Patient Centred Health Care

PATHS TO PROSPERITYPAT I E N T- C E N T R E D H E A LT H C A R E

A n O n t a r i o P C C a u c u s W h i t e P a p e r

S e p t e m b e r 2 0 1 2

The Ontario PC Caucus is focused on action to create jobs and grow the economy, but Ontario also needs to make difficult, fundamental reforms to improve the performance of our public sec-tor. Nowhere is that more apparent than in health care, where we are still failing to meet patients’ needs despite a substantial increase in spending that has gone on for almost a decade. A better system that puts patients, not bureaucrats, at the centre of decision-making is part of our plan for a more prosperous Ontario.

Ask people in Ontario what’s wrong with health care and they will tell you that too often they have to fight like hell to get anything done. It’s difficult to get a doctor, emergency room wait times are too long, they can’t get a long-term care bed for their elderly parent or there just isn’t enough home care available.

Ask experts on health care policy, and they point to a reason why we see those kinds of results. What we call a health care system in Ontario really isn’t a system at all. It’s a complicated series of loosely connected sectors with bureaucracies running other bureaucracies, and no one can really get a handle on how to make it all work together in a coordinated way for the benefit of patients. We spend lots of money, but we don’t always spend it in the right ways.

Ask people in government about these same problems, and they will talk optimistically about restraining the growth in health care spending while making the system even better. Great goal, but there is no plan. Worse, there is no willingness to make the tough decisions that such a plan would require.

Instead, the government tells us that the solution is to fine tune its Local Health Integration Net-works, an expensive layer of bureaucracy that has had six years to integrate health care and has precious little to show for it. The LHINs are part of a system built to fail, a system that lacks fo-cus, priorities and clear lines of accountability. Patients suffer long waits for service while millions of dollars are wasted on bureaucracy.

The combination of tweaks and wishful thinking the government proposes is like using 2x4s to shore up a crumbling foundation. It might work in the short term, but it won’t fix the underly-ing problem. We believe that the foundation has to be rebuilt before we will have a system that works better for patients. That means making some tough decisions that will change the balance of power in Ontario health care, tilting it away from government and bureaucracies and towards patients and the front-line professionals who understand patients’ needs best.

We suggest a new and completely different approach. Instead of complex layers of bureaucratic and political supervision of health care, we propose to let our existing local health care admin-istrators and front-line health workers lead the system. Local health care professionals know what’s best for patients.

We need to remember that the goal of the health system is providing health care, not creating well-paid managerial jobs. We need a system that is centred on patients, a system that treats them like human beings, not like OHIP numbers or an inconvenient drain on the budget.

Leader of the Official Opposition

Our plan will embed a Triple Aim approach – as defined by the Institute for Healthcare Improve-ment – that will enhance patient quality and satisfaction, improve the health of the population and reduce the per capita cost of health care.

The change we propose is long overdue. The last time Ontario made fundamental changes to health care structure was in the late 1990s, when I was parliamentary assistant to the minister of health. Since then, we’ve made the system more complex when it cries out for more simplicity.

In this paper, we describe how that new structure will work. There is more to come from us on health care, which we will present in a forthcoming Paths to Prosperity white paper. But we be-lieve the important first step is to rebuild the systems’ foundation.

Last year, Ontario spent $47.3 billion on health care, a figure that has been rising around six per cent a year under the current government. That’s just not sustainable. The current government knows that, but it has no credible plan to fix the problem. Instead, it simply imagines that it can fix the problem by tinkering with its Lo-cal Health Integration Networks. That’s like imagining that a gas guzzler will magically become a Prius – sim-ply by wishful thinking.

Numerous studies show that European countries that spend the same percentage of GDP as we do on health care produce better service for patients. We need to get more value for the billions of dollars we spend. The way to do that is to improve the efficiency of the sector through integration. That will produce a better result for patients and taxpayers.

We know Ontario patients deserve better. That is why the Ontario PC Caucus has put a bold new idea on the table with our third Paths to Prosperity white paper. We’re proposing rebuilding the foundation of our health system – not just tinkering around the edges. We believe this approach will improve patient care and provide more value for each dollar invested.

