Monthly Archives: May 2019

A Policy Framework for Ontario Health Teams

 

Over the last 25 years and more many schemes have been hatched to transform Canada’s health/healthcare “system”. All have had one basic aim – to connect the dots; to co-ordinate the work of the ‘players’, hospitals through primary and home care to mental health and other community-based providers, getting them working together to make it easier for patients and their families to navigate care transitions from one to another. Reform’s imperative has also been governments’ concern about healthcare’s growing cost, measured both in terms of its share of total spending and also the opportunity cost over the longer term of constrained funding for the social determinants of health, education, housing, financial security, et cetera. That concern also reflects people’s growing unease about sustainability, possibly combined with increased awareness that the outcomes achieved here in Canada are middling at best when compared to those achieved in other developed countries.

Ontario’s government appears to have recognized that:

  • Fundamental transformation of how health and healthcare services are organized and provided remains undone. What is referred to as a system is an illusion that needs to be made real.
  • Transformation is now urgently required to avoid jeopardy to the province’s less than robust economic status.
  • Connecting the dots and achieving greater cost-effective productivity can only be accomplished by health service providers themselves, working together in teams with patients and other community representatives to make the changes most appropriate for the particular community, district, or region each team serves.

Some fundamental policy requirements are needed to enable those teams to create real health/healthcare systems and run them so they meet the needs of the people they serve.

It is essential to have people willing to take on the challenge. At the head of the list, the government, supported by its Ministry of Health and Long-term Care and the Premier’s Council on Improving Healthcare and Ending Hallway Medicine, seems both game and well aware that new approaches are required to engage the ‘players’ who actually provide health and healthcare services. It appears now to have realized that top-down direction in accordance with a central design won’t cut it in the big, diverse of Province of Ontario. Those players, individual health service providers and their organizations and institutions, organized into teams, will have to do the heavy lifting and do so in accordance with the needs and priorities determined by the people of their communities, districts, or regions. Although it remains early days, it is already apparent in the very short time since expressions of interest in the formation of Ontario Health Teams were invited that a substantial number of those players are also keen to take on the challenge of change. They range from individual health service providers, public health units, through a variety of community agencies, and extend to the most sophisticated of referral hospitals. That augurs well for system-building.

Many factors are essential to support the success of Ontario Health Teams but none more so than having in place comprehensive, standardized health information systems, ones in which their contents are shareable by patient-owners and health service providers alike while securing the privacy of both. This central resource-in-common is especially important in these early days of the digital revolution to support not only electronic communication between patients and their service providers but also the application of wearable health parameter recording devices and the utilization of so-called artificial intelligence algorithms in the future of healthcare practices. It is also vital to facilitate easier transitions of patient care from one provider to another. Also essential is the development of new and better measures of not only the processes of providing care but of their outcomes, assessments of the health and wellness both of individuals and of the populations from which they are drawn. Such measures of accountability are vital not only to ensure that patients, their families, taxpayers, and elected governments are all getting their money’s worth but also so OHTs can quickly and reliably assess the impact of the changes they make, how well they are meeting the needs of patients and their families, and especially the degree to which their system’s services impact positively on the overall well-being of the populations they serve. The development of such measures and imbedding them in an information management system in common is something that can only be done centrally by government, working with the Province’s OHTs, the Privacy Commissioner, and others. Its development and application soon is vital to the success of systemizing the current ‘field of silos’.

Four other imperatives apply.

One is consistency of the goals, objectives, and degrees of freedom provided to Ontario Health Teams in the policy directions of government. Again, it remains early days but the locus of relevant decision making is unclear among the Minister of Health and Long-Term Care, the Premier’s Council on Improving Healthcare and Ending Hallway Medicine, contract agreements between the government and unionized public sector healthcare workers (including the Ontario Medical Association), and healthcare’s new ‘super-agency’, Ontario Health. Government’s expectations of OHTs must be made clear to their ‘worker bees’ and served populations and so also must be the tools, including funding, the Teams will have available to meet them.

