Renovate or start over — which way forward for the LHINs?

“The LHINs tell me time after time that they do not have the autonomy you say they do. They do as you tell them to do.” – Liberal MPP Donna Cansfield to departing Deputy Health Minister Saad Rafi, November 18, 2013

The health system is under a lot of stress at present as the Wynne government exceeds the level of restraint that even the Auditor General had previously described as “aggressive.”

With a long overdue review of the Local Health Integration Networks there is bound to be a lot of finger-pointing over who is responsible and how much culpability falls at the feet of these crown agencies.

The Ontario PCs want to start all over again with an unproven hospital-based model. The NDP would replace the LHINs with another undefined regional entity. None of the three parties seems particularly happy with the outcome after seven years. Even the Liberal MPPs, as the Donna Cansfield quote at the top of this post indicates, are far from pleased.

When former Health Minister George Smitherman sold the province on the LHIN concept in 2006, he may have set the bar far too high for them to ever succeed.

Decisions were supposed to be informed by local needs and priorities, and as the Ombudsman reminded us in his “LHIN Spin” report, and “made in
and by the community for the community.”

Yet when the Standing Committee on Social Policy met in November, the deputy minister of health made it clear that the point of community engagement was only to seek advice. That’s a far cry from the democratic language that had been part of the initial sell.

It was clear to us all along that the legislation and the rhetoric never aligned.

Ontario was the last province to move to a regionalized health system. As the LHINs got going other provinces started to roll up their regional health authorities and return to more centralized systems of planning and administration. Alberta is now into its fourth reorganization and health care providers are beginning to wonder who is even in charge there anymore?

At the time we pointed out that while Ontario was the last to embark on a regional model, there was no evidence to suggest that regionalization was in any way more effective than a central command and control structure.

If the other provinces had to jump into the lake, so did we. Rafi uses the same rational for excluding primary care providers from the LHIN umbrella. While physicians have long been regarded as the “gatekeepers” of the system, they mostly remain outside of the LHIN structure for no particular reason other than this is what other provinces do.

OPSEU was among the first to anticipate the dangers of this new structure. In 2006 we warned that services would be delivered from fewer locations requiring Ontarians to travel further for care. We worried that the LHINs would facilitate more purchaser/provider splits that characterized the difficulties we were experiencing at the time with home care. We calculated there would be downward pressure on wages and benefits for front line professionals and support staff. We flagged that there was no minimum level of public engagement and worried that the real decision-makers would distance themselves from unpopular choices. In varying levels of degree all of these warnings came true – the latest the government’s invitation to the independent health facilities to start bidding on hospital services.

The initial Standing Committee hearing with the deputy minister in November was striking for two reasons. The first was the lack of any defining evidence to prove that the LHINs have been effective or have produced good value for the combined $90 million a year they cost to administrate. The second is the lack of any hint by the Ministry that they had any reasonable ideas on how to make the LHINs work better.

Was Rafi having a bad day, or is the Ministry really that ambivalent?

To be fair, that initial session with the Standing Committee was a technical briefing and not a consult. However, Rafi did say he was there to provide advice – something that appeared to be in short supply.

There is a strong impulse to simply do away with the LHINs, but as we stated yesterday, you’d have to replace them with something.

The question is, is there enough of a frame to build that something else on, or are we going to scatter all the work – both good and bad – to the four winds?

In 2010 a lot of people took note when Matt Anderson, the CEO of the Toronto Central LHIN, stepped down to become the CEO of William Osler Health System. At the time Anderson told a Longwood’s audience that the amount of discretionary funding the LHINs had was in fact very small – about $10-$12 million out of a $4.2 billion budget.

That’s not very much.

By implication, Anderson’s estimate suggests that as funders, the LHINs could at best only tinker around the edges of the system.

Many of the problems that existed before the LHINs still are with us today. Health care providers, such as the CCACs, still run out of money long before the end of the fiscal year. Hospitals are still seeking bail outs – and the province has in fact set up a fund to assist them to get out of debt contingent on, of course, balanced budgets. Many Ontarians still cannot find a doctor – we recently called the North Durham Family Health Team to be told the wait list to get a doctor is presently eight months. North Durham is one of 30 new FHTs in the province.

Not everything the LHINs have done has been bad. Health care providers are talking to each other now – an issue that goes all the way back to the 1960s Hall Commission Report. The Health Links show promise in addressing high-needs patients who are often shuffled around the system at terrible expense. A myriad of local programs have been established to try to fill in some of the gaps in the system. There is some semblance of planning, even if at times it appears exasperatingly inadequate. More hospitals are balancing their budgets — albeit too often at the expense of needed clinics and programs.

After seven years no magic bullet has been discovered that will make health care more affordable or dramatically improve quality or access. But did we really expect that would happen? Likely the solutions will be gradual, many and take considerable time. It is likely we will never achieve a state where everyone will be happy.

Smitherman was smart to mandate a review right into the text of the legislation, even if the McGuinty government ignored the five-year timeline.

There are a lot of people unhappy with the LHINs right now. That’s the straw man we feared would be held accountable instead of the real decision makers at Queen’s Park.

The NDPs Gelinas asked if she could applaud as the Liberal’s Cansfield finished that first hearing with what amounted to a rant on the present dysfunction.

“What’s fact or what’s fiction, I don’t know; I can’t seem to separate it out,” Cansfield said.

There is a lot of frustration out there that needs to be acknowledged.

In 2006 it cost $20 million to dismantle the District Health Councils and start again. The cost to dismantly the LHINs would likely be much higher. We respect and understand those who think there should be another do-over, but fear that this a roller coaster than we may never get off in search of a workable system. We too could end up like Alberta.

We’ve met a lot of bright policy people who are trying to make the LHINs work. We sense their frustration too that the province has put them in a policy straight-jacket. Last year the LHINs took a five per cent haircut in their own funding while the challenges continue to escalate.

The LHINs could be made more democratic, more accountable, more transparent, more innovative and more responsive. (On Monday we asked five LHINs about their policy around posting and making available board documents — we’ve only heard back from one.) We liked the rhetoric, if not the substance, back in 2006. Why not try to fashion a system that really is for and by the community? The question is, what would that look like? Can that be done while maintaining a consistent province-wide health system? Is there a regional body that we would trust with that level of autonomy?

Our ongoing dialogue on the LHINs continues tomorrow.

—

Committee Road Dates: Fort Erie(January 27), Hamilton (January 28), Kitchener-Waterloo (January 29)Windsor (January 30), Sudbury (February 4), Thunder Bay (February 5),Champlain (near Ottawa)(February 10) and Kingston (February 11). Toronto dates may be added later. All dates are subject to change.

If you would like to present at one of the committee hearings, please contact Valerie Quioc Lim at valerie_quioc@ontla.ola.org or call 416-325-7352. Deadline to request an oral presentation at these road hearings in this Friday — January 10 at 4 pm.

Expand the discussion – if you liked this post, please share it with others (Facebook, Twitter, etc) using the button below.