Health providers strongly support creating a clear strategy for improvement. They want and need to know what is expected of them and how the system’s pieces should fit together to function more cohesively and effectively.

Ontario has some of the best health administrators and professionals in the world, but we don’t make the most of their talents because we require them to work in a system that is laden with bureaucracy and lacks a coherent plan for success. Ontario spends too much money on health bureaucrats, money that should go to patient care. Worse, our multiple health bureaucracies stand in the way of both innovation and real ac-countability.

The solution lies in leadership and clarity of thinking from the provincial government and, most importantly, timely and integrated services in our communities. We believe our proposed approach meets those objectives.

From my experience in the health care sector and as deputy health critic for the Ontario PC Caucus, I would like to thank the health care experts who contributed months of work to this innovative new approach. We also want to know what you think about our Paths to Prosperity: Patient-Centred Health Care discussion paper. Please send me your feedback by contacting my office through email at [email protected] or by phone at 416-325-6242 (Queen’s Park).

Ontario PC Deputy Critic for Health (Rural and Northern)

Bill WalkerM E M B E R O F P R O V I N C I A L PA R L I A M E N T B R U C E - G R E Y- O W E N S O U N D

TA B L E O F C O N T E N T S

A System Built to Fail

A New Foundation that Puts Patients First

Better Care for Patients

Patient-Centred Funding for Hospitals and Hubs

A New Role for the Ministry of Health and Long-Term Care

Summary

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PAT H S T O P R O S P E R I T Y

A SYSTEM BUILT TO FAILThe health care system in Ontario today is complex, inefficient and difficult for patients to navigate. The ideal system would operate more like a smart phone, still complex, but simple to use because the designers have gotten the engineering right.

Any consumer knows that a badly structured system of any sort creates frustration, delays and poor results. In health care, that means higher costs, long waits for service and health outcomes that are not as good as they should be.

Patients are paying a price for a poorly-built system, and so are taxpayers. An OECD study estimates that if Canadian health care was as efficient as the best-performing European systems, Canadians could save as much as 2.5 per cent of our GDP in health care costs. In Ontario, this amounts to $13.4 billion according to economist Don Drummond’s recent report on reforming the province’s public services. That’s money that should be going to patient care.

The government’s own agency, Health Quality Ontario, says people are waiting too long for treatment in emergency departments, for long-term care and even to see their own doctor. Despite spending over $2 billion, just over half of Ontarians have electronic medical records that can’t link up with other providers.

To determine how to re-engineer Ontario’s health care system, it’s necessary to look at the parts and determine what is working and what is not.

The first thing a reasonable person would observe is that there is layer upon layer of management in the health care system. There are the Local Health Integration Networks (LHINs), the Community Care Access Centres (CCACs), hospitals, as well as the Ministry of Health.

Despite all these chiefs, it often seems like no one is in charge. A lot of people are working hard to make this cumbersome system work, but the real solution is to rebuild it with

fewer players, fewer layers, clearer roles and real accountability. That’s going to mean big change. Change that will result in improved patient care. Change that will result in improved patient care and greater financial accountability.

The Ontario PC Caucus has long advocated the elimination of the LHINs. Don Drummond also concluded that the LHINs, as presently constituted, weren’t up to the job of integration that Ontario health care so desperately needs.

We propose the elimination of two layers of middle management – the LHINs and the CCACs. The case for shutting them down and using this money for patient care is strong.

Back in 2006, the provincial government created the LHINs with the idea that they could “transform the way our health care system is managed.” Unfortunately, the LHINs weren’t equipped to do the job. They have limited control over spending, not much ability to influence the way the sector works and are run by boards of provincial appointees, not the people who run health care on a day-to-day basis.

Increasing Share of Program Dollars Going Toward Health Care

Source: Ontario Ministry of Health

201220031993

$0.42$0.39$0.32

2024

$0.54*

*projected

Cos

ts p

er p

rogr

am d

olla

r

We do not directly provide

services.Source: LHIN Website, August 2012

“That last point is a key one. LHIN boards are stocked with people who are beholden to the provincial government. They don’t do anything that the province doesn’t tell them to do. They are assisted by managers

”

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care, long-term care and home care have either remained the same or worsened under the LHINs.

