LHINs — Opening up the “integration” process

The Local Health Integration Networks (LHINs) were supposed to bring health service decision-making much closer to the communities.

At the core of that decision-making is the integration process. As we stated last week, “integration” can mean a variety of things. The Act that created the LHINs defines “integration” as

(a) to co-ordinate services and interactions between different persons and entities,

(b) to partner with another person or entity in providing services or in operating,

(c) to transfer, merge or amalgamate services, operations, persons or entities,

(d) to start or cease providing services,

(e) to cease to operate or to dissolve or wind up the operations of a person or entity.

In theory the LHIN integration process is to include the posting of integration proposals and the public is to be given 30 days to respond to that proposal before a decision can be made. In reality, it is far more confusing, inconsistent and complex than that.

Despite the clear definition, many of these “integrations” take place without ever being considered “integration decisions” for the purposes of public disclosure and response.

Last year the CEO of The Ottawa Hospital announced that his corporation was going to perform 4,000 fewer endoscopies, telling the media low risk patients could safely access this service at one of many private endoscopy clinics in the community (the majority, incidentally, run on a for-profit basis). That’s a big change for an entire class of health care user, yet there was virtually no opportunity for input even after the proposal became public.

One might argue that this would normally constitute an integration decision as it involves the wind up of a service, even if the general inferred concept is one of service transfer. An integration decision only requires one of the two parties to be a health provider under the jurisdiction of the LHIN, however, the LHIN cannot make any decisions regarding specific transfers to entities it cannot also fund. It can make a decision around a proposal that involves a situation where the hospital will cease providing services, which does apply in this situation.

Instead the Champlain LHIN argued no integration decision was required given the hospital was merely carrying out its obligations under its accountability agreement with the LHIN. That means for the public, we have no idea where these services are really going or whether the transfers make any sense. For the professionals who perform these endoscopies at the hospital, it also denies them the reasonable opportunity to transfer with the work and preserve their employment rights. The clinics the hospital CEO calculated could handle his volumes are also known for implementing additional user fees – fees that had the clinics been under the LHIN jurisdiction would have been prohibited them from receiving the transfer.

In many cases where a service just ceases to be, we have observed that there is seldom any “integration” process at all. Given hospitals have a legal obligation to balance their budgets, too often there is a lack of community input on the shedding of services to achieve that aim. What are often described as “efficiencies” are really just the wholesale cutting of patient services. These may be efficiencies for the hospital, but not the public. Such cuts in turn usually create pressures elsewhere in the system that don’t necessarily save money.

If the Champlain LHIN’s logic applied, then any hospital cutting or transferring services to balance their budgets would be exempt from public disclosure or input. That represents about two-thirds of the LHINs’ funding envelope.

It’s not like the integration process is onerous. Nor does it give the public a lot of information to work from. Under the Act an integration proposal must describe the nature and purpose of the integration, list the parties involved, the actions they must take, and set out the relevant dates. There is a requirement that the two parties develop a human resources transition plan, but there is no requirement to disclose the details of that plan. Given how many of these decisions are driven by financial imperatives, remarkably there is no requirement to publicly disclose cost comparisons or other opportunity costs. Nor is there any impact analysis on what it means for other health care providers in the community or patient access.

Given there is a requirement for health service providers themselves to conduct community engagement around service changes, you would think the LHINs would take great interest in any reporting on the content of that consultation. We were present at one integration decision at the South West LHIN where details of the consultation were meticulously given – the who, where and when – but surprisingly not the “what.” Every single community respondent could have been opposed to the idea and had very good reasons to support their viewpoint, but the LHIN board would have been kept in the dark at the point of decision.

The other big limitation is that any transfer of services between sites of the same health care provider cannot be treated as an “integration” under the Act. As health care providers continue to merge and create larger more regional entities, this will mean even less input into decision-making for communities. The public hospital in Bancroft is about an hour and a half drive to the hospital in Belleville, yet both are part of the same Quinte hospital corporation. Any swapping of services between them would be significant to their communities. When the Rouge Valley Health System decided to move mental health services from Ajax to Scarborough in 2008, it was done largely behind closed doors. The community was angered that only a mere handful of days existed between the hospital making its proposal public and the LHIN rubber stamping it as part of the hospital’s improvement plan.

Here are some initial ideas for change:

1. The decision to implement an integration process should be simplified and made more universal. If proposed changes are going to impact access, volumes and quality of care, members of the community should have reasonable and timely access to information around the proposal and an opportunity to submit a response.  That not only includes transfers between health care providers, but also transfers between sites of an existing provider or reduction in service from a single provider.

2. In the event a provider should decide to cease providing a service, the LHIN should have the ability to order that provider to maintain services until such time alternative delivery can be reasonably arranged and an integration decision made unless exceptional circumstances apply – for example: bankruptcy, fraud, fire, or patient abuse.

3. Public disclosure should be enhanced around an integration proposal to include financial analysis, existing and proposed service volumes and an impact analysis on other health care providers in the community and patient access.

4. Integration proposals should be presented in a manner that can be clearly understood by the public and easily accessible on the LHIN website.

5. The length of time to respond to an integration proposal should be extended to 60 days to give reasonable time for the word to get out and for organizations to consult internally and draft a response.

6. Any LHIN board meeting making a final integration decision should set aside time for public deputations related to that integration. Any report describing community engagement conducted by the provider(s) should include a reasonable summary of what was heard as well as attach written submissions as part of the appendices.

So what do you think? Leave your comments behind. We’ll continue on this week looking at other specifics that could salvage the LHINs and bring them closer to their original vision.

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