Category: 11. Investigations/Grande enquête Publication: The Hamilton Spectator Date: Monday, March 12, 2012 Page: A1 Dateline: CONDITION CRITICAL Headline: A dismal report card Subhead: Health-care networks score very few As and too many Fs (Day 1 of a five-day series) By STEVE BUIST The Hamilton Spectator Hamilton's Local Health Integration Network ranks 11th out of Ontario's 14 LHINs, based on the results of a massive health-care report card created by The Hamilton Spectator. Only the province's three northern LHINs fared worse than the Hamilton Niagara Haldimand Brant LHIN, which has a $2.5-billion budget to co-ordinate health-care services for 1.4 million people from Burlington to Brantford to Simcoe to Fort Erie. The Spectator's groundbreaking analysis compares the performances of Ontario's LHINs across a wide spectrum of 266 different variables that measure population health, wait times, access to care and health system efficiency. The variables were further broken down into seven categories, such as cancer, cardiovascular issues and chronic diseases. It's believed to be the first time that Ontario's LHINs have been compared and ranked on such a comprehensive scale. The Hamilton-area LHIN finished last in the cancer category, 13th out of 14 in the wait times category and 11th in the long-term care/home care category. Donna Cripps, CEO for the Hamilton-area LHIN, acknowledged the results aren't flattering. "The numbers do challenge us," said Cripps. "You're painting a really difficult picture but we want to change. "We are so committed to making a difference person-by-person, issue-by-issue." While the HNHB LHIN includes a medical school at McMaster University, well-respected teaching hospitals and a large cancer centre, it also includes pockets of shocking poverty, high rates of unhealthy behaviours, like smoking, and Canada's most populous native reserve at Six Nations. "We have a population that has challenges from a population health perspective, from a socioeconomic perspective, but that is what it is," said Cripps. "We're not going to wave a magic wand and make a difference tomorrow. "What we are going to be able to do is plod methodically through some of these things and make significant differences. We're not going to back away from it." Stephen Birch, a professor in McMaster's Centre for Health Economics and Policy Analysis and a former board member of the local LHIN, said he was surprised and concerned by the results for the Hamilton-area LHIN. "I think population health would be a big factor here, but also we have to question whether we're being as well-served with the resources allocated to health," said Birch. "Are the additional needs of the population in the Hamilton LHIN being funded and are the funds being used as efficiently as in the other LHINs that are similar to ours?" Birch said that if he were still a board member of the HNHB LHIN, "I would want to know what's explaining this apparently poor level of performance of the Hamilton LHIN." The overall results of the health-care report card reinforce the findings uncovered in The Spectator's 2010 Code Red series and the subsequent BORN project published late last year. The two series highlighted the strong connections that exist between poverty, low levels of education and poor health outcomes. The three LHINs that finished at the top of The Spectator's report card are LHINs that include many of the wealthiest and best-educated municipalities in Ontario. Central LHIN, which finished first, is made up of the GTA north of Toronto, including wealthy cities such as Markham and Vaughan. Mississauga-Halton LHIN, which includes Oakville, finished second. Central West LHIN, which includes the GTA northwest of Toronto, finished third. Kim Baker, CEO of the Central LHIN, said she was proud of her LHIN's performance. "We've managed local health resources effectively and I would say our health service providers also manage their resources effectively," said Baker. "This isn't just about the LHIN administration, it's about all of the providers that impact the system." At the bottom end of the rankings, however, the report card reveals some gloomy results. The two most northerly LHINs lagged well behind their counterparts, not just in the rankings but also in their performances for many of the variables that were measured. "It's quite clearly inappropriate in a system like ours that you should have those substantial differences," said Birch. "It probably makes you question whether there's two classes of LHINs in the province." As part of the report card, The Spectator applied a statistical test to each variable to determine which results were significantly better or worse than the provincial average. The North East and North West LHINs were both significantly worse than the provincial average for 40 per cent of all variables measured. In the chronic disease category, the North West LHIN was far worse than the provincial average for 75 per cent of the indicators, and for the North East LHIN, it was nearly 70 per cent. "There are some serious, serious problems in the north - access, travel, awareness, social skills, lifestyle," said McMaster professor D. Wayne Taylor, a health services management expert in the DeGroote School of Business, pointing to the geography alone as a major obstacle. "How do you ensure compliance and adherence when they go home (from hospital)? Well, of course, they don't comply and adhere when they go home because they go back to the way they were living." The Spectator's analysis shows that the two northern LHINs have the second- and third-highest revenues per person of Ontario's LHINs. Only the Toronto Central LHIN receives more on a per-capita basis, largely because the LHIN is the site of several major institutions that serve the entire province, such as SickKids Hospital. The North West and North West LHINs receive more than twice as much revenue per person than the 14th-place Central West LHIN. Ironically, the three LHINs that receive the lowest amounts per person finished as the top three LHINs in the report card's overall ranking. "The dollars that have gone into the north have been way disproportionate to what's gone into the 905-519 belly of Ontario," said Taylor. "Obviously, they're not getting the results." The two northern LHINs cover about 85 per cent of the province's area but just 800,000 people. Geography, lack of accessibility, lifestyle factors, culture and unhealthy behaviours play key roles in the poor health outcomes across northern Ontario. "The hard reality is we have poorer health behaviours, we are dispersed," said Louise Paquette, CEO of the North East LHIN. "I look at some of my colleagues in southern Ontario who have hospitals within half an hour and I'm, like Are you kidding me?' I don't have that. Because the small communities of the North East LHIN are scattered across an enormous territory, there are 200 different health-care providers, including 25 hospitals. "Twelve of my hospitals have less than $10-million budgets, so they're very small," said Paquette. By contrast, Burlington's Joseph Brant Memorial Hospital has an annual budget of nearly $150 million. "Because of our geography and the sheer number of health service providers, it's a challenge trying to co-ordinate that care around a population that is very diverse," Paquette added. In an attempt to overcome some of the long-distance challenges, Paquette said the North East LHIN has become the biggest user of technology, such as telemedicine. "It's part of life, it's part of delivering care, it's part of who we are," said Paquette, a native of Sudbury. "It's a challenging region and it's not for everyone," she added. "As a northerner, I'm very proud of who we are and what we do and we are making progress. We're trying to move care beyond hospital walls into communities." Neil Johnston, a McMaster University health expert and collaborator for both Code Red and the BORN project, said it's not surprising the two earlier series' findings are echoed in The Spectator's report card. The LHINs at the top of the rankings have the same types of health problems as those at the bottom, Johnston said, but may have better coping mechanisms in place. "If you were to look at a community with a high level of poverty, the difference is they