Bill 41: Patients First Act, 2016
The Registered Nurses’ Association of Ontario (RNAO) is the professional association representing registered nurses (RN), nurse practitioners (NP) and nursing students in all settings and roles across Ontario. RNAO extends its gratitude to the standing committee for the opportunity to review Bill 41: Patients First Act, 2016 and offer recommendations to enhance it.
About Bill 41
Bill 41 was introduced by the Minister of Health and Long-Term Care on October 20 to amend 20 different statutes, including the Local Health System Integration Act, 2006 (LHSIA) and the Home Care and Community Services Act, 1994. A similar bill (210) was introduced in June, however, it did not advance beyond first reading because the legislature was prorogued.
Minister Hoskins indicates that Bill 41: “If passed … would help us to build a [health] system that best meets the needs of Ontarians, a system that closes the gaps that exist and one that would help bring health care services to the people who truly need them most. A system that best meets the needs of patients in an equitable way is one that is truly population-focused and deeply integrated at the local level. To do that, we need strong local health system planning and strong management.”
Bill 41 arose out of a discussion paper issued by Minister Hoskins in December 2015 and RNAO was credited for informing its development.
RNAO Offering Solutions
Nursing is the largest regulated health workforce in Canada and is consistently regarded as the most trusted profession among members of the public. There are nearly 98,500 RNs and NPs working in Ontario. RNs and NPs are present in all reaches of the province and health system. They are often described as the eyes and ears of the system and are intimately familiar with what is working and where gaps exist. RNAO is proud to be a trusted health system partner that is solutions-focused and has produced a model to achieve health system effectiveness (Appendix A).
The model has informed a number of policy outputs focused on transforming Ontario’s health system, including (but not limited to) the following:
- Primary Solutions for Primary Care: In 2012, RNAO led a provincial task force representative of leading system stakeholders. The purpose was to identify ways to fully utilize the competencies, knowledge and skills of primary care nurses to facilitate timely access to quality primary care. The task force was bold and visionary in recommending: “Identify[ing] areas of structural duplication and work[ing] toward better system integration by improving linkages across all sectors and moving care coordination to primary care.”
- Enhancing Community Care for Ontarians (ECCO): In 2012, RNAO released the groundbreaking ECCO model to build a robust foundation for community care and improve integration between all health sectors (Appendix B). A second version of ECCO was released in 2014 to enrich detail accompanying the policy proposal. RNAO was the first organization to recommend a single health system planner/funder – the Local Health Integration Networks (LHIN); while anchoring the health system in primary care and eliminating Community Care Access Centres (CCAC) as structural entities.
- Review of the Local Health System Integration Act: In 2014, RNAO presented to the Standing Committee on Social Policy when it reviewed the LHSIA. RNAO used the ECCO model to deliver a legislative proposal that strengthens health service delivery in Ontario. Specifically, RNAO called for a greater emphasis on health equity and the engagement of marginalized groups; amending the definition of health service providers (HSP) to include all health organizations/providers; and transitioning the planning/funding functions of CCACs to LHINs – thus making the LHINs responsible for whole system planning, integration, funding allocation, monitoring and accountability functions at the local level.
- Response to Patients First Discussion Paper: In early 2016, RNAO responded to Minister Hoskins’ discussion paper on strengthening patient-centred health care in Ontario. RNAO continued to urge the minister to enable LHINs to plan, integrate, fund, monitor and be ultimately accountable for local health system performance, while strongly cautioning against LHINs providing service delivery and/or management. RNAO re-iterated its call for the elimination of CCACs as structural entities and reaffirmed its insistence to relocate the nearly 4,100 care co-ordinators currently in CCACs to primary care.
- Mind the Safety Gap in Health System Transformation: In May 2016, RNAO released the results of an investigation into the relationship between Minister’s Hoskins patients first agenda and nursing human resource trends. The conclusion is that trends in nursing skill mix and organizational models of nursing care delivery run counter to the government’s goals for the health system. This conclusion may thwart efforts to positively transform the system. RNAO made eight recommendations:
- The Ministry of Health and Long-Term Care (MOHLTC) develop a provincial evidence-based interprofessional HHR plan to align population health needs and the full and expanded scopes of practice of all regulated health professions with system priorities;
- The MOHLTC and LHINs issue a moratorium on nursing skill mix changes until a comprehensive interprofessional HHR plan is completed;
- LHINs mandate the use of organizational models of nursing care delivery that advance care continuity and avoid fragmented care;
- The MOHLTC legislate an all-RN nursing workforce in acute care effective within two years for tertiary, quaternary and cancer centres (Group A and D) and within five years for large community hospitals (Group B);
LHINs require that all first home health-care visits be completed by an RN;
- The MOHLTC, LHINs and employers eliminate all barriers, and enable NPs to practise to full scope, including: prescribing controlled substances; acting as most responsible provider (MRP) in all sectors; implementing their legislated authority to admit, treat, transfer and discharge hospital in-patients; and utilizing fully the NP-anaesthesia role inclusive of intra-operative care;
- The MOHLTC legislate minimum staffing standards in LTC homes: one attending NP per 120 residents, 20 per cent RNs, 25 per cent RPNs and 55 per cent personal support workers; and
- LHINs locate the nearly 4,100 care co-ordinators (currently in CCACs) within primary care to provide health system care co-ordination and navigation, which are core functions of interprofessional primary care.
