Most people in the health sector breathed a sigh of relief when Ontario voters rejected the Tories — and with them, several seriously ill-conceived policies on the healthcare sector.

However, as I and others have consistently pointed out, it did not matter who won the provincial election, because, whoever formed the government would be faced with what is: a truly unsustainable system for delivering healthcare services.

While nobody in the provincial government today ever talks about “the discipline of the marketplace“, trust me. It’s coming. Ontario is in big trouble, and we are about to pay through the nose for it over the next three or four years.

Credit rating agencies analyze the ratio of provincial debt to revenue to gage each province’s capacity for managing debt — just as a bank examines our ability to pay the mortgage on our homes. What the government will be hearing these days isn’t good news.

Moody’s Investor Services says that Ontario has by far the highest ratio of any province — where our debt now amounts to 238% of our revenue. As a result, they just adjusted our status from “stable” to “negative”. That means the cost of borrowing money is going to increase for Ontario’s taxpayers.

A credit rating drop predicted to come within weeks — combined with a 1% hike in interest rates — can easily cost Ontario taxpayers another $4 or $5 billion in additional interest charges — on top of the $10.6 billion in interest payments we’re already paying today.

The new Ontario budget — which the people of Ontario voted for in the election — adds billions more to our existing $300 billion debt. However, the government has promised to reduce the deficit by at least $4 billion a year — for the next three years. People are asking: if 55% of our provincial expenditures are on wages, who is going to contribute to the $12 billion in “required savings” over the next three years? Whose ox will get gored?

Since it is estimated that up to 30% of our $50 billion healthcare expenditures are wasted, the healthcare budget will no doubt be under pressure — certainly in next year’s provincial budget.

Addressing these financial realities for our healthcare system, will require our provincial leaders to demonstrate unprecedented vision and courage. People truly want our leaders to succeed in transforming our healthcare system to be more customer-focused — with higher quality, and more effectiveness.

The people of Ontario did make a choice in the election: they want their government to be “force for good in their lives”. They are counting on our leaders to “fix” our healthcare service delivery system — including getting rid of waste, and reallocating resources to where they are needed.

But will Kathleen Wynne, Eric Hoskins and Bob Bell be visionary and courageous enough to cause those types of transformational changes over the next two, three and four years? Will they in fact lead our healthcare system through a fundamental transformation from caterpillar to butterfly — or, will they simply continue with the same/old tired health reform rhetoric that certainly seemed sincere out of the mouths of the last three Ministers — but never really materialized?

Where is all the “health reform” we already paid for?  The numerous examples of real innovation that I have seen came from local leadership and front-line wisdom — not from a costly government program. These issues will be the focus of my future blogs — as our new leaders hopefully seize control of the agenda.

I expect that Minister Hoskins will produce high-level strategic directions for the healthcare service delivery sector within the next six months — perhaps by next January.

In the meantime, I think our new Minister will be listening very carefully to what the various self-interest groups and patients’ groups within our healthcare service delivery system have to tell him about creating a better, more effective healthcare delivery system — for less money. As a passionate reformer and advocate for the little guy and the weak, he will also be “open to new ideas” from groups that have not traditionally had easy access to the Health Ministry’s inner circle of power and influence.

With the “Changing of the Guard” at Queen’s Park comes the possibility that old paradigms and ways of thinking will end. A new Premier, Minister and Deputy certainly generates hope for a fundamental mindset and cultural transformation. While “Changing the Guard” at Buckingham Palace is a very precise and disciplined process, at Queen’s Park, we encounter a very messy, complex, adaptive human system of interrelationships that are driven primarily by power, money, status and ego.

Changing all of the key power players at once creates a highly threatening environment to the status quo — and to those who thrived in the former regime and benefited from the lack of transparency.

However, the countervailing force against the existing status quo is Kathleen Wynne — with a very different grassroots perspective than her predecessor — who loved the high-tech and “big IQ” projects; Eric Hoskins, a social justice Rhodes Scholar, who, as a passionate reform-oriented  policy-wonk, has now been handed an historic opportunity to actually save medicare from collapse; and, the Minister’s key-person, Bob Bell, a self-described “healthcare rink-rat”, who, as Deputy, will oversee the implementation of the new government’s evolving policies for improving mental health services, reforming the primary care service delivery system, and finally getting in the illness prevention business.

This is the group that will be accountable for successfully transforming healthcare within the next four years. But will they succeed? Will this new leadership group actually “think-outside-the-box”? Will they reach beyond the same old tactics, to generate the actual transformation of the delivery system at the local level?

How will our new leaders — with their fresh perspectives — respond to the initial round of briefings that they will get at the same/old, same/old MOHLTC, and from the same/old vested interest groups?

