Unconventional Candour

by George Smitherman

  We did this both by increasing enrolment in Ontario’s medical schools and by speeding up certification for foreign-trained doctors. (The cliché fifteen years ago was that foreign-trained doctors were driving cabs in Ontario. That is no longer the case.) And one in four Ontarians is now attached to an FHT. The combined effect of these measures was to improve service for Ontarians and reduce pressure on emergency wards, the most expensive form of medical intervention.

  To accomplish this, we aligned our financial resources behind FHTs. There was no increase in the budget for sole practitioners charging fee-for-service, but there was $1 billion more for FHTs. This required buy-in from the doctors. So I spent my first year in office negotiating a new contract with the Ontario Medical Association (OMA), the union for the province’s twenty-thousand-plus doctors. We managed to strike a deal with the OMA bargaining committee. If you sign a deal in good faith, you really ought to try to sell it to your membership. Unfortunately, the OMA executive did not do that, and the deal was voted down by the members. The new OMA president, John Rapin, an ER doctor from Kingston who had replaced Erlick, then appealed to me to return to the bargaining table. “We don’t have additional resources to put on the table,” I told him. So we were at loggerheads.

  After a speech at a hospital convention, I had a massive “scrum” with the media on the OMA negotiations, where I said we would have to consider unilaterally legislating an agreement. The OMA went bananas.

  “We’ve been somewhat shanghaied,” griped Rapin.

  “When I looked the definition of ‘shanghaied’ up in the dictionary, it wasn’t usually associated with $1 billion in new pay,” I retorted.

  Nonetheless, we resumed talking with the OMA and achieved a deal, after some modest tweaking of the details. And as a quid pro quo in the subsequent provincial budget, Finance Minister Greg Sorbara gave doctors the right to incorporate, which was a huge benefit for them.

  Another investment was directed at reducing wait times for medical procedures in several critical areas (cardiac treatment, cancer care, joint replacements, and diagnostics [MRIs and CT scans]). The long wait for these procedures had become a major source of public complaints about the health care system. To tackle the problem, I hired Alan Hudson, a world-renowned neurosurgeon and former CEO of the giant University Health Network in Toronto. He had the wherewithal and the gravitas to tell surgeons and hospital administrators the things they needed to hear. Surgeons, stuck in their silos, had been keeping their own private lists of patients waiting for treatment. That practice had to end. So we created a provincial wait times registry, which was so successful that the model was adopted in the rest of the country. Wait times were significantly reduced as a result. Hudson and Sarah Kramer, whom he recruited for the job from Cancer Care Ontario, deserve enormous credit for this. Ironically, it was the success they achieved in the development of the registry that led David Caplan, my successor at Health, to elevate them to the two key roles at the newly formed eHealth agency. Unfortunately, their early steps at that agency further inflamed the already badly scorched electronic health landscape and led to their demise, as well as that of Caplan and Deputy Minister Ron Sapsford. More about that in a later chapter.

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  As I have mentioned, some of the funding for these investments came from the federal government as a result of the health accord with the provinces in September 2004. By that time, Ottawa was flush with cash, and the provinces demanded their fair share of it. After all, the provinces reasoned, the federal government (with Jean Chrétien as prime minister and Paul Martin as finance minister) had balanced its budget in the 1990s partly at their expense by cutting back on medicare transfers. When Martin became prime minister early in 2004, he set out to make amends by offering the provinces $41 billion in new medicare funding over the next decade. He said the money would provide medicare with “a fix for a generation.” But Martin, egged on by the Romanow Report, attached strings to the additional funding: the provinces would have to spend it on reducing wait times, reforming primary care, expanding home care, and improving long-term care. And there would have to be accountability: monitoring and reporting of the results. Ontario had no problem with any of this; we had already begun aligning every new dollar behind Ottawa’s targeted areas. And we were completely open to more transparency to make sure the money was spent as directed. But other provinces, notably Quebec, objected to federal interference in an area of provincial jurisdiction (health care). Martin, with a big assist from Premier McGuinty, had to stickhandle his way around that dilemma to get a deal.

  The result was “asymmetrical federalism,” a frank admission that Quebec is a province unlike the others. In fact, of course, all the provinces are different from each other when it comes to the delivery of health care. Anyone who thinks health care systems are the same across the country hasn’t travelled enough. For our part, we in Ontario sought to lead in accountability. We need to thank Peter Glenn from Kingston for helping drive the wait times information system forward.

  When Stephen Harper became prime minister just over a year later, many people lamented his hands-off approach to health care funding. He preferred to leave it to the provinces to decide how to spend federal funding while he fulfilled the terms of Martin’s accord with annualized increases. I saw it as more of a resignation on Harper’s part that the overarching values of medicare — public funding and universal access, laid down by Monique Bégin’s Canada Health Act in the early 1980s — could not be altered by his political philosophy. But Ottawa’s financial participation has diminished sharply from the original fifty-fifty cost-sharing arrangement for medicare. Now it is the provinces that pay the lion’s share of the cost and have all the responsibility for actually delivering health care to Canadians. But the average Canadian still sees Ottawa as being in the driver’s seat because medicare has become a core value for the country. There’s a public literacy problem here that works very well in Ottawa’s favour.

