BIG BANG FOR HEALTH CARE
Tory plans may cause upheaval, critics fear
It is being called the Big Bang approach to health-care reform: Blow it up and start over again.
That is, approximately, the plan being put forward by Ontario’s Progressive Conservative government. It is a plan that has been revealed, so far, in a series of leaked documents. After vowing to end hallway medicine, the province is poised to turn the health system on its head.
The provincial government is planning to create a super agency to oversee health care in Ontario, which would absorb agencies including Cancer Care Ontario and Trillium Gift of Life Network. It is also planning to get rid of the existing system of Local Health Integration Networks (LHINs) and set up a series of integrated service providers to deliver health care.
The move toward integrated care groups could mean closing hospitals and other health service providers and transferring services in some cases.
Sketchy details of the plan have been revealed through leaks in the media. Development of the plan appears to be moving quickly — the super agency has already been approved by Premier Doug Ford’s government, according to documents — although few details are public.
Health Minister Christine Elliott has emphasized that plans are not final. She has offered public assurances that the final product will be “reliable, public health care,” something she said the provincial government wants to strengthen. She made the comments in response to NDP claims that the reforms will result in more privatized health care in the province.
“Ontario’s health-care system is on life support,” Elliott said. “Patients are languishing on waiting lists and more than 1,000 patients are receiving care in hallways every day.
“We promised the people of Ontario during the election campaign that we would end hallway health care and we are fully committed to delivering on that promise. Part of that must include a needed transformation and modernization of the health-care system that puts the patient first, not bureaucracy.”
The government is committed to building a system “centred around the patient and redirecting money to front-line services — where it belongs — to improve patient experience and provide better, connected care and capturing better value for our health dollars,” Elliott said.
Many observers are calling on the province to slow down and be more transparent about what is coming and why.
“The government has not given us a valid reason for this change. There is no connection logically between the problems they have identified and the solutions they have identified,” said Agnes Grudniewicz, assistant professor at the University of Ottawa’s Telfer School of Management, who studies health systems.
Grudniewicz said there is no evidence that centralizing healthcare delivery improves care or reduces costs.
Patients are languishing on waiting lists and more than 1,000 patients are receiving care in hallways every day.
But one thing is certain, she said. Such dramatic, rapid change will be expensive and chaotic. And there will be unintended consequences.
While many want to see a more incremental approach to healthcare reform, others are embracing change. Some are looking ahead to where they might fit into the puzzle that is the future of health care in the province.
Among them is Eric Hanna, president and CEO of Arnprior Regional Health.
Hanna believes that tiny Arnprior, west of Ottawa with a population of 8,795, can be an example of how to make integrated health care work across Ontario. He is waiting for more details, but is considering putting up his hand to make Arnprior’s rural health hub an “early adopter” of the integrated health services model.
Among leaked information about the planning for health-care reform is an internal document that calls for “early adopters” of the integrated service provider model to show interest as early as March. It is not clear if that timeline is the final one.
What can Arnprior teach the rest of the province?
“I think we have been able to demonstrate how we can form collaborations among a variety of health-care providers.”
Arnprior has experience integrating health care. The Arnprior and Area Rural Health Hub is one of a handful across the province that are centred around rural hospitals and improving care for area patients.
The hubs join together various health providers — in Arnprior’s case, the group includes public health, Arnprior Regional Health (which includes the hospital and nursing home), home and community care, physicians and community programs. In total, five groups work together to improve care for patients in the area.
Among its projects has been co-ordinating diabetes screening. As part of the initiative, local pharmacies, community paramedics and physicians all use the same screening tool to identify those at risk. The rural health hub also created an online exercise guide to help people with chronic obstructive pulmonary disease find appropriate exercise programs in the community.
The group has also worked together to help reduce falls throughout the community.
“The No. 1 goal is about creating a better patient experience and improving the quality of care. But if we are able to have fewer people falling at home and people are diagnosed earlier with diabetes, it also results in a more cost-effective health system.”
The Arnprior and Area Rural Health Hub serves about 30,000 patients. It deals with challenges unique to rural Ontario, but not some of the complexities seen in larger, urban centres.
Still, Hanna said, the experience of the rural health hub is valuable when it comes to creating a system built around integrated care-delivery systems.