don't necessarily have the same degree of support, they don't have the same degree of control over their lives," said Johnston. "So because of other problems that may not be directly medical in nature, their care becomes far more complex. "It requires social workers, it requires placements after hospital, it requires a much more difficult approach to providing extended after-hospital care. Do we continue on the treadmill, or do we step back and say let's start again?" Johnston asked. "Is there a better way to give people a step up that would ultimately improve the system for all of us? "Those are the kinds of practical questions we need to ask." Sidebar 1: The waiting is often the worst of it Subhead: Too many patients and not enough doctors or beds Dr. Robert Lafontaine is a lonely man. And a busy one, too. Lafontaine is an orthopedic surgeon in Timmins - the only one, in fact - responsible for an area roughly equal in size to all of southern Ontario from Ottawa to Parry Sound to Windsor. It's little wonder then that the wait time for nine out of 10 people to have a knee replacement done at the Timmins and District Hospital is four years. That's the worst wait time for knee replacements for any hospital in Ontario - and three times longer than the hospital with the next-worst wait time. And that's not counting the year or so it might take to get an appointment with Lafontaine in the first place. "Even the wait list they're publishing is underestimated," said Lafontaine. "Our wait list is actually longer than it really shows. It's stressful. I do the best I can, I do the most I can." Compare that to the St. Thomas-Elgin General Hospital, where nine of 10 patients receive knee replacements in less than two months, the best performance by a hospital in Ontario. At 393 days, the North East Local Health Integration Network - which includes Timmins, North Bay, Sault Ste. Marie, Sudbury and up to James Bay - has the longest wait for knee replacements of any of the LHINs. That's almost twice the provincial average and more than 250 days longer than the South East LHIN, which has the shortest waits. The Hamilton Niagara Haldimand Brant LHIN has the third-worst wait times for knee replacements of all Ontario LHINs. It takes 267 days for nine out of 10 knee replacement patients to have their surgery, based on data from the last three months of 2011. These are some of the findings of the Spectator's report card on provincial wait times comparing the performances of Ontario's LHINs for certain surgical procedures and diagnostic tests. Across 32 different wait time variables, the Hamilton-area LHIN finished 13th of 14 LHINs. Only the Ottawa-area Champlain LHIN had a poorer overall performance for wait times. The Windsor-area Erie St. Clair LHIN finished first. Among the Spectator's findings for the HNHB LHIN: * It took 41 days for nine out of 10 people to get a CT scan, tied for the longest wait. It took just 14 days for nine out of 10 people to get a CT scan in the Central West LHIN, the best in Ontario; When all MRI variables were combined, the HNHB LHIN finished last in the province; * Just over half of the HNHB LHIN's Priority 2 MRI scans were done within the provincial target time. In the North Simcoe Muskoka LHIN, by contrast, 94 per cent of priority 2 MRIs were done within the target; Only 15 per cent of HNHB LHIN's Priority 4 MRI scans were done within the target wait time; * The HNHB LHIN had the fourth-worst wait time for hip replacement surgery. It took 235 days for nine out of 10 patients to have their hips replaced, compared to 93 days in the Erie St. Clair LHIN. "CT, MRI and joint replacement are the top three wait times that are on our plate right now," said Donna Cripps, CEO for the Hamilton-Niagara-Haldimand-Brant LHIN. Cripps said the HNHB LHIN is attempting to streamline the process to minimize the amount of down time for CT and MRI scanning machines. "Our Priority 1s and 2s are done within a very short time frame and are fine," said Cripps. "It's our Priority 4s that are the issue. Those are the ones that are less urgent. "We are starting to see some interesting improvements," she added. "We really started to focus on CTs and MRIs last fall and it's just starting to come down now." * * * Dr. Lafontaine sighs, then tries to do the arithmetic in his head. "Let's see, about 60 a year for the last decade, so I guess I've probably done around 600 knee replacements." It's not quite an assembly line, but Lafontaine has it down to a fine art. He books 2½ hours in the operating room for each knee replacement. That includes the time it takes to put the patient under and then close up when he's done. The actual replacement takes Lafontaine just 60 to 90 minutes. "I'm pretty fast," said Lafontaine. "I could do three or four (a day). "Actually in the bigger centres, they do four, even five in some places in Toronto, but that's with fellows and a lot of assistants. It's pretty hard to do up here. "Bed issues are another problem. Once we get another one or two orthopedic surgeons then we're going to have bed issues and then we'll need more funding to open more beds." Lafontaine grew up in Kapuskasing, 120 kilometres north of Timmins along a lonely stretch of Highway 11. He understands life in Ontario's north and the hardships it holds for his patients, and feels a responsibility to help. "I know what it's like," said Lafontaine. "Our family has had other health problems and you have to travel to Sudbury or Ottawa for other things, so I understand my patients having to travel to get their knee replaced when they could actually have it done here." For some patients in need of a new knee or hip, the only solution is a referral to another specialist in a place like Thunder Bay, Hamilton or Toronto, which means the added burden of travelling not just for the surgery but for pre-operative and post-op care as well. "I'm so swamped here, I barely have time to follow my own patients," said Lafontaine. "I refuse to follow other people's patients when I'm swamped myself, so the people end up having to travel back and forth to Toronto." Louise Paquette, CEO for the North East LHIN, acknowledged that wait times for joint replacement surgeries in her region are "unacceptable." "When you have a lone surgeon, they can only do so much," she said, pointing to Timmins as an example. The North East LHIN has opened five joint assessment clinics, staffed by physiotherapists, to ease the strain on its orthopedic surgeons and speed up the knee and hip replacement process. Paquette is also hopeful that the new Northern Ontario School of Medicine, split between Thunder Bay and Sudbury, will help retain family doctors and specialists in the north. "Attracting those highly qualified people is an ongoing challenge," she said. "I'm not a big advocate of forcing people to practise here," Paquette said. "I think incentives can certainly help." Lafontaine said he's fortunate because out-of-town surgeons are brought in to cover overnight and weekend on-call duties. "If I had to do a lot of on-call, I'd probably end up burning out for sure." Paquette did get some good news recently - a second orthopedic surgeon has been recruited to Timmins. Info box: WAIT TIMES: KEY FINDINGS * 32 variables measured, related to scans, surgeries and joint replacements; * Hamilton-Niagara-Haldimand-Brant LHIN ranked 13th of 14 LHINs; * Erie St. Clair LHIN ranked first; * On average, only half of Priority 3 MRI scans are done within the target time in Ontario; * Only two-thirds of Priority 2 cancer surgeries in Ontario, on average, are done within the provincial target; * On average, it takes at least 200 days for nine out of 10 people in Ontario to have knee or hip replacement surgery; * At 56 days, the Hamilton-Niagara-Haldimand-Brant LHIN had the third-longest wait time for nine out of 10 patients to receive cancer surgeries. Sidebar 2: Area LHIN is worst of a bad lot The Hamilton-area Local Health Integration Network failed to meet 10 of 11 targets in its most recent accountability report, the worst result of Ontario's 14 LHINs. In fact, its performance actually worsened for three of the indicators compared to the previous year. Each of Ontario's 14 LHINs is required to report its performance for 11 different indicators related mostly to specific