Comments on the OMA Submission to the “Patients First: A Proposal to Strengthen Patient-Centred Health Care in Ontario” Discussion Paper Consultation, February 2016
LHIN Capacity Role and Function
Much of the interest in integration stems from the United States where a robust primary care system has not existed historically. Unlike the US situation, Ontario has had a robust primary care system for many decades which has functioned well to serve the population for the most part. Tinkering by government over the past twenty years has not achieved desired outcomes. The cost of government attempts to integrate and coordinate are significant and the outcomes uncertain.
Having unevaluated LHINs tasked with integrating care is a project to keep the LHIN bureaucracy occupied. In attempts to create more value through integration, government is attempting to justify its creation of LHINs in the first place.
Although the concept of “local” in primary care makes sense, true local care is at the interface of the patient and the physician where patients and their needs are treated as unique. It’s not possible to standardize patients or their needs.
The approach that government has shown to the complex nature of patients and primary care predicts that government created LHINs lack the necessary insight to appropriately coordinate primary care further.
LHINs tasked with integrating primary care are simply a mechanism to redistribute primary care physicians without representation.
Further coordination of publicly funded care may seem laudable at first glance. However, evidence of the consequences is lacking. In complex systems such as health care it is difficult to predict the results of change.
The creation of sub-LHINs creates further levels of bureaucracy and requires more governance structures that have potential to become unwieldy. The inflexibility that is created poses concerns about interconnected failures. As one area becomes bogged down with complex governance, associated areas will also be affected. The ability to adapt to rapidly changing advances in health care will be diminished. The concept of independent practices which provide flexibility and rapid adaptation will be lost.
The advantage for government will be the optics of creating “added value” of accountability agreements. However, this is cause for concern as physicians may be limited in their access to sub-LHIN regions resulting not in primary care MDs going to underserviced areas but instead, leaving the province altogether; biding their time in some other line of work; or furthering their education while waiting for a practice opening.
Physician Leadership at the LHIN and sub-LHIN level
In current health care transformation it is usual to see “physician leaders” selected for their willingness to support the government agenda. This might seem reasonable except that the consequence of creating what are essentially political patronage appointments serves to solidify policy change that has politics at heart and not necessarily patients.
If patients were truly “first” in health care transformation efforts, there would be greater ability for the system to adapt to respond to individual circumstances. This is not the case.
The result of “partnering with local clinical leaders” who seek career advancement and compensation for their efforts will be that the sub-LHINs effectively become a conduit for the “local clinical leaders” to negotiate with government. The OMA as the “exclusive representative of physicians” could cease to exist simply because other mechanisms of interfacing with government have been encouraged to evolve.
The OMA could continue to exist but its main function would be significantly diminished.
There would then be a need for a true representative union for practicing physicians whose main leadership role is not to please government.
Access and Equity
The responsibility of LHINs for improving health equity and reducing health disparities is a daunting task that is noble in theory but problematic in reality.
It is understood that medical care is not the only contributing factor to overall health and that there are many variables contributing to individual and population health.
LHINs having the power to change personal health caused by external factors is a very big stretch.
A major concern regarding more funding funnelled to LHINs for integration and coordination is that more funding for bureaucracy will be required. Taking a loosely coordinated system between family doctors, consultant specialists, and focussed practice physicians and making it more bureaucratic and costly will divert tax dollars from much needed services for an aging population such as Long Term Care and Home Care.
LHIN involvement in primary care “access and equity” appears to be about forced distribution of physicians and allotment of patients rather than improving personal health. The concept of Patients First appears to be for optics only.
The government proposes to give LHINs more authority for local health planning and responsibility for managing accountability agreements with health units. In concept, government is creating mini health ministries. Public health units have been some of the most cost-effective mechanisms for delivering preventative services and population health. By absorbing health unit budgets into LHINs the costs and or cuts to services will be hidden from public view and scrutiny. This is not a transparent way forward. The benefits and costs of such maneuvering must be carefully weighed.
Home Care is increasingly important as our population ages. Integrating Home Care can be done but as long as funding for it remains inadequate the coordination efforts are misspent. More communication regarding patient care plans is meaningless when many patients can’t actually access the care they need in the first place.
Transfer of CCAC
LHINs acting in both the management of community services and in the delivery of community services are in conflict of interest.
Burying community care in LHINs risks harming the ability to evaluate not only the budgets related to community care but also the quality of the services provided. Once again, public scrutiny may be diminished and understanding the value of this manoeuvre will be problematic.
Preserving Physician Remuneration Models
Flexibility is a desirable goal for modern health care. No one payment model can address all patient need. However, the uncertainty that government has created in its recent movement away from honouring agreements with primary care physicians is problematic for improved transformation that is cost-effective.
Role and Function of the Ministry and Use of Performance Metrics in Accountability Framework
Increasingly accountability is tied to performance measures. The process by which local performance measures are established must be clearly defined and understood by all parties. Unintended consequences of performance measures in one aspect of care have potential to affect the care in other areas.
Physicians and hospitals pushed to provide care that can meet performance and budget targets will have an impact on patient choice. This is an important consideration in the context of “Patient First” discussions.
Role of E-Health
While generating data may have positives for research and scientific developments, there is conflict in spending more public dollars to integrate “patient information across the continuum” when vulnerable patients currently cannot access adequate Home Care services or affordable Long Term Care.
If our health care system cannot meet basic needs of vulnerable patients now, how will it meet the needs of growing ranks of patients with advanced dementia? Assuming that e-health can accomplish toileting and feeding patients with advanced dementia is problematic. The numbers of patients with advanced dementia is poised to increase dramatically with potential to overwhelm hospitals, ERs, and primary care. E-Health cannot replace human interaction with frail patients with dementia.
Without the inclusion and in-depth consideration of physician insights, any Patients First initiative is designed to be an optics-only exercise at best. At worst, it will lead to further destabilization of health care in Ontario resulting in hardship for patients and associated failures in care improvement.
Physicians should be cognizant that cloaking policy in sunny terms with public appeal does not equate with well-considered policy that includes highly valuable physician input.
Dr Merrilee Fullerton