Distributed Democracy: Health Care Governance in Ontario 9781487535872

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DISTRIBUTED DEMOCRACY Health Care Governance in Ontario

The Institute of Public Administration of Canada Series in Public Management and Governance Editors: Peter Aucoin, 2001–2 Donald Savoie, 2003–7 Luc Bernier, 2007–9 Patrice Dutil, 2010–18 Luc Juillet, 2018– This series is sponsored by the Institute of Public Administration of Canada as part of its commitment to encourage research on issues in Canadian public administration, public sector management, and public policy. It also seeks to foster wider knowledge and understanding among practitioners, academics, and the general public. For a list of books published in the series, see page 219.

Distributed Democracy Health Care Governance in Ontario

CAREY DOBERSTEIN

UNIVERSITY OF TORONTO PRESS Toronto Buffalo London

© University of Toronto Press 2020 Toronto Buffalo London utorontopress.com Printed in the U.S.A. ISBN 978-­1-­4875-­0725-­1 (cloth) ISBN 978-­1-­4875-­3588-­9 (EPUB) ISBN 978-­1-­4875-­3587-­2 (PDF)

_____________________________________________________________________ Library and Archives Canada Cataloguing in Publication Title: Distributed democracy : health care governance in Ontario / Carey Doberstein. Names: Doberstein, Carey, author. Series: Institute of Public Administration of Canada series in public management and governance. Description: Series statement: Institute of Public Administration of Canada series in public management and governance | Includes bibliographical references and index. Identifiers: Canadiana (print) 20190224088 | Canadiana (ebook) 20190224266 | ISBN 9781487507251 (cloth) | ISBN 9781487535872 (PDF) | ISBN 9781487535889 (EPUB) Subjects: LCSH: Public health administration – Ontario – Evaluation. | LCSH: Public health – Political aspects – Ontario. | LCSH: Public health – Ontario – Citizen participation. | LCSH: Medical policy – Ontario – Evaluation. Classification: LCC RA450.O5 .D63 2020 | DDC 362.109713 – dc23 ___________________________________________________________________________________ This book has been published with the help of a grant from the Federation for the Humanities and Social Sciences, through the Awards to Scholarly Publications Program, using funds provided by the Social Sciences and Humanities Research Council of Canada. University of Toronto Press acknowledges the financial assistance to its publishing program of the Canada Council for the Arts and the Ontario Arts Council, an agency of the Government of Ontario.

Funded by the Financé par le Government gouvernement du Canada of Canada

Contents

Foreword  vii Acknowledgments  xi List of Abbreviations  xiii 1 Introduction  3 2  The Democratic Arenas Framework  20 3  The Evolution of Health Care Governance in Ontario  41 4  Procedural Decision-­Making Bodies That Enable and Constrain LHINs  62 5  LHINs as Mandated Decision-­Making Sites  90 6  LHIN Advisory Committees and Public Engagement  115 7  A Democratic Arenas Analysis of LHINs  148 Appendix  179 Notes  181 References  203 Index  211

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Foreword

The provision of health care services is one of the most important functions of the modern welfare state. Few areas of public administration touch the lives of citizens so directly, significantly, and universally, which helps explain why they care so much about the state of health care. Health services also consume a vast amount of public resources. According to the Canadian Institute for Health Information, national annual health expenditures are projected to reach $264 billion in 2019, representing nearly 12 per cent of Canada’s GDP. About 70 per cent of this money is spent by government. This year, the Ontario government will spend over $60 billion to offer health care services to an aging and very diverse population, a sum representing over 40 per cent of the province’s total program spending. Given the importance of health care for citizens and governments, the governance and organization of health services constitute a central challenge of public administration, which is partly why this book by Carey Doberstein is such a welcome addition to the IPAC Series in Public Management and Governance. Beyond the impact of competing organizational designs and models of service delivery on health outcomes, core issues of democratic government are at stake in the governance of health care. For example, where should decision-making authority be located to ensure an optimal combination of effective stewardship, central control and planning, attentiveness to local needs and conditions, efficient delivery, and effective accountability? To what extent, and how, should elected officials, public managers, citizens, physicians and other health professionals, patients, and other stakeholders be involved in decisions about service availability and delivery? Given the bewildering complexity of health systems, how can we ensure that they still permit democratic control, citizens’ input, and accountability?

viii Foreword

In this timely book, Doberstein helps to tackle such questions by providing a sophisticated and nuanced assessment of one of the latest attempts at improving the governance of health services in Canada: the creation of Local Health Integration Networks (LHINs) by the government of Ontario in 2004. Despite their name, LHINs are essentially regional semi-autonomous Crown agencies, answerable to the minister of health and her department but also governed by their own corporate board, tasked with ensuring the coordination of health service providers in their region. Benefiting from some decision-making authority and a collective budget of about $25 billion, they are also meant to decentralize and democratize health care administration by providing citizens and stakeholders with the opportunity to influence policy and investment decisions at the regional level. In sum, LHINs are at the centre of a complex system of regionalized health care governance. In the following pages, Doberstein offers a systematic and balanced examination of one of the key aspects of the LHINs: their democratic character. Through a close examination of their legal and institutional framework, their governance practices, and their relationships with the health ministry, stakeholders, and citizens, he shows that, while the LHINs sometimes succeed in expanding opportunities for stakeholder input, they also largely remain under the control of the government and its health department, often fail to ensure meaningful and inclusive local representation and participation, ensure only limited coordination across decision and planning venues, and at times suffer from weak or dysfunctional accountability mechanisms. In sum, despite some notable democratic advances in the governance of provincial health care, the LHINs are falling short of their promise due to a combination of design flaws and poor local choices in governance practices. For readers who follow debates about health care policy and governance, shortcomings in the LHINs’ operations may not be surprising. Like other experiments of regionalization of health services across the country, Ontario’s LHIN system has attracted its share of criticism, notably for being excessively bureaucratic and complex. In fact, in April 2019, the Progressive Conservative government of Doug Ford enacted another restructuring of the provincial health care system that will recentralize its governance by creating Ontario Health, a new powerful “superagency” that will oversee the coordination of health care across the entire province and largely absorb the fourteen LHINs (as well as other agencies) over the next three years. However, Doberstein’s analysis provides a much more systematic and nuanced assessment that goes well beyond the typical critique and will allow the reader to much

Foreword ix

better understand the strengths and weaknesses of the LHINs as a model of regionalized health care governance. As such, the book provides insights that will not only be valuable for understanding health care governance in Ontario over the past fifteen years as well as passing judgment on whether current reforms are likely to address current flaws. By conceptualizing health governance as a system of interrelated democratic arenas through which decisionmaking authority is (more or less) distributed, Doberstein also provides a conceptual framework that can serve to guide the analysis of the democratic governance of health systems of other jurisdictions. In fact, the book will also be of interest to people working in other policy areas where network-based distributed governance is being attempted or contemplated. At a time when network governance and the co-creation of public services are among the most hotly debated issues of public administration, Distributed Democracy offers conceptual tools and analytical insights that are relevant to scholars and practitioners in most areas of public management and governance. In sum, it is a timely book that undoubtedly speaks to contemporary health policy debates, but that addresses fundamental problems that specialists of public administration will have to contend with for years to come.   

Luc Juillet, PhD University of Ottawa Editor, IPAC Series in Public Management and Governance

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Acknowledgments

Many people made helpful contributions, from the origins of the research puzzle through to the development of the manuscript. I would first like to acknowledge the financial support of the Social Sciences and Humanities Research Council (SSHRC) through an Insight Development Grant (IDG) from 2015 to 2018 that allowed me to support a team of research assistants and attend academic workshops and conferences to advance this work. Max Cameron provided immensely helpful comments on my draft SSHRC IDG documents through UBC’s Support Programs to Advance Research Capacity (SPARC), which was critical to my successful grant application. I am grateful to research assistants who gathered and distilled an enormous amount of information and data from the LHINs: Jasmine Reimer, Michael Flood, Amber Krogel, and Darielle Talarico. I have had the benefit of the insights and critical commentary from many colleagues who read pieces of this research in various states of (under-­ )development: Daniel Beland, Katherine Boothe, Amanda Clarke, Jonathan Craft, Patrice Dutil, Kyle Kirkup, Evert Lindquist, Susan Phillips, Beryl Radin, Jerry Sabin, Alison Smith, Phil Triadafilopoulos, and Özge Uluskaradag. Daniel Quinlan has been a treat to work with as my acquisitions editor at UTP, not only for displaying enthusiasm for the project when first proposed, but also for providing sage advice and guidance during the review and revisions stages. I am likewise grateful to the anonymous reviewers for their thoughtful comments and critiques of the draft manuscript. I thank all of those who agreed to be interviewed as part of this research. There is so much about the governance of health care that is not captured in public documents, and thus the cooperation of current and former officials, stakeholders, and members of citizen panels

xii Acknowledgments

was critical to the analysis of LHINs, as well as the broader argument about democratizing governance. Though there are always shortcomings revealed in the study of any system of governance, I remain in awe of the integrity, professionalism, and talents of those who work in public service. Carey Doberstein Vancouver, BC, Canada

Abbreviations

ALC AG CCAC CE CHB CIHI CRSSS DHC G2G HIDSA HPAC HSP HSSO IHSP KPMG LHIN LHINC LHSIA LSSO MLAA MOHLTC MOU MPP NDP NHS NIMBY OHA OHIP OLP

alternate level of care auditor general Community Care Access Centre community engagement Community Health Board Canadian Institute for Health Information Centre régional de santé et de services sociaux (Québec) District Health Council governance-­to-­governance Hospital Insurance and Diagnostic Services Act Health Professionals Advisory Committee health service provider Health Shared Services Ontario Integrated Health Service Plan Klynveld Peat Marwick Goerdeler (consulting firm) Local Health Integration Network Local Health Integration Network Collaborative Local Health Services Integration Act LHIN Shared Services Office Ministry-­LHIN Accountability Agreement Ministry of Health and Long-­Term Care memorandum of understanding member of provincial Parliament New Democratic Party National Health Service (UK) not in my backyard Ontario Hospital Association Ontario Health Insurance Plan Ontario Liberal Party

xiv Abbreviations

OMA OMSIP ONA OPSEU PC PFAC RHA RPNAO

Ontario Medical Association Ontario Medical Services Insurance Plan Ontario Nurses Association Ontario Public Sector Employees Union Progressive Conservative Patient and Family Advisory Council Regional Health Authority Registered Practical Nurses Association of Ontario

DISTRIBUTED DEMOCRACY Health Care Governance in Ontario

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Chapter 1

Introduction

This book considers the relationship between democracy and accountability in complex policymaking environments. More than ever before, across a host of issues, governance is characterized by multi-­level, collaborative, and consultative institutions, which on one hand present opportunities for more inclusive and coordinated policy development, but on the other hand present challenges of blurred or byzantine chains of accountability. On issues ranging from health care, to homelessness, economic development, transportation, and beyond, governance has shifted from a traditionally hierarchical, state-­controlled, policymaking environment to one that is much more decentred, with significant authority delegated to non-­government appointed actors and numerous participatory avenues for stakeholders, experts, and citizens. In this case, ministerial accountability through legislatures is obviously insufficient when much of the real policy work and decision-­making occurs elsewhere, and in particular through networks of actors and institutions who have no direct democratic link to voters. In some cases, billions of dollars of taxpayer funds are allocated and critical policy and program decisions are made, yet we do not have the analytical tools to begin to sort out and assess the democratic and accountability implications of these complex governance patterns. In this context, elected officials, particularly ministers, do – and must – retain authority and responsibility for the expenditure of public resources, yet across a variety of issue areas and across all levels of government, governments have created semi-­autonomous agencies and boards with complex relationships and mandates that contribute to policymaking, with duelling accountability to the government and to the community or broader public. So the question emerges: How do we know if a complex, multi-­level, and networked governance system enhances or undermines democracy? This is as much an academic question of the

4  Distributed Democracy

relationship between democracy and accountability as it is one of concern for policy and governance practitioners who design, manage, and participate in such governance institutions. To answer this question, this book devises an original analytical framework and applies it through an examination of Ontario’s local health integration networks (LHINs), which are local health authorities with characteristics as described above and are controversial when viewed through the lens of democracy and accountability. This study provides an opportunity to examine the complex institutional relationships involved in delivering health care in Ontario, and its implications for the other provincial health systems, yet informs a broader discussion on how to manage multi-­level, collaborative, and consultative governance in many issue areas and policy domains. LHINs were introduced in Ontario in 2004 to be responsible for delivery of local health services, with fourteen agencies across the province and two primary goals defined by the government: (1) to develop a more integrated and coordinated health care system, bridging hospitals, doctors, home-­care providers, and long-­term care facilities, to benefit the patient experience, and (2) provide more opportunities for citizens1 and stakeholders to influence health care policy and investment decisions at a more local level. The transfer of funding responsibility to LHINs was dramatic: 60 per cent of the total provincial health care budget, amounting to well over $25 billion, is dispensed through them. George Smitherman, the Ontario Liberal Party (OLP) health minister at the time of their inception, hailed LHINs as a “made in Ontario” solution that would break down health care silos.2 Smitherman also claimed, “We need local expertise from right across Ontario to help plan and co-­ordinate the health care services that are right for people in different communities.”3 Thus from their origins LHINs have been conceptualized as a governance framework both to improve the performance of the health care system and to inject more local influence in policy planning and decision-­making. The Ontario health minister’s call for more localized health planning was itself not an original idea in health care governance in Western democracies. Indeed, in Canada we can trace the development of local health-­planning bodies in Canada to the Royal Commission on Health Services in 1965, which recommended that regional councils be established within provinces with delegated authority for both planning and operations of health services. Quebec was first among the provinces to experiment with the regionalization of health care governance in the late 1960s, which shortly thereafter was replicated to varying degrees in all provinces. Yet the regionalization movement of health care governance

Introduction 5

in Canada and elsewhere has not been unidirectional – most Canadian provinces have tinkered with their systems back and forth along the centralized-­regionalized continuum as they grapple with questions of performance and accountability, efficiency and effectiveness, and how to best create a cohesive system of health care services. This book contributes to the debate on regionalization of health care governance by exploring the Ontario case, identifying its strengths and weaknesses from a governance perspective, with particular attention to democracy and accountability. Ontario was the last among the Canadian provinces to formally regionalize the governance and administration of health care, and thus there are similar attributes to the other provincial health systems, yet LHINs have been divisive from their onset. Early media coverage described them as “beefed up”4 and “bloated”5 bureaucracies that “swallow”6 money that should be going to front-­line patient care and were even nicknamed “eHealth 2.0” for showing the same “rot and mismanagement” of public funds for which the eHealth initiative became notorious in 2009.7 The most cynical analyses suggest that the only function of LHINs is to do the ministry’s “dirty work”8 and “allow politicians to distance themselves from controversial decisions,”9 where good news is delivered by the ministry, while LHINs deliver the bad news,10 play “bad cop,”11 deal with negative publicity,12 and function as the ministry’s “scapegoat.”13 The overwhelming conclusion from media commentators is that LHINs are a failed experiment. Likewise, political parties in Ontario are similarly scathing in their critiques of LHINs, though this is their expected and institutionalized role for virtually all policy issues in a parliamentary context. New Democratic Party (NDP) MPP Peter Kormos said in 2010 that LHINs were “flawed from the get-­go…. It is time for the whole kit and caboodle to be tossed,” largely from the sense that the community’s voice is not a genuine part of health planning.14 NDP Leader Andrea Horwath argued that the Liberals had “thrown our health-­care system into a complete state of crisis” and “after 13 years they have done nothing but destroy our health-­care system.”15 On the other side of the aisle, the criticism does not let up. In the 2014 election, Progressive Conservative (PC) leader Tim Hudak promised to scrap the LHINs, and subsequent leader Patrick Brown promised to “diminish the bloated health care administration in Ontario.”16 And most consequentially, PC Premier Doug Ford’s government has formally set forth a plan in the People’s Health Care Act (2019) to ultimately dismantle the LHINs and recentralize authority and accountability in a newly created agency called Ontario Health by 2022. When these plans were announced, a

6  Distributed Democracy

senior government official argued that the LHINs were a “very expensive oversight body” that does not make the system work more effectively.17 This is merely the latest volley a long-­standing debate in health care governance in Canada and elsewhere – but also governance more generally – about the merits and drawbacks of centralization versus decentralization, which will be explored in more detail in chapter 3. Yet to former OLP health minister Deb Matthews, “The future of health care is about integration…. I want those decisions made as close to the ground as possible,”18 and she had “complete confidence local decision-­ making is worth protecting.”19 Thus, to the creators of LHINs, they are essential to build an integrated and responsive health system. LHINs indeed create new layers of administration at the local level, as the opposition parties and media analysts argue, leading some media analysis to facetiously claim that “in Ontario, there are three levels of contracts before the patient gets a bath.”20 A physician, referencing the governance of health care in the province, wryly suggested, “Franz Kafka couldn’t have come up with something this convoluted.”21 The perception of LHINs as merely adding dysfunctional layers of bureaucracy from media and opposition parties is thus omnipresent. Yet probing deeper, one discovers lost nuance in the widely held opinions of this governance experiment: for example, LHINs’ average administrative costs are comparatively low at 0.3% of their budgets,22 and some of them have been credited with better connecting patients to doctors,23 developing more culturally sensitive services,24 and facilitating greater use of telemedicine services, among other achievements that improve the health outcomes of citizens. Furthermore, a recent comparative analysis of the provincial health systems in Canada by the Conference Board of Canada ranked Ontario among the best in Canada, behind only British Columbia.25 But this book is not focused primarily on the performance of the health system in health outcomes, but rather the governance of it through the lens of democracy and accountability, grappling with the difficult questions of how spheres of authority, representation, expertise, and deliberation among government actors, stakeholders, experts, and citizens are reconciled. These are central and unresolved questions among governance scholars and practitioners that a systematic analysis of LHINs can help to answer. Notwithstanding the media and opposition critiques, the real problem with LHINs, however, is not that they “swallow” money that should be going to front-­line patient care, but rather that they may be wholly unaccountable and undemocratic, while controlling tens of billions of taxpayer dollars. Ontario has over two thousand appointed boards of directors for organizations planning and delivering health

Introduction 7

care, “making lines of accountability fuzzy,”26 to say the least. Yet “community engagement” is a central aspect of LHINs’ mandate and is a legislated part of the process of health policymaking, including community meetings, focus groups, citizen advisory groups, or special advisory committees for special communities (e.g., Indigenous, francophone, etc.), and advisory bodies to gather input from health professionals. However, recent analysis by Paul Barker suggests that LHINs’ permanent consultative bodies tend to be “dominated by health service providers and others close to the provision of care” while “ordinary citizens in the community tend to be less prevalent.”27 In the same vein, Ontario’s ombudsman released a report in 2010 that claimed that Hamilton Niagara Haldimand Brant (HNHB) “LHIN board members actually counted conversations that they had on the golf course or at the grocery store as ‘community engagement’” and created bylaws that allowed for secret “educational” meetings among the board shielded from public view.28 If this were a pattern across LHINs, they may, rather than enhance democracy, be part of a disturbing trend towards elite deliberation and accommodation, based on the premise of more rational policymaking and problem solving across the system that is detached from lay citizens and even elected officials.29 Yet even on this claim, a fair assessment of LHINs demands a deeper analysis of the multitude of institutions, policy actors, legislative frameworks, and regulatory mechanisms that have been created under this scheme. Contemporary democratic theory from Jane Mansbridge et al. recognizes as much: an institution may look democratically defective when considered only on its own, but may be part of a larger set of interconnected venues – a system – that ultimately balances the needs of representation, inclusion, expertise, and rational policymaking.30 Prior to the arrival of LHINs, the Ontario Ministry of Health and Long-­Term Care (MOHLTC) was responsible for the funding and operation of health care in the province.31 Regional advisory and administrative bodies known as District Health Councils (DHCs) were first created in the mid-­1970s. Ultimately dozens of DHCs formed as advisory health planning organizations funded by the MOHLTC, comprising various stakeholders, including representatives of local health provider agencies, government representatives, and individual citizens in Ontario. DHCs provided advice to the central ministry about local needs, but the key policy and spending decisions were made centrally at Queen’s Park in Toronto. In 1999 seven regional offices were set up to increase local input into health planning and administration, marking further movement along the regionalization spectrum, consistent

8  Distributed Democracy

with most other Canadian provinces with respect to their health care systems. With the establishment of LHINs, the role of the MOHLTC was meant to shift towards health planning rather than operations, or what public administration scholars would refer to as “steering” the boat, rather than “rowing” it.32 The MOHLTC would set the overall strategic direction of health care, and LHINs would shape how that is implemented in their local area. The enabling legislation states that the MOHLTC “shall develop a provincial strategic plan for the health system that includes a vision, priorities and strategic directions for the health system.”33 Fourteen LHINs were created across the province, each with a board of up to nine members (later increased to twelve in 2016), all formally appointed by Cabinet (though based on “advice” from the community), but expected to have expertise, experience, and understanding of local health issues and needs. LHINs thus hold the responsibility to finance and coordinate most health services and programs in their designated area, including hospitals, community care access, and support service centres, community mental health and addiction agencies, and long-­term care facilities, among others. LHINs can adjust the funding and operation of health services, modify or cancel existing funding relationships with providers, with wide latitude, if it provides a better coordinated and more effective regional health care system. Integration of health care services is at the core of the LHIN mandate, yet several aspects of health care were initially excluded from LHINs’ mandate, including public health, physician services (i.e., salaries), ambulance services, laboratories, and provincial drug programs, as is the case in most other provinces with regionalized systems.34 Notwithstanding their name – Local Health Integration Networks – LHINs are in fact Crown agencies with accountability links to Cabinet, but with mandated participatory decision-­making avenues for stakeholders and communities, and thus also involve accountabilities to citizens. According to a senior LHIN official interviewed for this book, the network moniker “speaks to how we do business … more of a collaborative approach ideally embodying a broader systems perspective.”35 LHINs are thus delegated Crown agencies with their own ministry-­ appointed corporate boards, yet at the same time are expected to be responsive to their local conditions and constituencies, which puts them in a unique and complex governance position. As Paul Barker suggests, “The relations between the centre and the regions constitute a delicate – and continuous – balancing act.”36 Health politics and governance is especially instructive of the challenges associated with

Introduction 9

achieving this balance because it is a policy field in which the tension between technocratic and democratic control is among the most acute. How the various components of the system do or do not fit together in terms of democracy and accountability is an understudied, yet critical dimension of analysis that ought to concern academics and policy practitioners alike. While LHINs have been controversial since their inception, and often initially based on misinformation or a misunderstanding of their role, the province of Ontario in 2016 expanded the authority of LHINs and implemented other associated reforms as part of the Patients First Act. The legislation folded more authority and control into LHINs, responding to the criticism of duplication and unnecessary bureaucracy in the system, but also facilitated increasing localization of health care policy planning, given the diversity within each LHIN area – for example, the Toronto Central LHIN includes both very high-­income Rosedale neighbourhood and very low-­income St James Town area, each with stark demographic differences and health priorities. What is clear is that the Patients First Act (2016) represented the OLP government led by Premier Wynne doubling down in the basic premise of LHINs from a governance perspective. Yet as mentioned above, new PC Premier Doug Ford has since initiated a major reversal of this approach with the People’s Health Care Act, 2019. This will have significant implications for the relationships among ministry officials, health authorities, stakeholders, and citizens that are explored in this book, yet the core governance puzzles analysed here will remain, no matter the scheme advanced by Ford. LHINs are complex in and of themselves, are different from each other, and are situated in a complex policymaking environment, thus general claims about them in terms of accountability and democracy ought to be resisted. Only by examining LHINs through a broader systems approach can we arrive at conclusions about accountability and democracy in such a governance context, not only for Ontario, and not only for similar provincial health systems, but also for policy domains characterized by multi-­level, collaborative, and consultative governance frameworks. The fourteen LHINs in Ontario are subject to universal rules, such as mandates on corporate governance, the sectors within health care for which they have responsibility (and those for which they do not), and performance targets, yet they also have considerable flexibility on how to prioritize and allocate their funding resources, other aspects of corporate governance (such as the type and extent of public consultations and engagement), and special initiatives targeted to their local communities.

10  Distributed Democracy

In this vein, the fifteen years of LHINs in Ontario offer the opportunity to analyse them, as they were all created at the same time and exist in the same legislative environment and political context, but exhibit variation on all sorts of levels: governance patterns, citizen and stakeholder input in planning and decision-­making, and policy priorities. This naturally created variation, though in an otherwise similar context, provides analytical leverage that can be used to draw inferences about governance, democracy, and accountability more generally. And the Canadian federal system allows for an even broader analysis of health care governance in Canada, which will be selectively referenced throughout the book. For several decades there has been a regionalization movement in Canadian health care governance, to which Ontario was a latecomer, whereas today some provinces, like Alberta and Saskatchewan, pulled governance back to the centre (PEI did as well in 2005). And with Ontario poised to return to a centralized model of governance under PC Premier Ford by 2022, it reveals that matters of where authority is vested, accountability is rendered, and citizens and stakeholders included are a perennial concern. Yet regardless of a province’s position on the centralization-­ regionalization spectrum for health care governance today or in the future, there are universal questions associated with ministerial–agency relationships, interest group and stakeholder advisory committees, and increasingly demanding citizen participation and deliberation that this book tackles. Thus, while the focus of the book is on democracy and accountability in health care governance in Ontario, focusing in particular from 2004 to 2019, the historical and contemporary analysis will be placed within the broader comparative context of other Canadian provincial health systems, with lessons for all governance configurations of health authorities in Canada, particularly the relationships between elected officials, agencies, stakeholders, and citizens in the context of core democratic attributes we ought to expect in any governance model. This book is not concerned primarily with the relationship between governance patterns and health outcomes, given the countless possible factors that may influence life expectancy, chronic conditions, and health conditions of a population. Rather, the main line of inquiry is the extent to which the institutional framework of LHINs balances the influence of elected officials, bureaucrats, experts, interested stakeholders, and citizens on health care planning, and the consequences for accountability and democracy. Accountability in the public sector has intrinsic value (that is, related to the integrity and legitimacy of decision-­making), but to many, accountability is valued because it is linked to performance. Accountable actors in governance institutions

Introduction 11

that have sufficient transparency, publicity, and oversight have strong incentives to work towards improved health-­system performance and patient satisfaction. Whereas this book is focused on the intrinsic value, it is important for readers to recognize that the link between accountability and performance is well established generally, if contingent on a whole host of factors beyond the scope of this book. But accountability and democracy are foundational pieces of good governance. Democracy is fundamentally about having one’s voice heard, and accountability is fundamentally about decision-­makers being answerable for their actions. Health care governance in Canada has a lot of voices and a lot of decision-­makers, and we do not have a framework to evaluate how they intersect. Sorting through this maze of institutions and relationships systematically is critically important to scholars puzzling through complex accountability relationships, but also for policy practitioners designing and managing these governance frameworks, as well as reformers contemplating new governance experiments. To this end, I develop a principle-­based, analytical framework for governance in the abstract – that is, specifying which values and objectives are important to achieve at various levels and venues in the system – to make more nuanced judgments about particular strengths and weaknesses of governance models for democracy and accountability. This approach departs from typical political rhetoric or media analysis that makes simplistic declarations of system-­wide failure of governance and instead embraces the complexity of modern governance, providing the tools to identify the areas where a particular governance framework is working and where it is not. The main research questions examined in this book are thus as follows: 1. What is the role of metagovernance (steering and oversight) by the state and metadeliberation (citizen influence) in devising a governance subsystem? 2. How do we reconcile our understanding of democratic accountability with the complex institutional relationships that involve actors such as elected officials, stakeholders, experts, citizens, most of whom have no clear electoral-­democratic mandate? 3. What kind of institutional and interpersonal links between governance arenas produce an interconnected and responsive system? To answer these critical questions of governance, LHINs are examined using the analytical framework that I construct. The book does not

12  Distributed Democracy

involve a deep inquiry of a particular LHIN and does not engage in a systematic analysis of all fourteen LHINs, as that would not be feasible in a single book, but rather draws on data and developments from all fourteen LHINs through vignettes to illustrate key dynamics of governance. This is justified on the basis that a close examination of a particular LHIN or handful of LHINs would fail to capture the variation among the fourteen. Vignettes of developments in particular LHINs were selected on the basis of their reported innovations in governance, as well as on the basis of their reported problems or missteps. Care was taken to research marquee initiatives and any reported controversies for each LHIN over the period of study to ensure that major developments in each were understood, even if all such developments could not reasonably be covered in a single book with the stated purpose of this one. Furthermore, where appropriate, data from all LHINs are marshalled to provide a systematic comparison on specific measures. A vignette approach provides the opportunity to zoom in on a particular LHIN or set of LHINs for analysis to illustrate a key governance dynamic, yet still allows for a broader examination of the LHIN universe in Ontario. This book shows that some LHINs are closer than others to achieving tightly coupled and integrated governance venues, in which diverse stakeholder, expert, and citizen contributions are strategically contributory to policy planning and decision-­making with clear lines of accountability, and other LHINs engage in practices that fall well short and thus represent serious threats to democratic and accountable decision-­making. For governance scholars and practitioners, the analytical framework devised and applied in this book helps locate institutional design flaws that undermine the democratic character of complex governance systems. Methodology Mapping and analysing the governance bodies, relationships, and structures of accountability in the LHIN universe requires a multi-­ method approach that draws on data over a considerable period of time. This study begins the analysis in Ontario when LHINs were first announced in 2004 as the new governance structure for health care, although earlier key developments are covered when directly influential to future developments in the field. LHINs provide a unique opportunity to analyse governance institutions that were all created at the same time, in the same legislative and regulatory context, yet were permitted latitude to design governance patterns and policy priorities attuned to their local area.