He acknowledged that the province may want early adopter groups to be bigger, which could mean partnering with a larger hospital.
That is something Hanna knows about. A former vice-president at Queensway Carleton Hospital, Hanna helped put together an alliance of Queensway Carleton and Ottawa valley hospitals.
There are other examples of integrated health delivery at work across the province. Community health centres, for example, which exist in Ottawa and across the province, provide primary care from physicians, nurse practitioners and nurses combined with health-promotion and illness-prevention services.
In Ottawa, CHEO has made strides in integrating its mental-health services, among other things, to improve outcomes for patients.
But how, exactly, the integrated care system would work is one of many mysteries around what health reform might eventually look like in Ontario.
The 81-page draft legislation leaked by the NDP and other documents call for between 30 and 50 “MyCare groups” across the province to provide “seamless, co-ordinated care. Patients will have a single team of providers for all their care needs and will not experience gaps in service,” according to internal documents released by the NDP.
The documents also mention “more virtual options” for patients.
Those groups include hospitals and every other primary health provider and service in Ontario. There are currently more than 140 hospitals in the province, so each group would, presumably, include three to five hospitals in addition to other services and could cover vast geographical areas, especially in parts of the province with low population density such as northern Ontario.
The draft plan also opens the door to hospital and health-service provider amalgamations, takeovers and closings, with provisions for “required integration” that would allow the minister of health to order health-service providers to transfer, amalgamate or close. Members of the public would have 30 days after such an order is issued to make written submissions. The ministry can apply for a court order to force such integrations.
The possibility of dozens of hospital integrations and health-service transfers suggests future chaos at a time when hospitals across the province are trying to cope with overcrowding and an aging population.
Still, Doris Grinspun, chief executive officer of the Registered Nurses Association of Ontario, said people should not panic.
“I don’t necessarily think the sky will fall if it is done well. I don’t think everything is necessarily working perfectly as it is now.”
Among the changes she would like to see to draft plans is room for more MyCare groups. Grinspun said the 30 to 50 integrated groups currently being called for are insufficient. That number should be between 80 and 120, she said.
“I think if you made primary care more central to the system, you would start to see better wrapping-around services for patients.”
No other universal health-care system in the world functions really well, she said, without “robust” primary care.
Still, few are grieving the end of the LHIN system that was built under the previous Liberal government. While Champlain LHIN, which includes Ottawa, has helped improve health care by reducing wait lists for joint surgery, among other initiatives, critics said that LHINs were not given the tools to make a big difference across the province.
CEO Alex Munter noted CHEO must complete hundreds of accountability reports a year as part of 23 separate funding agreements in the current siloed system. He said a shift is needed to provide services around patient needs rather than expecting them to manoeuvre through a disjointed system.
When you do big changes, when you turn everything upside down, who it ends up costing are the patients and their families.
The extent and speed of the proposed changes are continuing to raise alarm bells across the province, even as those inside and outside the system wait for more details.
Dr. Bob Bell, former provincial deputy minister of health, fears absorbing Cancer Care Ontario into the super agency will harm the province’s world-renowned cancer system.
John Fraser, Ottawa South MPP and Liberal party leader, shares fears about the extent of proposed change in such a large, complex system. “It is complex and costly and that is why the change has always been incremental. When you do big changes, when you turn everything upside down, who it ends up costing are the patients and their families.”
That is something uOttawa’s Grudniewicz has studied. Centralization versus decentralization in health care often boils down to a political decision, she said. But there is no evidence to show that one way of organizing health care is better than the other.
What is known, though, is that such change, especially done quickly, is highly disruptive and chaotic.
“Governments do this over and over to the point that researchers just shake their heads,” she said. “Wanting to stop hallway medicine has nothing to do with centralization. There is no evidence that centralization saves money.”
Such health policy cycling, she said, is part of the problem. It takes the focus off actually solving problems and it costs money, causes disruption and often creates service gaps. Speed, which has been the Ford government’s preferred method when it comes to complex policy changes, can make things worse, Grudniewicz said.
“We need to be thoughtful and take our time and make evidence-based decisions before we throw a lot of money at creating chaos,” she said.
“To me, it is about politics as opposed to putting patients first. What we need to do is make health care a non-political issue.”