Ontario's Local Health System Integration Act
The Empire Club of Canada Addresses (Toronto, Canada), 24 Nov 2005, p. 160-171
Smitherman, The Hon. George, Speaker
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The objective of the desire to ensure that our medicare system is able to survive and to thrive for future generations. Current difficulties. Setting clear priorities. Some examples of success. The Local Health System Integration Act - some details and significant elements. The real question of what we will get for what we spend. A key test of public institutions. Changes to the CCACs. Directing dollars into patient care. Introducing accountability.
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24 Nov 2005
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The Hon. George Smitherman
Minister of Health and Long-Term Care, Province of Ontario
Ontario's Local Health System Integration Act
Chairman: William G. Whittaker
President, The Empire Club of Canada
Head Table Guests

Verity Craig, Managing Director, CV Management, and Director, The Empire Club of Canada; Madison Turner-Bob, Grade 12 Student, North Toronto Collegiate Institute; Reverend Dr. George Sumner, Wycliffe College; John A. Campion, Partner, Fasken Martineau DuMoulin LLP, and Past President, The Empire Club of Canada; Dr. Busha Taa, Member, Council of the College of Physicians and Surgeons of Ontario, President, Ethiopian Association of Toronto, and Member, African Canadian Social Development Council, Policy and Research Committee Board of Directors; Doris Grinspun, RN, MSN, PhD (Can.), OOnt, Executive Director, Registered Nurses' Association of Ontario; Carolyn Acker, Executive Director, Regent Park Community Health Centre; Jonathan Guss, CEO, Ontario Medical Association; Heather C. Devine, Associate in Litigation, Gowling Lafleur Henderson LLP, and Director, The Empire Club of Canada; Azmi Haq, Film; Heather Campbell, Director, Practice and Policy, College of Nurses of Ontario; Jan Kasperski, RN, MHSC,CHE, Executive Director and CEO, Ontario College of Family Physicians; and Kevin Dougherty, President, Sun Life Financial Canada.

Introduction by William Whittaker

Minister Smitherman is the second speaker in our luncheon series on the future of Canadian health care, sponsored by Sun Life Financial, a leading international financial-services corporation chartered in Canada in 1865. Dr Ruth Collins-Nakai, President of the Canadian Medical Association, spoke to us in early October and Alberta Minister of Health and Wellness Iris Evans will address us on Thursday, December 8. Invitations have been extended to others to participate in this series.

In his May 2004 health policy speech to a joint meeting of the Empire Club and the Canadian Club, Premier McGuinty stated succinctly that Ontarians support a universal publicly funded system of health care "anytime they are asked in a poll or at the polling booth." The debate for Ontarians, he said, is how to improve the delivery of publicly funded health care. This has been Mr. Smitherman's task for the past two years since being appointed Minister of Health and Long-Term Care when the Liberal government took office in October 2003.

One important aspect of Ontario's health policy being stressed by Minister Smitherman is individual health maintenance. A memorable quote of the minister's in his April, 2004 address to our club was that while medicare provides an excellent "sick care" system, Ontarians needed to take back their health through exercise, a healthy diet and not smoking. He noted that while the Liberal government's vision included community-based health-care professionals providing a continuum of health-care services tailored to a patient's needs, every citizen has a responsibility to adopt a healthy lifestyle. The newly established Ministry of Health Promotion is to assist Ontarians in this regard.

In his two years as Ontario health minister, Mr. Smitherman has embarked on ambitious reforms to Ontario's health-care delivery system, some of which he will discuss today. Health-care reform is not an easy task and the minister has stepped on a few toes. But Mr. Minister, take heart--difficulties and turmoil in bringing change to Ontario's health-care system are not unique to your watch! Toronto Star columnist Ian Urquhart, in a November 2004 article, asked three of your predecessors why it is so difficult to reform Ontario's health-care system.

Tony Clement, Progressive Conservative health minister from 2001 to 2003, commented: "You have the most sophisticated stakeholders in government," referring to doctors, hospitals and pharmaceutical firms. "They know which buttons to push. They know how to get media attention. They know how to make it hurt."

Frances Lankin, NDP health minister from 1991 to 1993 agreed with Mr. Clement's analysis. She recalled that when she tried to delist psychotherapy from OHIP coverage, she stirred up a hornet's nest. In the end, the NDP government capped the number of psychotherapy hours that OHIP would pay for any individual. But the psychotherapists just saw more patients Lankin said and the savings were minimal.

Murray Elston, Liberal health minister from 1985 to 1987, said that while change is the norm in health care, the constant change in day-to-day practices and procedures tends to make doctors and hospital boards even more resistant to suggestions for institutional changes flowing from government. Elston said: "The easiest way to cope with the change being thrown at you is to slow it down."