Introduction 13

In order to elucidate the empirical distinctions among LHINs and their theoretical implications, I present findings for various LHINs using longitudinal and comparative institutional analysis by drawing on archival records – including legislation, policy documents, annual reports, consultation documents, and Hansard debates and committee hearings (1,240 pages of the last). Key legislative documents include the Local Health System Integration Act (2006) and the Patients First Act (2016), and policy documents that outline the relationship between the government and LHINs. Other important documents analysed from all fourteen LHINs include annual reports, strategic plans, business plans, community engagement reports, meeting minutes from LHIN boards and subcommittees, as well as consultation reports such as those from community and stakeholder forums. Given the legislated transparency rules on such annualized reporting, I was able to review over two hundred reports, totalling well over six thousand pages of developments and evolution from LHINs since they were created. Finally, LHIN board meetings were viewed for those that provide webcast viewing or teleconference opportunities on their websites (e.g., Erie St Clair LHIN, North East LHIN), and a media search and analysis was conducted from 2004 to 2019, discovering 110 relevant articles, to identify trends in coverage and triangulate with information about events and controversies discovered in other records. I also conducted thirty interviews with key policy actors, among them current and former LHIN board members, key political and bureaucratic officials in the Ministry of Health and Long-­Term Care, LHIN staff, key stakeholders, and citizens who have been involved in advisory committees, citizens panels, and consultations. Interview subjects were first identified from publicly available directories of current LHIN and ministry officials, as well as annual reports dating back to 2008 which identified (in some cases now former) officials. Likewise, public documents which describe stakeholders and lay persons involved on subcommittees, advisory groups, and consultations were used to identify possible interview subjects. Furthermore, many interview subjects in various positions (current and former) were identified from interviewees using a snowball sampling approach. Interview recruitment was concluded when subjects were able to fill in key holes in information stemming from public documentation and when patterns of interpretation of the events became clearly demarcated. With so much published documentary data and personal accounts received from interviews and observation, the analytical strategy for this study was focused on identifying and extracting the relevant activities and developments in key governance venues, informed

14  Distributed Democracy

from the theory and analytical framework articulated in chapter 2. Theory helps us identify what variables or factors may be important to investigate and thus informs how one collects and analyses data to answer the primary research questions. In this vein, theory informs the analytical strategy in this study by targeting three venues for data collection: the legislative arena, the LHINs, and the broader citizen participation realms. Theory also informs what type of data or information is sought, such as the relationships between governance venues, policies, and practices on representation and inclusion, and the formal and informal mechanisms of accountability, among others. Documentary data in the form of Hansard debates, annual reports, and meeting meetings are especially helpful to establish a contemporary account of developments as they occurred, with the caveat that what is written down in official documents of course does not represent the whole story. In the case of annual reports and meeting minutes from LHINs, it represents how the LHINs view themselves, typically in the most positive or forgiving light. As such, personal accounts from interviews from former and current LHIN staff and board members, with opportunities for anonymous attribution, allow for additional disclosure of information, debates, or struggles not covered in official reporting. Likewise, personal accounts from interviews with lay citizens who have engaged with LHINs in community forums, citizens panels, and patient focus groups offered even more unvarnished perspectives, often much less guarded than those of the professional policy actors in the ministry and among LHIN staff with whom I spoke as part of this research. Therefore, the analytical strategy was to iteratively construct a narrative by triangulating official documents with personal testimony among those involved, as well as media coverage, using each to piece together a set of facts and perspectives, while exploring apparent contradictions and diverse interpretations, to help answer the questions set forth in the study. Outline of the Book The book begins in earnest by constructing an analytical framework in chapter 2 that draws upon governance-­driven democratization, metagovernance, and deliberative democracy literatures and concepts to guide the investigation for how the governance system in which LHINs exist have various venues, accountabilities, and linkages that must be analysed as a whole, not individually, in order to assess their democratic character. Chapter 2 thus sets the context for complex layers of institutions

Introduction 15

that involve diverse policy actors in different venues that are part of a recent and generally positive governance trend, though it identifies key areas where key dimensions of democracy and accountability can be occluded and compromised. The subsequent four chapters are empirical, and while each chapter deals with a different dimension of the LHIN governance system, the themes and questions introduced in the analytical framework are deployed across chapters and thereby tie them together. Chapter 3 begins at the establishment of public health care in Ontario, but quickly moves to more recent periods, beginning in the late 1990s when the predecessor to LHINs, District Health Councils (DHCs), ruled the day in concert with the Ministry of Health and Long-­Term Care. The chapter also briefly covers parallel shifts in other Canadian provinces towards the regionalization of health care, of which Ontario is the last in 2004. This sets the context for the evolution towards LHINs, marking the important differences and similarities with previous institutions, including the purported justifications for moving towards the LHIN model of governance. Chapter 4 examines the political level of health care governance. Though the Local Health System Integration Act (2006) devolved considerable governance and administrative authority to LHINs from the Ministry of Health and Long-­Term Care (MOHLTC), the ministry and minister retain critical metagovernance (oversight and steering) roles for LHINs in setting provincial policy priorities, devising enabling and constraining legislation on LHINs, and acting as the holistic system overseers that encourage LHINs to work together. This chapter analyses the practice of steering and oversight by the ministry, but also the moments in which the minister has vetoed LHIN decisions, which complicate the processes established by LHINs, their sense of legitimacy in the community, and their accountability relationships. The chapter reveals that this is disruptive to LHINs, yet emphasizes that the minister and Cabinet are essential connective tissue in any democratic accountability loop. Chapter 5 explores the diversity of leadership patterns across the fourteen LHINs by examining their board governance, including issues of inclusiveness, expertise, connection to community, and their relationship to LHIN executives. There is extraordinary variation among LHINs in board governance in this regard, and key patterns of success and failure over the past ten years. The corporate level – the staff of the LHIN Crown agencies – is also examined in this chapter to reveal differences in structure and process that are linked to accountability to LHIN board stewardship, and ultimately, the minister.

16  Distributed Democracy

One primary innovation of LHINs compared to other regionalized health systems in Canada is the legislated mandate for them to include stakeholders and citizens, and this provides an opportunity to evaluate the extent of metadeliberation (i.e., citizen influence not simply on the substance of issues, but the governance framework as well) in this context. Chapter 6 explores ways in which the fourteen LHINs have satisfied this mandate, among them public consultations, stakeholder working groups, deliberative polling, or randomly populated citizens panels, and investigates the successes and challenges of these approaches on key democratic and accountability criteria established in chapter 2. This chapter explores tensions present in matters of inclusion, diversity, and expertise, and matching participants to the most appropriate task of governance, whether it is problem definition, problem solving, decision-­making, or implementation. The final chapter of the book synthesizes the empirical lessons from LHINs across the venues explored in the previous chapters, demonstrating that what may look like an institution with democratic or accountability deficits when examined alone, in fact is an essential and functional part of the system. The final chapter illustrates that complex governance institutions like LHINs, with multiple venues, cannot be analysed by focusing on one component part, but instead ought to be assessed for how the pieces fit together (or in some cases do not fit together). This is the primary source of controversy with LHINs: observers too often pluck one venue out of its broader context and claim that it is not democratic, inclusive, or accountable. Yet the systems analysis, guided by the analytical framework devised in chapter 2, reveals that some LHINs are closer than others to achieving tightly coupled venues, in which diverse policy actors and citizen contributions are progressively integrated into the policy process with clear lines of accountability, and others fall well short and thus threaten democratic decision-­making. Conclusion While Ontario’s LHINs have been examined by scholars along particular dimensions, such as public engagement,37 health service integration,38 patient experience,39 and health system sustainability,40 there has been no systematic analysis of LHINs from a governance perspective, and in particular, one focused on key public administration and political science questions of accountability and democracy. This book builds on emerging ideas of governance-­driven

Introduction 17

democratization – institutional innovations in democracy through participatory mechanisms and more sophisticated citizen engagement in governance and administration rather than through reforms of electoral politics.41 LHINs are precisely the type of new governance institutions that are premised on inclusion of those affected by policy and administrative decisions, but for which conclusions about democracy and accountability are yet unclear. The complexity of LHINs – with layers of institutions from citizens panels, to stakeholder working groups, LHIN operational management, LHIN board governance, and all the way up to ministerial decisions – connects to the emerging deliberative systems approach, advanced by Jane Mansbridge et al.42 This approach holds that to assess democracy and accountability, it is necessary to go beyond the study of individual institutions and processes, and instead we must examine their interaction in the system as a whole. Whereas previous research into LHINs may touch upon single elements under investigation here, this book approaches the analysis of LHINs from an original angle, one that demands examination of the broader system in which LHINs operate, thus documenting and analysing relationships across venues and the models of representation and accountability used in practice. The key task in this vein is to examine how levels of governance and administration are connected such that they enhance the links of accountability and democracy, not break or obscure them. Further, the public administration concept of metagovernance, to which I have contributed,43 is helpful, because it captures the relationship and tension between the willingness of the state to engage and share authority with civil society in substantive policy planning and decision-­making, while maintaining some control over their activity to be consistent with traditional notions of democratic accountability. These are perennial concerns to modern governance analysis in Canada and beyond, and in the field of health care and beyond. This book also connects with public administration scholarship more generally that challenges how we think about public administration in the twenty-­first century, with a leaner public service that is expected to tackle more complex public problems amidst growing expectations of inclusive decision making.44 This book therefore unites important theoretical currents in the public administration and political science literatures to key practical questions facing governments today, particularly in terms of citizen involvement in policy development and implementation. There is no better case study than the deeply controversial and often misunderstood LHINs to explore what is going right and wrong

18  Distributed Democracy

in citizen engagement, “agencification” of governance, and democratic accountability. Scholarly contributions aside, insights derived from this research have important implications for policy practitioners and citizens. For policy practitioners in Canada, particularly in the health care sector, the research and analysis of LHINs contributes to debates on the evolution of regionalization of health care delivery in Canada – which is not unidirectional movement, as provinces have regionalized health delivery via local health authorities and then later snapped back to a single system of provincial control (as will happen in Ontario by 2022 with the so-­called People’s Health Care Act, 2019). Provincial government variation in the regionalization of health care governance is really a struggle to reconcile questions of who should set policy objectives, how much policy variation ought to be permitted to meet the needs of the local context, and what is the appropriate role of stakeholders, experts, and citizens in policy development and implementation. Variation among the provinces in their governance structures reveals that this is not a settled debate, and thus this analysis of Ontario, as the largest province and the most regionalized along the central-­regional spectrum, is a central piece to this ongoing debate among policy practitioners. And given the upcoming major system reform in Ontario, which will return to a centralized model of governance, this book will offer a snapshot in time of a decentralized model from which to analyse and compare the reforms to come. Finally, this book also will find an audience among citizens interested in the myriad ways in which they can engage in their democracy beyond the ballot box. Evolving citizens’ expectations have led governments of all political stripes and at all levels of government in Canada to open up more opportunities for consultation, engagement, collaboration, and, in some cases, decision-­making to interested citizens. This book takes the case of health care, typically a top-­line political issue among citizens’ concerns, revealing the opportunities and challenges associated with involving the public in policy planning and decision-­making. Citizens are not only the funders of the health systems in a Canadian context (as taxpayers), but also their clients, and thus have experiences and insights on its management that can contribute to continued enhancements of service equity, effectiveness, and even cost containment. Yet it is more challenging than it may appear to conceptualize when and how to involve citizens (and which ones), and this book reveals that when done with care, this type of engagement can empower citizens and generate policy dividends that would not otherwise occur, but when done poorly, can

Introduction 19

alienate citizens, breed distrust, and undermine the broader system. Using the approach developed in this book, we are better positioned to identify and differentiate the parts of the governance system that are strong from those that are weak, enabling more nuanced analysis and smarter reform prescriptions.

Chapter 2

The Democratic Arenas Framework

The myriad interacting actors and institutions that characterize the Ontario LHIN governance system, with various policy-­planning and decision-­making venues, accountabilities, linkages, and dependencies, is not unique to modern governance in Canada and elsewhere. Yet we are not equipped with the analytical tools to make sense of, let alone assess, how these pieces fit together as part of a broader democratic and accountable system of governance. Before we proceed into the empirical story of the creation and evolution of LHINs as an emblematic case study of this phenomenon, this chapter constructs a general analytical framework by drawing upon scholarly theory and concepts from the governance-­driven democratization, metagovernance, and democratic deliberation literatures. The analytical framework developed in these pages is normative to the extent that it specifies key features that ought to be present and the relationships and interactions across venues that would represent an accountable and democratic policymaking environment. The framework is developed by building on theories and concepts in the scholarly literature and weaving them together into a single framework to be applied when analysing subsystem-­level governance in practice. This chapter constructs what I have called the democratic arenas framework (DAF) to guide the investigation for how the governance system in which LHINs exist have venues, accountabilities, and linkages that must be analysed as a whole, not individually, in order to assess their democratic merits. The DAF sets forth a systematic approach to evaluating the venues, actors, functions, and accountability relationships in this multi-­level governance space, while articulating the places and moments in the system where key democratic principles ought to be privileged (e.g., transparency, inclusion, accountability, etc.), responding to scholars’ observation that a key problem in deliberative

The Democratic Arenas Framework  21

democratic spaces is that we typically engage the wrong people, at the wrong time, for the wrong purpose or objective.1 The DAF provides an idealized template against which real-­world governance relationships and dynamics at the policy subsystem level can be assessed for their strengths and weaknesses, and thus can be used to identify where reforms are needed to bolster its democratic character. This chapter begins by briefly setting the context under which governance patterns have evolved in Canada and elsewhere over the past four decades towards less hierarchical and more collaborative and participatory models of public administration. The chapter proceeds by introducing core concepts in the political science and public administration literatures that are particularly useful to understand these trends: governance-­driven democratization, metagovernance, and deliberative democracy. Thereafter, the core concepts are drawn together to create the democratic arenas framework that specifies the central features of a policy subsystem, the steering mechanisms that influence how it is designed and managed, and the ideal functions of each level of the subsystem. This chapter, while at times dense in theory and concepts for non-­academics, is necessary to provide a firm foundation for the normative claims being made. Yet for non-­academic readers, being guided through key theories and concepts, including where they exist in tension, will prove useful and rewarding, as they prompt reflection on core principles and normative objectives in the design and management of governance institutions. Governance-­Driven Democratization In the Canadian parliamentary system, the last four decades have been characterized by a shift towards the concentration of power among a few elites – the first minister and the managers of supporting central agencies.2 Yet in tandem with this shift in authority in high politics, a counter-­trend in public administration has emerged – most apparent in the social policy domain – towards more inclusive and collaborative policymaking and implementation involving civil society, and even lay citizens. Public administration scholars have noted this shift towards a bureaucracy that is more open and penetrable to public view, dependent on civil society partners for successful implementation, and increasingly charged with intensive public engagement and deliberation.3 This trend has also been identified by political theorists in the deliberative democracy tradition, such as Mark Warren, who has described this phenomenon of “empowered participation, focused deliberation, and attentiveness to those affected by decisions” within

22  Distributed Democracy

bureaucratic policymaking and administration as governance-­driven democratization.4 The shift from government to governance within the public administration literature rests on the recognition of a state that faces complex issues that do not neatly fit into departments in one level of government, where civil society organizations and stakeholders are key to modern policymaking and its successful implementation, and expectations of the public to play more of a role in policymaking than simply through periodic elections. Additionally, Neil Bradford argues that since many policy issues transcend jurisdictional compartments, they require place-­ sensitive, holistic approaches that are delivered through networked relations of governments and civil society.5 LHINs in Ontario represent precisely such place-­sensitive and holistic governance approaches with their emphasis on locally sensitive policymaking to integrate health services. Public administration scholars have focused on the practical improvements on policy implementation that are possible in this governance context, when silos among departments or governments are broken down, when stakeholder buy-­in makes it more likely for them to faithfully adhere to policy changes, and when political risk is better managed by engaging with the affected public before policy decisions are rendered.6 Others, namely Eva Sorenson and Jacob Torfing, have identified the democratic implications of such governance trends, though it has not been a primary focus of this literature.7 Democratic theorists have foregrounded the possibilities and limitations of governance-­driven democratization. These trends increase the chances that “those potentially affected by collective decisions can influence those decisions” – a key normative ideal of deliberative democrats.8 The rapid growth of venues such as citizen juries, citizen assemblies, consensus conferences, online dialogues, deliberative planning, and participatory budgeting – all of which are present in the LHIN governance universe – speak to the dramatic changes within modern public administration that are opening up this previously comparatively closed environment.9 A second hopeful possibility in this trend is that it constructs constituencies through a logic distinct from territorially defined electoral democracy constituencies, the latter of which has limitations on representation capacity. To Mark Warren, such constituency-­ building is “more suited to the ‘all affected’ principle than are territorial constituencies.”10 While these governance trends suggest the democratic possibilities, scholars have also pointed to important limitations. First among them is that these new venues tend to be elite dominated, not only among the participants – whereby certain demographics have time,

The Democratic Arenas Framework  23

interest, and ability to participate – but also by facilitators and consultants who have built up a cottage industry upon the practice of public engagement. That is, these new opportunities to influence policy planning have opened up democratic spaces, but too often they are filled by professional advocates or sectoral experts, who may claim to represent those citizens affected by decisions, but only rarely are actual lay affected citizens involved in these efforts. Furthermore, Genevieve Fuji-­Johnson warns, after analysing four cases studies of “deliberative” institutions in Canada, that “no matter how robust the procedures may be, if there is no elite willingness to empower them, they are essentially undemocratic.”11 These trends look more like stakeholderism or advocacy democracy, rather than a genuine opportunity for lay citizens to participate in governing for issues that directly affect them.12 A further limitation of governance-­driven democratization in practice is that it is often de-­linked from electoral democracy.13 Yannis Papadopoulos, among others, has labelled this a trend of “post-­democratic governance,” in which institutions of experts, stakeholders, or a highly motivated (but narrow) slice of citizens craft policy independent from electoral democracy.14 So when policy decisions in sectors need to be made, the mandate and legitimacy build from elsewhere, without a key accountability link to elected officials. Observers of governance-­driven democratization are thus careful to emphasize that these trends offer opportunities and possibilities to inject more citizen participation, representation, deliberation, and government responsiveness, yet at the same time argue that we must critically evaluate how venues are designed and transpire in practice in order to evaluate their democracy-­enhancing character. This leads us to the metagovernance concept developed in the literature. Metagovernance The importance of the design of governance-­ driven democratization venues, such as those associated with LHINs, connects to a well-­ established concept known as metagovernance in public administration and management literatures.15 Metagovernance is concerned with how to facilitate and manage decentred governance institutions. It is about all the choices that need to be made regarding how much authority from the minister (or ministry) is delegated, and to which bodies, how those bodies are constituted, the processes through which stakeholder and public engagement and deliberation are structured, and how accountability is expressed and rendered. However, there is broad agreement that whatever choices are made, engagement with stakeholders and

24  Distributed Democracy

citizens ought to be authentic, inclusive, consequential, and linked (in some form) to decision-­making.16 Metagovernance is observed at a high level in enabling legislation and regulations, which may specify the framework of governance in an issue area, but it may also structure public engagement and deliberation styles, set the inclusion criteria, and facilitate feedback processes. For example, in Ontario’s LHINs, the Local Health System Integration Act (LHSIA, 2006) is a key instrument of metagovernance, as it formally establishes the LHINs and specifies what authority they have (and do not have), and it lays out the government’s expectations of accountability, public reporting, and transparency. Metagovernance can therefore take various forms (from extensive to more limited regulation or steering), which may have important implications for building consensus, regulating conflict, reinforcing accountability, and implementing effective public policy. Metagovernance that is too restrictive or unilaterally imposed can give rise to resistance and conflict among governance actors, stifle policy innovation, and reduce the willingness of actors to invest themselves in collaboration, whereas metagovernance that is too flexible or undefined can lead to governance chaos and even governance failure.17 Insofar as the ruling government is empowered with legitimacy that stems from electoral mandates, it is uniquely positioned to authoritatively draw the boundaries of the playing field, or set the framework, for governance institutions like LHINs. Yet the importance of metagovernance as a practice does not imply that the state should make these determinations on its own, as that may simply reproduce exclusionary politics and governance that stem from electoral democratic institutions. As a complement to metagovernance, Claudia Landwehr advances the concept of democratic metadeliberation, arguing that “the legitimation of delegated decision-­making is not possible without a culture and practice of democratic metadeliberation which enables reflective institutional design.”18 Dennis Thompson similarly advocates for a “metadeliberative process” involving a wider public, designed to justify how the institutions of governance are structured.19 This means that how we design governance institutions in the policy subsystem should not be a question solely for elected officials or bureaucratic executives to decide, but also for the general and interested public. So, whereas most public management metagovernance scholars point to the centrality of the state as “metagovernors,” democratic deliberation theorists invite us to consider broadening institutional design to include the general and interested public, suggesting that metagovernance design choices themselves must be challengeable and revisable. It completes

The Democratic Arenas Framework  25

the accountability circle in this context, without making governance actors (many of whom are unelected, non-­state actors) subject to direct electoral control, by democratizing the institutional design under which they operate. For example, when creating a governance framework for LHINs in the health subsystem, a metadeliberative approach would invite citizens and interested groups to contemplate what authority ought to be granted to LHINs, their core mandate, how they will be judged (and who will judge them) on performance, and beyond. This approach thus shapes the governance framework, not the more traditional policy consultations that governments often conduct. The concepts of metagovernance and metadeliberation introduce the need to theorize the accountabilities at play in any multi-­level and complex governance subsystem. Simply defined, accountability in the public sector means fundamentally that actors involved in policymaking are answerable for their actions. Policymakers, administrators, and those involved in service delivery are pulled in various, and not always seemingly compatible, directions, in part because their institutions are embedded in “an ongoing struggle over who has authority over them.”20 Indeed, for David Mathews, to govern in such an environment is to “constantly contend with the multiple, diverse and often conflicting expectations generated through various systems of accountability.”21 Dubnik and Frederickson, scholars of accountability in the public sector, suggest that various mechanisms are valued for different reasons.22 They are sometimes valued for what they can accomplish directly – that is, their instrumental value (i.e., shape behaviour or performance) – or for the intrinsic value (i.e., integrity, legitimacy, fairness) they bring in a particular administrative or political culture. Decades of research suggests that actors in public sector institutions tend to think of accountability primarily in informational terms (i.e., through transparency, reporting, etc.), whereas citizens tend to think of it more in relational terms (i.e., who is holding whom to account and how).23 In complex policymaking environments, no single mechanism or instrument of accountability can satisfy the diverse roles of actors and to whom they are responsible. In this vein the Romzek-­Dubnik framework differentiates four types of accountability mechanisms: bureaucratic, political, professional, and legal, each with distinct normative bases, purposes, and operationationalization.24 Bureaucratic accountability is associated most closely with traditional notions of accountability, defined by its high degree of control internal to an organization, manifested in organizational roles, supervisory relationships, and standard operating procedures. Political accountability has external, though less direct, sources of control, often from key

26  Distributed Democracy

stakeholders or interest groups who have influence within the broader political system and make their expectations clear to policymakers and agency officials, but officials have discretion in how to respond. Professional accountability is derived from internal sources, but with less direct control and more discretion than bureaucratic accountability, as it emerges from professional norms and standards and is found in the informal relationships within organizations. Finally, legal accountability has external and high degrees of control, manifested in oversight and monitoring activities, and typically involves an independent actor or organization scrutinizing performance or process, such as an auditing body, leaving little discretion in how to respond to expectations of performance. It is easy to appreciate how, in the context of health care governance in Ontario, there are multiple accountabilities: bureaucratic accountability for the Ministry of Health and Long-­Term Care, political accountability for the governing Cabinet, professional accountability for physicians, nurses, and other medical professionals who self-­regulate, and legal accountability in the auditor general, patient’s ombudsperson, and beyond. Yet further in the context of LHINs, which involve non-­state actors in policy consultation, consensus-­building, and decision-­making, there ought to be an additional mechanism of accountability. This additional accountability link in deliberative systems involves what Robert Goodin calls “discursive accountability.”25 The non-­governmental actors in democratic subsystems, of which there are many among the stakeholders, interest groups, experts, and citizens, cannot be held accountable by threat of electoral-­bureaucratic reprisal. Instead they must be held accountable not for their actions and results, as elected and bureaucratic officials are, but instead by their intentions, as good or bad in the context of their organization or community goals, evaluated by peers via mutual monitoring and reputational sanctioning. Publicity is therefore an essential element in a deliberative context, in particular to connect deliberative actors to the audiences whom they potentially affect. In this way, Robert Goodin argues that non-­governmental actors in this context “hold each other accountable in different but complementary ways,” as evidenced by many studies that have established how much they feel accountable to their peers and the broader community and generally behave as such.26

The Democratic Arenas Framework  27

Deliberative Systems and Problem-­Based Approaches to Democracy The possibilities and limitations presented by governance-­ driven democratization, metagovernance, metadeliberation, and multiple accountabilities in complex governance environments connect clearly to considerations that underly the deliberative systems approach, championed by Jane Mansbridge and other leading democratic theorists in recent years.27 With the sustained uptake of mini-­publics, citizen juries, and other deliberative forums across governments around the world, critics identified the small scale of these initiatives as a fundamental barrier to the integration of democratic deliberation principles into large-­scale democratic political systems. For example, in LHINs, as we will see, there are many opportunities for citizens to become involved in consultation, engagement, deliberation, and even decision-­making, and this is enshrined and mandated in legislation, but we are still talking about only a very small fraction of the total population and one that seldom represents the broader population. This is the “scaling up” problem in the deliberative literature: in practice, deliberative democracy remains limited to a small number of citizens and thus lacks broad legitimacy, and it is too often disconnected from authoritative decision-­making and electoral democracy. Furthermore, leading deliberative democracy theorists such as John Parkinson, observing the countless deliberative experiments around the world, has argued that “we may have to give up on the idea of a perfectly deliberative institution” in either representation or process.28 Instead, we ought to think about how to connect several different types of institutions, operating at different points in time and space in the political system, to generate democratic legitimacy.29 After studying different participation mechanisms in Montreal and Quebec City, Bherer and Breux agree, warning that they “may be difficult to reconcile in practice if no thought is given to ways of harmonizing the different participation mechanisms and to the actors’ capacities to see positive relations between them.”30 The path-­ breaking development in the deliberative systems approach lies in moving the analytical focus from small-­scale deliberative moments considered in isolation from the broader political system, to espousing a framework that evaluates democratic decision-­ making across “a variety of deliberative venues and institutions, interacting together to produce a health deliberative system.”31 LHINs in Ontario – by virtue of their layers of governance arenas, combined with a legislated mandate of community engagement – are thus ripe for an

28  Distributed Democracy

examination informed by deliberative systems ideas. In this approach, we must examine all relevant institutions, venues, political spaces, and procedural mechanisms within a particular issue area, as a system, to determine its democratic quality. Foundational assumptions in the deliberative systems approach to democracy are that venues need to be thoughtfully “coupled” or linked, either institutionally (i.e., the resolutions from one feed into the other part) or relationally (i.e., individuals participate in both sites, carrying the outcomes from one site to the other, and vice versa) to promote mutual adjustment, learning, and convergence. Relatedly, a single system part must not dominate others; system design must ensure that influence is structured in a balanced way. This does not naively imply an idealistic system of perfectly equivalent influence, but merely that no single site can railroad another, or that any actor can easily make an end-­run around an important venue, in the policymaking process. In the case of LHINs in Ontario, this would mean the minister is not able to easily overrule the LHINs with little recourse, or alternatively that a powerful professional advocacy group (e.g., the Ontario Medical Association) is not able to unilaterally shape or constrain policy options under consideration by virtue of their important role in health care. Importantly, the deliberative systems approach allows for ostensibly non-­deliberative elements (e.g., protests, partisan media) to contribute to the deliberative system by conceptualizing the system in terms of division of labour. That is, parts of the system, each with deliberative strengths and weaknesses, can make up for deficiencies of the other parts. Yet this evolution concerns some deliberative theorists, given that it relaxes normative ideals of deliberative democracy such that there is conceptual slippage, resulting in a deliberative system that lacks any anchored meaning. That is, if a “deliberative system” can legitimately contain non-­deliberative elements, what is the essential meaning of deliberative? Some warn that over-­extending the concept of deliberation to include any discursive or political practice risks stretching concepts, particularly if non-­deliberative elements like disciplined political party representatives, partisan media, and protests are envisioned as compatible with this normative framework.32 As such, some scholars who are sympathetic to the deliberative systems approach emphasize that in most policy domains there is a range of interconnected forums and actors – and we ought to better conceptualize how each stands in relation to each other – but maintain that deliberation is but one important feature of democratic systems, more broadly defined.33 This is critical in the context of an adversarial, majoritarian parliamentary system in Canada, which clearly stands in contrast to key precepts

The Democratic Arenas Framework  29

of classical deliberative democracy theory, but nonetheless exists alongside smaller-­scale deliberative institutions of governance in many policy subsystems. So we are really talking about a democratic systems approach in this book – rather than the more narrow deliberative systems approach – the former of which does not focus on how political institutions satisfy a deliberative system standard, but rather how they solve three core problems in democracies, as articulated by Mark Warren: (1) how to empower inclusion of those potentially affected, (2) how to ensure that issues are well understood and choices are clear as part of collective will formation, and (3) that institutional arrangements have the capacity to make decisions.34 In this conceptualization, a variety of democratic practices – including deliberation, representation, voting, and protesting, among others – offer pathways to achieve core democratic functions. As such, the analytical framework constructed in this book draws heavily on the deliberative systems approach, in particular an emphasis on the relationship between multiple venues and actors and the division of labour among them, but favours Warren’s broader functionalist view of democracy, of which deliberation is a part of democratic practices, among others. We can thus theorize institutional mixes of practices, some deliberative, others not, that would maximize a governance system’s problem-­solving capacities. Democratic Arenas Framework With the core concepts developed within the governance-­ driven democratization, metagovernance, and democratic theory literatures articulated, they can now be drawn together in an analytical framework that specifies the connection and interdependent relationships between them, which will guide analysis of subsystem-­level governance institutions as it relates to democracy and accountability. A clearly defined analytical framework, presented at a level of abstraction that can be applied across issue areas, countries, and over time, can assist with comparative analysis, refine theory, and ultimately help locate institutional design flaws that undermine the democratic character of governance systems. While policymaking in governance systems can exhibit enormous complexity, feedback, and temporal variation, it is helpful conceptually to divide it into distinct “arenas,” each with specific venues, actors, democratic functions, and accountability. Arenas of policymaking are the institutions or places where discussion, debate, deliberation, and decision are conducted, some of which are characterized by formal

30  Distributed Democracy

and informal parts.35 The formal and informal parts, described below, include procedural decision-­ making bodies, mandated decision-­ making bodies, and public spaces, and each has implications for who ought to be involved, the appropriate functions, and the interconnections among the arenas, in the construction of an analytical framework. They are described below in general terms, as their precise nature may vary, but I will also highlight how they manifest in the context of health care governance in Ontario. Procedural decision-­making bodies are democratic institutions populated by representatives selected for political equality – that is, equal rights and opportunities for citizens to influence decision-­making within the bodies, which make rules that affect them36 – which in most cases means elected parliamentarians in majoritarian bodies.37 In the case of health care in Ontario, this is the provincial legislature of Ontario. Thus, procedural decision-­making bodies can include legislative committees (open to public viewing) and Cabinet deliberation and decision-­making (closed to public viewing). Inclusion in these bodies is not influenced primarily by an inclusivity condition, as it might for other venues, but rather from normatively defined “rightful political subjects,” which have gained legitimacy from elections meant to secure political equality.38 Procedural bodies gain legitimacy from adherence to political equality, and the standards against which these bodies are judged in terms of democratic principles are primarily on procedural grounds. In terms of democratic functions, procedural decision-­making bodies tend to exhibit strengths in collective will formation and capacity for collective decision-­making. Importantly, they also play a central role in the design of delegated (or mandated) decision-­making sites (i.e., in the case of this study, LHINs themselves), which Claudia Landwehr argues requires a clear majoritarian mandate for their creation to be legitimate.39 Mandated decision-­making bodies, by contrast, are democratic arenas such as boards, agencies, and associated empowered committees or working groups that are delegated decision power and have an indirect democratic mandate that flows from procedural decision-­making bodies.40 In the health care governance in Ontario, these are the LHINs themselves, which are Crown agencies governed by a board, created by law via the provincial legislature of Ontario. Members of mandated decision-­making bodies are typically epistemic representatives (i.e., they bring valued knowledge and experience to the role) selected by political representatives (who are in turn mandated from citizens through elections). They are not expected to be delegates of the procedural decision-­making bodies, but instead are to behave as trustees, drawing on information, arguments, and analysis rather than interests

