Rachlis MD MSc FRCPC
Policy Analysis, Epidemiology, Program Evaluation
November 29, 2004
What are LHINs and What Will They Mean to Toronto Health Organizations
What are LHINs?
The Ontario Government announced this fall that it is proceeding with the implementation of 14 Local Health Integration Networks - LHINs. The Ministry of Health says that the LHINs will eventually take on the functions of planning, system integration and service coordination, funding allocation, and evaluation of performance through accountability agreements.
Initially, the LHINs will assume the planning function which the Ministry claims will “help inform and shape the design and execution of the other functions”.
The government’s vision for the LHINs includes establishing equitable access based on patient need, preserving patients' choices, developing measurable outcomes, sharing accountability between the provincial government, providers, user, and communities, and implementing “People-centred, community-focused care that responds to local population health needs”.
The government claims that their plan will achieve a better integrated system that will facilitate patient access, reduce wait times for five services (MRI scans, heart care, artificial joint replacements, cancer, and cataract surgery), and free up hospital beds through better access to home and long-term care.
What has the provincial government done so far?
On September 9, the Ministry created the Health Results team led by assistant deputy minister Hugh McLeod, to lead the renewal of the Ontario health system. Team member Gail Paech is responsible for leading health system integration including the development of the LHINs. Former Toronto mayor Barbara Hall is the lead team member responsible for community relations.
On October 6, the Ministry established the LHINs boundaries. They follow hospital referral patterns as identified by the Institute for Clinical Evaluation Sciences (ICES). There are four LHINs that cross into Toronto. The Toronto Central LHIN includes all of the old City of Toronto as well as parts of North York, East York, York, and Etobicoke. The map of the Toronto Central LHIN can be found at: http://www.health.gov.on.ca/transformation/lhin/maps/lhin_map_7.pdf. Other LHINs maps can be found at: http://www.health.gov.on.ca/transformation/lhin/lhinmap_mn.html
The LHINs will rely on existing community boards. The Ministry will hold 14 one-day workshops over the next month to discuss the LHINs model and consult with communities and stakeholders. The Toronto Central meeting is scheduled for December 8. The deadline for registration is November 12. Registration forms are available at: http://18.104.22.168/LHINFeedback/Regen001.aspx.
The Ministry hopes to establish LHINS’ boards by April 2005 and have them provide input into the 2006-2007 budget cycle.
The Ministry established a the LHIN Action Group to provide advice to Gail Paech on design and implementation. It is made up of approximately two dozen major provincial associations.
The Ministry claims that its role will be to focus on system stewardship including establishing strategic directions and monitoring and reporting performance.
Ongoing information about the LHINs development project can be found at: http://www.health.gov.on.ca/transformation/lhin/lhin_mn.html.
Is there experience elsewhere with LHINs?
No other province currently has organizations like LHINs. But all other provinces do have regional health authorities (RHAs) which are more integrated structures than are evidently contemplated by Ontario. Quebec started their path to regionalization in the 1970s. All other provinces have regionalized since 1993, starting with Saskatchewan.
There are examples of regional organizations in most other countries, except the United States. In the United States in the past three decades there has been growth in so-called integrated systems of care. The prototypes for these models were pre-paid groups practices (such as Kaiser Permanente) on the West Coast. Evaluations in the 1980s showed that these models reduced costs and increased the use of preventive services although the evidence on other outcomes was less conclusive. In the past 15 years for profit HMOs have been responsible for most of the growth in this sector. For a variety of reasons, it is difficult to extrapolate from this experience to Ontario.
The RHA models vary from province to province and details can be very important. In Saskatchewan and Alberta the RHAs subsumed the public portions of the budgets of hospitals, rehabilitation, long term care, home care, mental health, and public health. The RHAs also took over the boards and management of hospitals and publicly run services in other areas. Catholic facilities maintained their boards but became subject to regional plans.
In general smaller provinces tend to have less than 100,000 population on average per RHA while BC and Alberta have more than 300,000 per RHA. Quebec has recently implemented a plan with 95 Local Services Networks with an average population of 76,000. In the smaller provinces and Quebec, RHAs outside of metropolitan areas typically have less than 50,000 people. The cities of Montreal and Vancouver are within one region although there are major portions of their greater metropolitan areas which lie outside their geography. No other cities have been divided into more than one health region.
There has been little evaluation of the RHAs that would provide conclusive lessons for Ontario. However, prior to their latest reforms, Quebec did have a similar model to the one being proposed in Ontario. The main rational for the disestablishment of the boards of hospitals, public long-term care facilities, and the CLSCs (Québec’s network of community health centres) was that it had been too difficult to establish integration using existing organizations.