Minister Smitherman was elected to the Ontario legislature as MPP for Toronto Centre--Rosedale in 1999. Prior to becoming an MPP, Mr. Smitherman served as Chief of Staff to Mayor Barbara Hall and as an advisor to federal ministers David Collenette and Herb Gray. He is a rare breed of politician having significant experience at all three levels of government.

Please join me in welcoming the Honourable George Smitherman, Minister of Health and Long-Term Care for the Province of Ontario to our podium today.

George Smitherman

I want to thank Bill for that very, very kind introduction. I enjoy the privilege of being back at the club again. I have taken to saying quite often that in this line of work I'm pretty happy to get invited back just about anywhere.

I am delighted that David Collenette was acknowledged. One of the things that I'm proud to acknowledge is that he's one of those politicians who taught me a lot and gave me an opportunity for success in politics. I'm delighted to call him a friend and I'm very honoured that he's here today.

I want to acknowledge as well the attendance here today of my colleague from the legislature Kevin Flynn, the very fine member from Oakville, and I want to acknowledge Elizabeth Witmer, a predecessor of mine in the role of minister of health.

It is truly for me a privilege to be here and I'm delighted to see so many people who have such a crucial role to play in helping to build a stronger health-care system in our province. The objective, which has been driving our government's health-care agenda over the past two years, can be summed up as the desire to ensure that our medicare system, the one that we all cherish, is able to survive and to thrive for future generations. I've always bristled when some critics have complained that our health-care system is broken. It's not broken. But that doesn't mean that it is not in need of some improvements and some changes.

The health-care system that our government inherited two years ago was struggling with some serious difficulties. There was a lack of planning and organization. Services were delivered in an unco-ordinated way. There was too little communication between hospitals, long-term care homes, mental health agencies and other providers. We didn't do well enough at sharing information or best practices and we didn't always look for ways to work together. In fact I've often wondered if our so-called health-care system really was a system at all, not to mention that the projected cost curve threatened medicare's very sustainability. Reform was overdue.

In order to undertake a job this big we set some very clear priorities--reduced wait times, improved access to doctors and to nurses and making Ontarians healthier. And I'm proud to say that over the past two years bold steps to reform the system and to bring Ontarians closer to these three goals have been taken. Let me give you some examples.

Together we passed the toughest anti-tobacco package in North America. Our premier created the Ministry of Health promotion to make Ontarians healthier and to give them the tools, the inspiration and the help to succeed. We launched "Operation Health Protection" to revitalize our often ignored but crucially important public-health system. We are improving access to doctors and nurses with the creation of family health teams, 39 new community health centres and investments to increase the overall number of doctors and nurses in this province. We are increasing medical school enrolment by 15 per cent and the number of family residency positions by 70 per cent and we're training more international medical graduates than ever before. We are also working to increase the number of nurses in the province and to make their jobs safer and more satisfying and we've already created 3,062 new jobs. We have funded 250,000 more procedures to reduce wait times in five key areas. We've launched a Web site providing Ontarians with wait times data broken down by procedure, by hospital, and by community. We have made commitments to build Ontario's capacity to be a leader in new-born screening. We've created a province-wide vision for end-of-life care. And this is just part of the list.

Because the people of Ontario deserve to know what they're getting for their money, we created the Ontario Health Quality Council. It's independent and it will help tell the complex health-care story in plain language. Together we have made some remarkable progress, but the challenge is continuous quality improvement and our government accepts this challenge. I'm proud to say that just hours from now I will rise in the Ontario legislature to move us one giant step forward along this road of continuous quality improvement, our single most significant step yet, and that's what I'd like to talk about this afternoon.

Ladies and gentlemen, I will be introducing a piece of legislation which if passed will bring about the most significant, the most far-reaching and the most enduring reform of all. I'm speaking about the Local Health System Integration Act. It's a complex bill, but the values it rests on are clear. It was written to reflect our commitment to equity, to community, and to returning our health-care system to the people. With some luck this legislation will ignite what could well be a spirited debate and it might be called a lot of things by a lot of people. Everything from magic panacea to devil incarnate. Neither will be accurate but there can be no doubt that the reforms initiated by this bill are long overdue and that the weeks ahead will be crucial if we are to be successful in giving real life and real meaning to the word "system." And to those who oppose it as a reflex, I say that the status quo is not getting the job done. The status quo is not what our government is about.

The most significant element of this bill is the power we are giving to local health integration networks known as LHINs. If you want to know what we are trying to achieve with LHINs, the answer is straightforward. We are addressing the very heart of the matter. Here in Ontario we often use the term health-care system, but the truth is it ain't really much of a system.

