Tag Archives: LHINs

Minister asks for review of Niagara Health System plan

Niagara Health System (NHS) will get a fresh look at its controversial Hospital Improvement Plan (HIP) that closed down two ERs in Fort Erie and Port Colborne.

The Minister of Health has ordered what is called a “third party” review although members of the NHS board will be part of that review along with representatives of the municipalities and the Local Health Integration Network.

The review will only look at phases of the hospital improvement plan that have already been implemented. It will not look at phases that have yet to be implemented, including changes to pediatrics and birthing.

According to Niagara This Week, the Minister stated in her letter to Niagara Regiojnal Chair Gary Burroughs “after thoughtful deliberation and consideration, I have come to the conclusion that an independent, third-party evaluation of the implemented phases of the HIP would be valuable.”

The review is certainly welcome, although two of the three parties engaged in the review were responsible for the initial HIP that has upset residents of the Niagara Region.

While deficits at NHS have been again climbing, Matthews insists the original HIP moved the hospital in the right direction.

Further terms of the review have yet to be determined and will be left up to the LHIN.

On the eve of an election, the news opens the door a crack after years of active lobbying by the local community, including Sue Hotte and the Yellow Shirt Brigade.

The HIP was ordered by the LHIN in May 2008 and was conducted largely by executives from the Ottawa Hospital, including Dr. Jack Kitts. The report was submitted in October 2008 and approved by the LHIN in January 2009.

LHINs — It’s not so much what you put in or out

There are three issues that really coloured OPSEU’s initial relationship with the LHIN – both of them taking place long before the LHINs were even a concept in former Health Minister George Smitherman’s brain.

One is competitive bidding in home care, where contracts come and go, and so do the workers.

The second is the dramatic difference between what workers earn in the hospital and how they are remunerated in the community.

The third is the betrayal of mental health. Significant cuts to psychiatric hospitals were made and the promised alternate services were only partially re-established in the community.

In 2005 when we first learned of the LHINs, it sounded like more of the same.

The 2006 Act that brought the LHINs into being did make some adjustments to recognize the transition of health care workers between employers, but as one presenter to this week’s Central East LHIN board remarked, “often you enter in an integration and people are afraid.”

When people are afraid, they fight the change.

Long before the LHINs there was something called Hospitals In Common Labs. It is a non-profit corporation run by Ontario hospitals that does lab work for 250 health care provider clients from across Canada. HICL has generated $100 million in revenue over the last decade that has gone back into its participating hospitals. It is considered to be the gold standard for medical lab testing. It is therefore astonishing when the South East LHIN tells the media they had to make hospitals in their region play nice in the sandbox. Sorry SE LHIN, your hospitals were light years ahead of you. HICL has been around since 1967.

With a focus on transitioning work, often overlooked is the idea of keeping the work in place but cooperating as a system, as HICL has done.

To be fair, many of the integrations we are now seeing are more along these lines. At the Central East LHIN a proposal was looked at that would merge the two cardiac rehab programs in Durham with the goal of expanding the program and filling in gaps. The program – which involves weekly sessions with those at risk for heart disease, stroke and diabetes – can only be successful if they are delivered within a 30-minute radius of the patient.

Expanding the program would be a huge benefit to the region. Not only does it improve the chances of survival for a high-risk group, but it also improves quality of life, including a measureable reduction in anxiety and depression.

This week the Central East LHIN also spent time on a strategy that would bring together service providers to improve specialized geriatric services. That strategy includes a CEO-level committee to plan an entire system of care for frail seniors. By involving the CEOs, it ensures greater buy-in within the organizations. The proposal for an umbrella organization for frail seniors is timely – growth in the seniors population is expected to grow 19 per cent by 2019, at which time 47 per cent will be over the age of 85. There is desperate need for a more coherent approach to these services.

When Dr. Alex Hukowich left the board of the Central East LHIN, he made it clear that he was unsure whether the parts the LHIN was taking out of the system or putting into the system were of value.

Maybe that’s part of the problem – the need to pluck pieces out and put pieces back in is probably limited. Getting the various pieces to work as a system is likely the greater challenge.

To deal with that, the Ministry and the LHINs have to overcome a lot of history, including addressing some of our longstanding grievances prior to when the LHIN was even here.

The trouble with LHINs Part II – How do you integrate half a system?

One of the key problems with the Local Health Integration Networks was evident from the start: they were given responsibility to better integrate our health system, but couldn’t address key parts of that system.

How do you integrate health care without the ability to better coordinate primary care? Physicians have always remained outside of system planning, and it could be argued that much of our system is defined by the agreement between the Ontario Medical Association and the Ministry of Health. This is totally outside the LHINs.