  While I want Ottawa to play an activist role in promoting good health, I have always found it cruelly ironic that the only group for which Health Canada has direct responsibility for the delivery of care is our Indigenous Peoples, who have far and away the most terrible health outcomes in the country. And for all those who think that reserves are teeming with money, consider that while federal health transfers to the provinces were growing at a very healthy 6 percent annually for a decade, Harper and his government decided to cap growth in spending on Indigenous Peoples at 2 percent a year. This history has led me to believe that we need to put more responsibility for health care spending directly in the hands of Indigenous Peoples.

  In Sioux Lookout, Meno Ya Win Hospital stands as a model for Indigenous Peoples taking the lead in health care delivery for their people. The Ontario Government and Nishnawbe Aski Nation (NAN) signed an agreement in 2017 that moves in a good direction, so long as we don’t create new silos of Indigenous health care organized narrowly across nations. Nor can we forget that very large numbers of Indigenous people live in urban centres, and many of them suffer from inequitable access to health care and the poor health outcomes that follow.

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  Another major reform on my watch was the creation of Local Health Integration Networks, or LHINs. This was an attempt to decentralize decision-making in the ministry by empowering the regions, in recognition of the principle that not all parts of Ontario have the same demographics or circumstances and we should allow for customization of program delivery at the local level. Other provinces had previously embarked on regionalization of their health care systems in one way or the other, but Ontario had long resisted the move before I took office. My feeling was that the people on the ground would have a better perspective of what worked in their regions, and I really hoped to create a culture where people could actually absorb what was happening in their area. Plus the sheer size of the health ministry when I arrived — over eight thousand employees and a budget of over $30 billion — made a heavily centra
lized operation difficult to manage. Since the scarcest resource is always time, I was determined to spend less of it mired in day-to-day issues like whether a local ER was going to stay open for the weekend.

  I concluded that the ministry was missing a fundamental element necessary to any large organization in the public or private sector: definable regional areas within which service providers could be held accountable for service outcomes. Unfortunately, there was no regionalization plan on the shelf waiting for me when I became minister. But there was entrenched opposition from the hospitals, which saw regionalization as a threat to their independence. (Ontario’s hospitals are fiercely protective of their independ-ent board governance.) I also soon discovered that all the other provinces’ regionalization models were flawed; there was nothing we could simply copy. As for anyone (Elizabeth Witmer, hello!) who thought regionalization would somehow shield me from political accountability, the evidence in other provinces on that point was also clear: shit still runs uphill to the minister’s office and will as long as there is a Question Period in the Legislature.

  Boundary-drawing for the LHINs was a particularly thorny issue. I learned that there is always going to be an unhappy faction somewhere and that we just had to accept a little imperfection here and there. People want all their hospital services to be close to home, but that is not always possible. Plus we planned to make the boundaries porous — that is, we did not want the LHINs to turn their backs on people from neighbouring jurisdictions. We have a lot of concentrated health specialties and services in Ontario. Accordingly, not all the LHINs could be self-sufficient and able to cover every single health service. Also, my mother lived in Collingwood while her doctor was in Etobicoke, and I wasn’t going to mess with my mom.

  Although many critics proposed we simply adopt municipal boundaries for the LHINs, this wouldn’t work because health care delivery often extends well beyond municipal jurisdictions. And then there was the snobbery factor. Burlington, for example, sees an affinity with affluent Oakville, not working-class Hamilton. But when it comes to health care, Burlington residents usually turn to Hamilton’s first-rate hospitals. It was my good fortune that Rob MacIsaac, then mayor of Burlington and now CEO of Hamilton Health Sciences, used hospital referral data to help bring reason to the debate.

  Finally, the opposition parties chose to attack the LHINs for allegedly adding another layer of bureaucracy to the health care system, But this argument flopped because I made sure the LHINs were created through the reallocation of staff from the closure of the ministry’s regional offices, the District Health Councils, and reductions in Community Care Access Centres (CCACs). That meant that LHINs began with no net new employees.

  The Ontario health care system is one of the most administratively efficient in the world. But the system cannot be run without at least some people managing the money. Considering that LHINs are responsible for the accountability agreements with the hospitals, their role is now pivotal to maintaining fiscal discipline as well as health care planning and delivery.

  Also overlooked in the opposition criticism is the 50 percent reduction in the size of the Ministry of Health, which declined from eight thousand employees when I arrived to less than four thousand today, as we strove to change the ministry’s focus from day-to-day operations and crisis management to overall stewardship.

