Category Archives: Health System

Woe is the outside consultant working for the Ministry of Health and the Ministry of Health Promotion.

For years outside consultants represented one of the fastest rising costs in health care. Between 2004-05 and 2008-09 the Ministry of Health came close to doubling its expenditures on consultants, while the Ministry of Health Promotion came close to tripling its consultant expenditures over five years leading to the 2009-10 budget.

According to the results of an OPSEU Freedom of Information Request, both Ministries have dramatically cut back their own consultant expenditures following the 2009 e-health scandal.

In 2004-05 the Ministry of Health was spending $56.6 million on outside consultants. By 2008-09 spending had topped more than $102 million.

By 2009-10 the Ministry of Health had cut back to $35.4 million, and this year spent less than $3 million by the end of May.

At the much smaller Ministry of Health Promotion, the government spent $703,641 in the first year, but by 2009-10 had spent $1.9 million in consulting fees. This year they have spent only $27,000 to get an outside perspective on issues of importance to them.

None of these fees includes expenditures by e-Health or the Local Health Integration Networks. Given the increased role the LHINs are playing, it is possible that some of this consulting may have shifted. Under Freedom of Information rules, requests have to go out to all 14 Local Health Integration Networks.

A year-by-year breakdown on consultant expenditures:

Ministry of Health and Long Term Care:
2004/05:  $56,606,391
2005/06:  $63,681,046
2006/07:  $67,446,823
2007/08:  $86,131,840
2008/09:  $102,242,731
2009/10:  $35,409,990
2010/11:  $2,985,074 (to the end of May)

Ministry of Health Promotion:
(The MHP began in 2005/06)
 2005/06:  $703,641
2006/07:  $946,608
2007/08:  $955,307
2008/09:  $1,631,257
2009/10: $1,904,842
2010/11: $27,000 (to date)

A significant redistribution of mental health beds throughout Southwestern Ontario is taking place without any decision-making process by the four Local Health Integration Networks that are supposed to be guiding services in this part of the province.

The Ombudsman’s office recently issued a report suggesting public consultation was little more than “LHIN spin” in Hamilton Niagara Haldimand Brant. In the case of Southwestern Ontario, there has been no public consultation at all.

Prompted by the redevelopment of Regional Mental Health Care – London (RMHC-L), the plan will reduce the number of beds in London and St. Thomas to about half of present complement.

While 138 beds will transfer to Kitchener/Cambridge, St. Thomas, Windsor and Hamilton, there are 67 beds unaccounted for.  This is in addition to the loss of 24 psycho geriatric beds at RMHC-L in the past year and a half. Further, RMHC-L has told us that up to 80 beds could be gone when the new facilities open in London and St. Thomas, four years from now.

Given the 450 beds that presently exist are frequently at capacity, this raises questions as to how the region will do without.

Over the summer OPSEU contacted the South West LHIN to ask about the plan.  At the end of July, the South West LHIN replied that neither they nor the Waterloo Wellington LHIN had yet to receive notice of integration, despite plans to begin moving staff and patients this fall.

The letter sent on behalf of SW LHIN CEO Michael Barrett states: “this process is complex as ultimately it involves four LHINs (South West, Waterloo-Wellington, Erie St. Clair, and Hamilton Niagara Haldimand Brant) and five hospitals.” Barrett says he expects an integration proposal in the “upcoming weeks,” of which time the LHINs will consider the submission “against our usual criteria which includes ensuring adequate community engagement throughout the process.”

In other words, the process has not even begun, yet staff at RMHC-L have been told they will transfer to Cambridge at the end of September with the patients to follow at the end of October. Further, the redevelopment project is presently being bid upon by private consortiums. That bidding is to close in December. The redevelopment is central to this entire plan, and it has gone to commercial tender without a shred of public consultation or detailed disclosure on the overall plan.

Given these circumstances, one has to question what the point of public consultation will be as it appears that everything has been decided.

