- © 2007 Canadian Medical Association or its licensors
If Ontario had regionalized its health care delivery system like many other provinces, would Toronto's 2003 severe acute respiratory syndrome (SARS) outbreak have been handled better? Would a decentralized and regionalized system mean better integration and communication among the players? It's a question that has been raised by many both within and outside the Ontario system.
Ontario Health Minister George Smitherman concedes that the question “might be a fair comment,” but others are more equivocal. “Maybe,” says Professor Colleen Flood, scientific director of the Institute for Health Services and Policy Research of the Canadian Institutes of Health. “But the fact of regionalization itself would not have ensured a better response,” she adds.
BC, which has a regionalized health system, handled the SARS outbreak more effectively than Toronto, but Dr. David Patrick, director of communicable diseases and epidemiological services for the BC Centre for Disease Control is loath to link Ontario's lack of regionalization with SARS as “causation.” While there are advantages to regionalization, there are a lot of different models, he adds. “The important thing is preparedness and communication, whatever the underlying structure.”
Two major reports have now indicated that communication and connection among hospitals and other health care institutions was clearly a problem in Toronto during the SARS outbreaks.
The recently released final report (CMAJ 2007;176:434-5) of the Commission to Investigate the Introduction and Spread of SARS in Toronto (the Campbell report), states that “A combination of robust worker safety and infection control culture at the Vancouver General, with a better systemic preparedness ensured that BC was spared the devastation that befell Ontario.”
The 2003 report of the National Advisory Committee on SARS and Public Health also noted that respondents “highlighted weaknesses in systems for communicating infectious disease alerts from public health agencies to the operational levels of the health care system. The process for issuing alerts was apparently more successful in BC.” It recommended that provinces and territories improve “linkages between public health and segments of the personal services system (hospitals, home care agencies, primary care).”
In Saskatchewan's regionalized system, for example, the chief medical officer of health for Saskatoon's region “sits at the table” with the chief executive officers and vice presidents of hospitals and long-term care facilities in his region. Dr. Cory Neudorf says that when SARS hit Canada, “we had a plan in place quickly. We didn't have to build links because they were already there.”
Neudorf says when public health operated at a municipal level, as it does in Ontario, “we had our hands full dealing with local issues, bylaws.” Regionalization allows public health to become part of the continuum of care and take a population health approach to prioritizing services. New links to acute care allow public health to use its surveillance to improve the whole system's responsiveness to, for example, influenza outbreaks.
While other provinces began regionalizing 10 or 15 years ago, Ontario is “working from the back of the pack,” says Smitherman. However, Ontario is now taking “big strides forward,” he asserts, by establishing Local Health Integration Networks (LHINS), which are “responsible for” public and private hospitals, long-term care and some other services. The province retains responsibility for public health, physicians and drug plans. The result is “much better communication than we had before,” Smitherman says, noting in particular the province's new integrated public health information system.
But Brenda Zimmerman, a professor with the Health Industry Management Program at York University's Schulich Business School, argues that it is “very challenging” to get improved communication and knowledge transfer within the current governance structure in Ontario. That's because within LHINS hospital governance structures have remained intact — “essentially an extra level of bureaucracy” each with its own protocols — whereas in regionalized systems individual hospital boards are disbanded.
Zimmerman says “there is a disconnect between the front line, government and the hospitals,” yet it is at the hospital level that polices are enacted. More attention needs to be paid to sharing learning and pooling resources among hospitals, she argues.
Dr. David Walker, dean of the Faculty of Health Sciences at Queen's University, notes that the 16 to 18 hospitals in his region each have different information systems and protocols. “We don't have a system. It is not integrated or coordinated, not enough,” says Walker, who chaired an Ontario expert panel on SARS that reported in April 2004. “It is set up to be discordant,” like having a basketball team playing against a hockey team, he says.