Chapter 5: Responsibility and accountability in health care

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Chapter 5: Responsibility and accountability in health care

The final factor contributing to hallway health care is the lack of integration throughout the provision of health care services in Ontario. There are barriers to true integration across different care settings in the province. For example, Ontario’s current health care system can be characterized as decentralized, large, and siloed, and it can be difficult at times to know who is responsible and accountable for ensuring Ontarians have access to high-value health care.

"There is such a gap in the transitions of care…the interest is not on the patient, but on each individual health service provider’s own unique budget and strategic objectives. Why does each agency have their own administration as opposed to a truly regional or provincial coordinated system?"

– Patient Survey Response

This is in part due to the size of the system. There are currently 21 health-related government agencies supporting the design and delivery of health care in Ontario. Many of these agencies were created to tackle specific problems, support research, or to establish quality standards and metrics to help the system as it matured. However, these agencies are not always well-aligned and there is limited strategic oversight to ensure the efficient and coordinated use of resources.

In addition to being over-sized, the system is also decentralized. Of the $54.6B in provincial health care expenditures, the majority of this funding is allocated by the Ministry of Health and Long-Term Care to transfer payment recipients.^{footnote 41[41]} Similar to other systems across the country, Ontario’s Ministry does not directly provide health care – it pays other people to deliver services to clients. However, the financial incentives and funding models used to pay health care providers to coordinate and deliver services need to be appropriately aligned, otherwise the system won’t work the way it needs to.

Decentralization can also contribute to duplication in processes and procedures, which can slow down access to health care services. One example of duplication in the health care system is in the assessment process. Approximately 11% of time spent on care coordination is used to conduct assessments and re-assessments for community and home care services.^{footnote 42[42]} Assessments are also done by service providers and hospitals, while primary care providers often have detailed and up-to-date patient records that could be used to inform care planning and delivery, and prevent patients from having to repeat their stories.

"The staff have all been kind and professional…the negative issue would be the constant need to provide basic information like address, date of birth, medications, family doctor, allergies, and more. It is very frustrating for a senior to be asked the same questions."

– Patient Survey Response

In addition to barriers to information sharing, some of the unnecessary duplication in the assessment process is driven by the separation between the coordinator role and front-line care. These kinds of system-design issues have a real impact on patients, since it is not always clear which service provider is responsible for delivering care.

It is also important to remember that the delivery of children’s health care is different from adults. The current system does not recognize this very well, and children receive health care in even more settings, like schools, primary care, home and community care , and of course with their families.

Patients and health care professionals alike are frustrated by the lack of communication between professionals, health care organizations, and patients. This lack of coordination and duplication in some roles and functions is costing the system in both time and money, and may not always translate into getting patients access to the care they need.

Stronger lines of accountability would help make the health care system more efficient, and also help ensure Ontario gets a greater value for what it currently spends on health care. Currently, the government spends about 42 cents of every tax dollar on health care.^{footnote 43[43]} Although this is the lowest per capita spend on health care compared to other provinces and territories, the system could work smarter and use this same amount of money to achieve better health outcomes.^{footnote 44[44]} When compared to similar countries in the world, Canada generally spends more on health care, but scores lower on some key performance indicators.^{footnote 45[45]}. With performance based incentives that link investments to outcomes, Ontario could shift the focus of health care spending to high-value, instead of high-cost. With clearer lines of responsibility and accountability in the health care system, Ontario could move towards strengthening the entire system and solve the problem of hallway health care.

Randy’s Story: The Big Picture

Randy, a retiree from Pickering, says patients like himself could benefit from a comprehensive electronic health record that covers the entire health journey.

Whenever Randy sees a new doctor, he carries a chart he designed himself. Across the page, a line that looks like a heartbeat tells the story of his health over time. When the line spikes up, it pinpoints a serious illness or health emergency at a specific age. There’s a concussion and broken nose in his younger years, and more recently, two cases of deep vein thrombosis and an atrial flutter.

Randy has recovered well from his most recent emergency, though he’s on blood thinners and is watchful for signs of other illness. While thinking about past health events that he should follow up on, he realized that while all his doctors might have different records that, together, would create a complete history of his care, he didn’t have one himself.

So, he made the chart based on memory. Without the complete picture, patients are left with fragments, he says. There are just too many sectors, too many contact points. The onus comes back to the patient or caregiver to put pen to paper or make some history of this.

