Healthcare Bureaucracy: Not a Myth

Taylor LougheedMarch 2, 2017 by | 11 comments

“The King’s cheese is half wasted in parings: But no matter, ’tis made of the people’s milk.” – Benjamin Franklin

I was a bit surprised to see that the Deputy Minister of Health in Ontario, Dr. Bob Bell, posted an article to the Huffington Post about healthcare bureaucracy.1 In these rather tumultuous times, wading into the debate on bloated system management is an interesting decision. I will admit that I was initially delighted to read from Dr. Bell that there have been concerted efforts to decrease areas of the healthcare bureaucracy at the Ministry over the past 10+ years. Indeed, in many ways these efforts do not ‘bust’ the myth that the bureaucracy is bloated as he suggests, but rather verify that much work had to (and arguably still has to) be done to create a leaner more responsive approach to healthcare management in Ontario. On further reading, however, I was extremely disappointed to learn that much of this ‘decrease’ was actually more of a repackaging or relabeling of existing bureaucracy. Divesting programs from the ministry and creating new organizations doesn’t mean that bureaucracy disappears, it just comes with a new name.

In fact, this narrow definition of bureaucracy that Dr. Bell proposes neglects to include multiple layers that exist throughout hospital administration, CHC management, CCAC programming, etc.
Take for example Bill 41 and the forthcoming ~80 subLHINs that will each have an executive to manage them.2 It is hard to imagine a sub-LHIN executive working in isolation, so we are left to wonder how many additional administrative staff will also need to be hired. This layer of extra bureaucracy is being added to an already bloated LHIN system with a questionable track-record. 3 4 5 Saying that the ministry has decreased its staff and is now a lean functioning healthcare manager is disingenuous with Bill 41’s proposed significant bloating effect and the doubling down on regional bureaucracy.

As an example of lean management, Dr. Bell specifically mentioned the integration of CCACs into their respective LHINs. The problem is that the CCACs have been widely recognized as bloated underperformers, and were highlighted as an area of inefficiency by the auditor general report from 2015.6 7 The finding that almost 40% of the CCAC budget was being used on administration was not a surprise to many front line physicians. The suggestion that shifting their responsibilties under the struggling LHINs, who themselves have been a regular target in auditor general reports, is deeply concerning. The LHINs were most recently called out in the 2016 report as being inefficient and having seemingly no major impact on improving health outcomes.8 9 Proposing that this marriage of two chronically inefficient healthcare bureaucracies will somehow reduce admin staff by 10% is both uncertain and likely inadequate given the overall ballooning effect of Bill 41. It is akin to trimming the nails on a progressively gangrenous limb – much, much more will need to be done if we have hope for our system to survive.

Another boondoggle that has not yet been mentioned is of course eHealth.

Smart Systems for Health Agency (SSHA), the predecessor to eHealth, started in 2003 with a mandate to create an integrated province-wide information system. Unfortunately (but not unexpectedly), an operational review in 2006 by Deloitte found significant shortcomings.10 11 A few key phrases from the report:

  • Governance: “SSHA does not have an overarching documented strategy that defines the organization’s development over the next 3-5 years, including its strategic goals and objectives.”
  • Management: “There has been insufficient coordination and collaboration across divisions, resulting in duplication of effort and uncoordinated initiatives.”
  • Compensation: “Actual compensation levels at SSHA are higher than expected largely due to undocumented compensation practices. Premium pay is offered for selected jobs, although the lack of a policy around this practice results in unrestricted premiums.”

This is sounding eerily similar to sections of the auditors report on the CCAC and LHINs.

The newest iteration, now eHealth Ontario, was meant to rebrand and leave behind the trail of inefficiency and poor stakeholder value at SSHA, but has been plagued with its own controversy and a string of negative auditor’s reports – the most recent questioning what has been achieved with over 8 billion dollars in eHealth spending over the last 14 years.12 13

These examples are unfortunately just the tip of the iceberg. While Dr. Bell is quick to point to some success stories  and promote a rather narrow view of how truly lean the MOHLTC is, there remains a tremendous amount of bureaucratic bloat and inefficiency that is not a myth. Healthcare management is an important piece of our system, but it has to promote and ensure adequate frontline patient care, not replace it. Changing names, and advertising that ineffectual management teams are being reduced, all while new ones are cropping up across the province, suggests instead that the myth isn’t that a bloated bureaucracy exists, but that government wants to contain it (or even can).

 

Photo credit: ~Boston Bill~ (of ceramic art by Beatrice Wood)

 

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Taylor Lougheed

About the Author

Taylor Lougheed is a physician in Family and Emergency Medicine, and passionate about sustainable public healthcare, quality improvement and patient safety, medical education, and global health.

  1. Busting the myth of bloated government bureaucracy
    (HuffPo – Bob Bell)
  2. Bill 41
  3. LHIN Failing Northerners (North Bay Nugget – Vic Fedeli)
  4. It’s Time To Eliminate Ontario’s Costly and Ineffective LHINs (HuffPo – Sohail Gandhi)
  5. LHIN has got to go (Northumberland Today – Valerie Macdonald)
  6. Auditor General’s report (PDF)
  7. Auditor wants thorough review of homecare services (TorStar – Donavan Vincent)
  8. Auditor General’s Report, 2016 (PDF)
  9. Time to Jettison Inefficient, Costly LHINs (Sudbury Star – Jim Merriam)
  10. http://www.ontla.on.ca/library/repository/mon/16000/269382.pdf
  11. Examining eHealth Ontario (CBC)
  12. Auditor’s Report (PDF)
  13. Highlights of the Auditor General’s Report (TorStar – Robert Benzie)

11 Comments

  1. Scott Kapoor

    Great article. Detailed, specific, and backed by evidence and facts.

  2. Bloated Health

    Spot on! This is even without all of the bloat in FHTs and hospitals.

    • Andrew S

      One of the worst meetings I have ever attended was at a FHT. I consider myself lucky to not have to attend hospital meetings.

  3. Andrew S

    Thank you for this great reply to Dr. Bell, Taylor. Your examples highlight that there IS bloat in our system and that there is a ton of room for improvement.

    • Taylor Lougheed
      Taylor Lougheed

      Thanks, as always, for taking the time to read and comment, Andrew S.

  4. miguel

    The first step to dealing with a problem is recognizing you have one. Bob Bell’s article comes across as dangerously delusional considering he is the deputy minister of health. If he and his team at the ministry truly believe there is no bloat, then they are too out of touch with the patient care system to make effective changes.

    • Taylor Lougheed
      Taylor Lougheed

      Thanks for your comment, miguel. I can’t imagine the current government is overly keen to follow-up their recent hydro mea culpa with one for healthcare.

  5. Karen

    A rebuttal that was actually very respectful is rare these days it seems. Thank you Taylor for adding to the debate without resorting to ad hominem attacks. It is clear that while there is some good work being done we can become leaner in our system.

    • Taylor Lougheed
      Taylor Lougheed

      Thanks for your comment, Karen. While there is certainly a lot of frustration, I have fortunately found the majority of those engaging in discussion and debate are very respectful.

      • Karen

        I agree with you Taylor. I have seen some very vocal people dismiss other opinions out of hand and appreciate that you did not do that here.

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