Despite spending $1 billion on an Aging at Home program, a Toronto Star investigation found the strategy failed seniors by not providing the care they needed to remain in their homes.

The LHINs have failed miserably at their most basic task, integrating our system. Drummond noted that “despite the title, the LHINs do not integrate key parts of the health system.” Premier’s Office

The Layers of Ontario’sHealth System

Cabinet

Minister of Health

Ministry of Health

Health Quality Ontario

eHealth Ontario, CancerCare Ontario, etc.

Regulatory Colleges

LHINs

CCACs

Hospitals

Community Providers

PATIENTS

Despite the title, the LHINs do not integrate key parts of the

system.Source: Drummond Report,

February 2012, Pg. 172

“

”The LHINs are not really local, they haven’t integrated health care and “Network” in their title remains only a concept. Put simply, LHINs just don’t work.

The situation with the Community Care Access Centres has received less attention, but isn’t much more encouraging.

Nearly one in ten patients is readmitted to Ontario hospitals through emergency departments within seven days of being discharged, according to the Canadian Institute

who often lack the experience or skills to qualify for the sophisticated leadership jobs in hospitals, where they could have a real effect on patient care.

The LHINs are condemned by their own results, or lack of them.

The LHINs haven’t improved health system performance. For instance, the average LHIN failed to achieve 77 per cent of the government’s health care targets in 2010-11, according to the LHINs’ own annual reports. Province-wide, wait times for services such as emergency

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for Health Information. This is due in part to a lack of quality community care. Hospital readmissions cost our system millions each year, use much needed hospital beds and are bad for patients. The CCACs have failed in their role in preventing readmissions.

The CCACs’ core job is managing patients’ access to care in the home care and long-term care sectors. The goal is to make home care and long-term care less confusing for those who need help. It’s a useful goal, but the CCACs are doing a poor job.

No one sees the big picture, which is that helping people stay in their homes is the best care for them, and the cheapest for the system. When it comes to long-term care, managing the waiting line has become more important than those the system is there to serve. People are forced into long-term care homes before they need them because they fear losing their spot in line.

The CCACs are failing at great cost. They devote 30 per cent of their budget, more than $500 million a year, to administration and case management, according to the

Auditor General. They simply aren’t getting results.

A PC government established the CCACs in 1996, and they were an improvement on the old system, which was fractured and mostly municipally-run. They also introduced some competition into the sector, which the Liberals weakened when they froze competitive bidding in 2008. Unfortunately, over time, the CCACs became top-heavy, siphoning away valuable front-line dollars.

We agree with the Drummond Commission’s position that CCAC functions should be absorbed by a

A failure of leadership at the highest levels within the WWCCAC resulted in a degree of

organizational dysfunction.Source: Corpus Sanchez, Ensuring Effectiveness & Accountability at the

Waterloo Wellington CCAC, June 2012

“”

regional health authority.

Both the CCACs and the LHINs are administrative bodies that don’t produce value for money in a health care system that struggles to afford real patients’ needs. They’ve got to go.

The Ontario PC Caucus believes it’s time for a fundamental restructuring of health care in Ontario, to create a system that puts patients first and stops wasting health dollars.

We don’t think that a platform of excellence can be established from

a foundation of weakness.

The reality is that LHINs don’t feature the capacity, leadership or track record of performance that other health care organizations in Ontario do. Building off the LHIN platform, as Drummond proposed in his report, would institutionalize weakness. We think it makes more sense to rely on our strengths by doing more with our existing high-performing health organizations. That’s why we are proposing specific hospital boards, directly linked with organized primary care physicians, serve as a platform to take over the job of coordinating the regional integration of health care.

There are 10,000 seniors waiting for home care and 20,000 seniors waiting for a long-term care bed, a problem the CCACs, the LHINs and the health ministry have not been able to tackle.

This reduces the CCACs to rationing home care, delivering it only to those who are absolutely desperate. CCACs end up in the news because they do things like telling a disabled Ottawa senior they can’t afford to give him a weekly bath depsite promises to do so, or telling a 105-year-old Toronto woman that she will have to wait two years to get long-term care.

