LHINS at 5 Years – Further Thoughts
My article two weeks ago in Longwood’s eLetter generated considerable discussion and a large volume of correspondence to the author. Most of the writers were broadly supportive of my ideas, but questioned or misunderstood my intention regarding some of the specifics. Given that both opposition parties in Ontario have now publicly stated that they will abolish Local Health Integration Networks LHINs) if elected, the issue of what to provide in their stead is worthy of further debate.
To summarize my proposal, I argued that we have created far too much organizational complexity and functional fragmentation in Ontario to have any hope of effectively reforming healthcare unless this complexity is addressed. In other words, the healthcare system needs a serious organizational pruning. I suggested we should, as a starting point, abolish LHINs and Community Care Access Centres (CCACs in Ontario broker the provision of homecare services) and dramatically downsize the Ministry of Health and Long-Term Care. We should then take leading existing organizations in each region (likely hospitals) and make them accountable for additional functions, starting with homecare and primary care and adding ambulance services and public health at a later date. To make them large enough to be workable, but small enough to be manageable I suggested thirty to forty Integrated Health Organizations (IHOs) across the Province.
A criticism I expected, and received, is that IHOs would be hospital dominated and would inevitably short-change community services. Ontario’s hospitals (with a handful of exceptions) are well led and well run and their operating statistics compare very favourably with institutions in other Provinces. They have strong public support in their local communities and are the greatest collective source of healthcare expertise in virtually any community in the Province. They have existing relationships with both family physicians and specialists and Boards of Directors that are highly influential in their communities. While they may not be an ideal candidate around which to build IHOs, they appear to me to be the best available. We need to integrate functions across the healthcare continuum and we don’t have the time to waste to set up a whole new set of organizations. Nor should we simply let all decisions be made from the Ministry of Health in Toronto – local input and decision-making matters.
The other aspect that gives me considerable comfort in suggesting that hospitals lead the creation of IHOs is a new culture of measurement and accountability that is emerging across the hospital sector. I give both the current government and the Ontario Hospital Association high marks for this development. Public reporting of statistics on hospital acquired infections, hospital standardized mortality ratios and other dimensions of quality of care and financial performance has promoted a healthy competition among hospitals for improved performance as well as better governance. Ontario’s Wait Times Strategy, much of it falling to hospitals and their clinicians to implement, has been a great success, with Ontario leading the country in tackling long waits for targeted procedures. A combination of carefully thought-out measurement requirements and funding tied to volume targets led to this accomplishment.
With the right measures and incentives in place, the new IHOs will focus their efforts where they are most needed – which today is on reducing the number of patients in inappropriate care settings, improving care transitions, providing better links with primary care and allowing palliative patients to die at home when that is their wish.
My overall goal is to reduce the large number of organizations involved in planning and delivering healthcare in the Province. The number today is excessive and the level of fragmentation leads to waste and duplication as well as to poorer care. Fewer organizations with clear accountabilities will deliver better care and be more accountable to their local communities as well as to the Ministry and to taxpayers.
Other readers thought I was advocating major job losses. Employers may change, but the functions being performed today will largely remain essential and will be performed inside my proposed IHOs, and subject to a single point of accountability through a CEO and a voluntary board of directors. There are also excellent leaders today in both CCACs and LHINs who would and should transition easily to leadership roles in the new IHOs. IHOs will need leaders who bring a system perspective and the best of these are often found outside of current hospital leadership.
Other writers thought I was “Ministry bashing”. Nothing could be further from the truth. We need a Ministry that is highly effective in its oversight role – planning, evaluating, funding and policy-setting – but not micro-managing other system players and making it more challenging for them to be effective. Having observed the Ministry for over twenty-five years I am convinced more than ever that this will occur only in a Ministry that is dramatically smaller than the current one; a Ministry that attracts and keeps the best talent in the system because it is highly effective and a rewarding employer.
I also was not “LHIN or CCAC bashing”. I pointed out why LHINs have not been broadly successful – they were woefully understaffed, micro-managed by the Ministry, had critical functions such as primary care left out of their mandates, and were left with hundreds of independently governed providers to attempt to coordinate. As for CCACs, I believe most of the functions they perform, such as care assessment and coordination, are critical. However, I believe these functions could be more efficiently and effectively performed if they were part of accountable regional organizations – my proposed Integrated Health Organizations.
I am worried we will see a further restructuring at the margin this year; one that will not address and simplify the hodgepodge of agencies that currently exist. We should not create any new agencies – we should abolish 14 LHINs and 14 CCACs and use 30 to 40 existing hospitals and their boards as the foundation for new Integrated Healthcare Organizations.
Asked to provide an example of an organization that could evolve easily into an IHO, I have been using Quinte Health Care Corporation – although there are many others across the Province. After a rocky start, Quinte has very successfully moved and improved services across its fours hospital sites in Belleville, Trenton, Picton and Bancroft, maintaining essential primary and emergency services at each, but rationalizing ambulatory care services and adding highly specialized services where appropriate. It has also established critical primary care links in Prince Edward County. There is no question the various communities it serves would be broadly accepting of Quinte taking on expanded roles in homecare and primary care to better serve its residents.
Thanks to all who took the time to speak to me or write. I don’t pretend to have all the answers, but the level of interest suggests that this is a conversation that needs to, and will, continue.
About the Author(s)John Ronson leads the strategy, policy and evaluation practice for TELUS Health Solutions. He can be reached at John.Ronson@telus.com
Will Falk wrote:
Posted 2011/06/07 at 08:51 AM EDT
Good to see someone opening up this debate. A firm proposition about what comes next is exactly what is needed to move beyond LHIN-bashing.
But your IHOs strike me as just regionalization and vertical integration with a new label. That means taking on board restructrucring in many communities. Not likely to gain much support after the western debacles
Where do the new "ground-up" mergers fit in your model? Could we encourage integration through bundled funding of cases and a strong 30-day readmit penalty?
Again thanks for getting us beyond LHINs yes or no?
steve lurie wrote:
Posted 2011/07/07 at 01:04 PM EDT
John is correct that EHCFA has succeeded in focusing attention on quality. But students of quality improvement know that mandating quality from the board or CEO suite is not sufficient, it needs focus and committment at the front line of services and aslo requires talking to the customer. There is no evidence in either the public or private sector literature that mergers improve quality or clinical care. In fact according to Grubb and Lamb who wrote a book on the subject most mergers fail. The government would be better of to focus on setting targets and funding needed community investments and helping all health care organizations improve quality and safety. Restructuring will divert attention from this for years and will likely increase costs.
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