RNAO believes that people value Ontario’s publicly-funded and not-for-profit health system. That being said, there are opportunities to improve it by tackling:
- Rising health expenditures and insufficient federal health transfers;
- Shifting demographics and rising care complexity;
- Delays and inequitable access to timely health services;
- Lack of emphasis on upstream preventative measures;
- Ineffective care transitions and lack of co-ordination;
- Variation in the quality and safety of care.
These challenges are not insurmountable. By incorporating the vital enhancements outlined in this submission, Bill 41 has the potential to address these gaps. However, RNAO’s biggest concern is that left as-is, Bill 41 will perpetuate current system limitations, albeit under a different façade. Instead, Bill 41 could represent a unique moment in history to transition and transform the health system.
RNAO is alarmed that while the ECCO model is credited as having informed Bill 41, there are a number of shortcomings in the bill that do not align with the ECCO model. As a staple of integration process, is critical that both health structures and service delivery models be adequately addressed in the government’s patients first transformation agenda.
Analysis of Bill 41
Definition of Health Service Provider
Section 1(3) of Bill 41 seeks to expand the definition of a HSP under LHISA. However, it is missing: most primary care organizations, public health units and home health-care providers delivering purchased community services. 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, there is a significant risk of perpetuating existing system limitations, including siloed decision-making that will translate into fragmentation for Ontarians.
RNAO is being joined by a growing number of system stakeholders in asserting that primary care must be the foundation anchoring Ontario’s health system. While it is encouraging that Bill 41 classifies interprofessional primary care organizations as HSPs, these organizations still provide health services to only a portion of the public (~25 per cent). Therefore, RNAO asserts that LHINs should be empowered to oversee the planning, contract management, funding and performance of all primary care entities. Otherwise, the way LHINs approach planning for primary care will be inconsistent and will not lead to a strong primary care foundation which is foundational to high performing health systems.
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 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. They are experts in upstream health promotion and disease prevention, as well as analyzing population health needs and delivering community engagement. Positioning public health units within the LHIN mandate, acknowledging implementation considerations, will better align public health with the rest of the system, and can stimulate a broader reach of health promotion principles in other sectors. RNAO believes that this can only happen if public health units are designated as HSPs.
One of the distinctions between Bill 41 and its predecessor Bill 210 is that it includes a provision that explicitly excludes home health-care providers from the definition of a HSP when delivering a community service purchased by the LHIN. It is unclear how LHINs will be capable of advancing the minister’s desire to build community care capacity, if these service providers are excluded from being HSPs? Instead, the current approach will be perpetuated whereby services are purchased from a large roster of providers, leading to an inefficient use of procurement resources and instability in the sector. Instead, RNAO urges LHINs to serve as funders of accredited home health-care and support service organizations that deliver a continuum of services and reform the funding relationship from a per-visit basis to predictable funding baskets that follow evidence-based pathways and leverage provider autonomy. This will assist in stabilizing the sector and make it more person-centred by incorporating a range of interventions, including health promotion.
Recommendation #1: Advance an integrated health system that is anchored in primary care. Amend section 1(3) to include all of primary care, public health units, home health-care and support service providers as health service providers (HSP).
Recommendation #2: Replace "health disparities" in section 4(2) with “health inequities” and adopt Health Quality Ontario's definitions of "health equity" and "health inequity” as outlined in its Income and Health Report.
Recommendation #3: Add the following LHIN object: Advance health promotion and disease prevention through leadership in planning, funding and monitoring health promotion services that address the broad determinants of health and support community development.
Recommendation #4: Remove all provisions that would position LHINs as delivering and/or managing health service delivery. Instead, empower HSPs and focus the scope of LHINs on whole system planning, integration, funding allocation, monitoring and accountability functions.
Recommendation #5: Amend section 19(2) by removing the exemption of public hospitals from receiving LHIN directives.
Recommendation #6: Establish patient and family advisory committees within LHINs and amend the bill to require that they reflect the diversity of the community being served. Furthermore, amend section 41 to require the ministry to establish a patient and family advisory council.
Recommendation #7: Amend section 12 by explicitly clarifying that the objects of the sub-regions are planning, funding and integrating services; not imposing barriers, unnecessary new bureaucracy and/or new governance layers.
Recommendation #8: Mandate tri-partite leadership models incorporating medicine, nursing and one other regulated health profession within each LHIN.
Recommendation #9: Fully dissolve CCACs and produce true health system transformation by preventing the automatic transfer of all CCAC functions, processes and resources to the LHINs.
Recommendation #10: Locate the nearly 4,100 care co-ordinators (currently in CCACs) within primary care as the sector is eager and ready.
Recommendation #11: Amend section 30 to remove the requirement that OACCAC employees be automatically transferred to a new shared services corporation.
Recommendation #12: Amend section 37 to require HQO to seek the advice of the public and health providers when formulating advice on the funding of health services and medical devices.
Recommendation #13: Remove Section 40(1) and provide adequate public funding for community support services.
RNAO is pleased to contribute its expertise to the review of Bill 41 – Patients First Act, 2016. The bill, with the pressing amendments specified in this submission, would positively transform Ontarians’ health system. RNAO is gravely concerned that left as-is, the bill would do little to put patients first. RNs, NPs and nursing students -- indeed all nurses -- are calling for authentic transformation. We look forward to an ongoing leadership role in health service delivery and in bringing about genuine and much needed health system improvements. Ontarians need and deserve no less.
Get the full submission with references below