Article from the Kingston Whig-Standard in Regards to the Deputation
Three and a half years ago the first Access Centre in Ontario, the Conservative government’s new agency for coordinating home care, opened in Kingston. Since then much has changed in community health care - mostly for the worse. The changes include: staff shortages, more frequent waiting lists, nurses working piece work, more for-profit agencies delivering health care, increased secrecy and a climate of fear among home care providers.
Four years ago the province mandated that all direct patient care must be contracted out. A process of competitive bidding was to be used to decide which companies would receive the contract to provide patient care. The local Access Centres cannot change this process but it can take actions to improve the results.
On November 30, 2000, the Kingston Health Coalition made a presentation to the Board of Directors of the Kingston Access Centre. We made recommendations on how the Centre could be more democratic, open and accountable. Steps were outlined that the local Kingston agency could follow to reduce the negative effects of the competitive bidding process. This article is the first part of two parts summarizing that presentation. Text in quotes is taken directly from the brief.
Democracy and Openness
There are 43 Access Centres in Ontario. Kingston is one of a few, if not the only one, that restricts its membership. The Centres were expected to be community controlled, with a large broad-based membership that would elect the Board of Directors. This is not what happens in Kingston.
The Kingston Access Centre limits its membership to 60 (30 from Kingston, 15 from Frontenac County and 15 from Lennox and Addington). “By limiting its membership to sixty the [Access Centre] has created a significant barrier to community governance. To make matters more undemocratic the Coalition knows of no guidelines to determine who will be selected for membership if more than 60 people apply. What Kingston has 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.”
It is also important, if the Access Centre is to represent the people it serves, to include communities that have increased health care needs and special care requirements among its members and Board of Directors.
To address these concerns the Kingston Health Coalition recommends that the Kingston Access Centre:
* remove the limit on the number of voting members.
* 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 Kingston Access Centre spends 24 million public health care dollars a year. This means that, to the maximum extent possible, the residents of Kingston and area should have full knowledge of the operations of the Access Centre, where the money is going, and the conditions that govern care.
The Access Centres’ annual reports are so general that they are not useful in understanding how our home care money is spent. “ 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 [for direct patient care] that outline the quality of care. In order for the public and for people receiving care to be able to effectively evaluate the performance of the Access Centre 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 we can evaluate whether the agencies and the Access Centre are providing the necessary protections for our care.
The Kingston Health Coalition recommends that the:
* 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.
* The details of the contracts between the Access Centre and the provider agencies should be public, especially with respect to matters affecting the delivery of service and quality of care.
This is the second of two article presenting a deputation that the Kingston Health Coalition gave the Board of Directors of the Kingston Access Centre, the agency that oversees home care in Kingston. The brief was presented on November 30. The text in quotation marks is taken directly from the presentation.
Since 1996 the provincial government has required that all direct patient care in the community be contracted out through a competitive bidding process.
“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 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. “
The local Access Centre is required to use this competitive bidding process, but they have significant local control that can help improve the system. Unfortunately, some of the results of the early contracts awarded in Kingston have shaken the communities faith in the process. The process was not open and transparent and the results did not appear to be fair.
The first contract for palliative care and oncology “went to an agency that did not have an adequate palliative care team and had to hire an agency that was rated below it in quality to train its nurses in palliative care. 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 happened despite earlier assurances from Access Centre staff that one of the first criteria any agency must meet when applying for a contract is one of financial stability.
The Kingston Health Coalition recommends that:
* The Access Centre 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.
The competition for contracts and the insecurity inherent in the process “has created a climate of fear in home care. Agencies are afraid to speak up and often prohibited in their contracts from criticizing Access Centre conditions. Staff feel a need to support the system and its policies so that they will not jeopardise future work.”
This climate of fear negatively affects quality of care. “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.” The recent inquest into the death of eleven month old Trevor Laundry recommended that “staff should be encouraged to report recommendations and enhancements to improve hospital systems”. A similar logic applies to community care.
We recognize that the province imposed the competitive bidding system and that the Access Centre can not directly change it. We feel, though, that there is an obligation on the Access Centre to be documenting problems with the system, encouraging open public debate, and publicly making the case that this system has to change.
Continuity of Care
“Continuity of care is primary achieved by having a 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.” The Access Centre can and should use the contracting process to improve wages and working conditions of home care workers.
The Kingston Health Coalition recommends that the Access Centre:
* Include in contracts a minimum percentage of regular part-time and full time health care providers that the agency must employ.
* Establish minimum wages and benefits, equivalent to the major province-wide institutional contracts, that agencies must meet before they can receive Access Centre contracts.
* 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.
* Remove from agency contracts ‘gag clauses’ that prohibit agencies from discussing the terms of the contracts.
* Work with community organizations to accumulate data on the costs, inefficiencies and other detrimental effects of the competitive bidding-contracting out system.
* To ‘kick start’ this process we would like to hold a public meeting with members of the Access Centre Board of Directors and senior staff to discuss these and other community care issues with Health Coalition members and other interested Kingston residents.
The Kingston Health Coalition is waiting for a reply from the Access Centre’s Board of Directors to its recommendations.
Ross Sutherland is one of the co-chairs of the Kingston Health Coalition.