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Rapid Recap: 2023 Annual Report from the Office of the Auditor General of Ontario

 

December 6, 2023- Ontario’s Acting Auditor General Nick Stavropoulos released his 2023 Annual Report today, containing 12 value-for-money audits covering a range of topics. While all eyes were on the contentious relocation of the Ontario Science Centre, the four audits focusing on the health system and long-term care services provided a stark glimpse into the condition of Ontario’s health system.

When taken together, the four audits suggest the province hasn’t got behind a unifying strategy for health care in Ontario, instead offering a series of solutions that have shown some challenges fitting together. This has given rise to some fragmentation and seen many parts of the health care system turn to stop-gap solutions, such as nursing agencies to fill much needed positions.

In the 2018 election, Premier Ford campaigned to end hallway medicine, yet the Auditor General has found many trends are moving in the wrong direction. Despite this, the pandemic undoubtedly scrambled the health care space. How much of these trends can be blamed on government choices vs. forces beyond their control will very much remain an open debate.

To stave off criticism from opposition parties on these contentious reports, especially with newly crowned Liberal leader Bonnie Crombie, the Ford Government has adjourned this legislative session for 2023, with MPPs not slated to return to Queen’s Park until February 2024.

Highlights from these audits are summarized below.

Emergency Departments

The Auditor General concluded that the Ministry of Health and Ontario Health, in conjunction with hospitals, do not have fully effective systems and processes to oversee the delivery of care at emergency departments. He also indicated that they are unable to manage resources efficiently to help ensure emergency care that is timely and meets all patient needs.

Perhaps most damning for the government, the AG found that the 2018 election commitment from Premier Ford to end hallway medicine was an empty promise, with the problem worse now than when he came into office. There were 203 unplanned emergency room closures at 23 mostly smaller and rural hospitals. None of these closures are closely tracked. In addition, wait times to see a physician spiked and varied significantly from region to region — in some cases, patients had to wait more than 24 hours for an inpatient bed.

Findings also indicated hospitals were over-reliant on temporary nurses from expensive staffing agencies, as staffing shortages continue to impact the ability to serve patients. While unique diversion practices have helped some emergency departments handle patient flows more efficiently, they were often not shared with other hospitals. For example, a virtual urgent care pilot program has had some early successes, but subsequent changes to the program may result in worse outcomes if not managed effectively, the AG found.

In a separate section of the report, the AG also looked at hospitals in Northern Ontario. Although the Ministry of Health and Ontario Health have processes in place to oversee the delivery of hospital services in Northern Ontario that is timely, consistent and meets patient needs, the AG found they can work on improving their effectiveness.

Many of the problems in Southern Ontario were more pronounced in the north. Ten Northern hospitals shut down their obstetrics units between July 2022 and September 2023. Three remained closed for over a year. Hospitals were over-reliant on temporary nurses from expensive staffing agencies — between 2018/19 and 2022/23, the use of these nurses increased 25 times at hospitals in Northern Ontario. In the rest of this province, they increased only two and half times.

The AG estimated that the province spent an estimated $65 million keeping patients in Northern hospitals in 2022/23 because there weren’t any available long-term care beds or home care services.

In total, the AG made 14 recommendations to address the audit findings regarding emergency departments. The Northern Ontario hospitals section contained 20 recommendations.

Public Health Ontario

The AG identified some modest challenges and recommended iterative improvements that could be made, but overall did not take a strong position on Public Health Ontario’s (PHO) future role. This will likely be dissatisfying, both to those who felt that the agency was underutilized during COVID-19 (and thus should be given greater power), and those who felt that it was a major issue in our response (and thus should be given a lesser role). Given the light touch by the AG, with COVID-19 already having received multiple special reports, the Auditor may have opted to focus their review on non-COVID-19 matters, and thus restricted itself to the less high-profile aspects of PHO’s mandate.

The AG concluded that PHO does not yet sufficiently collaborate with the Ministry of Health and local public health units to clearly define and ensure the agency’s role in areas such as undertaking public health research, disseminating knowledge and delivering public health laboratory services. The AG also found that PHO mostly measures outputs, and the agency’s suite of performance indicators does not cover all of its key functions.

Other findings indicated that PHO is not leveraged to achieve its full capacity and potential. This included its laboratory operations. The AG also found that PHO needed to adopt better data collection procedures.

In total, the AG made 10 recommendations to address the audit findings regarding Public Health Ontario.

Long-Term Care Residential Services

In another section of the report, the AG found long-term care (LTC) homes do not have fully effective systems and procedures to ensure that residents receive quality care and services. As the needs of residents are becoming increasingly complex, homes lack the resources to manage them. Health human resources (HHR) issues that are impacting the entire health care system are hitting LTC homes particularly hard.

There continues to be inequity in the sector, with the AG concluding that neither the Ministry nor Ontario Health has developed targets to effectively measure the performance of long-term care homes in relation to quality of care and resident safety. Certain populations have been underserved within the LTC space, including younger residents, those in need of culturally specific care and individuals with specialized behavioural needs.

While the AG found the sector struggling, they also noted that oversight and funding needs work. New legislation pertaining to alternative levels of care, the More Beds, Better Care Act, 2022, has not been effectively communicated to the public. The AG also found that the Ministry has not consistently analyzed the uptake of funding initiatives.

In total, the AG made 12 recommendations to address the audit findings regarding the long-term care sector.

Follow-Up Reports on Previous Audits

The Auditor General released seven health related follow-up reports on previous value-for-money audits and two follow-up reports on COVID-19 measures were released by the Standing Committee on Public Accounts.

2023 Annual Follow-Up on Value-for-Money Audits:

2023 Annual Follow-Up on Reports Issued by the Standing Committee on Public Accounts:

Further Reading

  • Read the press release here.
  • Read the Acting Auditor General’s 2023 Annual Report here.
  • Read the follow-up reports on previous audits here.
  • Read Santis Health’s memo on the Auditor General’s 2022 Annual Report here.
  • Read Santis Health’s memo on the Auditor General’s Special Report on Pandemic Readiness and Responsiveness in Long-Term Care here.