2/27/12

Hospitals under attack in every which way


The Drummond Commission into the reform of public services in Ontario has proposed the province shrink and privatize hospital services. 

Funding:  Drummond has recommended that health care funding be limited to 2.5% until 2017-18.  This is considerably less than the 3.6% increase proposed by the Liberals not long before the election.  Notably, even that proposal caused the Auditor General to observe in his pre-election review of Ontario's finances that
 $1 billion in hospital savings would have to be made (in addition to a two year wage freeze).
This would be a drastic reduction in health care funding increases, which have averaged 7% since the Liberals came to power eight years ago. 
Health care costs are driven by inflation, population growth, and aging.  Together these factors are significant cost drivers, likely over 4% per year.  But costs are also driven by a public that wants new health care services. When new services become available that prolong or improve their quality of life, people naturally want them.  People want to live, even if critics of public health care do not wish to allow these new costs.  The Drummond report itself suggests these new technologies alone drive up health care costs about 3% annually.
Without actually costing the changes it suggests, the Drummond Commission proposes funding increases much lower than these cost pressures.
Worse than Mike Harris:  Indeed, the Commission’s health care funding proposals are much less than those implemented by the Mike Harris government. The Drummond Commission admits that to meet its targets the “government will have to cut program spending more deeply on a real capita basis, and over a much longer period of time, than the Harris government did in the 1990s.”  In its first term the Harris government increased health care funding 4.1% per year on average.  At the time inflation was less than its current levels.  In its second term, the Harris government health care funding increases were higher still. 

Hospitals:  The main target for Drummond cuts in health care spending is hospitals. Diverting patients from hospitals is central.

Drummond is recycling ideas from the Mike Harris era, when the government justified hospital cuts with the claim that they would improve care in the community.  Eventually, after repeated crises, the Harris government quietly began funding hospitals again.  But only after significant damage was done and after communities had organized considerable resistance.  Many hospital services cannot be replaced by home and community care services. 
Moreover, the funding the Drummond Commission proposes is not adequate to strengthen non-hospital services – quite the contrary.  Replacing hospital services by home and community care is not a new policy – it has been government policy for decades and was implemented when much more new funding was available.  Even so, we have little to show for it but thousands of hospital bed cuts, dangerously high hospital bed occupancy levels, cancelled surgeries, backed up emergency rooms, EMS “code zeroes” (which occur when no ambulances are available for emergency 911 due to delays at overcrowded ERs), and a privatized home care system which has been in crisis for years.  Moreover, there are now 24,000 people on waiting lists for long term care services and 10,000 people on waiting lists for home care services.

Restructuring: Like the Harris government, Drummond suggests more amalgamations of hospitals -- and more specialization by hospitals.  In effect, hospital services would be moved from local communities to more distant, centralized locations -- just like Harris.  Here part of the rationale is to introduce
fee-for-service funding for more hospital procedures and force hospitals to compete to provide services.  Services will be moved out of local hospitals into those that provide larger volumes for lower prices.  Hospitals will specialise so they would no longer provide such a range of services and patients would have to travel to different hospitals or private clinics to get different services.
Also reminiscent of the Harris era, the Drummond Commission recommends the establishment of (another) Commission to guide the health care reforms.  In fact the Drummond report specifically cites as a model the Health Services Restructuring Commission (HSRC), the unelected body established by the Harris government to restructure hospital services.  

Everyone but Drummond seems to have regretted the expensive and ineffective restructuring of health care by the HSRC.  The HSRC was used by the Harris government to shut hospitals, merge hospitals, and centralize services.  It distanced the government from these unpopular policies.  Likely, Drummond hopes a Commission to implement his reforms would also provide some cover for a government implementing unpopular reforms.   If a Commission is set up, it will almost certainly mean serious problems for hospitals. 

Hospitals as acute care providers only: The Drummond Commission goes further than Harris in one respect -- Drummond appears to conceive of hospitals only as providers of acute care.  The Commission recommends:  Divert all patients not requiring acute care from hospitals and into a more appropriate form of care that will be less expensive ...”  This is a long way from the reality of hospitals today (or during the Harris era).  There are thousands of hospital beds that are not acute care -- providing rehabilitation services, complex continuing care, mental health care, restorative care, and long term care. There are also millions of hospital procedures provided to non-acute patients in outpatient clinics.  Removing these services from hospitals would have a very serious impact on hospital services and jobs.   