types of wait times, and each indicator includes a target to meet. The Hamilton LHIN wasn't alone in its poor performance in achieving the province's mandated targets, however. Only one LHIN met more than half of the 11 targets. Overall, the 14 LHINs failed to meet two-thirds of the targets, and their results actually worsened from the previous year for nearly one-third of the indicators. Neil Johnston, a McMaster University health expert and collaborator on The Spectator's Code Red and BORN projects, wonders if Ontario's LHINs are being given the proper resources to achieve their mandates. "If one of their objectives is to ensure equity of access to a battery of services and to eliminate or at least reduce wait times to some accepted minimum, then there obviously needs to be resources to go along with that," he said. The Hamilton LHIN's median wait time for placement in long-term care homes increased by 31 days in fiscal year 2009-10 to 178 days - 69 days longer than the provincial target. The result raises questions about the Hamilton-area LHIN's ability to accommodate its aging population. The fastest-growing segment of this LHIN's population is people 45 to 74. As of 2009, the LHIN has the largest number of seniors of all 14 LHINs. For knee replacements, the Hamilton LHIN's wait time went from 182 days at the start of 2009 to 209 days, which was over the target of 200 days. Cancer surgery wait times went from 54 to 58 days. The target was 50 days. The only category where the Hamilton LHIN reached its target was hip replacement wait times. The LHIN started the year with wait times of 182 days and reduced that number to 177, which was below the target of 182 days. Info box: How Condition Critical was done Condition Critical is a report card of performance indicators and population health for the 14 regions that make up Ontario's Local Health Integration Networks, or LHINs. A total of 266 variables measuring the LHINs was gathered from the 2011 Ontario Health Quality Report; the POWER Study published by the Institute for Clinical Evaluative Sciences in October 2011; performance indicators included in each LHIN's 2009/10 annual report; and data from Ontario's 2011 Cancer System Quality Index. The markers were divided into seven broad categories: Wait times (32 variables); Long-term care/home care (37 variables); Chronic diseases (51 variables); Cancer (32 variables); Cardiovascular (35 variables); Emergency departments/access to primary care/resources (32 variables); Healthy behaviour/reproductive health/harm prevention (47 variables). The results for each variable for each LHIN were tabulated in a spreadsheet. For each variable, the LHINs were ranked in order. The cumulative rankings for all 266 variables were then calculated for the 14 LHINs to provide an overall ranking. Date: Tuesday, March 13, 2012 Page: A6 CONDITION CRITICAL Headline: The ER door is often the only way in Subhead: Too many people are using the emergency room to gain access to the health-care system (Day 2 of a five-day series) By STEVE BUIST The Hamilton Spectator For a disturbing number of people in Ontario, particularly those who are recent immigrants, poor or suffer from mental illness, a hospital's emergency department isn't a place of last resort - it's often the only resort. "How do you access the health-care system?" Dr. Bill Krizmanich asks rhetorically. "You need an appointment. "You can't walk in to a cardiologist's office and say I think I might have some heart problems, can you run some tests on me?'" Krizmanich is the chief of emergency medicine for Hamilton Health Sciences as well as the emergency department lead for the Hamilton Niagara Haldimand Brant Local Health Integration Network. "The only access points we have, if you think about it, in our entire health-care system - this huge mammoth health-care system - are either your family doctor, (a walk-in clinic), an urgent care centre or an emergency department," said Krizmanich. "Those are the only places that a patient can walk in and expect to see a doctor without an appointment. "If you think of it in that way, we are the front door for a lot of the health-care system and sometimes we are the front door when things break down. Where else are patients going to go?" At this rate, though, the hinges are going to snap off that front door, thanks to overuse. Emergency department volumes in Hamilton alone are up 10 per cent this fiscal year from the previous one. More worrisome, the number of emergency room visits by so-called "high-acuity" patients - those with serious or complex problems - has skyrocketed by 22 per cent across the Hamilton-area LHIN in the first six months of the current fiscal year. In real numbers, that's an increase of about 30,000 high-acuity visits to the LHIN's ERs in just six months. It's no surprise, then, that the Hamilton-area LHIN had the longest wait times in Ontario for high-complexity emergency room patients. It took nearly 15 hours on average for nine out of 10 high-acuity patients to be seen. At the Hamilton General Hospital specifically, it took nearly 21 hours for nine out of 10 high-complexity patients to be seen, the second-longest wait of any Ontario hospital. As those complex patients move downstream through the system, it's easy to see how finding a solution quickly becomes complicated. About one in five emergency room patients in Hamilton gets admitted to a hospital bed. Yet a similar proportion of those beds were already occupied on any given day last year by patients waiting for a long-term placement. "What we're finding coming into the emergency department is a very complex patient," said Krizmanich. "How do you weave that patient into all the services to make sure they're getting total care?" These types of systemic pressures help explain why the Hamilton-area LHIN finished next to last across eight different variables related to emergency department performance. The rankings are part of the Spectator's comprehensive report card on population health and system performance for the province's LHINs. When 24 other variables related to health resources and primary care access were added in to emergency department performance, however, the ranking for the Hamilton-area LHIN improved significantly. Across all 32 variables in this category, the HNHB LHIN ranked sixth overall. The Kingston-area South East LHIN ranked first in this category while the Central West LHIN finished 14th. Among the Spectator's findings: * Less than half of all people in Ontario were able to see their doctor the same day or the day after the last time they needed medical attention. In the North Simcoe Muskoka LHIN, three out of four people were unable to see their doctor either the same day or the day after they needed medical attention; * Slightly more than half of patients in Ontario had to wait four weeks or longer to see a specialist in 2010. That was the worst performance in a comparison survey with eight other countries. In the U.S., just 17 per cent of patients had to wait four weeks or longer to see a specialist in 2010; * The top six LHINs with the highest proportions of specialists per 100,000 people are the six LHINs that have universities with medical schools. The proportion of specialists in the Toronto LHIN is three times the provincial average; * One in seven people in the North East LHIN did not have a family doctor, the highest rate in the province. In the Hamilton-area LHIN, just 3 per cent of the population did not have a family doctor, the second-lowest rate in Ontario. But the Hamilton-area LHIN's low rate of people with no family doctor masks a problem that is highly concentrated in pockets, particularly in Hamilton's lower inner city. According to data obtained for the Spectator's landmark Code Red series in 2010, there were 26 neighbourhoods in Hamilton where at least 10 per cent of the people who showed up in emergency rooms didn't have a family doctor. All 26 of those neighbourhoods were in the lower inner city. Those same neighbourhoods generally had higher levels of poverty, recent immigrants and higher rates of psychiatric-related emergencies. "The primary care physician plays an integral role as being a navigator and as an advocate for the total care for that patient," said Krizmanich. "Without the family physician, it