Wednesday, June 22, 2016

Who's Afraid of the Big Bad LHIN?

A meditation on the Ontario government's striking resemblance to Wile E. Coyote.

Fellow London physician Dr. Mario Elia has a thoughtful piece about Bill 210, the legislation behind the Patients First. I recommend it to anyone practicing primary care in Ontario, not only because it covers some of the key concerns well, but because it also makes the case for prudence and patience in deciding on an appropriate response. I'm going to go one step further. While I have previously expressed concerns about the long-term viability of Family Medicine As We Know It, I would argue that there's no immediate threat to the profession posed by the LHINs in and of themselves.

How can I be so sanguine? Well, first and foremost I'm not in practice. I have nothing to really fear, except perhaps more guilt about my former patients unable to get proper care under Patients First. More importantly, however, I am 100% sure that the Ministry's trust in the LHINs is 100% misplaced.

After the second theatrical Road Runner short, Beep Beep, Chuck Jones and his writer Michael Maltese created a brief set of rules for Road Runner cartoons going forward:
  • Road Runner never leaves the road
  • The principal enemy of the Coyote is gravity
  • The Coyote has absolute faith in the ACME corporation

So time and again, despite one failure after another, Coyote continues to shop from the ACME catalog, thus guaranteeing himself further burns or deformities, and the rest of us a good-old cheap laugh.

The Ontario government is really no different, with an unyielding belief in the power of bureaucracy. Though the energy file has been the more palpably mishandled, with things looking to get even worse, I can only speak to health care's bureaucratic bloat. Like the Coyote, the health care system seems wedded to its own four-letter source of products and services ranging from wastefully ineffective to downright destructive.

My own experiences in dealing with the LHIN (while working at a CHC, a health unit, and attending Health Links sessions) have proven more than a little instructive into how the LHINs operate.

In a nutshell, not well.

Regardless of their mandate to coordinate, integrate, and buzzwordificate, the LHIN bureaucrats I've dealt with have ranged in ability and achievement from clueless to pointless. True, they're not entirely ineffectual as enforcers for the Ministry, nagging subordinate institutions (CHCs, CCACs) to meet targets and do more with less. By and large, however, they lack any real understanding of how health care actually works on the front lines, and I didn't detect much interest in improving upon that.

Of course the LHINs are now being put on steroids courtesy of Bill 210, with massive new responsibilities for home care, integration with Public Health, and somehow, someway, someday organizing primary care into a 24/7, comprehensive, team-based, patient-centered, universal, guaranteed, equitable, culturally-sensitive, accountable, measurable, high-quality, integrated, affordable, sustainable, nationally-treasured, well-oiled, gluten-free system.

It's not going to happen, and doctors have little to fear. Why? Because like the ACME products in the cartoons, the LHINs embody ineptitude, inefficiency, and incompetence in design. Given their monstrous new responsibilities, particularly in rebuilding the dysfunctional home care system, LHIN bureaucrats are in over their fucking heads, and they still have no real power! The Ministry still controls how doctors are paid, a fact that will never change (not because of the OMA...why would the Ministry ever surrender that power?) It will take years to get the right people in place to meet the expanded scope of duties, never mind the impossible task of bringing doctors to heel without having access to the carrots and sticks of pay.

So give the LHINs all the proverbial rope they need to hang themselves. Go to the engagement sessions. Meet the bureaucrats and see for yourself how utterly hapless they will be in their onerous new roles. Ask them the tough questions they can't answer. Let them fret and call the Masters of the Universe in Toronto, and everyone will wait months to get an answer about anything. By then, the legalities will be worked out, the infeasibility of Patients First will become increasingly obvious to everyone, and who knows? The government might finally learn its lesson and rethink its approach, albeit learning said lesson the hard way.

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