Social Policy in Ontario

They also charge that there has been little consultation and raised questions about the extent of transparency the new health care system will have.

For instance, the super agency’s nascent board of directors, lead by interim board chair Bill Hatanaka, has held board meetings that have been closed to the public.

During the interview, Elliott said this is because Ontario Health is “still being organized and set up. They don’t have their full complement ready yet.”

“One thing is, they are getting organized right now to find a permanent chief executive officer. They are engaging in that process now. Once they are entirely set up and the board has been fully established then they will be [transparent],” said Elliott.

“Right now, it is a time of transition and there are still LHINs on the ground. Once that transition has been completed and Ontario Health is fully making the decisions on all aspects of those issues that were dealt with by the LHINs before, then they will be having public meetings. ”

Elliott said she expects Ontario Health board meetings to be public by the spring.

She also said the Ontario Health Teams — alliances of local health providers that will oversee most aspects of health care within their jurisdictions — will be required to hold public meetings and publicly post minutes.

However, it is not clear how the Ontario health teams will be administrated or to what extent they will be publicly accessible.

The provincial government is not imposing a governance structure upon the Ontario Health Teams, preferring instead to allow them to decide how they will be run.

Home care and long-term care

Responsibility for home-care contracts will be turned over to the provincial super agency instead of determined locally.

Right now, contracts for nursing, personal support, therapy, equipment and other home-care services are awarded by each of the 14 Local Health Integration Networks. A provincial listing of the service providers shows more than 280 contracts — including 20 in the Hamilton Niagara Haldimand Brant LHIN, which includes Burlington.

After the restructuring, the contracts will be the responsibility of Ontario Health, which critics say could lead to large for-profit private companies increasingly taking over the delivery of publicly-funded home care.

LHINs also currently are the point-of-contact for patients needing home care or long-term care and oversee its delivery. Under the new plan, the local Ontario Health Teams will eventually take over both of those roles.

Adding complication is that long-term care is no longer part of the Ministry of Health. It is now overseen by Minister of Long-Term Care Merrilee Fullerton.

Regardless, long-term care homes will be part of the local Ontario Health Teams.

“They will be funded through the Ministry of Long-Term Care,” said Elliott. “But the operation of them within the local Ontario Health Teams is still part of my responsibility as Minister of Health.”

Cancer Care Ontario and the rise of “provincial health teams”

As part of the project to centralize health-care administration into Ontario Health, the province’s much-lauded cancer agency — Cancer Care Ontario — will cease to exist as an independent agency.

The $1.9 billion agency oversees cancer care in Ontario. It, along with five other stand-alone health bodies including Trillium Gift of Life Network, is being gobbled up by Ontario Health.

Elliott said CCO will “still exist as a provincial resource” and will advise Ontario Health “concerning innovative cancer care and making sure every region in Ontario has the appropriate basket of cancer care resources.”

CCO and the other agencies are being absorbed into Ontario Health, she said, to cut costs and apply best practices across the health system.

However, the current health-care restructuring is creating a new group of effectively independent health care groups that will have their own administrations.

While most of the Ontario Health Team applications were made by health-care groups within a geographic region — both Niagara and Hamilton have OHT applications that are now moving to the next stage of development — there are some institutions that have applied to become what Elliott called “provincial teams.”

These teams would not be folded into Ontario Health, but would be provincewide teams that focus on a specific aspect of medicine, including children’s hospitals and specialized spinal treatments.

“They will be resources across the province so they will be dealing with situations where perhaps locally you can get to a hospital-level but you may need a specialized children’s hospital like CHEO or like SickKids where you need to make sure you have the resources available from that larger group.,” Elliott said. “The individual local Ontario Health Teams can then refer patients to or seek advice from them.”

She said the difference between these provincial teams and CCO is that the teams are focused on delivering service and are subordinate to Ontario Health.

The next steps in the transformation

The province is looking to combine some regional proposals as it works to keep the number of Ontario Health Teams below 100.

“What we are looking at now is … putting some of the smaller groups together that show promise,” said Elliott.

“But it has to be a natural fit. It can’t be just us putting two groups together that don’t have those commonalities.”

Hamilton, Niagara and Burlington’s proposals are not with those being considered for merger.

All three were among the 31 proposals invited in July to make a full application by Oct. 9. Elliott says she’s looking for teams that will take into consideration the needs of francophones, Indigenous people and other area cultural and linguistic groups.

“Are these organizations that are coming together going to make sure that everyone in their geographic area receives the care that they need,” she said. “We need to be able to reach everyone.”

Elliott initially expected the province would have 30 to 50 teams but is considering more since receiving over 150 applications by May 15. While she didn’t provide an exact number during the interview, she said it may be slightly more than 50 but doesn’t anticipate it will reach 100.

“The response has been tremendously positive,” she said. “Providers are very enthusiastic.”

Governance of the Ontario Health Teams

One of the most controversial aspects of the Ontario Health Teams has been the lack of direction regarding how the teams will be governed.

“We have not dictated what the governance structure needs to be,” said Elliott.

“It can be anything that will allow them to achieve the objectives that need to be achieved in that local area.”

