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Progressive Conservative health care policy: cuts, privatization, mergers, and cuts

The PCs have developed two papers on health care policy, one dated September 2012 and another (which “builds on that foundation”) dated February 2013.  Here are some key excerpts, with some commentary, starting with the 2012 paper, “Patient CentredHealth Care”.

Terminate the LHINs and CCACs and turn their powers over to 30-40 “hospital hubs”:  “Build off of the existing high performing health infrastructure in 30 to 40 Ontario hospitals to create health hubs. Hubs will organize, plan and commission services for the patients in their respective regions.”  “The health hub is a simple concept. Hubs take over the LHINs’ job of local health care planning, funding and performance. They also take on the CCACs’ job of connecting people with government funded home and community care and long-term care. Most importantly, they will be required to integrate acute care with primary care, home and community care and long-term care into a seamless partnership.”

Comment: This will give 30-40 hospitals funding power over all hospitals, long term care facilities, home care organizations, community health centres, and a myriad of other health care and social service agencies in their region.  With (say) 35 hubs, each hub will have authority for an average of 6.28 hospitals (or, put another way, 4.26 hospital corporations).  The hospital hubs will have “total control and responsibility” for their funding.  This is utterly unlike the LHINs  which have almost no real control over their budgets.  

With "total control and responsibility" comes great power to restructure and change health care delivery.  

Clearly the hospitals chosen as hubs will be large hospitals in the largest cities.  We already know what happens when smaller hospitals are placed under the control of large hospitals in larger centers: they are closed or cut.  That is just what happened when the Mike Harris government merged smaller town hospitals into multi-town hospital corporations.  More than any other hospitals, small hospitals financially controlled by hospital corporations centred in distant, larger cities have suffered cuts and closures. Just ask people who live in Fort Erie or Port Colborne, or Shelburne, towns which had hospitals that were forced into larger hospital corporations that subsequently suffered closure or radical reduction.   So this plan is a direct attack on small, rural and northern communities that will be beholden to large hospitals in large and distant cities for their funding and survival. Given the health care funding plans proposed by the PCs (see below), there will be a burning drive to restructure and centralize services, much more than now.   

Indeed, even large hospitals in large cities should also be quite concerned if they are not among the chosen hospital hubs.  Even greater concern should be found among the thousands of LTC facilities, home care organizations, Community Health Centres, and the myriad of other health care and social service organizations that will be forced to compete for cash from the tender mercies of the 35 hospital hubs.  Indeed, there is already significant distrust of large hospital corporations.

It is not totally clear if the PCs would give the hubs funding power over doctors as well. They certainly want to give more control over the doctors to the hubs than the LHINs have.  They do say there will be “formal integration” of primary care with the hubs and that they will require hubs to “establish a permanent, physician-led Primary Care Committee to integrate primary care physicians into local health care planning and to scrutinize their ongoing performance.”  In any case, control of doctors by hospital hubs could be a problem for the PCs, as the doctors are not likely to accept it.  As powerful actors, the doctors will want to deal directly with those who have real power –the politicians-- not their flunkies and flack catchers.

Overall, this plan is reminiscent of the large scale restructuring and merger mania of the Health Services Restructuring Commission (HSRC) period – except without the Mike Harris commitment to public consultation. Harris did allow some public consultation through the HSRC when he shut and merged hospitals -- but it didn't diminish the public antipathy to those policies. Nor did it diminish the enormous extra costs that Harris' hospital mergers, closures, and restructuring occasioned. The Auditor General revealed that Harris-era hospital restructuring costs skyrocketed to $3.9 billion -- 85% (or $1.8 billion) higher than they planned.

The PCs do note that “Local health care shouldn’t be run by people appointed by the provincial cabinet as is the case with the LHINs. The health hubs will have local, volunteer board members chosen based on their unique skill set.”  That idea at least has some merit.  Volunteer boards however are not elected boards, and the PCs don't suggest they will try to make the hub hospital boards representative of the various communities caught under them. "Expert" boards seems to be the idea. It is however notable, that the last time the PCs were in power they removed the local CCAC boards and replaced them with their own appointees when the CCACs began to complain about a lack of funding. That immediately silenced the CCACs.  

