We are told that the Ontario healthcare delivery system is on the precipice of a “fundamental transformation”. Is that a “good”, or “bad” thing?
Our Health Minister, the Hon. Eric Hoskins, and his Deputy, Dr. Bob Bell, are very up-beat in their presentations about the future direction of our emerging healthcare services delivery system. They are also very clear about their intentions: they would like to be seen to be doing something they say is: “patient-centred“, “integrated“, “more efficient“, “high-quality“, “transparent” and, “accountable“. They want people to get the “right care, at the right time, by the right provider“.
So that certainly doesn’t sound terrible. Indeed, many of us are quite keen to see such a transformation of our healthcare delivery system. If all those things actually happened, as you can imagine, things would really have to change in our healthcare delivery system. The status quo would simply not survive. Innovation and learning would flourish — because the system would be pushed to change and adapt.
But change and innovation are not something that bureaucratic systems are very good at. It is certainly not something governments usually want because, real change can mean political instability. That’s why governments tend to invest their efforts and talents in managing the “optics” of issues. Most Ministers and Deputies are under pressure– from the Premier’s Office and Finance — to “keep a lid on it”.
Indeed, my first-hand observation about the “Institution of Government” — under all three political parties — is that government (both political and bureaucratic) — is actually there to maintain as much of the status quo as possible. That’s their mission as government: maintain the “status quo”.
While some may think I’m being way too cynical; from my perspective, I’m simply telling the truth, as I have experienced it. As a recovering political scientist and Ministerial Advisor, I have observed up close that those who have “got” power and resources, have absolutely no intention of losing their resources and power to munchkins — who don’t have an existing power base; don’t really know how to influence government decisions; and, have never invested the time and resources required to achieve any personal or political linkages to the “inner circle” of influence at Queen’s Park. These are the people who are collectively working at shaping the design of our future healthcare services delivery system — and, in so doing, are creating the next generation of “winners” and “losers”.
People with power and resources are the ones who can invest significant time and effort engaging with political and bureaucratic officials. That’s why they made it into the “inner-circle”. They invest a great deal of effort working collaboratively with public servants, Minister’s staff/Premiers’ Office — and sometimes hiring professional government relations firms for help with strategy, communications, and political connections — as they set out influencing government thinking and public policy direction.
The “munchkin agencies” are just struggling to keep up with their patient workload, and their crushing reporting demands!
Of course, while the government-of-the-day — under all three political parties — has always sought to maintain and protect the status quo, they each have also proclaimed that they were being “patient-centred”, “patient-focused” and “more-efficient”. But is that really true? Are our governments really there to “protect the status quo”, or do they actually exist to “advance the cause of patients and taxpayers”? This is a Wicked Question, not a cynical question.
I think the answer will reveal that the status quo usually prevails; that change is almost always very incremental; and that there is little about our existing system that is either “patient-centred”, or “responsive to taxpayers”. I see numerous examples of this. Take palliative care, as an example.
In 1982, government polls for the Bill Davis government told us that 50 percent of the population preferred to die at home, surrounded by friends and family — with professional care and support services for families that did not want overly-medicalized, or high-tech hospital interventions for their loved ones. So, we started investing in home-based palliative care and hospitals.
Today — despite 40 years of growing taxpayer and health consumers support for expanded palliative care services in the community and at home — we still have only one in three patients with chronic illness who actually ever receive palliative care services. Patient-centred? Don’t think so! “More efficient”? Nobody seems to care.
Nevertheless, while two-thirds of us will not be able to gain access to the palliative care services we need and want, in a recent survey, 70 percent of hospitalized patients said they preferred “comfort measures” over high-tech, life-prolonging treatments. The question is: Why can’t taxpayers get what they want?
While there is no doubt that each successive government has claimed to be very supportive of comprehensive palliative care services, there always seems to be “no new money available at the present time”, or, only enough for incremental growth. The cold fact is that no government has been prepared to reallocate resources from acute care expenditures related to dying patients, to expanded community-based palliative care services. So the status quo survives — despite each of the very sincere statements from Health Minister Of-The-Day, that they “intend to expand the availability palliative care”; and despite the compelling business care for these less expensive services, there is never any significant growth.
In fact, it has only been on a few occasions when we have the required political and bureaucratic courage and alignment necessary to achieve “evidence-based decisions” — that disrupt the status quo, and produce real change. The rest of the time, public policy is too often about “power elites”, “inner-circles”, and “vested-interests” — who are all fully engaged in influencing and/or benefiting from decisions about public policy and strategic direction.
In the real world of healthcare politics, our Minister and Deputy Minister co-habit a shark thank where vested interests of all kinds seek their time and attention. So who our Ministers and Deputy spend their time with — will most certainly shape their thinking about “health system reform”.
So, what are the vested interest groups and inner-circle advisors clamoring about? Do any of their priorities reflect the patient/public interest — or are they all simply self-interested?
If there was alignment between Hoskins/Bell and Wynne on creating a Universal Palliative Care Program for the people of Ontario, it would certainly happen. But given all the various pressures they are under, who is pushing them for it? Do you think they have as many dialogues with Patients Canada, as they have with the Ontario Hospital Association and Ontario Medical Association? If they only listen to the power elites, to the vested interest groups, and to Queen’s Park’s inner-circle, it will not happen — because there is really nothing in it for any of them.
Even when the politicians clearly say they “want it to happen”, it does not happen.
Maybe if The Beer Store provided palliative care, they might finally convince the government to provide this “universal service” — as a succession of provincial Health Ministers from all three parties have talked about, but never provided.
FORWARD THIS BLOG TO COLLEAGUES WHO WOULD BE INTERESTED IN SEEING A UNIVERSAL PALLIATIVE CARE PROGRAM FOR ALL ONTARIANS.