Wednesday 13 July 2011

LHINS at 5 years: responding to John Ronson

Nan Brooks responding to John Ronson

Mr. Ronson in “LHINS at Five Years – What Now?” addresses a topic that requires urgent, candid and constructive debate. This essay continues the discussion on a way forward.

First, the context: Ontario is a geographically vast province with great c diversity. If Ontario were a country, it would be the 29th largest country in the world. Two of Spain or France and three Germanys could fit within Ontario’s borders. Few would suggest a single health system structure for Spain or Germany.

It is time to challenge the premise that one structure will fit all of Ontario. A few regions have very clear referral patterns, with primary and secondary clinicians referring to a tertiary/quaternary centre in the same region. Splitting the province into “integrated healthcare organizations” (IHO)s which are responsible for hospitals CCACs, primary care, ambulance services, public health and community care may work for this type of population where there are medium sized urban centers with defined referral populations.

In the GTA people generally do not live and access care within small geographical boundaries. Hundreds of thousands of GTA residents live in one community, and work and access most health care services in another community. Equally impactful is that residents living in a community travel to another to obtain health services from a culturally and linguistically compatible provider.

Choice of where and when to access services is a key outcome that is required in the future system. The goal is to respond to local variation in health needs, culture and population density while acknowledging variable access to clinicians, and ensuring provincial standards for outcomes and access are met. The challenge is greater equity for all: whether the most northerly or the urban.

So, how would I organize the province? I would say that the historic changes to the structure of Ontario’s health system have been based on the premise that form follows function. It has not worked. Instead of “form follows function” let us evolve to “form follows (desired) outcomes”. Rather than thinking first of the functions we want and creating silos around those functions, let us transcend this traditional approach and consider the outcomes that will lead to a healthier and more productive population. Then organizations can be held responsible for delivering those outcomes. An example of this is the Cancer Care Ontario (CCO) model. The CCO approach does not rely upon a single corporate structure, but works within multiple corporate structures defining clear goals, accountability and outcomes.

I have seen no evidence from other jurisdictions that firing organizational boards and implementing a regional model have achieved long-term success in producing the desired outcomes. In fact, it appears that every time providers in the healthcare system take their eye off their primary foci – providing patient care – the system becomes less oriented on patient care and efficiency. Most other provinces appear to be changing their regionalization model every 5 years or so, creating 2 years of havoc, 2 years of realizing the model does not work and one year of planning for the next change. If we want to enter that cycle, we can begin tinkering with structures.

To date, Ontario has chosen to observe this behavior and has in effect been a Canadian control group for Provincial management of healthcare and its impact on efficiency. Ontario results of note: average lengths of stay in hospitals that are consistently so low that national length of stay benchmarks are not used in Ontario because they are irrelevant; an aging at home strategy in Toronto Central LHIN that leads the nation.

My opinion is that many historic structural changes are wasteful and unnecessary. It is time to change this debate and focus on outcomes. We need to identify what system OUTCOMES are desired by , and then hold organizations jointly accountable for the outcomes. The structures used to deliver on the outcomes may vary greatly across the province. But the focus would be on equity of outcome, not consistency of corporate structures and models.

Who, then, should be part of this discussion: primary care, secondary care, tertiary care, quaternary care, community care, laboratories, and public health. If we were to amalgamate these current structures into a mega-organization there would likely be considerable and unnecessary cost, strife and political unrest. Alternately, we could choose to define specific outcomes and hold each of the provider groups/organizations jointly responsible and accountable for delivering on those outcomes.

We should differentiate populations and their outcomes and assign lead accountability for these desired outcomes to specific groups/organizations. For example, the lead accountability for frail seniors and chronic disease management should not be the acute care sector, but should be primary care providers or CCACs. This model requires thinking of different populations and determining which players would provide the most effective and appropriate care to that population. Authority and accountability would then rest with that group/organization to develop the structures and partnerships to achieve the desired outcomes.

As an example, a small rural hospital staffed primarily by family physicians belonging to a family health team would be accountable, jointly with the family health team, and the CCAC for outcomes related to access and quality of primary and secondary care. These outcomes would be monitored by a regionally designed structure that would hold individuals and organizations accountable for achieving the desired outcomes. That body needs to have the authority and responsibility to make it happen. Does that mean we have to demolish everything to achieve this outcome? No. It means that roles, responsibilities and authorities need to be changed. Alignment of acute care, CCAC, LHIN, ambulance, public health, and healthcare oversight with municipal boundaries would help.

Without overstating their significance, I am hopeful that my musings may prompt consideration of a perspective different to that in other provinces. In a time of unrest, political uncertainty, there is often a tendency to latch on to simple solutions that are well intentioned but not necessarily well thought out. Change is costly. Why would we waste funds duplicating and standardizing regionalization models that others have discovered do not work, and deliver inadequate health care in the process? We need to have a thoughtful yet quick change that is focused on the desired outcomes, and holds individuals and organizations accountable for the achievement of those outcomes. How? By identifying populations in need of healthcare, designing outcomes for those populations, equipping the organizations and providers to make the necessary alliances and modifications to deliver on the outcomes and holding them accountable.

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