Should the LHINs really be the e-Harmony of health care providers?

When the province decided to call its most recent crown agencies Local Health Integration Networks, it was clear where the emphasis lay.

Rather than plan a system based on need, it appears the primary function of the LHIN was to ‘integrate’ health services.

Integration can be broadly interpreted – it doesn’t necessarily mean mergers of health providers, although it can be. It can also mean greater cooperation and collaboration between providers, or transfers or even swaps of services from one entity to another. Under the Act’s definition, integration can also be the winding up or closure of a service – something most of us would not see under the normal dictionary interpretation of ‘integration.’ The extension of that illogical concept is that by blowing up the entire health system you’d have full integration.

It seems the province was short a philosopher when they needed one.

The province maintains that about 250 integrations have taken place since the LHINs came into effect in 2006 – most being of more recent vintage. That surprises us given much of the system seems to be still dipping a toe into the integration pool.

Some integrations happen by default. Sometimes a small agency just decides it can’t continue any more and the LHIN is left scrambling to transfer the work to another health provider. Perram House hospice, for example, gave the Toronto Central LHIN just a couple of weeks notice to say they were calling it quits.

Just because a service transfers from point A to point B, doesn’t mean that the system as a whole becomes any more fluid or patient-centered. Sometimes it makes it worse.

Sometimes we are told that services are not closing, but instead transferring to the community at some later date. Usually that’s when our BS detector starts ringing. Should it not be a rule of integration that we at least get told where these services are going, and when we can expect them to arrive? People should know that stuff because maybe they are relying upon those services.

Some of us may remember the mantra of mental health – every door is the right door. So why doesn’t the same mantra apply to the entire health system? Many patients have discovered there are in fact wrong doors. If you have a mental illness, you’ve probably already discovered a lot of them.

This week we contacted one of the new family health teams about getting rostered. We thought it would be simple. Turned out to be a wrong door. We were told instead to register with Health Care Connect and then call back. Health Care Connect is supposed to help Ontarians without a family health provider (doctors or nurse practitioners) to find one. That means you can’t decide that team based care is for you – you have to first be without a doc. We registered with Health Care Connect earlier this week and they haven’t yet connected. We’ll let you know when they do. In fact, if anybody wants to start a pool on whether we hear back first from the four LHINs we queried earlier this week or Health Care Connect, we’d be happy to post the results.

A number of years ago the Community Care Access Centres were practically stopping strangers on the street to tell them that their role should be that of system navigator. You may have crossed the street to avoid that. Maybe you thought they were going to hit you up for change.

You almost don’t hear that ‘navigator’ word anymore, yet if anything, the system has become that much more complex for patients. If it’s becoming more “integrated,” then why is it also becoming more complex?

At one point we thought our family docs were the navigators, that is until we found out that they also owned shares in private diagnostic companies and started to wonder whether we were being referred for our benefit or theirs? Even the radiologists began to openly question all the unnecessary diagnostics.

You have to pretty much be capable of  do-it-yourself triage before deciding whether to proceed to an urgent care centre or the hospital ER. Or you could call Tele-Health and wait for them to tell you to go to the nearest ER.

When we polled Ontarians, most didn’t have a clue where the nearest urgent care centre was. Those little blue H-signs will certainly direct them to the nearest hospital. Unfortunately the U’s are usually part of a ‘no u-turn sign’ and are not directing you to the alternative.

The point is we have spent a lot of time messing about with the concept of integration and yet for patients it hasn’t really changed all that much except to make us all a little more grumpy and wonder where stuff got to.

Would it not make more sense for the LHINs to have been oriented around other principles?

What if they were the Local Health Equity Networks, for example? Or how about the Local Public Health Networks? That certainly changes the direction, doesn’t it? What about the Local Health Access Networks?

While the LHINs revolve around three-year integrated health plans, which in turn revolve around the Ministry’s own action plan, these plans do not necessarily reflect health capacity planning.

If we are truly worried about sustainability, shouldn’t this be a key role for our health planners?

Instead planning has a very ad hoc feel about it. Today’s priorities may not be tomorrow’s. Just about every LHIN began their life placing a great emphasis on mental health. What happened as a result? We saw further divestment from the psychiatric hospitals and very minimal investment in community-based services. It got to the point where the police chiefs were publicly complaining they were becoming the first point of contact for individuals with mental illness and begged politicians to reinvest in mental health services. Despite this, mental health still feels almost like an afterthought.

If there is capacity planning taking place, we haven’t seen it.

Albeit capacity planning is no easy task, especially when technology and innovation and a bad economy continually throw us into a spin. With Federal Finance Minister Jim Flaherty cranking up income inequality in Canada and refusing to help citizens retire in dignity by improving the Canada Pension Plan, there will likely be a much greater need for health care than anybody is presently counting upon. Surely even Flaherty has heard of the social determinants of health? We’re definitely going to need all our fingers and toes to do this counting.

The lack of capacity planning particularly bites when you see the misalignment between service planning and capital projects. We were gobsmacked to learn that the spanking new expansion at the Ajax hospital is nowhere near big enough to handle demand, and that as a result, most Ajax residents are left seeking hospital care in the big city (and subsequently involuntarily helping flow funding away from their community). Now the Rouge Valley and Scarborough hospitals want the province to fund a feasibility study to build new capital (read: new hospitals) in both Scarborough and West Durham while the paint is barely dry in Ajax.

Integration is a strategy towards an end. It is not the mission. The broad definition of integration has only confused the issue further. The word shouldn’t be in the name, which may be a good thing given the LHINs really have become a damaged brand.

One of the discussions we’d like to see is a rethink of what the LHINs should be about. Should it really be the e-Harmony of health care providers, or should it be looking at what we really need and want as a society and figure out a way to get there?

Next week we’ll look at some specific changes to the LHINs that we think could make a difference.

It’s your last chance today to register to make an oral presentation at the Standing Committee on Social Policy Road show. See politicians in action in your own community! Here are the tour 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. Tour T-shirts are unavailable.

If you would like to present, please contact Valerie Quioc Lim by 4 pm today at or call 416-325-7352.

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