Analysis: Second Report on Improving Healthcare and Ending Hallway Medicine: “A Healthy Ontario: Building a Sustainable Health Care System”.
The Second Report from the Premier’s Council on Improving Healthcare and Ending Hallway Medicine: “A Healthy Ontario: Building a Sustainable Health Care System”.
This report is the second report by the Premier’s Council on "Improving Healthcare and Ending Hallway Medicine” chaired by Dr. Rueben Devlin. The first report highlighted systemic problems in health care. This report is designed to provide solutions to those problems.
Since the release of their first report in January, the government has taken major steps to restructure the system. Currently, the establishment of the Ontario Health Agency is underway. The government is also in the process of launching Ontario Health Teams. The recommendations in this report can be fulfilled within this new structure.
The second report from the Premier’s Council to the Premier and Ministers of Health and Long-Term Care was released on June 25, 2019. The report provides advice on how to achieve what it describes as a new vision for health care system centred on the patient that is modern, sustainable and integrated.
The Council makes ten recommendations to improve health care, through modernization while making efforts to end hallway health care, in four categories: integration, innovation, efficiency & alignment and capacity.
The report was developed in consultation with more than 1,500 patients, caregivers, families, health care professionals and organizations across the province.
From the perspective of the Council, an integrated health care system has the resources to follow the patient. It emphasizes prevention and well-being and efficient processes. It uses centralized intake and shared electronic medical records to help improve allocation of services and connect patients to the right care at the right time. It is designed to improve access and availability of services in the health care system which would improve wait times and help solve the problem of hallway health care.
While the advice from the Council is technically just that –advice, the Council is chaired by a close confidant of Premier Ford and is very likely aligned with the views and vision of the Ford government. At a high level, what you see is not necessarily a desire to spend a significant amount of new dollars, but rather to break down many of the legislative, regulatory and policy barriers that appear to prevent modernization, patient centredness and sustainability. “Unlocking” value of the current system seems to be a key theme. It also provides advice on the roles Ontario Health Teams should play in the future.
The Council’s ten recommendations (taken from the executive summary)
- Put patients at the centre of their health care. Patients should be well-supported and treated with dignity and respect throughout all interactions with the health care system.
Analysis: This recommendation really speaks to the human element of patient care and is consistent with some of observations of the first report “Hallway Healthcare: A System Under Strain” relating to the patient and caregiver experience. They expect to achieve a more compassionate approach through a mix of training and measurement through “PREMs: Patient Reported Experience Measures”.
- Improve patients’ and providers’ ability to navigate the health care system, simplify the process of accessing and providing care in the community, and improve digital access to personal health information.
Analysis: This relates the long-held view that patient records are stuck in siloes, and currently legislation serves as an impediment to data sharing between providers and for research. To this end, it recommends changes to the Personal Health Information and Protection Act (PHIPA) but is not clear on what additional changes are required. It promotes the concept of interoperability between different clinical systems according to standards rather than forcing clinicians to adopt a single medical record software platform.
- Support patients and providers at every step of a health care journey by ensuring effective primary care is the foundation of an integrated health care system.
Analysis: The report uses the term medical “home” to describe its view of how primary care should be delivered. This term has also been used to describe Accountable Care Organizations (ACO) in the U.S. or Primary Care Trusts (PCT) in the U.K. where the responsibility for primary care for a group or geographic area is consolidated within one organization. The report steers clear of any language that would appear to indicate it supports any limitation of patient choice, which can be a feature of these models. It speaks instead to strong and seamless connections with other services in the community. The report recommends that Ontario Health Teams should help to facilitate partnerships between primary care providers in the area whether they are fee-for-service or family health teams, without recommending it begin to pay these physicians directly.
- Improve options for health care delivery, including increasing the availability and use of a variety of virtual care options.
Analysis: The report provides a cautious but favourable position on the use of virtual tools such as virtual visits, emails and texts. The problem with these tools has always been the potential for increased reliance and over-utilization. In a fee for service world, the increased efficiency of servicing patient after patient could lead to higher overall costs, and at worst, health care providers refusing to see patients in-person. This is why the report mentions increasing virtual visits, “while also protecting patient choice” to ensure in-person visits can still continue. It also seeks “appropriate incentives” for telephone calls, texts, and even internet-based psychotherapy, to ensure the incentives do not promote over utilization. Regardless, it is still the strongest endorsement of virtual care to come from such a senior-level council.
