Will “Devolution” Die With The LHINs?

(Niagara At Large is posting this article on the trouble with Local Heath Integration Networks in Ontario with the permission of Ted Ball and Quantum Transformation Technologies)

By Ted Ball

Apparently there is something in the DNA of the Ontario healthcare delivery system that causes service provider organizations and their leaders to “hate the funder” – which of course is the Ministry of Health & Long Term Care. Everybody hates MOHLTC. It’s a rule, or something.

Ted Ball

However, in the McGuinty Government’s first term, they decided to devolve power and authority out of the powerful/faceless bureaucracy occupying the Hepburn Block at Queen’s Park in downtown Toronto. Instead, they decided to shift the functions of health system planning/funding and accountability to fourteen “local networks of healthcare service providers” where the boundaries reflected patient flow patterns.

This was radical change. Instead of centralized silo-management/control, Ontario was shifting to system-management, at the local community level. The vision was to create integrated and “seamless” health services at the local network level where “evidence-based decision-making”, rather than politics, would drive decision-making.
The big system shift introduced by the Liberals in their first term was to “empower local communities” to plan, build and operate local healthcare delivery systems that would be designed to meet the unique needs and circumstances of each community – by utilizing evidence-based decision-making, and by being empowered to allocate resources based on performance.

“Performance” was supposed to include patient/family satisfaction rates — as well as other critical success factors. Health reformers and medicare supporters believed that “devolution” would lead to an outbreak of innovations for improving services in our fragmented and dyslectic healthcare services delivery system. That didn’t really happen – although there were a number of innovations about which the LHINs should be proud.

But devolution never happened. Local communities and patients were never “empowered”.

It turns out that building 14 LHINs as Crown Agencies responsible for doing what the public servants at Queen’s Park used to do, caused countervailing negative dynamics that played out over the two terms of the McGuinty Government. Instead of “devolving authority” – the Liberal’s official health sector strategy – the bureaucracy at Queen’s Park designed itself to command-and-control the system — using the LHINs as a “scapegoat” in much the same way as Ministers of Health from all three political parties had used the District Health Councils in the “good old days”.

It is called “blame-shifting” – part of the political gamesmanship that I say is destroying our healthcare system. It’s health policy by optical illusion.

Rather than “liberating the LHINs to find innovative solutions to local problems”, high-level Ministry campaigns were conducted to re-focus the LHINs on the “consistency agenda”  that had been identified by the Ontario Hospital Association as a priority for the LHINs. “Consistency” became the new official buzz-word — replacing the original “stewardship role” (i.e. “being in service to, rather than in control of the healthcare system”) that the Ministry was supposed to become in the new “devolved” system.

Remember that idea? Did you ever experience the MOHLTC being “in service” to you and your organization?

While the healthcare delivery system is apparently pre-programmed by natural law to “hate the funder”, as it turns out, the LHINs never actually did become “the funder”. At best, they only had control over about 5% of the budget for their local networks. Decision-making continued to be entrenched in the Ministry, not the LHINs.

So Mr. Hudak is right. The Liberals turned the LHINs into “an unnecessary layer of bureaucracy.” Queen’s Park simply used them as a vehicle to create the “illusion of control” over the delivery system – and as their primary source of information-gathering on local health issues for Ministerial briefings. That, of course, isn’t devolution. So what happened?

It seems that once the original architects of the LHINs left their ADM spots at the Ministry of Health, the devolution process became perverted into the “consistency campaign” led by a new Assistant Deputy Minister with an apparent mandate to “control the LHINs”, and to “hold them accountable”.

You know the drill behind the “abuse syndrome”. The husband clobbers the wife… the wife hits the kids… the kids kick the dog… the dog bites the cat… the cat… In this case, the Ministry was to “hold the LHINs accountable”, and the LHINs, in turn, were to “hold the health service providers accountable” — which would have been fine if there was any sense of best practice accountability processes that would normally  begin with the “reasonable business bargain” about “mutual accountabilities”, and about “continuous improvement” within a “learning environment”.

But that is not what happened in the aftermath of the e-health scandal. Instead, “the dog bites the cat”…once more, with feeling, the abuse syndrome rolls out. Blame and blame-avoidance dynamics drive thinking and behavior in a risk-averse environment that kills off innovation.

Unfortunately, healthcare politics is usually about turf and power, seldom about outcomes for patients and taxpayers.

Using the language of health reform, but never the intention, the Ministry used the McGunity Government’s second term to entrench their ability to control the system — or at least to create processes that created the “appearance of control”. Anyone who reviewed the Accountability Agreements between the MOHLTC and the LHINs, know that there was never any alignment between what Health Minster George Smitherman said about “empowering local communities”, and what his two successive Ministers of Health and their senior officials actually did to entrench the existing “centralized”, “rules-driven” and “risk-averse” delivery system in these lop-sided bureaucratic performance agreements.

For an effective devolution strategy to actually work, there needed to be a solid Ministerial commitment to ending micro-management and centralized control. But no real efforts were ever made to ensure that the government kept their commitment to devolve power and authority to the LHINs. The Ministry was never down-sized. After Minister Smitherman and the original Assistant Deputies left the Ministry, their political and public service successors never seemed aligned to the original vision of a “devolved authority”. With their very tepid support, they seemed to just let the LHIN system flounder, and fail.

Ultimately, as Queen’s Park became engulfed in their various health sector scandals, instead of going after “wrong-doers”, the Premier and his Ministers unleashed a plethora of new ways for Queen’s Park to exert even more “controls” on the delivery system — in the name of “increased accountability”, “transparency” and, in the important process of blame-assignment.

