LHINs: Drivers of a More Equitable and Responsive Health System?

Bob GardnerDirector of Public Policy

Presentation of Family Service Association BoardNovember 21, 2007

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Local Health Integration Networks: Background

• LHINs were seen to be a key part of the overall provincial ‘transformation agenda’ unveiled in the fall of 2004 with:– primary care reform– family health teams and different practice models– waiting lists– electronic health

• Ontario is the last province to develop regional health authorities:– uneven and fraught history in other jurisdictions– but fairly clear evidence of potential of regional planning

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LHINs: Rationale

• basic idea is that the incredibly complex health care system can best be planned and coordinated regionally rather than centrally

• that RHAs are key mechanisms in supporting/forcing better linkages among hospitals, clinics, CHCs, docs and other providers

• 14 LHINs will control the envelope of funds for regions and will be trying to create more integrated organization and delivery of health care – have broad powers iii including to force integration of services and

providers• what’s in:

– hospitals, clinics, CHCs, CCACs (Community Care Access Centres),LTC facilities,

– many community service providers (or rather, many services provided by community organizations = part of complex funding picture forcommunity organizations

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But

• what’s not in -- some vital elements of the system are not within the LHINs mandate:– physicians– public health– Independent Health Facilities– pharmaceuticals and provincial drugs programmes like ODB and

Trillium• the LHINs will operate within an overall provincial strategy –– and

broad direction from the Ministry– the strategy is yet to be developed – nor is it clear how ‘stewardship’ relationship between Ministry and

LHINs will actually unfold • unlike other provinces, Ontario has left independent governance of

hospitals and other providers

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Realizing Potential

• goals of integrated planning and care have a lot of potential, but only if the LHINs– really are driven by community needs and priorities– develop effective and responsive governance and community

engagement that reflect the full diversity of communities and needs

– build on existing networks of providers and community organizations – very rich in Toronto

– foster innovation and then scale up what works across the system

– create a system that prioritizes equitable access and breaks down barriers -- in context of a diverse and unequal society

– provides a seamless continuum of care for all

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Uncertain Starts

• working groups of providers, community representatives and otherstakeholders developed initial priorities in late 04, reporting in February 2005 in all 14 areas

– extensive community involvement in Toronto – emphasized equity, diversity and wider social determinants

• slow to begin – as Boards and CEOs chosen though spring and summer of 05– no community input and not very diverse/representative– some initial consultations through summer and fall – fuller management teams by late 05

• significant concerns in early community reaction:– uncertainty -- esp over future of smaller community-based service providers –

would this be restructuring under another name?– boundaries – e.g. 5 in GTA, four are mixed urban and rural– would LHINs increase private provision of care as CCACs had done? → led to

consistent opposition from union movement and Ontario Health Coalition– would they really be representative and accountable to local communities?

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Then a Good First Year with Fuller Resources

• all the LHINs undertook extensive community consultations in late 2005 early 20067:– varied a great deal LHIN to LHIN– but far more comprehensive and intensive than ever before– 6,000 + people and 200 organizations participated in Toronto

Central LHIN consultations• LHINs undertook research to understand their local

environment:– population health needs– surveying existing local networks and coordinating bodies

• produced their first Integrated Health Service Plans in the fall of 2006 – 3 year strategic plans, to be refreshed annually

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Current and Coming Developments

• creating coordinating and planning structures to implement the IHSPs

• funding is flowing through the LHINs in fiscal 07-08 – extensive discussions are underway on funding frameworks– actual flow of $ is being phased– 18 hospitals this year, some 180 CHCs and others next fiscal

• a critical part of implementation and funding will be setting upservice accountability agreements with providers

• still concerns from community-orientated sectors:– forced integration– will community continue to have a voice– will there be enough $– is diversity and equity well enough recognized

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Toronto Central LHIN

• IHSP identified major integrated care priorities – mental health, seniors, rehabilitation – and building solid foundations – human resources, e health, back office integration

• fundamental planning assumption was to recognize the importance of broader social determinants of health

• built complicated system of advisory councils • it highlighted other unique features of Toronto’s population:

– incredible diversity– pervasive social and economic inequality– concentrations of specific needs – such as homeless, people with HIV,

people with mental health challenges– but also concentrations of research, specialized expertise, major

hospitals and other institutions, community-based providers, and dense networks and collaborations to build on

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Moving Forward: Challenges and Opportunities

