Busting the myth of bloated government bureaucracy


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  1. Michelle Cohen

    Can you comment on the 84 new VPs that will be added when the subLHINs are created? And if currently LHIN staff numbers are at 510, how many more new admin staff will be hired for the new subLHINs?

    • Bob Bell

      The VP’s in the new LHINs are not new positions. When the CCAC’s and LHIN’s integrate, we will reduce the total number of management and admin staff by 10% saving at least 8% of admin budget which will be reinvested in clinical care. The VP’s will be recruited from existing executives in the current LHIN’s or CCAC’s in many cases. If they are recruited from outside the current organizations, they will replace a current member of the admin teams. Staff will be reassigned to lead the sub-LHIN regions from existing staff members in most cases. The sub-LHINs are not a separate layer of administration- they represent a new way to integrate care using the existing team. This is reorganization and reduction of executive staff that is typical of organizational integration and redesign.

  2. Pagrin Shoulk

    Laughable. And wrong. Thanks for the entertainment and government spin

    • Harold

      Can you please provide any evidence or opposing facts for such a sweeping statement?

      • Pagrin Shoulk

        1. Bell mentions the CCACs as an example of success. They are specifically and widely recognized as bloated messes by the Auditor General. A whopping 40% of the budget was wasted on administrators when the industry standard was 2% in the 1970’s.
        2. eHealth Ontario is a boondoggle worthy of a book.
        3. Now, Bob Bell and the political leaders want to bring in MORE of the same? All while cutting funds to doctor’s clinics (where 90% of all patient encounters happen) and cutting nurses in hospitals? Insane.
        For an article with some intelligence, look here https://www.facebook.com/22Minutes/?hc_ref=NEWSFEED&fref=nf
        Nope. The best thing to do is vote the Liberals out. They are the worst cancer of all.

  3. Peter Auswage

    Bureaucracy is not just what you can see and count on a Provincial Org Chart. It’s all those employees and administrators at hospitals, agencies, CHC’s etc whose job has little to do with providing care. It’s the myriad of policies and procedures, often redundant from one institution to the next, and always replicating the same work hundreds of times over in the same Province. It’s the administrators hiring more administrators, so that they can have more meetings to discuss the same issues over and over. But most importantly it’s a culture where those providing the care have little input into how that delivery is provided and cannot even identify the appropriate bureaucrat to talk to should they have a great idea.

  4. Chris

    A never ending cycle of pilot projects and self-congratulation with no real accountability to patients, care providers or taxpayers. Sounds like a great gig. Sign me up.

    How’s progress on eHealth coming along?

    • Bob Bell

      Chris thanks for asking about digital health in Ontario which is alive and well and providing substantial benefit to our province. In her 2016 report on ehealth the Auditor General (page 4 of her report) referred to the Canada Health Infoway analysis of benefit from digital health investments to Ontarians in 2015. She described more than $900M in benefit which is nearly three times the annual investment in digital health made through eHealth Ontario. If all operating support of digital health programs are added up, we are just about breaking even from a financial perspective and of course digital health investments provide incalculable value in patient safety and convenience. There is still a ton of work to be done- e-referral, e-consult, telehomecare, telemedicine, patients accessing information through portals to name just a few projects- but all of these programs have already been started in Ontario and are ready to scale.

  5. Alexander

    Thank you for the eye awakening message as it made me realize and want to appreciate our current healthcare system. I have always believed in your vision & how you strive to ensure that our system is sustainable to provide a better & healthier tomorrow for all Ontarians. Sadly, I say that “bloated bureaucracy” does exist and you will see this if you look beyond the metrics that’s provided to you in paper. Under-delivering is brought about by securing numerous staff in the healthcare system who do not share your great vision. I remain hopeful as this is the very system that I will rely on in the future.

    • Pagrin Shoulk

      The fact that Bob Bell is supporting such an insane move to create 74 more sub-LHIN’s, when the current LHIN/CCAC is such a bloated, wasteful mess, shows that Bell does not have a “great vision”.
      Hire more nurses. Hire more doctors. Hire more social workers who actually see clients.
      Keep administration at less than 2% of all health care budgets, like we did in the 1970’s.
      Ontario has the highest health care administrative burden in Canada.
      Bob Bell, Eric Hoskins, and Kathleen Wynne need to go. We need change.

      • SC

        Hello Pagrin Shoulk, I have read a few of your comments; I wonder if you work in healthcare. I don’t mean this to offend you, I just think your solution of just hiring more Nurses, Doctors, and Social Workers in place of the dreaded “administrators” is simplistic and ignores the fact that there are many non-clinical workers and professionals in healthcare. You could not keep a hospital running without cleaning or maintenance staff for example. There are also other professionals who ensure patient safety such as Patient Advocates, Patient Safety Officers, Risk Managers, Emergency Managers, etc. I would urge you to reconsider your statement.

        Having said this, I do think that we can administer the health system better. I am not sure whey we need LHIN’s or even RHA’s. We have a Department/Ministry of Health why can’t they manage the administration of healthcare with minimal local area managers? I see no reason for CEO’s and executives within the system outside of the Ministry or Department of health.

