OPSEU Diablogue

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.