Dennis Timbrell, President, Ontario Hospital Association
WHAT IS HAPPENING TO HEALTH CARE IN ONTARIO?
Chairman: Dr. Frederic L. R. Jackman President, The Empire Club of Canada
Head Table Guests
Willis Blair, Secretary, The Empire Club of Canada; The Rev. Tim Elliott, Minister, Christ Church Deer Park; Dr. Bev Richardson, Chief of Medical Staff Affairs, Women's College Hospital; Peter J. Harris, Chair, Ontario Hospital Association; John H. Tory, Partner, Tory Tory DesLauriers & Binnington and a Director, The Empire Club of Canada; Penny Thomsen, Executive Director, Canadian Cancer Society, Ontario Division; John Bitove Jr., President, Toronto's NBA Franchise.
Introduction by Dr. Jackman
Talking about health-care reform during national budget week is, of course, a golden opportunity to let the world know that when it comes to health care, more money is better than less. In Ontario, for three years now there have been systematic cutbacks in funding our hospitals. As Dennis Timbrell said to the Ontario Legislature's finance committee "At what point does medicare crack?" "I've been told by health-care providers," he said, "in some parts of the province that soon they will not be able to look people in the face and assure them they'll be receiving quality health care." Hospitals are closing beds and services; some hospitals, especially in Northern Ontario, are just about closed. Diagnostic equipment is insufficient. Regarding doctors, there are too many, or too few, depending on where you live in the province. It would be easy to cry and lament our sorry state, but if I know Mr. Timbrell, that is not his style.
Mr. Timbrell is a pragmatist and he will work with the realities. I know he will talk today about how we can and should reform health care given the resources that are available.
Well, there is probably no one in Canada who can turn a pleasantly pragmatic approach to turmoil into solid success better than Mr. Timbrell. That this is true, he has demonstrated over and over in his career.
Born and educated in Kingston, Ontario, and Scarborough public schools, he chose a career as a teacher. Graduating from Toronto Teacher's College and York University, he taught junior high for three years. Then he went into politics.
One always wonders when a person changes career goals if one has failed in the former or excelled beyond expectations. In any event, Dennis Timbrell decided to throw his hat into the ring of North York city politics.
He was elected as alderman in 1969. Spotted as an up and comer, and with his interest turning to provincial issues, he ran in the provincial riding of Don Mills for the Progressive Conservative Party which he won and he kept for 16 years (1971-1987). In 1971, he was then the tender age of 25. By the age of 27 he became the youngest person to hold a cabinet post in Ontario history with a record that stands to this day. He impressed so many with his humane leadership qualities that he was chosen to receive a Vanier Award as one of five outstanding young Canadians (1975) by the Junior Chamber of Commerce.
Now I would ask the audience to please bear with me, as the list of distinctions I am about to read, is sufficiently long to be not only impressive, but also, excuse me, a touch tedious. Dennis is a political winner, victorious in the elections of 1971, 1975, 1977, 1981 and 1985.
And then, in succession, he became Minister of Energy (1975-1977), Minister of Health (1977-1982), Minister of Agriculture and Food (1982-1985), Minister of Municipal Affairs and Housing (1985), Minister Responsible for Women's Issues (1985) and Provincial Secretary for Resources Developments (1985). I think, sir, that you have held so many ministries that someday you should receive an honorary doctorate in theology.
Mr. Timbrell is a strong family man. Dennis' wife, Janet, in all due respect, seemed to keep pace with every change of ministry by celebrating the event with another baby. Now, parents of six children (two boys, four girls) they have a healthy and active family life.
After the fall of the Davis and Miller governments, Dennis Timbrell moved across the aisle to sit as a member of the Tory opposition. When the Honourable Bill Davis, and then the Honourable Frank Miller stepped down as leaders of the Progressive Conservative Party, Dennis attempted twice, both in January and again in November of 1985 to become leader. It has been said that the last person David Peterson wanted to have to run against was Dennis Timbrell. Well, David got his wish; Dennis didn't.
Between 1985 and 1986 he performed as House Leader of Her Majesty's Loyal Opposition.
