Russ Ford's Blog

Patients or Power First?

The provincial government has recently unveiled its plan to transform the health care system.  Patients First, it says will not only improve the patient experience but will transform health care into a more integrated system of care.

Most agree that the current system is not a system at all.  There is little coordination between providers and services seem fragmented.  Further, there are questions as to whether or not it is financially sustainable.  The working assumption is that a more fully integrated system should come at as cheaper price without compromising quality.

Patients First therefore must be a good thing, Right?  Well not so fast.
Let’s start with the “window dressing” or as they say in politics, the “talking points”.  Patients First has very little to do with patients.  It is a document about the structure of health care and how it is delivered. It is about how the health care bureaucracy or system is to be organized.  It claims it is about equity, helping individuals and groups that have barriers to accessing health care services but the model it is proposing has nothing to do with equity.  Rather, the model being proposed is about providing a model of health care that provides equal access to all.  That is not equity, that is equality.  That is not dissimilar from our current model which has left many individuals and groups on the outside of the system looking in.

There is a specific reference to our First Nations population suggesting that Patients First will somehow improve their access to health care.  I think we would all agree that the health status of our First Nations people is a national disgrace.  While it is encouraging that the government recognizes the poor state of aboriginal health, they do not need to enact Patients First to address this issue.

Ontario has organizations that have been set up to address First Nation’s health.  They are called Aboriginal Health Access Centres (AHACs).  Like LAMP, AHACs have had their funding frozen by this government for the past six years.  The government indicates that it has a commitment to equity but the two organizational forms it has set up to address equity issues, Community Health Centres and AHACs have been under a funding freeze. 

The first major structural change outlined in Patients First is the demise of Community Care Access Centres (CCACs) which are the mangers of the home care system in Ontario. CCACs are much like LAMP.  While funded by government, they are independent organizations with   a volunteer board of directors.  The Provincial Auditor recently completed a none too flattering review of the operation of the CCACs.  Among other things it found that too little of its budget was going to client service and too much to administration.  It also found that the senior staff of the CCACs were dipping into the trough too much each getting on average a 14 per cent pay increase since 2009.  The report made many recommendations as to how to reform the CCACs. It did not however, call for its elimination.

The Patient’s First proposal for reasons only known to the Ministry of Health transfers the CCAC funding to the Local Health Integration Network (LHINs).  On the surface and even perhaps below the surface this is a strange allocation. The LHINs are not service providers.  They are health planners who are responsible for making funding allocations to organizations like LAMP.  This is not only a significant diversion for the LHINs but it also places them in conflict of interest.  They will be making decisions around the allocation of funding yet they operate a service that is dependent on their funding.

Home care is however not the only changes that will come to the LHINs.  Patients First make reference to the fact that the Ministry needs to increase accountability from the LHINs.  LHINs in turn will be increasing its accountability over service providers like LAMP.  Patients First does not make the case for the need for more accountability, it is a given.  Accountability is however a significant driver of health care costs and meeting Ministry accountability requirements could be the reason why CCACs have had to spend so much of its budgets on administration.  These new measures, whatever they are, will be particularly onerous on smaller organizations which lack the infrastructure.  It begs the question as to whether the government really needs more accountability or does it just want more control?

Everyone will be accountable except the Ministry.  It is the Ministry that defines the health care priorities for the LHINs and the providers.  It is those priorities that determine who gets funding and for what service. Yet today and under Patients First there is no public process for defining those priorities or any real public accountability from the Ministry.  It should also be noted that the board of directors of the LHINs are appointed by the provincial government again without any public process.

But if the ministry wants more accountability, here is an idea.  Why not get a group of local people who use the services of the health care providers to form a board of directors and they could assist in holding the organization accountable. That could not only work, it actually does work. We have such a thing at LAMP as do all other community based organizations.

That however could create a power struggle.  What if the issues defined by the Ministry are different than what the community thinks are its priorities.  John Carver, a well written and often quoted expert on board governance refers to the board as the “owners” of the corporation.  They are entrusted by the membership however that is defined, to define the ends the organization wants to achieve and the means that are acceptable to meet those ends.  Management is directly accountable to the board.

This is of course the fundamental question regarding Patients First.  Who is the owner of LAMP or any other government funded organization?  Is it the Ministry who supplies us with about 65% of our funding or is it the community?  Who sets the direction or as Carver would say the “ends” for LAMP to achieve?

Until Patients First that has never been in question.  While any organization that accepts government funding understands that the Ministry or any government body has stewardship responsibilities for funding, the ownership of LAMP has never been in question.  Until Patent’s First it has been more or less a partnership between the board and the ministry.  Roles were both respected and clearly defined. And it worked.

The assumption that because we fund you, we own you is not a LAMP issue; it is a redefinition of the role of government and the concept of “citizenship”.
If you are someone who believes democracy begins and ends every four years when you put a mark on a ballot, Patients First will not offend.  If however, you see democracy as a system of public accountability with an obligation to promote an engaged citizenry, Patients First is certainly wanting.

Non profit organizations like LAMP are instruments of social inclusion and are a way for citizens to have a voice.  This notion of engagement is fundamental to the concept of being a community based organization.  You are not a community based organization if the locus of power is external to the community. LAMP has been in this community for 40 years and there is no reason to think we will not be here for another 40.  The question will be as we enter our fifth decade is whether or not we will be a Community Health Centre or just a health centre.

The difference   between the two is not a matter of a word.  It is fundamental to who we are as an organization and our belief that communities do matter.


(Be) Patient First

I am constantly amazed/confused with how the provincial ministry of health essentially tries to re-invent itself each time either a new government is formed, or a new minister of health is appointed. Each "new" wheel looks pretty much like the previous one, and all, regardless of the inventor miss a critical point: if one really wants to effect positive health outcomes in the population, an all weather tire is far superior than the all seasons (for all people) model that has been the norm. The former recognizes that certain specific conditions require different considerations to best insure success. The latter is designed, at best, to only address an average circumstance.
Citizen participation through boards of directors is far from a perfect model. It is not just the "what" that matter, but equally, if not more important, the "who." Like democracy in general, the community based board can be messy, frustrating, complicated and complex. But if we are serious about "ownership" and accountability, this model is definitely one worth investing in. While heath services cost are important things to consider, unless and until the ministry of health takes the notion of investment more seriously than it does, the wheel of fortune will continue to spin, and many will be left only to hope for change.

Thought- Provoking!!

Thought- Provoking!!

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