In addition to the “inner circle” of interconnected friends, the formal Government Structure of the MOHLTC will also be experiencing high-levels of anxiety. Will they be able to survive the leadership shift? Will they win the new guys over? There’s lots at stake! Jobs. Money. Power.

Over the past decade, MOHLTC was able to grow and thrive as they responded to the opportunities provided by numerous scandals to expand their “control” over the healthcare service delivery system from their Bay Street offices in downtown Toronto. Despite the government’s own legislation to create LHINs, and downsize the MOHLTC, the number of Assistant Deputy Ministers in fact grew over their first two terms from 5 to 14 — each with multiple new branches seeking even more things to “control”, and more people to “command”.

The assumption in our current health system design is that we need a centralized bureaucracy to provide the operating system with templates/processes/regulations that require extensive monitoring to ensure compliance with what Queen’s Park says. However, will Hoskins/Bell /Wynne stick with that assumption — that our delivery system needs to be micro-managed from Queen’s Park? Does the new team believe that because Queen’s Park puts forward the “illusion of control”, that they actually have any control?

It would be prudent for the new leadership to remember that the MOHLTC is itself a narrow self-interest group that does not always operate in the public interest. While the initial briefings for the new leadership team will no doubt feature a predominant underlying theme of the compelling need to “protect the status quo”; and, to maybe consider some additional “minor tinkering” that essentially leaves MOHLTC intact — in control — and continue to be unaccountable for the system chaos they create.

Nevertheless, the pressure for fundamental transformational change will be significant — and time will be of the essence.

The Wynne/Hoskins/Bell Team cannot afford to wander about for the next two years contemplating, “what we should do differently?” If they are going to demonstrate progress by the next election — four years from now — they need to start sooner than later. They need to set out high-level strategic directions within five or six months — perhaps by next January/February, 2015.

Along with their policies and priorities, they need an interlocking set of mission statements that clarifies everyone’s roles over the next four years: the role of the MOHLTC; of the LHINs, of governing boards and CEOs, and the roles of the Health Service Providers.

People who want to see changes in roles/authority/mandates, need to communicate their best thinking to the Minister now.

Some groups will understand and really “get” that this next six months provides a time-limited opportunity to think creatively about how our public services ought to be re-invented.

Formal Vested Interest Groups — including the OMA, OHA, RNAO, AOHC, OACCAC, etc — will be up-dating and re-aligning their self-interests with what they perceive the new power players want to hear. The more reform-oriented interest groups like Patients Canada, Association of Ontario Health Centres, RNAO, Canadian Mental Health Association, the Ontario Community Support Association and several others, could be welcomed into the evolving “inner circle” of influencers as the generational leadership evolves and transforms in partnerships with the new leadership team.

The more traditional lobby groups will also be tarting up their most recent policy papers, advocacy positions, and, in some cases, their “vision” for how Ontario’s healthcare system should be organized and managed. This, I think, will be time well-spent. These high-level strategies will almost certainly capture the attention of a scholarly policy-wonk like Eric Hoskins.

Policy Papers — like the ones created just before the election by RNAO, and by the OACCAC — are focused on the “big picture” — with an emphasis on how the system could be changed and improved. Hoskins has to address the big questions these groups raise.

Joining the debate about the design of our future system will be another powerful self-interest group that will be anxious to maintain the status quo: the CEOs of the Health Science Centres — who could potentially be faced with steep spending cuts over the next four years with a Premier and Minister who are strongly oriented to shifting to community care, primary care, mental health services, health promotion and chronic disease management.

Some Health Science Centres have already undertaken the exercise: how would they downsize by 5% if they had to? Some are exploring how to make money from “medical tourism”, and other revenue-generating ideas.

While there has been some negative gossip over the early summer about how our new Deputy, Dr. Bob Bell, may be limited by a rigid “University Ave Lens/Perspective“, paradoxically, our new Deputy could in fact become a countervailing force — as he grapples with his role of implementing the government’s priorities on: primary care reform, mental health service expansion, health promotion/illness prevention — and, improving the patient’s experience across the delivery system.

We don’t know where our Deputy is heading yet, but he clearly signed-on for “big changes” in our delivery system. The key issue of devolution may rest on the final report of the Standing Committee Of The Legislature that conducted hearings across Ontario to learn about what the system believes needs to happen with LHINs, CCACs and HSPs.

It will be interesting to learn about their insight on how the government could improve on this initial attempt at local empowerment through the Local Health Integration Networks. What will they recommend?