  6. CGBe

    I am sure this is all true, but likely not the whole truth. Ontario still needs fundamental changes that are not budgeted or really discussed with the public.

    Part of this problem is the daylight between senior civil servants like Dr. Bell and the politicians who generally can’t see beyond a two-year mid-term election horizon. Lean administration is admirable except when we don’t have the right people to get an overarching and integrating strategy developed and implemented. A provincial EHR is still missing and so is the system-level intelligence it would enable. Docs still send patient records by fax (!!!). Primary care still closes at 5:00 and takes weekends off. Wait times for specialists are still ridiculously long and unmanaged at a regional or provincial level. Prevention strategies for most chronic diseases are…where? Both CCO and the Ministry share cancer drug funding so no one is fully accountable…and may explain why Ontario still does not provide equal coverage for IV and orally-administered cancer drugs. One recurring theme seems to be a lack of patient focus.

    Yes there are some things to celebrate, and operational efficiency may be one of them. But with $52 billion spent, I think we need more than this short list of accomplishments to support the idea of good stewardship, accountability, effectiveness, and widespread adoption of innovation.

    • Pagrin Shoulk

      Hmm. Primary care closes at 5PM? I just saw my family doctor at 730, and she called me back at 10 pm. Most doctors are working well into the evening. According to my doc, about 90% of all doctors do some kind of call coverage to provide care for society 24/7. Most critical lab results (my dad has INR monitoring) are reported at 10 pm by the lab – and the results are relayed by a doctor to him.
      Nope. The only part of health care that closes at 5 pm are the administrators.

      • CGBe

        Hours of services are decided by each physician or group practice…and you got lucky. Primary care is not accessible in the evenings or weekends in the small city (>100K) where I live and the emerg here is a royal mess. The walk-in clinics are sporadic and therefore jammed when they’re open. One clinic never accepts patients after the first hour because the next three are spent treating those already waiting. The difference between your experience and mine suggests standards of care and of service should be developed that meet patient needs and expectations…everywhere.

    • Unnamed MD feeling unsafe

      I am a doctor, and I work easy 70-80 hours a week, sometimes 100 depending on my call schedule. Most MDs work beyond 5PM, not necessarily seeing patients as there is other stuff to do. A big chunk of my work is background UNPAID work, such as checking the results of the tests I ordered while sitting with laptop in my kids’ bedroom while my wife is reading them a beftime book just so that I am “with” my family, calling my colleagues to discuss patients, calling patients at night with their results, etc… Show me 1 more public sector that would be willing to do this, while their own minister is publicly demonizing them and reducing their pay schedule year after year after year. MDs in ON give job to 200,000 Ontarians in their private practices, but this will change if the medico-politics remain this toxic. 70% od MDs are burned out. This has to stop!!! Most MDs (and our patients) have no trust whatsoever in the current MoH no matter what the media spin is, just like this one.

  7. James Elliott

    Hello Dr. Bell,
    Can you tell us how many executives above Assistant Deputy Minister were there in 2004 and 2017, please? I speculate that this is where the bloating has happened.

    • Bob Bell

      thanks for your comment. Currently the Ministry has one CIO and two Associate Deputy Ministers. I am checking to see how many senior admin roles were present in 2004.

      • James Elliott

        Dr, Bell – I meant to ask you the change in number of executives – ADMS and above – from 2004 to 2017. Sorry for not making it clearer. Looking forward to hearing from you.
        JE

        • Bob Bell

          Thanks James. As usual with this type of comparison it is difficult to compare apples and oranges. For much of the time that you ask for data, the Ministry of Health was separate from the Ministry of Health Promotion. So I could say that we have fewer senior roles now than then because we have one Deputy Minister instead of two. I can say that we are always trying to rationalize executive roles in the OPS and MOHLTC. For example we recently eliminated a senior role by combining the Divisions of Public Health and Health Promotion under a single ADM- thereby reducing an executive role. At the same time, we recruited Ontario’s inaugural Chief Health Innovation Strategist who is already having a major impact on providing Ontario’s burgeoning life science innovation industry with access to procurement in our health system.

  8. Dr. Dennis Kendel

    Thank you, Dr. Bell, for this detailed explanation of the diverse roles filled by public servants in the Ontario Health Ministry. Your explanation reinforces my personal experience that we don’t understand the value that public servants bring to our system until we actually meet them and learn what they do.

    • Sinha Wituck

      Ontario has the most bloated health care bureaucracy in Canada. We have witnessed terrible waste in the system, with demoralized nurses and doctors. Not one of my doctors, or my dad’s doctors, agree with him. I suspect this powerful administrator, who hasn’t practiced for over two decades, and never in Ontario, is sorely out of touch with reality.
      I see how hard my doctor works. I also see what administrators in my LHIN do. Something smells funny here. Why are these non-practicing doctors defending the health care bureaucracy? Is there a conflict of interest here? Dr. Kendel, will you speak to any conflicts of interest? Have you now, or ever received funding, consulting fees, employment offers, or research grants from the Ontario government? An answer would be appreciated.

