“Saving medicare” is going to be a very tough assignment for our new Minister and Deputy Minister of Health given the state of Ontario’s economy. But while there are certainly many things that are not working well in our misaligned healthcare services delivery system, and while it’s true that our delivery system needs to undergo a fundamental transformation, there are in fact many examples of wonderful cost-effective innovations that really work well in our healthcare system today.
What we need to do is uncork the bottled-up innovation within the system, and, we need to re-invent healthcare delivery — by spreading these innovations. Instead of stifling everyone with endless rules/regulations and MOHLTC administrative control processes, we need to liberate the wisdom and know-how in the system.
What the Hon. Eric Hoskins, our new Minister of Health needs to understand is that the knowledge and wisdom on “how to fix the healthcare delivery system” is at the frontlines of care delivery — as close to the patient as possible. Yes, we have some smart and capable policy-makers, and several high-performing silo-organizations, but the healthcare services delivery system has not changed after 10 years of what we were told was “health reform”.
While hundreds of millions were spent of these reforms, it is difficult to see the impact of all these various health reform initiatives. Over the past decade there were some minor, as well as significant improvements — but we don’t have any transformational shifts that have taken place.
Real system reform — like the concept of devolving authority and accountability deeper into the delivery system — has been vigorously resisted by our public service for ten years. They don’t want to give up “control”, or even the “illusion of control”. Health Ministers Smitherman, Caplan and Matthews did not succeed in implementing their government’s legislation on local empowerment. They each spoke passionately about reforming the health system, but nothing changed — other than the law.
The fact is, over the past ten years, our Health Ministry successfully prevented devolution to the Local Health Integration Networks, and, as a consequence, most, or many people, believe that our LHINs are sub-optimal because they never actually had the ability to be successful. I think the “smart fix” now would be to implement “devolution”, and task each LHIN with the responsibility to fund their own Integrated Health Service Plan,either with frozen budgets — or perhaps, even with less money in future years.
If it’s true that there is 30% waste in our $50 billion delivery system, and that the government is compelled to find $12 billion in savings in the next three years, don’t you think that some of the required savings ought to be removed from the healthcare budget over the next few years, if there is indeed “waste”?
If it’s true that years two and three of the Wynne Government’s tenure are projected to be fiscally challenging — particularly when our federal government ends its transfer payment boost in 2016 — then prudent grassroots health system leaders will be including these calculations into their future planning scenarios.
Saving money in the health system isn’t going to be easy.
An old adage from a former Deputy Minister of Health was: “you can’t have a war with both the OMA and the OHA during a single term in office. Each government must pick one to go to war with.” While it sounds like cynical advise, if you look back over the years, it seems that each government had a fight with either doctors or hospitals during their term. But the easy life — when the government only had to fight with one of them, is over. The world has changed. Over the next four years the OMA and OHA will not be hearing a lot of good news from our provincial government.
However, no government has ever faced the tsunami of debt that the Government of Ontario must now contend with, as our total provincial debt approaches $300 billion — and, as our interest payments on the debt are now stretching beyond $11 billion annually.
That’s $11 billion in interest payments every year — at an historically low rate of interest!
A one percent hike in interest payments will cost taxpayers an extra $3 billion annually.
Nevertheless, eleven billion dollars in interest payments on our debt is more than we currently spend on education, training, colleges and universities annually. With a structural deficit, a stagnant economy, and the emerging reality of increasing interest payments on our massive $300 billion debt, we are most certainly going to be in “big trouble” within the next few years.
Moody’s Investors Service’s recent public sector debt report pointed out that “while California’s debt burden was 50% of their total revenues in 2012-2013, Ontario’s net direct and indirect debt is 226% of consolidated revenues.”
Several weeks ago Moody’s indicated that Ontario is currently undergoing a credit review that is expected to be completed shortly. Last week they downgraded our condition from “stable” to “negative“. To top off this bad news, the federal government has unilaterally reduced transfer payments to Ontario by $640 million — half of which was for health care.
While this seems to be difficult for some public sector leaders to comprehend, I know that mature groups like the OHA and OMA know in their gut that the government faces a solid brick wall on the province’s drastic financial circumstances. They know we have got to work on solutions — together. They know that the status quo cannot survive.