One of the delays in getting the proposal to the LHIN may have been the dispute between RMHC-L and Grand River Hospital over the first transfer. Despite no agreement between the divesting and receiving sites, workers were initially told that they would begin at the new site at the beginning of September. A number of these workers sold their homes in London, moved to Kitchener, and got their kids enrolled in school for the coming year. Then they were told that events might not quite unfold as planned. Whoops!

It is unfair to both the families of patients and the workers scheduled to transfer to delay implementation of the initial move to Cambridge this fall.

However, the Ministry should wake up and realize that there has been a shocking lack of process in this whole affair.

The Minister of Health should insist the present bidding process on the projects be placed on hold until the public has had an opportunity to examine and comment on the complete plan, not just the immediate transfers.

They need to revise the projects and restore the missing beds, taking into consideration a more realistic needs assessment that takes into account The Alzheimer’s Society of Ontario projection that the number of Ontarians with dementia is expected to double within the next 25 years.

They need to explain to Ontarians why provincial bed counts are falling well below their target of 35 beds per 100,000, especially in light of the lack of funding for alternative community based services. They also need to work with community agencies to make sure they are adequately prepared, funded, and coordinated for the changes proposed in the plan.

Finally, they should scuttle the plans to take these new projects private. One only needs to look at the calls in Britain for renegotiation of the rich PFI (P3) contracts that threaten the stability of front line health services (see Privately financed hospitals squeeze UK’s National Health Service). The bids should be revised to apply for construction only.

There is no question the Ontario government spent much political capital framing the Local Health Integration Networks (LHINs) as local decision-making bodies that would be informed by local needs and priorities, made in and by the community.

Ontario Ombudsman Andre Marin’s report “The LHIN Spin” makes clear that the legislative underpinnings never supported that rhetoric.

One of the central problems is that the obligation to consult the public is very weakly defined in the Local Health System Integration Act (LHSIA).

The Act does suggest ways in which consultation can take place, but there is no minimum established.

Further, as OPSEU’s own 2008 legal challenge demonstrated, there is no obligation to consult anyone provided the “integration” decision is agreed to by the provider(s) and the LHIN (see page 9 of the Ombudsman’s Report). It is only when the LHIN challenges a voluntary integration, or unilaterally orders one, is there any real opportunity for the public to review the details and offer an opinion.

Given the LHIN is also the funding body, the chances of a provider pushing through an integration the LHIN disagrees with is fairly remote. All the incentives are towards coming to agreement – and subsequently keeping everything deep under wraps.

The LHINs maintain they only have a responsibility for community engagement at a systems level, or what they often refer to as the “10,000 foot level.” They say community engagement on specific restructuring plans is supposed to be the responsibility of health care providers, such as hospitals, not the LHIN.

The Ombudsman writes: “It is one thing to engage in blue-sky thinking and philosophical debate about the future of health care in general. It is quite another when concrete proposals have been put forward which may have a direct and significant impact on the services available to citizens in the foreseeable future.”

In OPSEU’s court case, Rouge Valley Health System had kept the transfer of mental health beds from Ajax to Scarborough secret until the hospital board officially passed it. Three days later the LHIN rubber-stamped it. There was no public consultation beforehand by either party despite its very real impact on mental health patients in the West Durham region. Not even the LHIN’s mental health advisory group was aware of it.

Further, documents revealed in the case indicated the LHIN had been meeting in closed-door meetings with Rouge Valley to discuss this issue for months beforehand.

In the wake of public outrage over having being left out of the decision-making process, the LHIN held public consultations after the fact. When the results of those consultations were presented back to the LHIN board, there were some expressions of regret. The staff was quick to jump in and remind them that the decision had already been made. Oh well.

Given the distance between sites of a single hospital corporation can be considerable – for example, it takes about an hour to drive from the Walkerton site to the Kincardine site of the South Bruce Grey Health Centre – the government recognized the problem we raised in court and placed an obligation on the hospital to consult when transferring services between sites. This was later embedded in the accountability agreements between the LHINs and the hospitals, however, there is little evidence to suggest that this is common practice or that this is happening in any meaningful way.