      • Bob Bell

        thanks for your comments. I started practicing in Ontario in 1976 and saw my last patient at Princess Margaret in May 2014.

        • Chris

          Does it only take three years to get that out of touch?

          Why not come actually talk to us little people on the front lines?

          • CGBe

            This is rude, personal and disrespectful. This isn’t the G&M.

      • Pagrin Shoulk

        I think Ms (?Mr.) Wituk is referring to Dr. Kendel, who hasn’t practiced for a couple of decades, not Dr. Bell. But I too would like to hear if Dr. Kendel has any conflicts to disclose. I know that Dr. Bell is paid about $750,000 per year, roughly three times what a practicing physician takes home after expenses.

        • Bob Bell

          Thanks for your comments. I agree that I am well paid. My total annual comp (posted on the sunshine list) is about $310,000 less than you estimate.

          • Pagrin Shoulk

            Wow. One million a year? If you gave up just one percent of your income, my dad could get his hip surgery done tomorrow, instead of waiting a total of four years (and counting!) since diagnosis. My Internist moved to the US after getting hit with a 50% drop in her income (30% drop in billings, same overhead = 50% drop in take home income).
            I wonder, Dr. Bell, if you will be undergoing a 50% drop in YOUR income along with your front line physician brothers and sisters?
            No wonder why doctors-turned-administrators are smiling. And turning their backs. No wonder why you unabashedly support this government. I’ll say it again. The Liberals have to go.

            • Bob Bell

              You misunderstood my comment… my comp is $310,000 LESS than your estimate of $750,000… which you already know from the sunshine list.

    • Pagrin Shoulk

      You want to know who does amazing work? Ontario’s doctors. You know, the ones that the government are attacking.

      • Bob Bell

        Thanks for your comments. I agree that Ontario’s doctors do amazing work and I am proud to be an Ontario Orthopaedic surgeon.

        • The Doctor

          Dr Bell I appreciate your replying to questions raised in this forum. I would expect that as an Orthopaedic Surgeon you would be keen to assist the patients in Ontario with Ehlers – Danlos Syndrome. What I don’t understand is why the Public Fanfare by Dr Hoskins for a Clinic which will treat 1 in 10,000 or so suffering Ontarians.
          If you wanted to assist a substantial numbers Ontarians why not open clinics for people with ASD which affects about 1 in 70. Why not address their needs. I am sure the Children’s Hospitals in Ontario can provide you with ideas for tackling younger patients with ASD. I believe the OMA can provide you with some guidance on ASD in Adolescents and Adults through their Working Group. I’m sure Mental Health Provider’s could provide you with info on Dual Diagnosis clinics if there were any for patient with IQs over 80. You will probably find them in studies of the Homeless.
          So many avenues where you could benefit 1 in 70 SEVERLY UNDERSERVICED Ontarians.
          When and Where are going to start?
          Sincerely
          A mother of 2 who both have ASD.

          • bob bell

            Thanks for your comments and sharing your concern for facilities available for your children on the spectrum. I certainly have considerable respect for the challenges that you and your family face. My wife is recently retired but specialized in developmental paeds in the inner city and her practice really focused on ASD. Every public health system struggles with providing behavioural therapy in timely fashion and ensuring that the kids who need it most get it when it can have the biggest impact. As you know, behavioural Rx for ASD is provided by MCYS in Ontario and our colleagues are working very hard to rationalize access to treatment that works. Thanks for reminding us of the importance of this issue.

          • bob bell

            Thanks for your comments and sharing your concern for facilities available for your children on the spectrum. I certainly have considerable respect for the challenges that you and your family face. My wife is recently retired but specialized in developmental paeds in the inner city and her practice really focused on ASD. Every public health system struggles with providing behavioural therapy in timely fashion and ensuring that the kids who need it most get it when it can have the biggest impact. As you know, behavioural Rx for ASD is provided by MCYS in Ontario and our colleagues are working very hard to rationalize access to treatment that works. Thanks for reminding us of the importance of this issue.

          • Bob Bell

            Thanks for your comments and I am sure that everyone reading this imagines the challenges you face in caring for your two children. My wife is retired now but practiced for many years as a Developmental Paediatrician in the inner city and much of her time was spent trying to arrange a variety of services for children on the spectrum. As you know better than I, services for ASD children are organized through the Ministry of Children and Youth Services and my DM colleague Nancy Matthews and Minister Coteau are working very hard at making behavioural therapy services more accessible to kids who need them.

    • Real family doctor

      Now that response was written like a true public servant…oh, wait, it’s Dr Kendel, the career public servant.

  9. HeHateMe30

    This article is intentionally misleading. Dr. Bell speaks only of the actual Ministry of Health – but there are innumerable governmental organization that I suppose are an arms length away from the actual ministry that have thousands upon thousands of employees. These include: HQO, LHINs (14 I think each with), SUBLHINs (84 of these), CCAC (soon to be renamed), eHealth, OntarioMD, ORNGE, etc. They are innumerable and each is bloated. Not only are there an incredible amount of redundant employees, most of them are highly overpaid given their level of education — its hard to imagine they could find an equally paying job with as little accountability in the private sector. Don’t forget every one of these guys gets a gold plated pension and benefit package. Go on and vilify the doctors some more, who work round the clock like animals for less money, no pension and no benefits after 10x the education.

