Only in Ontario could a report from a one-man committee proposing service cuts, administrative upgrades and tax changes be awaited with such breathless anticipation.
On Wednesday, Don Drummond, a former federal government mandarin and bank economist, will present the final report of the Commission on the Reform of Ontario's Public Services.
Speculation on what will be in the report is rampant, with reporters parsing every ministerial statement for clues, and anxious interest groups issuing speculative pre-reactions.
(The absurdity is captured well in a little film by the TVO flagship public affairs show The Agenda called Waiting For Drummond – a clever twist on the play Waiting for Godot.)
The reality is that Mr. Drummond has been around the block a few times. Everyone on the "circuit" – the never-ending conferences, roundtables and inquiries in which experts share wonderful ideas for health reform that are rarely, if ever, implemented on a large scale – has a pretty good idea what he is going to say. Not the precise details, but the gist.
The reality, too, is that the Ontario government knew exactly what it was getting when it hired Mr. Drummond for the $1,500-a-day consulting gig. A middle-of-the-road government hired a middle-of-the-road guy to do "re-imagining." There will be no bombshells and no bombast.
Here are the Top 10 messages you can expect:
1) There is no magic bullet: The health system doesn't require radical surgery but long-term therapy. Incremental change in several areas is how the system is going to be made sustainable.
2) Across-the-board cuts don't work. They were an abject failure in the 1990s. They are a recipe for short-term pain and no long-term gain. You need to pick your battles to decide what will be funded by medicare and what won't.
3) Over time, a shift in emphasis is needed from sickness care to prevention. But one is not a substitute for the other.
4) Inefficiencies are a killer: Canada has one of the most expensive health systems in the world, and mediocre outcomes. We are not getting value for money. It is estimated that one-quarter of all health spending is wasted through inefficiency.
5) Public health insurance plans like OHIP should not pay for every service available; only for cost-effective treatments. Independent bodies like Health Quality Ontario can provide evidence-based advice on rationing based on results.
6) Health-care delivery should be better co-ordinated. The way to do that in Ontario is to give LHINs (local health integration networks) the authority, resources and accountability to ensure patient journeys are more seamless.
7) Pay more attention to the heaviest users: five per cent of patients account for almost 80 per cent of health costs. If you manage their care, you manage costs.
8) Health professionals – physicians, in particular – should be paid for the quality of care, not only the quantity of services they provide. The system needs more incentives – and payments should be tied to outcomes.
9) The health system is designed to bring the patient to the practitioner, often in a hospital setting. Patient-centered care means bringing care to the people with home care and community-based clinics. But community care has to be a substitute for institutional care, not an add-on.
10) The public-insurance model is sound. Creating a parallel private system might bring some efficiencies, but widespread privatization would distract politicians and the public and impede necessary reform.
The key between-the-lines message is to make the patient-taxpayer the priority and stop kowtowing to self-interested "stakeholders."
Even before Mr. Drummond's specific recommendations have been issued, the turf-protecting spin has begun.
The Ontario Health Coalition, a largely union-funded group, warned grimly of "dramatic" cutbacks in the range of $3-billion to $4-billion, with hospital, home care and nursing homes bearing the brunt. It is purely coincidental, of course, that these are the workplaces of unionized employees. The Ontario Medical Association, representing the province's physicians, crowed that it has already "helped find" $240-million in health-care savings and that it is 100-per-cent supportive of efficiency improvements – as long as these changes do not result in fewer physicians, lower incomes or less autonomy for doctors. The association representing Community Care Access Centres is touting the need for "functional reform" that, surprise, surprise, would expand the role of CCACs.
These are but three random examples of the virtual mountain of commentary we can expect denouncing Drummond report as having gone too far or not far enough.
Drawing up the list of recommendations for change was not easy, but it was the easy part of the exercise.It's now up to the government to withstand the mock outrage and make changes that will improve care.
There is broad consensus that the status quo is not working for patients – in terms of affordability, quality and timeliness of care. It's not going to get better unless someone will take on the vested interests in the public interest. That someone has to be the government, from the Premier on down.
Mr. Drummond will provide proposals that would pinch everyone a lot but savage no one. What we can expect is not the offering of the Grim Reaper out to destroy medicare but a level-headed functionary who wants it to flourish, albeit in a little more austere, less profligate fashion.
André Picard