Insights September 2014
The Premier's Mandate for Health

Mandate Letters: Why They Matter

John Ronson


Ontario Premier Kathleen Wynne publicly released mandate letters for each of her newly appointed Cabinet Ministers this month.  The letters outline her expectations of Ministers for their portfolios.  This note analyses the letters delivered to her Minister of Health and Long-Term Care, Dr. Eric Hoskins and her Associate Minister of Health and Long-Term Care (Long-Term Care and Wellness) Dipika Damerla.  Some of the comments are applicable to only the health portfolios; others may be apt for other Ministries, particularly those with large numbers of external stakeholders like Education and Municipal Affairs and Housing.  The letters are easy to read (and accessible at htpps://  Minister Hoskins’ letter is five pages; Minister Damerla’s is three pages.

To be clear, the Premier did not take pen to paper over the Labour Day weekend and generate the letters herself.  They have been the subject matter of intense negotiation since shortly after her Cabinet was appointed in June of this year.  This negotiation process is important because it serves to align the views of the so-called “Centre” (the Premier’s Office, Cabinet Office and Treasury Board) with those of line Ministries on key government priorities.  As importantly, the letters have the input of senior officials from each Ministry and serve an internal alignment function within each Ministry.  This is particularly critical in a Ministry as large and often unwieldy as Health.

System Signaling is Critical

The mandate letters contain a long preamble before specific priority initiatives are addressed.  The Premier is intent on setting a strong “tone from the top” and she makes it clear that the overall priority is to “grow the economy and create jobs”.  She also reinforces the message that all decisions will be made through a “lens of fiscal prudence” with a view to meeting her government’s balanced budget target.  Addressing health specifically, she emphasizes the need to “shift toward a sustainable, accountable system”.

Of special interest is the impact the letters may have on the literally thousands of organizations and hundreds of thousands of healthcare providers who are part of the Ontario healthcare system.  Ontario has taken “the road less travelled” and has the most decentralized healthcare system in the country, a subject the author has explored elsewhere (see: Ronson 2006 and Ronson 2007).  Ontario has eschewed Regional Health Authorities and opted for fourteen Local Health Integration Networks (LHINs) and has left thousands of independent healthcare delivery organizations in place, each with its own board, executive team and staff.  Aligning the system around particular public policy goals in this context is fiendishly difficult.  The mandate letters provide a form of system “signaling” that could prove significant over time.

It appears that the new Ontario government will not be making major changes to the structures that oversee how healthcare is planned and delivered in the Province.  LHINs will remain in place and hospital and community care organizations will continue to be independently governed and operated.  This makes it even more critical that the government use all of the influencing tools at its disposal to foster system improvement.

ECFAA Experience is Instructive

The Ministry’s experience with the Excellent Care for All Act (ECFAA) is instructive.  Enacted in 2010, the Act contains a long preamble that emphasizes the need for improved system quality and transparency.  It goes on to mandate the creation of quality committees and quality improvement plans for Ontario healthcare organizations with oversight from the LHINs and the Ontario Health Quality Council created by ECFAA.  It also introduced the concept of mandatory performance-based executive compensation.   At the time, I openly disparaged the new Act and declared that it would have little or no system impact.  And I was wrong.  In hindsight, ECFAA was and is an excellent example of healthcare system signaling – saying to the myriad of system players – this is important!  Pay attention!  And the system did – the Act changed the conversation about quality (and in some cases started the conversation) and it has clearly made a difference.

Publicly disclosed mandate letters have the potential to achieve an even greater impact than ECFAA.  Much depends on how they are used and if they become part of the culture of healthcare, in other words, part of how the system does its business.  Let’s look at the prospects for success.

A Mixed Bag of Priority Initiatives

The Premier’s letter to Minister Hoskins contains 27 specific “priority initiatives”.   Minister Damerla’s letter contains 12 initiatives.  They are a mixed bag and may send mixed signals to both Ministry staff and to Ontario’s healthcare providers.  The length of the list suggests that there was jockeying for inclusion on the list by particular parts of the Ministry.  Continuing to pursue capital investments and air ambulance oversight might fall into this category.  Other priorities are more populist but also reasonably easily accomplished, such as addressing hospital parking rates and appointing a patient ombudsman.  However, addressing these quickly will still leave a long list to be tackled that includes improvements in care quality, access to care, end-of-life care and broadest of all “healthy living”.  These broad and complex “priority initiatives” need to be quickly broken down into manageable pieces with specific actions identified, clear accountabilities, measures and targets set and careful thought given to sequencing.

It is hard to argue with any of them individually, but collectively they will need to be staged over the four years of the government’s new mandate.  Launching them all at once would overwhelm both the Ministry and a system that is already burdened with existing projects.  The government is quite brave in making its commitments public.  Perhaps they should be even braver in issuing an annual scorecard of progress against these priorities.  Priorities can also change.  A periodic re-issuance or updating of the mandate letters would make sense.

Learn Lessons from Cancer Care Ontario

The experience of Cancer Care Ontario (CCO) over the past decade is also instructive (and it is one the current Deputy Minister Bob Bell knows well from previous roles).  CCO set the audacious goal of “creating the best cancer system in the world”.  Concerted work over the past decade has moved Ontario significantly towards that goal, with an international comparison placing Canada among the top performers when cancer survival is measured (Coleman 2011).  CCO has adopted, through a Regional Program structure, a combination of provincially mandated initiatives married with local flexibility on implementation.  Rigorous, evidence-based measures and public reporting have driven performance improvement and inspired a healthy competition between regions to be top performers.  A similar dynamic could and should be fostered with Ontario’s Local Health Integration Networks, where there is considerable variability in pursuing provincially mandated initiatives such as Health Links.

Ontario is a big healthcare spender, but a middling performer when assessed against other developed countries (see the various Commonwealth Funds surveys at:  Indeed, on some measures such as speed of access to specialist referrals its performance is terrible (improving this performance is one of the Premier’s 27 identified priorities).  Getting organized quickly around the priorities identified in the mandate letters is critical.  Ontarians deserve better for what we are collectively investing in our healthcare system and the Premier is publicly signaling that we should expect it.

About the Author(s)

John leads the strategy, policy and evaluation practice for TELUS Health.  He can be reached at


Coleman, M.P. et al. “Cancer Survival in Australia, Canada, Denmark, Norway, Sweden and the UK, 1995-2007 (the International Cancer Benchmarking Partnership):  an analysis of population-based cancer registry data” The Lancet 377 (9760): 127-138, January 8, 2011. 

Ronson, J.  2006. Local Health Integration Networks:  Will ‘Made in Ontario’ Work? Healthcare Quarterly 9 (1): 46-49.

Ronson, J. 2007. Integrated Health Service Plans:  From Planning to Action Healthcare Quarterly 10 (3): 89-90. 


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