The lack of a blueprint raises questions about whether the teams will build empires or bridges.

Critics say more direction is needed to make sure smaller organizations get enough of a voice among massive players like hospital networks, universities and municipalities.

But Elliott said organizations need the freedom to break down silos that have log-jammed the health care system.

“We made the conscious decision to allow the health-care providers in local areas to provide the services that they know they need for their local communities,” she said. “So we needed to take away some of the constraints to allow them to do that work.”

She repeatedly referred the bundled care model introduced by St. Joseph’s Healthcare in 2012 that has been rolled out in Hamilton, Niagara, Burlington and beyond.

“St. Joseph’s Health Care really started this off with the provision of integrated care,” she said.

The “low rules environment” of health care changes

Some critics have warned the provincial government is proceeding with sweeping health-care change without a clear idea of what the system will ultimately look like.

The fact that no one knows how Ontario Health Teams will be governed prompted former Liberal deputy health minister Bob Bell to say the new system is being built in a “low rules environment,” that opens the door to problems.

“I would say that we do have a plan of where we want to end up. We want to end up in a place where every person in Ontario is connected to their health care system throughout their lives because they don’t feel that way now,” said Elliott.

“We feel the best people to do that are the people who provide the service on the ground. That’s why it’s really important that we have local Ontario Health Teams compromising the people that are providing the services because they know where the gaps are and they know how to fill in the service areas.”

She said the ministry and Ontario Health will have “controls over the accounting” but that local health teams are best suited to chart the future of health care.

“What health care providers have told us repeatedly over the years — I’m told since before my time here — has been, ‘You tell us what you want us to achieve and we will achieve it.’ What we want is better, more accessible, connected care for every Ontarian.”

Funding the Ontario Health Teams

For the first time, Ontario Health Teams are being promised some funding to help get them off the ground. The health minister says there will be cash for digital systems such as electronic medical records, which is usually not covered by the province.

She also vowed the teams will have “proper financial governance.”

“There will need to be a reporting mechanism with respect to the use of the funds, the distribution of the funds and if there is any money left over at the end of the year, what the plan is to put those funds back into the organization for the next year,” she said. “The funds will be locally retained and redistributed into local health care.”

She says accountability agreements will ensure that large organizations don’t take over the team’s money.

“Hospitals will not be making the funding decisions,” she said. “It needs to be a team approach and it needs to be across the board.”

Those same accountability agreements will ensure similar quality of care across the province no matter how the teams choose to govern themselves and deliver care.

“It will be up to certain standards that the ministry has decided upon,” she said. “The group will need to meet those standards.”

How she measures success

Elliott said she will know if Ontario’s health care changes are successful by how they are ultimately regarded by Ontario citizens.

“Everyone deserves an excellent standard of health care in Ontario. We will be able to measure that by patient surveys, by long term care, home care, hospital care,” she said. “What are people thinking about their health care system. Has it improved or not?”

The minister said success will also be measured by “financial considerations,” and that “a sustainable model for health care delivery in Ontario,” has been established.

“The more important aspect for me is the degree of patient satisfaction with the health care system. Have we really developed a patient-centred system of care that is delivering the care that people expect and deserve in Ontario and that is to everyone. We don’t want to leave anyone out.”

The super agency experience in other provinces

Elliott said the current health care reform is a “distinctly Ontario” project. However, Ontario is not the first province to reorganize its health care system under a super agency.

The Standard and Spectator series looked at the Alberta experience, where health care was rebuilt in 2008 along the same lines Ontario is doing now.

The system is governed by the super agency Alberta Health Services, which oversees nine regional health “zones” similar to the Ontario Health Teams.

The Alberta government claims the system has saved Albertans money. However, the province has the highest per capita health costs in Canada.

Other provinces that have gone down the super agency route face their own problems. Nova Scotia is facing a wait-time crisis and British Columbia’s superagency leadership has been in a state of flux.

“The biggest difference in Ontario is the fact that we have the large agency, Ontario Health, that is going to take over the overall governance and back-office operations to minimize (problems),” Elliott said when asked how the Ontario approach is different from Alberta’s. “The other distinctly Ontario difference is having the local Ontario Health Teams covering every aspect of the province that consists of the people who provide the system.”

Elliott could not say how Ontario Health is substantially different from Alberta Health Services.

However, she touted the Ontario Health Teams as a way to put patients first.

“It’s the system we are setting up structurally but it’s also the philosophy of let’s make this care based on patients not on institutions that are providing care.”

Hallway medicine

Premier Doug Ford has said he wants hallway medicine fixed within a year and the health minister says that is the “goal.”

“We are actively working toward that,” she said.

But she acknowledges that “there is no one simple answer to it” and it might take longer than hoped.

“I can’t guarantee that we will not have a single hallway medicine space in a year,” she said. “Part of it is the issue with respect to lack of long-term care beds with a lot of people remaining in hospital. Part of it is mental health and addictions.”

The province has promised to build 15,000 new long-term care beds in the next five years and modernize 15,000 existing spaces.

Elliott says the ministry is currently working on comprehensive plans for mental health, addiction and chronic care disease management.