The Democratic Arenas Framework  31

or a direct democratic impulse. While some scholars suggest that mandated decision-­making bodies ought to be designed and populated by procedural decision-­making bodies, others suggest that institutional design at this level ought to also be subject to metadeliberation, a process by which citizens also participate collectively in the design and redesign of non-­majoritarian decision venues.41 The key democratic functions of mandated decision-­making bodies are to empower inclusion of affected citizens, facilitate collective will formation, and make collective decisions by the mandate identified by the procedural decision-­making bodies. They are concerned with addressing problems rather than goals, which are derived from other venues such as legislatures and the broader public discourse.42 Mandated decision-­making bodies are not judged solely in terms of a procedural standard, but also by an outcome-­based standard, while allowing for “instrument independence” (i.e., how to achieve a specified goal).43 That is, mandated decision-­making bodies ought to be evaluated by the adherence of their decision(s) to the societal goals and basket of aims advanced by the procedural decision-­making bodies.44 We thus see that different venues ought to be assessed by different standards, as they have different actors and functions. The third general arena within a democratic system is the broader public space. This arena has few restrictions, if any, on who can participate and on what activities they may engage. It includes informal talk among citizens, part of the “informal track” of deliberative democracy specified by Jürgen Habermas, but also protests, advocacy, and cultural products (e.g., documentaries, research, art), and is justified by generating public opinion and increasing citizen participation in policy debates and the policy process.45 In the context of health care in Ontario, this could include citizens’ panels, grassroots advocacy groups, patients’ rights groups, community health forums, and health and social science research, among others. This may also include what Karpowitz and Raphael have called “enclave deliberations” in which marginalized groups meet in civil society associations or groupings to contemplate issues and policy in terms of their experience and their own terms, in order to contribute as autonomous and effective deliberators in wider, cross-­cutting forums.46 The primary functions played by the public space arenas are of collective will formation and empowered inclusion rather than collective decision-­ making. The public space must be independent from decision-­making sites, and not try to emulate them, but rather should be unstructured, spontaneous, unregulated, but stitched together through a dynamic and engaged civil society.47

32  Distributed Democracy

Interconnections between Arenas and Multiple Accountabilities With the various arenas, their ideal purposes, primary membership, and justification articulated in the emerging democratic arenas framework (DAF), the next challenge is to theorize the interconnections and accountabilities between them. Marit Böker has envisioned “co-­ development”48 of system components, whether mini-­publics (small forums for diverse citizens to engage in reasoned discussion on a public issue), agency boards, working groups, or legislative committees. Others emphasize “dialogue across deliberative exchanges.”49 Too often key sites of deliberation in democracies appear as mini-­publics of citizens that exist without even informal connection to larger (often non-­ deliberative) institutions of democracy.50 To Curato and Böker, without mechanisms of co-­development with other arenas, these elements lack external legitimacy if relevant discourses remain trapped inside certain arenas and venues, unchallenged by others and the broader public sphere.51 The DAF thus envisions different component parts, with different actors and contesting discourses, within and across both micro (e.g., mini-­publics) and macro (e.g., legislatures, referendums) arenas, as no single venue can adhere to all democratic principles and function simultaneously. How the layers within the democratic subsystem overlap and mutually influence each other then becomes a central concern for theorization and analysis. Two concepts capture this normative objective of linking parts of the governance system: venue coupling and actor circulation. Carolyn Hendriks advances the concept of “designed coupling” to articulate how to more effectively link citizens to elites in democratic systems through institutional mechanisms that bridge detached sites of deliberation and exchange.52 Coupling involves penetrating arenas with actors from other arenas and contexts to encourage “mutual influence and mutual adjustment.”53 It is conceived as “designed coupling” on the presumption that this is unlikely to happen naturally, but requires intervention (from the state through law or policy) such that coupling is prioritized and institutionalized. Yet coupling must neither be too “tight” (i.e., too overlapping or influenced by other actors or venues), as this would risk co-­option, nor too “loose,” as this would allow sites to ignore each other and lose the opportunity for mutual adjustment via learning, and must be conceptualized as multidirectional (rather than unidirectional) adjustment. Examples offered include bringing protest movements into board rooms and parliaments, or using social and digital media

The Democratic Arenas Framework  33

to connect wider publics with activities of mini-­publics, or establishing networks of actors from all facets of an issue area that would not otherwise interact, and even bringing legislative committee members as observers to mini-­publics to appreciate their work and efforts to form opinion (as described by Hendriks in an example from a New South Wales state government).54 Similarly, Ricardo Mendonca identifies “circulation” of participants and their representatives as a critical piece of a healthy democratic system.55 The various arenas indeed need to be linked institutionally (i.e., information or outputs flow from site A to site B) – which we can call venue coupling – but also need to be linked by people who “operate as connectors crisscrossing informal and formal settings” who effectively stitch the parts of the system together – which we can call actor circulation.56 This may include individual actors from various venues serving as connectors of venues, or may be what some have called a “public engagement broker” whose sole job is to travel throughout the system to share and receive the products of work in various venues to ensure that sites are not disconnected from each other.57 These circulating actors within the subsystem link moments in the deliberative process, enhancing connectivity and continuity within the system. Democratic Arenas Framework Summarized The core concepts that join the sections above can be represented in figure 2.1. Beginning from the left side of the figure, the two central steering mechanisms of a democratic subsystem emanate from the “top down” via metagovernance (largely state actors) and from the “bottom up” via metadeliberation (largely citizens and civil society). Jointly these two mechanisms of steering ideally represent the co-­development of institutional design of any democratic subsystem. Within it are three levels of formal and informal arenas: procedural, mandated, and citizens and public space. An ideal democratic system would see circulation (of actors) throughout the arenas – some people in the citizens/ public space arenas also participate in the mandated decision-­making arenas – and venue coupling across the arenas – that is, institutional links, where activities and by-­products from one arena feed into another. For example, societal goals on health care are identified by citizens and public space realms, formalized and prioritized by procedural decision-­ making bodies, and structurally linked into deliberations on the means to achieve those goals at the mandated decision-­making bodies. Actor circulation and venue coupling are critical pieces of any democratic subsystem, but there must be a balance to these features: too much

Figure 2.1.  Summary of the Democratic Arenas Framework

The Democratic Arenas Framework  35

circulation of the same actors limits the diversity of the system, while restricted coupling among venues contributes to group-­think. Figure 2.1 also articulates important features of each level of any democratic subsystem in typical venues, actors, their democratic functions, and mechanisms of accountability. Variation within these levels brings into clear view the key principle behind the DAF: components of a democratic system may be more equipped to handle certain functions, involve different policy actors, and are held accountable in ways matched to their characteristics. Measuring the Functional Features of Democratic Systems With functions linked to the various arenas, and the connections between them articulated, the final piece of the DAF is focused on the dimensions and measures of the core democratic functions we will track in democratic subsystems, captured in table 2.1. Empowered inclusion as a core democratic function includes dimensions such as equality, diversity, and dynamics of participation. Key measures of this as part of research and analysis will be to look for the share of relevant and affected actors approached and accommodated for involvement, as well as the breadth of accommodations made to provide a culturally safe and inviting context for participation. Other measures for empowered inclusion in a democratic subsystem are the extent to which there are structured and balanced opportunities for involvement, speaking, and dissenting, and the equality of voice (stemming from one’s perspective, experience, and/or credentials). The particular methodological strategies to identify and measure these dimensions include reviewing the rosters of participants or those involved in particular venues, but also in broader debates and perspectives covered in media, reviewing institutional rules or terms of reference in committees, citizens panels, etc., and interviewing participants to understand their personal experiences in consultation, engagement, and deliberation. Communication and collective will formation as a core democratic function in this conceptualization captures the discourse and procedures inside venues, with dimensions such as reciprocity and the extent of consensus-­driven procedures. Key measures include identifying and tracking exchanges of mutual benefit, and the extent of reasoning or persuasion (rather than coercion) to build intersubjective consistency, common agendas and metaconsensus on issues. Additionally, other dimensions are how smaller venues distil, synthesize, and transmit discourses to the wider policymaking realm and public, and how they seek legitimacy for their activity by responding to outside discourses

36  Distributed Democracy

and reacting to their activity (captured by transparency and publicity, respectively). Transparency is measured by the accessibility of meeting minutes and reports, and the openness to media and citizens, and publicity is measured by the extent of proactive promotion of activities, opportunities for input and decisions, and awareness of activity and role in the system (i.e., prominence of arena). Key strategies to identify and measure these dimensions are to interview participants regarding their perceptions of reciprocity and reasoning dynamics in their venues, and online searches for documentation and review of legislative committee hearings, board governance, and advisory committee meeting minutes for measures of transparency and publicity. And finally, the capacity for collective decision-­making as a third core democratic function captures the connection between venues to authoritative decision-­making and thus is concerned with consequentiality (i.e., to policymaking and implementation) and accountability. These dimensions are measured by how the venue is placed within the system and its autonomy relative to others (i.e., that actionable and implementable decisions can be made) and the type of accountability mechanisms used and the adherence to these mechanisms in practice. The particular methodological strategies to identify and measure these dimensions are to review enabling legislation and policy frameworks to understand venue placement and autonomy, and for accountability mechanisms and their adherence, to review formal accountability agreements, and to interview the holdees and holders of accountability. A further note on measurement is required. Whenever dimensions are presented as part of an analytical framework, questions of measurement follow. That is, if “transparency” is an important dimension, how is it measured as part of the analysis? Is it a binary choice contingent on meeting a threshold – either a governance venue is transparent or it is not – or is it more appropriate to measure as a spectrum? And perhaps more importantly, is it a score, so to speak, determined by the researcher, or is it a subjective sense reported by participants? For both questions, one’s answer will hinge in part on their ontological positioning as positivists or interpretivists, but on the latter question there is obvious value in measures that are independently verifiable by the researcher, as well as those subjective determinations by participants. On transparency as a dimension, for example, we can examine a governance venue by looking at how publicly oriented their reporting is and how easily accessible it is to outside inquiry, but then also collect subjective evaluations of those involved on their transparency, as well as those with relationships to the venue in question, in order to

Table 2.1.  Democratic Arenas Framework Dimensions and Measures, by Functions Core function

Dimensions

Measures

Strategy to measure

Empowered inclusion

Diversity

Share of relevant and affected actors approached and accommodated for involvement Equality of voice (perspective, experience, credentials) Structured and balanced opportunities for involvement, speaking, dissenting Exchanges of mutual benefit Intersubjective consistency, common agendas and metaconsensus, by reasoning Accessibility of meeting minutes and reports; openness to media and citizens; proactive promotion of activities, opportunities for input Placement and autonomy of venue in the system; actionable decisions can be made Type of accountability mechanism used and adherence to it in practice

–­ Review roster of participants –­ Review institutional rules or terms of reference –­ Interview participants

Equality

Communication and collective will formation

Dynamics of participation Reciprocity Consensus orientation Transparency and publicity

Capacity for Consequentiality collective decision-­ making Accountability

–­ Interview participants –­ Interview participants – Online searches for documents –­ Review committee meeting minutes –­ Review enabling legislation and policy frameworks –­ Review formal accountability agreements – Interview participants

38  Distributed Democracy

get further context and to explore areas of disagreement and nuance. This approach applies to all the dimensions specified in the analytical framework as we seek to construct a method of evaluating complex governance contexts (such as LHINs) that has measures scored by the researcher and by participants through interviews. Table 2.1 identifies the proposed measures for the dimensions of empowered inclusion, communication and collective will formation, and capacity for collective decision-­making, as well as the strategies used to measure these largely qualitative and sometimes subjective criteria. The democratic functions are common to all arenas but may well vary in strength across venues and still amount to a highly democratic system. For example, inclusion is an important feature of all venues, but all-­affected inclusion in any single arena is not necessary, provided all-­affected inclusion can be pieced together from other venues and feed into a process of mutual adjustment and consensus building. Empirical studies have shown us that within discrete deliberative institutions, too much difference or diversity can result in deliberative failure.58 In contrast, it may be legitimate for a micro-­deliberative venue to be characterized as an “enclave deliberation” to ensure that a historically marginalized affected group can deliberate first in an exclusive environment, provided that activity is then channelled into larger deliberative arenas, through circulation, co-­development, or another process of building outwards.59 Likewise, while transparency is a critical external feature of any democratic arena, total transparency of all venues in the same fashion need not be the standard, as it may introduce strategic or manipulative elements that run counter to democratic functions.60 There may be legitimate reasons why one arena, such as a patients advisory council in the context of health care governance, may legitimately offer less transparency in some contexts to promote frank discussions of such matters that may have personal dimensions, but also public policy consequences that may be important for actors to discuss and consider in a protected environment. Thus, transparency in this arena may look different from what we expect in another, less sensitive venue, but nonetheless must have a sufficiently public orientation to promote circulation and co-­development across complementary democratic venues.

The Democratic Arenas Framework  39

Conclusion The analytical framework constructed in this chapter can be used as a tool to evaluate a wide array of governance subsystems for democracy and accountability. It is especially well equipped to answer the main research questions set forth at the beginning of this book: 1. What is the role of metagovernance (steering and oversight) by the state and metadeliberation (citizen influence) in devising a governance subsystem? 2. How do we reconcile our understanding of democratic accountability with the complex institutional relationships that have been created that involve various actors (e.g., elected officials, stakeholders, experts, citizens), most of whom have no clear electoral-­democratic mandate? 3. What kind of institutional and interpersonal links between governance arenas produce an interconnected and responsive system? These questions are not only critical to answer in the context of LHINs in Ontario, but also about modern governance institutions and relationships more generally. For example, on the first question, the state has legitimate authority to create and manage governance institutions, yet without commensurate metadeliberation (citizen influence) on the design of governance frameworks, they may simply replicate the exclusionary politics that governance-­driven democratization efforts are meant to mitigate. Further, on the second question, LHINs introduce many non-­state actors into the policymaking process, which challenges conventional understandings of accountability. The analytical framework helps us conceptualize and then measure how these actors are held accountable and are linked with other policy actors and institutions. And finally, the last research question about links between governance arenas is aided by the framework, emphasizing venue coupling and actor circulation as part of the co-­development of institutional design, policy deliberation, and decision-­making. With the democratic arenas framework (DAF) articulated, the next chapter provides a historical account of the evolution of public health care governance in Ontario until the present day, marking the important differences and similarities with previous institutional frameworks, including the justifications for moving towards the LHIN model of governance, as well as recent structural reforms in 2016. This chapter sets the context for the subsequent three chapters, which examine the multiple democratic arenas of the LHIN system articulated in the

40  Distributed Democracy

DAF – procedural decision-­making bodies, mandated decision-­making bodies, and citizens and public space – exploring vignettes of various LHINs across the province against the democratic and accountability criteria established in this chapter.

Chapter 3

The Evolution of Health Care Governance in Ontario

The chapter begins at the onset of public health care being established in Ontario, quickly moving to more recent periods, beginning in the late 1990s when the predecessors to LHINs, District Health Councils (DHCs), operated in concert with the Ministry of Health and Long-­ Term Care (MOHLTC). The chapter also briefly covers parallel shifts in other Canadian provinces towards the regionalization of health care, of which Ontario is the last in 2004 (before a snap back to centralization in some provinces, such as Alberta in 2008, Saskatchewan in 2017, and as expected to occur in Ontario by 2022). This sets the context for the evolution towards LHINs, marking the important differences and similarities with previous institutional arrangements, including the justifications for moving towards the LHIN model of governance. As the origins and design of LHINs are described in this chapter, the various arenas of policy planning and decision-­making will be placed within the analytical framework constructed in the previous chapter. Subsequent chapters are devoted to analysing each layer of the governance system and the connections – or lack thereof – between them, using the criteria and measures that have been established to evaluate the democratic character of LHINs from a systems-­analytic perspective. Though LHINs as described in this book are expected to be dissolved by 2022, the questions of democracy and accountability in health care governance explored here extend beyond the precise configuration of authority in Ontario, as well as the other provinces. Beginnings of a Public Health Care System The first Department of Health in Ontario was created in 1925, emerging from the Provincial Board of Health of Ontario, which was truly the first administrative body for health care in the province as far back

42  Distributed Democracy

as 1882.1 A separate Department of Hospitals was created in the 1930s but was quickly subsumed under the Department of Health. At the time, hospitals and hospital care in Ontario (and the rest of Canada) were financed by municipal governments, religious groups, and out-­of-­ pocket patient payments. As more facilities were built and modernized, this funding base became increasingly inadequate, and by 1955 five provinces had in place universal hospital-­insurance plans to stabilize their hospital funding.2 Ten years prior, after a federal-­provincial conference of programs of social reform, the federal government had proposed a universal health insurance system modelled on the National Health Service (NHS) of the United Kingdom that would involve federal-­provincial cost sharing. The proposal was popular among various stakeholders and the public, but ultimately not pursued in the centralized NHS-­style as the result of provincial resistance to federal government jurisdictional intrusion.3 Yet the provinces endorsed cash transfers to support their budding provincial insurance systems and called for the federal government to honour its 1945 hospital-­insurance cost-­sharing offer by enacting nationwide universal hospital insurance. Ontario introduced insured hospital services in 1959 after protracted negotiations with relevant interest groups. It was a hospitalization insurance plan funded through a combination of compulsory premiums (approximately $10/month per individual in 2017 dollars) and provincial and federal contributions. It was nearly universal (91 per cent of Ontarians) when it started and included comprehensive hospital care for treatment of physical and mental illness, but did not provide outpatient diagnostic services or treatment, as the result of opposition from the medical profession.4 The financial incentives from the federal Hospital Insurance and Diagnostic Services Act (HIDSA) induced all provinces to adopt such universal hospital insurance by 1961. Public officials recognized early on that universally insuring hospital care but not primary care provided distorted incentives to citizens to seek out expensive hospital care rather than in the community. With federal financial support for hospitals via HIDSA, health care activists, especially in Saskatchewan, began in earnest to expand coverage for more comprehensive coverage of medical services. Tommy Douglas’s core principles that structured the early debates in Saskatchewan – prepayment, universal coverage, high quality of service, and public administration – would form the foundation of a provincial plan (and later inform the federal Medicare Act). The idea of universal public coverage for medical services, and not just subsidies for low-­ income citizens, and a government committed to its implementation,

The Evolution of Health Care Governance in Ontario  43

prompted the medical profession and private insurers to launch strong resistance in 1960, labelling the proposal “compulsory state medicine” to evoke visions of USSR-­like government-­controlled industries.5 The Saskatchewan government created an advisory committee consisting of stakeholders from industry, health professionals, labour, the bureaucracy, and lay representatives to devise a plan that all could accept after examining models around the world. The recommendation for publicly funded universal medical coverage was not unanimous, with the doctors and chamber of commerce representatives opposed, but in October 1961 the Saskatchewan Medical Care Insurance Act was introduced in the legislature. Tommy Douglas left provincial politics – and the implementation fights with doctors, including an unprecedented strike – to head the federal New Democratic Party (NDP), which put pressure on the federal parties to respond to this debate headed their way. At the same time, the Diefenbaker government appointed Emmett Hall to chair a Royal Commission on Health Services, which, after three years of inquiry and hundreds of witnesses in which he discovered significant inequities and lack of access, recommended the nationwide adoption of the Saskatchewan model of public health insurance in 1964. Yet the prospect of federal intrusion into provincial jurisdiction was resisted strongly by provinces, particularly Quebec and Ontario. Ontario, under Premier John Robarts, had established the Ontario Medical Services Insurance Plan (OMSIP) to provide subsidies for those who could not afford the existing pre-­paid private insurance, but still exposed citizens to possible catastrophic costs for medical services. Opposition parties at the time criticized it as a giveaway to insurance companies and called it “Robartscare,” a suffix with cross-­border appeal even today (see “Obamacare”) when concerning health care reform. But the Hall Commission offered resistant provinces a proposal that satisfied their need for financial cost-­sharing from the federal government, yet respected provincial jurisdiction for health care. Ontario introduced insured physician services in 1966, and the federal government followed with the Medical Care Act, which came into effect in 1968 and extended federal-­provincial cost sharing to physician services, removing many financial barriers to citizens with public funding, but retained the private delivery of physician services that predated the legislation. Hospital and physician services were consolidated under the Ontario Health Insurance Plan (OHIP) in 1972. Rapid increases in health care expenditures into the 1970s prompted many provincial governments to devise cost containment and governance strategies associated with what was becoming their largest budget line expenditure. The reports emerging from the provinces of Manitoba,

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Quebec, BC, and Ontario all identified the excessive use of hospital services and the control and organization of medical services as key issues, and recommended rationalization, deinstitutionalization, and – importantly, for the purposes of this study – regionalization, among the possible solutions.6 Given the historical anchoring of health care in communities, it is perhaps not surprising that soon after the state took the reins of health care financing and policy, calls to establish mechanisms of local input emerged. Indeed, we can trace the development of local health-­planning bodies in Canada to the Hall Commission in 1965, which recommended that regional councils be established with delegated authority for both planning and operations.7 There were several rationales for regionalization, but chief among them, according to health-­policy scholar Greg Marchildon, “was the desire to transform what had been a passive system of paying doctors, hospitals, and other institutions into a more actively managed system.”8 Additionally, on the ground-­level of service provision, there were an ever-­growing number of service-­specific local health boards largely independent of provincial governments – for example, Saskatchewan, prior to regionalization, had 435 health-­related boards for a population of one million – and thus regionalization also represented an effort to consolidate at the local level.9 That is, provincial governments wanted to deal with fewer authorities and try to break down barriers within the sector and across services. Regional health authorities (RHAs) were also championed to bring leadership over health care closer to the populations served, where they could decide how best to deliver services within budget to meet as many needs as possible, and to be more accountable for their actions, compared to a provincial ministry often far away in the capital.10 Indeed, various provincial reports emerging in the 1970s represent a clear shift in thinking on health care, away from privileging acute-­care services and towards health promotion and prevention. This implied a gravitation towards community-­based health services, as well as healthy living and daily experiences related to health, and thus the logic of reform “revolved around notions of local-­ness.”11 To nurture health promotion, dominant elite thinking urged direct public participation in health-­ services planning at the community level, which would incentivize local accountability to health care planning decisions. The primary objectives were to coordinate and integrate services, enhance patient responsiveness, and ultimately lower costs with a focus on non-­institutional services like health promotion and illness prevention. Regionalization was thus advanced as a mechanism to achieve efficiencies in the financing and delivery of health care in the context of

The Evolution of Health Care Governance in Ontario  45

strained public finances. And whereas in the United States and United Kingdom at this time reform was centring upon market competition to promote more patient control and efficiency in the health system, in Canada, Terry Boychuk argues, the debate focused on decentralization of health care governance and more direct participation in policy planning.12 Regionalization of health care planning and service provision – that is, structuring parts of health care planning and decision-­making to a more local level – has taken various forms around the world, and likewise in Canada there is considerable variation. There is no commonly accepted definition or ideal size of a health region, no agreement on what basket of services ought to be regionalized (and what should remain organized at a provincial level), and certainly no consensus on governance frameworks or procedures.13 Yet most regionalization of health care is characterized by appointed (i.e., non-­elected) governing boards, functional segmentation of various branches of health services, and are metagoverned (i.e., steered and constrained) and financed primarily by provincial governments. Thus, to some, like health-­policy researcher Greg Marchildon, the “dream” of robust local democratic control or input into regional health authorities (RHA) was “dashed very early on.”14 Yet in all regionalized health care governance systems, there are also countless patient and public advisory boards as arenas for local input. The evidence is sparse, however, on the extent of meaningful citizen engagement in these various arenas and how influential they have been on policy planning and decision-­making at RHAs across Canada.15 Quebec is where regionalization in health care governance finds its origins in Canada. The Castonguay-­Nepveu Commission reports in the late 1960s in Quebec recommended the creation of regional health authorities to integrate primary, secondary, and tertiary health services, and to “give institutional expression to a new model of health care, that of social medicine, which gave equal recognition to the social, environmental and biological determinants of health.”16 The vision was for local planning to create and manage interdisciplinary health teams involving doctors, social workers, and allied health professionals who focused on prevention as a means to cultivate a healthier population and make hospitals truly the option of last resort. Quebec would create regional social service and health councils (CRSSSs) to contribute to this vision, yet initially they held modest responsibilities, such as to advise the health ministry on financing and planning, and provide venues for consultation and collaboration among health providers. By the 1980s CRSSSs accumulated significant administrative authority, including

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over budgeting, planning and evaluating health services ranging from mental health to ambulance to home care, and ultimately the power to review and approve programs in hospitals.17 These were a set of powers vested in regional authorities not seen in other provinces at the time. The regionalization pioneered in Quebec was replicated to varying degrees in all provinces, and only recently subject to partial re-­ centralization by Alberta and Saskatchewan. By the 1990s all provinces except Ontario had regionalized health authorities in various forms, with some provinces with as few as four geographic areas and some as many as seventeen.18 Though all provinces with RHAs today are characterized by appointed boards that govern the local area, within a framework determined by the respective provincial government, in the 1990s the provinces of Alberta, Saskatchewan, New Brunswick, and Prince Edward Island had a mix of appointed and elected board members.19 The only constant in this context has been change; in every province, the region size and boundaries evolve, views on appointed versus elected board members shift back and forth, the degree to which the provincial governments are willing to delegate versus seize control changes, with little discernible partisan patterns of the provincial governments engaging in restructuring. With the broader context of regionalization introduced, we can now focus on the path towards regionalization in Ontario, which was the lone holdout among the Canadian provinces until 2004, when LHINs were introduced. DHC Creation in Ontario In some localities in Ontario there were long-­established voluntary hospital councils, which demonstrated the importance and effectiveness of cooperative planning for the health care services. Yet little formal action was taken on the 1965 Hall Commission recommendation – that regional councils be established with delegated authority for both planning and operations – until 1974, following the Mustard Report and the Ontario Council of Health advocacy, which advised the creation of District Health Councils (DHCs) for planning and coordination in an advisory capacity, but not an operational one. The MOHLTC accepted this recommendation in 1975 and established the basic terms of reference under which DHCs would operate through a policy document, not formal enabling legislation.20 DHCs in Ontario were not mandated by the provincial government, but instead were created if there was interest at the district level among citizens, health service providers, and local governments. The MOHLTC would maintain all fiscal, regulatory, and legal responsibility for the

The Evolution of Health Care Governance in Ontario  47

delivery of health care in Ontario, but they would now receive input from local advisory bodies. By 1982 twenty-­two DHCs were created across the province, covering over 80 per cent of citizens.21 Assisted by area planning coordinators in the MOHLTC, interested parties would identify potential DHC members to be formally approved by the minister and Cabinet, aiming for the 40/40/20 distribution of health service provider, citizen, and local government, respectively, as advised by the ministry, although considerable variation on this distribution was found among DHCs by researcher Maureen Dixon.22 Though the ministry was mindful of representational balance, it was explicit that “each member must set aside parochial interests and function as a representative of the public at large, rather than as spokesman for a vested interest.”23 DHCs appointed a small staff, usually no more than five, funded by the ministry, which was kept small as an explicit policy of the ministry to avoid the criticism that DHCs are another layer of bureaucracy in the system, foreshadowing a major critique faced by LHINs today. The ministry outlined a common mandate of DHCs, which was fundamentally advisory to the minister of health – to identify district health needs, to plan a comprehensive health program with short-­term priorities consistent with provincial policy objectives, and to coordinate all health activities to ensure a balanced, effective, and economical service – but each DHC focused on health planning specific to the district, and thus appeared quite different from each other in activities in researcher Maureen Dixon’s evaluation of them.24 Dixon, in her 1982 review of DHCs, suggests that long-­term care, mental health, bed rationalization, and emergency services appeared to generate attention from most DHCs. In 1977 the ministry expanded the role of DHCs with partial delegation of authority, requiring them to conduct “institutional review,” which involved reviewing proposals for new or expanded programs in hospitals and assigning a ranked order to them for the ministry to formally approve for funding. In the immediate years after DHCs were created, provincial support for them was strong. In a presentation to the Health Services Review in 1979, the minister of health said, “It is our belief and our experience that no-­one is better able to assess and coordinate the health care resources of a community than the people who live and work there. Thus, we have developed the system of district councils to examine available resources and needs and make recommendations on the health priorities for their communities.”25 Support for DHCs among key interest groups in the health system was more mixed or contingent. Prior to the creation of DHCs, in 1973 the Ontario Hospital Association (OHA) and the Ontario Medical Association (OMA) released a joint position paper

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endorsing the concept of DHCs, particularly as advisory bodies that would form from the ground up, not by ministry mandate. The hospital sector was clear, however, that DHCs should not be permitted to challenge the independent authority of local hospital boards and not be used as instruments to reduce health care spending by giving the ministry political cover. The Ontario Nurses Association (ONA) was very supportive of citizen participation in local health planning, but wanted more diverse membership on the councils from various employee groups in hospitals, and even argued for more of an operational role for DHCs to realize cost savings.26 Were DHCs ultimately successful? The answer to this question depends on one’s evaluative criteria, in particular if the focus is an outcome evaluation or process evaluation. An outcome evaluation – whether consumers of health services are healthier than before, waiting less time for needed services, and getting care at the appropriate venue – ought to be the ultimate measuring stick of the health system, but it is not the right one for DHCs, which represented advisory health planners with no control over spending and hospital operations. With the complexity of the health system and multiple state, market, and individual forces at play, the scope of evaluation on outcomes would have to extend well beyond the boundaries of DHCs. Instead, process evaluation – whether health needs were identified, collaborative opportunities were identified and explored, and community and provider voices contributed to long-­term planning advice given to the ministry – focuses on DHC activity and is the yardstick against which they should be measured. An extensive review by Dixon in 1982 found that some DHCs developed sophisticated approaches to planning, though often at the expense of establishing genuine links with the community. Other DHCs devoted great effort to community development but experienced difficulty in formulating plans, thus revealing tensions inherent in such an institutional arrangement. Indeed, over time the activity of DHCs revealed tensions that foreshadow their outgrowth into LHINs in the mid-­2000s. First, the most fundamental: at what level should health planning occur? At the municipal, regional, district, or provincial level? Second, should health planning occur in isolation from other human services, in particular social services? If yes, a third tension emerges on the issue of coterminosity: should the boundaries of health-­planning bodies align with the jurisdictional boundaries of other central and local government agencies, such as social services like housing, immigrant settlement, and early childhood development? Fourth, can appointed bodies (like DHCs)

The Evolution of Health Care Governance in Ontario  49

be held sufficiently accountable to the public, or ought they be elected or institutionally linked to local government? And fifth, should DHCs remain as advisory-­based planners or expand their mandate to perform operational tasks? Maureen Dixon, citing evidence from abroad, suggests that accountability for planning and operations should not be separated and that the planners and executive managers should be in the same organization and reporting to the same point in the system.27 Operational imperatives of efficiency and cost containment are tempered by planners’ forward-­thinking and innovation perspective, and planners’ “fantastical” thinking can be moderated by practicalities stressed by operational staff. Dixon also argued that DHCs remaining as advisory would limit their ability to generate the systemic change needed in health care governance.28 But some argue that it is expecting too much from a single organization to develop technical expertise for long-­term, rational planning, while also acting as a conduit for community engagement. DHCs were directly accountable to the minister of health, but as a non-­elected membership, had a responsibility, but no accountability, to the community at large. For many observers, community involvement in DHCs was a means to an end (i.e., rational health planning), not a democratic virtue in itself. For those involved with DHCs, the dominant sentiment emerging from Maureen Dixon’s research was that community engagement and long-­term planning are not in fact in opposition, but that each informs the other and must be united under one roof.29 As DHCs developed and became more sophisticated, calls began for them to move beyond merely an advisory role to the minister, towards more authoritative decision-­making on health planning and operations. DHCs were expected to consider the allocation of health resources in the pursuit of constraining costs and improving the quality and accessibility of service, yet did not have executive authority to implement approved plans. DHCs might fairly have been described as operating in a context of “centralized authority and decentralized blame.”30 As DHCs matured, they became viewed as health care planning institutions, yet without the authoritative control to directly initiate change or resolve problems in the system. This disconnect led to increasing calls for reform, particularly towards genuine regionalization. For the incoming OLP health minister in Ontario in the early 2000s, there were a number of examples of regionalized health planning to draw from within Canada, as described earlier. Ontario, in shifting from DHCs to LHINs, embraced authentic regionalization as practised by the other provinces, but with several unique features.