Another is time. Healthcare and the interactions among its providers have remained more-or-less the same for a very long time. Decade in and decade out the same dependencies and methods of communication[1] have become habitual as have the hierarchies that will have to change as people who previously considered themselves essentially free-lance performers learn how to play on a team. To succeed, OHTs will need both consistency in the policies that affect them and time to develop and implement the various strategies they will adopt within their communities, districts, and regions to replace those old habits with those transformational change requires.

Of the two final imperatives, one is the freedom to innovate, to do things differently, even to fail – to risk finding that a new way of proceeding will not work as well in practice as theory promised.

And the other is incentive. To be successful, Ontario Health Teams have to be able to identify reward for doing the heavy lifting of system-building. They, their willing participating health service providers together with the people of their communities, districts, or regions have to be able to see clearly in the larder the carrots on which they will be able to feed if and when the changes they make come to fruition. Change must be motivated. If there is nothing to be gained, nothing will be ventured and transformation of health and healthcare services in Ontario will not happen.

[1] Where else would one find fax machines in use?


 

Duncan Sinclair
Don Drummond
Chris Simpson
David Walker

Queen’s Health Policy Council members

What’s an Ontario Health Team?

 

Teams of different health service providers have been variously dubbed Accountable Care Organizations (ACO), Sustainability and Transformation Partnerships (STP), Integrated Health Systems (IHS), and Integrated Care Systems (ICS); some would claim their origin in Health Maintenance Organizations (HMO). Ontario Health Teams (OHT) is their most recent sobriquet. What’s an OHT?

There’s no easy answer. It is said of Accountable Care Organizations, the most numerous of the species, ‘if you have seen one ACO you have seen one’. They vary widely in terms of size, not only of their membership and structure but also the in the nature of the populations they serve, their geographic distribution, their mandates, the spectrum of services provided, source(s) of their funding, and other factors too. But they all exhibit the following core characteristics:

  • Each is (1) a collection of health service providers, (2) operating within a single, defined budget (3) serving collectively a defined population with (4) a defined range of health/healthcare services for which (5) it is held accountable both to its funder(s) and the population served.

Although no Ontario Health Team has yet been created, it seems clear that each will be expected to meet somewhat greater specificity with respect to at least some of these characteristics. With regard to membership (1) it appears certain from the outset that those who join the team will do so of their own volition – the phrase used is “a coalition of willing partners”. It is also clear that only those individuals, organizations, or institutions that are publicly funded will be partners. As discussed below, that restriction may prove to be a serious problem when considering the range of services (4) a defined population (3) needs to safeguard its health and well-being.

No detail has yet been forthcoming about how OHTs will be funded (2) other than that it will be in the form of “a single envelope”, expenditures from which will be restricted to the purposes for which funds were appropriated by the Ontario Legislature (the so-called ‘votes’). The degree to which an OHT can subsequently reallocate funds from its envelope to achieve for its population optimum outcomes and its members’ most cost-effective productivity is a question yet to be answered. Accountability for better outcomes and cost effectiveness (5) will be discharged formally in ways yet to be specified through defined, measurable contractual obligations to the government and to the people served through their representation in the OHT itself; each OHT must be genuinely “people-centered”, as opposed to provider- or government-centered.

 

An OHT is conceived of as a team of teams of health and healthcare service providers (HSPs). Think of a hospital, the biggest, most complex of Ontario’s health service providers. Each is, in fact, a team of doctors, nurses, aids, cleaners, maintenance and administrative staff, et cetera, in which the work of each member is both essential to what the organization accomplishes and is necessarily smoothly coordinated with the work of all other members. The same principle should extend to and among every other organization, large and small, that contributes to the range of services needed by a given population to maintain its good health and to restore it to individuals ill, injured, or disabled (4). Conceptually, an OHT would be composed of one or more acute and/or long-term care hospitals partnered with physicians and nurse practitioners providing primary care, whether individually or in teams with nurses, aids, pharmacists, physiotherapists, and other providers. Other partners would be the public health units providing services to the same population, home, paramedical, and palliative care, and agencies offering addiction and mental health support, street health, and other community-based services, including some concerned with the provision of housing and other services recognized to be among the social determinants of health. Few specifics are as yet known beyond that each OHT will be expected to offer “full service”, i.e. the capacity to provide the complete range of health and healthcare services needed by the people served, a population expected to be within a defined geographic area, to an upper limit of approximately 500,000 people. The great promise of an OHT is that each community, district, or region can organize its team of willing members so as to provide one-stop shopping for the full spectrum of health and healthcare services its population needs. In principle, each OHT can develop, structure, govern, and manage its internal system of health services to achieve the best outcomes for the people served at the lowest cost.

