Thursday, May 12, 2016

No Bureaucrat Left Behind, Part I

Ontario continues to move full-steam ahead with its plan to grind primary care reform to a screeching halt (now how's THAT for some mixing of metaphors?).

With all the hullabaloo around the doctors' pay dispute, too little attention has been paid to Patients First, the Ontario government's master plan for reforming the province's primary care system. While I've alluded to the plan briefly in other posts, I haven't gone into the details, nor backed up my claim that the plan is destined to fail.

Let's set aside the fact that the Minister of Health, Dr. Eric Hoskins, opened his speech unveiling the plan by discussing his time doing medical humanitarian work in Sudan, alongside a doctor whose political activism left him beaten and tortured on the orders of the Al-Basheer regime. Personally, I find it more than a little obnoxious to compare bureaucratic tinkering with Ontario's health system to the struggle for human rights in the face of war crimes, but your mileage may vary. We'll also, for the moment, have to set aside the doctors' pay dispute, since the development of Patients First almost certainly wouldn't have factored in a protracted conflict with doctors.

Patients First is comprised of four main "pillars": Access, Connect, Inform, and Protect. In a rather ironic twist, making an acronym out of these goals spells out PICA, a medical condition that entails eating various forms of dirt. Sometimes the punchline writes itself.

The "Connect" pillar focuses around getting Ontario residents to make better use of Public Health, Community Health Centres (CHCs), home care and long-term care services. That's all well and good, I suppose, except that the home care bureaucracy has been run atrociously by overpaid executives, and long-term care beds have been inadequate for decades. Moreover, the CHCs that serve the most marginalized (and challenging) patients almost always struggle to recruit and retain good staff.

"Inform" encompasses preventive care stuff - screening programs, nutrition, smoking cessation, etc. - and educational campaigns around heart disease and so on. Nothing that hasn't been done for years already, though the nutrition part hasn't seemed to make us any less fat.

"Protect" has two major components. The first is the establishment of the Patient Ombudsman to address unresolved complaints about the health care system. This is probably a good thing, in particular because the non-hospital bureaucracies do not have such offices in place as a rule. Moreover, I've heard this praised first-hand by Ontario's coroners, as the legislation governing their work (the Coroner's Act) isn't adequate for the role of health care ombudsman.

The second component is an increase in reporting and accountability. On the surface, this sounds like a good thing. I'm not so sure. There are so many layers of red tape and processes already attached to funding in health care, more reports in the name of accountability just diverts time away from care, and towards tedious paperwork for its own sake. Besides, isn't that what the Auditor General is for?

The major controversy of Patients First comes from the "Access" pillar, with the thrust of it derived from the now-mildly-infamous Price-Baker report. The report's recommendations seek to address distribution, accountability, access, and succession planning in primary care (care provided mainly, but not exclusively by family doctors). How will Patients First achieve all these laughable laudable goals?

By setting up a vague bureaucratic construct called a "patient care group" (PCG), which could be part of a LHIN or an extension of an existing Health Links setup. "Health Links" is a fancy label for a bunch of partner agencies - clinics, hospitals, home care - getting in a room to coordinate care for the 5% of patients that eat up 2/3 of health care dollars. Still with me?

The PCG (or "sub-LHIN" or whatever it'll ultimately be called) will then contract with local primary care providers to both provide after-hours access to care and take on new and "orphaned" patients (i.e. patients whose doctor closes up practice).

Sounds like a good idea, right? You could even call this a vision from primary care in Ontario, non?

Uh, non. This is a vision for a bureaucratic mess that will take years to implement, burning through millions and millions and millions of dollars without any measurable benefit to the population even IF it works. How can I be sure? Let me count the ways.

1. Contracts = lawyers. How much time and money will be needed to develop (and scrutinize) a binding legal contract on primary care providers? Are the contracts supposed to be uniform across the province? How can that be when different clinic setups are funded differently (fee for service, salary, etc.)? Or in rural areas where the number of providers might be under the threshold needed to meet the standard of access? How would such a contract interact with a doctor's existing contracts, such as fee splits with building owners?

2. The Ministry controls the money. The Ministry is responsible for negotiating with doctors around their pay. How can a local-regional body engage physicians to buy into a plan without knowing the carrots and sticks? Even if the current dispute is resolved, don't the details of this plan also need to be negotiated? When and how is that process supposed to take place? Where is the money coming from to pay for the implementation?

3. Will the patients understand it? The plan as outlined in the report implies a degree of reciprocal responsibility on the part of patients. If the doctors are contracted to provide after-hours care, are the patients obliged to access it? Patients will travel far and wide to see their regular doctor for something important, but will see anybody for a minor infection. How do you deal with patients in cities where there are walk-in clinics all over the place? Is the government trying to force the closure of walk-in clinics? What about those clinics' lease agreements, etc.? Can we expect new Canadians or seniors or those with mental illness to understand any of this?

4. Are these contractual obligations to be considered professional obligations as well? Will the respective Colleges of Physicians and Nurses (that govern Nurse Practitioners) be engaged? What if there's significant resistance from the Colleges or their members? What about practitioners with focused practices (never mind doctors that do non-insured services like Botox injections)?

5. Are the right people in place to implement the plan? The LHINs weren't set up to administer contractual arrangements with community providers. Health Links were conceived and developed as cost-savings initiatives, not to implement primary care reform. That's a potentially monstrous step up in terms of scope and responsibility. Are new leadership teams going to be recruited? By whom? Paid for how? At what scale?

These are off the top of my head, literally as I'm laying on the couch with a movie in the background. There's nothing in the Price-Baker document to indicate these issues have been explored even superficially. The authors themselves have walked back from it, labeling it a "discussion paper" rather than a concrete plan. But lo and behold, the Ministry is pressing ahead. Given the extraordinary scope of the Patients First initiative, one would hope that more than a passing thought would be given to the details of its realization.

Next time: scrutinizing the assumptions and aims of Patients First, and some alternative ideas going forward.

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