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The Arrival of LHINs In 2004 the government of Ontario introduced a new political and administrative structure for health care through Local Health Integration Networks (LHINs) to take responsibility for the delivery of local health care services. Notwithstanding the name – Local Health Integration Networks – LHINs are in fact Crown agencies, but with mandated participatory decision-­making avenues for stakeholders and communities. LHINs hold delegated authority from the MOHLTC for most health care spending across the province, yet operate under a legislative framework created by the province of Ontario, and formal accountability agreements connect the work of LHINs to the principles of responsible government. In response to the sense that DHCs were health planners yet without authority, LHINs would be health planners with the authority and resources to shift behaviour of service agencies in the health sector away from competitive and siloed service provision, and ideally towards a more integrated and navigable health system for patients. Figure 3.1 presents a simplified graphical depiction of the authorities and relationships created with the onset of LHINs. One Toronto area LHIN official interviewed characterized LHINs as “children of the ministry,”31 who have to adhere to high-­level ministry priorities, some of which change year after year, but local LHINs have autonomy to decide how to implement those priorities, as well as their own, locally. On one hand LHINs are delegated bureaucracies (though with their own ministry-­appointed corporate boards), yet on the other hand they are expected to be responsive to their local conditions and constituencies. This basic institutional design grafts seamlessly onto the democratic arenas framework (DAF) outlined in chapter 2, which differentiated procedural decision-­making bodies (i.e., legislature and Cabinet), mandated decision-­making bodies (i.e., LHIN boards and staff), and citizens and public space (i.e., extensive community engagement via advisory committees, citizens panels, and town halls, among others). The Local Health System Integration Act, 2006 (LHSIA), the memorandum of understanding (MOU), and the ministry-­LHIN accountability agreements (MLAAs) are the core components of the accountability framework between the MOHLTC and each LHIN, as seen in figure 3.1. Each of these framework documents is described in turn below. The LHSIA specifies that the purpose of LHINs is to plan, fund, and integrate the local health system, with integration being the central part of this mandate. LHINs are an attempt to meet two goals: (1) to develop a more integrated and coordinated health care system,

Figure 3.1.  Simplified Flow Chart of Authorities and Relationships in the LHIN Source: Produced by author

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bridging hospitals, doctors, home-­care providers, and long-­term care facilities, to benefit the patient experience, and (2) to facilitate a more participatory decision-­making process among key stakeholders and communities, under the presumption that this will lead to better decisions.32 LHINs’ health planning and funding must be in accordance with provincial plans and priorities, however. The enabling legislation states that the MOHLTC “shall develop a provincial strategic plan for the health system that includes a vision, priorities and strategic directions for the health system.”33 Planning is embodied in LHINs’ three-­year Integrated Health Service Plans (IHSPs).34 The Act also gives LHINs authority to restructure, merge, and close facilities,35 but LHINs were not initially assigned responsibility for the delivery of health services.36 LHINs thus hold the responsibility to finance and coordinate most health services and programs in their designated area, including hospitals, community care access and support service centres, community mental health and addiction agencies, and long-­term care facilities, among others. Integration of health care services is at the core of the LHIN mandate, which reflects the government’s recognition that a shift towards integration and regionalization was necessary to adapt to challenges and changing demographics in Ontario’s health system. Yet several aspects of health care were initially excluded from LHINs’ mandate, in particular public health, physician services (i.e., salaries), ambulance services, laboratories, and provincial drug programs, as is the case in most other provinces.37 Fourteen LHINs were created across the province, as shown in table 3.1, each with a board of up to nine members (now up to twelve, as of 2016), all appointed by Cabinet (though on the basis of advice from the community38), but are expected to have expertise, experience, and understanding of local health issues and needs. The board must meet at least quarterly and “give reasonable notice to the public” of board and committee meetings, which must be open to the public. One LHIN official interviewed suggested that in the early days the boards “were really community-­based, but a lot of them didn’t have governance background, and obviously there is attention to balancing skills, governance experience, and also diversity. But they have much more skills-­based boards now and a lot more attention on raising the overall standard of the governance,”39 signalling a decline in the diversity within this arena, which, it may be recalled, is one of the dimensions measured in the analytical framework, as is evident when reviewing current board membership of LHINs across the province. A comprehensive analysis of this is presented in chapter 5.

The Evolution of Health Care Governance in Ontario  53 Table 3.1.  The Fourteen Local Health Integration Networks Name of LHIN

Geographic area

Central Central East (CE) Central West (CW) Champlain Erie St Clair (ESC) Hamilton Niagara Haldimand Brant (HNHB) Mississauga Halton (MH) North East (NE) North Simcoe Muskoka (NSM) North West (NW) South East (SE) South West (SW) Toronto Central (TC) Waterloo Wellington (WW)

York-­Simcoe Oshawa-­Peterborough Peel-­Dufferin Ottawa-­Champlain Windsor-­Chatham Kent Hamilton Niagara Haldimand Brant Mississauga-­Halton North Bay-­Sudbury-­James Bay Barrie-­Collingwood-­Muskoka Thunder Bay-­Kenora Belleville-­Kingston London-­Stratford-­Owen Sound Toronto Waterloo-­Cambridge-­Wellington

The enabling legislation also specifies that the LHIN must establish a close relationship with the community, with public engagement, focus groups, and advisory groups leading to close working relationships with stakeholders and citizens as a central part of planning and implementation, “including establishing formal channels for community input and consultation.”40 The Act does not stipulate specific requirements for community engagement methods other than the following: community engagement must be ongoing, be part of setting priorities and developing the IHSP, engage the Indigenous-­and the French-­ language health-­planning entities in the region, and each LHIN must establish a health professionals advisory committee – the last of which has since been removed in the updated legislation in 2016 (discussed in detail in chapter 6). One senior LHIN official in charge of community engagement suggested that their LHIN had twenty-­five to thirty advisory committees at any given time, “where we involve patients, families, caregivers, health professionals, and more in the design, development, monitoring of the programs that we are creating.”41 Another LHIN official interviewed suggested that education, citizen feedback, and engagement are essential because “the data [we have in the health care sector] is great … but you can’t say what is that community’s first order of priority for what we need to do.”42 Whether they became a meaningful part of the policy process, however, is less concrete. Community engagement is “stipulated – but not specified” in the Act, which means that, according

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to Paul Barker, “less fruitful types of involvement can qualify as an engagement exercise,” such as simply informing the public of an LHIN decision.43 Yet other LHINs report success with resident councils or citizens panels to establish ongoing relationships between the LHIN, service providers, and the community to evaluate services and programs and to pilot new initiatives.44 Evaluation of the empowered inclusion, collective will formation, and collective decision-­making functions of these community engagement arenas, but also the linkages they form with other arenas (i.e., how their work, recommendations, or even decisions are “carried” up the chain of decision-­making), is facilitated by the analytical framework created in this book. The memorandum of understanding (MOU) outlines guiding principles for the health care system, which include acknowledgment that accountability is a fundamental principle to LHINs and that LHINs play a unique and meaningful role in developing and implementing government policies and programs. The MOU outlines the accountability relationships and responsibilities vis-­à-­vis the MOHLTC and LHINs. Many of the accountability relationships are typical of public sector agency corporate governance: The LHIN CEO is accountable to the board through the chair, and is responsible for managing operations and staff and translating the board’s leadership into operations. The LHIN board is accountable to the Minister through the chair for the oversight and governance of the LHIN, setting goals, objectives and strategic direction, and monitoring performance. And finally, the Minister is accountable to the Cabinet for “providing strategic direction to the LHIN for the health system” providing direction on, reviewing and approving LHINs’ annual business plan; reporting and responding on LHINs’ performance; ensuring LHINs’ annual reports are made public; determining the need for a review of a LHIN and recommending changes to its mandate, powers, administration, governance or operations; and recommending to the Cabinet any allocation of provincial funding to a LHIN.45

The accountability relationship between each of the fourteen LHINs and the MOHLTC is more or less identical. The Ministry-­ LHIN Accountability Agreements (MLAA) focus on the performance (goals, objectives, standards, targets, and measures) of the LHIN and local health system, the requirements for the LHIN to report on this performance, and a plan for spending the funding that the LHIN receives from the ministry. The original 2006 MLAA states as its central purpose the devolution of authority from the MOHLTC to LHINs, to enable

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the MOHLTC to become the steward of the health care system, and to enable the LHIN to be accountable for funding, planning, and integration. The MLAAs are clear that the MOHLTC provides overall planning, expectations, and standards for health care, while LHINs must abide by these guidelines and ensure health service-­providers (HSPs) do the same. LHINs must shape their Integrated Health Service Plans (IHSPs) around the Provincial Strategic Plan. The MOHLTC provides LHINs with dedicated funding envelopes – a set amount of funding that LHINs must use to fund a specific service. The MOHLTC thus sets required service levels for certain health services, while LHINs decide which services will be provided by HSPs in the local health system, which HSPs will be funded for those services (and how much), and the service volumes and performance requirements of the HSPs. A LHIN can also order a health service provider to integrate a particular service provided (or not to proceed with an integration of services). As described in the above paragraphs, the formal legal accountability mechanisms largely flow upwards from service providers, through various layers, to the minister of health. These accountability mechanisms are enshrined in law and policy, yet as described in the DAF in chapter 2, there are unique accountability mechanisms required for when community engagement is a central part of governance. They are operationalized not through hierarchy, but through discursive mechanisms and norms, given that they represent a different type of authority not granted via elections. As we will see in the case of LHINs in subsequent chapters, these discursive accountability mechanisms are much less formalized, yet are essential as part of a democratic and accountable governance subsystem. LHIN Reforms While LHINs have been controversial since their inception, and often initially based on misinformation or misunderstanding of their role, following their first decade of operation the government of Ontario in 2016 revised the authority of LHINs and implemented other associated reforms as part of the Patients First Act. There was agreement that integration, regional planning, and local decision-­making are vital to Ontario’s health care system, but there was growing recognition that the framework for LHINs, in their previous state, was too flawed to accomplish this. Specifically, they did not have enough authority. The auditor general (AG) of Ontario released a damning report in 2015 on the framework for the ministry–LHIN relationship, as well as how performance was tracked in the health system. The AG identified

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a key structural problem with the LHIN model compared to health systems in other parts of the country: LHINs do not directly govern or provide health services. Big health care providers like hospitals and long-­term care homes retained their own boards of directors, which made it difficult for LHINs to govern them.46 The AG plainly stated, “If LHINs’ mandate is for hospitals and other health service providers to meet certain performance levels to ensure that people get the right care at the right time throughout the health system, then LHINs have not yet succeeded.”47 And when the AG examined the ministry-­established performance targets across the province, as well as specific targets for specific LHINs (reflecting their unique population demographics), she discovered that LHINs repeatedly missed performance targets and no LHIN had ever met all of the targets in the fifteen performance areas.48 The AG also discovered that in some cases the ministry would simply relax the performance targets or simply do nothing, which is not really how performance management is supposed to work, to say the least (although several interviewees claimed the original targets were wildly unrealistic).49 Performance targets mean little without being linked to accountability. Yet in a broader context, between 2010 and 2014 Ontario’s performance was better than the Canadian average in most of the measured areas that relate to LHINs.50 Beyond questions of meeting targets, it is clear that performance indicators measured the effectiveness of hospitals “more than they measure the LHINs’ performance as planners, funders and integrators of their local health systems.”51 The ministry-­established targets related to access to health services (e.g., emergency room length of stay, wait times for various surgeries and tests, etc.), appropriate care (e.g., how often a patient occupies a hospital bed when unneeded), and high-­quality care (e.g., frequency of readmissions and repeated unscheduled hospital visits), but again, LHINs funded, but did not really control, these institutions and parts of the health system to which they were judged. The fifteen performance areas “are intended to measure the performance of the local health system rather than the LHINs t­hemselves…. [The ministry] did not have performance indicators to measure how effectively LHINs are performing as planners, funders and integrators of health care.”52 This is especially problematic, given that the motivation for regionalization is to establish more local control and accountability for the governance of the health system, but much of the performance measurement framework is misaligned with the authority of LHINs. Furthermore, according to the MOU, the minister can take action, or direct LHINs to take action, to correct their administrative or operational weaknesses. But in practice, typically the ministry has taken a

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“collaborative approach” to addressing these weaknesses, which arguably has not improved performance, according to the AG.53 The ministry indicated that it encourages LHINs to find their own solutions to performance problems. The auditor general report, however, said that the ministry could be more directive in its approach, provide better oversight of LHINs, and do more to ensure underperforming LHINs set reasonable time frames to address underlying issues, and hold them accountable to those timelines. Though the AG’s report was specific in her critique of the accountability relationships between the LHINs and the ministry, it was wholly silent on the nature of the accountability relationships with respect to the community and citizens, representing a major blind spot given the explicit mandate for LHINs to develop robust community engagement to inform decision-­making. The democratic arenas framework (DAF) applied in this book in subsequent chapters provides that system-­analytic approach that examines relationships across arenas and actors, applying consistent criteria and measures to evaluate the democratic character of the LHIN universe. In the wake of the damning AG report, the ministry set out to reform LHINs in what would become the Patients First Act. Since being proposed as legislation in June 2016, the Patients First Act was surrounded by controversy. Nearly all media coverage of the Act is highly critical. The Act is said to have passed “despite widespread protest by doctors, nurses, OPSEU, caregivers, patient advocates and health system pundits,” as reported in the Toronto Star.54 It should be noted that simultaneously the government of Ontario was cutting fees for many physician services, which would have prompted protests, regardless of the governance changes proposed. The two primary criticisms of the Act that are related to governance are that (1) it expands an expensive bureaucracy when more money should be going into patient care, and (2) it gives the health minister unprecedented power to act unilaterally to overrule LHINs. The province, as metagovernor of LHINs, removed some of the barriers to effective integration of health services. First, the reforms gave the minister power to issue operational or policy directives to hospital boards, in an attempt to curb their influence and make their existence more compatible with integration efforts. The fact is, unlike some other provinces, Ontario did not dissolve hospital boards upon creating LHINs, and that posed a challenge for planning and integration. This, in addition to LHINs’ new ability to audit and inspect hospitals (though not impose an operational or policy directive on them), represented the ministry’s attempt to curtail the influence of hospitals. The reforms also added home care (dissolving Community Care Access

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Centres – CCACs), “physician resources” and “public health services” to the objects of LHIN control, which are key pieces of the health care sector previously operating independently from LHINs. Furthermore, one critique from observers of LHINs is that they are not held accountable in weak performance, and that the ministry often relaxed targets or tried to work “collaboratively” with LHINs to raise performance. The Patients First Act seems to move the ministry and LHINs towards a very strongly directive and less “collaborative” relationship. The minister may issue directives to LHINs, which LHINs must comply with, and can now appoint an investigator to investigate and report on LHINs, aimed at financial accountability and efficiency. The new powers the Act gave to the health minister over LHINs reflect this history of unmet LHIN performance targets and what seemed to be the ministry’s expectation that they will not significantly improve their performance on their own. Thus, on one hand the province of Ontario gave LHINs more authority in key areas of the health sector (e.g., home care, physician services, public health, etc.) in order to facilitate more comprehensive integration, yet one the other hand appeared prepared to more forcefully supervise and hold LHINs accountable, particularly under-­performing ones. The new powers also gave LHINs the “teeth” they have been criticized for lacking and more health care planning authority concentrated at the local level. Yet the new powers given to the minister have also been criticized for centralizing health care planning, given that the minister was newly authorized to step in to give directives to LHINs whenever she wished (though it was understood this would be used only in cases of unacceptable performance). So the Patients First Act gave LHINs more authority, but also the minister more clearly defined power. According to one LHIN official interviewed, “It looks like an expansion of power because they’re saying you [LHINs] will now take on primary care, and there are some other pieces that seem to be coming under the LHIN. But the reality is they are listing what we are and what we will not be doing … which is in effect taking [authority] away from us.”55 Further, the new Act required LHINs to establish at least one patient and family advisory committee, in an attempt to more specifically articulate community engagement expectations. The minister was also given the power to establish a Patient and Family Advisory Council “to provide patient perspectives and advice on strategic health policy priorities to the Minister.”56 The previously required health professionals advisory committee now became optional. Criticism has been levelled against LHINs in the past for allowing only health professionals to influence LHINs’

The Evolution of Health Care Governance in Ontario  59

planning, and not providing space for patients and their family members to voice their concerns and influence planning. Requiring LHINs to establish at least one patient and family advisory committee may be a positive response to this criticism. A critical reading, however, might see that the health professionals advisory committee as now optional as a government attempt to take power away from physicians, but still meet community engagement standards by creating a less threatening patient and family advisory committee. On 7 June 2018 the Progressive Conservatives (PC) led by Doug Ford defeated the governing Liberals, and while health care was not a primary (or even secondary) issue in the campaign, many expected the new government to usher in reforms in this realm. Those reforms were announced in early 2019 as part of the People’s Health Care Act, whereby the fourteen LHINs would be “dissolved” and authority would be ratcheted back up to the provincial level in a health care “super agency,” called Ontario Health.57 Ontario Health will be governed by a fifteen-­member board of directors appointed by the province, yet the minister is granted the extraordinary power to use directives to Ontario Health, or any entity that receives funding from Ontario health, on any matter the minister wishes – an authority not expressed so clearly in previous legislation. The government expects Ontario Health Teams to voluntarily form, consisting of hospitals, primary care physicians, and home-­care providers, to coordinate their services locally, and each team will receive a single pot of funding and a single mandate to provide the range of health services its population needs. The team will jointly agree how to divide the funding to provide all those services, though at the time of writing we do not know how these teams are expected to govern themselves, let alone engage with their communities. It should be noted that these changes to Ontario Health Teams could easily have been made within the LHIN governance model, but there was a strong perception among PCs that LHINs were an unnecessary layer of bureaucracy. The stated aim of the legislation and governance reform, as per the preamble, is to “remove duplication while replicating and amplifying best-­in-­class clinical guidance and approaches to care.”58 Various health care experts and commentators expressed puzzlement by the reform effort, including Bob Bell, former deputy minister of health in Ontario, who stated that the more he learned about the proposed reforms, he was “increasingly confused and concerned about the proposed changes.”59 Public health care stakeholder groups such as the Ontario Health Coalition and the Ontario Council of Hospital Unions were vigorously opposed to the reform. Yet others, especially in the pages of

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the Toronto Sun, claimed that there was “too much government bureaucracy presiding over health care – twenty-­one agencies that don’t communicate with each other effectively, making it harder for patients to access timely and appropriate care.”60 And while full implementation of these reforms is years away – most LHINs will remain until at least 2022 – as of writing it remains unclear how the mechanisms of stakeholder and citizen involvement will take shape in the province-­wide Ontario Health agency. Notably, the public was not primed for this reform effort by any public consultations or even mention of reform in the PC campaign platform. The closest mention of community engagement in the reform legislation is found in sections 6 and 44 of the Act, which suggests that the agency will be responsible for patient engagement and patient relations, including the pre-­existing ministerial-­level Patient and Family Advisory Council. Yet “patient engagement” is distinct from community engagement, and after a review of the legislation, it appears the extensive community engagement mandate that came with LHINs at the local level will be sacrificed in favour of streamlined decision-­making at the provincial level. Though I have introduced the 2019 reforms here, they are not part of the core analysis of this study, as they were introduced only at the time of finalizing the book. I will, however, return to the People’s Health Care Act, 2019, in the concluding chapter to place it into context with the findings from the analysis on the history of LHINs in Ontario. Conclusion This chapter set the context for the evolution of health care governance towards LHINs in Ontario by documenting the broader regionalization movements in Canada and elsewhere, and by describing the development of District Health Councils (DHCs) in Ontario as predecessors to LHINs. The legislative basis for LHINs was then outlined, as was the normative basis for the various authorities and their accountability relationships, each of which was directly linked to three main arenas (e.g., procedural, mandated, and citizens and public space) specified in the democratic arenas framework (DAF). One of the narratives emerging about LHINs from their ten-­year-­plus history is a tension between the province as a metagovernor, setting the rules and context under which they operate, and LHINs as designed to be responsive to their local needs and pressures. Three key components of this narrative are (1) the challenges of devising a “systems approach” to health under this framework (i.e., broadening the scope of planning of LHINs),61 (2) the demonstrated need to further “localize” health care

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planning, involving citizens and stakeholders, below even the LHIN level (i.e., targeting communities within LHINs, known as sub-­LHINs), and (3) a ministry with a genuine desire to delegate to the local level, but reverts to top-­down control in key moments of highly politicized health care decisions. The next three chapters examine the various arenas of the LHIN system – procedural decision-­making bodies (i.e., legislature, Cabinet, and ministry), mandated decision-­making bodies (i.e., LHIN boards and staff), and citizens and public space (i.e., community engagement) – through a vignette analysis of LHINs across the province against the democratic and accountability criteria established in the previous chapter. Drawing on legislative and governance documents, as well as interviews with actors at all levels of the LHIN universe – from citizens and stakeholders, to LHIN staff and board membership, to ministry bureaucrats and political staff – the core empirical chapters analyse how the various arenas and actors are connected (or not) to construct a democratic and accountable system of health care governance in Ontario.

Chapter 4

Procedural Decision-­Making Bodies That Enable and Constrain LHINs

This chapter examines the political level of health care governance, in particular how political actors, particularly the minister of health and long-­term care and other elected representatives, interface with LHIN governance, stakeholders, and citizens. That is, this chapter focuses on bringing together empirical data and observations relevant to the top third of the democratic arenas framework (DAF) – the procedural decision-­making bodies – reproduced in figure 4.1. Though the Local Health System Integration Act (2006) devolved considerable governance and administrative authority to LHINs from the MOHLTC, the minister (and, by extension, the ministry) retains critical metagovernance (oversight and steering) roles with respect to LHINs in setting provincial policy priorities, devising enabling and constraining legislation on LHINs, and acting as the holistic system overseer that encourages LHINs to integrate services within and across their regions. Legislators and independent officers of Parliament, such as the auditor general of Ontario, also play an important role in the democratic accountability regime. This chapter documents the (largely top-­down, i.e., state-­driven) creation of LHINs and analyses the practice of steering and oversight by the ministry, legislature, and auditor general – with the guidance of the DAF in figure 4.1 – but also the moments in which the minister has vetoed LHIN decisions, which complicates the process established by LHINs and their multi-­directional accountability relationships. The chapter reveals that this can disrupt LHINs, especially in performance and their legitimacy in their communities, yet the analysis also emphasizes that the minister, legislators, and independent offices like the auditor general are essential nodes in the democratic accountability regime.

Figure 4.1.  Democratic Framework, with Focus on Procedural Decision-­Making Sites

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LHINs as the Brainchild of the Minister On 2 October 2003 Ontario voters went to the polls, and the Ontario Liberal Party (OLP) secured a majority government, toppling the eight-­year ruling Ontario Progressive Conservatives (PCs) on a series of promises to improve the services that citizens rely upon, namely education and health care. Incoming Premier Dalton McGuinty, who had relied on OLP MPP George Smitherman to be his go-­to “attack dog” in the legislature, appointed “Furious George” to be minister of health and long-­term care, as well as deputy premier. With the Health Ministry headed by a very powerful minister, and one who “didn’t care what anyone thought of him,”1 according to one former ministry official interviewed, the new government committed to making significant policy and governance reforms in health care. Those in the orbit of Smitherman suggest that he and the associates he brought into the Minister’s Office were the intellectual driving forces in the shift to LHINs. In the early days on the job, the minister lamented the power of the Ontario Hospital Association (OHA) to pressure Cabinet. One former ministry official remarked that the organization had become powerful, with routine and direct access to the minister: “If they wanted a 5 per cent increase in funding, I would get a call from the Minister’s Office saying ‘Write a cabinet submission for 5 per cent.’ So I would write out a 150-­page Cabinet submission and just work backwards from whatever percentage they wanted, and write these long arguments for why we needed exactly 5 per cent. And that’s the way it worked.”2 Thus there was a sense in the political and bureaucratic realms that the OHA, more than any other interest group or stakeholder, wielded too much influence within the existing health care governance structures. Smitherman resented this accumulated power – with reports suggesting that he was confrontational with them and the relationship was contentious3 – and, according to another former ministry official, many people thought the reason he created the LHINs was to “get rid of the OHA” – not literally, but to curb their unrivalled influence.4 With the creation of LHINs, hospitals would have to work with their particular LHIN, undermining the province-­wide lobbying efforts of the OHA. And the manner in which LHINs were created suggests an agenda that was designed in part to curtail the efforts of the most powerful lobby group in the sector. Fourteen LHINs were created as Crown agencies – with little advance public notice – by Cabinet in September 2004, with the minister appointing the fourteen CEOs to begin managing local health services, first with the hospital sector. A legislative foundation

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for LHINs would come in March 2006, at which point legislative debate and committee proceedings reveal various stakeholders questioning the legitimacy of LHINs as birthed from the shadows with no substantive stakeholder or public input into their design or purpose. In the parlance of the analytical framework in figure 4.1 above, there was only “metagovernance” and no “metadeliberation” in the formulation of LHINs. The story of the creation of LHINs in 2004 can only be described as “top down” – derived and driven from high levels of state authority rather than from the outgrowth of public consultation, citizen mobilization, or interest group pressure. Take, for example, how the boundaries of the fourteen LHINs were drawn. If the province is to be divided into smaller regionalized units for governance and planning, on what basis the province is carved up is of fundamental importance. Yet the minister did not seek citizen, stakeholder, or local government input on LHIN boundaries, instead used an analysis of referral patterns between various services (family physicians to hospitals, etc.) to get a sense of how people typically moved within the area so as to avoid drawing the boundaries such that a major service link for citizens did not in fact fall under control of another LHIN, as described by OLP MPP Kathleen Wynne, then member of the Social Policy Committee of the Ontario legislature.5 Citizens could, of course, receive health care services in an area outside the LHIN that covered their geographic area, but for governance and planning it is only rational that those frequently linked services or institutions fall under control of the same LHIN wherever possible. Yet under a technocratic system to draw boundaries such as with referral patterns – which some speakers providing testimony disputed as simply inaccurate6 – and no public or local government level input, the boundaries lacked political coherence for many. This is what “metadeliberation” processes, which involve citizens, stakeholders, and others in the basic design of governance institutions, can help avoid by building consensus through early engagement and deliberation. Instead, the local governments, service providers, and stakeholders in some districts were pushed together despite having no historical relationships, or in the case of Toronto, the five LHINs within the city boundaries extend seemingly randomly outside the city in some cases. LHIN boundaries thus became a controversial part of the reform and led to one particularly bizarre situation in which one MPP’s district – Etobicoke Centre, represented by Donna Cansfield until 2014 – was caught in the catchment of four (of fourteen) different LHINs. This makes it more difficult for such MPPs to perform their constituency service and oversight roles vis-­à-­vis LHINs on behalf of citizens.

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As Minister Smitherman barrelled forward with creating LHINs, there was little resistance from the bureaucracy. The shift towards a more substantive form of regionalization of health care planning and decision-­making was emerging as the professional consensus across health-­ policy analysts in the country.7 But that did not mean that Smitherman relied on the bureaucracy to implement his agenda; in fact, he trusted few in the health bureaucracy and created a “political bureaucracy within the Minister’s Office that was really powerful,” which he affectionately called his “dream team” as part of a broader system transformation effort, which included former Toronto Mayor Barbara Hall, Gail Paech, and Adalsteinn Brown from the University of Toronto.8 Smitherman wiped the program branches off the ministry organization chart, including the Hospitals Branch and the Long-­Term Care Branch. According to one former ministry official, “There was no one to call anymore, literally. And that was incredibly disruptive. It changed everything. They [the hospitals] didn’t know who to talk to anymore, they had to go to the LHINs.”9 Thus the procedural decision-­ making body, in this case Cabinet, created, through their metagovernance authority, the mandated decision-­making body – LHINs – that reshaped the locus of authority in the health care system. A ministry official present at this time, who largely supported these reform efforts and was eager to see the system change, reflected, “I’ve never seen anything happen so fast,” in part because of Smitherman’s determined and aggressive personality, but also because “he wasn’t politically connected with these guys [interest groups and stakeholders in health care] and he didn’t really care what anyone thought about him.”10 Other former ministry officials confirm that while Smitherman had rough edges, most in the bureaucracy “loved him” for being very action-­oriented and pushing his ideas through.11 While this aggressive, largely secretive push to reform was made possible in this political context, as we will see it came at a cost of legitimacy among stakeholders and the broader public who had no metadeliberation opportunities within the reform agenda. In a matter of months, DHCs were dismantled, regional offices closed, new LHIN boundaries drawn, and CEOs and staff hired.12 With the ministry offices hollowed out to some degree, many of these people ended up working in the LHINs, but this created a vacuum at the centre when Smitherman’s “dream team” dissolved after they set up the new system.13 As such, in the first several years of LHINs, they were flying without a pilot, as there was no comprehensive provincial governance or policy framework beyond the enabling legislation.14 Metagovernance, as specified in the analytical framework, does not entail just how

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authority is drawn from the state, but also includes the process and relationship among the procedural and mandated decision-­ making arenas (i.e., LHINs) to create a coherent governance framework. A former ministry official reflected that even if the ministry was no longer driving decision-­making, they still needed corporate leadership for the various segments of the health system, with a small staff who knew the big institutions and sectors like hospitals, long-­term care, and professional associations. That is, while these groups were structurally forced to work with LHINs at the local level, some institutional space at the provincial level was needed “to create provincial policy … that was never created [until much later in 2015],” thus revealing gaps in the relationship between key arenas of governance in the system.15 Critics of LHINs have long suggested that they were created as a shield for the often-­unpopular decisions that need to be made in a health system, such as hospital closures and service rationalization. Yet such critiques ignore the broader trend towards regionalization of health care governance and management in Canada and elsewhere, as described by Gregory Marchildon.16 That is, Ontario’s path towards regionalization was not unique, with narrow political objectives, but rather was consistent with the other provinces who set up regional authorities to better manage health care planning and governance. This is not to say that regionalization is universally accepted as the most effective path forward; Alberta in 2008 recentralized most governance back up to the ministry level after working with a regional model (but have since created five “administration zones”),17 as did Saskatchewan in December 2017. Yet Anthony Dale, CEO of the Ontario Hospital Association (OHA), cautions against assumptions about centralization that “because you’ve got one scope of authority and one set of decision-­making levers, it will all fall into place. I think the reality they experience in Alberta is dramatically different.”18 Minister Smitherman, in his testimony to the legislature’s Standing Committee on Social Policy, defended the regional model: “Pretend if you want, but you cannot appropriately micromanage a $33-­billion operation from head office. So we’re building a system where critical health care decisions will be made at the local level, by local people who understand the needs of the community and in many cases probably know by name many of the patients being affected by those decisions.”19 The LHIN model of governance represents an attempt to preserve the high-­level and over-­arching vision and direction for health care within Cabinet and the ministry (i.e., procedural decision-­making bodies), while harnessing the

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knowledge, experience, and particularities of local communities to sort out how they can achieve those provincially defined objectives (via the LHINs, the mandated decision-­making bodies). That is, how can they allow the ministry to function in a more strategic level, while “leaving the day-­to-­day negotiation of the twists and turns to people closer to the ground”?20 Despite these claims of the devolution of authority and decision-­ making downwards from Smitherman and ministry officials when LHINs were introduced, which garnered support among many, they were met with scepticism in some quarters, particularly among health service unions (specifically nurses and support workers) and other stakeholders. Where Smitherman identified more opportunities for “local” control over the health system, critics saw a new layer of bureaucracy created in LHINs as Crown agencies, with boards of directors whose accountability flowed not to communities, but up to the minister. To Ron Elliot, regional VP of the Ontario Public Sector Employees Union (OPSEU), “The minister will be the grand puppet master of the LHINs,” as it is the minister who “determines the funding levels, can veto or order integrations, and approve bylaws and set salaries,” not to mention hire and fire LHIN board members, and of course create and dissolve LHINs if so desired.21 Though LHINs may look powerful and relatively autonomous in the enabling legislation, John Ronson, a long-­time observer of health systems, argued that “many fear that LHINs will simply be a funding conduit, perpetuating the status quo; or that they will simply do the Ministry’s bidding and add another layer of unnecessary bureaucracy and contribute further to the inefficiency of the system.”22 To these critics, while the legislation and regulations that created LHINs offer new opportunities for communities and health service providers to have a more institutionalized role in health system governance and management, “the real lines of accountability run to the centre,” according to Ross Sutherland of the Kingston Health Coalition.23 The next sections of this chapter examine these critical claims that LHINs are merely a smokescreen for the provincial government to continue to unilaterally control health care governance, by exploring the provincial policy framework under which LHINs are expected to align, how LHIN boards are appointed, how the ministry bureaucrats conduct oversight of LHINs, and the how the accountability mechanisms work in practice. All of these dimensions are part of how the procedural decision-­making bodies, conceptualized in figure 4.1, constrain or enable the activities of the mandated decision-­making bodies, the LHINs.