Entering private corporate life, he soon joined the Ontario Hospital Association as its President. He also serves on the board of Ontario Blue Cross as well as holding other corporate directorships.
Now, this is a year of anniversaries. You all know, from the banner behind me, that The Empire Club is celebrating its 90th year. Also, acknowledging, if not celebrating, their 70th anniversaries are the Ontario Hospital Association and what is now known as our Ontario Ministry of Health--both established in 1924. Both have been around for a long time.
Please welcome the only person to have headed both the Ontario Ministry of Health and the Ontario Hospital Association--Dennis Timbrell.
Many of you are aware of the Ontario Medical Association's recent advertising campaign. That Ontario's doctors feel the need to communicate to the public about the social contract and its potential impact on the users of medicare is indicative of their growing frustration with the state of our health system.
They are not alone. In Thunder Bay, confusion surrounds a District Health Council report recommending the city's four hospitals be reduced to two, or even one on a new site at a cost in excess of $200 million. In Huron County, physicians have issued an ultimatum demanding payment from hospital budgets for providing emergency services, or else they will withdraw on-call emergency services. In Ottawa, rumours persist that two of the city's hospitals will be closed. Here in Toronto the Metro District Health Council has initiated a hospital restructuring project to re-examine how hospital services are organized and delivered in Metro. This could well result in the merger or closure of some hospitals. The fact is, there is not a community in Ontario that doesn't have some controversial health issue on its plate.
Is it any wonder then, that as I travel around the province, I am asked "What is happening to health care in Ontario?" It's a good question. Governments describe the situation as reform. Health planners and others use the term restructuring. But, I'll wager many of the public feel that what is happening is deterioration. That's not strictly true, but the picture is confusing. This afternoon, I will try to make that picture clearer.
I have to explain the changes taking place in health care from the hospital perspective. As well, I will describe what the future could look like. Most importantly, I will outline some of the obstacles hospitals face in getting from today to the future.
My main message is that all of us--hospital trustees and CEOs, doctors, health-care professionals, hospital employees and the public--can come through the current situation successfully. This is by no means--nor does it have to become--an impossible situation.
But we do need government to get its act together pretty quickly. We need government to clearly articulate its goals and expectations, and then back off and let hospitals manage and provide care.
At the outset, I want to say I fear planners in our Ministry of Health regard this current restructuring process as something that has a beginning and an end. It doesn't. Health reform is a continuum of evolution and progress that started when the first nun provided health care to the first farmer or trapper more than 350 years ago in New France. Change has been, and always will be with us, especially in our health-care system.
Tuesday's federal budget and the freeze on transfer payments simply adds further urgency to the task we face. Ontario Minister of Finance Floyd Laughren has sent warnings that further cutbacks in provincial expenditures will be required, particularly because of the absolutely bizarre scenario which is unfolding across Canada regarding taxation of tobacco products.
Let me say that the changes taking place in health care mirror changes taking place throughout the entire economy of Ontario and Canada. Like corporations in Canada and throughout the world, those of us in health care are dealing with strained resources and ever-increasing demands. This compels us to seek greater efficiencies and continue to eliminate duplication wherever feasible.
As well, health consumers are changing. The elderly, as a percentage of the overall population, are increasing. With the increase comes a higher incidence of degenerative disease. So the nature, complexities and costs of health services are changing to accommodate changing health needs.
Technology plays a commanding and ever-increasing role, just as it does in the private sector. Year after year, new drug therapies and technological advances are revolutionizing the way we provide service. Procedures that used to require lengthy hospital stays can now be performed on an out-patient basis. In some cases, drug therapy has replaced surgical intervention altogether. And the pace of change quickens as more advances are made.
So our employees need to continually learn new skills while, at the same time, the work force is being reduced through the restructuring process. In 1992 hospitals reduced paid hours in the system by 10 million hours, or about four per cent. I expect 1993 to show at least as large a reduction again.
Whether you are from King and Bay Streets, or Main Street, East York, this must sound familiar.
Finally, it is becoming increasingly difficult to find the money to make necessary capital investments in current technology and up-to-date facilities. But this must be done, to maintain quality along with access to necessary services and care as more beds close, more reductions in staffing occur and demand for service remains high.