- Modernize the home care sector and provide better alternatives in the community for patients who require a flexible mix of health care and other supports.
Analysis: This might be considered a call to reduce red tape in the home care sector. Currently, publicly funded home care services are defined in legislation and regulations which lay out the mechanisms for access such as through LHINs based case workers. The Council clearly seeks additional flexibility including allowing Ontario Health Teams and perhaps other providers such as hospitals and family health teams to offer patients a broader range of services (homemaking comes to mind) directly. It would also enable flexible staffing models and innovation, likely related to virtual care.
Efficiency & Alignment
- Data should be strategically designed, open and transparent, and actively used throughout the health care system to drive greater accountability and to improve health outcomes.
Analysis: This is a call for the sector to begin to use health care data to improve health care rather than sitting in siloes unused. It calls for data standardization that could be used to train Artificial Intelligence models, that in turn, could help to improve the system. The consolidation of these data assets can raise privacy concerns, so the government will have to explain how it will improve health care and why legislative changes to health privacy legislation is required. Also, it is silent on the enforceability of data standards which could create additional costs for health service providers.
- Ensure Ontarians receive coordinated support by strengthening partnerships between health and social services, which are known to impact determinants of health.
Analysis: Dr. Devlin has spoken at numerous occasions about the need for different Ministries to work together to meet the needs of the patient. Many of the highest needs patients also have significant interactions with social services. Legislative changes may be required to permit these Ministries to exchange information, although some changes were made in the recent 2019 Budget legislation.
- As the health care system transforms, design financial incentives to promote improved health outcomes for patients, population health for communities, and increased value for taxpayers.
Analysis: This is really a signal that the Council is concerned primary care funding models that range from salaried physicians, to capitated models to fee for service may not be meeting the needs of patients who need access (such as same day appointments). It calls for a review of these models for “cost-effectiveness and impact to access to care”.
- Address short- and long-term capacity pressures including wait times for specialist and community care by maximizing existing assets and skills and making strategic new investments. Build the appropriate health care system for the future.
Analysis: This is a call to take action now by expanding on what works. For example, it recommends expanding the “reactivation” care model that is currently used at the old Finch site of Humber River Hospital to reduce the numb9er of Alternate Levels of Care (ALC) patients in hospitals. Expanding capacity through better planning has been a key theme mentioned by Dr. Devlin and also finds its roots in the Ford’s PC Campaign platform. It also echoes the 2019 Budget by calling for a review to maximize the use of health professionals to their scope of practice, making it clear that it is all hands-on deck.
- Champion collaborative and interprofessional leadership development focused on system modernization capabilities.
Analysis: The report calls on clinical leaders to provide leadership to enable this modernization. Much of this presumably relates to the relationships within Ontario Health Teams where there is a degree of expectation that groups will work together. On this point they should be satisfied by the significant amount of interest that resulted in 150 Ontario Health Team applications for the first handful of slots.
In conclusion, the Council suggests the government create a health system scorecard that reports on progress throughout the system, aligned with the Quadruple Aim objectives, specifically scorecards could measure the performance of Ontario Health Teams. Indicators on a scorecard help ensure there is transparency and accountability during a period of modernization and transition. The actual indicators will report on access and availability of services throughout the system and will likely shift over time as more information becomes available.
The recommendations listed above are designed with a view to creating a fundamental change in culture and organization of health care service planning and delivery. Hallway health care, while a problem in and of itself, is also a symptom of system-wide problems such as the availability of services in the community and the low integration of health care settings.
The Council will continue to provide advice to government on long-term capacity planning and will provide on-going advice on the development of Ontario Health Teams and Ontario Health Agency. In the meantime, the Deputy Premier and Minister of Health Christine Elliott, the new Minister of Long-Term Care Dr. Merrilee Fullerton, and the new Associate Minister for Mental Health and Addictions, Michael Tibollo have a blueprint they can follow with the confidence it is based on consultations, the advice of a highly regarded group of Council members and sub-committee members and likely the backing of the Premier.