The new Ontario Tory plan for health care is simple – eliminate the Local Health Integration Networks and the Community Care Access Centres and let between 30-40 “hub” hospitals run the health care system – or at least the bits not run by the municipalities or the doctors.
The new PC Caucus white paper, Paths To Prosperity: Patient-centered Health Care, is thin on specifics and long on rhetoric – much of it borrowed surprisingly from the McGuinty government. Aside from attacks on the LHINs and the CCACs, the broader strokes are not that different from the government’s own plan, including the Triple Aim we continually hear so much about. The “Triple Aim” sets goals to enhance patient quality and satisfaction, improve population health and reduce costs. Who could be against that?
While dumping the LHINs and the CCACs, the Tories would create physician-led “Primary Care Committees” which would link to the hospital hubs. The role of these committees is not clear beyond giving physicians more of a say in how the health system runs and somehow charging them with scrutinizing their own performance. How nice.
While this plan appears to centralize decision-making functions to the hospitals, the Tories counter that this represents a “decentralized and delayered” system. At the same time they sing from the George-Smitherman-Career-Memorial integration songbook. Decentralize and integrate? Confused? We all should be.
This is not the first time we have heard this scenario – putting hospitals in charge was one of the options that Don Drummond looked at in his austerity report, and rejected in favour of a more robust LHIN closer in make-up to a regional health authority.
No doubt Drummond saw the obvious contradiction of placing hospitals in charge of the health system at a time when all political parties are pushing for greater community-based care.
The Tories actually believe that hospitals will divest their own services if they are put in charge. Others believe that someday pigs will fly.
Instead of providing base budgets, hospitals would have to compete for patients to get funding. These patients, in theory, would be a source of revenue, not a drain on funding as the paper states. With an unlimited cap? You can see the TV ads now with such a bonanza laid out before them. While the province has already begun more procedure-based funding to hospitals, the Tories want it accelerated despite the province simultaneously turning away from fee-for-service in primary care. It’s enough to make your head spin.
Given the Tories purportedly want to do this to save money, we’re not sure how that would take place given the functions of both the 14 LHINs and the 14 CCACs would have to transfer to the 30-40 hospitals. That’s work that needs a lot of warm bodies, including home care case managers by the hundreds. By giving a financial incentive to do more procedures, it is not likely that hospitals will do less, even where warranted. That means more spending, not less.
If cutting the LHINs and the CCACs weren’t enough, the Tories would further cut an already depleted Ministry of Health, leaving questions as to who would be left minding the shop. The Tories claim that the buck should stop with the Minister of Health, but we are talking about a $47 billion health system, not a Burger King franchise. The LHINs do work to keep the hospitals accountable, and some say they could do much more in this regard. If the hospitals are in charge, and the Ministry is depleted, who carries out that function, especially if the hospital mandate is vastly expanded?
While the Tories migrate to their new plan, they can’t quite leave the old one behind. They pick up on the high administrative costs of the CCACs in the report – but fail to acknowledge that much of this surrounds the process of contract management for hundreds of private sector home care agencies. This is a situation the Tories created through competitive bidding – something the paper criticizes the Liberals for freezing. Let’s also not forget it was the Harris government that created the newly loathed CCACs in the first place, not Dalton McGuinty.
Nowhere are the layers more pronounced than in the world of home care, where an individual nurse can be a contract provider to an agency, which in turn reports to the CCAC, which in turn reports to the LHIN, which in turn has its own accountability agreement with the Ministry of Health. The first two layers on that chain could be eliminated by simply making home care a publicly-delivered service. Somehow I don’t think the Tories would want to go there despite their opposition to layers.
While the paper correctly criticizes the political appointments to the LHIN boards, hospitals themselves are becoming insular, preferring self-appointing boards to membership-driven assemblies to approve or reject hospital nominees. Where does community input, let alone control fit in this scenario?
The idea of using hospitals as hubs is not an entirely bad one, but giving them so much power without accountability is not likely to work. There are dozens of examples of hospitals that do a good job of running community based services. These services range from mental health teams that do home visits to clinics for new mothers. Perhaps there is a need to take a broader evidence-based look at all services keeping in mind there are services that might actually return to hospitals. The costs of many hospital services are lower than those offered by private sector clinics. Just try to get a private MRI for what a hospital gets paid.
It’s easy to point the finger at bureaucracy, but all of us realize it takes people to manage any kind of system. The biggest rise in bureaucracy is likely linked to idea of evidence-based decision-making. The question is, is the evidence of sufficient quality that the costs of collecting it are offset by the benefits of a better-run system? The jury is still out on that one. And without evidence, where is the accountability that the Tories continually call for?
Some of the observations in the paper are correct – our system is costly and we could get more bang for our buck in terms of scope of services. In response Drummond himself recommends expanding the scope of Medicare, not shrinking it as the McGuinty government has. Canada has also had amongst the slowest level of growth in health care costs of any OECD country, so let’s bring a little balance and less hysteria to the discussion.
There is no doubt the Tories want to cut health care spending. It is a bit much for the Tories to say in the paper they want to stem 6 per cent increases when the McGuinty government has already implemented restraint of 2.1 per cent averaged over the next three years. It also makes us wonder when this paper was written.
The Tories promise more white papers on health care. We can hardly wait.