Oddly, while Family Health Teams remain outside the LHINs, Community Health Centres are in.

OPSEU has argued for years that the health system would be more efficient and cost-effective if hospital medical labs also conducted community-based work. Funding for community-based volumes would allow hospitals to increase staffing in their labs, expand scope of testing, and assist in the purchase of new equipment. For community doctors, it would result in faster turnaround of medical laboratory testing and give local physicians a direct lab contact in the community. In a comparison with some of the smallest hospital labs in the province, consultants RPO discovered that these labs were performing the same testing at two-thirds the cost of private labs. Once the hospital loses community-based work (there are only a handful left that still perform community-based testing) it is totally out of the jurisdiction of the LHINs. The North Simcoe Muskoka LHIN washed its hands of this issue when we raised it at the time Bracebridge and Huntsville hospital labs were losing their community volumes.

In Owen Sound the hospital is attempting to divest speech language therapy for preschoolers to the health unit. Once it is gone, the LHIN will no longer be able to address that service given health units are out of its jurisdiction. Who will monitor outcomes once that service is transferred? What happens if it turns out the hospital was the better host for the service, or perhaps another community-based agency? Who hold the health unit to account?

Within the LHIN jurisdiction, integrations are often about moving services around rather than facilitating strong links between health providers.

Integration shouldn’t just be about moving services from provider A to provider B and C.

As the Central East LHIN recently recognized, two addictions services don’t need to merge in order to cooperate on strategic goal setting. While it has been orthodoxy to move services out of hospital, the LHIN recognized the role of Lakeridge Health in maintaining one of these two addiction services.

The LHINs have consistently drawn a line between hospitals and community-based agencies, but hospitals do exist within communities. If a hospital is to provide community-based services, would it not by its very nature integrate well with other in-hospital services?

What role does prevention play? Not only is health promotion outside the jurisdiction of the LHINs, it is completely outside the Ministry of Health and Long Term Care.

We know, for example, that a more active population would dramatically reduce diabetes costs. One estimate suggests that if we were to bring diabetes down to the same level of northern European countries Canada could save $6 billion a year in health costs.

It’s true the LHINs do have contact with health providers outside their jurisdiction. But it has no ability to evaluate the quality of the work done by these providers, or whether the services they provide might be better delivered somewhere else. Nor does a friendly contact necessarily compel these providers to work more closely with hospitals, mental health agencies, home care or long term care homes.

The idea behind the LHINs was to make our health system just that – a system.

Some say five years is not long enough to get the job done. But what significant changes have the LHINs really made to date?

How long will it take to see a system emerge from the disparate entities that presently deliver public healthcare?

Are we expecting too much from bodies appointed to manage when what we really need are signs of bold leadership? Is this even possible within a LHIN model?

And where does the accountability lie? At present everything leads to the Minister of Health. Should it not also lead back to the communities?

Everybody has a shopping list of how we could do better. While our system is in the middle of the pack with regards to cost, there is no question that we could do better from an organizational point of view.

Our LHIN discussion series continues.

The trouble with LHINs

Local Health Integration Networks (LHINs) have become lightning rods in many communities.

The Hamilton Niagara Haldimand Brant LHIN was the focus of a scathing Ontario Ombudsman report “The LHIN Spin” which suggested public engagement was no more than lip service.

The South East LHIN recently sent their local communities into a panic after it floated the idea of concentrating all surgeries in Kingston.

The Erie St. Clair LHIN generated headlines last year when it unveiled plans to bring in a Disney speaker at a cost of close to $10,000. The speaking engagement was cancelled, although not the cost.

Aside from a horrible name, the LHINs have made many blunders to turn Ontarians against them – at least among the citizens that are even aware they exist.

68 per cent of PC supporters oppose plan to kill the LHINs

In a February 2011 Vector Poll, only 22 per cent of respondents claim to have either heard or read something about LHINs. Vector has been polling this question since 2006 with barely a change in results. After a brief description of what the LHINs do, 77 per cent of Ontarians opposed shutting them down. More troublesome to PC leader Tim Hudak, 68 per cent of PC voters are opposed to his promise to kill the LHINs.

It’s like that old song, “I can’t live with you, but I can’t get along without you.”

If the LHINs are likely here to stay, how do we fix them?

For starters, it’s about time the province come up with its overall strategic plan. It was supposed to be the guide for the LHINs to develop their own regional integrated health service plans. Instead, the province has been flighty in its priorities, often changing from Minister to Minister. George Smitherman was all about aging at home. David Caplan was about mental health. Deb Matthews is focused on getting alternate level of care patients out of hospitals.