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Provincial Strategic Plan The central bargain between elected officials and the local LHINs with their appointed boards is that LHINs are afforded a certain autonomy at the local level in how to achieve the broader system goals set forth by the provincial Cabinet. Yet, until recently, LHINs were rowing without an explicit map, as the promised strategic provincial framework that would guide their efforts was not produced until recently. The only element that resembled a strategic plan in the first several years was a stated provincial priority to reduce surgical wait times, and LHINs made strides to set service accountability agreements with the hospitals, negotiate targets, monitor change, and move patients or volumes around the system to leverage and reduce wait lists. These efforts brought Ontario from the “bottom of the pile to scoring straight As in the national scorecards,” according to Camille Orridge, CEO of the Toronto Central LHIN.24 In 2008 the province selected reducing ER wait times as a strategic priority, but LHINs had less success in that effort, in part because the family practice and broader public health sector fell outside the scope of authority of LHINs.25 This is a clear example of the boundaries of the system, as determined by the institutional design of the system, being misaligned with the policy goals determined by the procedural decision-­making bodies. Without a comprehensive strategic plan, critics thus had reasonable grounds to accuse the provincial government of merely using LHINs to shield them from unpopular decisions or, alternatively, to arbitrarily exert their control when it suited them. In 2014, when the enabling legislation for LHINs was being reviewed by the provincial legislature’s Standing Committee on Social Policy, it was apparent that the ministry still lacked a vision that could guide LHIN planning and decision-­ making. PC MPP Christine Elliott also suggested that “there is a large role for the Ministry of Health to play there, and … the lack of an overall vision by the ministry is causing some consternation at the LHIN level in not knowing what the priorities are and what should be focused on in each individual LHIN.”26 Leadership from major stakeholders were demanding the same in subsequent legislative committee hearings, with Jacquie Maund from the Association of Ontario Health Centres saying, “We’re interested in seeing greater provincial direction in terms of a provincial health care plan so that the LHINs are then carrying out and delivering health services in a high-­quality, more uniform way.”27 The importance of a strategic provincial plan is not only one of accountability, as it would be informed from priorities set by elected officials directly accountable to voters, but also because in its absence

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the LHINs developed at times wildly different plans and priorities, given the legislated autonomy to do so. Thus system-­ wide policy coherence suffered without a provincially defined strategic plan. This was especially concerning because a central aim of the Local Health System Integration Act was to facilitate integration and coordination in the broader health system. Instead, operating in the absence of strategic provincial framework, LHINs might work towards integration and coordination in their area, but there was risk of drifting away from one another in their strategic direction. Interview respondents suggested much of same in the ministry’s lack of a strategic plan as hobbling the efforts of LHINs themselves and the larger health system. To one LHIN official, “It was a bit striking … the minister of health never ever fashioned the ten-­year strategic plan. So what you can imagine then, not even having a blueprint, and the ministry says to the fourteen LHINs, ‘You’re inconsistent in your local strategic plans.’”28 But if there had been a ten-­year strategic plan from the government, the fourteen LHINs would have been compelled to use it for cues to move their own local agenda. That same interview respondent suggested that “the lack of a top-­of-­the-­pyramid strategy for the province, the fact that that’s been missing, has not helped the situation.”29 So in the early years of LHINs, the procedural decision-­making bodies like Cabinet and the ministry did not fulfil their mandate according to the formalized accountability framework, which was to specify over-­arching societal goals in a strategic plan, which directly affected the ability of LHINs, through close engagement with the community, to focus on the means to achieve those goals. In 2008, a report written by KPMG30 under the joint guidance of the ministry and LHINs weighed in on the effectiveness of the transition and devolution of authority, and an area of the ministry–LHIN relationship that did not comply with its imagined form: early and ongoing LHIN input into provincial strategy development and implementation. As discussed, the ministry produced no publicly available and comprehensive strategic plan in the early years, only identifying a few select priorities (i.e., reducing wait times, keeping Ontarians healthy, and improving access to health care providers). Yet KPMG heard overwhelmingly from LHINs in this review that the provincial strategic priority development often excluded LHINs and that “they have a lot of local knowledge that would be useful for the MOHLTC when developing provincial strategies.”31 This is part of the metadeliberation piece of the analytical framework, depicted in figure 4.1, that has been consistently lacking in this governance space: top-­down specification of policy priorities and governance processes, with very little input

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flowing upwards, from citizens, stakeholders, or middle institutions like LHINs, as will be explored in more detail in chapter 6. The ministry claims that with the Patients First Act and agenda in 2016, LHINs now have that strategic agenda, which some LHIN officials have noted is a helpful development, but other LHIN officials remain unconvinced: “To be very blunt with you, it [the provincial policy agenda] is a bunch of feel-­good stuff that is absolutely meaningless.”32 Appointment to LHIN Boards If part of the purpose of LHINs is to allow for more local control over health planning and operations, then the relative autonomy of the LHIN boards of directors is essential, otherwise they are just another layer of the bureaucracy, as critics allege. Yet as LHINs were created, the CEOs of the fourteen LHINs were hired by the minister, not the boards, as the boards had not yet been formulated, and this contributed to a perception, even today, that LHINs remain under the direct control of the minister. That said, within a year, some boards had fired their minister-­appointed CEOs and replaced them with their own selections, demonstrating some autonomy from the ministry.33 But the main function of a board is to manage the CEO, and thus LHIN boards firing their original CEOs was, to this observer, when speaking to a former associate deputy minister of health, “because they were unhappy with the direction you’re [i.e., the minister] giving, and you think you can give direction from the centre.”34 The key question here is not one that challenges the ability of the minister to make LHIN board appointments, as that is a key role of procedural decision-­making bodies in this governance space, but rather how much ministers consult and take recommendations for appointment from the community, particularly given the community-­oriented mandate of LHINs. The minister also appoints the chair and vice-­chair of the LHIN boards from among the board members whom they exclusively select. To some observers, like Don Gracey of the Registered Practical Nurses Association of Ontario, the appointment process demonstrates that the minister is inappropriately involved in LHIN governance, as “any board that cannot appoint its own chairman has been significantly neutralized.”35 Yet the legislation also permits the LHIN board to select up to three board members from their communities, but those nominees must be put forward through an Order in Council for ministerial approval. It was suggested that the exclusive appointment power held by Cabinet should be amended, allowing for “local” appointment (from local governments, or some other procedure to select them, as vaguely

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suggested in legislative committee hearings by opposition MPPs) or even the election of board members, much like school trustees. NDP MPP Shelley Martel, a fierce critic of LHINs from the beginning, suggested that under the current ministerial appointment procedure, “they can’t even claim to be representative of the community because they’re not even elected by the community, and they don’t serve at the request or the behest of the community. So I find it a little hard to hear again and again how this is all about devolving local power.”36 Helena Havlek of Charlotte’s Task Force for Rural Health in Petrolia also suggested the government set up elections for LHIN board members, as “having elected representatives makes it necessary for those people to respond to the needs of their community.”37 The Liberal government firmly rejected proposed amendments to the enabling legislation that would allow for elected boards for LHINs, primarily based on their conclusion that where other provinces had experimented with elected boards in the past, “they did not work throughout Canada, and they’ve reverted back to appointed boards.”38 Indeed no other jurisdiction Canada allows elections for regional health boards, but some do split the appointment power between the ministry and the community (in Nova Scotia, for example, members of their Community Health Boards [CHBs] are selected through a community-­centric process, but CHBs are more like Ontario’s old DHCs than the LHINs, which direct funds and set priorities).39 The government retained exclusive appointment power because, in its explicitly stated view, the government “continues to be ultimately responsible” and supports “the need for specific representation and expertise on these boards,” according to OLP MPP Kathleen Wynne.40 This debate about board appointments connects to elements of the analytical framework that emphasize the legitimate role of Cabinet to populate the mandated decision-­making bodies, but also the challenge to ensure that structurally the LHINs are also linked to the community. To critics, if LHIN board members are appointed by government, they are then responsible to the government, not the citizens for whom they are making decisions. There is fear that political appointees may not necessarily have the best interests of their assigned community at heart or have the incentives to adhere to the region’s preferences rather than the minister’s. “Who said that they should be picked in that manner?”41 – that question gets at the missing dimension of metadeliberation on the construction of these governance relationships. The way in which the entire governance framework of LHINs was created – in a secretive and insular manner that did not involve citizens or many stakeholders – has cultivated the image that LHINs represent

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ministerial shields (yet remain effectively under the control of the ministry). That devalues the work of LHINs to determine and implement locally sensitive health policy and programs, while also working towards the broader goals of the provincial government. Ministry Oversight For a governance model that was ostensibly designed to shift health care decisions down to the local level, the formal accountability relationships established under legislation and regulation flow back to the centre, not out into the community, even if there is a legislated expectation to consult and engage with the community as part of the enabling legislation. In a formal accountability chain, authority is devolved “downward,” and responsibility flows back upward to the minister in the form of political accountability. For example, the LHINs are explicitly defined as agents of the Crown, and each LHIN must enter an accountability agreement with the ministry that attempts to hold the boards accountable for the expenditure of public dollars and the performance of the health system under their authority. The LHINs are thus resourced by the ministry on terms and conditions that the minister exclusively defines. Yet as NDP MPP Shelley Martel pointed out in early debates about the legislation, “There’s no similar accountability agreement with the community that they’re purported to serve.”42 Martel thus concludes, as have others, that “to say that this is all about money going to the community and the community making decisions is just ridiculous.”43 To Joanne Evans from the Registered Practical Nurses Association of Ontario, “this governance model keeps the vast majority of the powers at the ministry level. But at the same time, the bill shifts all accountability to the LHIN.”44 Many of the big decisions – for example, base funding – still come from the ministry, but LHINs are presented to the public as the decision-­makers responsible for the health system in their region. Among those who defend the LHIN governance model, accountability must flow back up to the minister, especially when considerable public dollars are flowing through these Crown agencies. To Paul Huras, CEO of the South East LHIN, “Devolution should not mean every region does what it wants,” but instead the ministry sets provincial priorities and holds the LHINs accountable for improvement through ministry-­LHIN performance agreements.45 Kathleen Wynne, OLP MPP at the time, suggested that “what we’re trying to do is write a piece of legislation that recognizes that control of the financial well-­ being of the health system in the province rests with the minister. That

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is the minister’s responsibility … at the same time have the local planning process in place. We’re trying to find that balance.”46 Thus one level down the chain of decision-­making, the LHIN combines provincial priorities with locally determined priorities based on the particular needs of its population, and subsequently crafts accountability agreements with the health service providers it funds to implement services and programs that address those priorities. This tiered accountability, according to proponents, is essential to link the local priorities to province-­wide goals, which was not always observed in other provinces that moved towards the regional model, according to an Alberta deputy minister of health.47 Accountability Agreements The principles of accountability reflect a desire to retain ultimate responsibility for the health system to the minister, but how that works in practice is expressed in the mechanisms of accountability: agreements. Two key documents articulate the accountability relationship between the ministry and LHINs: the memorandum of understanding (MOU) and the Ministry-­LHIN Accountability Agreement (MLAAs), each with slightly different functions. The MOU is between the Ministry of Health and Long-­Term Care (MOHLTC) and LHINs, outlining the guiding principles for the health care system – including “the LHIN[s] hav[ing] a unique and important responsibility to manage health care needs”48 – and the accountability relationships and responsibilities as parties that jointly govern the health care system. The MOU states that the fourteen LHIN CEOs – who are charged with managing operations and staff and translating the board’s leadership into operations – are responsible to their LHIN board, which is accountable to the minister for the oversight and strategic direction of the LHIN, and the minister is accountable to Cabinet for approving LHINs’ annual business plan, reporting and responding on LHINs’ performance, and providing strategic direction to the LHIN for the health system. This is all determined at the Cabinet and ministry level of decision-­making, as it represents the oversight mechanisms that they must demand as ultimate decision-­ makers in a democracy. Yet it is only through the analysis of how these documents are operationalized, which is found in chapter 5, that we can evaluate how formal bureaucratic accountability is (or is not) effectively rendered in this context. Whereas the MOU is a foundational, non-­time-­limited document that sets out the relationships between actors and institutions in the health system in broad terms, the MLAAs are renewed every few years and

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specify the funding amounts transferred to LHINs, the performance goals and measures, and the transparency and reporting requirements for their activities. Among the requirements in the MLAAs is that each LHIN must produce an Integrated Health Service Plan (IHSP) that is guided by the Provincial Strategic Plan, which in some cases specifies required service levels for certain health services and dedicated funding envelopes for those services (e.g., hospital services, community mental health, acquired brain injury services, etc.), but the LHINs have latitude to decide which services will be provided by which HSPs, in what fashion, in what locations, and according to what performance standards. For the accountability relationships detailed within the MOU and MLAAs to be operationalized, routine reporting from the LHINs to the ministry has been the primary mechanism. Among health service providers (HSPs), which are funded by LHINs to actually deliver services to patients, there is consistent pushback on the extensive reporting required. One commentator joked in the media that “there are three levels of contracts before the patient gets a bath,”49 and for each contract there is regular reporting of data in order to evaluate the performance of the service. Ministry officials suggest that they are aware of the “reporting burden” and that it is something “we definitely have an eye towards” in streamlining reporting on “what matters,” but ultimately many of them are government directives from Cabinet.50 Yet it is important to keep in mind that what LHINs and health service providers call “reporting burden” is an essential component in this complex governance context to link the behaviour of actors at different levels of the system to performance, evaluation, auditing, and reform, as depicted in the analytical framework in figure 4.1, and thus great care must be taken when “streamlining” (i.e., reducing) reporting expectations. Regarding ministry–LHIN reporting relationships, it is important to distinguish between two required pieces: the LHIN Strategic Plan and the LHIN Business Plan. The LHIN Business Plan specifies how expenditures will be directed and must be approved by the ministry, whereas the LHIN Strategic Plan articulates a vision for policy, practice, and community engagement over the next three years, and are produced and approved by the LHIN board with no formal role for the ministry. In the early days, the minister, Smitherman in particular, would nonetheless ask for the LHIN Strategic Plans in advance for review to mitigate against political risk, and one former LHIN official recalled telling the minister, “No. These are independent boards that are working within the confines of the public system, around what’s local and important,” and while the ministry did not “want to be surprised by

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anything,” it was not their place and created a grey area in oversight.51 This is one piece of a larger cache of evidence of the minister micromanaging LHINs beyond the intention of the accountability agreements. The above-­mentioned “effectiveness review” in 2008 by KPMG also identified the LHIN-­to-­ministry reporting requirements, which grew to become time-­ consuming and redundant, and extended beyond how the accountability relationship was defined. As a result, KPMG reported that the ministry ought to align the reporting requirements of the LHINs more closely to the principles of a stewardship model and the vision for the LHIN model, which meant that the ministry should demand and receive only financial and performance updates, but no details of operating activities that are within the scope of LHIN authority. KPMG also recommended that the ministry limit their ad hoc reporting demands – which various LHINs suggested were outside the scope of the accountability agreement and often required quick turnaround times. Yet LHIN officials interviewed suggested that little has changed to reduce or streamline the reporting burden. That is a shame, given that KPMG outlined a principle-­based vision for streamlining that would preserve the essential accountability objectives while minimizing the extraneous reporting requests to the ministry that were aimed at political risk aversion. Performance Targeting One key mechanism of accountability held by the ministry vis-­à-­vis LHINs is through performance targeting and measurement. For eleven of the fifteen performance areas, the ministry has a provincial target and separate LHIN-­specific targets.52 For the other four areas, the ministry sets LHIN-­specific targets.53 Thus against the backdrop of provincial objectives – such as reducing wait times for surgeries or emergency room visits – the ministry sets performance targets for LHINs in close consultation and negotiation with the leadership LHINs. Why? Not all LHINs share precisely the same performance targets (e.g., to reduce wait times by 10 per cent) in recognition of the unique context of each LHIN, although the directional goals and areas (e.g., to reduce wait times) are consistent across the province, according to Kathryn McCulloch from the LHIN Liaison Branch in the MOHLTC.54 In a 2015 report the auditor general found that some of these individualized targets are developed on the basis of evidence, but others are based simply on their previous year’s performance and a vague sense of local challenges.55 Provincial performance targets are set with advice from a joint committee of LHIN CEOs and ministry officials, and negotiations at the

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individual LHIN level occur on more specific or tailored targets for that region. This is consistent with the “co-­development of institutional design” dimension of the democratic arenas framework (DAF), which suggests that key elements of the governance framework ought to be jointly crafted by government and LHINs and with community input. Likewise, the ministry, through its LHIN Liaison Branch, works very closely on performance issues, areas of success and challenge, and how the ministry can support them, and each LHIN files a quarterly performance report. The auditor general found that between 2007 and 2015, province-­wide performance in six of the fifteen areas improved. But in the other nine areas, “performance has either stayed relatively consistent or deteriorated since 2010 or earlier.”56 That said, however, “between 2010 and 2014, Ontario’s performance was better than the Canadian average in most of the measured areas that relate to LHINs.”57 There is some criticism of the ministry–LHIN relationship on performance targeting, particularly after the auditor general in 2015 suggested that when a LHIN failed to meet its targets, the ministry would simply adjust the targets downward in subsequent years.58 Exasperated opposition MPPs were incredulous about this behaviour, asking senior public servants if this meant the whole performance-­ management scheme was a sham. PC MPP Jane McKenna asked, “At what point do we bring someone else in here, to shake this up and get this to where we need to go?” A ministry official responded, “I don’t know if the conversation around target-­setting is where you can actually get the improvement. You can set a more difficult target; that doesn’t get you to the improvement. We meet with them to try and identify where the challenges are and where the opportunities are.”59 This exemplifies the dynamic nature of idealized performance reporting, which does not conceive of reporting as the end of the mechanism, but rather as an instrument to begin the collaborative work of identifying the source of the problem and possible avenues to meet the performance targets. But perhaps the biggest problem with the ministry-­LHIN performance­targeting regime is that it measures many elements of the health care system that are beyond the control of LHINs. Performance indicators measure the effectiveness of hospitals “more than they measure the LHINs’ performance as planners, funders and integrators of their local health systems,” according the 2015 AG report.60 When interviewed, LHIN staff seemed to agree with the auditor general’s conclusions about the performance measures and their settings, suggesting that the “benchmarks are totally off,” “arbitrary,” and “we’re going to fail anyway, before you even give us the numbers.”61 So when LHINs are measured against system-­wide health outcomes criteria, and they control

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only part of the health system, this can make them appear feckless, in ways that are unfair and do little to create a climate of collaboration to improve system performance. To Leonore Foster, board member of Frontenac Community Mental Health and Addiction Services, “This is akin to giving the coach of a hockey team the authority to direct the play of only half the players on the ice and, at the same time, holding him or her entirely responsible for the outcome of the games.”62 Thus the accountability regime for the ministry–LHIN relationship is flawed in its misalignment of performance measures with LHINs’ responsibilities. Accountability to the Community The accountability relationships flow in a particular direction and in a formal manner, although the minister and ministry rarely intervene to root out weak performers. But more fundamentally for some, how are the LHINs accountable to their communities? Board members serve at the pleasure of the government, not of local residents, and accountability agreements between LHINs and health service providers are not guaranteed to be disclosed to the public. That undermines public accountability.63 So imagine the following, relatively common scenario offered by a speaker who was testifying in the legislative committee hearings: suppose a citizen (or many citizens) disagrees with a decision from the LHIN board to close a hospital in the name of efficiency, integration, or for whatever reason they may have to do so. To whom may they petition to appeal this decision?64 The LHIN board makes the decision, and they are accountable to the minister, not to the citizens, who have no direct role in holding the board to account. In this scenario, the minister would be able to point to the LHIN as the authority who makes these decisions, and the LHINs would be able to point to their mandate from the ministry to meet objectives of the strategic priorities of the province, which include integrations and efficiencies where appropriate.65 This is precisely what happened in the Hamilton Niagara Haldimand Brant (HNHB) LHIN in 2010 when the board held secret meetings that led to the closure of emergency wards in Port Colborne and Fort Erie. Citizens attempting to resist this decision were neither able to influence the minister, who held that it was a LHIN decision, nor penetrate the LHIN decision-­making process to have the decision appealed or revisited. Ultimately, the process was reviewed by the Ontario ombudsman, who concluded that the LHIN process was “illegal”66 and urged the province to force LHINs to adhere to transparency standards, which

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the ministry subsequently did. But the decision to close the ER wards stood. To some, that exposed the weaknesses of the accountability regime as impenetrable to community pressure. Thus, to some, LHIN board members as unelected, appointed positions spend taxpayers’ money “with seemingly no accountability to anyone but the Minister of Health.”67 Suggestions made by several in the legislative committee hearings to set up a formal appeals board (perhaps at the provincial level) were rejected by the government, although it is important to note that if a minister felt enough heat over a hospital closure or any LHIN decision, one would expect that decision would be reconsidered by the board at the minister’s request. While the HNHB ER above did not prompt a ministerial reversal, in 2017 the minister announced the reopening of two recently closed hospitals at Humber River’s Finch and University Health Networks Hillcrest locations, a decision clearly within the scope of the LHIN.68 What this episode reveals is that on controversial decisions made by LHINs, at least the HNHB LHIN at the time, the lack of formal accountability linkages to the community insulated them from considerable community pressure on one hand, and effectively being overruled later by the minister on the other hand, both of which undermine them as legitimate decision-­makers in this domain. Ministry-­LHIN Interactions Accountability and oversight of LHINs by the ministry occurs principally through the formal reporting discussed above, but there are near-­ constant interactions among them. The absence of a strategic plan for most of the existence of LHINs did not stop the ministry from steering the activity – or injecting itself into decision-­making – of LHINs. Perhaps not surprisingly, when one asks those involved with LHINs whether the ministry is hands-­on or hand-­off in local planning and decisions, there is disagreement, depending on where one exists in the system. Ministry staff interviewed suggested, “In the first few years it was very Ministry hands-­off,” often inserting itself only to “undo from behind” (meaning to clean up a mess or controversy they perceived to be made by the LHIN).69 Yet among LHIN officials, the opposite perspective is common: “The government has been too micromanaging with LHINs for the longest while. This new act [Patients First, 2016] is going to change it. It looks like they’re giving way more powers [to LHINs] now.”70 To another LHIN official, “The Ministry still micromanages the system way too much. And I don’t know if it’s just been really

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slow to trust, and really truly devolve some of the authority for the day-­ to-­day oversight of the region.”71 One former LHIN CEO estimated that over 30 per cent of his staff’s time was dealing with inquiries from the ministry bureaucrats rather than working with his health care providers.72 When asked about this, ministry officials confirmed that this figure sounds right – and may even be higher on average – but framed it as necessary in this framework under which “we are really close partners.”73 To ministry officials, this engagement is critical, as it “(a) reinforces the partnership and (b) makes sure that direction is clear,” preventing LHINs from pursuing visions diametrically opposed from one another or the province.74 Ministry officials also noted, “It’s not always the ministry bringing up the provincial perspective – sometimes it’s the LHINs.” And sometimes the ministry might suggest circumstances where the LHINs might not want to approach a problem in their region exactly as another region has done, given their unique context.75 Contrary to what some opposition critics have suggested is the norm of LHINs shielding the government for unpopular, though perhaps justified decisions – there are have been times when “the ministry will roll over [i.e., veto] the LHINs’ decisions and undermine the LHINs’ authority, which can have a long-­term impact on the LHINs’ own credibility and authority.”76 This tension between local LHIN autonomy and ministry oversight is apparent throughout the system, and everyone accepts that in this context, the government has “a right to run their agenda,” given its democratic legitimacy, argued one LHIN official.77 That same LHIN official remarked, however, that it is a constant negotiation over “how much was local and how much was provincial” in their activities and priorities.78 Instead increasingly they are “very hands on, and that has caused some frustration, because you have people who want to design the system from a provincial perspective, whereas you recognize that a lot of the actual work that happens in the system and some of the challenges are very local,” according to another LHIN official.79 A LHIN attempting to address a problem of alternate level of care (ALC) patients can illustrate ministry–LHIN relationships in this respect. ALC patients no longer require high-­intensity resources or services, typically in hospital, but wait for weeks or months to get into lower-­intensity settings and thus prevent other patients from accessing hospital beds and other hospital services. The LHIN, with their community partners, including hospitals, worked very closely to devise a strategy to utilize beds freed up at a vacated hospital while enhancing programming in the community, and they had money and facilities

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ready, only to have the ministry direct that those hospital beds were to close before those services in the community had been set up.80 Part of the delay in ramping up those community services was attributed to “each individual component of that original plan requir[ing] ministry approval,” in one case waiting eighteen months for approval for just one part of the action plan, according to Ron Gagnon, CEO of the Sault Area Hospital.81 As a result, not only was the solution not truly local, but components of an integrated solution to a problem were slow to get off the ground as the result of ministry oversight and delays. So, to one service provider working with LHINs, “You shouldn’t have to be checking [with the ministry for] every individual action plan. I realize that that means mistakes will be made, but if we want an innovative health care delivery system, we have to be ready to accept mistakes.”82 When we think about this example in the context of the DAF, which guides how we ought to examine the relationship between ministers and delegated agencies like LHINs, we see that this is unstrategic micromanagement from the ministry that does not enhance democratic accountability, but does undermine the confidence in the community that LHINs are a legitimate governing institution that can devise policy priorities and execute them. This is merely one illustration, but former LHIN officials remark, “The reality is there’s a million ways that the ministry can reach into the LHIN and just tell them no. And they do do that, actually.”83 Elements as small as a press release or publication from a LHIN need to be submitted to the ministry for review and approval, and they contribute to the sense that LHINs are agents of the government, not independent agencies of government with a community-­oriented mandate.84 Prominent among the discoveries in the MOHLTC-­LHIN Effectiveness Review in 2008 by KPMG was that the ministry – and in particular the political arm within the Minister’s Office – was failing to respect the mandate of the LHINs and the authority granted to LHIN boards. For example, LHIN board chairs spoke of numerous occasions in which the ministry, driven by the minister’s political staff, reversed boards’ public decisions, and that undermines their core mandate and their credibility in the community. To one former LHIN official, “[We] were not always supported when we exercised our authority … [or] made decisions that were politically unpopular. The ministry didn’t always back them up.”85 There were also cases, documented within the KPMG report, where the minister’s office made funding announcements that were within the purview of the LHIN mandate but not a strategic priority of the LHINs. For example, in late 2006 the MOHLTC announced new strategies for aging at home and emergency department wait times, but

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half the LHINs had not identified seniors as a priority and thus had little in place to work towards that end.86 This also left those LHINs to explain to their communities and stakeholders why funding was being directed to these areas that were not prioritized during their extensive consultations and strategic planning. Such actions by the minister are a failure in faithful adherence to the governance framework, which is characterized by provincially defined objectives through locally determined means. Oversight by Legislators The minister and ministry are not the only overseers of LHINs; there is also a role for legislators, as specified in the analytical framework in figure 4.1, not only in legislative review and approval, but also as part of their representative and ombudsperson functions for citizens. When policy and operational decisions are devolved to Crown agencies, the influence of citizens on health policy through their elected representatives is potentially subverted, as structurally Crown agencies are designed with greater independence than ministries, which are much more penetrable to legislator oversight. As such, as LHINs were introduced, some were concerned that normal oversight and inquiry by MPPs on behalf of their constituents in the legislature would be threatened. One opposition MPP said, “I see this as a huge loss for the last voice you [citizens] have at Queen’s Park, which is the person you elected to go there and speak up for you. Even that is being taken away in this legislation because of the manner in which it is ‘scheduled’ … which determines how much you can discuss it on the floor of the Legislature.”87 But some observers are making a broader point that when authority is institutionally devolved as it is in LHINs, the minister ultimately responsible for health can credibly evade responsibility by saying “That’s not my responsibility. That’s what they manage,” or “I had nothing to do with that decision. That was a decision that was made by the [LHIN]. Go talk to them,” as MPP Ted Arnott suggested in legislative committee hearings.88 But there are key opportunities for legislators to exercise their oversight over LHINs that is distinct from ministerial accountability and are described below. The most formal element of legislative oversight and involvement happens when enabling legislation is reviewed or amended, which occurred in 2013–14 (review) and then in 2016 (review and amended legislation), despite a suggestion from the government that the legislation would be reviewed three years after first implementation in 2006. A review of the legislation is an essential piece of the accountability

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framework, as it provides an opportunity for legislators to probe and reflect on whether things are working as intended and refine the governance framework after learning lessons from implementation. This involves deputations from all around the province, with LHIN leadership and staff, stakeholders, advocacy groups, and citizens submitting written and oral testimony and reports for legislators to consider. While no legislative changes were introduced following the 2013–14 review, the legislative committee heard from LHIN leadership that the model was generally working but needed to include more elements of the health system (home care and public health, in particular were identified as big pieces outside LHIN authority), and also heard critical observations from other stakeholders who advocated for more transparent, democratic, and accountable LHINs. And only a few pushed for a return to the centralized model of full ministry control. A less formal but ongoing role for legislators is meeting with the LHIN leadership and staff in their district, typically twice a year. A former COO of the Mississauga-­Halton LHIN, Narenda Shah, claimed that “every [area] politician has to be met over a frequency of every six months. Meeting them, doing presentations, talking about the big picture LHIN at that level.”89 While not written in the legislation, ministry officials maintain that LHINs ought to communicate routinely with every area MPP, including by inviting them to sessions and board meetings, so they learn about what is happening in that LHIN.90 One MPP, Helena Jaczek, who was part of the legislative committee reviewing the LHIN legislation in 2014, remarked that she has seen improvement from LHINs in their engagement with her, with visits from the board chair and CEO twice a year now.91 But another MPP, Donna Cansfield, who represented an area covered by multiple LHINs remarked, “I never get to see one of my LHINs. They just don’t bother with me,” and “yet the service the person receives in that top end [of the district] is different from the service two blocks away,” making it hard to explain to constituents why this is a suitable governance framework.92 And to a former high-­level LHIN official Narenda Shah, connecting with local MPPs is critical, “because any message about the LHIN not doing its job in their community, we’re going to hear about it [from the MPP]. So we need to have good relationships with them so they can say directly, ‘By the way, I’m hearing this. Is this factual, [and] if so what are you doing about it, or is it noise?’”93 Thus the relationships between LHINs and their associated MPPs is very context-­specific, contingent upon the LHIN and legislator, which could be more formalized with more consistent expectations set out either in law or policy to institutionalize that engagement.