    • Yesman

      Exactly. Kind of like putting all of your money into investments and different accounts and then claiming you have no money because your chequing account is empty.

    • Bob Bell

      thanks for your comments. Just a couple of clarifications. There is no LHIN sub-region budget or separate staff. The sub-LHINs are part of the LHIN and simply represent a separate planning and performance structure within the LHIN. Current LHIN/CCAC staff will be reassigned to new roles within the sub-regions. The CCAC’s will merge with the LHINs in the near future and when that occurs a layer of bureaucracy will sun-set with a ten per cent reduction in positions of the two organizations and 8% reduction in admin budgets which will be invested in clinical care. So… LHINs, sub-LHINs, CCAC’s… are will soon be one organization with a reduction in admin staffing when the new integrated LHIN is formed.

      • Chris

        Will each sub LHIN have its own EMR that doesn’t talk to any of the others? That’s what we’re dying to know.

        Don’t want to break with tradition now, do we?

      • HeHateMe30

        So what you are saying is that you agree that your estimate above is intentionally misleading because there are other massive organizations that, while technically aren’t MOH, are really a repackaged version that has allowed you to disqualify them as “moh employees”

        And it seems you and the ministry agree there is excessive administration as you are trying hard to reduce the number of beurocrats by merging two bloated organizations who accomplish little and spend huge $$$ on admin.

  10. Sharad

    There is plenty out there that speaks to Ontario’s bloated health care bureaucracy. There’s a limit to how many hyperlinks I can cut-and-paste, but please read:
    http://news.nationalpost.com/full-comment/matthew-lister-canadian-healthcare-needs-to-be-leaner
    http://shawnwhatley.com/hospital-beds/
    http://www.theglobeandmail.com/opinion/the-best-health-care-system-the-numbers-say-otherwise/article5577290/
    http://www.torontosun.com/2015/10/24/inside-ontarios-bloated-health-care-bureaucracy

    • Bob Bell

      Sharad thanks for your comments. I think part of the problem we have in understanding the value of the work done by people employed in the Ministry or government agencies is the definition of “bureaucracy” or “bureaucrat”. Is the Ambulance Call Center worker responding to an Ontarian complaining of severe chest pain over the phone and sending an ambulance to the scene a bureaucrat? How about an inspector ensuring that frail seniors have appropriate care plans in a long term care home? What about the systems engineers ensuring that doctors’ OHIP claims are paid in timely fashion and that pharmacies are promptly paid for public drug claims? As I mentioned in the article above, these roles are simply essential to our publicly funded system… I think that you would agree… and comprise more than 60% of the employees of Ontario’s Ministry of Health.

  11. Zain

    Bob, when can Ontarians expect to have electronic medical records?

    • Bob Bell

      Zain thanks for your comments. Electronic Medical Records (EMR’s) are used by more than 80% of Ontario’s primary care providers and Hospital Information Systems (HIS) are used in 100% of Ontario’s hospitals. Integration of digital health information into an Electronic Health Record (EHR) that provides integrated information at point of care is available to more than 80,000 clinicians working in ER’s, hospitals and Home Care. These EHR’s are called “Clinical Connect” in Hamilton, Central Ontario and the South West of the province and “Connecting Ontario”in the rest of the province. A provincial repository that holds virtually all lab data, most imaging reports, and hospital records will be completed in the next year. Medication records for publicly funded drugs and all narcotics are currently stored in a medicatio repository that is updated daily. Access to this repository is rolling out across Clinical Connect providers in the next six months and will be activated for Connected Ontario clinicians starting in the summer. The medication repository is currently available in Guelph hospital and Guelph primary care. Home care information is available in both Connecting Ontario and Clinical Connect through access to the CHRIS system provided by Health Shared Services Ontario (formerly OACCAC). The next challenge will be to connect EMR data into the EHR’s. Important information from hospital systems (discharge summaries etc.) Is already fed into many EMR’s directly through Hospital Report Manager and of course OLIS can feed lab results directly into EMR’s as well.

      • Chris

        “A provincial repository that holds virtually all lab data, most imaging reports, and hospital records will be completed in the next year.”

        We’re going to hold you to that one, Dr. Bob.

        Imagine if there was (or would have been) actual real leadership on this file. Then we wouldn’t have all this complicated mess. Man oh man, what a lot of wasted time and money. All those extra tests and visits and face palms that could have been avoided. The soothing sound of a fax machine never gets old…

        EHRs connecting to EMRs… I think you and I will be long gone before this one is sorted, Dr. Bob. Paint has dried and grass has grown and we still are where we are. Were you the type of surgeon who blamed a longer than expected OR on the anesthesiologist? Certainly, you cannot take the blame on this one, right? It’s someone else’s fault, of course.

        But alas, no other jurisdiction has been able to figure this out… oh, wait… actually, others have been able to figure out. In Canada. Shall we phone (or fax) a friend?