By Christmas or New Years, Minister Hoskins will no doubt lay-out his high-level strategic directions for the healthcare sector based on input form the Ministry of Finance and, designed to address each of the key challenges we face — including our financial realities. His strategic plan may also empower the healthcare delivery system to transform themselves — as patient-centred, high-quality, seamless services across the delivery system.
Ministers traditionally take the lead on the policy development front — with lots of support from the public service: from their personal staff; with input from LHIN Boards and CEOs; and, from the interest groups that they engage with.
So how will Hoskins build on the “health reform policy”, “lessons learned” from the past? How will he begin to build on the many successful innovations that already exist in isolated places throughout our healthcare services delivery system? How will he build on the solid footing of so many excellent world-class services?
Given our new Minister’s grassroots orientation, I suspect that his role over the next four years may be — to become “The Voice of the Patient” — while holding his multiple other perspectives as a doctor, an academic, social justice advocate, etc. He recently said that his top priority is to “improve the patient experience”.
If Hoskins were to come out with his Health Sector Strategic Directions by January, it would be very effective if he then invested three-months in February, March, April making a provincial tour — hosted by each of the Local Health Integration Networks — to explain his strategy paper to health service providers in each LHIN.
It would be wonderful if the new Minister invested a day or so in each of the 14 LHINs and get a chance to visit/see a number of these wonderful innovations at the local level. He would certainly gain real insights into what is/isn’t happening at the operational level where care is being delivered. He needs to see and hear about “what’s working, and what’s not working, across the province”.
While a provincial tour would enable Health Minister Hoskins to discover some wonderful new directions to invest in, over the next year or two of his expected four-year tenure, he will only have access to money from the savings he can get out of system improvements in “quality” and “safety” in the longer term — and in the short-term, by actually re-allocating money in the system. As a activist Minister, he will need lots of internal savings to pay for new grassroots innovation projects. Or, he could listen to the “inner circle” and the “vested interests”, and just maintain as much of the status quo as possible.
Historically, the Liberals have said: “we’re putting a protective blanket over the healthcare and education budgets — because that reflects our values.” The problem is, in the healthcare sector, about 30 percent of our expenditures do not “add value” — and are in fact wasted spending that could be both redeployed, and used in part to pay down our $300 billion provincial debt.
But if the Wynne Government were to continue to maintain a “protective blanket” over our healthcare budget, we would be irresponsibly protecting a great deal of the waste in our $50 billion health budget. What kind of “values” would those be, when the consequences are that government would then need to cut very effective programs outside the healthcare budget –including programs and supports that are in fact part of the “determinants of health”?
We could actually end up reducing “social supports” for children in the Community and Social Services’ budget — in order to “protect healthcare spending”. And then, because we would fail to adequately address the determinants of health, we will end up spending even more on treating the outcomes from the increased burden of illness among poor children that we were too short-sighted to prevent.
So, by “protecting the Ministry of Health’s budget”, we could paradoxically end up with a sicker society that cuts other Ministers’ programs like breakfast programs. That does not sound like the values of the Wynne/Hoskins/Matthews government that Ontarians elected.
In political systems, money flows not to where evidence says it is required, but to those who have political “power”. This is our existing system. That’s why our Health Science Centres and large community hospitals fill their boards with top business and social elites. Once a group has power and money, they naturally become dedicated to maintaining the status quo.
In rational economic systems, money flows to where there is the greatest return-on-investment (ROI). We do not have a rational system in healthcare.
The problem is that while today’s budget puts issues on hold for this year, next year, and three years after that, the health system is expected to be implementing big changes. But that’s not really how our existing system functions and behaves.
Dr. Hoskins will discover that our system encourages “spin-doctoring communications”, overt political behavior, and focusing on our narrow self-interests — rather than on the public interest. Public servants even ask interest groups to focus their submissions to align with the government needs — not their community’s needs.
In the current model, “the health system is in service to the Ministry”. Perhaps under Hoskins, “the Ministry will be in service to the system”. That would certainly be transformational! But we need change in how our LHINs and Health Links structures think and act as well.