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In streamlining the health care system, we asked, how do patients really use health care?

For example, consider the situation of a typical older person with chronic illness. She might require home care through the CCAC, primary care from her physician or help at the hospital. In reality, there is a close connection among all these needs, but they are met by separate systems, with the LHINs as the weak glue that tries to hold them together. It’s up to patients to understand how all this works and try to connect the pieces. We don’t think that’s the right approach.

We also observed that the province’s 14 LHINs cover large territories that don’t always reflect how and where people live and seek care. We believe some of the geographic zones the LHINs represent are simply too large

A NEW FOUNDATION THAT PUTS PATIENTS FIRST

to be considered “local”. Similarly, the Ministry of Health is too far removed from patients and what’s happening day-to-day to really understand local needs.

Our solution is to have 30 to 40 existing hospital corporations, based on regional health care characteristics, serve as a platform to take over the functions of the LHINs and CCACs. The health experts we consulted thought this was the appropriate number of hubs to service a province with Ontario’s patient needs. Unlike the LHINs, which were prescribed at Queen’s Park, specific hub proposals would be developed by communities themselves to address local characteristics. These health hubs build off the best parts of our existing infrastructure. We believe the care needs of Ontarians will be better served by this decentralized

and delayered system — with smaller, regional hubs that follow natural referral patterns, that are more connected to patients, that are well regarded by the community and that are run by health leaders with a track record of success.

The health hub is a simple concept. Hubs take over the LHINs’ job of local health care planning, funding and performance. They also take on the CCACs’ job of connecting people with government funded home and community care and long-term care. Most importantly, they will be required to integrate acute care with primary care, home and community care and long-term care into a seamless partnership.

Health hubs will provide the administrative expertise that this new system requires. They have strong performance and accountability mechanisms already in place. Ontario has the most efficient hospitals in Canada, according to the Canadian Institute for Health Information. They have a long history of success and are a visible centre of care in the community. Patient-centred funding will make them even better.

In our proposed model, the people who actually manage and deliver your health care today would run the system without costly and extraneous bureaucratic organizations that impede innovation. Decisions will be able to be made in a timely manner and without bureaucratic processes, ensuring patient care is always the priority.

Local health care shouldn’t be run by people appointed by the provincial

Hub/Hospital Corporation

Informal Coordination

Hospitals

Formal Integration

Health Hub Model

Long-TermCare

Home and Community Care

Primary CareFamily Doctors, Nurses

Public Health,Mental Health, EMS

PATH 1

PATH 2

PATH 3

PATH 4

PATH 5

Eliminate two layers of middle management – the 14 LHINs and the 14 CCACs – and use this money for home care and other frontline patient care instead.

Build off of the existing high performing health infrastructure in 30 to 40 Ontario hospitals to create health hubs. Hubs will organize, plan and commission services for the patients in their respective regions.

Require the health hubs to integrate into a seamless partnership, acute care with primary care, home and community care and long-term care.

Require each hub to establish a permanent, physician-led Primary Care Committee to integrate primary care physicians into local health care planning and to scrutinize their ongoing performance.

Investigate options of coordinating municipally-run public health units and emergency medical services with the hubs.

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cabinet, as is the case with the LHINs. The health hubs will have local, volunteer board members chosen based on their unique skillset. These people will bring professional expertise and knowledge of their own communities, making them well positioned to manage the new system.

For physicians, it will mean a stronger, more hands-on role in planning primary care, as well as new accountability for producing results. This will be driven through physician-led Primary Care Committees. These permanent hub fixtures will have formal authority for integrating primary care physicians into local health care planning and

scrutinizing their ongoing performance in quality of care, patient experience and other metrics.

Because our patient-centred care approach will call on communities to develop a proposal to establish health hubs, rural and Northern health needs will be given a renewed focus as communities will design their health hubs to serve their unique populations. This means, for example, that a health hub in Central Ontario will look different and service different population needs than would a health hub in downtown Toronto. The design of these hubs is nimble enough to adapt to geography and circumstance. Rural and Northern health needs must be prioritized in the

design of hubs, and we will look to leading best practices in all jurisdictions.