Under LHISIA the government is obligated to review the LHIN legislation after five years. Instead the Premier has ignored his own legislation and is now talking about doing so after the election. At one point he openly mused about not having a review at all until he was reminded it was a legislated requirement.

The LHINs have damaged their brand across much of the province. The Ombudsman’s report only echoes sentiments that were already out there in communities like Niagara and Hamilton. It will be difficult for any LHIN to engage in consultation now and be taken seriously by the community.

However, if the McGuinty government chooses to try and fix the problem, they may want to begin by following the Ombudsman’s recommendations to better define the consultation requirements and to enforce and enhance rules on transparency. They may also want to broaden the requirements to include voluntary integrations. More on this to come.

It’s hard to fathom the Central East Local Health Integration Network.

A week after the Ombudsman’s report criticizing inappropriate closed-door sessions at the Hamilton-area LHIN, the CE LHIN has decided to hold its August board meeting entirely in camera. While they call this a “special meeting,” there is no other open board meeting scheduled for the month.

Before the board can do this, a motion to exclude the public must clearly state the nature of the matter to be considered at the closed meeting and the general reasons why the public is being excluded.

On the CE LHIN web site it states: “Please be aware that the Board will enter into an in-camera session as per Section 9(5) of the Local Health System Integration Act (LHSIA). A report on the closed session will occur at the open Board meeting scheduled for September 22, 2010.”

Section 9 (5) of LHSIA states that a location health integration network may exclude the public from any part of a meeting under a number of specific circumstances. These range from matters of public security to discussions of litigation. The LHIN does not offer which of these reasons it is using to exclude the public.

At the end of each LHIN board meeting Chair Foster Loucks usually invokes Section 9 (5). Despite OPSEU attending many CE LHIN meetings, we have never witnessed any debate on this, nor have we been given any general reasons for excluding the public. Often, the closed sessions don’t even have a heading on the agenda beyond “closed session.”

Does this satisfy the requirement to “clearly state the nature of the matter to be considered” or provide “the general reasons why the public is being excluded?” Not likely.

The CE LHIN must have read the Ombudsman’s Report. It’s only 40 pages. We know the Ministry and the Hamilton Niagara Haldimand Brant LHIN have had a preliminary draft since 2009. The final report has been public since August 10. (OPSEU President Smokey Thomas comments on the issue this month:  http://www.opseu.org/presidentsmessage/aug-16-2010.htm )

It is possible that the entire August board meeting is dealing with appropriate confidential issues permitted under LHSIA. However, we don’t know that. We have no clues as to what will be discussed, even in the broadest terms.

Coming on the heels of the Ombudsman’s Report, the optics are terrible. One has to question whether this is a case of really bad timing, or whether like the HNHB LHIN, the CE LHIN is showing some level of defiance to Ontario Ombudsman Andre Marin’s report?

Fifty-eight more complex care beds are scheduled to close after the Hamilton Niagara Haldimand Brant Local Health Integration Network (HNHB LHIN) approved a plan that will take “continuing” out of “complex continuing care.” That brings to 181 the number of complex care beds that have been cut since last December.

Under the new plan complex care patients will be limited to those seeking between 45 and 90 days of care, including those seeking end of life care.

The HNHB LHIN claims it is right-sizing the number of beds based on a formula that takes into consideration the number of alternate level of care (ALC) patients occupying the beds, an adjustment for population growth, a calculation of unmet need, and an assumption that 92 per cent of the beds will be occupied at any one time. The task force does not give us the data in which they made these calculations.

Instead of looking at average occupancy to determine present use, the LHIN task force simply took a one-day snapshot which indicated 590 complex care (CC) patients were occupying beds. These patients fit the new definition of complex care, and therefore would not include ALC patients.

At present there are 686 beds available. 590 patients represent an 86 per cent occupancy rate – considered by many health administrators to be full occupancy. Yet somehow the report also claims between 35 per cent and 38 per cent of the beds are occupied by ALC patients. How could that be, given it adds up to 121 to 124 per cent?