Secondly, the LHINs are likely too small and have too few professional staff to effectively carry out their work. They like to crow about how small their administrative costs are relative to funding they shell out to hospitals, long term care homes, home care and other health providers, but it may be unreasonable. The Ministry has added to the workload with additional performance indicators and a broadened scope of oversight, but it refuses to allow the LHINs to hire appropriate staff to get the job done.

This may have something to do with point three – the LHINs have been very focused on reigning in costs, mostly at hospitals. It would be political folly to add to the LHIN administration while front line health professionals are being cut. This was supposed to be an exercise about quality, but clearly the focus has been on cost. One hospital CEO showed up at a LHIN board meeting to discuss progress on his hospital’s improvement plan. Missing from his presentation was information about the hospital’s performance on the LHIN’s quality indicators. To their credit, Ontario hospitals are in a far better place financially today, but it may be at a cost in quality.

The LHINs were supposed to take their strength from the communities they served, but no community has really warmed up to them. A few years ago OPSEU was invited to participate in a panel discussion on the LHINs by the Rural Ontario Municipal Association (ROMA). When the floor opened for questions, Mayors and Councillors of small towns lined up at the microphone to vent their frustration with the LHINs. The mayors felt the LHINs were unaccountable and were carrying out a hatchet operation on their local hospitals.

When a matter of concern comes up on the LHIN board’s agenda, often communities show up in considerable numbers. The LHINs lack any mechanism for representatives of these communities to address their concerns directly to the board. Recently two LHINs opened up their board meetings to deputations, although the process at Central East may be far too onerous and controlling to ever work.

When the LHINs did hold events for public consultation, these events often involved round tables with facilitators and set question lists. Many who have attended these events found the process manipulative.

When OPSEU took the Central East LHIN before judicial review in 2008, the lawyers for the government argued the LHINs were only responsible for high-level consultation, not on specific changes. In other words, the LHINs could ask what kind of health services a community might want, not on whether 20 mental health beds should be shut down at their local hospital and moved to another community.

It’s these specific initiatives when the public is most engaged, and it is these moments when the LHIN shuts them out of the process.

There are signs the LHINs are beginning to learn from their mistakes. At a recent Central East LHIN meeting they said they looked at integration between two addiction services and realized that while cooperation between the two of them was encouraged, it didn’t make sense for them to merge. The LHIN also acknowledged that Lakeridge Health was a good place to host one of these two services – a radical departure from the LHIN’s early days when it seemed they couldn’t move services out of hospital fast enough nor convince enough providers to integrate. This is the same LHIN than asked hospitals to set aside 1 per cent of their budget to allocate to a community-based health provider while trying to maintain it was making evidence-based decision-making.

There is a value to have a process by which health care providers must justify changes in service delivery.

The Southwest LHIN recently put the breaks on a plan by Grey Bruce Health Services to jettison speech language therapy for preschoolers. The hospital made the announcement under a hope and a prayer that the Health Unit would be able to pick up the work. The LHIN has since written to the hospital asking them to submit a formal integration proposal. Such a proposal will require more than a hope and prayer in the transfer of a service — it will need a HR transition plan.

The South West also responded to complaints that the Regional Mental Health Centre in London and St. Thomas was cutting beds without providing appropriate alternate services in the community. The LHIN allocated another $2.9 million for community delivery of mental health as a result. It won’t be nearly enough, but at least there was evidence they are listening.

It is far more productive to start talking about what the LHINs or their replacement might look like rather than take an axe to it all as Tim Hudak proposes. Diablogue will write more on this in the weeks to come.

What’s beyond the LHINs? Hudak says he’d replace them with nothing

There is no question the Local Health Integration Networks have had their share of problems.

When they were first proposed in 2005, OPSEU warned that it would lead to a rationalization of health care services and shield the politicians from unpopular decisions. To a degree, both concerns have turned out to be true.

One of the few promises provincial Tory leader Tim Hudak has made is to scrap the LHINs. The Tories say it would save $250 million, however, that is the total cost of the LHINs since 2006, not the annual cost. At present the LHINs take about $70 million per year to administer. On a $47 billion health budget (about half of which is within the jurisdiction of the LHINs) that’s a very small percentage allocated for administration.

If Hudak were to scrap the LHINs, he would not even save the $70 million. The LHINs replaced seven regional Ministry offices and 16 District Health Councils which previously cost $48 million. With inflation, the costs would likely remain equivalent to the LHINs if Hudak were to turn the clock back.

But Hudak says he would not replace the LHINs, he would simply cut them. We’re not sure how that would work, and likely neither does Hudak.

