Tom Closson calls it the Goldilocks principle.
What is the point where governance within our health system is “just right?”
Writing in Healthy Debate, the former CEO of the Ontario Hospital Association points out that Ontario and Alberta are at opposite ends of the spectrum when it comes to health care governance. Ontario has many boards that make up the 14 LHINs, 14 CCACs and about 150 hospital corporations. Alberta runs everything centrally – recently the Redford government even dismissed the board of Alberta Health Services and has placed a single individual in charge. Either way, the buck should stop at the desk of the Minister of Health, although a quick survey of comments to this BLOG would indicate responsibility is thought to reside in a great number of quarters.
Closson argues the trend is towards fewer points of governance, but there is no evidence to suggest many decision points are better than one central command and control environment. Alberta, despite having a much younger population, spends much more per capita on health care than other provinces. That situation doesn’t appear to fluctuate despite the changes between regional and central governance.
Dr. Michael Rachlis often makes the case that fears about health care sustainability are unfounded given governments will always spend according available resources. Alberta appears to be proof of that.
What Closson doesn’t discuss is how these various forms of governance are constituted.
It used to be Ontario hospitals were far more democratic in their approach to board appointments. For a few dollars you could purchase a hospital membership and vote for board representation during annual general meetings. In most cases it was merely deciding whether or not to ratify board candidates put forward by the hospital, but at least there was some semblance of community control. That has been quietly eroded, and now most hospital boards are self-appointing and beyond the direct influence of their local communities.
While the province set up the Local Health Integration Networks to bring decision-making closer to the communities, it was never decision-making “by” the communities. All appointments to the LHIN boards are done so centrally through the provincial public appointments secretariat.
There is a 200-page guide the Ministry put together in 2009 with the help of KPMG that describes what good governance looks like for the LHINs.
If you ever wonder why there are so few tough questions asked during these board meetings, you might want to check out page 31 where the government thought it necessary to outline positive and negative behaviour types and traits for LHIN board members.
You’d have to agree that many of these are a matter of interpretation. For example, while the government sees it as positive that board members be “challenging,” it doesn’t like board members who are “critical.” “Objective” is good, “subjective” is bad. “Measured” is good, “intransigent” is bad. “Dedicated” is good, “micromanaging” is bad.
It is interesting that the objective mandate in the document is defined as “business and financial success” as well as to “align with public policy objectives and the core mandate put forward by the Government to meet public interest tests.” While the document does acknowledge that citizens have a legitimate role to influence organizational objectives, it is typically through “representative democracy.” That suggests influence should be through the local MPP, not through the LHIN itself. Given the rhetoric around the LHINs role in community engagement, this is revealing.
It also raises the question as to the purpose of community engagement. If public policy decisions have already been made, is the purpose of engagement to gather information, solicit buy-in to existing policies, or is it just so much window-dressing?
Some say that the LHINs would be improved if some members of the board were actually elected (either directly or indirectly, such as the appointment of municipal Mayors or Counsellors), but if the board is essentially to be compliant with the direction of the Ministry of Health and democratic participation is to be directed to the elected representatives at Queen’s Park, then the question is, what would be the point of a board at all?
Did we essentially close the regional offices of the Ministry of Health simply to recreate them in another form?
We have seen rare examples where a LHIN has bucked the Ministry and lived to see another day. There was a point, for example, when the Ministry seemed to be hell-bent to close down the Pinewood Centre, an addictions counselling facility operated by Lakeridge Health in Oshawa. The Central East LHIN had made mental health a priority and was reluctant to cast Pinewood overboard at the whim of a Ministry whose singular objective appeared to be reducing hospital operating costs. The LHIN not only saved Pinewood, but now Lakeridge receives appropriate earmarked funding to keep the Centre going.
For $90 million a year we don’t get a lot of these moments. If we did, our communities might embrace the LHINs a little bit more and we might be inclined to see them as a bit more independent.
The answer to our question as to whether there should be a LHIN board is entirely dependent on what LHINs are. If they are to be, as the governance documents suggest, extensions of the Ministry of Health, then we likely don’t need the boards at all. If the LHINs are to be more independent and have the ability to respond to local priorities, then perhaps the boards should owe their appointments more to the communities they serve.
How that would work is open for debate.
The tale of Goldilocks and the Three Bears perhaps teaches us not all answers are absolutes, that sometimes the solution is somewhere in-between.
If the LHIN mandate is towards more independence, then perhaps we should look at ways to put a little more “sandpaper” on that board that not only reflects the interests of the community, but encourages broadening the debate outside the board structure.
Then again, what the tale doesn’t impart is a healthy respect for bears.