Big things happen every few decades. We landed on the moon in 1969. The Berlin Wall fell in 1989. The Ford government tabled Bill 74 in 2019.
At least that is how everyone talks about Premier Ford’s new bill. Former Deputy Minister of Health, Dr. Bob Bell, said that The People’s Health Care Act is the biggest change to healthcare in 50 years.
Minister of Health, Christine Elliott, announced Bill 74 on Tuesday. It had already been leaked, condemned, defended and modified. So it did not spark the same surprise had we known nothing.
The NDP’s Andrea Horwath said the leaked legislation guaranteed private healthcare. The end was not near: it was here. But Bill 74 does not mention privatization.
Bill 74
The People’s Health Care Act (Bill 74) dissolves the Local Health Integration Networks (LHINs). Most clinicians cheered.
The LHINs are full of eager, well-intentioned people, who inflict programs and metrics on clinicians to justify the LHINs’ existence. I feel bad for the LHIN people. But anytime they launched a new LHIN directive, I felt worse for us.
Here are five things you need to know about the bill:
A. “The Agency”
Bill 74 creates a Crown Agency called, Ontario Health. The bill refers to Ontario Health as “the Agency” throughout. The Agency swallows up over 20 other health agencies into one “super agency”.
This should decrease redundancy and bureaucratic waste, but it might just make a monolithic monstrosity.
Aside from the caterwauling of those whose ox is being gored, most people applaud canning the current alphabet of agencies.
B. HSPs and ICDSs
All hospitals, clinics, health teams — almost anyone and any group that provides clinical services — have been renamed Health Service Providers (HSPs) or Integrated Care Delivery Systems (ICDSs).
The bill does not mention physicians. But physicians could fall into one of these definitions. Let’s hope not.
C. Power
The Minister of Health (MOH) gains power. Granted, the MOH probably had these powers before. But the bill extends and makes it explicit.
The MOH may order HSPs/ICDSs to:
provide or cease to provide a service;
increase the quantity of a service;
change location;
stop operations;
amalgamate with other HSPs/ICDSs;
transfer all operations to another person or entity, including transfer of property
(“Required Integration” 33(1)).
D. Oversight
The Agency can direct HSPs/ICDSs to submit audits, operational reviews, or peer reviews.
E. Inspection/Supervision
The Agency can appoint inspectors and supervisors to go through all the details and documentation of an HSP/ICDS.
Check out the OMA’s summary for more detail.
Reflections
The bill declares that care should be centred on “people, patients, their families, and their caregivers.” It talks about removing duplication and empowering providers to work together. It sounds different than a Wynne bill.
Bill 74 concentrates power in one big agency. But power was concentrated before also. Bill 74 just makes it explicit. Now, no one can hide behind the LHINs, or some other agency, when quality and service lags. We can hold the Agency CEO accountable.
Nevertheless, concentrating power should make us squirm. Dividing power decreases the risk of harm.
A bad decision by one small organization, which controls a corner of healthcare, causes a small disaster. A bad decision by a super-agency causes chaos everywhere. All organizations make bad decisions at some point.
Demand a Plan
Bill 74 would not exist if Ontario healthcare were not a mess. In the face of crisis, people demand action. They demand change. That should scare you.
Many people criticize the bill for not having a plan to solve hallway medicine, homecare, long-term care, and dozens of other things. But a master solution, crafted by smart people at the centre of power, guarantees failure on the frontlines.
No one knows enough to plan a healthcare economy. It has been tried and failed.
Government needs to set the rules — create the playing surface — and then let doctors and nurses find creative solutions to deliver care.
Everything is Still Political
Finally, the bill calls the Agency a “Crown Agency”. But it is not arm’s length. It is not a free-of-the-election-cycle agency that we need. The Agency has intimate ties with the Minister of Health. Those ties allow the Minister to direct the Agency. That power brings responsibility and accountability.
When politicians own accountability for outcomes, they make decisions based on political outcomes, not patient outcomes. It has always been thus. We were desperate for change on this issue.
What Kind of Politics?
I am cautiously hopeful. Who knows whether the conservatives will act like classical liberals, traditional conservatives, or Red Tories.
Will they use this consolidation to shrink the size and power of government, like a classical liberal?
Will they maintain big bureaucratic budgets, like a traditional conservative?
Or will they expand bureaucracy and social programming, like Red Tories?
Classical liberalism once united Conservatives and Liberals. They supported the supreme value of the individual and freedom of the same. Classical liberals know that individuals need protection from government’s sovereign power.