At 92 per cent occupancy, CC patients would occupy 577 beds based on the new target of 628 beds – that’s 13 beds less than their one day snapshot. In addition, if they calculated for a five per cent unmet need, based on 590 patients, they would need to find an additional 29.5 beds. They claim their calculations also include population growth. Unless “growth” was negative, this definitely does not add up.

The task force neglects to report on what the average length of stay presently is for a complex care patient. Given they knocked “continuing” out the title, one would expect many of these patients to be long-term. What happens to these patients is never defined.

How the LHIN and the hospital determine which CC patients are ALC is an interesting question, given new criteria for overall admission to CC includes completion of the acute phase of illness, completion of the major portion of diagnostic tests, and the fact that the patient is no longer requiring acute daily medical intervention by a physician. This is very similar to the definition of ALC.

The report also redistributes beds by sub-region within the LHIN. The biggest loser would be the Niagara region, which would lose 41 beds. This compounds other losses under the Niagara Health System. Hamilton would lose 24 beds and Brant would lose 18 beds. Burlington would gain 23 beds while Haldimand-Norfolk would gain two beds – just months after cutting 10 complex care beds.

The plan also envisions a greater role for the Community Care Access Centres, which are to provide assistance to hospitals in placement of individuals currently designated ALC into more appropriate settings. However, with no new long term care beds and home care at capacity, it is unclear where the CCAC would be placing these individuals.

The task force needs to give us the complete formula on how they made their calculations. A back of the napkin calculation would suggest there is a reason the numbers have not been filled in on the report – it’s because they don’t add up.

“You ask anyone from any community if they think the LHINs are looking out for their interests and they’ll tell you no,” NDP Leader Andrea Horwath told the Peterborough Examiner Thursday. “They’ve been set up to be the buffer of accountability for the government.” Horwath arrived in Peterborough as the hospital finalized its “hospital improvement plan,” which will cut more than 180 full-time equivalent positions to balance its budget. She said the shredding of local health care was “absolutely unconscionable.” … South Bruce Grey Health Centre officially took away voting rights of hospital members at their Annual General Meeting on Wednesday. The board also reduced its size from 21 to 11 and took away controversial voting rights of its CEO. Outgoing board chairman Dan Gieruszak said the vote was taken away from hospital members out of concern that special interests would “hijack” the agenda of the board. By special interests, he could very well be speaking of community members upset by how their hospital is being run. In recent years SBGHC has cut services with little consultation with the community. …. A report from the Saskatchewan Health Quality Council says one in three long term residents in that province has been given the wrong medication at some point in the year. The Council is also concerned about how often prescriptions are written for benzodiazepines, a medication prescribed for anxiety and insomnia that increases the risk of falling. … Doctors in Moncton are outraged by the suspension of a local doctor. Dr. Richard Garceau, a microbiolgoist and an infectious diseases specialist, was suspended four weeks ago without explanation. Garceau had been outspoken about the New Brunswick’s pandemic preparations. He had also criticized management of his own local hospital. “Yes, we are afraid of speaking out about this because who is the next doctor that will, like Dr. Garceau, tell what he thinks is not correct in the hospital and is there a possibility of this doctor being suspended,” Dr. Gabriel Girouard told the CBC. … A controversial UK health care CEO was awarded £190,000 (almost $300,000 Canadian dollars) after winning her court battle over a severance payment. Rose Gibb, former CEO of the Maidstone and Tunbridge Wells National Health Service Trust in Kent, went to court after the government withheld severance payment she was offered in return for stepping down. Gibb left her £150,000-a-year post in October 2007, days before a highly critical report was published on the spread of Clostridium difficile (C diff) on overcrowded and dirty wards. One of the worst hospital outbreaks in the UK, it left 90 people dead. One family member who lost her mother-in-law at one of the Trust hospitals, described the decision as an “outrage” to all who lost friends and relatives through the outbreak. The board of the Trust resigned upon publication of the report. … The Metroland newspaper chain has begun running an investigative series on long term care. See

http://www.caledonenterprise.com/article/90126

Do you know where your nearest urgent care centre? Most Ontarians don’t.