In short, like the corporate world, the entire business of health care is changing in ways that could not have been predicted a few years ago. And as it continues to evolve, hospitals will continue to adapt and do things even better and even more effectively. We must work smarter. And we are.
Day-surgery cases as a percentage of all surgery have risen from 53 per cent to 70 per cent in just two years. In the same two-year period the average length of stay in hospital has decreased from 8.7 to 7.2 days. A one-and-a-half day, or 16 per cent reduction in the average in-patient stay is significant when you consider the cost of in-hospital-stays.
Hospitals have already reduced the number of acute hospital patient days of utilization per 1,000 of population from 1,100 in 1988 to just over 800 in 1993. This represents a 27 per cent decrease, at a time when the actual number of acute cases treated in the system rose by a full eight per cent. In fact, there are some hospitals which have reduced their acute-care-patient days to well below 600. Stratford, Newmarket and Belleville are three examples that come to mind.
Perhaps the largest single similarity between what is happening in health care and what is happening in private industry is our mutual focus on the customer, or in our case, the health-care consumer. This determination to measure what we do in terms of consumer or patient satisfaction, and in terms of outcomes, is a touchstone for us. It ensures that quality is the key to all our processes. And quite frankly, we understand that some processes and treatments, that are, at this moment, simply glimmers on the horizon, will replace major components of what we do today.
In short, like the private sector, we are constantly in search of defining and shaping our future.
To help us on our quest, last year we began a task aimed at defining the hospital of the future more precisely. We call it the Hospitals of Tomorrow project. We started the project with broad-based consultation with hospital managers and trustees, community-health agencies and health-care professionals. This is ongoing.
What we have confirmed is that our members, your Ontario hospitals, do indeed clearly understand and accept the many factors which create the need for change. They also accept the responsibility to help make it happen.
Participants indicate the patients whom hospitals of tomorrow will serve will likely be different again from those of today. Evolving technology will lead to patients being increasingly cared for in non-institutional settings, many of which will be operated by, or in concert with, hospitals. Advances in less-invasive surgery will enable more patients to return home in a matter of hours rather than days. And progress in outcome measurements will lead to even more effective treatment choices, leading to even fewer admissions, lower lengths of stay for many, even fewer acute beds than we have today and further reductions in the number of employees.
Many more procedures may be done in a community-care facility, or even in the home. As a consequence, many believe that hospitals will serve many more patients who are sicker, and have more acute problems, than is the case today.
So, while there will be fewer in-patients and fewer beds, the cost per in-patient will increase, not decrease. Technological advances will mitigate the cost to some extent, but the net result is expected to be a higher cost for each patient served. Among other effects, these changes will require new funding mechanisms and efficiency standards.
It is also recognized that these developments will result in a continued rationalization of the existing hospitals and hospital networks, and also significant role changes among professionals in the hospital and outside.
It can be a promising future. But it is going to take some doing to achieve this vision without suffering serious dislocation, the emergence of gaps in service, or even a decline in quality of care. Those are the things hospitals fear. Those are the things hospitals are determined to guard against.
Let me give you a glimpse of the problems that confront us in our change process. We know that the emphasis in the system must shift away from the treatment of disease to prevention. Who can argue with that? Surely we don't have to be reminded of the huge advances in health made in this century.
But as a corollary, some say everything that is institutionally-oriented must be bad and everything that is so-called "community-based" must be good. One represents treatment, the other prevention, as if the day will come when treatment will no longer be needed. One is costly, the other cost-effective, though an apples-to-apples comparison is seldom provided to support such claims. One is the past, the other the future.
These are the extreme--the simplistic and false generalizations that limit debate and prevent creative change. We have to get beyond this point.
The development of our health system has been a sometimes arduous journey. Part of the problem is the number of hands on the wheel. The ministers, and the bureaucrats, both federal and provincial, physicians, other practitioners, unions, community groups, and of course, hospital boards and CEOs all have their own perceptions and needs.
We must recognize that this competitiveness, in and of itself, can be one of our great difficulties. In this environment, the competitiveness that has served corporate Canada so well, can sometimes interfere with the effective provision of health care. Here, we in health care, part company with the private sector.