We want to be clear that this does not amount to letting hospitals make all the decisions. This will be a partnership among equals. It is also about putting the patient first and making better use of existing sites, not closing them down.

Today in Ontario, public health and ambulance and paramedic services remain under the control of municipalities and outside the main health care system. The hubs will ensure that local health systems are coordinating with these municipal services.

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What does this mean for patients? Let’s go back to the smart phone analogy. We know that most people don’t care about the mechanics of the health care system. Like smart phone users, their main concern is getting the service they need, when they need it.

That requires a system that can respond quickly and appropriately to your requirements. Our health hub plan makes that easier by having primary care, home care, long-term care and acute hospital care all operating on the same platform. Putting all those services under one administration and making proper use of electronic health records will make it easier for all the health professionals that serve you to work together to make timely and

appropriate decisions about your care.

We see big gains from the integration of primary and acute care with the other two large parts of the health care system, home and long-term care. This will lead to more rational decisions about how money is spent, what volume of services are available and more timely care.

Here’s a concrete example. Today, one in six Ontario hospital beds are filled by people who don’t really need the level of care hospitals provide. They are stuck in hospitals when they don’t need to be.

We’re told the system can’t afford the cheaper home or long-term care, so people get the most expensive

care in the system instead. This is because of the lack of planning and coordination. This one problem alone costs Ontario $400 million a year according to the Ontario Hospital Association.

This is one of the problems the new system is designed to fix. It puts all the local health care money in one pot, under the control of one board. If home care is cheaper and better for you as a patient, the board will provide that care. Under the new system, it is in the hub’s interest to do so.

With far fewer patients who really need an alternate level of care stuck in the hospital, more beds will be available for those who really need them. This will lessen emergency room backups and make more beds available for surgeries, too.

BETTER CARE FOR PATIENTS

PATH 6

Accelerate the implementation of patient-centred funding at Ontario’s hospitals and hubs.

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PATIENT-CENTRED FUNDING FOR HOSPITALS AND HUBSAs part of our plan to put patients first, we propose changing the way hospitals and hubs are funded.

Ontario is moving far too slowly in adopting patient-centered funding – a model that most developed countries have been using for years.

There are two principles to patient-centred funding. The first is making sure health care dollars follow a patient as they travel through the health system. The second is making sure that health funding reflects a community’s health based needs.

Patient-centred funding doesn’t mean less money for hospitals and hubs – it simply means they’ll get the right amount of money. Here’s

just one example.

Historically, Ontario hospitals have received a lump sum of money for the entire year. This had the unfortunate consequence of turning patients into a drain on hospital budgets. Under this model, every time a patient walked into a hospital for care, the hospital had less money. The province also uses the same funding model for the CCACs.

We’re proposing to reverse this. Under the new system, hospitals will get money for every service they perform. This simple policy change turns patients into valued customers, not drains on hospital budgets. They will be treated like human beings and will get better customer service.

It creates the potential for healthy competition between hospitals and independent health facilities, such as the Kensington Eye Institute. It also reduces variations in rates now being paid.

Hubs will be funded on a patient-centred basis as well. Nearly all of the money they get from the province will be based on a community’s health needs. Hubs will have total control and responsibility for this funding. For example, a hub might choose to locate a nurse practitioner-led clinic adjacent to a hospital emergency room, so that people with less urgent problems can be seen quickly. A region with higher than average rates of diabetes will be able to tailor their services to local needs and be compensated accordingly.

PATH 7

Reduce the size of the Ministry of Health. Make it responsible for provincial health system planning, funding and quality control. Eliminate its role as micromanager of the system. Make the Minister ultimately accountable for Ministry performance.

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A NEW ROLE FOR THE MINISTRY OF HEALTH AND LONG TERM CARE

CONCLUSION

The health ministry will play an important role in Ontario’s revamped health system, but that role will be fact-based planning, not bureaucratic micromanagement of the system.

As it exists today, the ministry is an organization that takes a long time to produce very little. The ministry’s recent “action plan” on health care took nine years to write, but it is only 14 pages long and doesn’t address vital issues such as how much home care or chronic disease care we

will need in the future. That kind of performance is unacceptable.