• will illustrate a number of challenges currently facing LHINs and health care system or on the immediate horizon

• for five challenges will highlight:– nature of issue– implications for progressive equity-driven care– possible policy solutions or directions

• all in context of Toronto:– crucial to recognize problems and challenges that are unique to

or much more concentrated in major cities

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System Change

• enormous challenges:– shifting funding and management of huge institutions and amounts of

money, let alone myriad of smaller providers – in context of extensive reform of incredibly complex overall system– attempting to steer this transition to more integrated and coordinated

state– using array of funding, policy and regulatory levers and incentives to

allocate resources and link up services more effectively• and if that’s not enough – want the shift the system to totally

different way of delivering care and organizing itself:– more equitable– person centred high quality– responsive to diverse and changing community needs and perspectives

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Challenge I: Health Care in a Diverse Society

• challenges:– ensuring equitable access to services– culturally competent care– providers’ capacities – translation, language, quality– governance that represents and reflects diverse communities– health human resources that builds in diversity

• directions:– recognize diversity as a central goal of LHINs– cascading expectations = specific expectations and incentives could be

built into funding arrangements with LHINs, and then between theLHINs and individual service providers, to ensure service use reflect the diversity of the local population and provide equitable access to all

– specific diversity planning tools and resources need to be created– funding to support enhanced capacity of providers to deliver services in

more languages

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Challenges II: Equity

• diversity as one crucial part of a bigger goal• pervasive disparities in health

– both health outcomes and access to services– along various lines -- income, neighbourhood, education,

gender, race, ethno-cultural background• need broader strategy for health equity:

– reducing disparities– creating equal health opportunities for all– priority for TC LHIN– significant focus at provincial level

• start by understanding roots of inequitable health → to guide policy and investment

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Roots of Disparities Lie in Social Determinants of Health

• clear research consensus that roots of health disparities lie in broader social and economic inequality and exclusion

• impact of key determinants such as early childhood development, education, employment, working conditions, income distribution, racism, social exclusion, housing and deteriorating social safety nets on health outcomes is well established

• real problem is differential access to these determinants – many analysts are focusing more specifically on social determinants of health disparities

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Act on Equity Within the Health System

• evidence shows that health care system has less impact on healththan broader social and economic factors

• this doesn’t mean that how the health system is organized and how services and care are delivered are not crucial to tackling health disparities

• directions include:– reducing barriers to equitable access – targeted interventions to improve the health of the poorest fastest –

generally as part of community/local initiatives – primary care as a key enabler of health equity– enhanced community participation and engagement in health care

planning– more emphasis on health promotion, chronic care and preventive

programmes

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Example: Non-Insured

• significant number of people – concentrated in most vulnerable sectors of society –do not have health cards:

– particularly concentrated in larger cities – has a serious adverse impact on the health of disadvantaged groups– Street Health report

• solutions:– CHCs developed funding mechanisms to ensure clients across the city would be served;– some hospitals began moving to create models that will ensure access for non-insured

people, but these efforts have inevitably been local and disjointed, and the results fragmented and inconsistent

• this is a prime example where coordinated policy is going to be far more effective than each institution trying to deal with the issue on their own

– a number of Toronto area hospitals have established a collaboration to look at this issue –would this have happened without context of LHINs?

• an effective policy instrument could be creating a funding pool in appropriate LHINs that can be drawn upon by institutions providing services to the non-insured

– prov leads → the required funds would be concentrated in Toronto, less so in other cities, and likely very little in other parts of the province

– or LHINs act on their own

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Levers for LHINs

• funding and resource allocation are key levers for LHINs – so could:– fund providers that concentrate services in most disadvantaged areas– locate new services in most disadvantaged neighbourhoods– prioritize services that will have the most equitable impact – increased

primary care– pay careful attention to community input and needs in allocation

• ensuring community and consumer-driven standards get built into performance agreements with providers:– how can you operationalize equity – what indicators and expectations

on providers?– what are good standards of culturally competent care?– what would a continuum of care look like from consumer’s point of

view?– what does good care in hospitals or long-term care facilities look like?