While it is not clear what organizations might initially be subsumed into the LHINs, there is speculation that the LHINs will initially include the 7 Ministry of Health and Long-Term Care regional offices and the 16 District Health Councils.
What does this mean for the health organizations in South East Toronto?
At present the only function transferred to the LHINs from the Ministry is planning. There will be no immediate changes to budgets or service. It appears that significant change will be postponed at least 1 ½ years until the implementation of the 2006 provincial budget. The ministry will have to overcome political opposition to have the LHINs assume the other contemplated functions.
The boundary changes with LHINs mean that there will be much less focus on the city and its institutions. The Toronto Public Health Department will remain, for now, as a municipally based organization but it will have to deal with 4 separate LHINs. The Department will find it a major challenge to effectively participate in four separate planning processes. In the future, there may be pressure to transfer public health departments to the LHINs.
In the short term, Toronto Central is less affected than other Toronto-area LHINs because it is all within the city of Toronto.
Communities are strengthened when public institutions have coterminous boundaries. If services like education, public health, and social services share boundaries it makes it much easier for citizens get services, particularly if they need a lot of services. Citizens and their organizations also find it easier to participate in decision-making.
Intersectoral action on the determinants of health is easier to develop at the municipal level rather than at provincial or federal levels. Toronto was the home twenty years ago to the international Healthy cities Movement. Although that initiative waned here, it has grown in Quebec and Europe. It could be argued that the broad intersectoral policy-making of the healthy cities movement is reflected in the Toronto City Summit.
The LHINs are based on tertiary care referral patterns. This makes it more likely that their focus will be tertiary care matters which are also the most politically compelling. In other jurisdictions, even with a stated goal for reallocation to community services, new regions sometimes siphoned resources from community health services to institutions.
Public health and prevention services are vulnerable because a focus on averting deaths in the future usually means a lack of a vocal constituency in the present. Community services are vulnerable because their true value is unappreciated and they aren’t glamourous enough for TV. Mental health services are especially vulnerable because their clients usually lack resources to be effective advocates.
Some other provinces implemented policies to ensure that resources were re-allocated to community care. In Saskatchewan they used a so-called “one-way door” where regions were allowed to move money out of institutions but not into them. It did increase reallocation but it also led to some gaming.
Other provinces have tried partly electing boards but no province currently elects board members. They are appointed by the provincial government. Turnouts in health board elections were typically very low. The boards were not captured by single-interest groups although that had been feared.
Some health regions such as Saskatoon, Calgary, and Edmonton have used their integrated budgets to develop more integrated seamless services. For example, they have been able to keep a low census of patients awaiting placement in long-term care facilities. Saskatoon has had less than 1% of their acute care patients awaiting a long term care bed for four years. Gradually the regions are developing more region-wide programs such as palliative care and diabetes education. In Calgary less than 35% of cancer patients die in hospital (compared with over 70% in other parts the country) and almost all AIDS and ALS patients also die outside of hospital. Edmonton centralized intake and redesigned their diabetes education services and decreased wait times by almost 90%.
In the short term resources will be allocated according to historical aliquots. But, the province could be pressed to provide an innovation fund which would hasten the development of projects needed to fill gaps in services.
Questions to be answered
What will be the operational goals for the LHINs and what will the accountability contracts look like? Will they include population health indicators e.g. % HIV rate in IDUs, % stable housing for people with serious and chronic mental illness, or will they focus on wait times for surgery?
What functions will the LHINs acquire? Will they just stay as planning bodies and become extended DHCs? If they are given resource allocation then they might become mini-ministries of health. Finally they could evolve into RHAs which also directly run many services.
It is politically easier in the short term to only take on the planning function but the lessons of other jurisdictions are that budgetary integration does appear necessary for system re-design. How can we prevent short term harm to patients by policies which aim to provide better care in the future?
If LHINs acquired resource allocation, would it be any easier for them for to create winners and losers than it would be for the Ministry?
How will the LHINs be staffed? Will they encompass the present staff in DHCs and other organizations they subsume? Will the ministry move staff to the LHINs? Labour readjustment strategies have been key to facilitating real integration. Saskatchewan has the most comprehensive legislation covering realignment of labour after regionalization.
How will physicians in private practice relate to the LHINs? How will the LHINs initiative dovetail with reforms to physician payment including primary medical care reform and academic alternative payment plans? In Alberta the association representing RHAs now sits at the bargaining table with the provincial government when they negotiate with the Alberta Medical Association. Will the LHINs evolve to take on direct relationships with physicians?
What will be the role of the for-profit sector? Will the LHINs be a vehicle to contract out more services, especially short-stay surgery? Will Elinor Caplan’s review of CCAC contracting have any implications for the LHINs?
What opportunities will there be for innovation, especially in the short-term? Are there successful examples of implementation we can follow?