Established by authority of the Ontario Legislature in April 1996 the Health Services Restructuring Commission is a stand-alone corporation, with a four year mandate, operating at arms-length from the Government of Ontario.
The Commission has the authority to restructure hospitals in Ontario. In addition to directing hospital restructuring, the Commission makes recommendations to the Minister of Health on restructuring other elements of the health services system.
The Commission's recommendations include advice concerning funding needed both to restructure hospitals and to enhance other health care services to meet the goal of developing an integrated health services system.
The following statement of the vision, desirable characteristics and overall structure of Ontario’s health services system is a preliminary one. It constitutes a working hypothesis that the Health Services Restructuring Commission will use as the basis for further development of a policy framework and for recommendations on the steps and strategies required to proceed from vision to actual system-building.
This document is also intended to stimulate public discussion and elicit suggestions to help the Commission refine our vision of a system of health services that will meet the needs of Ontario into the 21st Century.
Although most of the necessary elements are in place, Ontario does not have a health services system in the ordinary sense of the word. Rather, we have a collection of disparate parts with isolated management structures, separate budgets, and little coordination.
In our search for answers to these and related questions, the Commission has developed a vision of a system of health services for Ontario (Figure 1).
Figure 1: Vision of Ontario’s Health Services System
Our vision is of a publicly administered health services system that provides universally available, comprehensive, accessible and portable services that meet or exceed internationally-derived performance benchmarks. A provincial system organized to foster diversity among its elements and decision-making by the people affected, it is constituted of sectors1 that together provide the full spectrum of health services needed to promote health and provide health care for Ontario's population. We see a health services system in which regions, the sectors and their component institutions and organizations are distinctive, but committed to purposes in common. The contributions of each region, sector, institution, and organization are integrated, and complement those of all others to meet the provincially set policies, goals, objectives, and priorities necessary to achieve Ontario's vision of health.2 |
1 Long term care sector, home care sector, primary care sector, hospital sector, etc.
2 The following Vision of Health was developed by the Ontario Premier's Council on Health Strategy and adopted in the Provincial Legislature in the Spring of 1989: We see an Ontario in which people live longer in good health, and disease and disability are progresively reduced. We see people empowered to realize their full health potential through a safe, non-violent environment, adequate income, housing, food and education, and a valued role to play in family, work, and the community. We see people having equitable access to affordable and appropriate health care regardless of geography, income, age, gender, or cultural background. Finally we see everyone working together to achieve better health for all.
The Health Services Restructuring Commission believes the following are essential characteristics of a genuinely integrated system of health and health care services in Ontario.
| Common vision – All sectors and every constituent institution and organization share a common vision. | Shared goals, priorities and performance standards – Sectors have shared goals, priorities and performance standards to optimize accessibility and quality of service. | Backdrop of provincial legislation, policy and standards – Policies and plans are set by the Ministry of Health, and adjusted periodically in response to ongoing evaluation of how well the system is achieving the government’s goals and objectives. |
| Focus on population health – The system’s focus includes population health as well as individual health. | Balance between health care and population health – The emphasis and resource allocation between the long-term goal of enhancing the population’s health, and the immediate imperatives of diagnosing and treating illness are balanced over time. | Common information system – A shared information system provides comprehensive, up-to-date and accurate data and information to plan, co-ordinate and operate the integrated health services system. |
| Vertical and horizontal integration – The diverse institutions and organizations that offer the same type of services are organized horizontally into sectors. These sectors are vertically integrated so they operate together within each region. |
Diversity in developing strategic alliances that support greater integration and efficiencies – The system fosters local, district, and regional initiative and diversity, and achieves horizontal and vertical co-ordination among institutions, organizations and sectors. | Shared accountability –Fiscal envelopes and purchaser-provider concepts (among others) are used to achieve specific objectives and safeguard particular services such as mental health and children’s services. |
| Incentives – Incentives are created and disincentives removed to encourage providers and consumers to make and keep people well. | Leadership – Professionals and others provide strong leadership and commitment to meet current and evolving health care needs. |
Capitation funding – Envelope funding allows organizations to meet the total health needs of a defined, rostered population, and operate within the financial limits of individuals, the public purse and the provincial economy. |
The Commission’s vision is one that requires a dramatic change in the concept of a health services system, from one akin to the Ptolemaic view of the solar system, with the hospital at the centre, to a Copernican model, in which the system revolves around the users (Figure 2).3
3 Adopted, with permission, from a presentation given by Roger S. Hunt, President and CEO, Greater Rochester Health System, to the Annual Fellows Dinner of the Canadian College of Health Service Executives, November 4, 1996.
Figure 2
| Current Model |
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Building on the core characteristics, the restructured health system will link the hundreds of autonomous organizations, agencies and providers into an integrated, interactive and dynamic system. This system will shift the focus from the present hospital-centred health system to one that focuses on the health needs of rostered populations (Figure 3).
Figure 3
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The roles and responsibilities of each of the key players in a restructured integrated delivery system will be as follows:
The provincial government will assume responsibility and accountability for:
Responsibility and accountability for operational decision-making, program/service delivery, and performance outcomes will rest with regionally-oriented integrated health systems (IHSs) and regional integrated academic health systems (IAHSs). These integrated systems will:
The Commission is not specifying particular models of ownership or governance for IHSs and IAHSs (i.e., decision-making structures). Rather, the Commission believes that:
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Partnership Governance = provider partnership + community representation Central management = resource distribution to partners + common information systems + accountability for reporting outcomes |
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What the Commission will do now is debate the policy framework necessary to create an integrated, co-ordinated health services system. We will begin with the recommendations of the Policy Group on Health Reform4 that address the following issues and principles:
1. Role of government: funding, consultation, standard-setting, ultimate accountability.
2. Integrated delivery systems: incorporating health professionals in organizations that cover the entire spectrum of health care services.
3. Health care funding: envelopes based on capitation, rostering and risk-sharing.
4. Primary care reform: co-ordination of first-line services by primary care organizations serving rostered populations.
5. Physician compensation: alignment of incentives with policy goals that include evidence for effective and efficient care.
6. Health information: development of a comprehensive population-based data system to support system planning and management.
7. Accountability: explicit contracts and, in large urban areas, structured competition among integrated delivery systems.
8. Health care report cards and public information: on the costs, quality and outcomes of health care – locally, regionally, provincially and nationally.
9. Private sector role: private-public partnerships.
The Commission invites comments on this initial statement of our vision of Ontario’s future health system. The feedback received will be used to refine the vision statement and further develop the concepts put forward in this document.
4 Policy Statement on Canada's Health Care System. 1996. Policy Group on Health Reform. Insight Information Inc., 1700-55 University Ave., Toronto, Ontario M5J 2V6.
| Health Services Restructuring Commission Members |
Mark Rochon, Chief Executive Officer
David Naylor, Special Adviser