  My critics also suggested LHINs would introduce inequities into the delivery of health care, given that they were allowed some flexibility in tailoring local delivery of provincial priorities. Again, this criticism is wrong-headed. We already had built-in inequities in the system, and for once we were moving toward quantifying and addressing them. To a certain extent, our model of concentrating high-cost services builds in inequities. But that can’t be an excuse to refrain from doing our utmost to meet patient needs locally. Someone living in Timmins does not have the same immediate access to world-class hospitals as someone living in downtown Toronto. That, in turn, explains our heavy reliance on Ornge, the air ambulance service. But with LHINs, we could pursue excellence everywhere, either through the sharing of best practices or just sheer jealousy. I called it virtuous competition, the idea that uncorking fourteen vats of creativity would raise all boats with citizens in one area clamouring for services offered in another. Unfortunately, as soon as I left the ministry, my successors started to roll back the autonomy of LHINs. In my opinion, we should be liberating them and letting them be more innovative as we continue to grapple with the systemic challenges. I think it is far more likely that local communities are going to be the first to identify that some of the resources they need are perpetually being wasted, as 20 percent of their hospital beds are clogged with patients who would be better accommodated elsewhere. Today in Ontario, we are actually debating adding new acute-bed capacity to address pressure largely from an aging population. Instead, we should be discussing measures to stop ambulances from rolling to hospital emergency rooms in the first place.

  In order to make local needs and wants a priority, I also pushed the ministry to locate the LHINs’ offices in less logical locations. I say “less logical,” because outside of the GTA a lot of public services might tend to concentrate in a region’s largest municipality. I wanted to make sure that the beaten path for health care didn’t cause us to lose sight of the vastness of Ontario. My time spent looking up at the map of Ontario in our family trucking business office had driven this point home to me. So for LHIN offices (and the jobs that went with them), I chose Orillia not Barrie, Grimsby not Hamilton, Belleville not Kingston, and North Bay not Sudbury. In some cases, these decisions were greeted with slacked jaws. But I stuck to my guns and enjoyed the response.

  The premier cut me a lot of slack on these issues. So did the Liberal caucus — I hope because individually they knew I had their backs. I learned my lessons from Hugh O’Neil well. With Scott Lovell’s help, I tended to the needs of MPPs and tried never to leave a smouldering wreck behind when I left town. It did not hurt that I was the biggest good-news provider in the government, with almost weekly announcements of new health care initiatives.

  The future of LHINs is now up in the air, with a new Conservative government at Queen’s Park under Doug Ford. It is unclear what Ford intends to do in this area. He could choose to tinker with LHINs by changing the name and shifting the boundaries. Or he could decide to abolish them. If the latter, he will find that their core functions cannot be fulfilled unless he brings responsibility for overseeing all those hospital accountability agreements back to head office. Then perhaps Toronto will be the beneficiary as hundreds of new staff are hired at the centralized Ministry of Health while hundreds of others are being laid off in smaller municipalities across Ontario.

  Personally, I would devolve more authority to LHINs, not less, and I would create an Indigenous LHIN that covers all of Ontario. The 2005 Kelowna Accord — agreed to by the federal government, all the provinces, and the Indigenous Peoples themselves — would have transferred more responsibility to the provinces for delivering health care to Indigenous Peoples. Unfortunately, it was a casualty of the NDP decision to bring down the Martin government. That resulted in the election of a Conservative government under Stephen Harper, who promptly killed the Kelowna Accord.

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  In the midst of all this activity at the health ministry, which included answering more than half the daily questions in the Legislature, I added a new title to my job description: deputy premier. The Star reported at the time that I was given the title because I had threatened to quit cabinet and the Legislature to run federally. This was not true. It is a fact that in the summer of 2006 I had breakfast with my federal counterpart and friend, Bill Graham, and he told me he was leaving politics. Previously, he and I had an understanding that I would be interested in succeeding him. But by then I had a great job at Queen’s Park and a pending marriage to boot, and the federal Liberals were in opposition. Maybe someone in McGuinty’s office was worried I would decamp, but it was a groundless fea
r. I was a very happy camper, although my temperament might not have adequately conveyed my happiness at all times.

  The deputy premiership came about because I raised the idea with Peter Wilkinson, then McGuinty’s chief of staff. At that time, there was no one with the title of deputy premier. Instead, the government relied on a rotation of ministers filling in for McGuinty when he was unable to be in the Legislature. That was less than ideal from a messaging standpoint. Because I was a target of so many opposition questions in the Legislature, I was pretty much forced to be in attendance. Otherwise, all those answers would have to be foisted on the premier or another minister. “So,” I said to Wilkinson, “if I am going to be there anyway, why not make me the deputy?” The logic of my position evidently appealed to the premier.

  Dalton McGuinty and me with my stepdad D’Arcy Kelley, my mom, Christopher, and my sister Joanne, on the occasion of my being made deputy premier of Ontario.

  Of course, being deputy premier involved not just subbing in for McGuinty in the Legislature but also delivering some speeches around the province on his behalf and doing more fundraising duties for the party. Fundraising can be a real drain on politicians’ time and energy in a way that is utterly out of proportion to the actual dollars being raised. Before Kathleen Wynne’s move to ban corporate and union donations and enhance public funding, political parties were raising $10 million to $20 million annually. And I was a big draw at fundraising events.