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Report to the Ontario Council of Hospital Unions Convention April 2007

Doug Allan, CUPE Research Representative.

OCHU’s 25th Anniversary: Congratulations to OCHU on its 25th anniversary and its role in building a union that fights for hospital workers and working people. OCHU conferences and conventions are a vital part of building consensus around the fight back. Only through united, province-wide action are we able to build a fight back that is large enough to be heard by the governments, corporations, and working people across the province.

Our strategy was to place maximum pressure on the provincial government to extract concessions before the election. So far that has proven useful and we have gotten significant concessions from the government on hospital privatization. We have even been able to go on the offensive in a modest way and gotten some promises regarding improved staffing guarantees in long term care.

LHINs, the Competitive Market, and Health Care Restructuring

The CUPE LHIN working group met with ten of the LHIN CEOs since the spring. The LHINs did not provide an awful lot of new information, but we were able to fully brief them on our concerns.

Although actual change before the election appears relatively modest, behind the scenes, more is likely going on. Competition versus cooperation as models for health care delivery has become a major theme. Importantly, there is some interest from LHINs to at least listen to the call for a health care model based on cooperation between providers rather than competition.

We have flagged two major sorts of concerns: restructuring (mergers, closures and transfer of services) and the introduction of the competitive market model.

A] Restructuring

There are strong signs of work in various regions to move back office and supply chain services to new, not for-profit corporations. As well, there are some signs that other services may get rolled in: e.g. providers in SE LHIN through the Southeastern Ontario Integration Project (“SOIP”) are looking at the supply chain, but also promise to look into HR, laboratory, and pharmacy services. It’s reasonable to expect attempts to expand the scope of such regionalization.

B] Introduction of the Market

LHINs and related restructuring opens up several areas for the introduction of a “competitive market model” for health care delivery:

    1. The purchaser/provider split between LHINs and health care provider organizations. This split distinguishes LHINs from regional health authorities in all other provinces. Regional authorities in all other provinces directly deliver services.
    2. The introduction of pricing and purchasing of hospital surgeries and procedures. This “fee for service” system has, initially been introduced through the government’s new “Wait Time Strategy”. But now the list of services covered by the Wait Time Strategy is expanding (to paediatric surgery) and influential sources are calling for even more. (Government wait time advisor and advocate of the competitive market model, Michael Kirby calls for 30% to be funded via such mechanisms; the OHA favours fee for service payments for all hospital surgeries.)
    3. The government has also begun to turn surgical and diagnostic work over to independent clinics, rather than hospitals: The Kensington surgical clinic is the lead case.

    Given these steps, it is only surprising that it took as long as it did for Conservatives like John Tory to call for full-fledged privatization of surgeries.

    Britain has moved down this path earlier: It now has competition and private delivery for hospital services. Indeed, since Jan 1,2006, allBritish NHS patients should be offered a choice of at least four hospitals for non-emergency services. Moreover, The British government has just announced a flagship NHS website designed toencouragepatients to exercise their choice. NHS Choices will give statistics on hospital times, MRSA rates and cleanliness. This data is similar to the information that Alan Hudson says he will (eventually) collect and publish.Likewise, Hudson and the Ontario governmentare vigorously promotingtheir ‘wait time’ web site.

    Under the guise of ‘patient choice’ it is all too likely that this model will be used to introduce a competitive market for hospital services.

    Unless we stop it.

    OCHU and CUPE have played a vital lead role fighting the introduction of the market and private delivery for health care services. But, given these developments and the state of the popular movements, we face even heavier responsibilities in the future.

    A cooperative model of health care, where providers work together, share best practices, and create seamless care for patients is the opposite of the competitive market model. Indeed, cooperation, sharing, and seamless care make the competitive market model impossible.

    Wait Times Strategy

    The Wait Times Strategy (WTS) introduces the purchase-price model to hospital funding that is often associated with the market and competitive bidding. The OHA has stated that it would like to see the WTS expanded to all surgeries.

    It’s apparent that there are currently both cooperative and competitive tendencies within the WTS reform. It is not yet clear which will predominate. The competitive model, however, would seriously harm CUPE members. I believe we need to promote initiatives based on cooperation between providers, thereby undermining competition.

    Below are highlightsfrom a recent hospital / provincial government conference on wait times:

    The Wait Times leadership see significant concern from doctors, hospital boards, and hospital CEOs about this reform. The wait time strategy transfers responsibility for managing wait times from doctors to hospital boards and CEOs. The Wait Times leadership also questions the role of these same people.

    The Wait time leadership flatly states that less and less funding will go to hospital global budgets (and presumably more and more will go to price based funding via the WTS).

    The closely associated wait times information system (WTIS) will expand to all surgeries, going well beyond the “first five” wait time priorities.

