Bill 41: Patients First Act, 2016
Good afternoon to you all.
My name is Carol Timmings. I am a registered nurse and the president of the Registered Nurses’ Association of Ontario. As the professional association representing registered nurses, nurse practitioners and nursing students in Ontario, we thank you for the opportunity to provide advice regarding Bill 41.
Nursing is the largest regulated health workforce in Ontario and polls consistently show we are the most trusted professional group. There are nearly 96,000 RNs, 2,400 NPs, and 39,000 RPNs working with Ontarians in all areas of our health system. We are often the eyes and ears for patients and for the health system. Our role is to advance health, as well as prevent and treat illnesses. Our everyday experiences working across all sectors and in all roles – from direct care providers, to teachers, researchers, policy makers and top executives – enlightens our understanding of what’s working and what must be improved to best serve Ontarians.
This moment in time presents a once in a generation opportunity to deliver on a promise to better our health system. We are afraid we are wasting a precious opportunity to do what’s right for Ontarians.
RNAO assessed Bill 41 with the following in-mind:
- Will it improve Ontarians’ timely access to quality health services where it makes the most sense to receive them? This includes anchoring the system in primary care.
- Will it remove barriers so people receive person-centred services that help them as close to home as possible?
- Does it promote integration and equally consider structural and service delivery enhancements?
- Does it maximize the effectiveness of the system so it’s sustainable for generations to come?
While we first cheered Minister Hoskins’ bold goals for real and meaningful health system transformation when he released the patients first discussion paper in December, what we see now falls short in meeting this goal. RNAO’s biggest concern is that left as-is, Bill 41 will perpetuate current health system limitations, albeit under a façade.
Our written submission provides an overview of RNAO’s complete analysis of the bill and 13 recommendations. In our time together, we will focus on key areas.
None of RNAO’s feedback should come as a surprise. RNAO has provided detailed advice to the government and opposition parties on how to achieve health system transformation. In fact, RNAO’s Enhancing Community Care for Ontarians (ECCO) model first released in 2012, has been extensively quoted by Minister Hoskins and many others, as a source of inspiration for what our health system should look like. It is a clear roadmap that details what is needed to achieve whole health system integration, improve access, quality and sustainability. I want to stress that the government has recognized our model as having informed the development of the bill. But as we have repeatedly pointed out, there are foundational shortcomings in Bill 41 that do not align with RNAO’s ECCO model. My colleague, Dr. Doris Grinspun, RNAO’s CEO will review these for you.
First, Section 1(3) of the bill seeks to expand the definition of a health service provider under the LHINs’ legislation. However, critical players are missing. These includes: most primary care providers, public health units and home health-care providers. Effective health system integration will not occur unless there is a single body -- LHINs -- that is capable of making planning and funding decisions that consider the health system as a whole. Otherwise, we run the risk of perpetuating siloed decision-making that translates into fragmentation for Ontarians. For them, nothing will really change.
The bill does seek to strengthen the role of public health units in supporting planning, funding and service delivery. However, RNAO is concerned that the provisions in the bill are insufficient to adequately advance a population-health planning approach in Ontario. For example, sections 9 and 39(1) require the leadership of LHINs and public health units to “engage” on an ongoing basis. This is a vague and weak expectation with no “teeth,” no clear parameters and no expected outcomes. For RNAO, public health units must assume a leading role in advancing health equity as they are experts in upstream health promotion and disease prevention, as well as analyzing population health needs and delivering community engagement. This sector can not remain in the sidelines.
Our first recommendation is to amend section 1(3) of the bill to include all of primary care, public health units, home health-care and support services as health service providers under the LHINs’ legislation.
A number of provisions within Bill 41, position the LHIN as a provider and/or manager of health services. RNAO profoundly disagrees with such a role. As captured in RNAO's ECCO report, the most effective role of the LHIN is to plan, integrate, fund, monitor and be ultimately accountable for local health system performance. It would be ineffective, and at times a direct conflict of interest, for LHINs to engage in direct service provision. It is challenging to “row” and “steer” at the same time. RNAO urges you not to perpetuate the existing limitations of CCACs by having LHINs act as a case management brokerage that allocates hours of service to Ontarians based on a command and control approach. Rather, service provision and the management of service, should be the focus of health providers that have the best understanding of patient need.
Our second recommendation is to remove all provisions that would position LHINs as delivering and/or managing health service delivery. Focus the scope of LHINs solely on whole system planning, integration, funding allocation, monitoring and accountability functions.
RNAO was the first organization to call for CCACs to be dissolved, beginning in 2012 in our ECCO report. We argued then and today, that maintaining both CCACs and LHINs results in unnecessary structural duplication. It leads to - by design – fragmented service delivery. It hinders the ability of the LHINs to deliver whole system planning and allocate funding based on demographic and evolving health system needs. RNAO is also concerned, as was Ontario’s Auditor General, with the administrative cost of the CCACs. Having dual agencies - LHIN and CCACs - with their associated costs does not enable the delivery of effective person-centred care.
RNAO is also concerned that bill 41, simply seeks to “transfer” the CCACs, including all of their limitations to the LHINs; in effect creating a merger and business as usual.
Therefore, our third recommendation is to:
Fully dissolve CCACs and produce true health system transformation by preventing the automatic transfer of all CCAC functions, processes and resources to the LHINs. Instead, efforts must be made to transform the funding model in the community away from fee-for-service and anchor the health system in primary care.
This can be done by locating the almost 4,100 CCAC care co-ordinators within primary care. Respecting collective agreements, a secondment could be struck with the LHIN as the employer. Doing so, along with fully utilizing the already existing 4,000 primary care RNs, 1,100 NPs and 2,900 RPNs, will enable Ontarians to get the services they need more quickly by securing:
- seamless transitions so that no Ontarian falls through the cracks when navigating through the system;
- an efficient process to initiate home health care and support services;
- ready access to health information and prompt communication among providers;
- reductions in the duplication of tests and other assessments; thus reducing health expenditures.
In conclusion, RNAO is pleased to contribute its expertise to the review of Bill 41. With the pressing amendments specified in our written submission and our presentation today, the bill could transform Ontario’s health system. However, RNAO is gravely concerned that left as-is, the bill would do little to put patients first. Nurses are calling for authentic transformation – not smoke and mirrors.
We look forward to receiving your questions.