Doing that will be easier said than done. All of the willing, and those unwilling to be partners, will be fearful of domination by their potential partner hospitals, of subordination of the entire cascade of health service providers to a hospital’s mission, and management of the OHT’s funding envelope to support its priorities, fears well founded in an unhappy past and present history. But on the up-side for the creation of effective OHTs, most hospitals are well aware of their reputations as predators of other players and that they have to live down that reputation going forward by ensuring that leadership of the OHT of which they are member is truly shared, not only with its other HSP members but with those who represent the people, including patients, of the population they serve. That awareness of the need to avoid dominance is reinforced by the fact that to progress toward the Premier’s Council’s goal of “eliminating hallway medicine” Ontario’s hospitals need more than ever the strong support of their primary, long-term, home, and community care partners. Providing them generous funding and other assistance will be in the hospitals’ best interest, not to mention those of the patients and their families provided care in surroundings more supportive to their health than a hallway’s hard gurney.

As for the administrative ‘back office’ services each OHT will require, the straightforward goal of achieving maximum cost efficiency makes clear the sense of loading that on the already well-tested, relatively sophisticated personnel and processes most hospitals have in place.

How does the mandate of OHTs differ from the planning and resource allocation decisions that Local Health Integration Networks (LHINs) were theoretically set up to make? The goal of integrating the whole spectrum of HSPs in given, communities, districts, and regions remains the same. The only difference is that the integration into genuine systems is to be done directly by representatives of the people served and of their health service providers, the OHT, instead of as directed by a LHIN’s and/or central Ministerial bureaucracy. The promise of this distributed approach is that the between 30 to 50 OHTs that are forecast to be in place on Ontario when they are fully rolled out will be able to coordinate the work of their service providers in ways that fit best the particular characteristics, cultural, ethnic, geographic, density, or whatever, of the population each serves. The failure of one-size-fits-all planning demonstrates conclusively how substantially these characteristics differ among Ontario’s 14.3 million people. OHTs, with sufficient freedom to implement solutions that differ among communities, districts, and regions, offer the opportunity to succeed in system-building where the LHINs failed.

The major proviso, of course, is OHTs have to have the freedom to allocate their resources in accordance with what they find to be the most efficient and effective ways of achieving smooth integration and good communication among the HSPs that serve their populations. Theoretically the LHINs were to have had that freedom but never did. Whose decision will prevail if an OHT’s decision relating to what would work locally conflicts with one following on from government’s central bargaining with the OMA, ONA, or other public-sector unions? To what extent will central government’s political interests constrain what OHTs consider both desirable and achievable in their individual communities, districts, or regions? Such questions will have to be answered before any OHT takes on its intended responsibilities.

Finally, public funding does not extend to many of the services required by people to promote and preserve their health and to restore it when lost. The high cost of prescription drugs is currently much discussed but so also could be home care services, dental care, rehabilitation, addictions and mental health, and many others now more readily available to those able to pay for them out-of-pocket or by private health insurance than to those with fewer financial means. If our society’s goal is to optimize the health of the population, as surely it is, how will OHTs interface with private sector health service providers in their communities, districts, or regions? Could they too be “willing partners”? Could they be contractors to OHTs? And what about those, publicly or privately funded, who are unwilling to become OHT members? Their services will remain essential to the people’s well-being and can’t continue to remain as outside, uncoordinated components of the systems OHTs are to be mandated to create.

Answers to these and other questions must be forthcoming in short order out of discussions with Ontario Health and the Government as proposals to develop Ontario Health Teams are developed in communities, districts, and regions and are submitted. Nobody wants an OHT to be set up to fail.