Under our health hub plan, a smaller, streamlined ministry will shift to a position of strategic advisor with responsibility for provincial health system priorities, regulation, funding and performance measurement through Health Quality Ontario. This is significant work, but we don’t need hundreds of health bureaucrats to do it.

The main challenge for the ministry

will be capacity planning, determining the province’s future health needs. The last such plan in Ontario was created in 1998. Without a detailed assessment of our needs and how to meet them, the health care system is on a journey without a map. This broad guidance is the kind of role that is appropriate for government.

The ministry will set the policy structure for the hubs but they will allow these regional health organizations the freedom to design programming to meet patient needs. The ministry will ensure accountability for quality either directly or through Health Quality Ontario, and financially through audits.

With a $15 billion deficit, Ontario can’t afford to keep throwing money at health care. We need to be smart-er about how we spend what we’ve got and to always put patients’ needs first. That’s the context in which we offer our ideas for restruc-turing health care.

This paper doesn’t attempt to ad-dress all the challenges of the health system, but we believe it will fix a significant problem that is prevent-ing the kind of health care improve-ments that Ontario patients deserve

and need. This is not the only new idea we will propose. We will ad-dress other apsects of health care improvement in a future Paths to Prosperity discussion paper.

We believe that the introduction of health hubs will lead to a nimbler health care system that has clear roles and accountability for all the players. This will mean quicker deci-sions and more money spent on pa-tients. The multi-layered bureaucra-cy that attempts to guide our health care now will be slimmed down and

brought closer to patients. This opens the door to innovation and tailoring our health care to the needs of our communities.

The new system will make the most of the talents of the people who actually deliver health care. Local health care managers will be able to make timely decisions without hav-ing to get them approved by a LHIN or the Ministry of Health.

The provincial government will re-main ultimately accountable for

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health care, but it will stop micro-managing the delivery of it. Instead, it will focus on policy and measuring results.

It is not our goal to deliver more health care in hospitals. That’s cost-ly and not medically necessary. The new health hubs will have strong budget incentives to deliver care in the community that’s appropriate and cost effective.

In our proposal to restructure health

Please let us know what you think by contacting us at:

[email protected] (Constituency)416-325-6242 (Queen’s Park)

RM 410 Main Legislative BuildingQueen’s Park, Toronto, ONM7A 1A8

email:phone:

mail:

care, we rely on our core principles. First, build on what’s already work-ing. Then, examine the plan to make sure it has the absolute minimum amount of bureaucracy. Finally, test the plan to make sure it delivers value for money. We are confident that this proposal meets those three tests.

Health care is the government’s most costly service and the one most vital to the welfare of all On-tarians. The problems that patients

have in accessing health care today are not due to lack of money in the system or shortfalls in our medical professionals. The problems stem from the way we’ve organized health care. The so-called system is diffi-cult to understand and the pieces don’t interact well enough. For pa-tients’ sake, we simply have to do better. With the bold new focus we suggest, we will succeed.

PATH 1

PATH 2

PATH 3

PATH 4

PATH 5

PATH 6

PATH 7

Eliminate two layers of middle management – the 14 LHINs and the 14 CCACs – and use this money for home care and frontline patient care instead.

Build off of the existing high performing health infrastructure in 30 to 40 Ontario hospitals to create health hubs. Hubs will organize, plan and commission services for the patients in their respective regions.

Require the health hubs to integrate into a seamless partnership, acute care with primary care, home and community care and long-term care.

Require each hub to establish a permanent, physician-led Primary Care Committee to integrate primary care physicians into local health care planning and to scrutinize their ongoing performance.

Investigate options of coordinating municipally-run public health units and emergency medical services with the hubs.

Accelerate the implementation of patient-centred funding at Ontario’s hospitals and hubs.

Reduce the size of the Ministry of Health. Make it responsible for provincial health system planning, funding and quality control. Eliminate its role as micromanager of the system. Make the Minister ultimately accountable for Ministry performance.

PATHS TO PROSPERITYPAT I E N T- C E N T R E D H E A LT H C A R E

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Documents

Patient Centred Health Care