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.