Also notable: the PCs established the Community Care Access Centres (CCACs) under Mike Harris. Although Tim Hudak was the Health and LTC parliamentary assistant under Harris, now the PCs  want to close the CCACs down, justifying this with the claim that they have become “top heavy” (an odd complaint given that the biggest executive salaries by far are found the biggest hospitals, not the CCACs).  The CCACs were one of the major health care reforms under the  former PC government -- but now the PCs view them as another failure. That doesn't build a lot of confidence in PC judgement. 

Reduce the role of the Ministry of Health and LTC:  “Reduce the size of the Ministry of Health. Make it responsible for provincial health system planning, funding and quality control. Eliminate its role as micromanager of the system. Make the Minister ultimately accountable for Ministry performance.” “The main challenge for the ministry will be capacity planning, determining the province’s future health needs.”

  • Comment: The reduced role for the Ministry of Health and LTC goes hand in hand with the increased responsibility of the hospital hubs. This arrangement may help a PC government to step out of the direct line of fire of people angry about funding cuts, mergers, centralization, and the loss of service in local communities. 

Paper #2:  “A Healthier Ontario” February 2013

Funding: “Many people will suggest all of this will cost more money than we can afford, but the evidence suggests the opposite. In fact, when the delivery of care is centred around the patient, significant savings can be achieved.” (Christine Elliot).   Notably, in the PC paper entitled “Paths to prosperity: A new deal for the public sector”  the PCs state:  “The top priority for the Ontario PC Caucus, and the public, is frontline health care. Even there, we will carefully examine spending to control costs. One study by Boston Consulting Group and Bridgepoint Health estimated the savings possible from better local coordination of health care could be in the range of $4 billion to $6 billion a year. In a previous white paper, Paths to Prosperity: Patient-Centred Health Care, we put forward a plan to achieve this target.” (Page 10.)

Comment: the suggestion that they can cut $4-$6 billion from health care is chilling.  Already, health funding increases have fallen short of population aging and growth cost pressures, never mind inflation, driving down health care quality.  Even Mike Harris did not decrease health care funding – far from it.  Indeed over his first term in office (when he was still hell bent for leather) he increased health care funding on average 4.07% annually.  Over the PCs second four year term (after the government was pilloried for overflowing hospitals and ambulances that had to bounce from hospital to hospital to find a space), the PCs increased health care funding just under 8% per year.

Focus on Chronic care: “Build a system that treats chronic disease as the leading health challenge of our time, not as an afterthought in a system designed around acute care.”

  • Comment: given the rapidly aging population, chronic disease may well be the "leading health challenge of out time".  This may be one of the few good ideas that the PCs have.  

More home care and more LTC: “While we cannot rely on funding more of everything at a time when we simply do not have the money, we must deliver more of the services like home care and long term care that keep people healthier, and away from unnecessary hospital visits.... Shift resources and incentives to promote care closer to home, particularly by expanding home care and long-term care availability, and by promoting more types of care in the home. Allow pharmacists, paramedics, nurses and nurse practitioners to provide more types of advice and treatment where these are most convenient and beneficial for patients, updating scope of practice where required.”

  • Comment: here the PCs diverge a little from the Liberals.  Both parties emphasize cutting hospital services, but the Liberals have also strictly limited long-term care bed growth, despite huge increases in the relevant population (i.e. people aged 85 and over). The PCs don't, however, exactly say that they will expand long term care beds (despite the obvious growing need for that), they make the vaguer promise to expand "availability" of LTC -- whatever that means.

Privatization of home care funding and delivery:  “Give patients more choice in the health services they receive. Allow patients receiving non-clinical home care services like housekeeping and personal support to choose whether to have a care provider purchase home care for them, like CCACs do today, or whether to use the same money to hire their own home care.”