The most elegant of bureaucratic solutions manifests itself in the convoluted and nonsensical RFP processes, and other forms of “rules and regulations” that have been designed to create the “optical illusion” of public interest controls – when in fact, they have unleashed what everyone knows are expensive, unnecessary “control” processes that simply create more and more bureaucratic steps and tasks to be done.

Let’s be clear: public servants and centralized vested interest group bureaucracies benefit from system fragmentation, complicated rules, and endless task work on the details of all the mumbo-jumbo that was created in the wake of the various health sector scandals. They get to work for their silo, in their silos, at the provincial level. While we have now created a significant industry around our rule-driven system, from a patient/taxpayer perspective, these bureaucratic activities add little to no-value.

If our elected politicians were to authentically serve the public interest, they would ensure that devolved decision-making systems, structures and processes are designed to actually work, not – as with the LHINs – designed by Queen’s Park to ensure that devolution never in fact takes place.

So, let’s once again review the groups who wanted the LHINs to fail. It includes: a critical mass of healthcare leaders at the service delivery level; as well as, public servants. Another group keen to capitalize on the poorly-functioning LHIN system were, of course, the Official Opposition Party. They have had a field day.

Tory leader Tim Hudak saw the LHINs as a group of local board members who where more likely to be connected to the local Liberal Party Riding Association, than to a knowledge and passion for healthcare transformation. He had some great examples of both “bad judgment” and “bad processes” in the LHIN system that the Liberals designed and led for the past seven years.

While there are certainly a number of outstanding, passionate and dedicated LHIN Board members, as well as some very talented and knowledgeable professional staff, the fact is that when the Ministry sought to command-and-control them, LHIN Boards and their CEO’s did not effectively “push back”.

As “Crown Agencies”, rather than as empowered “Local Community Boards”, the leadership of the LHIN’s seemed to comfortably go along with the “consistency” and “accountability” campaigns conducted by the Ministry bureaucracy and the 90-person LHIN Liaison Branch – who ultimately became their most important customer. While there are examples of some LHIN leaders speaking up, most LHIN’s basically complied with the directions they got from Queen’s Park. As a result, spirits in the LHIN sector have been very low — at both the staff and Board levels — for the past several years now.

Why? Why are spirits so low? I think it is really all about leadership — at many levels, starting at the top.

Without consistent and committed leadership for devolution on the part of the three different Health Ministers under the McGuinty Government, the fact is: the LHINs didn’t stand a chance. They were doomed to fail.

Despite many examples of good work and real innovation in the LHINs, Mr. Hudak has been able to point to a number of terrible flaws in the system — including his personal experiences with healthcare restructuring in the Niagara region, and ultimately the impact that this chaos has had on the quality-of-care in that region. His conclusion is: “The LHINs are a failure”.

It is true: the Liberals failed to successfully implement “devolution” because they:
·    Didn’t produce a provincial health system vision – or high level strategic directions – that could be accounted for, and adjusted to, at the local level, where appropriate;
·    They never empowered the LHINs to allocate resources to health service provider organizations based on their performance, and based on evidence about what is, and isn’t effective; and,
·     They didn’t encourage LHINs to discover innovative solutions to their unique local problems. Instead, Queen’s Park pushed for a “consistency agenda”, and sought ways to “hold LHIN CEO’s and their Boards more accountable”.
However, the fact that LHINs failed, does not mean that “devolution doesn’t work”.

The flip-side of “devolution” is “empowerment”. “Empowerment” starts with patients and their families; and moves up to the healthcare professionals and their organizations. That’s how devolution was supposed to work — but the Liberals never delivered. So, what’s next? Will the Tories “fix devolution”, or abandon it?

Mr. Hudak’s position in Changebook is clear. The PC’s say: “we will close the LHINs, and redirect those dollars to patients”. However, once in power, it is possible that a Hudak government – focused on an eight-year health system transformation vision –could keep their promise to close the LHINs, but determine that they do, in fact, need a local delivery system vehicle that would enable them to successfully implement their election pledge to create a more “patient/client-focused system”.

The truth is that the $70 million currently allocated for community empowerment under the LHIN system isn’t a lot of money on a base of $44 billion. I think if the next government were to dramatically downsize the Ministry (by up to 70%), and create perhaps ten Health Services Planning & Allocation Authorities (that build on the local/network relationships that were developed over the past seven years), it might actually be more prudent to invest $100 million in results-focused local empowerment vehicles that will create the conditions for success at the local community level

The delivery system – and the government – really do need this type of positive, focused support in order to successfully transform the system. But everyone really has to step up their efforts to collaborate with their local partners.

I hope the next government will see the wisdom of making devolution work – with the right alignments, and right economic incentives to support their vision – as well as the right structures and processes to implement their strategy.

While “closing down an unnecessary layer of bureaucracy” would of course be supported  by voters, so would creating local structures that will enable the health service providers in each community to transform their services—with a focus on actually improving the patient/family experience — and with a particular emphasis on quality and safety — as well as a “seamless experience” across the continuum-of-care.

But this will never happen without “devolution” and local empowerment – starting with the patient/client/resident.

TED BALL has worked as a speech writer, policy advisor and chief-of-staff to Ontario ministers of health for all three political parties in the province. You can read more of his views on health care at http://quantumtransformationtechnologies.com/category/blog/ .

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