is very difficult to get that all-encompassing care model for that patient." The frustration, Krizmanich explained, is that an emergency department's role is to treat the immediate problem that's presented. "Where it kind of falls down is that we are not going to be able to follow up with them," Krizmanich said. "We aren't their family physician, we can't see the outcomes. We can outline a care path for that patient, but it's so important that you maintain that. "When you see a large increase in high-acuity visits attending emergency departments, somewhere along that line, that's not being managed. Until the next thing comes along and they end up in emergency again." In the Toronto LHIN, by contrast, there's a relative glut of physicians. The Toronto LHIN has more than twice as many family doctors per 100,000 people than the Erie St. Clair LHIN, and six times as many specialists than the Central West LHIN. "There are docs in Toronto who are struggling to make a living," said McMaster University professor D. Wayne Taylor, a health services management expert in the DeGroote School of Business. "You have family docs who do just about everything under the sun. "They're basically underemployed and the cost of living is higher too, remember, so they've got to be making at the top end of the scale to live as well as someone out here in the boonies." A couple of years ago in Cambridge, where Taylor lives, two new family doctors had come to town and were establishing their practice. "They set up tables in an ice rink on a weekend in the summer and within the weekend, they each had their 3,000 patients signed up," said Taylor. "You do that at the corner of Bathurst and Eglinton and I don't know if that's going to happen or not." Info box: EMERGENCY, PRIMARY CARE, RESOURCES: KEY FINDINGS * In eight of the 14 LHINs, less than 50 per cent of their emergency room patients who were eventually admitted to hospital were seen within the provincial target of eight hours. In the worst LHIN Central the proportion was a meagre 23 per cent; * The proportion of health professionals in a LHIN had little connection to its overall ranking in the Spec's report card. The North West LHIN finished 13th overall, yet it had the third-highest proportion of family docs in Ontario, as well as the highest proportion of nurse practitioners and registered practical nurses. The Central West LHIN finished third in the overall rankings, yet it was 13th out of 14 LHINs for the proportion of family doctors and last when it came to specialists, RNs, nurse practitioners and RPNs. Sidebar: A non-stop need for long-term care Subhead: Finding a place in the local cemetery may be faster than getting a bed in a care facility There are 200 beds in St. Patrick's Home, a long-term care residence not far from Ottawa's Carleton University. There were 395 people waiting for one of those beds to become available the last time St. Patrick's CEO Linda Chaplin checked her list. That's more than just an arithmetic puzzle. "It is heartbreaking," said Chaplin. The sad truth is that some of the people on the waiting list will get a spot in an Ottawa cemetery before they get a bed in St. Patrick's Home. At Grace Manor in Ottawa's west end, it's the same story - a 128-bed facility filled to capacity, with hundreds more on its waiting list. Even the good news that St. Patrick's is in the midst of adding 86 new beds to its facility is tempered with the reality that those beds are a drop in the bucket compared to the demand for spaces. "They will be filled and it's not going to make much of a dent in the systemic need," Chaplin acknowledged. Across the Ottawa-area Champlain Local Health Integration Network, which extends from Deep River to Cornwall, thousands of new long-term care beds would be needed just to soak up the excess capacity and help unclog acute-care beds in Ottawa hospitals. On any given day, Chaplin said, up to 150 hospital beds across Ottawa are occupied by people who are waiting to be placed in a long-term care home. The Champlain LHIN had the longest overall wait times of Ontario's 14 LHINs for finding long-term care spots for people, based on data compiled for the Spectator's report card on LHIN health performance. It took 209 days on average for Champlain LHIN residents to get into a long-term care facility, nearly double the provincial average of 113 days. In the Central West LHIN, which includes Dufferin County and Peel Region north of Highway 401, it was 47 days, the best in Ontario. The Hamilton Niagara Haldimand Brant LHIN had an overall wait time of 178 days for placement in a long-term care home, which was the third-longest in Ontario. When it came to the amount of time it took to move patients specifically from acute-care hospitals to a long-term care bed, the Hamilton-area LHIN had the second-longest waits in Ontario at 107 days, nearly twice as long as the average of 58 days. Across 37 different variables related to long-term care and home care, the Hamilton-area LHIN ranked 11th of Ontario's 14 LHINs. Only the Central West, Waterloo Wellington and North Simcoe-Muskoka LHINs fared worse. The Toronto Central LHIN ranked first. Among the Spectator's findings on long-term care and home care: * Nearly four in 10 long-term care residents in the Hamilton-area LHIN reported increased difficulty in performing everyday tasks, the highest rate in Ontario; About one in four home care clients in Ontario reported that their pain is not well-controlled; * One in six long-term care residents was physically restrained at least once in the previous three-month period. That figure is more than double the rates found in other countries, such as the U.S. and Switzerland, and it's an area in need of "major improvement," according to the provincial government's 2011 Ontario Health Quality Report. The Spectator's analysis also raises questions about the appropriateness of the drugs being prescribed to seniors in Ontario's long-term care residences: * About one in five long-term care residents in 2009-10 was being prescribed drugs that should be avoided in the elderly; About one in four newly admitted long-term care residents in Ontario was being prescribed a class of sedatives known as benzodiazepines. In the Hamilton-area LHIN, the rate was 28 per cent, fifth-highest in the province; * One in seven newly admitted long-term care residents was being prescribed antipsychotic drugs without a clear reason. In the Hamilton-area LHIN, the rate was 17 per cent, the third-highest rate in Ontario. The Ontario Health Quality Report again calls this an issue with "major room for improvement." Yes, we have an aging population, and yes, people are living longer. But that's only part of the challenge for those charged with caring for Ontario's elderly population. "There have been many advances in medicine, people live longer and they have more complex medical issues, so their care needs are much heavier," said Chaplin. "I have a lot of long-term staff and they recall new admissions coming here, parking their car in the parking lot and carrying their own luggage in. Now, practically all our new admissions come in by stretcher from hospital." Reducing the number of hospital beds that are being occupied by elderly patients who really need some other form of care has been a major priority for the Hamilton-area LHIN, according to Donna Cripps, the LHIN's CEO. In health care terminology, those are called "alternate level of care" beds, and about one of every six acute-care beds in Ontario hospitals was taken up with ALC. patients last fiscal year. The Hamilton-area LHIN has had one of Ontario's highest rates of beds occupied by ALC. patients, but Cripps said the proportion has been cut in half from July 2009 to September 2011. Part of the success is due to an aggressive strategy to get older patients back into their own homes when appropriate. In the past, Cripps said, an elderly patient with two or more medical issues might end up in hospital for a few days of tests and even a short spell like that could make it difficult for them to get out of bed. "You'd say, Well, I don't know how they can manage at home independently, I think we need to go to a nursing home,'" said Cripps. "And very quickly the decision would be made. "We realize now that care wasn't what we ought to