        • Bob Bell

          Chris, I think if you talk to the anaesthesiologists that I worked with at Mount Sinai and UHN that you would find that I do not shift the blame to others (certainly not other members of the OR team) when things go wrong in surgery. And I really wonder what that has to do with a discussion of digital health in Ontario? If I can assume that you are a physician or health professional, perhaps I could suggest a more rational and civil tone might be undertaken when we are discussing important issues.

          With respect to digital information being seamlessly uploaded into the EMR, the cSWO/OntarioMD Hospital Report Manager (HRM) program does just that. Started in 2014, by August of 2016, 1,288 doctors were receiving hospital reports loaded into their EMR’s with another 400 docs waiting to be connected. Across the province, 134 hospitals, 39 specialty clinics and seven CCAC’s were connected to HRM and sending reports into EMR’s as of August of last year. Lots of work remains to be done… but there is already lots happening connecting digital resources to EMR’s.

          • Chris

            I believe eHealth in Ontario is entirely relevant to this discussion on health care bureaucracy. A PhD, best-selling novel and/or Netflix series could be done on the eHealth story in this province. It is an incredible example of the lack of leadership and a culture of waste and poor accountability that seems so enshrined within the politics and bureaucracy of health care in this province. When I fail my patients or colleagues, I confess, apologize and ask others for guidance. There is no shame in doing that.

            This toxic culture, created and enhanced by characters like Hoskins, is not conducive to real progress from the perspective of non-politicians. He is a master manipulator.

            Continually, politicians and bureaucrats shift focus to minor issues or pilot projects, without making substantial progress on the things that front line providers and patients have literally been shouting about for a decade. It is a terrible culture to be a part of, that starts right from the top with Hoskins and filters all the way down. We need renewal at the Ministry of Health in order for trust and a culture of collaboration to be restored.

            Don’t even get me started on the lack of leadership or progress on the opioid crisis… but it is another example of how the bureaucracy is failing patients.

        • Bob Bell

          Chris digital information is already being uploaded seamlessly into EMR’s through Hospital Report Manager (HRM). This program, started by OntarioMD and Connecting Southwest Ontario in 2014 had connected 134 hospitals, 39 specialty clinics and 7 CCAC’s to 1,288 doctors’ EMR’s by August 17, 2016- with another 400 docs signed up and waiting for this application. Chris this is no future vapourware- it is already happening. Lots left to be done in digital health- but lots of progress being made.

          • Chris

            In all seriousness, I do appreciate your reply. It is refreshing to finally get an answer from a politician on the eHealth file. Quite a difficult task, hence my earlier sarcasm. Being polite in prior attempts over the years was met with failure.

            I personally have not seen this improvement in my area of work.

            If someone wants to become more well-versed on eHealth in Ontario, where we were, where we are and where we are going, could you point to any publically available resources?

            If that is not available to scrutinize and critique, how could we possibly hold people accountable for failure?

              • Harpaul Cheema

                This story illustrates all that is wrong with Ontario’s health record system:

                Mount Sinai hospital and Toronto General Hospital are about 50 metres across the street from one another. They use different computer systems. It is difficult to get immediate access to records from the other hospital, and certainly not user friendly (using PRO or OLIS). When I did my training there 4 years ago (I assume it is similar now), it was easier to walk across University Avenue in the middle of the night and print off records from the other hospital’s computer system than it was to actually get records via the proper channels. St. Mike’s is 2 km away, they use a different system. Toronto East General is 5 km away, they use a different system. And Sunnybrook which is about 20 km away uses a completely different system. Humber River, North York, Mackenzie Heath are all in the GTA and use different systems. I would encourage anyone working for the the Ehealth file to spend one night at the hospital with me and try and get relevant clinical notes from another hospital after hours. I experience this on a daily basis. It’s inefficient, wasteful, and most important delays clinical care.

  12. Janis Bisback

    You say that there isn’t a bloated bureaucracy? When I had my hip replaced in the fall the PT and RN both when asked about purchasing additional service informed me that they were independent contractors who worked for companies that billed CCAC out at $165 per hour. They received no benefits and certainly wouldn’t be paid an excessive wage. That middle tier is costing the health system far too much.

    • Bob Bell

      Thanks for your comment. According to the September 2015 report of the Office of the auditor general of Ontario (pages 35 to 41), payment to Health Service Provider organizations for RN’s averaged about $57 per hour. The organizations that hired Physiotherapists for home visits were paid about $73 per visit.