Privatization: Also like Harris, Drummond recommends health care privatization.  The government told Drummond not to recommend health care privatization.  Drummond interpreted this very narrowly, only excluding (for now) recommendations for the expansion of for-profit insurance of health care. The Drummond report sees for-profit delivery of health care in many areas as a step forward. 

Drummond claims the USA is “not a useful comparator” for Canadian health care – noting that US health care is extremely expensive.  Certainly, the USA is not a useful comparator and it is too expensive.  But the single most important distinguishing feature about the US health care system is that, more than any other developed nation, it is highly privatized.  Despite this object lesson, Drummond proposes we become more like the USA.

Drummond also proposes the introduction of contracting for hospitals services, but does not even consider the other major example of compulsory contracting out in health care services in Ontario.  Home care compulsory contracting has led to low wages, high staff turnover, and breaks in the continuity of patient care.  The process has been so troubled that it has been under suspension for many years.  Yet, Drummond does not even refer to this obvious, failed example.

Private, for profit clinics providing surgeries and other hospitals services through fee for service funding is one privatization initiative Drummond especially prefers.  Not only would non-acute services be removed from hospital (as discussed above), but also some acute care services would be hived off. 

The Harris government also set up for-profit clinics to provide MRI and CT diagnostic services.  That failed experiment also passes without comment from the Drummond Commission.  While some of the hours of these private clinics were set aside for patients from the public service, the clinics were also allowed to sell access to the tests to private citizens.  The well to do would get preferred access to medical services and the for-profit corporations would get revenue from both the public taxpayer and private citizens.  Eventually, the Harris for-profit CT and MRI clinics experiment was ended after a public outcry. 

While the government says it is committed to health care integration, these proposals will fragment health care providers, as new for-profit providers are established to take business away from public hospitals.  Indeed, for-profit privatization will create a culture of secrecy and competition between providers, as for-profit businesses try to improve their bottom line by taking business away from other providers.  Cooperation and integration will be out of the question in this environment. 


Arbitration
Also like the Harris government, the Commission attacks the interest arbitration system used to settle collective bargain disputes in essential service industries (such as hospitals). 

The establishment of an independent tribunal or commission to create, maintain and
manage a roster or a panel of independent arbitrators. Three might be the optimal number. Arbitrators would be assigned to cases by the tribunal/commission independent of the parties. Arbitrator and mediator assignments should be co-ordinated across the BPS, including provision for the appointment of arbitrators across sectors of the BPS. Either a roster or a panel of three arbitrators could work, but without the principles/outcomes outlined for the interest arbitration process, neither would work well. The Commission also emphasizes that the independence of the arbitrators from government influence or interference is of vital importance for either the roster or panel model to be implemented;”


Clearly, the Commission fails to understand that for the interest arbitration system to work, arbitrators must be acceptable to both parties, which is why arbitration has traditionally rested on a consensual basis, with the arbitrator chosen by the parties themselves in the majority of cases.  

The Commission proposes time limits on the arbitration process:

“Establish a time limit on the arbitration process and the time arbitrators can take to issue a decision (currently they can take as long as three years, often because parties seek a particular arbitrator who is busy — such delays in decisions can mean they are ultimately out of sync with the current environment)”

Parties seek arbitrators that are busy because they are the ones seen as qualified by their impartiality, their expertise and general acceptability to both management and labour.  The Commission would replace this system with one where an “independent tribunal or commission” would establish and manage a roster or a panel of arbitrators who would be assigned to cases without any input by the parties affected.  The arbitrators who would be readily available to work within these time limits would be the ones lacking in expertise, experience and impartiality – and hence not acceptable to the parties.

The Commission also attacks bumping provisions in collective agreements as “unduly impeding the move towards a progressive and efficient public service.”  The government, it adds, “needs to work with bargaining agents and employers to explore options for modifying these provisions and monitor progress towards fixing this problem.”