be doing and we've changed that really dramatically." Now, the Hamilton-area LHIN attempts to place those patients in a so-called "assess/restore" bed in a long-term care facility, with the goal of providing short-term rehabilitation for three months or less. Cripps said that for every 100 people transferred to an assess/restore bed, about 80 are ultimately able to return to their own homes. The focus is beginning to shift toward strategies that allow people to remain at home as long as possible, Chaplin said, and providing appropriate levels of home support so they don't end up in hospitals in the first place. "When I talk to groups or organizations, I'll often open by asking, Hands up anybody who sees as one of their goals in life to get a spot in a long-term care facility,'" Chaplin said. "There's just a resounding groan. "That's not a goal for people. They want to be well, they want to be independent." Info box: LONG-TERM AND HOME CARE: KEY FINDINGS * One in four residents of long-term care facilities in Ontario reported worsening symptoms of depression or anxiety; * It took 173 days on average in Ontario to move a person from the community to a spot in a long-term care facility. In the Champlain LHIN, the wait time was 314 days. In the HNHB LHIN, it was 215 days, fifth-highest in the province; * The Hamilton-area LHIN finished significantly worse than the provincial average for seven of the 27 variables specific to long-term care. Date: Wednesday, March 14, 2012 Page: A6: CONDITION CRITICAL Headline: Screening and care for cancer vary wildly across Ontario Subhead: Smoking rates higher here than provincial average. So are the lung cancer numbers. (Day 3 of a five-day series) By STEVE BUIST The Hamilton Spectator Delivering bad news is never easy. Repetition doesn't make it any easier. For Dr. Peter Ellis, a lung cancer specialist at Hamilton's Juravinski Cancer Centre, delivering bad news is an all-too-common part of his job. Nearly 1,000 new lung cancer cases are diagnosed each year in the Local Health Integration Network serving the Hamilton-Niagara-Haldimand-Brant region, the highest number of any LHIN in Ontario, he says. What's worse, the HNHB LHIN also has higher rates of patients who are diagnosed with advanced stages of lung cancer, meaning treatment options are already limited and long-term survival prospects are dim. "A lot of the people I see have disease that from the outset is non-curable and that's challenging," said Ellis. "It's difficult to sit and say to someone, I can't cure your cancer.'" Condition Critical reveals that the Hamilton-area LHIN ranks last in the province based on 32 cancer indicators related to incidence, survival rates, screening and treatment utilization. The HNHB LHIN finished in the bottom five LHINs for 17 of the 32 cancer variables. Among low-income men in Ontario, the Hamilton-area LHIN had the highest rate of lung cancer incidence at 88 per 100,000, tied with the Erie St. Clair LHIN in the Windsor area. Their rates were twice as high as the Central West LHIN, which was best in the province at 43 cases of lung cancer per 100,000 low-income men. The Hamilton LHIN also has the second-highest incidence of cervical and ovarian cancer of the 14 LHINs. Nearly half of the lung cancer patients in the HNHB LHIN are not screened at least once a month for the severity of their symptoms, the third-worst rate in the province. By contrast, 84 per cent of the lung cancer patients in the Central and Waterloo Wellington LHINs are screened at least monthly for symptom severity. At the provincial level, the Spectator's analysis reveals a number of gaps in cancer screening and treatment, as well as shocking differences in rates across Ontario's LHINs: * Excluding lung cancer cases, just 40 per cent of Ontario cancer patients are screened at least once a month for the severity of symptoms. But even that figure masks the glaring differences that exist across Ontario. Less than 5 per cent of the non-lung cancer patients visiting Toronto's two downtown cancer centres are screened at least monthly for symptom severity. In the Central and Waterloo Wellington LHINs, the rate is 79 per cent; * When it comes to chemotherapy, nearly half of Ontario's cancer patients are not seen within the target wait time from referral to consultation. In the North East LHIN, less than 30 per cent of chemotherapy patients are seen within the recommended wait time. In the Central East LHIN, however, the rate is 84 per cent; * One in three women between 50 and 69 didn't have a mammogram in the previous two years, and more than one in four between 20 and 69 didn't have a Pap test in the past three years; * About two-thirds of Ontarians between the age of 50 and 74 have not had a fecal occult blood test in the previous two years, even though the simple, inexpensive screening test can help in the detection of colorectal cancer. When Ontarians between 50 and 74 did take the test and got a positive result, one in three didn't have a followup colonoscopy within six months. * * * "There is certainly a skill in delivering bad news," says the soft-spoken Peter Ellis, an Aussie who came to Canada 12 years ago and became a Canadian citizen earlier this year. "You can never dissociate yourself but it's about being realistic and setting realistic goals. "My goal isn't to cure someone with incurable disease, my goal is to help improve their overall situation. If I achieve that, then I've done something positive for somebody." Lung cancer presents a number of challenges for specialists such as Ellis. For one, there's a stigma attached to lung cancer that is absent for other types of cancer because up to 85 per cent of lung cancers are caused by smoking. In the eyes of some, said Ellis, that makes it a self-inflicted, preventable disease. "You can't treat lung cancer and be judgmental," said Ellis. "That's the bottom line. If you start thinking that this is self-inflicted, then you should be treating something else. "These are people who have real health problems, they're very sick, often with a high burden of symptoms, they have a limited life expectancy," he added. "They need people who are interested in offering them appropriate and effective treatments." But an even greater challenge is the absence of effective early screening for lung cancer, which means patients often have advanced tumours that may have already spread by the time they discover a problem. About half of the province's lung cancer patients have already reached Stage IV - the final stage when the disease has already spread elsewhere - by the time they're diagnosed. Another 30 per cent are diagnosed at Stage III, meaning the disease is locally advanced. Just 20 to 25 per cent are diagnosed in Stages I and II, when surgery is a realistic option. Compare that to breast cancer, where 80 to 85 per cent of patients are diagnosed in the first two stages. "Part of it is the fact that breast cancer has effective screening," said Ellis, "and part of it, as well, is that people aren't as aware of what's happening inside their lungs (and) therefore present not because something is there but because the symptoms have spread." The numbers help explain why the overall five-year survival rate for lung cancer remains discouraging at just 18 per cent in Ontario. Yet when the disease is caught in Stage I or II, Ellis said, "the five-year survival rates are in the ballpark of 50 to 70 per cent." In the Hamilton-area LHIN, several factors contribute to the poor lung cancer performance. Smoking rates in the LHIN are higher than the provincial average, in large part because smoking is strongly linked to people with lower income and lower education. The HNHB LHIN also covers part of Ontario's tobacco-growing territory, as well as the Six Nations reserve, which also has high smoking rates. "The better educated you are and the higher your socioeconomic status, the more likely you are to partake in preventative health behaviours," said Ellis. "So it's not surprising, given the population distribution we have, that we might have low levels of preventative health behaviours. "I think you see that not only in cancer-related issues but also with other lifestyle factors - smoking rates, obesity and alcohol intake are all areas where we have higher rates." Info box: CANCER: