does not need more money invested in the status quo.

The system needs to be re-imagined, redesigned, transformed, and aligned for the emerging needs of the population in each community in the approaching “Post-Pandemic Era,” or perhaps, the “Perpetual Pandemic Era.”

The survival of Medicare—and the continued wellbeing of our public healthcare delivery system—will depend, to the greatest extent, on the capacity/capability/skills/and stewardship-orientation of each local healthcare delivery system’s leadership team.

That is, the 2,000 local health service providers—their CEOs and executive directors, along with their community governance boards—who have agreed to join one of the eighty existing and proposed Ontario Health Teams (OHT) across the province to integrate care at the service delivery level.

These are the people who know what to do, and how to do it.

The system needs more “servant-leaders” capable of and willing to step up and help facilitate the OHT managerial and governance leadership group so they can think through the next steps that need to be taken to save their local healthcare system.

Reflections and Lessons Learned

I stopped writing essays and blogs about saving and designing health systems on TedBall.com five years ago, when I retired.

Back then, more than 2,000 people a week viewed/read what were intended to be thought-provoking essays that asked the big “wicked and probing” questions. Like a good coach, I did not provide what I thought were the “correct answers” to my wicked questions. My role was to provoke thinking.

In this new weekly series of “lessons learned” essays, I will provide what I think are the right answers to the question: What do we need to do for the healthcare system to be successful?

I am convinced that much of our existing healthcare delivery system will begin to deteriorate by 2025–2026 because most of the local OHT development efforts will, unfortunately, have failed to produce a transformed and integrated delivery system at the local community level. There will just be lots and lots of busy work.

For those whose role it is to avoid such catastrophes, these next few essays will provide some of the key lessons learned from both the successes and failures of past attempts at health system integration. I will provide my best advice on what pragmatic steps can be taken to achieve service integration at the local OHT system level.

These essays will provide an overview of the historical and current realities that Ontario faces, as well as some pragmatic recommended actions—based on best practices—tweaked to incorporate my assessment of how to succeed.

Where Is Our Health Sector Going?

The norm for large-scale change in healthcare systems is a 70 percent failure rate.

Among the 30 percent of successful transformations, the most constant feature was having a common language and common frameworks to talk about, plan for, and implement complex change. These were systems that utilized best-practice, systems-thinking frameworks that focused on system design.

The actual challenge before each of the OHT Leadership Teams now is just that—to embrace and incorporate the art and science of system design. While everyone uses “system design” language, they don’t give much thought to what a system is and what changing it involves.

A system is a series of component parts that have been intentionally designed and aligned to create an intentional outcome. The cooling system of a car, for example, has component parts that are designed and intentionally arranged to prevent overheating of the car.

Our healthcare system in Ontario, on the other hand, has never been intentionally designed, aligned, or incented to produce a set of intentional operational outcomes.

Instead, our healthcare services “non-system” has evolved randomly over decades, mostly in response to a variety of complex external forces as well as from sustained, timely, and strategic inputs from the well-organized and publicly financed hospital and medical lobbies.

So our healthcare “non-system” is the product of top-down, command-and-control, fragmented, centralized bureaucratic silos that have historically led to complaints about Queen’s Park’s centralized and bureaucratic decision-making processes that misunderstand local communities and are unable to respond to the community’s unique circumstances.

That is why we occasionally get politicians who honestly believe that the best decisions can bubble up from the inherent wisdom of the so-called system, rather than being imposed top-down from the lofty heights of a centralized bureaucracy at Queens Park.

Community Empowerment

Ontario Health Teams are the next step in the regular Ministry-led health system redesigns that have included the formation of thirty-three District Health Councils (DHCs); fourteen Local Health Integration Networks (LHINs); and the eighty-two Health Links (HLs)—all MOHLTC’s versions of “decentralization” and “devolution.”

It is important for OHT leaders to understand how Queen’s Park has managed the issues of devolution and decentralization in the past, in order to appreciate the new OHT system’s probable future. So, let’s start with the past.

Ontario’s first attempt to decentralize and devolve authority in the healthcare system happened in the 1970s, under Red Tory Premier Bill Davis, and his Health Minister, Dennis Timbrell.

Their government believed that local communities were in the best position to determine how to achieve better, more efficient services through increased collaboration at the local system level, to achieve what citizens and families said they wanted: “a seamless patient experience along their journey across the continuum-of-care.”

The Davis government recognized that, at the operational level, a centralized and fragmented MOHLTC produced a fragmented, uncoordinated, and non-collaborative group of silos that compete with one another for resources.