When I first took over this job there was a big map of Ontario hanging on the wall in my office. In the middle of Toronto was a big red dot labelled Ministry of Health and all around it throughout the province were smaller dots representing hospitals and other health-care entities. Literally hundreds and hundreds of them and practically the only thing uniting them was their relationship to my corner office at Queen's Park.

If I can speak frankly about Queen's Park for a moment, the folks there are so preoccupied with the harsh grind of the day to day that the longer-term vision and planning work struggles for attention. That's no system. And when you don't have a system you are failing the fundamental test of any publicly delivered service. That's equity. We are failing the test of equity when the wait time for an MRI can range anywhere from three to 50 weeks depending on where you are in Ontario. Where's the equity when some hospitals want to charge the ministry $450 and others $2,000 to perform the exact same cataract surgery. That's no system. And surprising as this may sound, when we took office Ontario's so-called health-care system could not even measure how many cancer surgeries were being performed any given year.

So we set out to build a true system and we proceeded on a very simple premise. It is this. In an environment where we all agree that there will be fewer resources than we might prefer, it's just common sense that we ask people from local communities closer to the action to help to determine which local priorities must be supported first. That's what local health integration networks will do.

Let me tell you more about what local health integration networks are, how we propose they will work, what they will do and what they won't. The name itself provides some insight. Local health integration networks.

First and foremost they are local. Located in 14 communities across this province, their mandate is to serve those communities, to identify the priorities and the needs of the people who live there and to respond to them in the most effective way possible. We are taking real decision making and spending power, $20 billion of it, and putting it into the hands of local people. Local health integration networks will have the power to make decisions about planning and integration of local health services. They will work with their communities to determine where money is spent, whether certain services should be strengthened or perhaps consolidated and how to improve patient care. Not only will local health integration networks be locally based they will also have a duty. In fact they will have an obligation to engage their communities in a discussion about these issues.

For far too long the debate about health care has deliberately shut out the vast majority of Ontarians. It shut them out because it was conducted in mind-numbing technical language and impossibly obscure acronyms, some of which I still struggle to pronounce even if I can remember them. We want to give health care back to the people. After all it belongs to them. It belongs to the people who pay for it.

This legislation makes it very clear that decisions made by local health integration networks must be made on the basis of public interest and must be made in full public view. We must no longer pretend that a head office can sensibly maintain relationships with thousands of health-care providers and still hear the voices of communities and patients. Head office can't but LHINs can. They can and they will. I know that because they are already doing it. Each or at least many of the inaugural LHIN CEOs and board chairs are here today and each one of them can tell powerful stories about a system awakening to its own potential. Decisions they make will reflect the advice they receive and will acknowledge the community that they experience. So our choice of the word "local" was very deliberate. When we say local we mean local.

The second word is "health" because that and that alone is what LHINs are all about--the health of Ontario's patients. Their crucial objective is to improve and strengthen patient care in their communities, and we're proposing to give them the power to do this. Specifically LHINs are expected to have responsibility over hospitals, community-care access centres, mental health and addiction agencies, long-term care homes, community health centres and community support service organizations. The Ministry of Health will be better able to focus our energies on our crucial strategic mission while initially retaining responsibility for ambulance services, for laboratories, for provincial drug programs, independent health facilities and for public health. Doctors do not come under the umbrella of this legislation because we believe that physician services are a large provincial program that requires provincial standards and management.

The third word is "integration" and I predict that this is where some people will try to create mischief and spread misinformation, the same people who blindly defend the status quo. So let me tell you what integration means. It means positioning Ontario to take advantage of advances in technology.

And for this I tell a simple story. In Ontario we deliver hip and knee surgery in more than 50 hospitals, closer to 55, and all I ask is that in an environment where technology very often enables us to take big leaps forward, where the surgery can become as an example less invasive, if we have a platform that is that broad does anyone really believe that we will be able to take advantage of all that technology has to offer? Here in the province of Ontario as a result of our wait-times strategy, we have basically purchased every hour, every minute of surgeons' times. That is based on the way that surgeons work now in our province. In Ontario orthopedic surgeons spend 35 per cent of their time in operating rooms. In the United States it is 65 per cent of the time. We have the potential in our province to lead the way across the country and to show people the way, the new way of doing things.

Some people will pretend that this is an exercise in cutting costs. But the reality is that health-care spending in this province will continue to grow and we all know it. The real question is not will spending grow, but what will we get for it. This is an exercise in empowerment--empowering patients, empowering communities, empowering them to identify and to address gaps in health care. LHINs will be able to make the necessary changes consistent with their understanding of and connection to the local community and to the needs of Ontario's patients.