KEY FINDINGS * The five-year survival rate for prostate cancer ranges from 90.6 per cent in the South East LHIN to 98.9 per cent in the Central LHIN; * An extra seven people per 100 lung cancer patients reach the five-year mark in the Central LHIN compared to Erie St. Clair; * An extra seven people per 100 colorectal cancer patients reach the five-year mark in the Central West LHIN compared to the South East LHIN; * There are enormous gender and income differences in Ontario's lung cancer rates. For high-income women, the rate is 36 per 100,000; for low-income men, 73 per 100,000. Sidebar: Diabetes is the scourge of the day Subhead: It's a huge problem everywhere, but in northern Ontario, it's close to an epidemic The frustration begins to boil over in Susan Griffis's voice. Griffis is CEO of the Thunder Bay-based Northern Diabetes Health Network, which plans and co-ordinates diabetes care for all of northern Ontario. Diabetes has become a massive problem in Ontario. Between 1995 and 2005, the number of people with diabetes in Ontario more than doubled. In northern Ontario, however, diabetes has moved beyond a problem to near-epidemic status, especially among the native population. The prevalence of diabetes for the province's aboriginal people is three times higher than non-aboriginal Ontarians. In the huge North West Local Health Integration Network, which includes Thunder Bay and Kenora, one in four people aged 65 and over has been diagnosed with diabetes, and the hospitalization rate for diabetes-related problems is more than twice as high as the provincial average. Hence the frustration that spills out of Griffis. "My question is, if chronic diseases are such an issue, which we know they are, why aren't we putting more money into prevention and public health?" asked Griffis. "Is the money going where it needs to go and where it can do the most? "Money keeps being poured in, I believe, in the wrong places. "Sometimes it's not more resources, it's less duplication of those that exist," Griffis added. "All of a sudden, you've got the federal government giving money, you've got the province giving money, you've got doctors going in, you've got nurse practitioners going in, I've got a diabetes nurse going in, I've got a community health nurse and the poor patient is so confused as to who is actually managing their care." The Spectator's provincial report card for chronic diseases has found that Ontario's two northern LHINs lag far behind the rest of the province. Across 51 variables related to chronic conditions such as diabetes, hypertension and chronic obstructive pulmonary disease, the North West LHIN finished last among Ontario's 14 LHINs. The North East LHIN finished marginally better in 13th place, but both LHINs were well behind the rest of their provincial counterparts. The North West LHIN finished last for nearly half of the 51 individual chronic disease variables. The Spectator also applied a statistical measure to determine the significance of the results for each variable in the report card. For 38 of the 51 chronic disease variables, the North West LHIN's results were significantly worse than the provincial average. The North East LHIN's performance was nearly as alarming - 35 of 51 chronic disease results were significantly worse than the Ontario average. Lifestyle factors and unhealthy behaviours contribute to northern Ontario's high rates of chronic disease but geography also plays an important role. Combined, the two northern LHINS have just 800,000 people spread across an area that would be roughly equal in size to Germany and France together. "If I send one of my co-ordinators up to Dryden, it's four hours, with trees, in the middle of winter," said Griffis. "It's a whole different world. "It's not that anybody has it better or worse, it's just to understand the diversity of the needs that we're working with." The Hamilton Niagara Haldimand Brant LHIN ranked ninth in the chronic disease category. The Central LHIN, which encompasses the GTA north of Toronto, finished first. Among the Spectator's findings for chronic diseases: * Only half of diabetes patients in Ontario had an eye exam in the previous 12 months, even though 40 per cent of people with diabetes develop eye disease; * In the South East LHIN, just 6 per cent of men with diabetes and 7 per cent of women with diabetes received care from both a family doctor and a specialist. In the Mississauga Halton LHIN, the rates were more than three times higher; * Nearly half of all low-income women over age 25 in the South East LHIN reported having two or more chronic conditions, which was twice the rate reported in the Central West LHIN; * One in three women and one in four men aged 25 and older reported having arthritis in the North East LHIN. The Spectator's report card also showed massive gender and income differences for some chronic disease markers. Take asthma, for instance. The hospitalization rates for asthma-related problems were nearly 50 per cent higher for low-income people in Ontario compared to those with high income, and the rates for women were more than twice as high as those for men. At one extreme, the rate of asthma-related hospitalizations was 93 per 100,000 low-income women in the North West LHIN, compared to a low of six per 100,000 for high-income men in the South West LHIN. The same trends existed for chronic obstructive pulmonary disease. The incidence of COPD was about 50 per cent higher for low-income people in Ontario than those with high income, and it was about one-third higher for men compared to women. * * * The more Griffis talks about the explosion of diabetes in northern First Nations communities, the more exasperated she gets. She recalls the time a government-funded research organization conducted a study that looked at access to diabetes care. The organization had marked down that patients in the remote native reserves north of Sioux Lookout had access to diabetes care within 30 minutes. "Obviously, I questioned that and they said, Well, we really didn't know. You send up a fly-in team, so they're in the community and when they land it's only about 30 minutes for anybody in that community to visit them,'" Griffis said, incredulous at the logic. "I said, It's once a year they fly in.' "They said, Well, where else do we fit it in?' and I said Make a new box.' "That's the problem, we've got so many different people making judgment calls and decisions," said Griffis. "All I say is get the facts and put the resources where they are needed based on the factual evidence." Sandy Lake First Nation, a remote fly-in reserve in Ontario's far north, has the third-highest rate of diabetes in the world, according to a report by the government's Ontario Aboriginal Diabetes Strategy. More than a quarter of the Sandy Lake population has Type 2 diabetes and another 14 per cent are considered to have a condition commonly referred to as prediabetes. "What we are noticing more in the aboriginal population is the young children who are being diagnosed with Type 2 diabetes, which used to be an old person's disease," said Griffis. "It is frightening." The isolation of northern native reserves also makes it challenging to live a healthy lifestyle. At Big Trout Lake, a remote native reserve a couple of hundred kilometres inland from the shore of Hudson Bay, four litres of milk costs nearly $15 and a five-pound bag of potatoes is $10. Yet a can of Coca-Cola sells for $1.25. "Doesn't that blow you away that something like that is allowable?" asked Griffis. Info box: CHRONIC DISEASES: KEY FINDINGS * 10 per cent of adult men with diabetes in the North West LHIN reported no contact with a GP or specialist over a two-year period; * There were massive gender and income differences in the rate of chronic obstructive pulmonary disease, from a low of 122 per 100,000 high-income women in the Central LHIN to 740 per 100,000 low-income men in the North West LHIN; * 37 per cent of low-income men in the Hamilton-area LHIN reported two or more chronic conditions, Ontario's third-highest rate. Date: Friday, March 16, 2012 Page: A8 CONDITION CRITICAL Headline: Free universal health care isn't free or universal (Day 5 of a five-day series) By STEVE BUIST The Hamilton Spectator We like to think we have free health care in Ontario. We