In the May Vector poll, 62 per cent of Ontarians said they were not sure where their nearest urgent care centre.

Urgent care centres are intended to relieve pressure on hospital emergency departments by providing care for people who require urgent medical attention but do not have a life-threatening condition.

Having an urgent care centre does not mean communities are willing to give up their hospital emergency department.

Asked how concerned they would be if an urgent care centre replaced their emergency department, 65 per cent said they would be very or somewhat concerned.  That number was slightly higher in the Hamilton-Niagara area. The closure of two Niagara-area hospital ERs and a teen fatality following a boxing day car crash has led to extensive local debate over this issue.

The poll also asked how confident individuals were in making a self-diagnosis to determine whether they should go to an urgent care centre or a hospital. Thirty-seven per cent of Ontarians were very confident they would make the right decision, while a little over one in ten said they were not too confident or not confident at all.

In the UK the College of Emergency Medicine, which represents emergency doctors, told the Daily Telegraph in 2009 that it was concerned “urgent care” centres were acting as barriers to getting needed treatment for seriously ill patients.

“In emergency departments we are used to seeing patients who may develop serious complications,” John Heyworth, president of the CEM told the newspaper. “We want to make sure GPs appreciate the risks and handle things very carefully.

Ambulances have been reluctant to take UK patients to urgent care centres, preferring to take them to hospital emergency departments.

The poll was taken between May 6-17, 2010.  The Vector polls uses a sample of 1,101 adults across Canada, 500 in Ontario.

OTTAWA — One of the world’s leading health economists came out swinging today, shattering the myth that public health care is unsustainable and laying the blame for rising costs at the feet of private health services not covered by Medicare. The message was delivered to Members of Parliament by Dr. Robert G. Evans, an internationally renowned health economist.

“Since 1975, Medicare spending – hospitals and doctors’ services – has remained remarkably stable at between 4% and 5% of our Gross Domestic Product,” said Dr. Evans. “The key cost drivers in health care are the private, for-profit parts – pharmaceuticals, for-profit diagnostic tests, dental and other non-insured services. For example, private drug plan costs are rising 15% a year.

“Opponents of Medicare claim that public health care is fiscally unsustainable and that the only viable solution is a shift to more private coverage. Bluntly, this is a lie,” Dr. Evans said.

“Sustainability is often a code word for privatization and for-profit health care,” Dr. Evans said. “But any debate on the sustainability of public health care must start from who and what drives health care spending, and include a clear identification of the winners and losers of any erosion or dismantling of Medicare.”

Speaking to Members of Parliament and senior government advisors at a breakfast meeting on Parliament Hill, and later at a news conference on the Hill, Dr. Evans took on several of the most popular myths about health care costs. “Canada’s public health care spending is not skyrocketing,” Dr. Evans said. “In fact, our public expenditure on health care is below the OECD average.”

Dr. Evans pointed out that Medicare spending now takes up about the same share of provincial revenues it did 20 years ago. “The problem isn’t uncontrolled public health care spending,” Dr. Evans said. “It’s uncontrolled private health spending combined with a drop in provincial revenues created by large tax cuts over the years.”

Dr. Evans also dismissed the myth that the needs of an aging population will make health care unsustainable. “Population aging is a very small factor in increasing health care costs at 0.8% per year, less than other factors such as population growth (1%)”, said Dr. Evans. “Panic-mongering about a “grey tsunami” is simply a distraction.”

Canadians consistently show they support public health care. Nik Nanos, president and CEO of Nanos Research, joined Dr. Evans on Parliament Hill to present results of a recent national poll that showed almost 90% of Canadians support public solutions to problems in the health care system, and that health care is the most important national issue.

Dr. Evans, O.C., Ph.D. (Economics, Harvard), F.R.S.C., is the University Killam Professor in the Department of Economics at the University of British Columbia. His internationally respected work includes groundbreaking comparative studies of various health care systems and funding strategies.

The briefing session was hosted by the Canadian Health Coalition, a public advocacy organization dedicated to the preservation and improvement of Medicare. Its membership is comprised of national organizations representing nurses, health care workers, seniors, churches, antipoverty groups, women and trade unions as well as affiliated coalitions in nine provinces and one territory.

