Rapid Recap: 2024 Annual Report from the Office of the Auditor General of Ontario
Tuesday, December 3, 2024 – Ontario’s Auditor General Shelley Spence released her 2024 Annual Report today, containing 10 audits covering a range of topics. While all eyes were on the contentious redevelopment of Ontario Place, five audits examined the province’s opioid strategy, the funding and construction of health care facilities and the digitization of government services by ServiceOntario.
Spence said the province needs to develop a new comprehensive strategy to deal with the opioid crisis as the current one has not been updated since 2016. The audit concludes that the Ministry of Health does not have effective processes in place to meet the challenging and changing nature of the opioid crisis and the province’s plan to close 10 supervised consumption sites was made “without proper planning”.
While she applauds the government’s plans to launch 19 new Homelessness and Addiction Recovery Treatment (HART Hubs), Spence stated the province has not planned properly for the transition to the new hubs. Her audit finds that more than 1,600 overdoses were reversed at those sites in 2022-23 and health workers, advocates and users of the sites have raised concerns that there will be a drastic increase in deaths when the sites close by March 31, 2025.
Several audits also suggest the province relies on a piecemeal approach when it comes to building urgently needed health care infrastructure. This has resulted in ballooning costs for the province and Infrastructure Ontario’s changes to the P3 delivery model for major infrastructure projects has resulted in the province taking on greater risks, and as a result, fewer risks are transferred to the private sector. Spence states that construction needs to begin soon for nearly 40,000 long-term care beds to meet provincial targets and timelines by 2028/29 and that Infrastructure Ontario needs to review their processes for infrastructure projects to ensure these are completed on-time and on budget.
The Auditor General also found that ServiceOntario does not have a comprehensive, end-to-end plan for digitalizing its services resulting in a fragmented approach. Ontarians’ data is particularly vulnerable to cyberattacks and data breaches and more work needs to be done to ensure large volumes of sensitive information, including public health data, names, addresses, phone numbers and health card numbers are securely stored and accessed.
Following the release of the Auditor General’s 2024 Annual Report, several Ontario Ministers including Hon. Sylvia Jones, Deputy Premier and Minister of Health; Caroline Mulroney, President of the Treasury Board; Paul Calandra, Minister of Municipal Affairs and Housing; and Michael Lindsay, President and Chief Executive Officer of Infrastructure Ontario responded to Spence’s findings in a media availability to answer questions from the media. Minister Jones primarily responded to questions about the province’s plans to provide addictions treatment and services and stated the Ministry will perform outreach to public health units to update their harm reduction strategies. She also indicated that HART hubs will be subjected to third-party evaluation to determine outcomes, lessons learned and areas for improvement that will help inform future decisions on mental health and addictions services, including HART hubs in Ontario.
Highlights from these audits with a health focus are summarized below.
Implementation and Oversight of Ontario’s Opioid Strategy
The Ontario government implemented the province’s Opioid Strategy in 2016, however the opioid crisis continues to escalate with both opioid-related deaths and emergency department visits increasing significantly by almost 300% in the last decade. Initially, this crisis was driven by over-prescription, but has gotten worse due to more potent drugs and increased access to illegal supply.
Key findings include:
- The 2016 Opioid Strategy is outdated and does not address increased risks and needs, even with the new Hubs Model.
- The province’s opioid strategy lacks clear accountability structure and leadership.
- Poor data tracking made it difficult to accurately plan, monitor and improve addictions services.
- The decision to change supervised consumption services was made without proper planning, impact analysis or public consultations.
- Access to supervised consumption services in regions with high or growing needs was further reduced without evidence-based analysis.
- Access to comprehensive care through opioid agonist therapy (OAT) providers was limited.
- Initiation of OAT in primary care settings and emergency departments was infrequent despite benefits.
- Performance of rapid access addiction medicine (RAAM) clinics has not been monitored due to a lack of accurate and complete data.
- RAAM clinics were not available or not accessible in all communities with the highest service needs.
- Naloxone claims from pharmacies were not monitored adequately to identify inconsistent and inappropriate billing practices.
- Questionable or unusual distribution practices by pharmacies were not addressed in a timely manner to prevent potential abuse of the Ontario Naloxone Program for Pharmacies.
- Opioid prescribing and dispensing activities were not monitored adequately to identify concerning trends.
- Information on opioid prescribing and dispensing activities was not regularly shared with regulatory colleges to support their enforcement work.
- Not all prescribers and dispensers had real-time access to drug dispensing data.
- Overview of physician billings for addiction medicine services continued to be lacking.
- Emerging practices and other forms of treatment such as Safer Opioid Supply and injectable opioid agonist therapy exist in isolation and require evaluation.
The Auditor General found that the 2016 Opioid strategy is outdated, lacks clear accountability, does not address increased risks and needs and is worsened by poor data tracking/collection making it more difficult to plan and improve addiction services. The Auditor General states the province needs to develop a new comprehensive strategy to deal with the opioid crisis. The audit also concludes that the Ministry of Health does not have effective processes in place to meet the challenging and changing nature of the opioid crisis and the province’s plan to close 10 supervised consumption sites was made “without proper planning”. The Auditor General’s audit provides seven recommendations that have been accepted by the Ministry of Health to help meet the challenging and changing nature of the opioid crisis in Ontario.
Procurement and Delivery of Selected Infrastructure Projects
As of October 2024, Infrastructure Ontario had 30 infrastructure projects in the pre-construction or construction phase with an estimated value of $58 billion, and an additional 11 projects in the procurement phase with an estimated construction value totalling $10 billion. Since 2021, Infrastructure Ontario has made changes to the P3 delivery model for major infrastructure projects to encourage more market increases and competition in projects. With these changes, the province has taken on greater risks and transferred fewer risks to the private sector.