Other Commission recommendations:


·         Recommendation 5-13: Consolidation of health service agencies and/or their boards should occur where appropriate, while establishing any new consolidated agencies as separate legal entities to limit major labour harmonization and adjustment costs.
·         Recommendation 5-18: Where feasible, services should be shifted to lower-cost caregivers. Across the spectrum of caregivers, full scope of practice needs to be exercised.
·         Recommendation 5-22: Increase the use of personal support workers and integrate them into teams with nurse practitioners, registered nurses and other staff members where appropriate to optimize patient care.
·         Recommendation 5-25: Hospital capital plans that extend out-of-hospital services such as those for outpatients should not be entertained by Local Health Integration Networks. This is part of the attempt to stop the provision of non-acute care services in hospitals.
·         Recommendation 5-33: Tightly integrate Community Care Access Centres (CCACs) with Local Health Integration Networks (LHINs) to improve patient case management.  This could mean merger or simply tighter cooperation between the two organizations. 
·         Recommendation 5-42: Resource the Local Health Integration Networks adequately to perform their expanded functions. Additional resources should come in large part from the Ministry of Health and Long-Term Care (MOHLTC); this would entail a significant transfer of employees from the MOHLTC to the LHINs.  
·         Recommendation 5-26: Resist the natural temptation to build many more long-term care facilities.  While governments have long tried to divert patients from hospitals, they (and the Drummond Commission) are now also targeting LTC facilities, despite a rapidly growing 85 and older population.
·         Recommendation 5-38: Chronic issues should be handled by community and home-based care to the fullest extent possible. Again, this is part of the proposals to divert patients from hospitals.
·         Recommendation 5-44: Move critical health policy decisions out of the context of negotiations with the Ontario Medical Association and into a forum that includes broad stakeholder consultation. (i.e. delist services without negotiating with docs- - and turn decision making over to Health Quality Council)
·         Recommendation 5-46: Expand the mandate of Health Quality Ontario to become a regulatory body to guide treatment decisions and OHIP coverage.
·          Recommendation 5-51: Create a blend of activity-based funding and base funding managed through accountability agreements.  This means more fee-for-service funding to encourage competition between hospitals and private clinics for funding.
·         Recommendation 5-56: Make primary care a focal point in a new, integrated health model.
·         Recommendation 5-64: The regional health authority (i.e. LHINs) should establish incentives to discourage Family Health Teams from referring patients to acute care.  Again, this is all part of the policy of moving as many services as possible out of hospitals. 
·         Recommendation 5-74: Increase the focus on home care, supported by required resources, particularly at the community level.
·         5-78 and 5-80Integrate public health into the LHINs and consider uploading public health to the province.
·         Reduce Ontario Drug Benefits for senior -- recommendation 5-85
·         Centralize all back office functions.  Apparently, the Drummond Commission wants more centralization of health care back office services than in new regional back office organizations that have been set up to take over hospital work in the last several years.  Recommendation: 5-95
·         Put to tender more service delivery 5-98 Part of the privatization proposals.
·         More specialist clinics 5-95  Both of these last two recommendations are designed to move work out of hospitals and into private, for profit clinics.
·         Paramedics should provide home care when not providing emergency services. Recommendation 5-100. 
·         Discuss expanding ‘health care’ to drugs, LTC, and aspects of mental health - -either through a ‘social insurance model’ or ‘the current public payer model that applies to most aspects of primary and physician care’.
·         Recommendation 5-105: Do not let concerns about successor rights stop amalgamations that make sense and are critical to successful reform.  Successor rights as currently defined do not necessarily limit the right of the government ... Inherited agreements do not live forever; provisions can be accepted initially and bargained differently when they come up.


The government’s response? The Commission’s report contains only recommendations.  The government will decide what they implement.  How far the Liberals will go down the Harris Progressive Conservative road is a good question.  Health Minister Deb Matthews has already indicated that health care funding will be less than 3% (despite pre-election promises otherwise).  

A lot will depend on how hard local communities (especially small and rural communities which have the most to lose) fight back. 


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