Comment: This is a major attack on unionization and decent wages for PSWs and would thoroughly undermine the recently proposed $4 an hour increase for PSWs, never mind the promise to reduce casual work in the industry.  Notably, despite Liberal promises to improve PSW home care work conditions, they also proposed something similar in their failed 2014 Budget.  

Privatization of clinical and non-clinical services: “Hospitals and other health institutions frequently tender for non-clinical services like cafeteria service already. We would build on existing best practices by requiring them to seek competitive bids for all relevant non-clinical services like IT, just as we propose for the rest of the public sector. For clinical services that can be provided outside a hospital or physician practice, we can also use well established tendering processes to ensure we get the best service at the best price when expanding system capacity. These would include services like MRI tests, dialysis services and high-volume, less complex surgeries such as cataract surgeries, hernia repairs and simple joint replacements.”

Comment: On clinical services, they are on the same page as the Liberals here, except there is no cover about using (so-called) “not-for-profits” for private clinics. The PC plan to privatize hospital clinical services flies flat in the face of their promise in their slightly earlier public sector policy paper (discussed here) that "of course" they would not privatize nursing.    Promises can vanish pretty quickly for these guys, apparently. 

On non-clinical services they go much further than the Liberals. The PCs will require hospitals and health care institutions to seek competitive bids for all relevant non-clinical services (just as they propose for the rest of the public service).  This is a party determined to turn large revenue streams over to their corporate pals.  Under the previous Mike Harris government, the PCs introduced compulsory competitive bidding in home care -- that did not work out and was eventually ended, but not before they had all but decimated long standing not-for-profit home care providers (like the VON).

Administrative cuts: “While administration is not the biggest driver of growth in the health system, we spend billions on it every year and any waste is too much. By eliminating LHINs and the administrative component of CCACs in favour of health hubs that will actually deliver better care, we can redirect millions of dollars from administration to patient care. And more importantly, we can avoid the waste of literally billions of dollars that the current government has directed towards failed, out-of-control agencies like Ornge and eHealth Ontario.”

Comment: There is no connection between the eHealth and Ornge scandals and administration – those problems arose out of privatization, something the PCs apaprently do not wish to talk about.  Moreover, while administrative costs have been going down in public health care, they have been going up in private health care.  Indeed, they are much higher in private health care than in public health care –so increasing privatization goes in the opposite direction of their promise to squeeze administrative costs.   Eliminating LHINs and CCACs does not mean that the cost associated with their functions can be eliminated.  Those costs will simply have to be borne by the hub hospitals (unless the PCs expect people to work for free, or, perhaps, have some fairy dust handy).

Health Care costs: They claim (citing TD) that health care costs as a percentage of expenditure amounted to 46% of total expenditure in 2010 and will be 80% in 2030. 

Comment: In fact health care expenditures as a percentage of total expenditures have gone down since 2003.  They are currently at 38.3% -- they were at 40% in 2003. 

Wage freeze for health care workers: “[W]e must recognize the biggest driver of cost increases besides utilization growth is wage inflation. Over time, compensation for our capable and dedicated nurses, physicians and health workers can and should grow along with other wages in the economy. But at a time when Ontario faces a deficit of over $10 billion and private sector wages have stagnated, we simply cannot afford to go back to six per cent and eight per cent budget increases every year. While we make the long-term changes that will make our health system stronger and more sustainable, we will implement a temporary wage freeze for health care workers as part of a comprehensive public sector wage freeze.”

Comment: The suggestion that freely negotiated wage increases led to 6-8% cost increases for health care is as odious as it is ridiculous.  Public sector settlements over the last 24 years have averaged less than private sector settlements, with the latter at 2.2% and the former at less than 1.9%.  The general wage settlements for hospital service and administrative staff follow that trend.   Far from driving 6-8% cost increases,union wage settlements in that area have actually been a moderating influence on rising health care costs.

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