Adapt or die

South East LHIN CEO Paul Huras

LHINs look to grow and sub-divide

The Local Health Integration Network (LHIN) has governed a large swathe of health care for 10 years. Borne amid controversy and skepticism (who knew the problems of health care might be fixed by another layer of bureaucracy, some complained). Since then, the LHINs have endured persistent criticism from every flank. The Ontario PCs in the last election promised to scrap the LHINs altogether. Last year, the province’s Auditor General put the LHINs under the microscope, criticizing the lack of progress in meeting targets despite spending many millions on administration.

Among the AG’s key criticisms was that the LHINs had failed to define their role clearly or establish measures to judge their performance.

Now the LHINs have produced a new proposal that seeks to address these criticisms.

“We have to be smarter about how we manage our resources,” acknowledged Paul Huras, chief executive officer of the South East LHIN.

The Ministry of Health and Long- Term Care is currently floating a set of proposals to overhaul the LHINs and other health care agencies. They could be in place by the fall.

THE LHIN AND ITS ROLE IN OUR HEALTH
The South East LHIN is one of 14 regional health authorities established across Ontario that allocates funding and seeks to ensure that health care providers, services and hospitals in the region use their dollars better. The south east region stretches from Prescott to Smiths Falls and Bancroft to Brighton. The LHIN guides and nudges the region’s hospitals and other health care agencies as they navigate the shifting landscape of patient care, demography, technology and skills against a backdrop of rising health care costs, and the necessity of controlling these costs.

Critics have complained that the LHINs have consumed more resources than they have saved.

Huras counters that administrative costs are a critical part of managing a $50-billion system. He adds that it is these decisions are better made closer to the patient than in an office in Toronto. He also notes that every province in Canada delegates funding authority to regional health authorities, with the exception of Alberta.

A FIRMER GRIP
The Patients First proposal seeks, among a range of recommendations, to draw Community Care Access Centres (CCACs), the agencies that co-ordinate home care and long-term care, as well as regional public health units, under more direct control of the LHIN—relieving these agencies of administrative burden and reducing duplication across the region.

Huras notes that when patients and their families are asked about the care they receive from a CCAC, 94 per cent say it is either good, very good or excellent. Yet the number-one complaint in our health care system relates to community and home care.

It is challenging, however, for the LHINs to make changes and enforce accountability while part of the agency’s funding comes through the LHIN another directly from the province.

“Some saw this as a duplication,” said Huras.

Others, including the Auditor General and a legislative committee that looked at the issue last year, concluded that home care services are overly complicated, cumbersome, expensive and suffer from a lack of transparency for patients and caregivers.

Huras contends that these issues weren’t evident in this region but concedes that the current arrangement isn’t ideal either.

“Management is more art than science,” said Huras. “You can’t throw it all out when you encounter challenges in the system. But you do need find the right mix. I was comfortable with our CCAC because I knew our admin structure was less than other places. But I agree that anything we can do to minimize and streamline administration is a good thing.”

ANOTHER LAYER
One recommendation getting a great deal of scrutiny is the notion of creating smaller subregions.

“The needs of the people in the Bancroft area are different than those in the Kingston area,” explained Huras. “Their access to services is different. You have to plan differently.”

It has already spurred a discussion about which communities might best comprise a sub-LHIN. Some will argue the needs and priorities of those in Prince Edward County vary widely from those in Belleville or Bancroft.

Huras knows this will be a challenge in this LHIN. He has contracted a research firm to look at the region and provide a recommendation and rationale for the division of the sub-LHINs.

“I am already being lobbied by communities suggesting they should be a sub- LHIN,” said Huras. “It’s about getting the right balance. Some people say the LHINs are too big. On the other hand, you can’t get too small—otherwise it becomes difficult to manage risk.”

BUREAUCRACY BEGETS BUREAUCRACY
Creating another layer of LHINs begs questions about expanding bureaucracy and the relevance of the upper layer once a network is established closer to the patient. Huras insists the sub-LHINs will guide planning and streamlining processes.

“If this moves forward— I am not going to create a bureaucracy at the sub-LHIN level. Most likely, one of my existing staff will support that smaller region as far as the planning goes and assisting [to] co-ordinate services. There will be no additional staff. It would be one of my current staff working with primary care groups, the hospital and long-term homes, and helping them coordinate their care better.”

Bureaucracies, however, tend to expand over time and Huras doesn’t deny that those pressures may arise, but he expects the shortage of new money in the health care system will keep a lid on this risk.

“Eventually, those discussions will take place,” said Huras. “Not likely in the first year, but the pressure will come.”

But he argues that pressure will be constrained by the fact that no new money will be put into the sub-LHINs. Any additional administrative capacity or function needed at the sub-LHIN will have to come from current resources.

“What can you give up?” said Huras, suggesting how he will respond to the pressures to grow the sub-LHIN. “That will be the only basis [upon which] their role could expand.”

WHAT DOES IT MEAN?
The Patients First proposal, at its core, is a set of recommendations aimed at streamlining processes and administration. It is less clear in reading the report what it means to patients, caregivers or the community.

Huras says the Patients First recommendations, if implemented, promise a profound improvement in the way primary care services are coordinated and delivered.

“For example, care coordinators may be more closely tied to primary care providers,” said Huras.

It enables the family doctor or nurse practitioner to direct care services, manage these resources and better monitor patient response.

“So if you need two or three providers of care— the doctor’s office would have one number to contact. There would be consistency in the people who provide care and the doctor would receive regular updates. It would make life better for your family and for the doctor overseeing your care in addressing specialized care or services.”

Are these recommendations a tacit admission that the LHINs haven’t worked?

Huras rejects this reasoning.

“LHINs have been in place for 10 years,” said the LHIN chief. “After 10 years, there is an expectation that things should change and evolve. That was part of the original plan. I expect every plan should be reviewed toidentify the things that are working well and those that aren’t—with an emphasis on fixing the problems.”