The final word is "network." Local health integration networks will truly function as networks, sharing information within their areas and with one another. For the first time, we will have networks in place that will allow us to build a true system. Instead of being an empty phrase, the term health-care system will have actual meaning. That means that when good practices emerge in one part of the province we will now have a platform to spread that best practice province-wide and the big winners of course will be our patients. That's what I call the system helping the system.

As I said earlier, one of the key tests of public institutions is equity. The legislation that we are introducing will be a profound step in this direction as we return one of the public's most precious assets to them. After all it belongs to them. They are the ones who pay for it and deserve a much better chance of exerting influence over it.

I had an example of this in spades. I was very recently in Bramalea, part of the great city of Brampton, to talk about our local health integration networks. On that day I was approached by two women, one of whom works for Hospice Peel and one of whom works for Hospice Dufferin. These are places on either side of a political line drawn on a map, but for eight long years those two organizations have sought to get help from the Ministry of Health to make a $22,000 adjustment, an equity adjustment, in the way that their budgets have been determined. When they came and approached me I immediately took them to Joe McReynolds and told them that this was the man that we had asked to be the chair of the local health integration network in their area. I have an awful lot of confidence that a guy with community roots like Joe McReynolds will be able to resolve the situation that for eight years has been a real problem for Hospice Peel and for Hospice Dufferin. This is why we have to take health care more to the people.

The Local Health System Integration Act is about more than local health integration networks. As the name suggests, it is about system integration and another part of this integration is community-care access centres. Community-care access centres or CCACs are a crucial part of our health-care system but there is room for improvement. Under our proposed changes there will be no disruption in the crucial relationship between case managers and clients and all existing CCAC storefronts and offices, all 209 of them spread across this vast province, will remain in place, but in order to provide more efficient and more effective service this bill will enable us to reduce the number of CCACs from 42 to 14 in order to align with local health integration network boundaries. CCACs are aware of this proposed alignment and in fact many of them have advised us to do it because this alignment makes sense. It will create a system positioned to provide improved and equitable access for all CCAC clients and contribute to improved efficiencies.

We are also introducing changes to allow CCACs to select their own members and executive directors. By taking this step we will be returning CCACs to the communities that they serve, reversing a move by the previous administration to steal CCACs away from their communities. Finally this bill will allow us to broaden the mandate of CCACs. We'd like to see or examine how more clients might use CCACs as their first point of contact for a range of community services because they are ideally positioned for this role as system navigators. CCACs are an important and an effective part of our health-care delivery system. We want to make them even stronger still.

Let me take a moment to highlight one more important component of the legislation that we are introducing, that dealing with back-office integration. I think all fair-minded people recognize that there is room for greater integration in our health-care system. But hospitals sharing a single payroll system rather than replicating it hundreds of times just makes sense. In an era of scarce resources I believe that we have an obligation to direct every possible dollar into patient care and if we can realize more resources for patient care by say integrating back office functions, I think that's the right thing to do. In fact I think that's long overdue. This bill gives LHINs the power to do that and the procedures we're proposing are familiar to and respected by labour.

Roy Romanow, someone whose understanding of health care and whose ideas on improving health care have enormous resonance with me, once said that the Canada Health Act which enshrines in law our nation's commitment to medicare is missing a sixth principle, namely accountability. That's precisely what we want to introduce.

Our commitment to medicare is deep and it is unshakeable. I've always said that medicare is the best expression of Canadian values. I want to help build on Canada's distinguished and historic commitment to medicare, not because this is an abstract political goal or because it is some kind of legacy project, but because medicare is the most profound way in which government performs its most sacred task--serving its people. It saddens me how often the people most affected by political decisions are overlooked and even ignored as those decisions are being made. That is not my style of politics. That's not the promise I made to the people of my riding, the people who elected me, the people who taught me the meaning and the power of community.

My friends, I will be holding my head high an hour or 30 minutes or so from now when I table the Local Health System Integration Act on the floor of the Ontario legislature because I'm extremely proud of the legislation we are introducing and because I am absolutely certain that it's the right thing to do. And I offer this piece of legislation in the profound hope that my friend Stephen's first granddaughter born yesterday at Markham Stouffville Hospital might enjoy a long and healthy life and the familiar embrace of medicare.

Thank you very much.

The appreciation of the meeting was expressed by Heather C. Devine, Associate in Litigation, Gowling Lafleur Henderson LLP, and Director, The Empire Club of Canada.

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Ontario's Local Health System Integration Act

The objective of the desire to ensure that our medicare system is able to survive and to thrive for future generations. Current difficulties. Setting clear priorities. Some examples of success. The Local Health System Integration Act - some details and significant elements. The real question of what we will get for what we spend. A key test of public institutions. Changes to the CCACs. Directing dollars into patient care. Introducing accountability.