Patients, families, and staff said they wanted a robust system of public healthcare services that would enable people to travel seamlessly and safely across the operational silos in their community as if it were a single integrated system, owned by the people of Ontario, governed by community boards, and operated in their best interests.

So the Davis Government set up thirty-three District Health Councils (DHCs) to undertake planning for a locally integrated delivery system of healthcare services in each region. That, of course, set off the never-ending power dynamics between the “central powers” at Queen’s Park, in their fragmented ministry-silos, and the “local powers” in the thirty-three DHC Regions across Ontario.

In the 1980s, when many DHCs produced world-class compelling and visionary solutions to issues that their community had been struggling with for years, Queen’s Park’s public servants became increasingly jealous—particularly when Minister after Minister referred to the DHCs as “the Minister’s eyes and ears on what is happening in healthcare—in your community.”

But the public service has always had time on their side—Ministers, after all, come and go.

Indeed, our public service patiently waited for their new Minister in the Harris government to arrive—and then suggested that, instead of having thirty-three DHCs doing local planning, it would be much cheaper for the Minister, a fiscal conservative, to announce that, in order to save money and reduce bureaucracy, the number of DHCs would go from thirty-three local planning bodies to sixteen District Health Councils.

That initial downgrading and weakening of community decentralization, local planning, and local empowerment meant that the next generation of DHCs— in the 1990s— were, sadly, transformed into rather weak and ineffective local planning bodies.

Billions of dollars later, they were not able to produce integrated delivery systems in their regions.

Health Services Integration

In 2003, the McGuinty government’s “health reform” Minister, the Hon. George Smitherman, arrived and started the macro-system design process all over again— this time called, the Local Health Integration Networks, or LHINs.

Smitherman passed legislation—endorsed by all three political parties—to replace the sixteen DHCs with fourteen citizen-controlled LHINs that would: (a) be required to work with local system partners to produce an agreed-upon Local Health Services Integration Plan (IHSP); and (b) receive the authority to allocate the resources required to achieve their agreed-upon system outcomes. This represented a shift in decentralized power that the traditional command-and-control, top-down public servants have resisted for decades.

A few years passed as MOHLTC public servants —with time on their side—waited patiently for “health system reform” Minister Smitherman to be replaced by a new Minister, who turned out to be the Hon. David Caplan. He agreed early in his tenure that the “devolution over resource allocation to the LHINs” would not, in fact, be implemented while he was Minister—despite the law that actually governed our province. 

So, what happens when you intentionally destabilize and disempower the LHINs? The result was that not a single LHIN ever successfully implemented their Integrated Health Service Plan. Thirteen years of LHINs and billions of dollars later—nothing! Just an awful lot of wasted human energy, taxpayers’ money, and good will.

Morphing into Ministry Offices

When Deputy Minister Dr. Bob Bell and his Health Minister, Dr. Eric Hoskins, ran the “Ministry of Doctors and Hospitals,” they declared that the LHINs had been so successful over the previous thirteen years that they were being rewarded with even more responsibility—they were given a service-provider role, to provide all the home care services that had previously been delivered by the Community Care Access Centres (CCACs).

Ultimately, by 2018, the LHINs had simply morphed into extensions of their head office bosses at Queen’s Park. 

Today, two years into the Ford government’s first term, the people who worked at the fourteen LHINs have now become part of the Ministry’s new centralized “super-agency”—Ontario Health—which may or may not be a re-branded MOHLTC with the same command-and-control-micro-management bureaucracy except that at the top is an experienced and knowledgeable board and a new, very experienced and capable senior management team led by a talented, natural “systems thinker” CEO, Matt Anderson.

Can a small group at the top turn around the ingrained, decades-long habits of thinking and behavior of centralized bureaucrats? We don’t know yet.

The multibillion dollar seesaw battle over decentralization and devolution continues to this day. It employs lots of people who, while very busy, don’t really add any value and the stakes are still very high for the Ontario Public Service.

Former Health Minister George Smitherman says that the implementation of devolution when he was Minister meant a loss of up to 50 percent of jobs at the MOHLTC—and, I guess, also now at Ontario Health. These jobs exist to micro-manage operations, adding little to negative value, but diverting billions from care services to expanding and empowering the bureaucracy—all while avoiding any accountability for the results created.

Devolution and Decentralization

During the last election, the MOHLTC staff prepared yet another macro-structure system-redesign proposal for the new government to consider.

Their “secret” report on decentralizing the Ontario healthcare system and devolving authority over resource allocation was released by the NDP several months into the tenure of the new Ford government.