Modern Liberals shifted left. They increased faith in the moral superiority of government. They now focus on oppressors and victims; power and central control.
Conservatives have changed too. Many so-called conservatives push illiberal ideas, such as, “We just need to ban doctors from solo practice”, or “We should pass a law and force doctors to work in under-serviced areas”.
Bill 74 gives government broad power. In the hands of modern left-Liberals, it would be a prescription for command and control.
IF the conservatives stand by principles of classical liberalism, then we should see individualism and freedom, not command and control.
But all governments change eventually…
Photo credit: CBC.ca Super Agency
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I am hopeful that there will be PRACTICAL changes and improvements in the delivery of health care. I hear complaints that the government is not getting results fast enough. I hope that this will not be another example of a quick fix to save Medicare for a generation. It will take many years to implement change. I am glad that there are not too many details about what will happen at the front lines so there can be more feedback as things unfold.
The current situation strikes me as a Pandora’s box except with good possibilities flying out instead of bad. To complete the simile, the last thing we have is not hope but your “all governments change eventually…”
Exactly, well said. The last thing we want is a quick fix. It will take time. Details should come out as we work out how to make persuade true change.
Still, I worry about concentrated power. If it came down to election results versus doing things right, the current set up favours politicization of decisions. But maybe that’s a given with a nationalized industry.
Thanks so much for posting a comment, Gerry!
Predict more smart MD emigration from Ont. Top corneal expert moving to Vancouver.
We’ve already seen a huge number of unmatched family med spots in Ontario.
Thanks for writing about your take on the new bill. I have to say given what’s going on in my corner of Ontario, I’m worried that hospital administrators will have more power and make poor decisions based on their budgets. I’ve relayed to many politicians that they need to engage in front line community physicians to collaborate and let us give suggestions how to make his work and how to end hallway medicine. Not rely on the same usual suspects and hospital CEOs that they usually turn to and have no idea about real life medicine.
Good point, Lisa.
Accountability is great depending on whom is held accountable. Those held accountable also need the freedom to deliver.
This bill is a big change in some ways, but it does not (yet) address the fundamental root of why the system struggles. The system will struggle until they change the rules.
Thanks for posting!
I ‘ll drag out that quote attributed to Gaius Petronius Arbiter AD 60 …” I was to learn later in life that we tend to meet any new situation by reorganizing: and what a wonderful method it can be for creating the illusion of progress while producing confusion, inefficiency and demoralization”.
So its BOHICA time yet again( Bend over, here it comes again).
Another opportunity for an evidence based world class health care system slips away yet again….as it will south of the Canadian border.
A and B are frightening enough…C ‘s transfer of persons, entities and of property are even ore so.
A colleague of mine ( decades ago) told me of the experience of his father , a GP in the UK, who had built his own medical building/ office prior to the introduction of the British National Health Service in 1948…the government nationalized his office without compensation…valuing his building around £4000 they promised him that he would get the value of his building back on his retirement at the prevailing very low interest rate.
He retired decades later and he got his £4000 +puny interest back, his unimproved ( by the government) property was worth £ millions….so…BEWARE.
D & E are simply icing on the statists’ cake.
“If you find yourself in a hole…stop digging”…each political party in Ontario has taken its turn at the shovel and it’s getting darker and darker in the Ontario medicare pit…changing governments have proven not to be a solution…” plus ca change, plus c’est la meme chose”…”the more things change , the more they stay the same”.
Progressive deterioration and erosion in take home income and quality of life is all that young and middle aged medical professionals can look forwards to…self prervation is nature’s oldest law…you young ones look beyond Ontario and Canada…those whose life savings are invested in their medical buildings and practices should put their thinking caps on and then take action before the trap snaps shut.
The government will do the presently unthinkable, those who wish to survive will have to do the same in order to survive the government’s inevitable actions.
Many were drawn into the abattoir enticed by shiny objects and sweeteners…the doors are about to shut….there is still time to avoid the fate being planned for them by the central planners as they move the interchangeable health care provider widgets on their spread sheets.
Hey Andris,
Loved your quote about reorganizing. I didn’t know that one. I also loved your story about your colleague and his clinic. I agree, we must be very careful. I guess the incentive to avoid such a fate is for the large clinics to rush in and apply to become an Ontario Health Team as soon as possible.
I’m still committed to trying to stay positive. While I agree, there are some very worrisome features of this legislation, I also know that the government cannot implement without support from physicians. They cannot abuse all of us at the same time. So, I’m trying not to go to such a dark place as you describe in your comments. Perhaps you can say, “I told you so” in a few years when your predictions come true. I sure hope you are wrong. But again, this bill does not do much to lift the morale of most docs. While we cheer that LHINs are leaving, they will be replaced by other gatekeepers.
