Doris Grinspun, the executive director of the Registered Nurses Association of Ontario (RNAO) has been a tireless defender of public not-for-profit health care. We’ve seen her speak truth to power at numerous conferences and public events. When she advocates on behalf of the RNAO, she speaks plainly and passionately.
Last month the RNAO released its submission to the government on Ontario’s seniors care strategy.
The document is full of good recommendations, from strong staffing standards in long-term care homes to a broadening of the policy lens to include government’s impact on the social determinants of health.
The biggest surprise, coming out during the same month as the Hudak health care platform, is the RNAO’s recommendation that the Community Care Access Centres be scrapped and the work be redistributed to the Local Health Integration Networks and to primary care providers, such as family health teams, community health centres and nurse practitioner-led clinics.
Unlike the Tory platform, which cuts both the CCACs and the LHINs loose and hands over local decision-making to large unaccountable “hub” hospitals, the RNAO splits the role of the CCAC into two. The planning, contracting and monitoring of home care migrates to the LHINs, the system navigation and assessment becomes the work of primary care providers.
The RNAO argues that it cuts out duplication and better integrates the system, yet having the navigation function carried out by hundreds of primary care providers rather than 14 CCACs suggests less overall system coordination. It also raises questions about primary care providers that are not in team practice.
Persistently long waits would also make it interesting as hundreds of primary care providers try to advocate for their patients in a newly crowded placement field.
While the RNAO says there will be substantial cost savings – the CCACs account for about $2 billion of the province’s $47 billion health care budget – there is no real costing on how this would work, especially when the RNAO sees the 3,000 CCAC case managers migrating to primary care, a continuation of contract-based home care delivery, and an unspoken enhancement of LHIN resources to accommodate new functions.
A few years ago the LHINs were miffed to be asked to provide oversight on capital projects with no new resources. Clearly they couldn’t take this additional role on without a substantial boost in their funding.
The CCACs at one time pitched themselves as system navigators, yet their role was never expanded beyond home care and long-term care. When the government gave the LHINs – not the CCACs – the reins of the aging at home strategy, there was clearly an opportunity lost to stake out a significant role within community care.
It’s not like the LHINs did a stellar job with this money, and the issue was further clouded when then Health Minister David Caplan suddenly required half this money be applied to dealing with the newly manufactured alternative level of care problem.
The end of competitive bidding does present an opportunity – to migrate front line care staff directly to the CCAC. Not only would it reduce the cost of administering dozens of home care contracts, many with private for-profit agencies, but it would make the CCACs much more nimble in addressing community need.
When The Ottawa Hospital briefly took over the Champlain CCAC after a series of scandals, staff reported to us that the new administrator was frustrated by the fact that he simply couldn’t go out and hire the wound care nurses the CCAC needed. By breaking the ban on new direct care staff at the CCAC, the situation could be very different.
The flaw in the RNAO plan is there is no place to build direct public not-for-profit front line care. Nor does RNAO address the existing CCAC direct health providers – most who would be therapists – who never got contracted out either because of high cost or lack of credible bidders in the local community.
RNAO complains that the CCACs have high administrative costs, especially when compared to the LHINs. This is a bit unfair. Competitive bidding and contract management itself created significant administrative burdens on the CCACs – an issue we have repeatedly pointed to. A system that migrated to more direct publicly provided care would reduce such burden and increase continuity of care (see our story on the two physiotherapists).
The RNAO says the LHINs have low administrative costs relative to their budgets, but this is largely because most of the money in that budget is simply flow-through from the province to large providers, such as community hospitals. This does not mean that the hospitals and other funding recipients don’t have their own layer of administration – much of it essential in this new world of metric-driven health care. It’s true that the LHINs have been encouraged to be more proactive in redistributing funding, but it’s hard to believe that after adopting a new hospital funding formula the province would sit by and watch the LHINs redistribute this money based on alternate criteria.
The RNAO also risks adding fuel to the fire over the Tory proposals, which are far more political than pragmatic. The Tories play on the public’s lack of knowledge of the work done by the LHINs and the CCACs.
The end of competitive bidding provides a new opportunity to look again at opportunities in home care. Rather than simply mess about with market share among existing providers, it would be good for progressive groups to look at publicly provided care models, including those that already exist in other provinces. To do that, it may be a bit premature to throw out the CCACs.
As a postcript to this, the RNAO have asked us to wait and see their full proposal on this issue before coming to any final conclusions. The report is due out soon. We look forward to it.
I like the idea of the District case managers working in primary care settings with birth to grave coordination of care. Why can’t it be flipped. End LHINs, go back to District Health Councils, keep the CCAC as the body that monitors and identifies needs who are the professionals and understand the needs. First we have to end the walk-ins expand the CHC’s NP clinics, overhall the FHTs to that they are more like the with salaried physicians as members of the team or have them switch to the CHC model of care. And give a deadline for physicians to join these primary care models where teams of professionals are used as appropriate and not in isolation
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