In the future, we need local decision-makers who will develop the capacity to take on a much more evidence-based approach to our policy development, and to our strategic investments in healthcare that will also enable us to achieve significant ROIs, and to actually save money!
For example, for every $1.00 we invest in community-based mental health services and supportive housing, we save $2.17 in unnecessary costs in our emergency departments jails and courts. The previous government had no interest in such sound investments. They really seemed much more interested in “flashy” issues like the MARS Project, and the e-Health Program, than on sad, little mental health issues at the community level.
Making change is not easy. Normally, in political systems, if you move to reduce spending in those areas where people have “power”, there will be major “push backs” — sometimes with the underlying threat of more public battles. While the OHA says they support further investments in community care, they have never suggested that growth in community care should be funded by redeploying resources from acute care to community services.
While the political rhetoric of the past ten years has been about “transformation”, the actual reality has really been about maintaining the “status quo”.
So, how will our provincial government behave in a fiscally responsible way — while actively perusing their progressive agenda? This is the Red-Tory debate.
I think Premier Kathleen Wynne may yet emerge as our next modern-day Bill Davis — a Red-Tory Premier who always “pushed the envelope” to create a more equal, more just, and fairer society — while creating the environment for wealth creation and job growth, and ensuring the very prudent and ethical management of public resources.
That’s what people want from the Wynne Government — open, honest, fair processes that improve our public serves. To do that in healthcare means a fundamental transformation, rather than the on-going optical illusions and empty rhetoric.
With the Hon. Deb Matthews assigned to achieve cost savings, it will be impossible for her old Ministry to bring her new spending plans. She knows there is waste in the system, and that the system needs to be redesigned to be more efficient.
In the past, the Liberal government certainly talked about “population health” — and rhetorically Smitherman/Caplan and Matthews stated that they intended to “shift resources to community care” — but there is still little real evidence that there is any significant transformational shift in resources from institutions to community services — or from “treatment” to “prevention” programs. Those were Ministerial “Wishes”, rather than a strategy to shift resources.
So, “transformation” needs to be more than just noble rhetoric, and a new Secretariat. There needs to be focused action. What is the “transformation”? What should transform? That’s for Health Minister Hoskins to decide over the next several months. He needs to decide the what, and, how of the changes that are going to happen.
A good place to start? How about the “devolution of authority to the local level” — to provide the community empowerment promised by the original legislation that was passed nine years ago — but never acted on? The legislation passed under Health Minister Smitherman foresaw that LHINs would, one day, actually need to be “shifting resources” within their local service delivery system to meet their community’s unique needs. That certainly would have been transformational!
However, we’re still stuck with the same/old status quo, because Queen’s Park expanded their mandate over the past 10 years as they held on to the jobs, and the power to do resource allocation centrally in MOHLTC silos — while our political and bureaucratic leaders would babble-speak about “transformation” and “integration” for everyone else — and while staying in their own silos, and constantly making incremental changes that keep operational people busy “shuffling on the margins”, and “cutting on the edges” of the system.
As we move ahead, we really should stop wasting everyone’s time, creativity and good will on “hospital mergers”, and “munchkin mergers”? We need real, fundamental patient-centred reform. That fundamental reform should involve devolving spending authority to the local level — within a transformed and re-skilled LHIN system. We need to push control down into the system — right to the patient.
Minister Hoskins ought to let communities decide for themselves how to allocate the healthcare spending envelope for their community — as they address their unique needs, with either the same, or increasingly fewer resources, all with a set of provincial standards. That means transforming, rejuvenating and empowering the LHINs — as well as empowering Health Links; empowering our very capable operational managers; empowering our brilliant front-line care providers; and, empowering “patients as partners”.
The knowledge, know-how, wisdom and the insights into “what to do”, and “how to do it”, is in the hearts and minds of the people in the health care services delivery system — at the Health Link and LHIN-levels — and at the front-lines of patient care services. It’s in the hearts and minds of patients and their families. People are brilliant.
So, what do you think we need to succeed? What should Hoskins pay attention to? What should be “let go of”?
Here is your chance to share your best thinking with the new Minister & Deputy as they begin the process of determining the new strategic directions for the Ministry over the next four years. Click on Health Leaders’ Survey On Advice For Hoskins.