The plan to reboot health care, home care in Ontario
Ontario’s broken, $50-billion health-care system will finally try to integrate family doctors and home care.
Thestar.com
Dec. 17, 2015
By Martin Regg Cohn
Facing the biggest overhaul in a generation, Ontario’s “fragmented” $50-billion health-care system will finally bring family doctors under closer control while blowing up its broken home-care network.
Queen’s Park is unveiling long-awaited proposals Thursday to streamline the way elderly and recovering patients receive care in their homes, winding down the controversial Community Care Access Centres that have become a lightning rod for complaints in recent years.
The $2.5-billion CCAC home-care system, which dates from the Mike Harris era two decades ago, would “cease to exist,” according to a ministry discussion paper, “Patients First: A Proposal to Strengthen Patient-Centred Health Care.”
With their governing boards set to be “dissolved,” most of the CCAC home-care workers, nursing staff and co-ordinators serving more than 700,000 patients a year would be taken over by expanded regional health networks made directly accountable to the health ministry.
The goal of the ambitious roadmap is to finally create an integrated health-care system after years of planning and talking - a quasi command and control (and co-ordination) system tailored to regional needs. While the plan makes sense conceptually, operationally it’s not so simple.
Health Minister Eric Hoskins faces daunting challenges as he tries to implement his vision at a time when there is little money to lubricate the process or buy off doctors as in the past.
The current system operates in silos that appear impervious to the province’s 14 existing Local Health Integration Networks - little-known LHINs that have never lived up to their name because they failed to truly integrate patient care.
The most glaring gap - echoed by the auditor general this month - has been a lack of control over family physicians who act as gatekeepers for services. Now, the ministry is finally prepared to make most primary-care doctors - the roughly 75 per cent of family physicians who work in clinics and teams - more accountable to government by bringing them under LHINs.
More than half of Ontarians cannot see their family physician within two days, and have trouble getting access outside office hours. The ministry wants LHINs to make doctors’ clinics more responsive by releasing their performance records to the public and requiring clinics to abide by contractual obligations - now rarely enforced - that would make them more accessible to patients (reducing costly emergency room visits).
Reconfigured regional hubs - significantly expanded in Toronto - would create a “process to match unattached patients to primary-care providers,” the ministry paper proposes, with more authority for “recruitment planning.” But both physicians and patients would still be free to make or break their relationships: “Patients will always have the right to choose their primary-care provider, and . . . clinicians would retain choice.”
While long overdue, the integration plan comes at an awkward time because of a long-running feud with the Ontario Medical Association over doctors’ fees. With the OMA lashing out at the ministry, relations are at a low ebb - too little money, too much toxicity - and it remains to be seen whether doctors will resist any increased government control over their workplace.
Government officials remain confident they can smooth over any tensions, noting that family doctors have long called for a more integrated health-care system that is more patient-centred as people navigate from hospital care to home care. The ministry notes that it would continue to negotiate physician compensation and any contracts for medical clinics directly with the OMA.
Under the latest proposals, local medical officers of health and public health services would also be funded and integrated under the control of LHINs, eliminating another longtime silo beyond ministry influence.
The new supersized LHINs will not only be rebranded with a new name, but subdivided to bring decision-making closer to ground level, creating a total of 80 “sub-LHINs” across the province. For example, much of Toronto is now covered by the Toronto Central LHIN, which would be subdivided into five community entities tailored to neighbourhoods within the city - recognizing that the populations of Rosedale and Thorncliffe Park present different challenges.
The discussion paper calls for greater equality of access for recent immigrants, aboriginal people, and franco-Ontarians, and those dealing with addiction or mental health challenges. The ministry concedes that health care delivery is uneven - a “variation across LHINs in terms of health outcomes” - due to geography, demography and ethnography.
“Having common standards and targets for the whole province will ensure more consistent and higher quality care,” it says, promising “clear standards for home and community care (and) greater consistency and transparency around the province.”
The ministry recognizes that “CCAC employees perform essential work that will continue under this proposal,” but adds that the “management structure would be reviewed.”
As the CCACs are taken over, not all CEOs will make the cut. After giving themselves embarrassingly generous pay hikes - while frontline staff faced pay freezes - some chiefs will be frozen out. The auditor reported that CEO salaries averaged $250,000 in 2013, up 27 per cent from 2009.