The Auditor General reviewed three infrastructure projects as part of her audit – Trillium Health Partners Mississauga Hospital, Lakeridge Gardens Long-Term Care Home and Highway 427 Expansion. The audit found that two projects were completed behind schedule and both cost more than the original budget. Lakeridge Gardens Long-Term Care Home was completed one month later than originally estimated and over budget by 27%. As of October 2024, the Trillium Health Partners Mississauga Hospital was still in the pre-construction stage and the estimated costs of the projects are expected to be over $4 billion higher than the current approved budget.
Key findings include:
- Competition for infrastructure contracts has decreased despite changes made to delivery models to increase market interest. The procurement process changes have limited potential options in the negotiation process resulting in higher costs.
- There are significant costs and risks for the Ministry of Long-Term Care under the Accelerated-Build Long-Term Care Projects.
- Construction needs to begin soon for nearly 40,000 long-term care beds to meet provincial targets and timelines by 2028/29.
The risks and costs for the selected infrastructure projects could also have been better managed by Infrastructure Ontario and the sponsoring ministries (Ministry of Health and Ministry of Long-Term Care). The cost overruns on the Lakeridge Gardens Long-Term Care Home were borne entirely by the province and the Auditor General found that the decisions to cancel certain procurements for infrastructure projects were made with due regard for costs and impacts on the public sector. The Auditor General provided 13 recommendations to Infrastructure Ontario, the Ministry of Health and the Ministry of Long-Term Care who have accepted these recommendations.
The Public Accounts of the Province of Ontario
For the March 31, 2024 fiscal year, the Ministry of Health (Ministry) had a transfer payment budget of approximately $65.3 billion allocated among over 50 separate transfer payment programs. In conducting controls design and implementation testing over significant transfer payment programs, the Auditor General’s Office found that the Ministry of Health is not completing its year-end reconciliations for various transfer payment programs on a timely basis. The Auditor General found the Ministry is behind for some service providers for five fiscal years.
The Minister uses the transfer payment reconciliation process to facilitate the recovery of unspent amounts, but also provides feedback to the Ministry regarding the service providers’ capacity to deliver the services outlined in their transfer payment agreements and/or service demand in the area where the service providers are operating. The delay in year-end reconciliation is having a direct impact on service providers as the Ministry uses this information to make resource decisions at the program level regarding funding allocation and this leads to difficulties in recovering outstanding amounts from service providers that may impact current year service delivery or take years to fully recover the funds.
Minister’s Zoning Orders (MZOs)
The Auditor General’s audit on the Minister’s Zoning Orders (MZO) found there has been a drastic increase in the use of MZOs from 2019 to 2023. Over this five-year period, 32 MZOs were made at the request of partner ministries such as the Ministry of Infrastructure and the Ministry of Long-Term Care to speed up the construction of projects such as the building of long-term care homes and seniors’ residences despite objectives from Ministry staff and municipal governments.
Key findings include:
- The Ministry did not consistently assess whether re-zoning by MZO, as opposed to the municipal planning process, was needed and did not detail risk information normally factored into municipal zoning decisions.
- This includes key information about infrastructure capacity and servicing; natural hazards and the environment; and financial burdens to regions, municipalities and taxpayers.
- Some projects on the sites re-zoned with an MZO will not have access to servicing (for example, water and wastewater) for years and sometimes decades and these projects face foreseeable and significant delays.
- The audit concludes that the Ministry did not have mechanisms in place to measure whether the projects enabled by MZOs were progressing or metrics to measure the benefits for Ontarians i.e. a targeted number of housing units.
The Auditor General’s findings show the Ministry has on several occasions prepared briefing documents regarding the expected accomplishments of MZOs for elected officials based on unsubstantiated claims provided by proponents including that the MZOs would facilitate thousands of long-term care beds and create around 900 supportive housing units. In total, the Auditor General provided 19 recommendations to the Ministry which has accepted all recommendations.
Digitalization of Government Services by ServiceOntario
ServiceOntario has spent $27 million over the past five years (2019/20 to 2023/24) to digitize nine of its top 10 services per its mandate; however, the digital adoption of the government’s services has been slow with only 16% of health cards renewed online. Of a total of 57 services related to health cards, seven (12%) are available online and the remaining 50 are only offered in person. The Auditor General indicates that ServiceOntario does not have a comprehensive, end-to-end plan for digitalizing its services resulting in a fragmented approach.
ServiceOntario’s plans do not include digitalization objectives with targeted outcomes and metrics; do not identify the key government services to be digitalized, with related activities and timelines; and did not estimate costs. The Auditor General has recommended that ServiceOntario work with relevant partners and ministries, such as the Ministry of Health, to develop a strategy that includes criteria for prioritizing services for digitalization, and timelines for completion.
The audit also found that Ontarians’ data is at risk of unauthorized disclosure or a cybersecurity attack, such as phishing, as only 18% of 2,055 ServiceOntario staff at public locations that handle Ontarians’ personal data had completed one of the two mandatory cybersecurity training sessions in 2023. None of the 1,261 staff at private locations have access to this training. The Auditor General has indicated that this may lead to an increase in cyberattacks and that more work needs to be done to ensure that large volumes of sensitive information, including public health data, names, addresses, phone numbers, and health card numbers are securely stored and accessed to prevent cyberattacks and data breaches.
Follow-Up Reports on Previous Audits
The Auditor General released several health-related follow-up reports of note on the 2022 Performance Audits including:
- The Public Accounts of the Province of Ontario
- COVID-19 Contracts and Procurement
- COVID-19 Vaccination Program