Trusting the Ford government to get health reform right? That’s a big ask

Posted on January 19, 2023 in Health Policy Context

Source: — Authors: – Opinion
Jan. 18, 2023.   By Bruce Arthur, Columnist

When it comes to walking the fine public-private line of health care, the devil is in the details

Nobody argues the Canadian health-care system doesn’t need fixing. You may have noticed it was put under enormous strain for the past three years and was prone to struggle before that. You may also have noticed that it was underfunded in Ontario by a billion or so in the last fiscal year, where less was spent per capita than in other provinces. That may not have helped.

Meanwhile, nobody should argue the Canadian medical system is purely public. It’s not Britain’s NHS. Every doctor in Canada is a private medical corporation, and that was the deal Tommy Douglas struck. That’s Canadian health care for you.

But it’s the proposed solutions you need to watch for, because none of that means the system needs to abandon its fundamentally public nature, or that it couldn’t have its arteries nicked or even slit by people who don’t appreciate the value of public institutions or equitable access.

And that leads us to Ontario, today. As emergency departments remain chaotic, as staffing remains endemically short, as public health is battered, as family doctors are scarce, the solution Ontario has come up with is … uh, more cataract, knee replacement and hip replacement surgeries in private clinics, and more private clinics.

I asked one GTA-area hospital executive where cataract surgeries rank on the current list of problems affecting hospitals. “They’re not even on the list,” the executive said.

That doesn’t mean this isn’t worth doing; it doesn’t necessarily mean opening the gates of private hell, though one of the conservative premiers across the country seems a good bet to unlock those gates eventually, because why waste a good crisis?

But if the Ford government actually wants to protect a public system it has often misunderstood and abused, the details need to be handled with care. The government is promising safeguards, but, then, the Ontario government also promised to protect the Greenbelt. Doug Ford’s crew has an unhealthy habit of steering public good to private hands, from Ontario Place to Highway 413, and health care is absolutely chock full of opportunities for that.

There are safeguards available if they want to protect public health care, based on conversations with several experts.

The first is critical: associating private clinics with public hospitals. Ontario Health is responsible for that negotiation, and it needs to be completed in good faith: without mandatory privileging, you would see doctors leave the public system, because working 8-to-4 in a private clinic for a pile of money beats answering phone calls in the middle of the night. Hospital privileges come with responsibility, and if you want doctors working overnight on-call shifts when you have a medical emergency, you want doctors to be associated with hospitals.

Second, wages. Maybe higher wages at private clinics would convince some doctors or nurses who are retiring to stay on for a few more years, but if you’re going to constrain wages in the public system — which in the case of nurses and Bill 124 clearly hurt staffing and should be repealed — you should do so in the private system, because otherwise that will push a schism between public and private. And it will become more expensive for the system, over time.

Third, public hospitals aren’t for-profit but they have budgets, and they make money on the easy procedures so that they can afford to handle the hard, necessary, more laborious ones. Toronto General Hospital is an incredible hospital partly because it does procedures and treatments nobody else does: farming out easy surgeries without expanding public capacity needs to be considered carefully.

And as far as upselling, as Michael Garron Hospital ICU chief Dr. Michael Warner points out, the auditor general spelled out the difference in public versus private upselling in her 2021 report, and said there was no meaningful oversight to protect from predatory charges in private care.

Ontario hospitals routinely offer things such as private rooms or other upgrades, but a private profit margin makes for a different fish altogether. Not acknowledging the difference means you’re not taking the conversation seriously. Ontario’s government isn’t.

The details matter because they speak to the basic concept of making changes that either preserve or bleed the public system, and that’s where it is truly difficult to trust the Ford government on this. If you talk to hospital executives, they will tell you that more or less every single department in every hospital in Ontario is facing budgets cuts, because a one per cent increase in funding is being eaten up by the rise in labour and material costs.

Forget the strawman argument that bizarrely says this is better than doing nothing; that’s not the debate. Forget any blanket push for private care — running a public system into the ground during a pandemic shouldn’t be an excuse to undermine it. In a province that sold Highway 407 and most of Hydro One and opened up long-term care to the private sector — that turned out very badly in the pandemic — the government should remember that selling public goods makes it hard to get them back.

Which is why the safeguards, which haven’t been established yet, are the key to this plan. They will speak to intent.

“Irrespective of political party, if you’re gonna do this, you better (expletive) be thoughtful about it,” said one health expert who has no particular political affinity, but who requested anonymity because some of their work is in association with this government. “You’ve got to think it through, and you’ve got to think about what you’re trying to achieve and what are the goals. Is it about increased access and efficiency, better outcomes, right place, right time for patients, all that kind of stuff? Or, are you doing this to say, well, some people are going to get rich?”

That’s the question. Ontario still has time for the right answer, whether you believe they want to find it or not.

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