Thanks again for taking time to share a colourful comment.
Cheers
Take a look at Section 20 of Bill. The Minister can issue directives. There is no legal remedy against the Minister for issuing a directive.
Thanks Perry.
I saw the part about directives, but I did not think to look for legal remedies against them. Scary. I found it odd that the Minister would want that kind of authority, because it brings a huge amount of accountability with it. It also makes this new approach even more political than the last.
Sure appreciate you taking time to share!
No accountability for ministers and the government…if it is a success they will take the bow…if a disaster ( the more likely result) , it will be attributed to sabotage and “ wrecking” ( to utilize the Stalinist term) on the part of greedy, self serving MDs requiring even sterner governmental actions directed at them.
The profession has revealed a propensity to rolling over in the face of governmental action no matter how malicious…it has buckled repeatedly…the government can implement whatever hare brained policy its MBA’s can concoct without fear of resistance…all it needs is to have the cooperation of a few Quislings from the medical ranks to give it cover…and there are plenty of those…they are likely already lining up, lobbying for governmental sinecures for submissive Quislings.
The only solution for those at the coal face who can expect no protection from anyone is flight…for the older into retirement….for the younger to anywhere other than Ontario.
Good point about assigning blame, Andris. You are right: someone always needs to wear the failures.
So far, the system has lagged because docs went on strike in 1962…and because of fee for service…and because of physician autonomy…and, well, everything would be so much better if we could just get rid of the whole medical profession. Do we really even need doctors at all?
Shawn, Thanks for excellent precis. The challenge boils down to governance: is it a health care system or a loose network? Health care requires distributed decision-making. The challenge is classifying the decisions and placing each class of decision at the right level. Many decisions have to be agreed between the physician (or caregiver) and the patient; others at the top – E.G., drug price negotiation. Too many decisions at the top yields the paralysis we’ve experienced in the past; too many distributed throughout the system yields the chaotic network we’ve also experienced. I’m not sure any jurisdiction can nail it: some have come closer than us but so far no one is perfect. Beyond the examples I cited above, I have yet to see a careful analysis aimed at decision classification and redistribution. jg
Hello Jonathan,
I really like how you classified the different kinds of decisions that must be made in health care. I agree for the most part. I lean towards letting a bit of chaos reign (probably no surprise there). After all, it seems to work well for cars, houses, bread, and airplane tickets. I worry about quality, service, access, and innovation more than chaos per se. Having said that, I still like how you’ve framed the discussion. Brilliant!
Great to hear from you! I hope you are well. Looking forward to the next time we meet.
Cheers
From what I have heard, groups of doctors often collaborate to make their *local* health delivery work. Some family doctors work together and adjust their practice patterns to service their communities when there are no formal specialists around. Coordination of holidays and days off were always informally coordinated. This decentralized responsibility worked. But now, so many rules coming out of “head office”, with fee cuts, loss of physicians to emigration and retirement, in addition to resentment by physicians, there is less will and ability to do these things for local communities.
The centralization of rule makers and that includes LHINs, has taken away the local autonomy and pride to make the system work. The pride of making a local system work has been “burned out” of physicians.
Jonathan, you are right. Let’s hope that a reasonable balance will evolve.
In the early ’70’s , on my arrival in my community in suburban Ontario , the hospital was essentially a GP hospital, it was unthinkable not to be on hospital staff, to do OB and to do ones shifts in the ER…the various groups met via the hospital committees, they were on the Board , pretty well telling the administrator what to do, new staff and specialists were vetted by the community MDs…and decisions were made via the local medical society.
I had a kick looking through the society minutes…in the 50’s 60’s…they decided the value of fees between themselves …how much for a house call, how much for a night call, office visit etc., …evidently other societies decided on their fee schedules depending on local market forces.
If today’s health ministry and all of its pointy headed ” experts” and bureaucrats vanished tomorrow the world of medicine in Ontario would still go on, we would all adjust and self organize immediately.
That whole health care pyramid believes itself to be essential…it is not…yet there it is…sitting on us all like a corpulent Jabba the Hutt.
Had the Ontario government carried out liposuction on the bloated pyramid flushing the fat away it would have been a positive…instead it has promised not to flush any of the fat away ( or bury it in an abandoned mine) promising instead to merely redistribute it …presumably from the belly to the buttocks Kardashian style?…solving nothing.