Tag Archives: LHINs

Relationship building with the LHINs

Health care providers have found religion when it comes to involving patients in the planning and decision-making process. At this year’s OHA HealthAchieve every administrator was quick to extol the virtues of soliciting community participation.

In a meeting in Belleville yesterday, Paul Huras, CEO of the South East Local Health Integration Network, told us they constantly review new proposals from a patient perspective.

That, after all, is what this is all about.

LHINs are also subject to a parade of presentations by health care administrators that tend to gloss over the problems and highlight the progress, unless the problems are leading to a specific ask. Let’s face it, who wouldn’t want to look as competent as possible before the funding body they report to? That does mean, however, the LHINs are not always seeing the complete picture, especially the many realities not captured by scorecard data.

Contrary to former Ontario PC Leader Tim Hudak’s wild assertions about the LHINs being some huge bureaucracy, the reality is they are tasked with a big job and very little in the way of resources. We all want accountability, transparency, community consultation and responsive regional planning — the question is, how much are we willing to pay to get it? Last year Huras’ LHIN transferred a little more than $1 billion to provide health services in his region – about two-thirds of that going to hospitals. The amount Huras has to run his own administrative shop? In 2012-13 it was about $4.6 million – a drop of about $200,000 from the previous year. The LHINs have not been immune to government austerity.

Our meeting with Huras was the second around a proposed redesign of mental health services within the SE LHIN. In addition to OPSEU staff, there were front line representatives from Providence Care, Hotel Dieu Hospital and Frontenac Community Mental Health and Addiction Services.

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LHINs should integrate with the Ministry of Health — Thomas

OPSEU President Warren (Smokey) Thomas appears before the Standing Committee on Social Policy this morning in Kingston. The Queen’s Park Committee, made up of MPPs from all three parties, is conducting the review into the Local Health Integration Networks mandated in the original 2006 legislation. OPSEU is asking that the LHINs themselves formally integrate with the Ministry of Health and that “integration” proposals undergo a much more rigorous process, including detailed public disclosure. The full presentation is below:

The Ontario Public Service Employees Union represents more than 130,000 members. About a third work of those members work in a variety of health care settings, including hospitals, long-term care homes, ambulance, home care, mental health, independent diagnostics, community health centers, public health, and Canadian Blood Services.

We were the first union to sign up members at a Ontario Family Health Team.

We also represent health professionals in the province’s corrections system and Ontario Public Service members at the Ministry of Health and Long Term Care.

As a result we believe we have a unique 360 degree perspective on health integration.

OPSEU was among the first trade unions to warn of impending issues with the Local Health Integration Networks (LHINs).

In 2006 we warned that the LHINs would be used to deflect public criticism from the real decision-makers. That not only came true, but did much to damage the brand of the LHINs.

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CCACs not entirely to blame for high home care administrative costs

What to do with the Community Care Access Centres?

Yesterday’s Toronto Star column by Bob Hepburn suggests we should roll them into the Local Health Integration Networks and send the CCAC CEOs packing. The urge to spank the CCAC board that approved a 50 per cent salary increase for their CEO is compelling, but blowing up the CCACs is likely not the answer.

There is no question that the CCACs are a very cumbersome way to deliver home care. Let’s not forget CCACs also are involved in discharge planning in the hospitals and coordinate placement into long-term care. They are also responsible for the Health Care Connect program that assists Ontarians to find family doctors or nurse practitioners. They directly employ nurses that go into schools to provide mental health support as well as rapid response nurses to assist with chronic disease management. Nurse practitioners are also working with palliative pain and symptom control.

Nobody seems to know how much of their work is taken up by administration. The CCACs say its 10 per cent, but that doesn’t count all the layers at the agency level. We don’t know what the CCAC spends on contract competitions or enforcement to existing home care providers. Let’s face it, accountability is not free.

Hepburn says administration and case management amounts to about 40 per cent, which seems to be as fair a guess as we’ve seen.

By anybody’s standard, that’s not the best bang for the buck.

The problem with the proposed alternative is the CCACs are not really parallel organizations to the LHINs.

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Want direct front line input into health planning? How about whistleblower protection?

A few years ago we were in discussion with the Central East Local Health Integration Network about the idea of having a number of consultative committees made up of unionized health professionals in each of the sub-regions.

We sent out an invitation to our colleagues in the other unions to be part of this and got little response. Neither did our own members show much enthusiasm to get on board.

Part of this is likely ambivalence towards the LHINs. Part of it is also concern that Ontario continues to have very weak whistleblower protection. Part of it is a concern by these front line workers that they would feel manipulated by the process.

For most LHINs we remain strangers. Our employers get invited to present at the LHIN board meetings. We don’t. Our employers have ongoing working relationships with the LHINs. Ours is hit and miss, depending on the LHIN and how willing locals are to spend time at LHIN board meetings that can sometimes be opaque.

That’s too bad.

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Do LHINs need boards at all if they are simply to be the arm of the Ministry?

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.

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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.

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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.

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