Our most recent Leadership Survey @ found that 76% of health system leaders believe in some devolution/local empowerment — but with many calling for the transformation and re-skilling of the LHINs. But will the status quo still win?

If the choice is between saving our healthcare system through local empowerment, and downsizing the Ministry of Health, it will also be interesting to see where our public sector unions stand on that question. Former Health Minister Deb Matthews will be drawn into this debate about “Saving Medicare” vs. “Saving MOHLTC” in her key role on spending controls and dealing with the public sector unions.

Remember 19 unions spent $9 million in the final week of the campaign on ads saying: “Don’t vote for Hudak“. How will the government respond to their election allies? Or, will they actually opt for real health system reform, and topple the Ministry in favor of local empowerment — while being fair and generous to its employees?

There will be no end of complex and messy challenges for the new leadership team. The issue will be their preparedness to actually step away from the status quo, and the same/old same/old solutions and “fixes-that-fail” in order for them to take focused leveraged actions that will propel our health services delivery system into transformation, as we shift from caterpillars to butterflies. Real transformation, not rhetoric.

While consumer empowerment is the ultimate goal, our leaders need to start empowerment earlier in the food chain — by empowering the LHINs to liberate HSPs, and by Health Links to implementing their local health system improvement agendas, while HSPs empower their front-line healthcare service providers to re-design the patient experience in their silos.

It will be interesting to see what LHINs do in response to the arrival of the new Minister.

The LHINs could potentially become the new Minister’s “eyes & ears” on the delivery system — like their DHC predecessors. They could also be the Deputy’s “window on the delivery system”. However, the LHINs have historically been strongly influenced by the MOHLTC staff, rather than having strong relationships with the Minister’s Office. Will Hoskins embrace LHINs as his “agents” in local communities?

Since their establishment, the LHINs have mostly been silent on the “devolution” issue — as three Ministers, two Deputies and four ADMs ignored the legislation empowering the MOHLTC to devolve spending authority from Queen’s Park to local communities. The idea was to “empower the LHINs” to  fund their own Integrated Health Service Plan for their community. Some LHIN leaders have spoken up, but most have been silent.

So the question is: will there be a serious effort to transform, re-invent and re-skill our public services, or, are we going to continue on our long slide from a healthcare system that ranked third place in the world just ten years ago, to having now slipped to 11th place — behind the US, and behind most major developed countries?

Pulling us out of this rut and leading strategy implementation bureaucratically will be the new deputy Minister and his three Associate Deputies — Susan Fitzpatrick, Helen Angus and David Hallett — with Fitzpatrick basically operating as the COO of the Ministry.

Will this MOHLTC Executive Team become “out-of-the-box thinkers”, or are we up for more of the “same/old, same/old”? Most people seem optimistic, but time will tell.

While Dr. Eric Hoskins is still an unknown quality, the fact is that the very survival of Medicare in this province, and in this country, is now in his hands. He didn’t ask for this job, let’s hope he, his Deputy and the Executive Team at MOHLTC do well.

I don’t know anybody who doesn’t truly wish our new leaders the very best. We need them to be successful. When they succeed, we all succeed. We each need to ask: how can we help the Minister and Deputy be successful? We also need to hold them accountable for the results they produce. They are in stewardship to the system.

Within the next 100 days — to six months — we will learn whether Mr. Hoskins and his aligned team will embrace the status quo/the inner circle/and the same/old namby-pamby empty rhetoric about health reform, or, if indeed — as I predict — our new reform-oriented Minister will actually lead the fundamental paradigm shift required to re-invent and transform how our existing health and health-related social services are delivered — perhaps just-in-time for the next election, perhaps even with Dr. Hoskins heading to the polls as leader of his party in 2018.

There are a number of successful Health Ministers who have sought their party’s leadership — several successfully. They say: “Here is what I accomplished in healthcare, imagine what I could do as Premier.”

So Hoskins, and the staff he puts in place, will indeed be open to new ideas — and to new ways of seeing old problems. They have the very important task of “saving medicare and transforming healthcare” ahead of them.

Nevertheless, for the most part, over the next few months our new leaders will be encouraged at numerous briefings to maintain as much of status quo as possible — with only some “minor tweaks”. So how would YOU advise the new Minister? Here is your chance to join with perhaps a hundred or more other leaders to communicate your best advice — anonymously.

Health Leaders’ Surveys @ have provided the 1,500 to 2,500 readers who reviewed them each time with important insights from the 150-200 leaders who invest 10 minutes to provide anonymous briefings to Minister/Deputies/decision-makers/health system leaders.

So, share your wisdom/insights with Hon. Eric Hoskins by clicking on and completing the Anonymous Health Leaders’ Survey.