  13. Denyse Lynch

    While we hear about number of people employed in health care, have not heard discussions about the “deficits” or “calibre” of their competencies…i.e. the collection of knowledge, skills, attitudes required by the people who hold various positions and plan, organize, manage and deliver health care. I researched job competencies and job standards required for certain positions. Found that while the people competencies and job standards were clear and defined, many people from many elements of our health care system are not being held accountable for meeting their job standards. I can speak specifically to experiences with MDs, RNs, Personal Support workers, CCAC case managers, management positions etc… Who is observing each person’s performance, in the health system, providing them feedback to improve in the competencies they lack, in order to meet their job standards, coaching them to ensure they meet the standards (continuous improvement), as well as advising them that they have to find a job elsewhere, when they are unable/incapable of doing the job or unwilling to do the job. If all employees were held accountable and their supervisors, managers were held accountable for the performance of their staff’s ability/willingness to conform to their job standards, we just might not need as many people and we’d be getting better performance outcomes and patient/caregiver satisfaction with the health system. Quality, which we hear all the time is “conformance to job standards”, not just meeting key targets. Until we have leaders, managers, supervisors, employees who get that and implement it, across all health care system elements, Quality and Patients First are just slogans. We have some great talented individuals in many areas. Unfortunately, they are burning out, as a result of their employer’s tolerance and continued retention of the incompetent performers. Let’s look at this as one major root cause of our health care system’s dysfunction. Peter Drucker said: “the most important decisions any managers make are ones concerning their people. THEY determine the capacity of their organization”. I’d add to that “people (employees) also determine the sustainability and cost effectiveness of their organization.”

  14. Marlon Hershkop

    Let’s do a thought experiment. Dissolve all LHINs. No Physician or patient would notice the difference.

  15. Mark Fruitman

    I think that this article is a straw man. Dr. Bell cites multiple examples of important work performed by bureaucrats. That would be an appropriate response if anyone made the claim “We do not need any health care bureaucracy and everything that the Ministry does is useless.” But it does not respond to the concern that government bureaucracy is bloated

    Let’s take one example that Dr. Bell provides:

    “A further 630, or 21 percent, are responsible for maintaining and operating the IT systems that run OHIP and other claims systems for doctors, pharmacies and patients, as well as maintaining our various databases and analytic capacity.”

    We all agree that IT systems are important. Do they require 630 people to maintain them? Are those 630 people deployed as efficiently as possible? Is the procurement of the IT systems done in a cost-effective manner and are the systems themselves well-suited for their tasks and well-maintained? Dr. Bell does not address any of these questions. He establishes that bureaucrats do important jobs, but does not demonstrate how effectively or cost-efficiently they do them. In short, he does proffer any evidence that speaks to whether or not our bureaucracy is bloated.

    This omission seems ironic given the Ministry’s contention that an aggregate cap on physician billings will curtail unnecessary physician services, effectively a claim that there is “bloat” in physician services. If I do as Dr. Bell has done, and enumerate the important tasks performed by doctors, will Dr. Bell concede that there are no efficiencies to be found, and that an aggregate cap on physician services is therefore a misguided policy? Conversely, perhaps the solution is to impose a hard cap on aggregate salaries of bureaucrats, with a clawback of salaries if that aggregate cap is exceeded. If the Ministry’s theory holds for physician services, does this not imply that a “bureaucratic services budget cap” will keep “unnecessary bureaucratic services” in check?

    Absent competition, there is no economic incentive for bureaucracies to become more efficient or more limited. Rather, they tend to become self-justifying, arguing that their work is so important that they must expand. The arguments are generally very similar to those used here by Dr. Bell: Our work is important. None of this speaks to whether their tasks are being completed efficiently or effectively, however, nor whether they are even best performed by a government bureaucracy.

    • Bob Bell

      Thanks Mark for your comments. In this Healthy Debate piece I have not commented on the methods used by the Ministry to assess cost effectiveness in the services provided. That would exceed the 700 to 1,000 words that were allocated to this myth busting essay. However there are some pretty simple metrics that you can use in assessing value for money that I have provided. First the health care budget expanded from about $30B to 52B over fourteen years while the head count in our Ministry remained stable. Second the population in ON increased and our demographics changed to an older population representation over 14 years- again with no increase in staffing. All IT procurement is done according to BPS guidelines with competitive tenders. The number of consultants providing service in the MOH has shrunken substantially. These are all indicators of prudent expenditure of public funds. Finally we do a third party review of all government IT/IM spending on a regular basis, the most recent in the past year and MOH was judged to be highly cost effective.

      • Mark Fruitman

        Dr. Bell, thank you for taking the time to reply.

        Cost-effectiveness is really the only metric that matters if you are refuting the notion of bloat. A list of important tasks performed by bureaucrats does not address the issue at all, for reasons that I described.

        It is not clear to me that the bureaucracy necessarily needs to scale with the budget or population. Head count at the Ministry is not necessarily meaningful, either, if government funded bureaucracy has expanded elsewhere. LHINs did not exist 14 years ago, for example, and your essay implies that this additional layer of bureaucracy is not included in your “head count”. It would be interesting to know the total amount spent on bureaucracy by the government (not just the MOHLTC) compared to 14 years ago.

        You cite population growth and aging. While it is not clear that bureaucracy should scale with those factors, it is clear that physician workload will. And yet your government has proposed a global cap on the physician services budget which does not meet the predicted demand increase.

        (I will also add that your government has disingeniously billed this as a “raise”. You know that is not true.)

  16. CGBe

    Dr. Bell, your column has sparked some interesting and sometimes inaccurate and even disrespectful discussion.

    This is the first time I’ve seen an author respond to so many comments and try to set the record straight. You’re a busy guy, so many of us probably want to say thank you for being so accessible on this website.

    It would be fabulous if the Ministry (not the politicians) could find a way to communicate this information more broadly into our communities and encourage an inclusive and constructive dialogue across Ontario.