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Auditor General Oversight Another piece in the accountability framework is the auditor general of Ontario, an independent office of the legislature, which examined LHINs in 2015 and issued what many observers described as a blistering report on their performance and the ministry’s stewardship over the health system. The AG report found problems with the role of the ministry as metagovenor, but also among LHINs as health system planners and service funders. As mentioned above, when the AG examined the ministry-­ established performance targets across the province, as well as specific targets for specific LHINs, she discovered that LHINs repeatedly miss performance targets, but they “are intended to measure the performance of the local health system rather than the LHINs themselves.”94 The ministry indicated that it encourages LHINs to find their own solutions to performance problems, but the AG argued that the ministry could be more directive in its approach, provide better oversight of LHINs, and do more to ensure that underperforming LHINs set reasonable time frames to address underlying issues, and hold them accountable to those timelines. And on a more practical level, the AG found that the ministry can undermine the LHINs by finalizing its annual funding too late in the fiscal year, which then often prompts the LHINs to issue funding to their health service providers late.95 The independent oversight role of the AG uncovered governance problems that escaped ministerial and LHIN self-­analysis, as well as legislators’ limited ability to access key operational features of the governance framework. The reaction to the AG report among the ministry and LHINs was predictably divided, yet both acknowledged weaknesses in the relationship and legislative framework. Thus there was broad support to refine the legislation via Bill 41, ultimately leading to the Patients First Act, whose goal was to extend the authority of LHINs into new areas of the health system, “physician resources” and “public health services,” as well as folding CCACs (home care) into LHINs, at the same time as pronounce a legitimate role for the minister to intervene to issue policy or operational directives to a LHIN. In this case the oversight role of the AG contributed directly to governance reforms that would clarify responsibilities and establish a more principled basis under which the ministry ought to legitimately insert itself into otherwise local policy-­ making procedures at the LHIN level. New Era of Direction to LHINs Whereas in the first phase of LHINs (2004–16) the ministry was very involved with LHINs, although somewhat arbitrarily and informally,

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in the second phase (2016–19) the direction was more formalized. At the same time as the ministry has become more comfortable with LHINs exercising increased autonomy, they have now identified specific areas or processes in which their oversight will be enhanced. To some officials in the LHINs, “It’s a bit of a dichotomy, [whereby] we’re going to give you more room to take a stewardship role and you can do things more locally, but yet we’re going to tell you specifically these are the things you have to work on.”96 For example, in recent years the LHINs received mandate letters for the first time from the ministry. They are typical for Crown agencies, but LHINs had not received them in the past, likely because it was understood that the ministry had more direct ability to control LHINs. They specify the short-­and long-­term objectives of the provincial government that LHINs ought to work towards. In the past, and without a comprehensive provincial strategic plan, the LHINs went off on their own directions, some prioritizing seniors services, others mental health, others emergency department diversion, etc. For one former LHIN official, “that’s helpful to say ‘Here’s some standardization, and now you implement this locally.’”97 That means that tailoring is not only permitted but encouraged, say, in the northern areas, where there are large geographies or different populations compared to more urban areas, but there is sufficient direction such that the LHINs are moving in the same direction. The negative element to the mandate letter mechanism, to echo the theme identified throughout this analysis, is “that it is so top-­down.”98 To this LHIN official, “There always has to be that loop” that allows LHINs to identify patterns across LHINs, and the ministry reflects that “we probably need to change a policy.”99 Hopeful, that interview respondent suggested, “I think we’re actually getting to that place eventually.” The Liberal government, which set up and refined the governance framework around LHINs, might be forgiven for feeling exasperated about the critics of LHINs, particularly on suggestions of “minister control.” That is, opposition critics and various stakeholders expressed suspicion of clauses in the initial legislation and subsequent Patients First Act (2016) that afford the minister opportunities to constrain LHINs through appointments to the board, approval of business plans, or even review and overrule decisions made at the LHIN level (i.e., section 28 integration order, or appointing a supervisor for LHINs). Yet as OLP MPP Kathleen Wynne correctly asserted in legislative committee hearings in 2006, “The legislation as it’s written doesn’t grant new powers to the minister; the powers already exist. What it does do is put process in place around those powers

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and specify how those powers can be exercised.”100 Notably section 28 was never used by the minister under this legislation, though it was modelled on a provision in the Hospitals Act, which was used by previous governments.101 But where critics are on stronger ground is where the governance framework for LHINs has much more complex chains of accountability that can be difficult for citizens – and researchers! – to follow that can obscure and confuse roles and their function. This is further complicated by the newest addition to the legislation in 2016 that gives the minister authority to issue operational or policy directives to LHINs, which is designed to assert provincial interest in the health system, but was further evidence to critics that LHINs are merely a political buffer for the government, and the really important decisions on the health system remain with the minister. Likewise, the updated legislation also includes the ability for the minister to appoint a supervisor of a LHIN (section 21.2), which stakeholders, such as Gail Czukar, CEO of Addictions and Mental Health Ontario, hoped would be “exercised sparingly, only when absolutely needed, when efforts to work with providers to work better together and integrate their services for the benefit of clients have failed in some way.”102 The hand-­off of responsibility from the ministry for decisions on regional planning and the implementation of those plans was too tentative, as evidenced in the interviews with LHIN and ministry officials, legislative hearings on the revisions to the original enabling legislation, the KPMG report in 2008, and the auditor general’s report in 2015. To stakeholders interviewed, that was undoubtedly wise at the start, while the LHINs were being organized, staffed, and learning how to deal with their new responsibilities. But the issue, according to one interviewed participant, “is that the ministry has not really yet empowered the LHINs to really use all the levers and powers that they might have to do what is expected of them around health system integration.”103 So more than ten years after from their creation, for Leonore Foster of Frontenac Community Mental Health and Addiction Services, it is “now over time for the ministry to loosen, if not cut, the apron strings and let the LHINs have the authority necessary to discharge their mandates.”104 Yet of course “cutting the apron strings” is unrealistic and unwise – LHINs must be rationally and clearly connected to elected officials. While the Patients First Act (2016) aimed to provide clarity on roles, while expanding the scope under which LHINs exercise authority, it also appears that the ministry wants to make clear something that was true and practised all along: they will intervene if they wish.

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Conclusion This chapter focused in on the procedural decision-­making venues and actors associated with LHINs in Ontario to examine how they are responsible for the creation of the governance framework, as well as oversight of the mandated decision-­making bodies (i.e., the LHINs). Guided by the democratic arenas framework, this analysis revealed an important gap in the normative standard on the creation of a democratic subsystem: the virtual absence of any metadeliberation that involves citizens and stakeholders. Instead, it was entirely state-­driven and largely done in secret, which interviews and legislative testimony revealed is a major contributor to the controversial status of LHINs that still persists. Further, the formal-­legal and informal-­relational connections between Cabinet and the LHINs was examined, and revealed that the concern that LHINs are unaccountable to the ministry is simply false – there is significant and regularized reporting from LHINs to the ministry such that the greater concern among those involved is that there is perhaps too much reporting and micromanaging from the ministry. Finally, the auditor general, as an independent officer of the legislature, has demonstrated the unique role that office has played in oversight and critical analysis that led to positive and informed suggestions for reform that have improved the accountability structure of the ministry–LHIN relationship. And how did the procedural decision-­making venues and actors fare in the democratic function dimensions and measures outlined in table 2.1? Recall that the functions were differentiated by empowered inclusion, collective will formation, and collective decision-­making capacity, each with several dimensions and associated measures. And in the DAF, not every venue at every level needs to satisfy every dimension, as theory suggests certain democratic functions will be met at some venues and less so at others; the important test is whether the collection of venues, when layered on each other, sufficiently satisfy all of the democratic functions and their dimensions, as a whole. Much of the analysis of the democratic dimensions in relation to each other must wait until chapter 7, when all the venues have been described and analysed, but we can establish a few brief takeaways from the procedural decision-­making venues here. The procedural decision-­making venues of the Cabinet, minister, legislators, and auditor general are rarefied offices in government and thus themselves do not meet the criteria of a space that is designed to be inclusive and or representative of the diversity of the affected populations. But recall that there are legitimate exemptions to these

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two standards that apply to Cabinet and ministerial decision-­making that relate to the source of their democratic authority: they are representatives legitimized by their receipt of a plurality of the votes in elections, or in the case of the auditor general the expertise and independence they bring, not by identity or epistemic diversity. But that means that the criteria of inclusion and representativeness will need to be considerably stronger in the mandated decision-­making venues and the citizen and public space venues examined in the subsequent chapters for the system as a whole to have broad democratic legitimacy. However, legislatures offer structured and balanced opportunities for involvement, speaking, and dissenting from representatives, an important dimension of inclusion, as specified in table 2.1 in chapter 2. So where are the strengths of the procedural decision-­making venues in democratic functions? They reside primarily in the realm of communication and collective will formation and capacity for collective decision-­making, in which they satisfy most of the dimensions specified in table 2.1. In communication and collective will formation, the legislature that formally created and oversees LHINs is structurally characterized by transparency and publicity, with thousands of pages of transcripts available for review and open to the media, and they have a public orientation that few other government institutions possess, given that the legislators and ministers must defend their actions in public, in a legislature, with intense media oversight. Yet for one dimension within the collective will formation function they do not perform as well, as legislatures are not designed to reciprocate or to build intersubjective consistency, common agendas and metaconsensus, per se, as they are adversarial political institutions, as was evident in their role described in this chapter. Yet these dimensions are more evident in other venues, particularly the mandated decision-­making bodies analysed in the next chapter. Accountability is where the procedural decision-­making venues in the LHIN context are generally strong, with clear formal and regular reporting and oversight, and interventions if required. While there are weaknesses uncovered in this realm as well, such as with tricks used in performance measurement, on the whole the political and bureaucratic mechanisms of accountability are operationalized appropriately to ensure a democratic link between LHINs and the procedural decision-­ making sites. And there is no doubt on the final dimension of the collective decision-­making function, consequentiality, that the procedural decision-­making venues are empowered to contribute to policy formulation and decision-­making. We will see that on these latter dimensions,

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particularly for the mandated decision-­making bodies and citizens and public space, that is not always so. With the procedural decision-­making bodies associated with LHINs described and analysed, the next chapter examines the mandated decision-­making bodies – the LHINs themselves – as key arenas in the system. The key task of mandated decision-­making bodies is to deliberate and reach decisions on how the goals and priorities identified by the procedural decision-­making bodies should be realized. LHINs are created by legislation, with mandates given to them in that legislation and accompanying regulations, and are subject to formal and informal accountability mechanisms, but also have considerable latitude to govern themselves, including how they engage with citizens and stakeholders. This space in the democratic subsystem is the focus of the next chapter.

Chapter 5

LHINs as Mandated Decision-­Making Sites

Introduction The chapter explores the diversity of leadership patterns within and across the fourteen LHINs by examining their board governance, including inclusiveness, expertise, connection to community, and relationship to other LHINs. This chapter focuses on bringing together empirical data and observations on the middle third of the DAF – the mandated decision-­making bodies – reproduced in figure 5.1. There is extraordinary variation among LHINs in board governance in this regard, and key patterns of success and failure over the past ten years in establishing and operationalizing complex accountability relationships towards greater health care integration and community engagement – the two primary objectives of the enabling legislation. Recall from the DAF developed in chapter 2, and reproduced in figure 5.1, that in complex governance contexts like those investigated in this book, it is helpful to differentiate procedural from mandated decision-­making bodies, as they involve different actors and institutions, possess different authority and legitimacy, and thus ought to exhibit different accountabilities. The procedural elements of the LHIN system were analysed in the previous chapter, focusing on elected officials, in particular ministers and Cabinet, but also unelected officials like the auditor general who assist procedural actors. The primary mandated decision-­making bodies, by contrast, are arenas or institutions that have been created by the procedural decision-­making actors but have no direct electoral-­democratic link. In this case we are talking principally about the LHIN boards of directors and LHIN organizations, who are empowered to make decisions on health care policy and programs in their geographic area.

Figure 5.1.  Democratic Arenas Framework, with Focus on Mandated Decision-­Making Bodies

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This chapter begins by analysing and comparing the board composition within and across the LHINs in the average size of the board, the skills and representation sought, and the procedures proposed and used to select board members. Thereafter, board governance will be examined, paying close attention to transparency rules (and those actually practised), the frequency and publicity of board meetings, and the management of staff. A third area of governance is analysed, referred to as “governance-­to-­governance,” which describes the board-­ to-­board relationships developed among the LHIN, hospitals, Community Care Access Centres (CCACs), and service providers, among others, to work towards a more integrated health system within LHIN boundaries. From this, short vignettes of various LHINs will be drawn on to illustrate the performance of LHINs in meeting provincial and LHIN-­specific targets, as well as LHINs serving as “laboratories of democracy” – that is, using their autonomy and smaller scale to experiment, such that the successful innovations are likely to be adopted by other LHINs. Finally, the chapter analyses LHIN efforts to collaborate with each other, from the informal LHIN collaborative (LHINC) to the newly institutionalized and formalized Health Shared Services Ontario (HSSO). The central lessons that emerge from the chapter are that (1) LHINs exhibit governance variation, some of which is laudable, some of which is deeply concerning, to democracy and accountability, (2) the decentralization allows for experimentation, which has led to innovations that have since diffused to other LHINs, and (3) the collaborative efforts among LHINs are difficult but necessary to establish a common trajectory amidst diversity. LHIN Board Composition LHINs are agencies of the Crown in which the Cabinet holds exclusive appointment power to boards of directors, as specified in the enabling legislation. The composition of the LHIN boards is a critically important element of the DAF, as it relates to goals of representation and inclusion in decision-­making. The initial LHSIA legislation stated that each appointed board member could serve for a three-­year term, with one renewal – thus limited to six years maximum – although this was changed in 2016 to allow for one to serve as a board member for up to six years and then board chair for an additional three, in recognition of “the experience that is necessary in order to do an adequate job,” according to OLP MPP Sophie Kiwala.1 The longer term available for potential board chairs seems appropriate, given that the experience

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accumulated and relationships developed would be useful to effective leadership and is balanced by retaining shorter term limits for board members to ensure sufficient turnover for new ideas and approaches to inform decision-­making. The original legislation in 2006 specified that each LHIN board would have up to nine directors, which is a typical size of a public sector board in Canada. During a review of the legislation in 2014, the legislative committee heard testimony that a full board complement was not being maintained in some LHINs (i.e., often operating with fewer than nine board members), and from other LHINs that the size of the board ought to be expanded, and dramatically. Among those who testified that boards were operating at less than full capacity, they pointed to the board appointment processes, which in their view were arduous and not approved in a timely fashion by Cabinet.2 The impact of a reduced complement of board members was perceived as significant to a LHIN CEO testifying in front of the committee: “I know what it’s like in our organization if I’m missing two or three board members for a long period of time. I’m missing that skill mix. I’m missing that geographic representation. I’m not here suggesting that the Order in Council [process] is wrong; it just needs to get done in a much more expeditious fashion.”3 This suggests a frayed linkage between the procedural and mandated decision-­making bodies, given that LHINs depend on higher-­order decision sites to populate their arenas to do the work envisioned in the governance system. At the same time as some were lamenting the difficulty of maintaining a nine-­member board, others were suggesting that these boards are far too small. Gerda Kaegi of the Canadian Pensioners Concerned advocacy organization, for example, asked the committee to introduce an amendment that LHINs have boards of twenty-­one to twenty-­five members, pointing to former DHCs that had boards that large. Kaegi said the argument is straightforward: “The LHINs areas are very large, and some of them encompass a very large, diverse population. We do not see how a board of nine can possibly represent and truly hear from the community with that size of a board.”4 Drawing on DHCs as a justification to enlarge the LHIN boards may make sense intuitively, given their outgrowth, but the DHCs were not decision-­making bodies accountable to the minister that are comparable to LHINs, and little organizational scholarship supports a board with such responsibility to be that large. That said, the Patients First Act did expand the maximum size of LHIN boards to twelve in response to arguments that the boards of nine were too small for the diversity of the population and the complexity of the issue being governed. As of writing in 2019, twelve of the

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fourteen LHINs used the larger permissible board size – only the Erie St Clair and the Waterloo Wellington LHINs remained at nine members. The debate on the appropriate size of the LHIN boards is related to differing expectations on the purpose of board members: to bring diverse skills to the table, or to bring diverse representation to the table? The minister and government maintained that the board should comprise those with diverse skills, whereas many in the sector and community believed it should be about diverse representation. Yet the government implicitly, and sometimes explicitly, acknowledges that representation ought to be a factor – implicitly by suggesting that LHIN directors are to be selected from the communities that the LHIN is intended to serve (i.e., you have to live within the LHIN boundary), and explicitly by government MPPs, such as Kathleen Wynne, defending LHIN board appointments of diverse folks in the Northwest LHIN as “much more connected to the community than ministry bureaucrats at Queen’s Park.”5 At the same time, the regulations specify that board appointees must have a background in health care, public administration, management, accounting, finance, law, human resources, labour relations, communications, or information management – that is, skill sets that are involved in managing a health system, not representative criteria of populations, geographic areas, etc. In the first few years of the LHINs, many felt the appointment of board members tilted towards the representation objective at the expense of the skills objective. Recall that prior to the LHSIA (2006) legislation, the LHIN members of the boards and CEOs were appointed simply by Order in Council. Thus when the actual enabling legislation providing the comprehensive governance framework was put before the legislative committee, they received feedback from those in the sector and in the communities they were already operating. Some suggested that “the appointed LHIN Board members have a stunning lack of health care experience,” and that this was not a surprise because the minister was on the record “at the first meeting of the people who had been appointed to the LHINs that he really wasn’t looking for people with experience in health care.”6 One interview respondent familiar with the initial thinking on this issue acknowledged that “they appointed people who they wanted to represent more of the community, so they didn’t necessarily have business folks, or they wanted to make sure not to have too many hospital-­centric folks or business folks on it … [but] often times a lot of community folks were not ready to take on the responsibility that’s required when you’re managing like $4 billion [in Toronto Central LHIN], you’re dealing with fairly sophisticated health service providers.”7 Others were similarly concerned that they

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populate the LHIN boards with people with expertise and community interest, “because they have a very, very challenging job and it’s a very complex role.”8 The appointment patterns have certainly changed in more recent years, with board representatives increasingly coming from high positions in industries, often outside of health care, and “very high-­ powered,” according to a former top LHIN official, Narenda Shah.9 This, according to some critics, sacrifices the “community” dimension that characterized the earlier years. Aubrey Gonsalves, a citizen speaking at the legislative hearings, remarked that “looking at government appointments to Boards, it is clear that it is not what you know, but who you know,” implying that the minister and Cabinet were looking for board members whose behaviour would be more predictable than if board appointments were truly open to people from all walks of life and experience.10 Yet when skills are prioritized over constituency-­ based representation on boards, there are real concerns that most board members will be located in the most urban part of the LHIN, as that is where their often high-­powered professional experience has led them, leading to risk that more isolated or rural communities have less of a voice on a board that is ostensibly governing their “local” area. Most LHINs have acknowledged this critique and addressed rural concerns in their areas by creating “travelling” LHIN board meetings to the outer edges of the boundaries to demonstrate an awareness of the importance of geographically sensitive decision-­making. While criteria set forth in regulations have always in some sense “tipped in favour of business and administrative elites,” given the governance task, the priority for board recruitment and appointment certainly tilts in favour of a business executive rather than a retired nurse or caregiver, for example.11 According to union representative Shawn Rouse, for example, “There has been only one, to my knowledge, one person from a labour group ever appointed to a board of a LHIN.”12 The implications, for some, are that board members who bring skills cultivated in business or government will focus on “economic efficiencies” and “cost control” over equity or service standards.13 As a result, advocates like Florence Wong, CEO of the Yee Hong Centre for Geriatric Care, wanted explicit language in the legislation or regulations that “specify the requirement for LHINs’ boards of directors to reflect the diversity of the population they serve based on language, culture, gender and other grounds.”14 As articulated by testimony at the legislative committee proceedings, “There’s a dilemma in any public organization around whether the board should be what’s called ‘constituency-­based’ or whether it

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should be ‘competency-­based.’” Others add that constituency-­based boards give voice to different groups, geographic areas, linguistic or ethnic groups.15 But the risk is that such boards may provide representation but not the kind of technical and management experience and dedication required to oversee a very complex agency. A board without management experience can be more easily deceived or misled by CEOs and executive staff, or simply less confident in the challenge function that boards hold vis-­à-­vis agency executives. Also, when representation-­or constituency-­based appointments are privileged, it quickly proves difficult to truly represent the diversity of the area. One person’s testimony reflected on an initiative in Britain to have the community select boards of hospital foundation trusts, recalling that one member of the board said, “There are 71 different ethnicities in my community, and I don’t know which ones you’d suggest that we try and put on the board of the foundation trust.”16 There is no obvious stopping rule for inclusion on this basis or manageable size of board that would satisfy representation defined on identity-­based features. Further on representation grounds, some advocated for reserved spots for Indigenous Canadians and municipal government on LHIN boards, and even local MPPs as ex officio directors of LHINs. Given the unique history and place of Indigenous Canadians in Canada, and there was some pushback from that community on the composition of LHIN boards and requests that there be “a minimum of one Indigenous seat on [each] LHIN board.”17 This was also noted in the 2016 review as well.18 To these advocates, Indigenous Canadians are not just another ethnic minority, but are nations that the federal and provincial governments have special obligations to accommodate. Guaranteed representation on the LHIN boards was rejected by the government, but they did mandate the creation of an Indigenous “health planning entity” for every LHIN.19 Others, like the Association for Municipalities of Ontario, made the case that the legislation should “provide for municipal representation on LHIN boards.”20 This proposal was also rejected, given the preference of the government for competency-­based boards. And as one person asked in the hearings, “How do you choose a [municipal government] representative from that huge area” that comprises most LHINs?21 Rather than decide who deserves reserved representation on the LHIN boards and how that could be resolved with only nine (subsequently twelve) spots per board, some argued for open elections for the LHIN boards, much like school boards.22 So instead of trying to find a composition of representative appointed figures, representation would be incentivized through direct electoral accountability. Although

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this may seem an unusual proposal in the area of health care, Alberta (2002–3), Saskatchewan (1995–2002), and Quebec (up until 2002) have used direct local elections for regional health-­planning bodies. The provincial government dismissed this suggestion on several fronts, among them low voter turnout (as low as 10 per cent in 1999 in Saskatchewan23), the threat of factionalism, and a lack of capabilities as likely outcomes. The government heard testimony from governance experts that in other jurisdictions “we got all these people elected, the members are contentious, there’s factionalism, they don’t get along and they don’t have the capabilities we need to do the job.”24 MPPs themselves were explicit that when boards are elected or too independent from government, “people who didn’t like the government, just openly hated us, and they got themselves on these boards.”25 Ultimately, OLP MPP Wynne rejected arguments for elected LHIN boards on the basis that provinces couldn’t find enough people willing to run.26 She did not say, however, that local direct elections for health boards was less attractive because provincial governments maintained strict control over finances and other controls.27 In lieu of elections, yet acknowledging the importance of balancing competency-­and constituency-­based representation, Wynne argued that the LHIN framework “is an appointment process that has the community nomination aspect to it, that the LHINs will be expected to get community nominations for people who would be able to represent the community and stand for appointment.”28 That is, while the government would formally appoint members to the board, who are collectively accountable to the minister, the LHINs are driving community nomination for at least three of the nine directors, not the province. The regulations require that all LHINs “identify potential appointees to the board of directors of the network through a local community nomination process,”29 although only a handful of them (MW, MH, Champlain, CE, TC Central) describe their process in publicly available documents, and they can be quite different in their approach. Some, like the North Simcoe Muskoka LHIN, post board openings like a job advertisement, whereas others like the North West LHIN create a community-­based nominations committee consisting of two board members and two external community members.30 The Mississauga Halton LHIN also had a community-­based recruitment and nomination process, which included representatives from academia, business, and municipal government, but any reference to this process has been dropped from public documents since 2008.31 For some advocates, rather than have a minimum of three of the nine board members nominated from a community-­based process (as

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opposed to being recruited by the provincial government), all board seats should be populated in this manner. To David Gibson, who represented the Eastern Ontario Community Health Centre Network, “Community governance encourages and promotes local action and responsibility. Community-­governed organizations are able to transmit political pressure and social change upward to promote higher-­level policy change.”32 Other related health boards, like hospital boards in Ontario, are “community-­based” and “have repeatedly held the government accountable for funding cuts and funding shortfalls, and they have been very successful in restoring funding to local communities.”33 One suspects, however, that the metagovernor, the provincial government, is not looking for a framework that is structurally designed to hold it accountable in possibly confrontational ways, but rather will devolve some authority to a group of people from the community that it trusts to balance the goals of the province and the local area. Finally, retaining full formal authority to appoint, the province also retains full authority to remove, and there have been “a couple of cases where the ministry had to intervene and have the board chair nicely asked to move on,” according to a former top LHIN official.34 In the foregoing section that has described and analysed LHIN board appointments and composition, we see that the actors and institutions in procedural decision-­making bodies have struggled with how to define and balance inclusion, a critical dimension in the democratic arenas framework in figure 5.1. To Robert Morton, chair of the North Simcoe Muskoka LHIN, the LHIN boards bring a rich mix of skills and experience to the LHIN and have a deep understanding of their community. “One of the strengths of Ontario’s approach is that LHIN governors do not come with a hat on, representing a particular sector or community. They come with the goal of representing all of the people in our communities.”35 This claim certainly remains contentious among some, but when board members are conceived as primarily bringing epistemic diversity (i.e., knowledge and experience), rather than identity-­based representation, it relieves the burden of board members from “speaking for” their group (few of which in practice are comfortable doing), but instead they exchange knowledge and experience, challenge interpretations, and develop shared policy priorities as part of their role in decision-­making. Board Activities Public sector board responsibilities differ dramatically from private sector boards in mandate, shareholders, appointment process,

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compensation, and performance measurement. For example, the mandate in public sector boards is “taken as a given” as defined by the minister under ministerial responsibility and Crown ownership, and thus boards tend to focus more or less exclusively on satisfying the mandate within their spheres of authority.36 Public sector boards are thus defined as “dependent executive boards,” with authority defined by the ministry, but key decisions are made by the LHIN board under those constraints, as described in chapter 4 in relation to the DAF.37 Yet as public sector boards, LHINs do not just have accountability relationships flowing “upwards” to the minister, but also “downward” to LHIN management and staff, and “horizontally” to the communities they serve and the health providers they fund. As such, extensive board training has been part of the LHIN framework since they were created in 2004, as the multiple accountabilities and constituencies can be difficult to untangle in order to understand one’s role and the mandate of the organization to which one belongs.38 Unlike hospital boards in the health system in Ontario, the LHIN boards are not voluntary (that is, unpaid). Directors are paid $200 per diem and the board chair $350, and they must meet at least four times per year as per the legislation, but every LHIN board meets much more frequently than that, typically once per month, and board chairs seem much more involved than that. Complete records are difficult to obtain, but in 2010 the Hamilton Spectator found the average amount billed in per diems for each LHIN board chair was $57,600, and a year earlier it was $63,725, which is equal to 182 days, or 36 five-­day work weeks.39 This is extraordinary involvement among typical public sector board members, suggesting LHIN board chairs as acting more like CEOs. This was also a concern raised by a LHIN effectiveness study commissioned by the MOHLTC, which suggested LHIN boards were spending a lot of their time delving into operational matters that should be handled by LHIN staff, in particular LHIN executives. A spot check for LHINs in 2017 revealed that among those who report board chair and director per diems, it still suggests very active chairs, with the Southwest LHIN board chair billing $61,089 (not including expenses), for example, suggestive of more than 35 five-­day work weeks for what is supposed to be a part-­time position.40 Most accepted frameworks for board governance hold that board chairs have limited responsibilities or authority between board meetings, and the CEO runs things in between. This finding reveals that governance within LHINs remains in some cases unstructured, at least in terms of the board members versus LHIN CEO roles, such that board members, who are the ones formally accountable to the minister, are micromanaging their CEOs, who

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ordinarily would be empowered with some operational autonomy to execute the board’s vision. Transparency Transparency is a key dimension measured in the DAF against which governance venues are judged for their democratic character and function. Public sector boards – school, university, hydroelectric, economic development, etc. – come with high expectations for transparency, and LHINs were no different when they were proposed. Without elections and direct accountability, transparent decision-­making becomes the central mechanism through which stakeholders, media, and the broader public can evaluate the activity and performance of the board. Transparency in this context means board meetings open to the public, active disclosure of annual reports and financial statements, wide and timely communication on initiatives advanced by the LHIN, and an appeal process for decisions taken (or not taken). The dimensions of transparency in which LHIN generally perform well are in the online publication and distribution of annual reports, annual business plans, Ministry-­LHIN Accountability Agreements, Integrated Health Service Plans, and expense reports for board members, among other documents. Reviewing the websites for the fourteen LHINs in April 2018, reports for at least the last five years were posted on all of their websites, and many have every report described above since they were created. Also important to note, but which may sound trivial, is that by design all LHIN websites look the same and are very easy to navigate. Compared to my own to research into public organizations similar to LHINs, this was refreshing to encounter and is obviously the result of a deliberate effort of the ministry to demand their publications be as transparent and easy to access as possible. Yet few citizens will find themselves on the LHIN websites reading 100-­page reports, so transparency and openness regarding monthly board meetings is another important dimension to analyse, and on this front the record is more mixed. Section 9 of the LHSIA (2006) requires that board meetings be open to the public and “reasonable” notice to the public of the meeting schedule, though there is a long list of exceptions in which the board can legitimately exclude the public, such as for discussions of financial matters, personal health information, personnel matters, issues under litigation, and “board education,” or if they are deliberating about excluding the public for any of the prescribed reasons. If the LHIN board chooses to go in camera for legitimate reasons