It is instructive for Ontario Health Teams to read this confidential report, which recommended to the new government that they establish thirty to fifty Ontario Health Teams—each headed by, guess what?, a trusted hospital CEO who would receive a devolved “bundled payment” from what they called the Super-Agency that the Tories insisted be called simply, Ontario Health.

Deputy Minister Helen Angus gushed about the OHT model because it created what she called “a single point of accountability,” or what organizational scientists call the “one throat to choke” management philosophy. Paradoxically, Ministry slide-decks claimed that this very traditional, command-and-control structural design would somehow result in improved system collaboration.

Again, the use of this particular word by the MOHLTC is an adjective intended to convey a wish or hope, rather than an actual design feature.

I don’t think the Ford Cabinet understands that, by the next election, in less than 600 days from now, the OHTs are not going to be engaged in integrating services for all patients, but rather, will be focusing on a fragmented population group.

OHTs are being asked by the fragmented, siloed Ministry and their Rapid-Improvement, Support, and Exchange program (RISE) to simply select a “priority population group” and design integrated services for them—putting off any serious integration efforts on behalf of the whole community for the foreseeable future.

Best practices suggest designing for the whole population and priority/vulnerable populations at almost the same time. Once the macro-system design is in place, tweaking the macro-system to meet the special circumstances and unique needs of sub-population groups is the most efficient design sequence.

The OHT system-integration effort is also undermined whenever the Ministry feels the political need to communicate that ending “hallway medicine” is a purpose of the OHT rather than an outcome of their integration designs. 

CEOs and Governance Accountability

Now the “non-elitist” Ford government appears to have rejected—or at least not embraced— the MOHLTC’s idea of devolving authority over resource allocation to the Ministry’s hand-picked hospital CEOs.

What if, instead, the allocation of resources became the responsibility of the whole team of OHT health service provider (HSP) CEOs who—individually and collectively—would be accountable to their respective community governance boards, for the system outcomes listed in both their local OHT local system scorecard—as well as for the “silo” outcomes listed in their own organization’s balanced scorecard?

Some may ask: Why should our local OHT CEOs (vs. the centralized public servants) have all that power and control over how our public resources are allocated to support healthcare service delivery in their community? 

Individually, the CEOs are in charge of their silo’s strategy and, collectively, the HSP CEOs also need to be accountable for developing and implementing the local healthcare system’s strategy and achieving the governance-approved strategic outcomes set out both in their OHTs local system balanced scorecard and their silo scorecard.


So, if we are going to hold our CEOs accountable through their respective, collaborative community governance boards, they need to be empowered to decide where in the delivery system the resources need to be invested in order to ensure that their OHT’s vision and scorecard outcomes are actually implemented.

Those who have been arguing that the OHT transformation can’t take place without investing billions of dollars into the existing dyslexic, fragmented system really need to be challenged. The Ontario Hospital Association (OHA), University Health Network (UHN), and all the bigger lobbyists claim that the problem with healthcare services delivery is a lack of funds to run the system.

Mr. Ford and his fellow Premiers wanted Trudeau to—once again—invest billions of additional tax dollars (borrowed on Wall Street) to pour into our badly designed, wasteful, and inefficient provincial healthcare delivery system.

But the sad truth is that the many additional-billions of dollars that Trudeau was being asked to pour into our poorly designed, badly fragmented healthcare services delivery system would have been wasted money.

It would be like pouring another liter of oil into a cracked and leaking engine block—the result would be oil splattered all over the road. Wasted! ….And now we are out of money.

Will Healthcare Services Survive?

The real drama over the survival of Medicare—and the preservation of our public healthcare services—won’t be played out until its conclusion in the first two to three years after the next election, which is still eighteen months away.

My assumption is that, in less than 600 days, there will be a second five-year term for the Ford government.

That is why Ontario Health should immediately approve each of the eighty proposed OHTs and give them one year to produce their refreshed post-pandemic shared vision along with the OHT’s balanced scorecard for achieving their outcomes.

My prediction is that, during the second Ford term, by 2025–2026, there will be a measurable and notable deterioration of healthcare services at the OHT community level.

So, how can your OHT be among the successful transformations?

Published with permission from Transformation Lessons Learned

ABOUT THE AUTHOR: “Ted Ball is one of the best-informed health policy analysts in the province. He has excellent connections at Queen’s Park and an encyclopaedic knowledge of the healthcare system.” —Carol Goar, columnist, Toronto Star.

This entry was posted on Thursday, February 18th, 2021 at 1:04 pm and is filed under Longwoods Online.