    The Wait Times leadership noted a number of “innovative care initiatives” above and beyond Kensington Eye Institute:

    • Cataract Centre of Excellence (Central LHIN),
    • The Cataract Surgery Centre (South East LHIN),
    • Reducing Cataract Wait Times in Central East LHIN,
    • Regional Eye Medicine and Eye Surgery Centre (Hamilton, Niagara Haldimand Brant LHIN),
    • Fast Tract Arthoplasty Initiative (SW LHIN),
    • Integrated Model of Care for Total Joint Disease (North Simcoe, Muskoka LHIN),
    • Joint Health and Disease Management Program,
    • Total Joint Assessment Centre (Central LHIN),
    • Total Joint Replacement Program (HNHB LHIN),
    • Regional Cancer Program (Champlain LHIN).

    It’s not clear to me, at this point, which of these are clinics independent of hospitals. Small, independent surgical and diagnostic clinics would fragment health care and be very difficult to organize. They could also significantly advance the competitive / market model.

    The wait times leadership wants to use public reporting to spur competition between hospitals.

    The “Trauma” Wait time panel wants the LHINs to identify the lead trauma hospital for each LHIN or LHIN cluster. They see a great advantage in high volumes. They want the specific trauma role of each acute hospital spelt out in the accountability agreements with the LHINs. (This type of division of labour may become a model for other divisions of labour between hospitals.)

    There is some interest from the Trauma panel in specifying wait times for people once they are in hospital (e.g. rehab within a certain time, or a CT scan within a certain time after arrival). This could actually be beneficial.

    There was some discussion of cooperation between hospitals, with the main example being “coaching teams” visiting other hospitals to help them improves their practices. This sort of cooperation is inimical to competition between hospitals.

    There was discussion of moving work to the most efficient sites.

    There was open discussion of the need to fundamentally change the Public Hospital Act (after the election).

    Even the representative of the OHA Board recognized that voluntary hospital boards may be on the way out. This, likely, would have a profound impact on CUPE bargaining units.

    One suggestion from a panelist: boards must look at new governance models that involve integration with other providers. This could dramatically increase cooperation.

    Britain – Frank Dobson Tour

    CUPE brought the former UK Health Minister Frank Dobson to Ontario to explain the perils of privatized, market based health care delivery. His key point: contracting for services adds extra administrative costs, which a cooperative system simply does not have. The worst-case example of this is the US system, which need an enormous bureaucracy to oversee all of its prices and contracts, wasting billions on administration. But fee for service funding the British system has also brought greatly increased administrative costs.

    Dobson’s tour (done in conjunction with the Health Coalition) proved successful, garnering significant media attention, and providing useful information and education to public health care campaigners in Ontario about the threat of market health care delivery.

    We may wish to examine the administrative waste in the privatized US system in the future, as a way of furthering our campaign.

    Long Term Care: Bill 140 (The Long Term Care Homes Act, 2007) is moving to Royal Assent. A concerted campaign, led by the Ontario Health Coalition, with strong support from CUPE Ontario, has achieved some gains. It now appears that the government will re-introduce a minimum number of hours of daily care for LTC residents. This is an important gain for residents and LTC staff.

    Here we appear to have actually moved the yard sticks modestly forward for residents, families, and workers, rather than simply stopped an attack!

    It is also a small victory for hospital workers in complex continuing care. A minimum staffing standard will make it somewhat less attractive to transfer patients from hospitals, where more care is provided, to LTC facilities.

    The OHC: The Ontario Health Coalition continues to be a very valuable ally on public private partnerships, health care privatization, long term care reform, and restructuring. I want to encourage CUPE locals to continue to work with (and fund) the OHC and its local affiliates. Their struggle for universal, accessible and public health care is our struggle.

    Public Private Partnerships

    The provincial Liberal government continues to pursue “P3” hospital projects. However, with the Health Coalition community plebiscites (supported by CUPE), the government has made a significant concession; only “hard” maintenance services (e.g. maintaining the HVAC, or the electrical system) and some non-patient “soft” services (e.g. parking, security, cafeteria) may be included in the deals. This should greatly narrow the scope of the privatization. Nevertheless, some jobs will still be privatized, and long term private financing (which costs more) still continues.

    This issue continues to be a major issue in the local communities saddled with these projects. We expect about twelve or thirteen such projects. It is apparent that many other hospital projects (perhaps 25) will not be blighted by long term private financing and the privatization of jobs.

    The campaign, including community plebiscites, to stop these P3s will continue.

    Hospital Acquired Infections (HAIs)

    OCHU and CUPE have campaigned on HAIs (such C. Difficile, MRSA, and VRE) for several years, connecting it to the need for high quality, publicly delivered health care support services. In the past year, HAIs have finally become a major news issue. Importantly, the media has often (but not always) connected this issue to the need for high quality hospital cleaning.

    The issue has tremendous potential for us to demonstrate the vital role of hospital support services, an issue too often dismissed as “auxiliary” or “hotel” services by pro-corporate ideologues.

    CUPE Health Care Workers Across Canada

    Work through the CUPE National Health Care Committee continues to be an important way to broaden and deepen our struggle for public health care. The scary role of Stephen Harper and the federal Conservative government may well make this work even more important.