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specified in the legislation, it must approve a motion to do so in an open setting and explain the reasons for doing so. Critics of the legislation identified areas that could be strengthened to ensure greater transparency. For example, the provision for the board to offer “reasonable” notice of their meetings should have been replaced with “a specified number of days of public notice being required,” according to Bea Levis of Care Watch, a health care advocacy group in Ontario.41 While some boards post the board agenda documents online five working days in advance of the meeting, like the Central, South West, South East, and Erie St Clair LHINs,42 others like the Central East LHIN were accused in testimony before the legislative committee of “put[ting] up a notice on its website at 11 a.m. for a board meeting that it was holding at 2 p.m.” on an important decision regarding the merger of hospitals, which to one respondent was “an outrageous abuse of process.”43 Further, others have reported that even when board meetings are open and advertised in advance, documents are withheld in some cases, sometimes long after meetings and in one case captured in testimony in front of the legislative committee, a report received and filed by the HNHB LHIN in 2011 has still not be received by a citizen requesting it.44 These observations are obviously inconsistent with any reasonable interpretation of what transparency means in a public setting, and represent unacceptable deviations from expectations set forth by procedural decision-­making bodies, as articulated the DAF in chapter 2. There are even more unfortunate examples of a lack of transparency at the LHIN board level. Controversial former board chair Michael Shea of the HNHB LHIN, who angered some citizens when he claimed that his golf course and grocery line chats with people amounted to public consultations on major decisions, also defended the practice of holding back documents because he “doesn’t want the public to be able to read the reports until after the board has dealt with them.”45 Local journalists following the activities of the HNHB LHIN “have been blocked when they ask for information about the LHIN.”46 Articles from the St Catharines Standard demonstrate that a “culture of secrecy” characterized the area LHIN, exemplified by staff resistance to release board meeting minutes and reports before their six-­week time frame.47 Once Ontario’s ombudsman announced a review of its practices, the LHIN reversed itself and thereafter aimed to provide reports that were tabled in board meetings in advance.48 A report prepared for the HNHB LHIN after these controversies broke out noted that only North Simcoe Muskoka LHIN mirrored this practice of posting documents four weeks or more after meetings, while most other LHINs post before or the day

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after.49 The new board chair evidently does things differently, with citizens suggesting, “Since then, when we do go to LHIN meetings, we’re cordially welcomed … the LHIN has opened up – I find that that’s positive.”50 So it is apparent in this case, and others, that LHIN boards do feel pressure from citizens and the media to commit to transparency as part of their work, even as their formal accountability ties exist with the minister. While certainly few citizens governed by their respective LHIN attend monthly board meetings, some boards, such as the Waterloo Wellington LHIN, report active interest among citizens, stakeholders, and the media in their proceedings, reporting that they receive at least 50 and often more than 100 observers monthly.51 To this board member, board meetings are not just decision moments, but opportunities to “receive regular feedback about the health system when we’re in conversation with community members who attend our meetings.”52 Media presence is particularly strong in some LHINs, and opportunities are proactively offered to interview the board chair after each meeting, so that there is no barrier between the decision process and the public, as is the case in the South West and Champlain LHINs.53 Likewise the Erie St Clair LHIN will “post online all reports, our public scorecard, expenses, community reports and other important information, provide direct phone or walk-­in contact with our staff and CEO for issues management, [and] have a two-­business-­day response policy to all email and letters.”54 These cases are model examples of active transparency at the LHIN board level, which by their nature invite citizens and media to engage with their work and contribute to their legitimacy as decision-­makers in this system. As public sector agencies, with delegated responsibility from the provincial government, it is essential that their interactions with media adhere to public sector norms, as they are the main conduit of information and analysis of LHIN activities for residents. Given the vagueness of the enabling legislation, openness of board meetings means different things in practice across the LHINs. For example, in some LHINs guests are merely allowed to observe and are not given time or formal opportunities to speak or question the board. Some LHINs by contrast, such as Erie St Clair, invite citizen participation during open-­mic sessions.55 Ontario’s ombudsman noted far less than this in the case of HNHB, suggesting that this “LHIN board does not accept public delegations at its meetings,” but that the practice is not uniform across the LHINs.56 Yet others, in recognition that the headquarters of the LHINs are usually in the largest city in the geographic catchment, and thus sometimes 300 kilometres or more away from citizens governed by that LHIN, have

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either taken the board meetings on the road to smaller communities or have enabled webcasting of board meetings (Erie St Clair is noted for enabling the latter effectively, although others with expansive geography are doing so as well now). In fact, all LHIN boards have reasonably regular travelling board meetings, except Toronto Central, which is the one LHIN with a relatively small geographic footprint, given population density, according to Camille Orridge of the MOHLTC.57 For example, every spring, summer, and fall the Champlain LHIN board travels to seven subregions in its domain, recognizing that each region has distinct needs and so that citizens of the various areas “have an opportunity to meet and talk to board members and tell them how they think things can be improved for them.”58 Likewise the board chair for the South West LHIN reported that after eight years, “we have visited most towns across our geography” for board meetings, including meeting on the Thames First Nation and on the Munsee-­Delaware First Nation territories.59 The universalized “travelling” LHIN board meetings to the outer edges of the boundaries speaks to the importance LHINs attach to cultivating the perception that they are sensitive to unique conditions and needs across their geographic catchment areas. Yet LHINs ought to be evaluated for transparency, not just on the day-­to-­day activities, which are often not particularly interesting, but instead when controversial decisions, like hospital mergers (i.e., closures) are made. And on this front, there is again a mixed record. The HNHB LHIN again was the centre of controversy in 2008–10 when it was revealed that they “held over 11 closed meetings over hospital restructuring without access [to] the public,” though on some occasions particular stakeholders or service providers were invited.60 The LHIN was considering a voluntary integration proposal by Hamilton Health Sciences (HHS) restructuring hospital services in Hamilton and the closure of emergency rooms in Fort Erie and Port Colborne. The LHIN can approve (by not vetoing within sixty days of receiving the proposal) or reject this action, and they would consider the merits and whether the community engagement by HHS was sufficient.61 The LHIN chose not to respond, which effectively gave the go-­ahead to HSS, despite receiving formal pleas from the Hamilton city council, health care professionals, and residents that community consultation by HSS was inadequate. The LHIN chose not to do any community consultation of its own, and a board member resigned in part on this basis.62 The merits of these closures were reasonable and were viewed by many as appropriate, but the secrecy and deliberate efforts by the LHIN to obscure their agenda is what was appropriately condemned by even more observers. The LHIN was not sensitive to the fact that when LHINs were created, they

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were marketed as institutions in which local consultations and engagement were paramount to the decisions (and non-­decisions) they made, and thus residents had reasonable expectations of more extensive consultations on a major restructuring effort than what may be technically permitted under the legislation. Trying to defend itself, the HNHB LHIN suggested that while it appeared as if there had been no community consultation or even meaningful discussion about the HSS proposal, board members had “informally” consulted in the community and held unadvertised and closed “board education” meetings around this plan. They created a by-­law that allowed them to hold secret meetings if they were focused on “board education” – i.e., learning about issues. (The ministry later confirmed that board education by-­laws that allowed closed board meetings were legitimate, but decisions cannot be made in this setting).63 This explanation did nothing to quell the controversy, as citizens and stakeholders had no idea what was presented or discussed at these closed-­door meetings, which seemed to stretch beyond the spirit of the legislation that allowed closed board meetings in certain circumstances. The “board education” sessions were also used to discuss a separate effort to close emergency rooms in Fort Erie and Port Colborne, which was so controversial that one community consultation by Niagara Health System attracted 5,000 residents in Fort Erie opposed to the plan.64 Again, the merits of these health service integrations are not the focal point for analysis here, but rather the extent to which the LHIN balances its competing accountabilities to the local community and the objectives of the provincial government. The HNHB LHIN has not been the only one accused of less-­than-­ transparent activities when approving integrations or maintaining services. We find examples such as the North West LHIN’s role in the closure of the Revera Thunder Bay nursing home in 2012,65 Champlain LHIN holding closed-­door meetings away from public scrutiny,66 and the Central East LHIN’s refusal to release line-­by-­line cost-­saving cuts it approved to the Scarborough Hospital in 2013 in order to find the $20 million it needed to balance its budget.67 This angered the local MPPs, both Liberals, one of whom said, “These are organizations that get public dollars but are not being transparent.”68 In all of these cases, the LHINs maintained that the relevant service providers actually making the closures or cuts are responsible for disclosing their information, but as the steward of the local system and the body formally approving these efforts, the LHINs have an obligation to proactively release information to help residents understand their decision-­making process.

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LHINs were created to make these tough decisions, but the minister was “very clear that decisions must be made on the basis of public interest and in the full view of the public.” 69 For the “localness” of decision-­ making to be realized and granted as legitimate, it must emerge “from a decision-­making process that is transparent, accessible to the public, and mandated by law,” as described by the Hon. Madam Justice Louise Charron, Supreme Court of Canada.70 While these examples of LHINs failing to meet expectations about transparency give pause, they do not imply that LHINs ought to be compelled to conduct their business in precisely the same way as dictated by the provincial government or by agreement among themselves. Clearly fourteen LHINs have interpreted the expectations around transparency differently, with some a more restrictive view, and others a wide open and proactive view. But there is need for the minister to “set clear standards on what Ontarians may expect in terms of transparency and openness,” as part of their metagovernance role in setting the explicit ground rules for LHIN board decision-­making, as depicted in the DAF in figure 5.1.71 Governance-­to-­Governance As LHINs have been delegated authority from the MOHLTC to plan, fund, and integrate health services, they have accountability relationships with service providers in their region (hospitals, long-­term care facilities, community health centres, etc.), by devising and monitoring service and performance agreements with them. It is at this level where health care is most directly integrated and streamlined towards improving patient experience, and thus involves many moving pieces that need to be coordinated, and particularly where through reasoning and deliberation among actors, intersubjective consistency, common agendas, and metaconsensus can be formed, which recall are critical dimensions of the collective will formation function of democratic subsystems. As such, as part of the analysis of the mandated decision-­ making bodies in this chapter, we must examine these relationships in terms of the dimensions established in the DAF. In this vein, most LHINs create what they call governance-­ to-­ governance (G2G) bodies and working groups, involving the leadership of the board, CEO, executive directors of hospitals, LTC homes, mental health and addictions agencies, community health centres, and more. They often involve senior officials from the MOHLTC and LHIN board chairs and CEOs, and in the view of Narenda Shah, former COO of the MH LHIN, “It’s a great forum where the board members from small agencies, for the first time are actually getting a half

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an hour session directly with the deputy [minister of MOHLTC]” and the latest developments in health care at Queen’s Park and “how it’s going to affect you and your role in governance.”72 What is unique in Ontario, compared to other provinces with regionalized health boards such as BC, is that the HSPs typically are individual corporations led by their own boards of directors who actually deliver the services, and the typical board mandate is to make decisions on what is best for the organization. That often means survival, but also sets up a competitive atmosphere among some HSPs, discouraging collaboration if that would threaten their historical activities. This is not a new context for HSPs in Ontario, which has been a source of tension, misunderstanding, and resistance that G2G relationships are in part meant to work through. This is a chief responsibility of LHINs in their geographic area and is linked to questions of representation, accountability, and consequentiality in division of roles and responsibilities in this realm that the DAF aims to systematically evaluate. While G2G events or meetings vary considerably across LHINs – usually three (some as high as six) per year per LHIN – the main thrust behind them is to gather leaders of the main players in the health system in the region to reflect, learn, and share how governance practices in their organizations can be improved to work towards the objectives of the LHIN’s strategic plan. The chair of the WW LHIN stated, “We see health service provider board-­to-­board and governor-­to-­governor engagement as a key aspect of our role. For this reason, we host meetings and events that bring people from different boards together so they can learn from one another, better understand their role within the system, and provide ongoing input to the LHIN.”73 Sometimes this means basic education on the role of a service provider board, but also about how their accountability agreements with the LHIN require them “to see their organization as one asset of the greater LHIN wide community and not an entity totally onto itself” and “to act for the benefit of the wider community not as a competitor of other HSPs for scarce resources.”74 Furthermore, the HSPs are expected to identify opportunities to integrate the services of other HSPs in the local health system to provide appropriate, coordinated, effective, and efficient services, and this requires trust-­building and knowledge exchange, which are facilitated by G2G events or meetings. G2G events and other LHIN-­driven events bringing together their HSPs are a recognition that integration, quality improvement, and a patient’s first approach are unlikely to emerge organically, given the continuous pressure on organizations to simply keep up with day-­ to-­day demands of their work. Yet if health service providers do not

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collaborate, coordinate, or integrate, the strategic objectives of the LHIN – and province – will simply not be met. In recent years, observers in the health system think the LHINs have turned a corner on these efforts, and after resistance, learning, and trust-­building, “a lot of the providers at a local level are working together, sharing information about the population, deciding together with community input what are the priorities in their area, figuring out the best ways to deliver services, and starting to share referrals and coordinate a lot better.”75 And this interview respondent credits LHINs for this as much as it ultimately is driven by the health service providers themselves: “I think the LHINs are definitely an enabler. That wouldn’t just happen organically, the LHINs are really the facilitator for that change.”76 And there is no other institution mandated to conceptualize the system as a whole in each geographic area, so it falls to the LHINs to use their tools of information-­ sharing, persuasion, spending power, and regulation-­ making to incentivize these changes among service providers. Performance and Accountability As presented in chapter 4, LHINs have been subject to highly critical evaluations of their performance, chief among them by the auditor general of Ontario in 2015. Examining how the policy outcomes have changed since LHINs were created, the AG found that province-­wide performance in six of the fifteen areas improved, but in the other nine areas, “performance has either stayed relatively consistent or deteriorated since 2010 or earlier.”77 Yet it is not entirely fair to evaluate the LHINs using broad-­based health system measures, given that (1) they do not control some very important levers of power, namely physician salaries, and (2) they receive line-­item budget constraints from the ministry, meaning that even though a LHIN like Toronto Central nominally controls $4.2 billion, the LHIN has less than $20 million in truly discretionary funding, and (3) the hospitals that LHINs fund still have much of their own discretion in how their funding is allocated.78 Yet nearly all of those measures used by the AG (what the ministry identified in consultation with LHINs as their performance measures) are related to hospitals. That said, the AG also noted that “between 2010 and 2014, Ontario’s performance was better than the Canadian average in most of the measured areas that relate to LHINs.”79 Likewise, the Canadian Institute for Health Information reported in 2012 that Ontario was the only province to reduce wait times for specialist services, and there are LHIN-­driven programs that can take credit for a substantial jump in the population having a regular family doctor (e.g.,

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80–96 per cent in the South East LHIN).80 Other individual LHINs note impressive wait time reductions for MRIs, for example, with people on average getting scans two months sooner after LHINs than before, and wait times for hip and knee replacement surgeries have been reduced from over fourteen months to eight months in the HNHB LHIN.81 A long-­understood virtue of decentralization, and often cited in the federalism literature, is that autonomous subnational authorities can serve as the “laboratories of democracy,” largely for their ability to experiment with initiatives at a smaller scale and thus with less risk. If the policy idea is judged to be successful, it is then more likely to be adopted more broadly among other jurisdictions. There are numerous examples in the Canadian federation, from carbon pricing first tried in BC and Quebec and then spreading nationally, to foreign buyer taxes on real estate in Vancouver and then Toronto and likely beyond, and of course to publicly funded universal health care in Saskatchewan spreading across all provinces and territories. This argument has also been applied to municipal governments driving innovations that then spread to others.82 It can also be applied to LHINs: they are granted relative autonomy to experiment or pilot initiatives, which can then be evaluated or observed by other LHINs and subsequently adopted if successful. Bill McLeod, CEO of the MH LHIN, noted that “sometimes we do not know the right solution, so the right answer is to create many tests of change to see what does work and under what circumstances.”83 He also suggested that the LHIN framework “did not guarantee local innovation, but it certainly led to a condition that favoured innovation” and remarked that he heard someone in health care quip that ‘if you want something done 14 different ways, ask the LHINs to do it,’ which is exactly the point” and is “something most central governments consistently struggle with.”84 The next paragraphs provide concrete examples in just one LHIN – Mississauga Halton. They speak to the incentives to innovate on a smaller scale that are created in a decentralized context, one that allows for experimentation suited to local needs, and where accountability is structured to reward successful innovations and mitigate against risk for underperforming strategies. The Home First philosophy was introduced by the Mississauga Halton LIHN in 2008 with the launch of the Patient Flow Program in Halton Healthcare Services. It has a data-­driven focus on optimizing bed management in the hospital with close attention to alternate level of care (ALC) patients (those occupying higher intensity care beds in hospital than they required while they wait for appropriate placement elsewhere in the health care system, often in long-­term care facilities). The Mississauga Halton LHIN area has a very low number

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of long-­term-­care beds per population greater than age seventy-­five, which causes an increased number of ALC patients, which leads to limited access to new admissions from the emergency department, causing them to remain in the ER for those beds. The key innovation from MH LHIN was to address the issue in ways that few had conceived before: limit patients who are designated as destined for LTC and send them home with appropriate supports. This is what Home First denotes: always consider home first as the possible decision after receiving hospital care, at which point decisions can be made about suitability for LTC, should that be required, thus freeing up beds in cascading fashion. The MH LHIN, in partnership with their service providers, implemented a comprehensive service known as Supports for Daily Living, available for patients who would normally be eligible for long-­term care, which could be delivered cost-­effectively in the person’s own home. And numbers of ALC patients dropped dramatically, with no observable marginal negative health outcomes for those in the program. It was such a successful innovation that it won the 3M National Quality Award, and it was 2014’s recipient of the Minister’s Quality Medal in Ontario.85 The success of Mississauga Halton was repeated in the Central LHIN, Toronto Central LHIN, and the North West LHIN, and now it has been scaled up across all LHINs and in various provinces. Furthermore, the MH LHIN was asked by the fourteen LHINs to contribute to a document that highlighted all innovations and successes under the Home First philosophy. Once created, this document was used extensively around the province by all LHINs to look for local opportunities to implement the good ideas identified through proven success in other LHINs.86 Another area in which the LHIN model of collaboration in Mississauga Halton (MH) produced innovation is caregiver respite. Since its creation in 2004, the MH LHIN has given particular attention to support family caregivers of elderly or chronically ill citizens, as this type of support is key to avoid unnecessary ER or hospital admissions, yet can be all-­consuming for the family member caregiver. In essence, respite programming offers relief for the caregiver by trained personal support workers when caregivers (usually family members) need a scheduled break or have a last-­minute emergency. The major changes as part of the Caregiver First Strategy advanced by the LHIN in 2013 were to create a central registry and assessment procedure in the MH region as a collaborative, integrated program provided by Nucleus Independent Living, AbleLiving, Links2care, and HomeInstead in consultation with the Alzheimer Society of Peel. This evolution of caregiver support services responded to what the LHIN was learning about the needs of

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caregivers that were not adequately being supported under previous models, which tended to support out-­of-­home respite, with restrictions in timing, and simply was not being used optimally. CEO Bill McLeod noted that “through a major caregiver consultation program, we were able to redesign and re-­launch the program”87 with a new model that allows for a menu of services to be customized for the caregiver, smooth access to services, support the caregiver, and maintain flexibility of services in order to address caregiver need.88 This was a “funded” integration, as opposed to a “voluntary” integration of the above service providers, meaning that it was a priority area for change by the LHIN, which used its spending power to drive change in collaboration with the service providers. The Mississauga Halton LHIN was recognized for its Caregiver Respite Program with the national 3M Health Care Quality Team Award in 2016. This type of collaborative and integrated programming represents the ideal scenario for LHIN proponents: innovative services emerging from stakeholder and community engagement on long-­standing health system problems, where service providers collaborate to make a seamless point of service for citizens. This model has since been adapted by the TC and HNHB LHINs, among others. Another example of innovation in LHINs, the lessons from which have since spread across other LHINs and jurisdictions, is telemedicine. The initial prompt came from the province, when in 2007 the Ontario Telemedicine Network launched the largest Telehomecare program piloted in Canada, and then later expanded with the participation of three LHINs in 2012: North East (NE), Toronto Central (TC), and Central West (CW), and has since spread to nine of the fourteen LHINs. In this context, each LHIN oversees its telehomecare program planning and implementation in partnership with a CCAC or hospital. In this type of programming, telehomecare nurses teach and facilitate patients actively managing their condition, while keeping the primary care provider in the loop. LHINs have adapted and innovated this type of programming, experimenting with initiatives that address particular issues dominant in their regions. The NE LHIN, among the most rural of the LHINs, is the highest user of telemedicine in Ontario and focuses on patients with chronic obstructive pulmonary disease and heart failure, and has recently experimented with telepsychiatry. By contrast, TC LHIN developed two innovative foci for telemedicine targeting their patient population: (1) withdrawal management service, which allows patients to receive medical clearance for withdrawal management services virtually instead of having to visit an Emergency Department, and (2) the TeleWound Care project, where a telemedicine registered

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nurse will provide timely access to wound specialists for individuals with chronic diseases, thus diverting many cases from the hospital. The foregoing paragraphs reveal that when decision-­making is decentralized via LHINs, the dynamic predicted by the principles of federalism (as creating “laboratories of democracy” where new ideas can be tested) is apparent, revealing their basic consequentiality as an arena of policymaking, and this has contributed to improved health services, but also improved local accountability, as LHINs feel empowered to experiment with initiatives designed to address their unique needs and priorities. LHIN–LHIN Relationships Notwithstanding the provincial role in establishing a common framework for LHIN activities, identifying province-­wide priorities for policy, and setting performance targets, the LHINs themselves have long assembled their board and staff leadership to work towards commonality amidst regional diversity. This collaborative governance among LHINs is important, given that the LHIN boundaries are administrative – they do not constrain residents or patients (i.e., one’s family doctor could be in Central LHIN, psychiatrist in MH LHIN, and could receive specialist care at the major academic hospitals in TC LHIN), and thus the mandate of LHINs to better integrate health care services demands LHINs cooperate with each other. According to ministry officials, the board chairs meet regularly, and “if it is a common issue, they have a process [whereby] if two-­thirds agree, then all fourteen [LHINs] adopt the recommendation of the two-­thirds position.”89 Furthermore, they argue that “we are seeing significant leadership out of the LHIN boards. They are starting to be more of a provincial resource versus looking at the interests of their particular LHIN.”90 Catherine Brown, of the MOHLTC, in testimony to the legislative committee, confirmed that “they’re very good at sharing their best practices across the fourteen [LHINs], particularly where they have similar populations or similar problems.”91 This is an important dimension of shared, horizontal accountability among the LHINs across the province for building a cohesive and integrated health system. While there are of course many informal opportunities for LHIN leadership to meet and cooperate when appropriate, there are also increasingly more formalized gatherings and institutions aimed at LHIN collaboration. For example, in 2009 there was a LHIN Consistency Workshop attended by board chairs, CEOs, ministry officials, and health service providers to improve and support consistency among the LHINs. At a more sustained level of cooperation and engagement, the

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LHIN Collaborative (LHINC) was formed in 2009 as a secretariat and as a space for LHINs to share best practices and provide a provincial advisory structure to inform province-­wide governance and policy. It was led by the LHINC Council, composed of leaders from the nine health sectors and the LHINs and was formally housed in the TC LHIN. Over time it expanded its role to explicitly focus on improving provincial coordination of LHIN activities, and supports more than thirty active committees, including a Chairs Council, CEO Council, System Strategy Council, CCAC-­LHIN Collaboration Table, working groups related to knowledge sharing across LHINs, and service accountability agreement coordination, among others.92 This type of collaboration among LHINs strengthens the ability of LHINs to be less “policy takers” of the ministry, and more joint “policymakers” as their capacity grows to become more system planners than administrative flow-­through agencies for the province that their critics once claimed they were. Most recent priorities for the LHINC, according to their annual business plan, is to introduce more systematic ways to identify and spread leading and consistent practices across the province.93 In a sign that pan-­LHIN activities are increasingly formal, in March 2017 the LHINC merged with the CCAC version of LHINC and the LHIN Shared Services Office (LSSO) to become a new agency called Health Shared Services Ontario (HSSO), which has a broad mandate to provide key shared services to LHINs. At a very practical level this means shared services like payroll, financial, and IT services and supports for LHINs to produce efficiencies, but also at a higher level it is an institutionalized environment for LHIN collaboration and ministry stewardship. The governing body of HSSO differs, however, from the former LHINC Council in that it has more leadership from ministry officials (three ADMs as of writing), two LHIN CEOs, and one former CCAC board member, suggesting that the metagovernance role of the ministry is becoming more institutionalized at this high level. At this point it is premature to evaluate its role in meeting the objectives under which it was created, but it signals the desire to formalize LHIN influence at the provincial level, suggestive of more robust “metadeliberation,” whereby more actors are involved in institutional design and high-­level policy priority-­making, as well as an approach that serves to build intersubjective consistency, common agendas and metaconsensus on health care in Ontario. Conclusion This chapter has analysed the governance within LHINs as mandated decision-­making bodies, as depicted in the DAF reproduced in figure 5.1

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at the beginning of this chapter. LHINs were examined for their board governance, including inclusiveness, expertise, connection to community, and relationship to other LHINs, as well as how they are held accountable not only “vertically” (or upwards) to the minister and legislators, but also “horizontally” to each other and the broader stakeholder community through institutional relationships like governance-­ to-­ governance and the LHIN Collaborative. Several vignettes of controversial moments in LHINs were presented to reveal how they stand up in measurement of the primary democratic functions and their dimensions. making arenas and actors And how did the mandated decision-­ fare in the democratic function dimensions and measures outlined in chapter 2 in table 2.1? Recall that the functions were differentiated by empowered inclusion, communication and collective will formation, making capacity, each with several dimenand collective decision-­ sions and associated measures. And in the DAF, not every venue at every level needs to satisfy every dimension, as theory suggests certain democratic functions will be met at some venues and less so at others; the important test is whether the collection of venues, when layered on each other, sufficiently satisfy all of the democratic functions and their dimensions, as a whole. Most of the analysis of the democratic dimensions must wait until chapter 7 when all the arenas have been described and analysed, but we can establish a few brief takeaways from the mandated decision-­making arenas here. Where do the LHINs as mandated decision-­making venues exhibit strength on the democratic systems criteria? They certainly meet the test of consequentiality, as LHIN boards are empowered, especially after the 2016 reforms, to generate big changes in the health sector, and thus they now have authority more appropriately matched to their responsibilities as health system integrators. Relatedly, on measures of accountability, the LHIN boards are rendered accountable through various mechanisms, on one hand “upwards” to the minister for their business plans and investment priorities, but also to the community for how they conduct their business, as evidenced by the enormous pressure felt when LHINs were drifting too far from community expectations in some cases documented in this chapter. Further, on the dimensions of the extent of efforts to build intersubjective consistency, common agendas, and metaconsensus through reasoning, LHINs have demonstrated particularly in recent years a collaborative process of policy planning and decision-­making that is not characterized by raw interest group power, but instead by developing mutual understanding of shared objectives across actors and institutions in the health sector.

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The areas where a more mixed record was observed in this chapter along the democratic dimensions applied in the DAF are transparency and publicity of LHIN activities. Some high-­profile cases of LHIN boards have demonstrated unacceptable lack of active transparency and publicity to their publics, which appropriately has been condemned by many, including the minister, auditor general, and Ontario’s ombudsman. This is such a critical dimension of the democratic character of LHINs that where it is observed to be weak in some LHINs represents a fatal flaw in their work. Fortunately, the most egregious transparency and publicity flaws in some LHINs, such as HNHB, have been rectified after public, media, and ministerial outcry. But it does reveal that LHINs, despite not having a direct electoral mandate from the people, are indeed responsive to them in these moments. As noted, however, many other LHINs are models of transparency and publicity, such that other similar government agencies seem closed off by comparison. Finally, the main areas of weakness across most of the LHIN boards examined in this chapter are inclusion and equality of voice. Most LHIN boards are populated by those from the business or professional sectors, and often from the urban parts of their geographic catchment area. In the early years, however, there were attempts to make LHIN boards more diverse or inclusive of different experiences in the community, but this made way for an evolution towards more professional board representatives in subsequent years. This was rationalized as an attempt to make board decision-­making more professionalized, but it comes at a very high cost when the wide epistemic and experiential diversity of the citizens in the fourteen LHIN regions is not found at the board level. Attempts to make a board diverse on these grounds are not easy, but the approach by the province to populate LHIN boards represents a clear choice towards “professionalization” at the expense of important challenging or critical voices in the community that could contribute to positive change at this level of collective will formation. The next chapter examines how the LHINs and province have engaged with ordinary citizens and patients – one of the pillars of the shift towards LHINs – and a key measure of the extent of metadeliberation, whereby the voices of citizens are used to inform not only policy, but also the structure of governance and how that fits within the accountability regime.