• Toronto Central LHIN is requiring hospitals to submit health equity plans

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Plan with Social Determinants In Mind

• LHINs will need to develop collaborative and planning processes beyond health care if they are to really address broader social determinants of health:

– some of this will be quite practical planning – all LHINs are going to need to include public health in their planning

– the value of cross-sectoral planning tables was demonstrated with SARS, and intensive coordination and joint planning is proving vital to pandemic flu preparation

– idea: all LHINs to establish cross-sectoral planning tables to ensure health care planning is coordinated with education, social services, housing, transportation and other policy and programme spheres that shape health and health equity

• encourage innovations in programming that build in SDoH – like CHCs – who link clients into non-health support – locate social services in same buildings

• to make this real → need to build into cascading expectations:– the Province would also need to recognize the costs of such coordination in its

funding arrangements;– a workable mechanism is to build incentives and requirements for necessary

cross-LHIN coordination into the funding arrangements;

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Challenge III: Unique Challenges of Big City

• GTA CHCs have developed urban health framework– highlights both unique challenges – depths and concentrations of

disadvantage – and strengths – dense provider and expert networks, concentration of research and teaching

– sets out planning tool– and tested this tool on developing integrated community-based

diabetes care and support

• more concretely -- how to coordinate across LHINs– particular challenge in Toronto with 5 LHINs → need cross GTA

planning table

• Toronto Central gets huge numbers coming in for surgery or specialized treatment in Toronto

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Challenge IV: Building In Community Engagement

• the complexities of health needs, resources and networks means that community engagement for consultation, planning and priority setting purposes will necessarily need to be more intensive:

– how to create structures and processes that will embed significant community participation in planning, budget development and priority setting from now on?

– how to make boards and other planning bodies more representative?– so there is real consumer and local input to the inevitable trade-offs and complex

priority setting to come• one lever or incentive could be to:

– require significant community participation in planning in funding agreements btwn MOHLTC & LHINs

– dedicated lines in each LHIN budget to support engagement & participation, and in the funding arrangements with individual providers who are expected to engage with their communities;

– with incentives & requirements for certain standards of participation;– these kinds of arrangements would need to apply to all LHINs, but, at the same

time, the particular challenges and dynamics of community engagement in major cities could be specifically recognized

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Challenge V: Supporting Community-Based Innovation

• experience and evidence from many jurisdictions = supporting front-line and community-based innovation is key element of progressive health reform

• but community-based providers especially have little resources slack to develop the innovation and collaborations they would like –

– CHC innovations with key implications for equity and quality -- the inter-CHC referral system and co-locations of services -- are not explicitly funded;

• levers:– to make such innovation happen, the Province would need to build incentives

and resources into funding arrangements with the LHINs;– there could also be dedicated funding lines for pilot projects to address social

determinants in practice – e.g. better collaboration between health and non-health providers, housing, employment training & other referrals as integral components of health care programming, expanded child & respite care on site in various health care settings;

– dedicated funds for providers or networks to do community-based research, needs assessments, programme evaluations, etc.

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Sustaining and Building on Community-Based Innovation

• critical to addressing health disparities and improving local planning will be experimenting and relying on local community-based and other front-line innovations

• to realize this potential, senior governments need to develop a framework to support experimentation and innovation:

– common data and information platforms– funding for pilot projects – available to CHCs, different practice models and community-

based providers– dedicated funding lines to LHINs for pilots, and expectations that each LHIN will undertake

innovations– looking for results and value, but also need funding regimes that are flexible and not too

bureaucratic• then need a provincial or national infrastructure to:

– systematically trawl for and identify interesting local innovations and experiments– evaluate and assess potential beyond the local circumstances– share info widely on lessons learned– scale up or implement widely where appropriate

• all to create a permanent cycle and culture of front-line driven innovation on equity

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Dangers

• have set out pre-conditions for realizing progressive potential of LHINs

• additional problems could be:– over-burden on community agencies -- financial reporting,

performance management– still medical model and dominance by professionals and big

institutions– paying only lip-service to equity and diversity– not shifting resources:

• from hospitals to community providers• up-stream from acute care to preventive and health promotion

– increasing private for-profit provision → inequitable impact

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Possible Implications for FSA

• small but important part of your budget → how much effort to put into LHINs?

• your long history of progressive service delivery:– focussing on most disadvantaged communities→ position yourself as champion of equity

• you work within social determinants of health perspective→ position yourself as leader in concrete practice– lead community drive for cross-sectoral planning beyond health care

• like many service providers, extend beyond boundaries of TC LHIN→ demand cross-GTA coordination– community can create its own forums if LHINs don't

• also long community experience and connections → position as principled/pragmatic leader on community engagement