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OPINION: Patients First – A New Mindset

By Janine Hopkins, Principal at Santis Health

The topic of health system reform is typically met with cautious optimism at best and simmering frustration at worst.  Despite the many reasons for skepticism, I believe that Ontario’s current health reform gambit, Patients First, has the potential to bring about lasting – and even transformational – system change.

I’m sure that some readers have already concluded that I drank the Kool-Aid and are preparing for an onslaught of talking points. However, I’m not a cheerleader for Ontario’s latest reform effort – or any other particular strategies.  What I have is a unique vantage point, having served as an advisor to a former Ontario Minister of Health and Long-Term Care when many underpinnings of Patients First – including LHINs – were introduced, and through executive roles in the broader health sector, at the Toronto-Central LHIN and now as a consultant helping clients keep up with the changes underway.

Patients First is the latest chapter in a transformation strategy that began in the first days of the McGuinty government and arguably even earlier, during the upbeat days of the Romanow Commission.  Every jurisdiction with an aging population faces similar challenges. All have some kind of plan – and every plan has flaws. Every attempt to disrupt the status quo is met with resistance.  Health care is political and always will be.

If we are to fundamentally fix what’s broken and, ultimately, deliver better results to patients and the public, this will have less to do with policy prescriptions and structures and more to do with mindset and leadership.  In other words, it’s better to think of Patients First as a plan, not a solution.  What matters is what we do, individually and collectively.

Why am I optimistic about Patients First?  As a start, there are at least three things in it that everyone seems to agree on:

First, stakeholders acknowledge that the system has been designed around the interests of providers and that we need to turn this on its head so we begin and end with patients and communities.

I’ve never heard anyone disagree that patients and caregivers need to be true partners in their care.  We need to keep getting better at patient engagement. We are starting to measure and speak honestly about health inequities and efforts to co-design services with patients and caregivers show that were making meaningful progress here.  Could Patients First be a lever to tackle health equity and achieve a real impact on indigenous health?

Second, there’s lots of head nodding about the need for integration.

Ontario’s health system is too confusing and disorganized.  It’s not as efficient as it could be and, as a result, we end up squandering resources and talent.  Ontario needs to continue to move away from compartmentalizing services and toward a system where collaboration is the norm.  The move to sub-regions – where all providers are accountable for the same outcomes for people in their area – has the potential to be a game changer.  It will take enormous hard work and perseverance to integrate primary care, public health and the other large pieces of the system.  While we are taking this on, we need to recognize that fast-growing areas of health care are only tangential parts of the health care ecosystem – eye care, drugs, and retirement homes, for example, are rarely part of LHIN planning tables.  Does this need to change?

Third, Patients First marks an important step in better aligning public health and the LHINs.

It’s well accepted that strong, integrated primary and community care is the foundation of a person-centred and affordable health system. It makes sense that this is the centerpiece of Patients First.  Everyone understands that people’s health is influenced more by education, housing and other social determinants than what goes on in the health system. Of course, the big play is tackling the social determinants through a wholesale commitment to healthy public policy and prevention.

So, how do we move from planning to doing?  Here are five modest proposals:

  1. Let’s build on what’s working. For example, Health Links and now sub-regions are enabling providers to tackle problems differently.  There is still competition, naturally, but there’s also a growing realization that the greatest returns come from working together for patients.  The acceleration of voluntary integrations of health service providers is a symptom of this new mindset.
  2. Avoid believing that restructuring is the answer. I’m not going to weigh in on whether the CCAC-LHIN merger is necessary, but we can all agree that it’s not sufficient. It will be a major undertaking and careful execution is crucial to ensure continuity of care.  But the LHIN-CCAC merger is one means to an end.  The government and LHINs need to be clear about how the structural changes lead the transformation of care delivery.  They need to be able to simply and convincingly answer questions like “What will be different for the 86-year-old woman in rural Ontario who just lost her spouse, has no caregivers, is deeply depressed, and struggling to cope?”
  3. Don’t spend energy worrying about what “sectors” play what roles. Everyone needs to be flexible.  Every part of the system has its strengths and lines are blurring – the reality is that hospitals have much bigger budgets, better infrastructure, and have been able to invest in management expertise.  Community and home care agencies have deep knowledge of their communities and are experts in caring for the entire family. Volunteers are part of the lifeblood of community health organizations and hospitals alike.  Once strengths are understood and respected, they can be leveraged for everyone’s benefit.
  4. Involve front-line staff at every step. The real transformation happens at the point of care – in a family home, a community clinic, or bedside in a hospice.
  5. Opt for more accountability and less top-down control. The LHINs have been tasked with leading system transformation.  They need more freedom to lead.  The sub-regions are a golden opportunity to bring in different perspectives. Without new voices and leadership renewal, Patients First will get stuck in the echo chamber.

Optimism is necessary because fear-induced change won’t last.

If fewer organizations say we are doing this before it’s done to us and more say we are choosing to change because we can do better for patients, we’ll know the mindset has shifted.