The Hamilton Spectator
Province should operate hospitals
Forever ago when I started my medical career, our public hospitals were seen as stalwart supports of the health-care system: relied upon for world-class care for Ontarians. Over the ensuing decades and in the aftermath of the pandemic, these same institutions have emerged bruised, battered and beaten. As provincial and federal governments negotiate funding agreements, and Ontario plans for private surgical delivery, forgotten is one of the biggest drivers of health-care inefficiency: the way our hospitals are governed.
Ontario is relatively unique in that each of its 140 public hospitals are individual corporate entities, governed by separate, and largely self-appointed, boards. This means hospital leadership does not report directly to the Ministry of Health, but rather to local board members. This dates to a time when a community would fund a hospital to serve its needs. That time has long since passed. Hospitals now serve regional needs and co-ordination between hospitals and geographies is paramount to effective care delivery.
Amid this evolving landscape are Ontario hospitals, isolated and each serving separate masters. The Public Hospitals Act, which hasn’t changed substantively in decades, remains stubbornly resolute in its approach of having hospitals managed independently. This has created perverse disincentives to regional collaboration through the establishment of barriers between hospitals, regardless of how well-intentioned its individual members are.
Let’s take a simple (and hypothetical) example: Hospital A has excess infrastructure and capacity for a regional program like hip and knee surgeries while Hospital B down the road is bursting at the seams. Logic would dictate that Hospital A should shoulder some of the work to help with wait times from a regional health-care delivery perspective, which would mean adding some resources to do the work. In a truly unified system, smoothing of surgical capacity would be a relatively straightforward task: the paymaster of both hospitals, the government, is the same. Shifting resources or reallocating care could be done through a simple directive from the ministry.
In our existing system, the decision framework is much more complicated. Even if hospital leadership becomes somehow aware that excess capacity is available regionally (which they may not), two separate corporations with two separate boards and two separate budgets would somehow have to involve two separate corporate bureaucracies and two separate governance approvals to make it work.
The Ontario government has attempted to tackle regional health-care delivery. This was originally through the Local Health Integration Networks, which were not particularly successful, and now through Ontario Health Teams. This latter initiative, meant to integrate everything from primary care to complex hospital admissions, hopes to regionalize care in a better manner. However, the fundamental problem of hospitals being governed in silos remains a barrier to regional integration.
I have had the privilege of serving with some of the brightest people I’ve known on hospital boards. These are well intentioned, highly educated leaders who have sacrificed their time and efforts to better their communities. The model of a volunteer board worked well when hospitals were local and still had hitching posts outside for the horse and carriage, but not today, when hospitals have billion-dollar budgets. It is unfair to expect a part-time volunteer to somehow absorb thousands of pages of briefing notes and provide truly independent governance counsel without being biased by hospital leadership.
The ministry provides hospital funding. The ministry tracks regional health care delivery. The ministry keeps statistics on wait times and provincial health programs. The ministry is responsible for the care of each of this province’s citizens. Why in heaven’s name, unlike in almost every other jurisdiction in this country, doesn’t the ministry run hospitals?