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Who is best placed to decide? Who should say what a hospital is in Picton? In Trenton? Or Belleville? Windsor? Cornwall? Does it matter? We are, after all, the same species, with a fairly predictable basket of health care needs.

For most of the past century it was the hospital itself that determined how to spend the money it received. Each year, hospital administrators negotiated increases over last year’s budget. Some were better at this than others. Inefficiency was baked in—efficiency was hard to extract.

But as costs spiralled upward over the past three decades, both federal and provincial governments increasingly insisted upon a greater say on how the money was spent. They needed to show voters additional funding was delivering measurable improvements in care, efficiency and performance.

Meanwhile, the way we use hospitals has changed. Surgical and clinical improvements have led to shorter stays. Technology is playing an ever-increasing role.

But hospitals, their governors and donor base had invested in their buildings. Many missed the signals that might have prompted them to consolidate and transform their facilities to the changing health care landscape.

So the province began by tinkering. But when that proved unsatisfying, the Harris government embarked on a radical experiment—to smash the status quo—closing hospitals, slashing beds and forcing clumsy amalgamations. Thus the heavy hand of provincial government intruded upon the business of hospital administration. Local control was out. Provincial mandarins were in charge.

When the Liberal government came to power, they decried much of what the Harris government had done. But they liked the control they had inherited to govern health care. The provincial government has tightened its grip ever since

The goals aren’t wrong. Health care costs can’t continue to rise at historical rates. There just isn’t enough money. Hospitals must be responsive to market signals. There is nothing inherently wrong with hospitals competing on the basis of quality and cost for a whole host of treatments. Further, there must be better integration between health care services—if Brockville can process knee replacements faster, cheaper and better that is where we should be directed.

Yet there is something fundamentally wrong with the transformation track we are on in Ontario. The province holds all the levers. The community has none. The pendulum has swung too far. The community has been forcibly removed from the decision-making process. Less than a decade ago, we elected directors to the hospital board. No longer. Hospital directors are accountable to the corporation. The corporation is accountable to the province.

The community has become a bystander in the delivery of health care services. We are little more than consumers. We are encouraged to take part—to play a role in this transformation— but that role amounts to smiling and nodding approval.

It can’t work this way.

Hospitals are not Tim Horton’s or Jiffy Lube franchises. They aren’t Ikea stores. We just can’t design a few standardized hospitals and scatter them around the urban landscape of Ontario.

Health care is not like buying a donut or a chair. The health care needs of the people of Prince Edward County are not the same as those Pembroke or Atikokan. Age, demographics and health patterns vary greatly.

So who is best placed to decide? Bureaucrats who see us as the sum of predicted ailments? Or is it the folks in the community who work and serve here every day? People who are sensitive to our needs and in the best position to respond?

For much of the last century, communities decided what their health care looked like. They funded hospital buildings, the purchase of technology and equipment. These purchases were informed by the doctors and healthcare professionals who saw patients every day. They decided what that hospital should do, and what it couldn’t afford or justify. They understood— still understand—the needs of the community. They are surely better barometers of what healthcare services should be.

It is time for the pendulum to swing back.

rick@wellingtontimes.ca

I wish to thank Paul Huras, CEO of the South East Local Health Integration Network and Brad Harrington, CFO, Quinte Health Care, for their assistance in preparing our briefing this week examining health services funding reform and the ways in which it is reshaping health care services in this community. Please see story here.  Mr. Harrington’s full response can be found here.