Ministers and officials in the government of Ontario usually dread the release of the Ontario Auditor General’s report. Indeed this year’s contained the usual litany of waste, lax oversight and lack of coordination. But it appears the Ministry of Health and Long Term Care was already taking some potentially game-changing steps even before the report was released. The Auditor General’s report looked at 14 different government programs including, in the case of Health, the Community Care Access Centres (CCACs) that provide home care, and the Local Health Integration Networks (LHINs) that provide funding for hospitals and other health care institutions, but, importantly, not family doctors.
The Auditor General was harsh in its criticism of the CCAC system noting that many had become top heavy with well-compensated administrators who were eating up almost a third of the funding, leaving only 69 cents on the dollar for actual patient care. The Ministry reacted within days, announcing that the CCACs and their boards would be disbanded, and responsibility for the services would fall under the LHINs. The problem was that as funders of the CCAC’s, the LHINs had already been responsible; but clearly had been unable to do anything about the home care mess.
As the Auditor General observed, a big part of the problem in managing the health care system is that the Local Health Care Integration Networks are only responsible for half of the money spent on health care in Ontario. They do not control or fund the primary caregivers—the family doctors, whose decisions create the demands on the system. It is the family doctor or specialist who orders an MRI or CT scan or who requests an admission to hospital. The LHINs are in the position of paying the hospitals and home care providers but have no control over the demand side of the business– at least not until now. Health Minister Hoskins, himself a doctor, has issued a discussion paper that would bring about some sweeping changes, including:
* As mentioned, shutting down the Community Care Access Centres and transferring home care management to the Local Health Integration Centres.
* Giving the LHINs more ability to coordinate health care with family doctors and specialists. Making sure patients who most need special services like dieticians, mental health workers and physiotherapy receive it.
* Making Public Health and population health a more integrated part of the picture.
There are challenges with these proposals. First, again as pointed out by the Auditor General, the LHINs have not been particularly effective in managing the system. The report noted that in many instances when hospitals and other providers failed to live up to various performance measurement targets –length of wait times, hospital readmissions, etc., that often the LHINs would lower the targets to make them more attainable. The Hoskins discussion paper acknowledges that the LHINs will need to be beefed up in order to exercise more control of the system, but still apparently believes that the regional approach the LHINs offer is the best way to manage the system. When the government established LHINs, it touted the fact that decisions would be closer to the communities served. But critics at the time said it was also a way to divert complaints and blame away from Queens Park.
The 800-pund gorilla will be how the doctors, represented by the Ontario Medical Association respond to the proposed changes. So far the response has been cautiously positive—the OMA saying it welcomes
an opportunity to sit down with the ministry to look at ways of improving the system. But the OMA is also currently embroiled in a contract dispute with the ministry over money, noting “system transformation necessitates a long-term, stable funding mechanism.” The OMA has been without a collective agreement with the Ministry since 2014 and accuses the government of making unilateral changes to the system affecting doctors during the ensuing months. The OMA is reportedly not happy that the Hoskins paper was produced with minimal input from the doctors.