The LHINs need more central guidance for primary care reform

Health Minister Eric Hoskins released the Patients First discussion paper in December 2015, detailing the government’s plans for primary care reform in Ontario. Like most individuals involved in primary care, there were a number of aspects of the paper which concerned me, but none more so than the shocking lack of detail provided to guide implementation at the LHIN level.

The ministry invited feedback, albeit within a disappointingly tight timeline. The OMA and OCFP both provided very detailed responses to the paper, which can be found here and here. I agree with many of the positions and concerns of both organizations, and was perhaps naively hoping that we would see the ministry refine its plans in response to the detailed feedback from experienced organizations.

Nope.

Instead, what we have now is 14 separate LHINs actively moving full steam ahead with their own distinct plans for how to manage primary care in their regions. Having read detailed summaries of each LHIN’s implementation plan, I was struck by how needlessly different each implementation plan is, even in the most basic of principles.

As someone who is generally supportive of the need for primary care reform, I am frankly horrified at the degree of variability I’ve seen in the plans. As sharply as the Price Report has been criticized, at least it could be argued that it attempted to provide a unified plan for a province-wide framework to move forward with. What we have now is essentially 14 separate LHINs each creating their own version of the Price Report.

Many of the LHINs reference “current performance standards accountability”, or “performance and outcome framework with associated accountability and services agreements that reflect common dimensions”, or other variations on this theme. They make the erroneous assumption that we are anywhere close to being able to implement a consensus accountability framework for physician activity. We’re not even close! This needs to be negotiated centrally, and there needs to be significant consistency province-wide. The LHINs should not, and cannot, be allowed to negotiate these accountability agreements locally with physicians, as it violates the Representation Rights Agreement (RRA) that exists between the OMA and the ministry. LHINs will likely, by default, use AFTHO and HQO indicators to rely on for any accountability measures, which have not had appropriately broad physician consultation. (On a separate note, there are hundreds of RRA violations to be found in these implementation plans).

Most of the LHINs reference the types of patient-level, practice-level, and population-level data that they want access to. This again needs to be negotiated centrally, and physicians (and patients) need to be consulted on who should have access to what data, where it will be stored, and what will be done with it. This is not a trivial point by any means. One LHIN has asked for “direct access to detailed data for local analysis”. Who is dealing with this data at the LHINs? Do they realize that most of the practice-level data is generally of poor quality? They suddenly have the resources to be dealing with reams of complex primary care data? And each LHIN will be staffed to deal with this data?

Some of the proposals, in an effort to increase “access”, promote fragmentation of care in the community, which directly conflicts with the establishment of patient-centred medical homes. (Patient-centred medical homes have been fully endorsed by nearly all physician groups, including the CFPC, OCFP, and the OMA).

I will give deserved credit to a few of the LHINs that have been candid in the possible hurdles that have been encountered in what they have been tasked to do. One LHIN stated that “without a standardized incentive approach, variation in incentive methods across the province may have a negative effect on relationships and trust with physicians”. Couldn’t have said that better myself.

Other LHINs have actually put forward completely reasonable components of what could be a good framework moving forward. But it’s a patchwork of some LHINs with good ideas, others with unpractical ideas, and some with ideas that will instantly draw the fiery rage of physicians.

Here is my fair warning to the ministry and to the LHINs, as someone who has been often accused of being too “pro-LHIN”. This is shaping up to be a complete disaster. 14 solutions to similar problems will prove to be a enormous waste of time and resources. It’s already proving to be a partial waste, as we have 14 separate implementation plans that have taken thousands of hours of time to put together, much of which will likely be tossed aside prior to any meaningful implementation.

The LHINs need to walk before they can run. The ministry needs to stop this process immediately, re-engage with the OMA and the OCFP, and develop basic principles for primary care reform that most of us can agree on. Some of the good ideas in these implementation plans can even be used in a master plan. But a basic framework for accountability and human resource organization, bargained centrally (not at the LHIN level), is essential to guide the LHINs before they add their own customized local touches for their local implementation.

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