Dismantling the LHINs would not be free, as we discovered in the transition from District Health Councils and Regional Offices to LHINs. Costs ranging from broken leases to severance costs would be borne by government. Then there is the cost of transitioning the work.

Hudak doesn’t say what existing infrastructure would absorb the LHIN work, from planning and accountability to public engagement and integration. Is he actually suggesting we don’t need these functions?

The recommendations of the Health Restructuring Commission once dominated Ontario’s health care policy-making. Those recommendations are now more than a decade old. The data by which they came to their conclusions is closer to two decades old. There is a need to gather new evidence and make sound decisions around the future of our health system.

If we are to move forward we really have two choices – reinvent the existing LHINs, or come up with a new structure altogether. Both have their pros and cons.

Unfortunately the McGuinty government never followed-through on the requirement in the Local Health System Integration Act to conduct a review of the LHINs after five years. That would be now.

Neither did McGuinty ever produce the provincial plan that was supposed to be the guiding direction for the LHINs. Instead the LHINs scramble to fulfill whatever priority whim is the flavour of the day at Queen’s Park. Nowhere was this clearer than in the province’s focus on alternate level of care.

While the LHINs were making plans to utilize their aging at home funding, the Ministry changed its mind and suggested that at least half that money be devoted to getting ALC patients out of hospital.

Regardless of who gets elected, it is likely the LHINs will look very different after the October provincial election.

LHINs claim benefit of local decision-making amid attacks from Hudak

The Local Health Integration Networks (LHINs) appear to be making an effort to communicate their value amid increasing attacks from provincial PC Leader Tim Hudak.

Hudak is campaigning hard on a platform of eliminating the LHINs. The problem is, he has never said what he would replace them with.

In today’s Sudbury Star, Louise Paquette, CEO of the North East LHIN, makes a pitch about the importance of LHINs making decisions locally, despite the fact that the geography of her LHIN runs from Parry Sound to Hudson’s Bay and North Bay to Wawa.

April 2nd Gerry Macartney, CEO of the London Chamber of Commerce, echoes Paquette’s comments in the London Free Press, claiming “all decisions are made in our community at open, public board meetings.”

Macartney met with the South West LHIN’s CEO Michael Barrett and came away a convert, claiming that while not perfect, the LHINs “are a huge improvement over what was there before.”

The LHINs do provide some level of process and planning to changes in the health system, but it is far from consistent. It is also sometimes overstated – Paquette claims credit for reduction in wait times while remaining silent on the substantial transfers of cash from the Federal government and the province.

Having a LHIN in place has made a difference. A decision this spring to close a community-based transitional mental health facility was put on hold by the Central East LHIN after we raised questions about the lack of planning for patients who resided there.

At the beginning of this month we raised questions about a botched transfer of a preschool speech and language program from Grey Bruce Health Services to the Grey Bruce Health Unit.  Unable to come to an agreement as to how these services would transfer, the hospital simply issued layoff notices to the speech language pathologists and their assistants. The Health Unit is now attempting to recruit the same people.

The problem is, the hospital has yet to submit an integration proposal to the South West LHIN as required under the Local Health System Integration Act. That integration proposal is supposed to have a HR plan — something clearly missing.  They are shooting first, asking permission afterwards. The LHIN informs us they have notified Grey Bruce Health Services that the proposal must be treated as an integration.

If there is one profession health care providers have particular difficulty recruiting, it is speech language pathologists. On average, it takes a health care provider a year to recruit a SLP in Ontario. Should these individuals decide to take their experience elsewhere, the health unit may face difficulty maintaining the preschool speech and language services the hospital formerly provided.

In 2008 the South West LHIN received a report from their Children and Youth Priority Action Team. The team recommended greater integration between providers of adolescent and youth services, including speech language therapy. They also stressed the need to have more equitable service throughout the LHIN, particularly in the north – represented by Grey and Bruce counties. It is not clear how transferring the service outside the scope of the LHIN will help integrate the program with other services within the LHIN.

Media reports suggest the decision had been made by the Ministry of Children and Youth Services, which only partially funds the service.

So, will we actually see a real decision, or will the SW LHIN make another decision after the fact?

It wouldn’t be the first time – Regional Mental Health London and St. Thomas issued layoff notices to staff long before the LHIN was able to rubber stamp plans to move their work to Cambridge. This January the Central East LHIN approved an integration after the agency had already closed its doors at the end of December. The question is, when the activity happens before the decision, is the LHIN really making any decision at all?

Given the SLPs and their assistants will be finished at the hospital in August, there is little time left to make a real decision. There are enough questions here for the LHIN to do more than wield a rubber stamp and claim how important local decision-making is.  Stay tuned.