    • Bob Bell

      Thanks for your comments. I will chat with Dr. Laupacis and determine whether he would be interested in further pieces from myself and colleagues at the Ministry. I am especially interested to describing the rationale behind the LHIN sub-regions which are the foundational element of Patients First. We shamelessly stole the idea of regional organization of primary care, home and community care from David price’s advice on Patient Care groups and from the OCFP work on the PCMH model. Indeed I spent the morning chatting with the Chairs of Family Medicine about the opportunity afforded to primary care by the sub-region model. I want to re-emphasize that there are NO additional staff in the new LHINS as we reorganize around a sub-region model… we are simply reassigning existing staff in the LHINS. Perhaps the idea that this organization of primary care, HCC and MHA and public health on a regional basis will form the ON model of an ACO would be a good topic for another piece… what do you think?

      • Payam

        Thanks Dr. Bell. I think this would be a great topic for further exploration.

      • CGBe

        Thank you for asking us. Given your enthusiasm, there is probably merit, but I don’t know enough to comment in detail. I would suggest physicians are not the only experts on organizational structure and administrative efficiency. I would also say that as long as physicians occupy a privileged place of consultation and stay outside community oversight, e.g., that of a LHIN, then primary care cannot be effectively organized to serve Patients First.

        The number of LHIN staff is not so much a concern as their calibre and expertise operating within an appropriate mandate to manage (and govern/oversee/improve) a region’s health services. I cannot say what LHINs have done for my region – primary care access is still far from optimal and there’s no communication to say what will change, why, and by when. A Patient First system should provide a forum for regular community dialogue and accountability – the LHINs (our potential ACOs) could do this. I could speculate that’s part of the reason you’ve had such a broad and intense reaction to your column: there are very few other channels to engage well-informed senior leaders.

  17. Karin

    We would be ok with the administrative jobs if I didn’t earn so little as a community FFS psychiatrist I couldn’t pay a secretary. I didn’t get EMR help. Yet if my referrals from all over the GTA said anything it was the need was there. No benefits, no days off, and never broke 200k gross. Burecrats are great but psychiatrists should be more important. I got cut and they get new jobs ( yes I think there will be new jobs not just switches but I’m not always right).
    So until the government and our leaders stop thinking we all work at academic institutions/ community hospitals or are in a family health group many of us will continue to point out bloated for you isn’t the same as for me.

    • Bob Bell

      Thanks Karin. I certainly agree that the equity of remuneration for physicians could be considerably improved.

      • Dave M

        I don’t think thats what Karin is getting at.

        Hoskins has repeatedly unilaterally cut physician fees in the last few years, routinely under the guise of “equity of remuneration”. In fact, that hasn’t happened. Lower billing specialties have not been propped up as a result of cuts to high billers. The truth is the cuts are across the board, period.

  18. Peter G M Cox

    Everyone following this article and the comments should read the links provided by Pagrin Shoulk, Darren Cargill and Gerald Goldlist. The statistical information in those articles, comparing ratios of bureaucrats, hospital beds, overall healthcare costs, comparative performance, etc. compared to other advanced economies seems to be at very much at odds with Dr. Bell’s contentions. I would add that OECD data also indicates that Canada employs substantially fewer doctors and considerably fewer nurses per capita than almost all the countries in Europe with similar per capita GDP and/or healthcare spending. It would be interesting to see Dr. Bell’s response to THESE facts (rather than selected data and conclusions limited strictly to the Ministry of Health and Long-Term Care).

    • Bob Bell

      Thanks Peter, this is a good challenge. However you make the assumption that a process measure like the ratio of docs or nurses to population will result in better health outcomes for Ontarians. Writing in Healthcare Policy in 2009, Watson and McGrail found NO correlation between doc/pop ratios and avoidable mortality measuring both variables in OECD countries. The authors found that while Canada had a fairly low doc/pop ratio of around 2/1000, avoidable mortality was quite low in this country at less than 80/100,000. Looking at figure 1 in this article you will see that there is NO correlation between ratios of docs to pop and avoidable mortality. As I mentioned in this piece, some of the most important treatment related outcome measures like cancer survival show that Ontario has internationally leading outcomes measures (reference provide In opinion piece above). If we are going to argue relative system effectiveness I would rather argue outcome measures that mean something to patients rather than discussing process measures.

      • Mark Fruitman

        Respectfully, I believe that wait times are a measure that “mean something to patients” even if it doesn’t show up in avoidable mortality data. However, if you truly believe that patients do not mind long waits for specialists because it will not affect their (aggregate) life expectancy, then I think that it is incumbent upon the government to make that case directly to patients. Launch an education campaign that explains that the government does not intend to increase physician supply because increased access does not affect mortality. Then we can see what patients truly value.

        Also, if physician ratios are unimportant then why are we so obsessed with ensuring universal and equal access? If it doesn’t make a difference whether there are fewer physicians then why is it important to make sure that patients don’t “jump the queue”? It logically follows from what you are saying that we should ensure some basic minimum universal care and then allow a free market for those who don’t want to wait. Since physician access (above that provided in Canada right now) is a superfluous luxury anyway, why not treat it like any other luxury?

