What kind of health system does Ontario want?

TheGlobeandMail.com – life/health/new-health
Published Wednesday, Jul. 06, 2011. Last updated Thursday, Jul. 07, 2011.   André Picard

Local health-integration networks. Remember that term because, as a fall election approaches in Ontario, LHINs (pronounced Lynns) are shaping up to be a hot-button health issue.

The Conservatives, who are leading in the polls, have promised to scrap them. So, too, has the surging NDP. The ruling Liberals are promising to make LHINs more accountable and effective.

The sudden interest in governance of the health-care system should warm the heart of any policy wonk. But one can’t help but wonder if politicians are really interested in addressing the complexity of co-ordinating and managing care, or if they have merely zeroed in on a small and unlovable element of the government apparatus and made it a convenient scapegoat.

Ontario has a massive health-care system with a budget of $44-billion.

The Minister of Health, Deb Matthews, does not personally dole out that money dollar by dollar. Nor does the Health Ministry centrally distribute the money. As most provinces do, Ontario has broken down its territory into regions; there are 14 of them. Regionalization is supposed to allow the health system to be more responsive and better able to meet local needs.

About half of Ontario’s health budget, $21.5-billion, is funnelled through LHINs. But they have a lot more power in theory than in practice because a) the ministry likes to micromanage; b) there is no clear hierarchy so no one really answers to LHINs and; c) there is a lot of manoeuvring by vested interests that undermines regional authority.

A regional health authority, if it’s going to be effective, should be able to determine how money is spent within a region, shifting money from hospitals to community care, from treatment programs to prevention, and so on. This approach worked extremely well in Alberta, so well that it was dismantled because it stripped too much power and control from politicians and policy-makers in the Health Ministry.

In Ontario, LHINs were never given much power. More than half of all health spending is on labour, and contracts for nurses, physicians, pharmacists and so on are negotiated centrally. The province never wrested power away from hospitals (which have all kept their own boards of directors) and community-care access centres maintain control over health services in the community.

What does that leave for LHINs to administer? Well, nothing really. Only about 1 per cent of their budgets are discretionary. Other than that, all they do is transfer money without adding any value.

There is a lot to dislike about LHINs. They are essentially a layer of middle management with nothing to manage. Their boards are larded down with political cronies. They spend way too much on bogus consultations. They are often undemocratic.

But to suggest that scrapping them is going to improve the health system, or save a lot of money, is illusory. The 14 LHINs have only about 400 employees in total, compared with more than 4,000 in the Ministry of Health and Long Term Care. The total budget for LHINs is $68-million.

Yes, LHINs, in their current form, are ineffectual.

But is scrapping them the only answer? What if LHINs were given real authority and spending power? If you are worried about excessive bureaucracy, why not eliminate the overlap with hospital boards and CCACs? Why not take an axe to the ministry itself?

The two harshest critics, Conservative Leader Tim Hudak and NDP boss Andrea Horwath, have both said they will take the money spent on LHINs and put it directly into patient care.

Sorry, but that’s hollow rhetoric. Do they honestly believe that a health-care system can magically manage itself? There needs to be an administrative apparatus. The question is: What should it look like?

What we need to hear from Ontario politicians is what they are proposing as an alternative to LHINs. That should be the central health-care debate.

Do we want the system in which administrative power is centralized in the Ministry of Health and Long Term Care in Toronto? Or do we want a highly decentralized system in which regional authorities have real power?

Ontario has to do decide if it wants to continue to have a health system in which decisional and spending power is concentrated in hospitals or whether it wants regional authorities – called LHINs or something else – that determine the right mix of spending among institutional care, community care, prevention programs and so on.

The fundamental problem is that Ontario has tried to do all these things simultaneously. The result is a bloated bureaucracy with no clear lines of responsibility. The reality is that the province’s regionalization efforts have, at best, been half-assed. LHINs are not the problem, they are a symptom of a much larger problem.

Good governance and stewardship are essential – in the public and private sector alike. And in health care, we have taken these fundamental matters for granted. We lurch from problem to problem, in perpetual crisis-management mode, and that is why our system is adrift.

Planning and management should not be dirty words. And those who want to lead the government should articulate their vision of how that system should be run.

“Scrap LHINs” is not a vision; it’s a cop-out.

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