Public Health Restructuring Proposed

An “expert panel” appointed by the Minister of Health and Long-Term Care (MOHLTC) has now recommended the reduction in the number of Public Health boards from 36 to 14, matching the number of Local Health integration Networks (LHINs — provincially controlled regional bodies that oversee hospitals, long-term care, home care, and other health services).

The 36 currently existing public health units provide health promotion and disease prevention, health education, communicable disease control, immunization, screening services, and food premise inspections.  Each health unit is governed by a board of health and is administered by a medical officer of health who reports to the board. 

The boards are largely made up of elected representatives from the local municipal councils (and, in some cases, are the municipal council).  The MOHLTC cost-shares
the expenses with the municipalities, providing up to 75% of costs for ministry approved programs, 100% of costs for certain programs (e.g. Healthy Smiles Ontario, the Infectious Disease Control Initiative, Smoke-Free Ontario), and 100% for programs in areas without municipal organization.

The expert panel states that its members “agreed with findings and observations of
a series of reviews over the past 20 years, which all determined that Ontario’s public health sector would be stronger if:
·       there were fewer health units with greater capacity
·       there was a consistent governance model
·       the sector was better connected to other parts of the health system.”

The panel was comprised of nine people:  four public health officials, one municipal official, a hospital official, an advisor from an indigenous nation, a LHIN official, and
an academic.  The panel has devised a proposal that would leave public health with significant independence from the municipalities, the LHINs, and, to some extent, the province. 

The new regional public health organizations would have similar but not identical geographic boundaries as the LHINs.  The new organizations would have free-standing, autonomous boards.

The restructuring would impact existing legislation.  The expert panel, however, notes that “a detailed analysis will be required to determine how much of the proposed structure and governance model will require legislative amendments”.

The expert panel also notes that the “current public health funding model may be a barrier to implementing the proposed structure” and adds that “the ministry will need
to re-visit funding constructs in order to implement the recommendations”.

Municipal response:  Municipalities currently play the lead role in public health and have legislated authority for public health.  Public health geographic boundaries are based on municipal boundaries.  Moreover, in many large municipalities, the municipal council directly controls public health and the public health workforce is integrated into broader municipal bargaining units.  So, the response of the municipalities to this proposal is important. 

The Association of Municipalities of Ontario (AMO) plans to convene its Health
Task Force in early September to consider the report.  The Task Force will help
the AMO Board develop a response at the AMO Board’s September meeting.
There was also be a session at the AMO Conference on the future of public health on August 15th.

Some municipalities may not be too pleased with the expert panel proposal, particularly those municipalities with direct control over public health (Toronto, Ottawa, Hamilton, York Region, Durham Region, etc.).  They will lose control over a significant portion of their operations, but may still be required to fund those operations.

Toronto public health would be divided up several ways.  So, for example, Scarborough residents would be lumped into a public health unit that would extend into Algonquin Park.  Aside from Toronto, six other existing public health units would be split in two.  Most large municipalities (e.g. Ottawa) would have their pubic health unit placed in public health units with much larger geographic areas, including large rural and country-side areas.

Municipalities that formally controlled their own public health would have to vie with other municipalities for seats on the public health board.

Notably, the expert panel places the Ministry of Health and Long-Term Care at the top of the public health pyramid, just as is the case for the LHINs:

Labour relations: There is no contemplation or consideration in the report of the impact on industrial relations.  The panel only notes that “it may be helpful to engage consultants with a strong track record in change management to help with transition planning”.  The impact on working conditions, collective bargaining, bargaining units, and work locations are unknown at this time, but could be significant. 

The provincial response:  To move this proposal ahead, the provincial government must consider a myriad of legislative, funding, and implementation issues.  It must provide significant political support for the proposal.

Publicly, the Ministry of Health and Long-Term Care (MOHLTC) was non-committal in its initial response to the report — claiming only that the Ministry is now reviewing the recommendations provided by the panel, and exploring options for further engagement. Health minister Eric Hoskins said that this report and the “subsequent conversations” are “important first steps”.

Political viability:  To date, the proposal has received little or no media scrutiny.  The Ministry of Health and LTC released the report over the summer in a “bulletin” rather than with a media release.  Large urban municipalities that currently directly control public health may have the most to lose if this proposal goes ahead, but those same geographic areas have in the past been the main base of support of the Ontario Liberal government.
While municipal concerns about this proposal may grow, a provincial election is scheduled for June 2018 making passage of the required legislation challenging for a Liberal government trying to focus on “good news” in the remaining months before the election.  Public health alignment with the LHINs may be controversial.  In the past, the Progressive Conservatives have been highly critical of LHINs. 

The expert panel proposal is brief and is vague on many important implementation issues.  The panel itself suggests that more work is required to identify the scope of legislation that needs to be revised.  The panel also suggests that the MOHLTC will have to review “funding constructs” to implement the proposal—that alone could be a very difficult issue.  The panel also suggests that a change management consultant is needed to deal with “transition issues”.  No comment was even made on labour relation issues by the panel. 

Public Health is a vital public service and should not be tampered with lightly.

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