Drummond sends some signals on health care

Don Drummond’s 'lecture' for the C.D. Howe Institute does not propose too much new, but does raise some possibilities of what his Commission on Ontario public services might recommend for health care. 

The main point Drummond makes is that health care restructuring must happen more quickly.  Although Drummond has tried to distance himself from the health care reforms of the Mike Harris government, the two are united in many ways.  Both are driven to system redesign by a goal of implementing austerity.  Drummond doesn’t quite have the nerve to say that public health care is unsustainable, but the threat of unsustainability sustains his argument.  Here are key parts of Drummond’s proposals in his C.D. Howe Lecture:

• Like the Harris reforms, a key part of the argument is to cut hospitals and increase home care.  This is a very old proposal that has been worked on for, literally, decades. It’s often presented as a new idea, especially when austerity is in the air.  While home care services should be expanded, the reductions in hospital services are never made up for by an increase in home care services.  After decades of working on this very idea in Ontario, we have a 10,000 person wait list for home care, tens of thousands fewer hospital beds, and near constant back-ups in the hospital system. Expect more of the same.  
• Also consistent with the Harris health care reforms, Drummond wants to consolidate public services and stengthen restructuring capacities.  Drummond told the Ottawa Citizen this week that “as a matter of fact, much of the thrust of the recommendations I’ll be doing in the Ontario commission is consolidating things."  In his Lecture, he floats the idea of reducing the number of Local Health Integration Networks and giving them more authority and resources to carry out reforms.  Alternatively he suggests “the co-ordination could be done through the administrations of the large hospitals in a region.”  LHINs however are under hot attack and do not have the credibility to bring about restructuring, especially in small towns and rural areas, which have the most to lose when services are centralized or consolidated.
• Also like Harris, Drummond advocates greater private-sector delivery of health care services, under the public-payer umbrella. Instead of cooperation between providers, Drummond (as any Bay Streeter would) suggests competition and privatization as the mechanism of choice. In particular, he flags the idea of moving surgeries and diagnostic tests out of hospitals and into clinics.  For-profit delivery proved disastrous for the Harris government on two fronts it tried: home care ‘competitive bidding’ (under suspension for the last 7 years due to its shortcomings) and opening new private MRI and CT clinics (a policy subsequently abandoned). 
• Appropriately (given his desire to privatize) Drummond asks the corporate world to become more involved in the health care debate.  Not exactly what we need...
• Drummond doesn’t discount the idea of two tier health care, but suggests, “It seems best to simply leave this issue aside for the moment. ... introducing more private charges may distract the public and politicians, putting progress on all reform into paralysis.” It certainly sounds like he conceives his reforms as the thin edge of the privatization wedge.  And on that he is probably right.  For-profit providers will not be satisfied with getting whatever profit they can out of public sector funding.  They will want to get extra cash by selling preferred access to those who have more money.  That was the model the former Harris government used when they introduced private CT and MRI clinics. 
•  As part of a shift away from acute care, Drummond suggests a much bigger role for primary care.  He apparently wants to expand the one area where the government has been spectacularly unsuccessful in controlling cost increases.
• Drummond wants a national discussion on end of life care.  He believes, it seems, that more people would opt for less medical care at the end of life and feels this could save some cash.  He suggests that consideration be given to development of a common model where people set out their preferences while still cogent.  He is not advocating euthanasia.
• Drummond also suggests that the provinces should work together.  This would provide some cover for their activities.  Presumably, Drummond means the provinces could simply point to the other provinces when their electors complain about the results. 

Drummond makes a number of other recommendations, a few of which are fairly obvious and innocuous (e.g. more chronic care is needed).  None, however, are going to save big dollars.  Drummond seems aware of the weakness of his notions:

Critics will argue that because I cannot demonstrate quantifiable savings from the reforms proposed in this paper, governments might prefer to do nothing. Policymakers are rarely allowed to conduct laboratory-style experiments for policy reforms. However, I underscored examples of different provincial approaches to improve the health system’s efficiency that are, at a minimum, evidence that experimentation in the pursuit of such reforms is worthwhile.

Health care reform has been ongoing for decades and, overall, some efficiencies and improvements have been achieved.  There are more positive reforms that can be made, but there is no magic wand, and certainly not in Drummond's lecture.  

Government’s however often pretend there is a magic wand when they want to effect major cost cutting. It's much easier to sell system redesign than service cutbacks.  

The previous go-round of major health care restructuring (during the Harris years) did quite a bit of damage before it was stopped.  The Harris government had to do a 100% turn on hospital funding after three (painful) years and the costs of the restructuring itself were much higher than planned.  We will see how much damage is done by this new attempt at major restructuring.