In the hospital sector, competition contributed to the development of a first-class system in Ontario. Hospitals, communities, even neighbourhoods, sought the best specialists, most modern facilities, and the most up-to date equipment. This served Ontario well in an earlier phase of our system's development. But in recent years, as needs changed, technology changed, treatments changed, and as government resources were curtailed, hospitals curbed competitiveness to seek co-operative strategies.
Let me give you a few examples. In Windsor where there are four hospitals today, one agreed merger and another set of merger talks are leading to the creation of two hospital entities with a wide-range sharing of services, concentration of programmes and integration of planning. The hospitals started this process in 1991.
The hospitals led the way, and the hospitals are making it happen.
Last fall, a new hospital opened in Timmins which consolidates services previously provided on three sites. Here in Toronto, six west-end community hospitals coordinate planning and service delivery and today are examining the potential for consolidating laboratory services and a number of other services. Other examples can be found in many communities such as London, Peterborough, Guelph, Sault Ste. Marie, to name just a few.
Hospitals are proving they can do the job as they have done in the past. In the late 1950s when government wanted to introduce hospital insurance, it turned to the Ontario Hospital Association and its members to develop the programme. And they did that successfully until the early seventies when it was incorporated into the newly-structured Ministry of Health. Today when the system needs re-building, hospitals can again be counted upon.
Our goal must be achieving better outcomes at lower cost for the benefit of all Ontarians. But to achieve this, hospitals need the co-operation of government. With tighter and tighter control by the Ministry of Health, hospitals run the risk of becoming nothing more than 222 more units of the Ministry.
There seems to be a tendency for some in the Ministry to want to micro-manage the hospital system--to intervene on an issue by issue basis.
Government should know better. Set the funding. Set the parameters. Define what is needed. But let boards govern and let managers manage. We are supposed to have a system of socialized health insurance in which the insurer--government--is expected to define clearly what they want to buy for the insured--all of us--what they are prepared to pay for it and then let the providers get on with their jobs.
Great care must be taken to ensure the management tools that hospitals need are not whittled away by the imposition of unclear and unreasonable planning conditions; or by the social contract; or by unrealistic deadlines imposed by the Ministry; or by the imposition of programmes which are felt to be politically necessary, but prove difficult to absorb with practicality, on top of all the other changes that are being accommodated.
Wave after wave of policy direction has hit hospitals in the last few years.
This is a new priority. That is a new priority. Send us your operating plans tomorrow.
Send them to the District Health Council yesterday. Your budget increase is x per cent.
Sorry it's a decrease of y per cent. No, it's now the social contract. Some consistency from government is essential.
As well, health-care reform can't simply become a euphemism for deficit control. Hospital workers on the front-lines resent being told by bureaucrats that their work is unnecessary or redundant, and that therefore massive savings can be extracted from the system to help deficit reduction.
These are the people who want nothing more than to render the highest quality of care that they can. They are the ones who have to treat patients in corridors, not the bureaucrats.
I make that statement on behalf of the doctors, nurses, managers and other front-line workers who are tired of being abused by the rhetoric of health-care reform. And I make that statement to point out the need for a more cooperative approach among all stakeholders.
Workers have a right to be concerned. Who can say at what point access to health care is threatened? We have taken over 6,000 acute beds out of service in Ontario in the past six years--the equivalent of six Toronto general hospitals. As I mentioned earlier, part of this has been accomplished through working more efficiently. Part has been enabled by new treatment modalities. But part has also been a response to constrained resources. So hospital workers fear that hasty or unplanned change could lead to the creation of a two-tiered system. That the dignity of patients could be put at risk. That is something all of us should fear.
Change, which should be a constructive force, could prove destructive if not managed appropriately. For example, in some areas we may be on the verge of repeating the mistake made two decades ago when Ontario introduced regional government in the province.
Let me elaborate. It has been suggested that more efficient health care can be found by giving District Health Councils the power to allocate funds among hospitals and other health agencies, and eventually even community-based agencies. It is said such a regional approach would ensure the elimination of duplication, achieve economies of scale and improve access and the continuity of care.
