On December 14, 2001, the Ontario Government enacted new legislation significantly increasing its role in how community care access centres (CCACs) across the province are governed and operated.

The 43 CCACs across Ontario fill a critical role in the provision of home health care services to Ontarians. CCACs purchase home services for clients, including nursing, physiotherapy, occupational therapy, and homemaking services; provide case management for clients receiving home services; offer placement coordination for long-term care facilities; and provide information and referrals to the public. Like most public hospitals, each CCAC is a not-for-profit corporation that is governed by a volunteer Board of Directors, who are elected by a community membership of interested stakeholders.

Bill 130, An Act respecting community care access corporations, gives the Minister of Health and Long-Term care the power to designate existing CCACs as "Community Care Access Corporations". Once a CCAC is so designated as a Community Care Access Corporation, its corporate existence changes forever. All of the CCAC's corporate members are immediately removed, as are the Board members then in office. The Government, through the Lieutenant Governor in Council (LGIC), then appoints all the members of the board of the CCAC on an ongoing basis. Unlike District Health Councils - whose boards are also appointed by the Government - there is no requirement for the Government to consider "the importance of ensuring that the membership of the [board] reflects the diversity of the population in the council's geographic area in terms of gender, age, disability, place of residence within the council's geographic area and cultural, ethnic, linguistic and spiritual factors."¹

Under Bill 130, the LGIC also appoints the Executive Director of the CCAC and sets the Executive Director's salary and other benefits. This appointment process could create tensions between the Board and the Executive Director (its sole reporting employee) from the outset. The Board/Executive Director relationship is critical to the proper functioning of any corporation. Typically, the Board is responsible for searching for and appointing an Executive Director or CEO who it feels has the ability and skills to turn the Board's strategic vision into an operational reality. Under Bill 130, an Executive Director is selected by the Government, and not by the CCAC's Board. Also, while Bill 130 clearly states that the Executive Director is accountable to the CCAC's board, press material prepared by the Ministry of Health and Long-Term Care² states that the Executive Director will have a dual accountability to both the Board and the Ministry. It is all too easy to imagine the difficulties and conflicts that can arise where an Executive Director must answer to two different masters.

Each CCAC, once designated, will be required to establish a community advisory council. While Bill 130 does not describe the mandate of this council, it was described by Associate Minister of Health Helen Johns, when introducing the Bill, as "a forum for identifying issues of concern among the partners that CCACs link with - specifically hospitals, long-term-care facilities, and other community-support services."

The Government has stated that two recent reviews provided the impetus for the Bill. A 2001 province-wide review, conducted by PricewaterhouseCoopers, highlighted a number of areas where fledgling CCACs needed to improve their operations, including accountability and fiscal practices. An operational review of the Hamilton-Wentworth CCAC, released in April 2001, also highlighted concerns with the governance and operations of that particular CCAC.

As a result of Bill 130, the Government has significantly increased its control over CCACs. In addition to determining who will govern and manage the CCACs, the Government (through the Minister) can:

1. issue mandatory directions on any matter relating to the exercise of a CCAC's rights and powers and the performance of its duties under Bill 130; and
   
2. appoint a supervisor to take over the governance and management of a CCAC, where the Minister considers it to be in the public interest to do so.

Bill 130 is, in some ways, a departure for the Government, particularly when one looks back to the directions issued by the Health Services Restructuring Commission (HSRC), which was appointed in 1996 to restructure health care services across the province. The HSRC was supportive of a health care governance model in which directors were elected by representatives of the community. For example, the HSRC expressly took into consideration "the need for broad community representation that reflects the demographic, cultural, linguistic, geographic, ethnic, religious and social characteristics of [the Region]"³. In that same report:

The HSRC was concerned that the facility's current processes for determining board membership might not lend itself to broader public representation and accountability. ... The HSRC believes that in order for this organization to continue governing hospital services, it must become more representative of and publicly accountable to its community.

Over the past two years, however, we have witnessed an increased willingness on the part of the Ministry to take a more "hands-on" approach to health care governance and operations. For example, the Minister has recommended the appointment of a supervisor for a public hospital on two recent occasions: Hamilton Health Sciences Corporation (April 2000) and The Ottawa Hospital (July 2001). Under the Public Hospitals Act, a Government-appointed supervisor replaces the board and the members of a public hospital. This past summer, the Minister also appointed a designate to manage and operate the Hamilton-Wentworth CCAC, using his powers under the Long-Term Care Act. Bill 130 is the most recent example of the Government's apparent inclination to become directly involved in appointing the board - and the Executive Director - of a health care organization on a long-term basis⁴.

The legal and health care communities will continue to monitor with interest the Ministry's increasingly direct involvement in health care governance. We will also be watching to see what impact Bill 130 may have on other health care organizations. For example, will potential volunteers be discouraged from participating on hospital boards, knowing that the Government has set a precedent by replacing volunteer, community-elected CCAC boards with government-appointed boards?

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1. Section 8.1(11), Ministry of Health Act.
   
2. Community Care Access Corporations Act, 2001Frequently
   Asked Questions (November 9, 2001), available on the Ministry of Health and Long-Term Care web site.
   
3. Waterloo Region
   Health Services Restructuring Report (May 1998).
   
4. The Minister must undertake a comprehensive review of Bill 130 in
   five years.
   

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