      • Mark Fruitman

        With respect, access and wait times “mean something to patients” even if they do not affect aggregate population mortality data. If the govenrment believes otherwise then it should start an education campaign. Explain that the Ministry has chosen to constrain physician access because patients probably won’t (in aggregate) die from the wait. Then we can see what metric matters to patients.

        Also, if physician access (beyond a basic minimum) is a superfluous luxury then why so much concern over “jumping the queue”? We are not concerned about people purchasing other non-essential goods. Why not allow people to purchase health care like any other luxury?

        I understand that physician supply and access are not synonymous but efficiency gains are at the margin. Physician supply will ultimately affect access.

        • bob bell

          Thanks Mark. I am going to close off commentary this morning but your comments deserve a reply. The physician supply as well as supply of nurses, health professionals and service workers is very important to the health of Ontarians and I am pleased that we are educating over 1200 post-graduate physician learners in this province annually. Most of these trainees stay in Ontario resulting in a NET increase of more than 900 docs per year in the province in the past couple of years. The numbers of nurses and health professionals have also increased substantially over the past ten years and with the requirement for a baccalaureate degree Ontario nurses are highly sophisticated life long learners who are a remarkable asset to our system

          • Bob

            I should clarify this comment by saying that we ADMIT about 1200 post-graduate learners to our residency programs annually.

          • Mark Fruitman

            I appreciate the reply and understand that you cannot continue to comment here indefinitely.

            There is a contradiction in your response. On the one hand, health care worker supply is important and you are pleased that we are adding 900 doctors annually. On the other hand, the ratio of doctors to population is unimportant because it does not correlate with (and this is distinct from “affect”) preventable mortality. So either your government should be ashamed of its misallocation of resources by training so many unnecessary doctors or you are conceding that physician numbers matter to access and thus to patients.

            You also laud the fact that RN’s require a baccalaureate degree. I would like to see the scatterplot that correlates years of RN education to preventable mortality. The evidentiary base that you use to justify government policy is selective. (This is a comment on selective use of evidence. None of this diminishes the role of nurses and other AHPs.)

            You also chose not to respond to my suggestion that if physician access is a luxury then there is no reason to so strictly ensure equal access. I suggest to you that the government’s repeated admonitions against “jumping the queue” belies its true beliefs about the importance of access to physicians.

  19. Dave M

    Hi Dr. Bell,

    I believe that a big part of the problem between doctors and MOH is distrust.
    Yourself and Dr. Hoskins are both MDs, and you personally worked a long time on the frontlines. As such, you both understand the difference between “gross billings” and “salary”. Yet, Dr. Hoskins has repeatedly conflated the two in an effort to intentionally mislead the lay public. This is disrespectful to physicians, and ruins the working relationship (not to mention lying to the public)

    1. I am curious as to why this strategy was chosen.
    2. Can you please ask him to alter his speaking points?

    • bob bell

      Thanks Dave. I am going to close off commentary this am but your comments deserve a reply. I have belonged to the OMA for more than 40 years and both Dr. Hoskins and myself are delighted that we will be starting meaningful discussions with the OMA when our negotiating teams complete their preparations.

      • Dave M

        Thanks for the reply, but I don’t think my point was addressed.

        Specifically, why has Dr. Hoskins repeatedly conflated “gross billings” with “salary” when talking to the media?

  20. bob bell

    Thanks to all the respondents who have taken time to contribute to this Health Debate designed to Bust the Myth that Ontario healthcare suffers from bloated bureaucracy. I hope that I have convinced readers that the committed public servants who work in our Ministry contribute real value to the health of Ontarians. Publicly funded healthcare stimulates passionate interest in our country and a respectful discourse regarding how our system should evolve is part of ensuring that our model of providing care based on client need rather than ability to pay remains both scientifically appropriate AND responsive to our cultural and social values. A very big shout out and thank you to Andreas and the Healthy Debate team for providing us with this venue of record for sharing ideas. And to the care providers of Ontario- from our Ministry- thanks for the work that you do every day. You inspire us. Best wishes, Bob

  21. Dave Wismer

    Bob,Thanks so much for all your prompt reply.Great discussion!What assurances do we have the dedicated funds to hospitals for performing Total Hip and Knee Arthroplasty in a timely fashion will continue,and are you able to track those funds to ensure the monies go to the orthopaedic arthroplasty budget in all the groups that provide this service with quality and efficiency.When will dedicated funding be provided to the other Orthopaedic Services presently not funded be available to shorten waiting lists,which according to the Fraser Institute are the longest of any surgical procedure.As a very important Member of the OOA Board for many years you will remember how passionate the OOA is to help Ontario provide Timely Access to Quality Care.

    • bob bell

      thanks Dave. I have finished comments but cannot resist responding to a fellow Orthopod!! Funding for QBP’s in hip and knee arthroplasty will continue and hopefully be expanded to other MSK procedures. As you mention, waits for MSK conditions are amongst the longest waits. Best wishes, Bob

  22. Mike

    Do the right thing and address relativity in physician payments.

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