(From the Canadian Health Coalition)

Now that Ontario Ombuds Andre Marin has been reappointed for another five year term, he has restarted his campaign to expand his powers to the MUSH sector – municipalities, universities, school boards and hospitals. Marin told the Toronto Star yesterday that the Premier and his health minster regularly paint “doomsday scenarios” of health care consuming 70 per cent of government spending within 12 years. Yet “we still have no investigative body that can number-crunch the performance independently of hospitals.” The Ombuds’ example is one that has raised much interest, particularly with the frequency in which the government uses this statistic. While presently out of the jurisdiction of the Ombuds’, on Thursday a group of economists are meeting with the Canadian Health Coalition in Ottawa to also discuss these claims. What is within the Ombuds’ jurisdiction are the Local Health Integration Networks, of which Marin will soon be issuing a report. The government must have some idea of what is in that report — the LHINs were given new guidelines earlier in the year around their spending practices.

To read more on these claims, see

https://opseudiablogue.wordpress.com/2010/03/26/bad-math-in-the-provincial-budget/

Dr. Alex Hukowich was at his feisty best June 15 during his last day on the board of the Central East Local Health Integration Network (CE LHIN). Board members are limited to two terms, and for Hukowich and William Gleed, time was up.

Hukowich is frequently the conscience of the board, serving up his unembellished insights into the shortcomings of the health system and sometimes the LHIN itself. When others may have chosen their language carefully in a meeting open to the public, Hukowich often let his words fly.

When he’s not speaking, you can read his expressive body language across the room. Following the blow-up over the transfer of mental health beds out of the Ajax-Pickering Hospital, Hukowich spent much of the next meeting holding his head in his hands.

When residents from his home community of Northumberland County came to the LHIN this spring to complain of cuts to the local hospital, Hukowich lectured his colleagues on the board, suggesting there was a difference between access to care and availability of services.

Hukowich was fiercely independent. When we asked him if he would be interested in meeting with some of the workers impacted by the decision at Rouge Valley, he looked like a scalded cat, saying it would be inappropriate for him to do so.

June 15 Hukowich was very much engaged in the board proceedings. He was upset the board had no input into how hospital performance funding was weighted, suggesting it was inappropriate that quality indicators were rewarded less than financial accountability.  He questioned the trend towards larger long-term care homes in Canada while other countries were moving to smaller, more “homier” facilities.

When he was given the opportunity to offer some parting words, Hukowich stood up with a big grin on his face. At first he brought back the issue of accessibility versus availability, reminding the board that unless they could find a way of measuring accessibility by looking at the cost of time and travel for patients, any discussion of accessibility was “just talk.”

He presented a gift of a DVD on the Art of Critical Decision-making, claiming he had watched it too late in his board tenure for it to be much use to him.

Noting the recent passing of one of the creators behind Trivial Pursuit, Hukowich then brought out his own LHIN game to pass on to Board Chair Foster Loucks. The game consisted of a box and several coloured playing pieces. Green pieces represented funded parts of the health system that were valuable. Red pieces represented funded parts of the system of little to no value. He also introduced yellow and white pieces that would be thrown into the box by the opponents as the player engaged in the task of trying to remove the wasteful parts from the box. White pieces were new initiatives that would be good for the system, whereas the yellow pieces represented new projects from special interests that were of little use. Hukowich said there was one last component to the game – the player, representing the LHIN, had to pick out the pieces blindfolded.

Loucks, wearing the blindfold, picked out three green pieces and one red piece.

Hukowich’s metaphor for the LHIN was a telling one. Clearly the board members feel they are making decisions without all the information, not knowing if they are taking out valuable parts of the system or trimming waste. For a person of conscience, this would be troubling. For those of us who use and pay for the system, it speaks volumes on the caprice of decision-making under the LHINs.

Amid much nervous laughter, Hukowich was applauded one last time. The CE LHIN board meetings will simply not be the same without him.