Board members of the Local Health Integration Networks (LHINs) serve at the pleasure of the government of the day. They are appointed by Order in Council, and have a reporting relationship directly to the Minister of Health.
There isn’t much direct criticism from the LHINs of government health care policies, including organization of the LHINs.
Last week the Change Foundation issued a new report on integrated health care — Winning Conditions to improve patient experiences: integrated health care in Ontario. What’s significant is the Change Foundation report was reviewed by key players within the system, including Bill MacLeod, CEO of the Mississauga Halton LHIN.
While the Change Foundation suggests the final report wasn’t necessarily endorsed by the reviewers, this is an organization that has some high level participation from key stakeholders, including former deputy minister Ron Sapsford, who sits on the Foundation board alongside departing Ontario Hospital Association CEO Tom Closson.
The Change Foundation suggests that the LHINs function differently in reality than on paper, calling their “authority” a debatable point, the conditions on which they’ve had to operate “have been hardly winning.”
“There is a disjunction between formal and de facto authority in Ontario’s devolved model,” the report states. “The Ministry/government appears to have low tolerance for discontent and conflict regarding proposals for substantive change.”
The Change Foundation argues that from the outset the LHINs have been restricted in their capacity to operate compared to their counterparts in other provinces, implying the LHINs should be given more power to make real funding decisions.
“LHINs are planning bodies and are technically the ‘funders’ for healthcare providers,” the report states. “But in reality they serve as a route through which the Ministry flows pre-determined funds.” Some LHIN CEOs say LHIN discretionary funding is “trivially low,” about one per cent, a situation the Change Foundation would like to change.
“Clearly, LHINs are not yet true commissioners of health services. LHINs don’t choose between providers. Much of the clout they may seem to have is compromised, especially when the going gets tough, by government’s unwillingness to devolve real decision-making power.”
The report acknowledges the LHINs don’t have the resources they need to monitor or measure performance in real-time, or to explore any measures or indicators beyond those included in the accountability agreements.
The report calls for a strategy to integrate primary care with the rest of the health system. At present only Community Health Centres (CHCs) are in the LHIN structure, most other primary care providers are outside. The report gives the example of a Peterborough Family Health Team that couldn’t access LHIN funding to develop an integrated delivery model for at-risk vascular patients because there was no direct accounting relationship between the two organizations.
Calling primary care providers (aside from CHCs) “largely publicly unaccountable for service standards,” there is no question there is a strong desire for a regional model that includes primary care.
The Change Foundation also suggests Ontario should move further from the fee-for-service model for doctors to a more blended payment model, including the possibility of “bonuses” for doctors who achieve system goals.
Such recommendations would be part of a “Payment and Funding Commission” to improve funding models across the health system.
The report also dances around the idea of leaving local provider boards in the place, calling for “collaborative planning between regional bodies and health care provider organizations.” At the same time, they say that “leaving local boards in place has created a governance and management challenge for system-level change.”
That includes difficulties in achieving consensus between the LHINs and local health care provider boards.
“Change can get stalled and promising initiatives remain unrealized if consensus proves difficult or impossible to achieve,” they state. While the report doesn’t come out and recommend it, the implication for the future of local boards — including hospital boards — is not good.
The report suggests that “consolidation” of community agencies could be offset by new mechanisms to engage the public, but doesn’t say what those mechanisms could be.
This could be a Achilles heel in any plan to beef up the LHINs. It is unlikely any health minister is going to support a bad decision that roils a local community no matter how determined the local LHIN is to implement it.
One could argue that had the LHINs taken their obligation to consult local communities more seriously, many of these problems could have been averted. We’ve seen for ourselves how local providers submit integration proposals that indicate when, where and who they consulted, but nothing of what was said to inform the board of public sentiment towards the integration proposal.
The Change Foundation calls the current structure involving 14 LHINs and 2,700 accountability agreements as “unwieldy,” a suggestion that both the agreements and the number of LHINs may soon change. This is consistent with what we have been hearing for several years now.
The report states a 2008 LHIN effectiveness review by KPMG suggested a framework was lacking to clearly identify who has decision-making authority over processes and functions. Of course, with the 2006 legislation, ultimate authority always comes back to the Minister of Health.
“Whether LHINs acquire more authority to plan and commission programs/services and allocate resources, or are replaced by another governance arrangement, the need for clarity and communication about respective authorities and accountabilities of regional bodies and the Ministry is paramount.”
Not acknowledging the fact that hospitals are already overcrowded as a result of rosy and unrealistic projections of what community-based health care could take on, the Change Foundation believes it is still possible to further decrease hospital beds per capita by 50 per cent over the next 20 years. They provide absolutely no supporting data for this.
It would have been instructive for the Change Foundation to state what issues the Ministry felt they had a “low tolerance for discontent.” While they may consider this to be political interference, Ontarians expect to have some say in how the health system they fund and rely upon is actually run. Until the accountability runs back into the communities that are served by these structures, it is unlikely any politician is going to accept a more powerful model of regional governance.