know it's not really free. In fact, we actually pay tens of billions of tax dollars for this "free" health care - the equivalent of about $3,600 a year for every man, woman and child in the province. And we're really talking primarily about hospital and physician services when we talk about free health care. As stated in the recently released Drummond Report, which was submitted to the Ontario government by economist Don Drummond, "the list of services not covered by medicare is long: out-of-hospital drugs, nursing, psychology and other counselling, community mental health services, nutrition advice, ambulance services, addiction treatment, long-term care, eye care and dental care." Nonetheless, we cling to this comforting notion of free health care. We believe that free health care means equally accessible health care for all, since no one needs to bring a chequebook to the doctor's office or emergency room. And, by extension, we believe that equally accessible health care means equal health. As the Spectator's comprehensive new report card clearly shows, however, there's nothing equal about the health of Ontarians. Across 266 different health indicators, the spreads from top to bottom separating the province's 14 Local Health Integration Networks are disturbing. For some variables, rates differ by three or four times from the best LHIN to the worst in a province where everyone, in theory, has equal access to the same standard of health care. When all of the indicators are taken together and added up, the overall ranking of Ontario LHINs paints a more worrisome picture. It's a portrait that would be familiar to readers of the Spectator's Code Red series in 2010 and the subsequent BORN project from four months ago. The LHINs with the wealthiest and best-educated populations in the province - essentially Toronto and the suburban ring around it - perform significantly better than poorer LHINs, which includes the Hamilton-area LHIN, ranked just 11th out of 14. Whether it's the results of Code Red or BORN or the LHIN report card, the connection between health and wealth seems undeniable. At a time when the sustainability of Ontario's health-care system is under the microscope, so too is the whole model of health care and what it means to keep people healthy. As the Drummond Report noted, the health-care system is only part of the picture. "We need to get past our myopic focus on health care to a broader view of health more generally," Drummond wrote. "Health is much more than patching up people once something has gone wrong." When the Drummond Report was released last month, much of the public's attention was fixated on the doom-and-gloom number-crunching. But read the chapter on health and there's another more important message that shines through. Ontario's current model of health care is ill, and it's time to try a new prescription. Based on the findings of the Spectator's report card, here are five issues facing Ontario's health-care system and its 14 LHINs: * The one percenters Much ink was spilled over the past year about the Occupy Wall Street movement that took root in New York. Its aim was to draw attention to the issue of income inequality, highlighted by the statistic that the richest 1 per cent of Americans takes home 24 per cent of the nation's income. Ontario's health-care system has its own version of the "One Percenters." In some ways, it's an even more frightening statistic. One per cent of Ontarians accounts for nearly half of all the province's hospital and home-care costs, according to figures contained in the Drummond Report. Take it a step further: 10 per cent of Ontarians consume 95 per cent of hospital and home care costs "That's a remarkable figure," said Murray Glendining, executive vice-president of corporate affairs for Hamilton Health Sciences. "That in itself tells you something. "It's not a wellness system," he said. "We're fixing up sick people." Apparently the same ones, over and over. When both Ontario and B.C. analyzed their data for clues, the 1 per cent problem came into sharper focus. These frequent flyers were typically "complex in-patients," as they're called, suffering from multiple illnesses. The B.C. study showed that a significant proportion of these complex patients had six or more illnesses. Many of the patients are elderly and they also are more likely to have lower incomes and less education. Mental health and addiction issues were also a factor, especially when it came to emergency room use. Records show there was one person who turned up 148 times over the past 12 months in the various ERs of the Hamilton-area LHIN. For those types of heavy ER users, Glendining said, "it's basically one of two things - it's mental health or it's unspecified pain, which typically means a request for some drugs. "Now that we have this information, we can actually flag these patients when they present in emergency. This person was in Jo Brant last night and Brantford the night before.'" * Moving beyond the eHealth boondoggle For many people in Ontario, the term "ehealth" is associated with failure and waste. They remember the provincial auditor's damning report and headlines that suggested $1 billion had been squandered on the development of an electronic health management system with little to show for it. What they may not realize is that ehealth solutions are quietly being pushed ahead. "Let me let you in to the best kept secret in this province - it's what we have here," said Glendining, who is also the ehealth lead for the Hamilton-area LHIN. He's talking about ClinicalConnect, an in-house ehealth system at Hamilton Health Sciences that has been expanded to now serve both the Hamilton-area LHIN and the neighbouring Waterloo Wellington LHIN. ClinicalConnect is an ehealth system that links the 28 hospitals and two Community Care Access Centres in the two LHINS, as well as 2,500 health-care providers. "And we've done it for a fraction of what it's costing the rest of the system," added Glendining. "What we've learned from this data is incredible in terms of things we would never have known five years ago when you had eight different hospitals that never spoke to each other," said Glendining. "Now the data is all shared. Everyone has access to the aggregate level. "Some of the stuff we're learning is just out of this world in terms of how people use the system, who uses the system and who abuses the system," he said. The key, Glendining said, was recognizing that there wasn't necessarily a need to create a provincewide ehealth system. "Ninety-nine per cent of the clinical information for a Hamilton patient starts and ends in this community," said Glendining. "Very little comes from outside. "As such, regional solutions make sense as long as they can talk with other regional solutions when required," he added. "It also means we do not need to wait for the rest of the province to catch up with us." The Drummond Report agrees. "History has shown that huge IT projects are unwieldy," Drummond wrote. "Most gains will come from local and regional records, so electronic recordkeeping should begin with (family health teams) and hospitals; these could then be connected and expanded from this base." But ehealth isn't just about the electronic storage and sharing of online medical records between hospitals and physicians. The Drummond Report envisions an Ontario where patients can access their own records and test results, and go online to book their own appointments at times they find convenient. * Patients versus consumers and the "threat of exit" If you walked into your local big-box retail store and were told you'd have to wait 427 days to get a toaster oven - and that you might have to drive to Sault Ste. Marie to pick it up - your reaction would be fairly predictable. Once you stopped laughing, you'd head down the street to the next store and buy your toaster oven there. In the North East LHIN, one out of every 10 knee replacement patients has to wait at least 427 days for the procedure, and some of those patients end up being seen by specialists hundreds of kilometres away from their homes. So why do we, as patients, tolerate behaviour that we would never dream of accepting as consumers? "Because we don't have that sort of money moving with patients," said McMaster