November 30th, 2000
Deputation Presented to the CCAC
Thank you for taking time to hear our concerns. The Kingston Health Coalition is a coalition of groups and individuals from the Kingston area who area committed to preserving and developing a public non-profit health care system that will meet the needs of our community. Attached to the back of our deputation is a copy of the Coalition's Statement of Purpose.
In keeping with our Statement of Purpose we would like to address issues that we believe will improve the quality of home care in Kingston, specifically focussing on the areas of governance, accountability and quality of care.
The provincial government, in its background documents setting up the CCACs, describes them as community non-profit agencies which are controlled by members from the community. It is clear that the government’s conception was of organizations that would have a large, growing and involved membership. For most CCACs in Ontario this is at least a possibility, if not a fact. The KFL+A CCAC has taken another route. By limiting its membership to sixty the KFL+A CCAC has created a significant barrier to community governance. To make matters more undemocratic we know of no guidelines to determine who will be selected for membership if more than 60 people apply. What we have here is a situation where the board arbitrarily selects a limited membership who then elects the board. This has both the appearance and reality of an undemocratic procedure which is a barrier to community control.
We understand the limit of 60 members is in part an attempt to ensure some fairness of representation for the counties. We agree with this concern but feel that it can be achieved ed through other measures, for example, allotted positions on the board. With a similar intent we would also like to suggest that steps should also be taken to increase the involvement of other communities that are likely to be under represented, specifically, visible and ethnic minorities, the disabled, people with mental illness, the under housed, and lower income people, including those on welfare. It is particularly important to involve those groups that have increased health needs and special care requirements. We think it would improve the democratic nature of the CCAC if measures were taken to increase representation from these members of our community, both in the membership and on the board.
1) remove the limit on the number of voting members.
2) increase representation in the voting membership from various communities that are likely to be under represented, including, the disabled, the mentally ill, ethnic and visible minorities, the under housed, and the low income residents, including those on welfare.
The accountability of the CCAC to the community should be a central component of its existence as publicly funded agency delivering an essential service. This means that, to the maximum extent possible, the residents of Kingston and area should have full knowledge of the operations of the CCACs, where the money is going, the conditions that govern their care, and access to the CCAC for answers and input. Having a democratic membership as outlined above is an important part of accountability but it is only a start.
While the CCAC issues annual reports they are so general that they are not useful in understanding how our money is being spent on home care. We know which agencies are potentially receiving public money but we have no idea how much they are receiving and how this amount is changing over time. The expenditure of money is not open and transparent.
Similarly, we assume that there are provisions in the contracts that outline quality of care and service delivery issues. In order for the public and for people receiving care to be able to effectively evaluate the performance of the CCAC and the provider agencies, we need to know what is in the contracts. As a comparison, when a road is built with public money we know how long it is supposed to be, the type of materials used, time lines, and many other details as part of the public record. When receiving intimate personal care we have very limited knowledge of the rules under which the workers and agencies proving that care work. As with the actual expenditure of public money all aspects of the contracts need to open and transparent. We have a right to be informed so that we can assess how agencies are treated, and so we can evaluate whether the agencies and the CCAC are providing the necessary protections for our care.
Another element of accountability is that in the awarding of contracts the process has to be open and transparent and yield results that are and appear to be fair.
The first complete round of ‘competitive bidding-contracting out’ shook the community’s faith in this CCAC’0s procedures. Awarding a palliative care and oncology contract to an agency that did not have an adequate palliative care team and had to hire an agency that was rated below it to train its nurses in palliative care raises serious doubts about the process.
The results of the second round of palliative care contracts fared little better. One of the winning agencies, Caregivers, went into receivership promptly after receiving the contract. This unfortunate result happened despite earlier assurances from CCAC staff that one of the first criteria any agency must meet when applying for a contract is one of financial stability.
We would encourage you to have a full public review of the way contracts are awarded.
3) There should be a public record of how much money is actually spent on each agency under contract, not just a listing of agencies and total figures by broad categories.
4) The details of the contracts between the CCAC and the provider agencies should be public, especially with respect to matters affecting the delivery of service and quality of care.
5) The CCAC should undertake a full review, with public input, of the way it awards contracts in order to improve the system and boost public confidence in the process.
Quality of Care
While there are numerous actions the CCAC can take to improve quality of care, it is important to recognize that the competitive bidding process and under funding are the main threats to the quality of community health care.
The competitive bidding process is making it more difficult to attract, train, and keep the quality of staff needed to provide excellent home care. The process has created tremendous duplication in the system, excess administration and profit taking, all of which are diverting needed dollars from patient care to running the system. The reality of using competing companies, with the work divided between many agencies, is that it is very difficult for all the health care professionals and workers involved in a patient’s care to share information and coordinate their efforts. This harms quality of care. Staff are demoralized, burdened with excess bureaucracy and heavy case loads, all of which harm the quality of care. And finally the competition and insecurity of contracts has created a climate of fear in home care. Agencies are afraid to speak up and often prohibited in their contracts from criticizing CCAC conditions. Staff feel a need to support the system and its policies so that they will not jeopardise future work. This climate of fear is important because one of the main safety measures in health care is the ability of providers, organizations and individuals to openly question orders and practices they feel might compromise someone’s health.
We recognize that the province imposed the competitive bidding system and that the CCAC can not directly change it. We feel, though, that there is an obligation on the CCAC to be documenting these problems, encouraging open public debate, and publicly making the case that this system has to change.
Continuity of care is primary achieved by having committed, well trained staff who are enthused by their work. Research in Canada shows that community health care workers in non-unionized environments with poor working conditions have a turnover rate twice as high as those in unionized agencies with stable working conditions and better wages and benefits. We believe this is a key to continuity of care. The CCAC can and should use the contracting process to increase continuity of care, a central component of quality of care.
6) Include in contracts a minimum percentage of regular part-time and full time health care providers that the agency must employ.
7) Establish minimum wages and benefits, equivalent to the major province-wide institutional contracts, that agencies must meet before they can receive CCAC contracts.
8) Meet with unions and workers involved in the community health care sector to consider other ways of using the competitive bidding system to increase staff retention and training.
9) Remove from agency contracts ‘gag clauses’ that prohibit agencies from discussing the terms of the contracts.
10) Work with community organizations to accumulate data on the costs, inefficiencies and other detrimental effects of the competitive bidding-contracting out system.
11) To ‘kick start’ this process we would like to hold a public meeting with members of the CCAC Board of Directors and senior staff to discuss these and other community care issues with Health Coalition members and other interested Kingston residents.
Thank your for your time today. We welcome any comments and questions.