One such new bureaucracy, or a version of it, may be proposed for Windsor and Essex County at a rumoured cost of $2 million per year. That's what it costs to pay about 50 front-line hospital workers for a year.
There are striking parallels to today's arguments in support of the regionalization of health-care planning and service delivery, and those used to advance the concept of regional government in the 1970s. Efficiency is most often cited, followed closely by better co-ordination of services.
As a former minister of a government that introduced regional government, I remember hearing those same arguments. One of the major reasons regional government was not widely embraced was that local municipal governments were felt to be closer to the people and more favoured by them. Ontarians rejected another layer of bureaucracy and the perceived loss of their local municipal identity.
It seems the farther a government is removed from the local community, the more voters see it as being out of touch. The same is true in health care. The strength of our hospital system lies in its proximity to its community. In every case across Ontario, local hospitals were built, and for many decades funded, through the voluntary efforts of the community which they serve. The hospital in which I was born was 120 years old before government-funded hospital insurance came along!
Almost 4,000 community representatives sit on the boards that govern our hospitals. You cannot draw a line between where the community stops and the hospital begins. While this is certainly true in the smaller areas of the province, it applies equally to urban settings where hospitals form part of the social anchor of a neighbourhood or municipality. The community hospitals throughout Metro Toronto's neighbourhoods are an example.
The moment another layer of administration is imposed on top of local health agencies, including hospitals--no matter how well-intentioned the effort--that is the moment that local people will begin to lose touch and confidence in those same facilities. They will lose confidence in their ability to control that local service.
Perhaps it is time to consider a different approach altogether. Perhaps it is time to re-think the role of District Health Councils. Do we really need 32 of them? Do all the members have to be appointed by the Government? DHCs must not be used as a shield, or buffer, between the Ministry and health-care providers.
If a regional decision-making model is desirable, then the Government might consider a different form of decentralization and regionalize the Ministry of Health--a model that creates openness and accountability for those in the Ministry of Health who are ultimately responsible to all of us--the health consumers, the taxpayers, and the electors of Ontario. This would bring services closer to customers. There might be significant savings to government as a consequence. There might be regional economic benefits, too. Of course, new mechanisms for consumer input would need to be found. But most of the other 20-odd ministries cope without DHC-type bodies.
Some in the District Health Council community will be quite upset by this idea. But remember, I founded a large number of Health Councils, including the Metropolitan Toronto District Health Council, when I was Minister of Health. I'm not anti-DHC-quite the contrary. One of the problems I see is that they are now seen as agents for and of the Ministry--even apologists at times. After 20 years, they still do not have a legislative mandate. That is, they still exist at the pleasure of the government and minister of the day. It seems to me the role of any planning body should be to give objective advice--including telling the Ministry when it's wrong, or when its directions are unclear or totally lacking. But for some reason it isn't happening enough to give confidence that the health needs of all parts of Ontario are being planned for appropriately.
Ladies and gentlemen, the great American poet Robert Frost spoke of the choices one makes on life's journey saying of the two roads that diverged in a yellow wood, that the one chosen "has made all the difference." We must be very careful on our health-care journey to ensure the road we choose makes the right difference. We must be careful to ensure we reform our system while preserving the best of what we have.
So this afternoon, I am making a number of appeals to my fellow travellers.
To hospitals I say you must lead in the reform process. I think hospitals have only 18 months or so to achieve major realignments given Ontario's and Canada's fiscal dilemma. Hospitals have the skills and the resources to make real change happen the right way. Open your institutions to the idea. Contemplate new roles. Contemplate new alliances and structures. Understand the urgency. But always be guardians of quality.
To health professionals and all health workers I say that the public has enormous confidence and faith in you. Respect that trust by making this transition work.
To the public I urge active involvement. Your expectations need to be known. And the limitations facing health-care delivery have to be understood.
Finally, I say to government, hospitals understand the job that has to be done. Now let them do it.
The appreciation of the meeting was expressed by John H. Tory, Partner, Tory Tory DesLauriers & Binnington and a Director, The Empire Club of Canada.