Overall, Randy is quite happy with the care he’s had – he gave the hospital that fixed his atrial flutter a five-star review on Trip Advisor. But he would like hospitals and physicians to give patients more access to digital records so that they can take the next steps on their health care journey. Health care is a shared responsibility, he points out, and patients can’t adjust their behaviour if they don’t have the information readily available.

Randy already knows how he would use broader records – he would check on the most pressing things, like his heart health, and review conditions that might need attention, and share some of the genetically important information with his grown children, so they can ask their doctors the right questions. If we want to look in and see our data, we can. If we don’t feel comfortable, wait. To me, it should be a choice, but available.

The system has different metrics on me but none of them have the full story.

Opportunities for improvement

Digital & Modern Health Care

Ontario’s health care system has room for improvement when it comes to using technology as a tool to help coordinate and deliver services, and improve outcomes for patients. As the Council continues its work, it will make a focused effort to consider technology solutions to help improve health outcomes for patients across the province. This could look like new partnerships to deliver specific services or to help support the integration of care at the local level. This could also look like identifying options for integrated health information systems that would help facilitate smooth transfers between care settings.

According to the 2018 Health Care Experience Survey, only 16% of Ontarians could make an appointment with their health care provider by email or on a website. Perhaps even more surprising, is that less than 1% of appointments that year were conducted virtually in Ontario.^{footnote 46[46]} This is just one example of how Ontario could be doing a better job connecting patients with care. As Ontario’s health care costs are projected to rise more closely with aging demographics than inflation it will be more important than ever to explore how adopting technology might help bend the cost curve and unlock potential savings.

Accessing health care doesn’t have to be complicated, and the Council will be looking for ways for patients and families to be able to connect easily with a truly integrated health care system.

Integrated Health Care Delivery

The Council is also interested in providing advice that could help inform how health care is delivered in Ontario. Integrated health care has the potential to involve the full continuum of health care services, and connect all health care providers and care settings into one seamless partnership motivated by a common goal: providing wrap-around services to patients and improving health outcomes. This includes considering the impact of the social determinants of health, and providing more proactive health care interventions.

There are already examples of integrated health care working across the province. The Council will be looking for innovative solutions to support leaders and pioneers in integrated health care, and will consider how to scale up these initiatives so that everyone can benefit from co-ordinated care. This could include thinking about the roles and functions of health professionals, and reconsidering how to streamline certain functions, like care-coordination. The Council may also provide advice on how Ontario could introduce innovative payment and accountability mechanisms to ensure alignment with service provision and government objectives – including patient self-determination.

What is Integrated Health Care?

Integrated health care means different things to different people – and may look like a new way of accessing care within your community. Integrated health care is motivated by one main goal: providing coordinated, wrap-around health care services to patients.

Integrated health care means the system doesn’t act as a barrier to providing timely health care services to patients. It means that your home care services are working in complete partnership with your local hospital and primary care providers to make sure that everything is ready to go at home once you or your loved one has been discharged.

Efficiency In the System

Simply adding more hospital or long-term care beds to the system will not solve the problem of hallway health care in Ontario. The Council will consider strategies that include prevention, early intervention, and evidence-based programs that improve health outcomes, and will look at best-practices in Ontario and in other jurisdictions across the world as it develops advice for government.

The Council will ensure recommendations included in its next report will address a balance of both short and long-term needs across the health care system, make the system more efficient for patients, providers, and care-givers, and ultimately help set Ontario up for success in the years to come.

Footnotes

footnote[41] Back to paragraph Ernst & Young. (2018). Managing Transformation: A Modernization Action Plan for Ontario. Line-by-Line Review of Ontario Government Expenditures 2002/-3 – 2017/18.
footnote[42] Back to paragraph Ministry of Health and Long-Term Care. (2019). MOHLTC Data.
footnote[43] Back to paragraph Ernst & Young. (2018). Managing Transformation: A Modernization Action Plan for Ontario. Line-by-Line Review of Ontario Government Expenditures 2002/-3 – 2017/18.
footnote[44] Back to paragraph Canadian Institute for Health Information. (2018). National Health Expenditure Database Trends, 1975 to 2018 .
footnote[45] Back to paragraph Conference Board of Canada. (2012). International Ranking: Health
footnote[46] Back to paragraph OTN. (2017). OTN’s Annual Report 2016/17, and OMA. (2018). Not a Second Longer.

Updated: November 22, 2023

Published: June 18, 2019