 

Duncan Sinclair
Don Drummond
Chris Simpson
David Walker

Queen’s Health Policy Council members

Public Health Redux

 

It was a cold winter in Toronto in early 2003 when a foreign killer came to town. Hundreds sickened, coughing, fevered and breathless and 44 people died as their lungs filled up and failed. It was unclear what was causing this illness and initial attempts to identify it failed. In the meantime, even in this most sophisticated of health systems, society relied on the age-old mechanism of quarantine to control the spread of this novel disease – while the World Health Organization issued a travel advisory to avoid Ontario!

The events of that time were frightening and raised many, many questions. How did a new bug get here without our noticing? How did it spread? Where did it come from? Why did Toronto seem to bear the brunt of it, rather than another world city? Were we adequately prepared and if not, why not.

As SARS was brought under control, the then Minister of Health and Long-Term Care, Tony Clement, in the Conservative Government of Ernie Eves, appointed me to chair an Expert Panel on SARS and Infectious Disease Control to review how SARS was handled in Ontario, what lessons were learned, and to make recommendations for the future.

The panel consulted widely, held many public focus groups, and produced both an initial and final report which gained much attention at the time. Those interested may find the report on the Government website (with difficulty). It resides under a banner that says it was “released by a previous government”.

In a nutshell the report identified that our Public Health system had been allowed to deteriorate significantly and required substantial restructuring, investment and accountability – both to Government and to the Public. The panel was surprised to find that our Public Health labs had minimal capacity to identify the SARS agent, their professional resource having been allowed to languish over the years. Some health units had no medical officers of health and few graduating doctors were choosing the discipline as it was significantly underpaid and under recognized. Municipalities were responsible for a significant proportion of public health funding resulting in wealthier communities benefitting far more than poorer, often rural communities. At budget time at City Hall, Medical Officers of Health would be competing for funding with hockey rink and soccer field requests. International collaboration and information sharing was imperfect, surveillance mechanisms were outdated and, critically in Ontario, the ability to communicate important information to the public in a time of crisis was impaired by political considerations.The analogy, often used, was that given the prior success of fire prevention strategies, it would be quite justifiable to close many fire stations since there were so few fires! And that is what had happened with Public Health.

The panel’s recommendations bore fruit. A full Public Health capacity review followed, and subsequent change was executed following legislation, strengthening that most fundamental public policy, health promotion and disease prevention.

The simplicity of the premise of public health and its invisibility when fully operative form its Achilles heel. Crowded hospitals and wait lists for Long Term Care result in quite proper attention, but we forget at our peril that many solutions to those very acute problems reside in the community – for example improved home care, housing, addictions and mental health programs, based on a platform accountable for the health of the population. Furthermore, public health is cheap. Its impact is huge. And it is easier to cut spending for public health than it is for pacemakers or knee replacements.

Those of us who became preoccupied with identifying a blueprint for the renovation and rebuilding of our Public Health system note with interest another Conservative government’s plans. Some, such as reducing the number of health units, were suggested by the Expert panel. But combining such a plan with requiring increased municipal funding ratios may well be quite problematic- many towns may choose to pass the buck to their neighbour; and there are still those hockey rink priorities. And any reduction in public health spending will surely have significant ramifications.

Ancient societies recognized the critical importance of public health; clean water, sanitation, and control of infectious diseases. The invisibility of public health program success should not lead us to ignore its critical importance. As with public security measures, we can’t and don’t celebrate the terrorist attack that was aborted; we take it for granted. The same is true for public health. We are not celebrating the pandemic that did not happen, the surveillance that keeps us safer, the whooping cough that did not infect our children. We do know that one day the son of SARS, or a novel influenza, will appear. It has always been thus. Will we be ready? Or will we form another Expert Panel. We drop our defences at our peril.


DMC Walker MD, FRCPC
Stauffer-Dunning Chair and Executive Director, School of Policy Studies
Professor, Emergency Medicine, Family Medicine and Policy Studies
Queen’s University

Chair, Expert Panel on SARS and Infectious Disease Control, 2003-2004 and Inaugural Board Chair, Ontario Agency for Health Protection and Promotion