I’m not an expert on health care in Ontario – I still live in Alberta – but from afar the health chapter of the Drummond Report looks good. I think they got the diagnosis right! The health care system isn’t a system, there are inefficiencies, and the system needs to be reoriented.
The prescription is by and large right too. What’s important is that Drummond doesn’t suggest there is a single, simple quick fix that will make the problems go away. There needs to be a large number of initiatives (105 recommendations in the health chapter) that together will start Ontario heading in the right direction.
Many of these proposals have been around a long time. Some are tried and tested elsewhere. Some won’t achieve much. Some express nice sentiments (care should be integrated!), but don’t have much substance. The report also squibbed on how to structure the system, leaving open both Local Health Integration Network and hospital options. On the balance though, Drummond got a lot right.
But what about implementation?
The report clearly demonstrates that health care in Ontario needs to change. It even maps an appropriate path for change. The problem is it’s a path many have mapped before. We know change is needed, we even know the direction things need to head, but actual change keeps eluding us. Implementation must now be our focus. How do we actually change the system?
The answer is tautological: change requires change. Change to how things are done. Change to power relationships. Change to the established order and priorities. All of which will move us away from the comfort zones of powerful players.
The most important change we need is to the culture of health care. But I wonder, do the powers who shape culture really want to change it? Do they share the implicit values reflected in the Drummond report about primary care pre-eminence and so on? As the old aphorism goes, where you stand depends on where you sit. To what extent will Ontario’s big hospitals and their powerful boards accept a system which shifts some power away from them, involves more decentralization etc? Some institutions will embrace the change Drummond recommends, but others will resist
There are levers available to move this culture change along: information provision, financial incentives and structural change. Changing financial incentives is hard too. Think about physician remuneration. Do we know what is really the right way of remunerating physicians to affect the new system?
But the lever I’m most worried about is structure. Although I think structure can be overdone as an issue (and leads to an obsession about one’s place on the new org chart), this time I think it is really important. Drummond left the door open to either develop new regional structures around existing hospitals or reinvigorate the LHINS. What would be the differences be? Working through hospitals would mean more administrative bodies, for a start. But it would also run the risk of ‘hospital’ culture dominating the new regional structures and priority being given to addressing problems inside the walls as opposed to the linkages between the hospitals and community-based services. This reminds me of a story told by a friend of mine, a community-based psychiatrist, who was asked to fill in on an in-patient unit at a nearby hospital. She was reviewing cases and thought: “yeah, this person could do with a few more days in hospital,” but pulled herself up short when she realized that if she had seen the same person in the community, she would not have recommended that he go to hospital at all!
Drummond recognizes that the current structure in Ontario will inhibit the system change that is required. So in this case, structural change is essential. However, this change is necessary, but not sufficient. If culture is going to change, the new structures will need to be led and populated by those who’ll embrace the new orientation, and welcome (and generate) a new culture. Moving boxes around (as difficult and challenging to current leadership as that may be), will be the easy part here. Embedding the right values will be much harder.
So, my summary of Drummond? A really good start. The report presents some genuinely difficult choices to the government and to those currently working in the system. But the challenge in the report is clear. Change is necessary to ensure better and sustainable care into the future. As for implementation, I’ll watch with interest.
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In both Canada and the USA, reliance on avoidable “Emergency Room Care” needs to be curtailed. How? Patient accountability, education and inculcation. Produce receipts on the actual cost of care rendered for that “Mild Flu” visit to the ER, as opposed to working with Primary Care givers/Community Clinics.
Maybe it’s time to charge patients a nominal access fee to ER Care for ailments better attended to with thier primaries or community clinics.
And perhaps high school students should be taught (in civics) the true cost of healthcare delivered in the ER as opposed to the standards suggested above.
I think the biggest take away from your write-up is the line,”As the old aphorism goes, where you stand depends on where you sit.”. Nothing is going to change unless the message of Drummond report is acted upon each and every level of healthcare. We are all caught up in our routine work, or doing something of immediate importance.
The big questions is how to operationalize the suggestions at each and every level. We need to question ourselves whether our thought process at work or the decision we make are carrying forward the message. One of the key things that leaders “at all level” need to do is discuss the system issue regularly in their routine meetings. It is this churning in meetings at all level that will create an atmosphere where the spirit of the report is acted upon subconciously.
It is all about implementation. However, continuing as is in Ontario will lead to further inefficiencies with associated unnecessary costs in a province with a significant fiscal challenge. I agree the ideas are not new, most proven very successful in other provinces. However, politicians are reluctant to upset their power base. But lack of dollars can drive change-maybe now.
With respect to healthcare, the Drummond report is a collection of good ideas that have been circulated for some time and frankly are starting to become a bit stale. I think this highlights Stephens point about structure being a barrier to change. However I would argue that we should avoid trying to repurpose existing structures and focus more on creating both the right structure and the right environment that might enable real change.
Health care is adept at change at the level of patient care, the professionals at the coal face adopt new techniques when they believe it will improve care for patients or their work environment. But as you move away from the front line of care resistance to change increases dramatically. Substantive change to how care is delivered and organized is largely stalemated by existing organizational entities, and operating paradigms, or as Stephen says power structures. These same structures stifle innovation.
Hospital boards and LHIN’s are populated with bright people who operate in cultural paradigm that will make change difficult. Both groups are committed to improving value for their consumers/patients but both are captive to their particular paradigm.
A better method might be new entities with the mandate and authority to provide a comprehensive system of care. They need to have the power to change existing paradigms, and they need to be protected from political interference and end runs from within their organization. They need to be small enough or organized in a manner that focuses on health outcomes and encourages bottom up innovation. They need a funding system that is fair, transparent and balanced across the province so that the entities can focus on innovating new models of care instead of tools to increase funding.