University professor Stephen Birch. "The patient is not in charge in that sense." Birch is an expert in McMaster's Centre for Health Economics and Policy Analysis and a former board member of the Hamilton Niagara Haldimand Brant LHIN. "The patient is still being directed by the provider," said Birch. "If we could bring that into the system more, then it might help to focus the minds of the providers." And what could help sharpen that focus? It's the "threat of exit," as Birch calls it: the ability of patients to move their health care around - and, more importantly, the funding attached to it - to the places where the needs can best be accommodated. Birch describes a British example involving the simple case of blood tests. Under the old model, a doctor would send a patient to the hospital for blood work and the hospital would say it will take two weeks to get the results back. Control of the money for the blood tests was then transferred into the hands of the family doctors. In essence, they were now free to buy blood tests for their patients from anywhere. "They started saying, Fine, we'll go to a private lab for these tests because they say they can get back to us in 24 hours,'" Birch recalled. "As soon as that threat of exit was used, it focused the hospital's mind. They realized they were going to lose money." Lo and behold, the hospitals started to match the private labs for speed and efficiency. As one family doctor reported, Birch joked, "we used to have to send Christmas cards to the hospitals, now they send them to us.'" Here in Ontario, the threat of exit exists in theory. Patients do have the ability to seek care in communities outside their own LHIN, but as Birch notes, "I don't think it's ever used in practice. "You have the right to do that, but I don't think a lot of patients are aware of that," said Birch. "I certainly don't think the providers are interested, in any way, in pushing that because it's likely to affect the funding that's coming into the area. "The system needs to be about what's best for the patient, but a lot of time it's what's best for the providers." Neil Johnston, a McMaster researcher and collaborator on the Spectator's Code Red and BORN series, said LHINs should be recognized for what they are - a purchasing authority that acts on behalf of its residents. "We'd like to feel confident they're making the right decisions on our behalf so that when we need care we get the best available service," he said. "If that is not available within the LHIN, then perhaps the LHIN should be empowered to purchase that service from someone else." * The juggernaut and the tsunami Dr. Stuart Connolly is not sounding particularly hopeful about the future. At times, he's even downright pessimistic. "It's a slow, ongoing crisis," said Connolly, a cardiologist at Hamilton Health Sciences. "As someone described it to me recently, it's a huge catastrophe in slow motion as this baby boom gets older and older. They're just getting into the expensive years now." The sustainability of Ontario's health-care system is a growing concern. Since 1997, the health-care budget has grown to about $47 billion from $17 billion and health care now consumes nearly half of the provincial budget. "Health care is a huge juggernaut that's rolling along with all sorts of structural elements that are very hard to change," said Connolly. "It's hard to make it change direction. "It's difficult to make improvements in very fundamental things involved in day-to-day care, it's hard to change behaviour, it's hard to change systems. "What we need to do is learn how to deliver simple things better and learn how to discriminate the expensive things that we really need from the ones that we don't really need, which we don't do well," Connolly explained. "There are a lot of competing interests out there and everyone wants their high-tech thing to be the one that we buy and we use and we're not very good at sorting through the huge shopping list of expensive things we could use to improve health care in Ontario." And heading toward the health-care juggernaut is a baby boom tsunami. "Can we continue to deliver even what we're currently doing?" Connolly asked. " As the baby boom continues to age and the younger generation is in a sense thinned out, we're facing a true crisis in terms of our ability to sustain the cost of it," he said."It's a huge number and it's going up every year and no one knows how to control it." The Drummond Report makes a similar warning, noting that Canada's health-care system was one of the most expensive compared to other countries in the Organization for Economic Co-operation and Development. "Worse, many of the other countries have older populations than Canada," the report stated, "so, other things being equal, our system should be less expensive because health spending rises sharply with the age of the population. "Adjusted for age, Canada definitely has one of the most expensive systems." * LHINs and the medical school phenomenon Of the top six LHINs in the overall rankings of the Spectator's comprehensive report card, five of them are LHINs that do not have universities with a medical school. Conversely, the LHINs that include the medical schools of the University of Ottawa, Queen's, Western, McMaster and the shared northern Ontario medical school finished seventh, eighth, ninth, 11th, 13th and 14th respectively. It seems counterintuitive, doesn't it? "Academic health science LHINs are supposed to be the best, both in quality and resourcing," said McMaster professor D. Wayne Taylor, a health services management expert in the DeGroote School of Business. "Obviously, there are other things at work." Taylor has a theory that he admits is "purely subjective." "It's been my experience that community hospitals are more flexible, community hospitals are more responsive, community hospitals are able to change and improve faster than teaching hospitals," said Taylor. "Because of the university connection, they're just by nature very, very small-c conservative. "For one thing, there's just so many layers of decision-making," he added. "Secondly, those decisions have to be taken in tandem with the university and the teaching faculties. There's just such inertia as size gets bigger. Since their creation five years ago, LHINs have been criticized for everything from administrative costs to ombudsman André Marin's scathing "LHIN Spin" report in 2010 to charges they lack true fiscal power - a point also made in the Drummond Report. But Drummond's report also says LHINs can and should play a key role in revamping the province's health-care landscape. "In principle, and even in name, the LHINs were given responsibilities and roles that are essential to a co-ordinated regional health system," Drummond wrote. "However, it is now apparent that LHINs were not given the proper authority or resources to execute the vision for Ontario's renewed health system." The question is whether the LHINs and the health ministry can learn to play in harmony, said Johnston, the Mac researcher and Code Red collaborator. "We've got 14 LHINs which means we've got 14 members of the band. Either we've got a jam session or we've got a symphony orchestra," Johnston said. "And if we don't have a symphony orchestra, then we need a conductor." "Without that, then the rest of this discussion is relatively pointless." INTERACTIVE GRAPHICS FOR THE CONDITION CRITICAL SERIES: http://www.thespec.com/website/thespec/article/685536--interactive-graphic-lhin-rankings http://www.thespec.com/website/thespec/article/686664--interactive-graphic-how-the-lhins-rank http://www.thespec.com/website/thespec/article/685556--interactive-graphic-lhin-wait-times http://www.thespec.com/website/thespec/article/685537--interactive-graphic-a-snapshot-of-ontarios-lhins Story 2 gallery/2012IN_11/1357326202_1.txt Story 3 gallery/2012IN_11/1357326202_2.txt Story 4 gallery/2012IN_11/1357326202_3.txt Story 5 gallery/2012IN_11/1357326202_4.txt Supporting letter (optional) gallery/2012IN_11/1357326202_5.txt   Author Steve Buist Year 2012 Affiliate Waterloo Region Record Finalist Steve Buist Waterloo Region Record   Isabelle Hachey La Presse   David Bruser & Jesse McLean Toronto Star   King\'s College Investigate Workshop, Huffington Post Canada Huffington Post Canada