Essays

Essays March 2019

The Unintended Effects of Reorganizing Health Authorities on Patient Engagement

Umair Majid

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Regionalization is a way to decentralize health service authority and decision-making and has been utilized by provinces across Canada. Some of the reasons to regionalize include increasing diversity and experimentation in care delivery, encouraging learning and competition between organizations, bridging the gap between decision-makers and services users, and engaging users in planning, delivery, and quality improvement decisions.

After important motions to restructure health service delivery through regionalization, provinces have taken steps to de-regionalize by removing, reducing, or reorganizing the number of health authorities. There appears to be a back and forth between regionalization and de-regionalization, which may reflect evolving values, beliefs, and preferences surrounding how health services should be designed and delivered. Therefore, the news of Ontario’s provincial government to dissolve the 14 Local Health Integration Networks (LHINs) into one agency (“Ontario Health”) and 30-50 “Ontario Health Teams” comes as no surprise.

Dissolving LHINs will likely have many effects on decision-making and service delivery, some of which may be perceived as advantageous from the viewpoint of certain groups. Although I do not want to discuss the political issues apparent, I will discuss the “unintended” side effects of this decision on patient engagement in Ontario.

I believe that Ontario has progressed considerably in the last decade to offer greater and more meaningful opportunities, mechanisms, and supports for patients' voice to be integrated into health system improvement. The proposed Bill 74 The People’s Health Care Act (2019) focuses on providing care that is centred on patients, family and caregivers. An aspect of this bill seeks to include the Ministry’s Patient and Family Advisory Committee (PFAC) as a permanent function, effectively institutionalizing PFAC at the provincial level. However, it is unclear how PFACs at other levels will be retained, most notably, LHIN PFACs. As a result, although the Ontario government may believe that reorganizing LHINs and creating Ontario Health will lead to stronger patient-centred care, unfortunately, it is more likely that the proposed changes will delimit the decision-making capacity of patients in healthcare activities.

In Ontario, LHINs are mandated under the Patient Firsts Act (2016) to have Patient and Family Advisory Committees (PFACs) that discuss on matters related to clinical care, service delivery, and quality improvement. Recently, the Ontario Ministry of Health and Long-Term Care introduced their own PFAC to ensure that patient voices are incorporated into health system discussions. Moreover, hospitals not just in Ontario but in other jurisdictions have established PFACs. In a recent survey, 59% of hospitals in the State of New York reported having a PFAC and 12% were in the process of establishing one. A survey is underway on Ontario hospitals showing similar results. These PFACs influence operations, leadership decisions, and strategies, provide training on patient engagement to healthcare professionals, advocate for patient engagement in other hospital committees, and conduct ongoing evaluations of their work.

PFACs are important mechanisms to solicit and incorporate patient preferences and experiences in healthcare activities. These committees improve transparency and accountability in health system processes. Recent research has found that members of PFACs provide insight and knowledge vital to optimizing health service delivery. PFACs have also reinforced the need to improve communication and facilitate opportunities for patient involvement in quality improvement. Therefore, it goes to show that PFACs are important mechanisms to achieve higher responsiveness of health services and improve patient experience.

In Ontario, there are three levels of PFACs. At the Ministry-level, which look at the overall system structure and function; at the level of hospitals that examine the structure and function of individual health service organizations; and at the level of LHINs which consider function and structure within regions (i.e., the collaboration, allocation, and cooperation between neighboring health service organizations). The membership of LHIN PFACs are represented from the region they are located in. These PFACs provide essential opportunities for patients and healthcare professionals from different health service organizations to discuss regional health issues such as allocation and priority-setting. This opportunity exemplifies a higher level of collaboration because it brings forward issues of intra- and inter-regional diversity in healthcare needs, preferences, and values. The voices, concerns, perspectives, and experiences of patients in each region are solicited and incorporated into the design, delivery, and decision-making of care structures within that LHIN. In this way, PFACs may support the LHIN to be more responsive to the needs and preferences of patients within a region – something that is linked to the quality, legitimacy, responsiveness, and uptake of health services.

Since their creation, LHIN PFACs have contributed to greater and more meaningful involvement of patients in an array of activities. Their removal, however, will delimit the extent to which patients can contribute to or catalyze organizational-level change. The reorganization of LHINS will widen the gap between decision-making and service users, which must be compensated through other structural changes. The Ministry PFAC may not be able to adequately represent the diversity that exists within regions of Ontario and appropriately address organizational and regional issues. Certain discussions can and should be facilitated from the perspective of the Ministry PFAC, but care processes, structures, service delivery mechanisms, and regional allocation imperatives at individual health service organizations are more appropriate for regional PFACs.

Decisions pertinent to individuals and the relationships between health service organizations should be made by individuals who have experienced the relevant contexts. LHIN PFACs not only examine issues within individual health service organizations, but also the cooperation between several hospitals in a particular area. In essence, LHIN PFACs contribute to a more socialist system that prioritizes collective efficiency rather than competition between individual organizations, a characteristic that distinguishes healthcare systems in North America.

 
Removing LHIN PFACs may inadvertently ignore the degree of responsiveness in health services achieved by structuring healthcare activities within regions. The relationship between patient voices at the level of organizations (i.e., hospital PFACs) and how they can transform overall system structure and functioning (i.e., Ministry PFAC) will likely become more complicated without the LHIN PFACs as the link between these two levels of patient engagement. Without these PFACs, the ability of decision-makers to recognize the needs and preferences of patients, family, and care representatives may become limited.

In the era of patient engagement and patient-centred care, we need more strategies and initiatives that improve (and not oppose) our ability to provide responsive, sustainable, and appropriate healthcare. The “unintended” outcomes highlighted in this essay are symptoms of broader effects of the proposed changes to the province’s health system. This essay encourages health system stakeholders to consider how the system structure and function may influence the responsiveness of care by devolving or delimiting the power of patients in planning, delivery, and improvement of the healthcare system. Bill 74 does not explicitly mention how the functions of LHIN PFACs will be retained in the new system. Therefore, it may be prudent for decision-makers to consider how the gaps in their proposed changes may be compensated, particularly how the contributions that LHIN PFACs make to health system design will be retained in the new system of proposed integrated care. This is especially important if decision-makers seek to create a system that is “centred around people, patients, their families, and their caregivers.” However, without acknowledging the inadvertent and unanticipated limits system reorganization may place on patient engagement, I am skeptical of whether we are approaching or furthering ourselves from patient-centered care.

About the Author

Umair Majid, MSc, MEd, PhD (student), Institute of Health Policy, Management, and Evaluation, University of Toronto, Division of Clinical Decision-Making and Healthcare, University Health Network

Umair Majid completed his MSc in health research methodology at McMaster University where he investigated the quality appraisal process of qualitative research. Also at McMaster, he holds appointments as a Curriculum Designer, Program Developer, and Instructor where he is teaching and designing courses on epidemiology, the Canadian healthcare system, and pathophysiology. As a research consultant, Umair has diverse experiences, knowledge and expertise in qualitative, quantitative, and mixed-methods research, which he uses to provide qualitative evidence to agencies investigating technologies to include under the provincial or national funding mandate. Umair also has a MEd from Queen's University where he examined innovative, effective ways to design and evaluate curricula. Currently, Umair is a PhD student in Health Services Organization and Management Studies at the Institute of Health Policy, Management, and Evaluation at University of Toronto. For his dissertation, Umair is investigating how to improve the mechanisms of patient engagement in hospital planning and designing activities.

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