"Alienation through bureaucratic proceduralism."
- Franz Kafka
There are many things that medical school doesn't teach future physicians. Amongst the most glaring omission, is the lack of appreciation for how challenging it is to navigate the complex health care system when you are trying to help a patient. The sheer number of organizations in the health care system, and of course, differing requirements for engaging these organizations is mind numbing.
A while ago, one of my colleagues had an idea for improving patient care. It required an Information Technology Solution. However, finding out who to call to get approval for the project was really an eye opening experience. Should he contact the Local Health Integration Network (LHIN) IT department? Or the Community Care Access Centre (CCAC) IT as this project related to outpatients? Or is it eHealth as they are supposed to be looking at Health Care IT solutions? But the Ministry of Health (MOH) has an IT department too -- should they be called? (And no, I have no idea why the MOH has an IT department for the Province if eHealth is supposed to provide provincial solutions).
As I have come to appreciate, there has been an explosion in bureaucracy over the past 12 years in Ontario Health Care. Most of it has been because the government has set up various "arms length" agencies such as the LHIN's, eHealth, Health Quality Ontario (HQO), CCAC and so on, rather than simply accept responsibility for these tasks under the MOH. From a politicians point of view, this gave them the ability to defer criticism for any decisions by saying such and such agency is "independent." For the most part, for a Liberal politician, this worked -- they did win four elections in a row. But it certainly hasn't helped the patients any.
My colleague, Dr. Shawn Whatley, posted a superb blog with a look at how many bureaucrats are in health care in Canada. While I encourage you to read the full blog at the link, the short version is that there are 0.9 health care bureaucrats per 1,000 people in Canada, compared to 0.4 per 1,000 in Sweden, 0.255 in Australia and 0.23 in Japan. Germany rocks at 0.06 per 1,000. Worse, as Dr. Whatley points out, Ontario has only 1.7 acute care hospital beds per 1,000 population which is about HALF the average for other OECD countries. Ontario got to this number by closing 17,000 acute care beds (and laying off the nurses needed to staff them) between 1990 and 2013.
Unfortunately, that trend continues. You know that recent Canadian Institute for Health Information (CIHI) report? The one that Kathleen Wynne and Eric Hoskins say shows that "Ontario has the best paid doctors in the country." That's a nice enough sound bite, but if one reads the report in detail, it also showed that 12,000 nurses have left the profession this past year. Additionally this same report showed that Ontario had only 176 physicians per 100,000 population (SEVENTH place in Canada). Unsurprisingly, only 10 per cent of family docs in the Ontario now take new patients. A great powerpoint summary of the report is here.
Ah, but at least the bureaucrats are producing meaningful reports and are happy to be helping with moving health system transformation forward right? Alas, a Health System Leaders (HSL) survey done by Quantum Transformation Technologies in June 2015 shows otherwise. A full copy of the report is here. Some notable results:
• 55 per cent of HSL's think Dr. Hoskins is doing a poor to fair job
• 62 per cent think the LHIN's are doing a poor to fair job
• 72 per cent (no really 72 per cent!) have poor to fair confidence CCAC can be fixed by current government
• 50 per cent feel that the government has a POOR (not poor to fair, just POOR) track record of helping those with mental health issues
This list goes on. It's dramatic just how poorly the leaders view the system, and how badly they feel the system is functioning. The comments at the bottom of the survey are equally telling as to how they feel the system is run. There are repeated calls to reduce the number of LHIN's, reduce the size of the bureaucracy and "bold transformation" of the health care system. As a side note, a senior executive form on of the LHIN's told me that the people who responded good to excellent on the questions did so because they didn't truly believe the survey was confidential.
So in short, in Ontario, we are burdened with a bloated, ineffective, demoralized health care bureaucracy. Kathleen Wynne and Eric Hoskins solution to this? Lay off nurses and start a fight with doctors. Franz Kafka couldn't have come up with something this convoluted.
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