Chapter 6

LHIN Advisory Committees and Public Engagement

Introduction At this stage of the analysis of LHINs in Ontario, it may appear that this is a governance framework that, while substantially devolved to the local level, remains driven and managed by elites. We have learned that LHINs were created in late 2004 by ministerial edict, under terms specified exclusively by Cabinet with little public involvement (though later articulated and enabled by legislation in 2006), governed by appointed boards, and supported by staff largely drawn from previous ministry roles. Yet there is a significant role for local stakeholders, patients, and the larger public in LHIN governance that is unique in many ways, compared to the health systems in the other Canadian provinces. To public engagement researchers John Grant et al., the creation of LHINs signalled a change in the location and governance of the health system, but also “a new philosophy” centred on regular public engagement and consultation with the “community.”1 Not only does the legislation legally require that LHINs maintain consultation with the public, but they have individually and collectively built up a common framework, fairly sophisticated in some cases, under which there are mechanisms of public consultation, ranging from relatively unstructured open forums to institutionalized citizen assemblies or panels, at various stages of policy development and implementation. Recall from the analytical framework developed in chapter 2, and reproduced in figure 6.1, that in complex governance like that investigated in this book, it is helpful to differentiate the procedural from the mandated decision-­making bodies from arenas involving citizens and the broader public space, as they involve different actors and institutions, possess different authority and legitimacy, and thus ought to exhibit different accountabilities. The procedural and the mandated

Figure 6.1.  Democratic Arenas Framework, with Focus on Citizens and Public Space

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decision-­making bodies of the LHIN system were analysed in the previous two chapters, and in this chapter we explore the citizen-­centred arenas and activities in the system. In this case we are talking about advisory committees, citizens panels, surveys, and protests, among others, as opportunities for the public to be engaged, and how they connect (or not) with the earlier arenas in the mandated and procedural decision-­making spheres. This chapter begins by situating the LHIN reforms in the long history of public engagement in health care in Canada, and analysing the purported virtues of enhanced public involvement in this sector, as well as the observed challenges and barriers associated with putting this normative agenda into practice. Following that, the specific provisions for public engagement that surround LHINs in the enabling legislation and regulations are discussed, with particular attention to a debate on the benefits and drawbacks of the vague mandate to regularly consult with the community. This discussion sets up subsequent analysis of the stages at which consultation and engagement are most appropriate or effectual, and how we ought to think about how the consultations and engagement is used by the ultimate decision-­makers. The remainder of the chapter explores the practice of public engagement in the LHIN context, guided by the DAF devised in chapter 2 and reproduced above in figure 6.1, examining the metadeliberation, advisory committees, citizens panels, surveys, and protests, among others, all as opportunities for the public to be engaged. It is discovered that some LHINs are conducting public engagement in a previously unrecognized sophisticated manner that is linked to dialogical decision-­making, and thus approaches a systemic ideal in democracy, while other LHINs are failing substantially in this regard. The Long History of Public Engagement in Health Care With the centrality of health care in our lives, it is perhaps no surprise that in some form or another, there emerged citizen expectations for public involvement in its governance not long after government assumed a primary role in its provision in most Anglo-­American welfare states. The earliest “citizen-­representative” health authorities are found in health systems agencies in the United States, community health councils in the United Kingdom, and district health councils in Ontario (as well as other provinces).2 A primary objective of public engagement in this context, according to health policy scholars Julia Abelson and John Eyles, is to garner information about the needs and preferences of the population on a functional health system, and rejects

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an earlier assumption that only professionally controlled governance by experts and bureaucrats could achieve health system efficiency and equity.3 In Canadian provinces in particular, the early 1990s marked a gradual, though resisted, shift away from a tightly bound relationship between health bureaucracies and stakeholder interests (such as physicians and hospitals) to add community input and control into the governance framework.4 But efforts to establish a truly “people-­ centred” or community-­ based approach to health care governance have been challenged by historical institutional arrangements with key established stakeholders who wield extraordinary power and strong resistance to relinquish it.5 Researcher Harley Dickinson argues, however, that regional health authorities like LHINs can recognize different forms of interest representation (health service providers, stakeholders, patients, citizens) as legitimate and employ consultation, engagement, and collaborative procedures to negotiate among them.6 The regionalization of health care administration in Canada in the 1970s represented the first wave of efforts to bring decisions closer to the affected population,7 but it is in the 1990s where provinces experimented with public hearings, town halls, and open houses as key mechanisms to connect health care decision-­makers to the public. Observers identified a trend away from “large, formal, and often confrontational” engagement processes like those above in favour of smaller and more targeted venues like focus groups, surveys, deliberative polling, and citizens panels.8 In 2002, the Canadian Centre for Analysis of Regionalization and Health reported that approximately 80 per cent of regional health authorities in Canada involved the public to set goals and priorities, as well as help design services.9 Thus the public engagement by LHINs described in this chapter is not itself unique to health systems, but it is in having a more institutionalized status, even forming the core principles motivating the governance framework of LHINs. Public Engagement Virtues and Vices The trends toward more substantive public involvement in governance is observed in most democracies and in virtually all policy areas (save for sensitive policy issues like national security and defence, which remain largely closed from public involvement). Public engagement has long been a key principle in local policymaking in municipal institutions in Canada, and to the extent that health care policy planning and implementation has shifted “downwards” to the regional or local level, expectations of public involvement rise in concert. Even more, in

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health care in particular as an issue area, there are numerous reasons to believe that more systematic public engagement has value. First among them is that in Canada, where public funds represent the primary financing mechanism for services, the public are “the most important stakeholders,” as argued by Rebecca Bruni et al.10 Nearly half of provincial revenues are devoted to financing health care, and in many cases, as in the 2017 BC and 2018 Ontario provincial elections, very little substantive debate transpired among the political parties to gain a mandate to pursue particular health reforms. As such, key principles of democracy demand more substantive public involvement to set the direction of government expenditure in health care. Second, public health care policy planning is focused on priority setting in a context of finite resources, and public involvement provides a “crucial perspective about the values and priorities of the community, which should lead to greater acceptance of priority-­setting decisions.”11 That is, by granting routine input in decisions that so critically affect our lives, it may improve the public’s trust and confidence in the health care system. Finally, analysis by consultants KPMG noted that institutionalizing public engagement in health-­system planning may enhance local responsiveness and accountability by simultaneously facilitating more transparency and providing direct input into decisions, but also “spread ownership through involvement.”12 Thus, for many researchers who have studied public engagement in health care in Canada for decades, like Julia Abelson et al., “approaches to public involvement can yield productive, long-­term, trusting relationships between citizens and decision-­makers,”13 but there are significant caveats to this statement. To Abelson et al., the metagovernors (those designing the governance framework to include avenues for public engagement) must clearly articulate the purpose of the engagement and its link to the larger decision-­making process, present basic and technical information clearly and honestly, and use procedural rules that promote power sharing and information exchange among participants and decision-­makers. The first caveat is the most important to consider, as inviting more public involvement without being clear about the purpose of the engagement – i.e., visioning vs information sharing vs priority-­setting vs decision-­making – can raise expectations to unreasonable levels, resulting in disappointment or cynicism if the ultimate decision-­makers do not closely adhere to the outputs of the engagement. This reveals a primary so-­called vice of public engagement: it can be very difficult to manage expectations among those involved, even if designed well, to be clear about their expected role in policymaking.

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Abelson et al. held six focus groups in five Canadian provinces with citizens who had experience in public engagement, and they were “highly critical” of their experiences. According to one interview respondent in the study, “It has a lot to do with how we were treated last time,”14 referring to perceptions of tightly controlled and predetermined agendas and outcomes. Citizens reporting this kind sentiment is a big problem, as part of the justification for enhanced public engagement is to generate legitimacy of the process. The McMaster Health Forum, which has convened dozens of citizens panels on health care and system planning in the last decade, lamented “several participants suggesting that patients’ and citizens’ sense of accountability to their communities, their health system and to other taxpayers had eroded over the past few decades.”15 This is ten years into the LHIN framework that is presented as one that privileges sustained public engagement! The treatment for this diagnosis? Increasing health system literacy (among the public) and “engaging diverse publics in the difficult conversations that need to be had,”16 according to the McMaster group. In other words, more engagement. A second potential problem with expanding public engagement in health care, conveyed by Rebecca Bruni et al., is that “members of the public are not objective – they have an inherent personal bias and cannot represent interests other than their own.”17 Yet Bruni et al. reject this argument by saying that there is no reason to believe that members of the public are less objective than any other type of stakeholder, and the point is to structurally bring together diverse perspectives. Others are less optimistic and instead see institutionalized public engagement as opening up avenues for the health care equivalent of NIMBYism – that is, a proposed hospital closure will be vigorously resisted by locals, regardless of its inefficiency or age, because it may inconvenience them or represent change they refuse to accept, even if arguments beyond their immediate self-­interest are compelling to others. Thus some, such as researcher Harley Dickinson, have noted that the “numerous sites for active public involvement in health care planning and system governance appears to have helped mobilize public resistance to health reform.”18 That is, the public can be at times be very resistant to change, a lot of which is needed to modernize and adapt the health system over time. So, while there is much promise and optimism among some of the benefits of institutionalized and expanded public engagement in health policy planning, there are also caveats about the need to manage expectations and also design these opportunities so that they are not simply sites for the most recalcitrant citizens to resist reform. Speaking in 2009

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to the Change Foundation, Julia Abelson, a leading researcher on community engagement in health care, suggested “two potential futures for LHIN community engagement. The first is what she terms a perfect storm – the LHINs, the provincial government and the public and stakeholders set on a collision course. The second is an alignment where the interests of all come together to improve the local delivery of health care.”19 In 2009 it was perhaps too early to analyse community engagement systematically, but in 2019, more than ten years into LHINs, we can start to render judgments about which of these two futures best describes the LHIN system. LHINs’ Mandated “Community Engagement” The Local Health System Integration Act (LHSIA), 2006, which created fourteen LHINs as Crown agencies, also contains provisions that specify they “shall engage the community of diverse persons and entities involved with the local health system about that system on an ongoing basis, including about the integrated health service plan and while setting priorities.”20 While there is some debate in Anglo-­American law about what “shall” means – is it more like “must” or more like “may”? – it is clear from the context of the legislation, the preamble, and the stated purpose in legislative debates that “shall” ought to be interpreted as “must.” The “community” is defined in a subsequent section as patients and other individuals in the geographic area of the LHIN, as well as health service providers and employees, and the methods for community engagement include, but are not limited to, community meetings, focus groups, or establishment of advisory committees. The legislation implies that community engagement ought to be broad and include diverse populations, but there are special “duties” to engage with Indigenous and French-­language health-­planning entities.21 In the legislative committee hearings and debates in which the LHSIA was under consideration, there was substantial resistance among stakeholders and the opposition to what they claimed were “vague” provisions on community engagement, and they asked that clearer guidelines be specified directly in the legislation, not left for interpretation or future guidance via regulations. Stakeholder groups requested specific advisory committees be mandated in the legislation, including one for seniors, one for mental health, one for physicians, one for disabled individuals, and others. The Liberal government resisted such requests on account of the anticipated onerousness of numerous explicitly mandated committees. But it was clear in their response that they were struggling to conceptualize the objective of community

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engagement: was it to help make “better” decisions or help make more inclusive and representative decisions of what the community wants or needs? Ultimately the government resisted further specification on the grounds that part of the premise of LHINs was to provide semi-­ constrained autonomy to govern and consult as appropriate and desired in their area. That is, if there was particular interest or perceived value for an annual seniors forum in the North West LHIN, but the South West LHIN determined that a seniors advisory committee was more valuable, they would have that autonomy to construct public engagement bodies as they saw fit. In other words, not specifying precisely the nature of community engagement in legislation would allow LHINs the flexibility to try various methods and approaches, and create or dissolve them as appropriate. And most scholars of community engagement, like John Grant et al., share this view, that since there is “little agreement between scholars and decision-­makers on what is the best, most meaningful, or most effective approach to citizen engagement,” government ought neither to merely pick one nor mandate all types of engagement.22 This view is reflected in a 2009 ministry-­funded KPMG “Good Governance Guide” prepared for LHINs that argues, “Community engagement is a complex undertaking that employs different tools and processes to inform the community and obtain input, feedback and validation from the community.”23 While some nonetheless see vague legislation on how LHINs are to conduct community engagement as a challenge, the North West LHIN CEO saw this as a positive in that it gives LHINs freedom to be creative and responsive to the populations they serve.24 There is a sense among some observers and critics of LHINs that community engagement is the “soft stuff” that does not affect patient care, and thus in times of budget constraint, or otherwise, it ought to be curtailed. One LHIN CEO noted that some health care organizations in the past when facing budget crunches have cut the number of their community engagement staff in half.25 Yet to community engagement researchers and advocates, this is a long-­term endeavour, with multiple conversations, focused on relationship and trust building, and not just when decisions need to be made, which also makes it more complicated than it may first seem to track how LHINs “use” public engagement in their decision-­making.26 Yet everyone acknowledges that community engagement is difficult to execute and evaluate systematically. There are barriers in time available for community engagement (CE) and lack of resources to bring people together (especially if jurisdiction is geographically large).

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There are challenges to getting the right mix of diversity and expertise and sustaining participation, but also to ensuring sufficient turnover among participants, managing expectations and even disappointment if certain priorities do not make it into final plans, and to educating the community on what is and is not within the mandate of the agency.27 To experts in community engagement, like Peter MacLeod of MASS LBP, the MOHLTC can help to achieve a culture of engagement by requiring that each LHIN dedicate program budgets towards CE. It can also publicize and reward innovation in engagement and more closely evaluate LHINs in their CE efforts. Likewise, for LHINs, MacLeod argued that engagement processes must not be arbitrary or selected for ease or convenience, but instead be linked to their strategic objectives, and they must be diverse in their engagement offerings, as many folks cannot attend an evening forum, but could participate in a webinar, for example.28 Similarly, Paul Huras, CEO of the South East LHIN, in 2009 “cautioned that there is not one ideal approach – LHINs need to select approaches that meet their CE goals. LHINs don’t need a CE template as much as a CE tool-­kit.”29 Key considerations in a community engagement toolkit mirror those that have been specified as core democratic system dimensions in the DAF: empowered inclusion, communication and collective will formation, and collective decision-­making capacity, all of which are measured and analysed as they relate to LHIN community engagement practices in this chapter. Stages of Public Engagement Health care is a complex web of interdependencies, and through dialogue and engagement a shared understanding and balance amongst competing priorities ought to be a primary goal. Public engagement in the policy process can occur in various forms as a result of multiple elements at play: who is involved, at what level of input, with what goals, and what types of decisions are being made.30 When we think about who is involved, metagovernors need to decide if diverse representation of ordinary citizens is needed, or if a particular community of interest ought to be targeted for recruitment, depending on the issue or task. Public engagement scholars Francois-­Pierre Gauvin et al. speak of the multiplicity of “publics” in the context of health care, including citizens (and taxpayers), patients, health professionals, health service providers, support workers, elected officials, academics, and ethicists, among others.31 And there is potential for tension between technical expertise and citizen engagement on a host of issues within the health system, ranging from system navigation, to health technology assessment, to

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clinical care standards, among others.32 Researchers Loes Knappen and Pascale Lehoux, who study patient and public involvement in this context, lament the vague and contradictory ways in which this role is conceived. They argue that patient, public, and expert involvement needs to be structured “to help participants incorporate universal norms defined in the abstract, without compromising the participatory ideal that participants’ own expertise and norms” codetermine planning, policy, and practice.33 The level of input sought is also a critical consideration, whether it be idea generation or idea legitimation, and other dimensions in between. The goals of public engagement are likewise an important element shaping the type of engagement and can range from setting the political agenda, filtering policy alternatives, assisting with policy implementation, to conducting an evaluation.34 And finally, the types of decisions (if any) being made will shape the desired approach to engagement, whether it is brainstorming for aggregation, consensus advisory, or consensus decision-­making. And the combinations within these elements can represent quite diverse public engagements, and every combination is not equally likely to be effective. For example, researcher Kathy Li noted that empirical research has shown that ordinary citizens “as collective decision makers often feel ill-­equipped to make systemic, programmatic and organizational policy decisions, where issues are highly contested and complex.”35 Researchers Li et al. also argue that a willingness of policymakers to listen to citizens is merely the first step; the larger challenge is to determine “the relevance and meaning of the public’s wishes.”36 In their view, mediating bodies or “public involvement brokers,” which are singularly focused on obtaining, interpreting, and transmitting the products of public involvement are key. Thus, there are target populations, objectives, and venues that are uniquely appropriate to certain tasks, and the broader question is how to design a system of public engagement that connects into policy planning and decision-­making in a coherent and productive manner. Various LHINs in Ontario have devoted considerable attention to devising frameworks that guide their community engagement, demonstrating that they are grappling with how to appropriately balance the elements at play. The Central East LHIN, for example, produced a framework for community engagement that differentiates the levels and the corresponding tools of engagement.37 If the fundamental objective is to inform or educate the public, the parts of the toolbox that ought to be used are open forums, fact sheets, and other, typically one-­ way, communication. Yet if the purpose is to gather input, then surveys, focus groups, and targeted open forums are the most appropriate

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tools. For the highest complexity and degree of involvement, the Central East framework convenes action planning events, citizens panels, collaboratives focused on co-­production, and other mechanisms that involve routine and sustained activity and encourage participants to take responsibility for solutions. As is evident in the above described community engagement framework used by the Central East LHIN, not all community engagement must be group-­based, publicly oriented, and necessarily deliberative to contribute to the policy process in a meaningful way. Further, while transparency and publicity are critical principles of decision-­making in a democracy, all deliberations or engagements need not be conducted in public, provided disclosure of results and description of the process follow. In certain contexts there is value to private deliberations, particularly in the realm of health care information and personal narratives, that encourage free and open discussion without immediate exposure to the broader public or media scrutiny.38 Group-­based deliberative “mini-­ publics” are resource intensive, time-­ consuming, and applied most effectively when concrete decision-­making options are being considered, in relatively short time frames.39 Also, when comparing deliberative engagement processes to non-­deliberative engagement processes in a review of 175 empirical articles, Craig Mitton et al. found that participants tend to perceive “good” outcomes from deliberative engagements (78 per cent) compared to non-­deliberative ones (54 per cent).40 Julia Abelson et al. also found through experimental methods that opportunities for deliberation (compared to non-­face-­to-­face engagements like traditional survey approaches) made it more likely that a participant’s prioritizations could change, but also found that deliberations seem to have caused participants’ dominant views (e.g., highest priorities) to become more entrenched.41 As such, deliberative approaches hold notable promise for particular tasks and populations, but non-­deliberative forms of engagement also have a legitimate and uniquely useful role in the broader democratic system, and both must be employed thoughtfully, consistent with the normative position of the DAF constructed and applied in this book. Utilization of Community Engagement Outputs Apart from how community engagement is designed, a major question revolves around how the outputs or products, whatever they may be, are utilized by the ultimate decision-­makers. Leading thinkers of knowledge utilization, such as Robert Rich, resist a deterministic view of how public involvement is used and are critical of observers who demand

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a direct line of attribution from information gathered into a decision setting for it to be considered an effective community engagement exercise.42 The “messy and complex conditions of health policy making, which is heavily influenced by institutions, interests, and ideas,” makes the deterministic view unrealistic as a standard against which to evaluate community engagements.43 In a complex and dynamic policy environment like health, public involvement processes interact with other types of evidence and influences, and become interwoven in the process of negotiation and policy feedback.44 This reality, however, sits in contrast to some in the broader public who “might have the impression that policy decisions are solely based on or driven by public involvement,” which can breed cynicism among the public when their presumed determinism does not materialize.45 The Change Foundation surveyed all the LHINs in 2009 and asked them how difficult it was to utilize the results of engagement with the community in setting priorities and plans. Nearly 50 per cent said it was “very difficult/difficult,” with only 15 per cent suggesting it was “not difficult at all.”46 A review by Amina Jabbar and Julia Abelson in 2011 found that most LHINs do a poor job of systematically evaluating the effectiveness of their community engagement strategies, instead focusing on superficial assessments like the number of participants and their satisfaction with the process.47 And even after a brainstorming event with thirteen of the LHINs that sought to enhance the evaluations, the researchers reported that most reforms emphasized process-­related measures like representativeness, transparency, and accessibility of community engagement, and not outcome-­oriented measures.48 But for public engagement to be viewed as successful from the perspective of the public (participants) and the decision-­makers, there are several dimensions to strengthen: (1) decision-­makers’ willingness to listen to the public’s input; (2) a “public involvement broker” to mediate the relationship and travel across venues, coupling them; and (3) a closing of the communication feedback loop with the public via a response from decision-­makers to signal the impact of citizen participation.49 With the virtues and vices of public engagement specified, as well as the legislative framework for LHINs that mandates it, the remainder of the chapter examines the patterns in public engagement used by LHINs from 2004 to 2019. This second half of the chapter is guided by the DAF devised in chapter 2, examining the metadeliberation, advisory committees, citizens panels, surveys, and protests, among others, as venues and opportunities for the public to be engaged, and how they connect (or not) with the earlier-­analysed venues in the procedural and mandated decision-­making spheres.

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Metadeliberation Recall that metadeliberation is a concept that has been advanced by democracy scholars who argue that citizens ought to be involved not just in the deliberation of substantive issues, but also in the process of institutional design.50 To Claudia Landwehr, metadeliberation is required to democratize choices about how we are designing decision points in the political system, who is involved, and their primary role.51 In the DAF specified in chapter 2, metadeliberation (citizens) and metagovernance (state) are conceived as ideally jointly responsible for the creation of the governance framework. The history of the creation of LHINs in 2004 and the major amendments to the governance framework in 2016 offer an opportunity to evaluate the metagovernance/ metadeliberation balance. Of all of the dimensions of the systemic evaluation of the LHIN governance framework conducted in this book, it is the metadeliberation piece that is by far the weakest. Citizens have played virtually no role in the debate or construction of the governance framework under which LHINs operate – it is nearly entirely driven by the state (metagovernance) via the ministry and Cabinet. The process of involving citizens in the basic construction of LHINs from the basic idea to the more complex decisions about authorities was so poorly done when they were created in 2004 that arguably this is principally why LHINs have a negative reputation in many quarters of society. In February 2004 the Liberal government indicated that they were developing a “made in Ontario solution”52 to health care, but notably “never sought nor received a mandate to create a new system of health care delivery,” according to Rick Moffitt of the Waterloo Regional Labour Council.53 When a bill to create the LHINs and the governance framework was presented to the legislature in early 2006, many citizens and stakeholders who testified in front of the legislative committee claimed that they “have had no input into the LHIN design.”54 Others claimed that “there has been no meaningful consultation with the public,”55 that “nobody in this province seems to know what a LHIN is unless they’re an activist within a union that is fighting against it,”56 and that the LHINs have been “under the veil of secrecy … with as little public debate as possible.”57 The government pushed back on these claims at the time, with Minister Smitherman arguing that “nobody can pretend that this initiative came out of the blue,” and that the province held public meetings and working sessions that were attended by more than 4,000 people.58 OLP MPP Kathleen Wynne also pointed out that they established a

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provincial action group to provide advice on the design and implementation of LHINs, the members of which were provincial associations representing home care, community support service providers, community mental health service providers, hospitals, public health agencies, and others.59 In addition, Wynne noted that nearly fifty community and union groups were part of a technical briefing on the bill in order to give feedback. Taken at face value, these claims of pre-­consultation by the government look like reasonable metadeliberation, but in reality, these efforts were not true (or substantive) metadeliberation, for several reasons. First, engaging 4,000 people, most of whom were associated with the health system – not ordinary citizens – in a province with a population of nearly 14 million is clearly low for an important issue like health system reform. Furthermore, long-standing health care activists like Kelly O’Sullivan testified in committee that “I didn’t receive any information about being involved … and I actually live in the Minister’s riding.”60 Second, what actually happened in these pre-­ bill consultations was not as vision-­generating as claimed by the government. According to one person who attended the consultations, it “amounted to the ministry telling the attendees what it was going to do. The ministry may feel this is consultation. We don’t.”61 Others were “disappointed that they were unable to put forward ideas or to influence the direction the ministry was going in.”62 Third, technical briefings of the proposed legislation are clearly not metadeliberation, as it is not a space to raise or address issues with the bill – it is designed to show the stakeholders what is coming and to answer questions about implementation. Another sign that metadeliberation was among the weakest features of the LHIN roll-­out from a democratic perspective is that the actual LHINs were created and their leadership was hired many months before legislation was tabled and the regional ministry offices were closed. In addition to leadership hired, the ministry drew the boundaries of LHINs without public input, instead relying on a more technocratic method of analysing referral patterns in various regions. A robust system of metadeliberation would certainly have drawn on public input into the geographical areas of the LHINs. Many did not like this process, claiming that “there should be a requirement in the bill for extensive public consultation on the existing geographic boundaries of the LHINs. LHIN boundaries should reflect the real communities of health care interest so local communities can have an impact on LHIN decisions.”63 Public input was later sought for minor adjustments, “yet this may have been the most critical decision in the whole transformation

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process,” according to Lisa Hems of the Ontario Coalition of Senior Citizen’ Organizations.64 This led to charges among some in the community that the cart was put before the horse, and that citizens and stakeholders would have little substantive input on the design of the new governance framework, given that big portions of it were rolled out before legislation was enacted. A significant initiative like health system reform ought to begin with a White Paper process, with considerable public debate, and certainly without major pieces in place before the enabling legislation was even introduced. To Harold Sault of the Red Rock Indian Band, “It’s like shooting a bullet at somebody: You can’t stop it. You’re forcing this upon us and then you say, ‘… We’ll talk about working it out later.’”65 Other observers, like Rick Moffitt, were even more frank: “This government has treated this whole proposal like they’re growing mushrooms; i.e., in the dark, plenty of manure.”66 Those who were critical of the early process often claimed that this effort was “centralized” or amounted to “centralization,” which an exasperated Kathleen Wynne emphasized was nonsensical, given that the government was proposing to shift from full ministry control to devolved decision-­making to the regional level with mandated community engagement. Yet, upon further analysis, it is clear that on many occasions when people were referring to “centralization” they were talking about process, such as Peggy Land from the Ottawa Raging Grannies advocacy group: “It’s centralized in that it’s from above; it’s imposed. But people aren’t necessarily asking for this.”67 Thus on balance, the claims by the government to have courted extensive public involvement in the run up to health care governance reform are weakly supported and did not represent true metadeliberation whereby citizens were empowered to help shape the future LHIN governance framework. There was a broad failure in metadeliberation, but what about traditional legislative hearings for which public comment is solicited? Once the legislative committee received the bill, they convened four sessions of hearings, one each in Toronto, Ottawa, London, and Thunder Bay. While the committee did permit a number of deputants to teleconference in from more remote corners of the province, many were nonetheless critical of the limited opportunity to communicate their reactions to the bill. John O’Brien from OPSEU stated that “we have over 500 municipalities that are going to be affected by this legislation and you’re going to have four cities where you’re going to talk to people? That’s crazy.”68 And the failings of metadeliberation were on display in these hearings, with O’Brien claiming, “It’s totally ludicrous to think

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that now you’re coming out to consult. This is crazy. You’re supposed to consult before you put the stuff before the Legislature.”69 And while various speakers in front of the committee expressed gratitude for the opportunity to weigh in on the proposed legislation, many others were sharply critical of the process and adamant that consultations need to take place in all parts of the province, not be confined to four cities into seven days. One suggested that “at an absolute minimum, hearings should be held in each of the 14 proposed LHIN catchment areas” and not during business hours, when many in the public are not available to attend.70 On the metadeliberation front, the provincial government also failed in the promised legislative review of the LHSIA, 2006. When the Liberal government passed the law in 2006 they indicated that a formal legislative review would occur after four years, at which point the public and stakeholders would have considerable opportunities to weigh in and shape reform further. The review actually happened eight years after the law was passed, in 2014, and while there were mixed reviews among stakeholders and the public, the government did not act to make amendments until 2016. In the 2014 hearings, one deputant complained that “if the public input is three weeks, after something has been delayed for two years, you’re not going to get a good sense of what’s happening.”71 Others emphasized that “you need to listen and go out and invite people in.”72 This last comment is especially important, as government tends to think opening up pending legislation for public comment represents an open and comprehensive approach, yet the passive orientation – one that receives feedback from interested stakeholders and citizens – often fails to engage those who are not tapped into policymaking cycles and reforms, but nonetheless are affected by proposed reforms. Thus, empowered inclusion, a core democratic function, via metadeliberation is woefully unrealized in this context. While no major amendments were tabled in 2014 as a result of the legislative review, in 2016 the government initiated a reform effort they called Patients First, and this time did release a White Paper of sorts for public consideration in advance, although the major tenets of both bills (for LHINs and CCACs) were already in place.73 Many stakeholders submitted briefs to the minister in response to the White Paper and thus may have influenced the development of the Patients First governance reforms, but they were clear in their testimony in legislative hearings that they had no sense how their ideas were considered in the development of the legislation. There was no communication or two-­way exchange from the minister or ministry to stakeholders about their views on the way the governance framework ought to evolve. Yet

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still many major stakeholder groups like Patients Canada claimed they were consulted when the bill was already drafted, rather than at the vision-­setting stage. Ministry folks interviewed for this book pushed back on this claim, suggesting that after the White Paper was released “there were a number of consultations with 6,000 people [over a three-­ month period and] based on that feedback we went to Cabinet and got approvals.”74 So while formally the ministry may have at least released a White Paper in advance and received feedback, there was little confidence among many major stakeholders and the broader public that it can be considered serious or substantive metadeliberation. Whereas metadeliberation clearly emerges as a core failing within LHIN system, other types of public and stakeholder engagement was found to be quite strong, namely the plethora of advisory committees in operation at each LHIN. Advisory Committees Community engagement as defined by the enabling legislation of LHINs includes patients and citizens, health service providers, and employees in the health system, and this is achieved primarily through an extensive array of advisory committees at each LHIN. In the original legislation in 2006, the only mandated advisory committee was the “health professionals advisory committee,” which consists of those in regulated health professions (e.g., physicians, nurses, social workers, etc.), but this requirement was later dropped in the Patients First Act, 2016 (examined in more detail below) and replaced with a newly mandated “patient and family advisory committee.” In 2006 the legislation made it appear as though the only groups with whom the LHINs were in some sense forced to consult were health professionals, and this prompted concerns that LHINs, while nominally designed to be positioned towards the public and stakeholders, would have no legal duty to do so as expressed in the legislation. A member of the Brampton Health Coalition, emblematic of those concerned, testified that “what struck us, however, was that there was very little participation and input in the process from front-­line health workers and those most affected: the users of the system, the people of the community. It seemed to us that there was a need for transparency in the operation of LHINs and a mandate for community input and participation in LHIN decisions.”75 The government signalled in legislative debates that regulations created after the legislation passed would make the consultation requirements more specific, but ultimately these never included more clarity on who ought to be consulted and the minimum standards for

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those processes. In this regard, the suspicion raised by Gord Gunning, from Canes Home Support Services, was warranted in 2006 when he said, “We believe this matter should be addressed in the legislation and not left to the regulation-­making process.”76 Some, however, supported the government’s preference to address consultations via regulations rather than legislation, stating that “binding the LHINs to a specific process for engagement that may prove to be inadequate or unworkable over time.” They pointed to how previous legislation for CCACs required the formation of “community advisory councils,” which in the view of Ross McCrimmon, of the Ontario Association of CCACs, “were not an effective mechanism for community engagement.”77 Instead, the government maintained that “one size won’t fit all,” and they were willing to “be quite flexible on how particular regions and neighbourhoods decide to organize themselves.”78 This was a reasonable position to take, provided that LHINs were prepared to fully operationalize the core principles behind public engagement mandate without clear legislative or regulatory guidance. But at this point stakeholders and interested citizens, reflecting on their systematic exclusion from the design of the LHIN governance framework, were right to be suspicious of whether later community engagement would be guaranteed throughout the province. Opposition MPPs like Shelley Martel noted that the legislation is “pretty well void of any kind of framework with respect to how the community is going to be engaged.”79 And there was perhaps legitimate suspicion among opposition members and some stakeholders that the government was simply portraying the legislation as community-­ centred, but in reality was much less committed to seeing this manifest in practice. And a stakeholder obtained Minister Smitherman’s speaking notes to the committee – after they were mistakenly left at the table! – and their discovery did nothing to assuage this suspicion in view of what the minister himself crossed off: “The original draft, which perhaps his staff had prepared for him, … said, ‘We set out to craft a piece of legislation that would ensure that decisions would be taken in a transparent, accountable manner, based on priorities set in communities, after open public meetings and extensive consultation.’ However, the minister scratched out the words ‘and extensive consultation.’”80 Stakeholders and interested citizens were thus reasonably wary about how community engagement would work in practice. Much of the criticism on community engagement and the advisory committees specified (or not) in the legislation was about way may happen in the future. What did happen? After all, once the legislation passed and LHINs were fully operational, it did not much matter what

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Health Minister Smitherman might have intended in terms of community engagement – LHINs had wide latitude to self-­govern. What we see is that the LHINs created substantially more advisory committees than simply the one mandated for health professionals in the legislation. A systematic compilation of the active advisory committees at all LHINs, in table 6.1, reveals that most have six to ten committees or working groups that include a focus on representation, like Indigenous people, francophones, seniors, rural, children and youth, but also system sectors, such as primary care, hospices, emergency departments, telemedicine, mental health, surgery, and particular objectives, like wait times, patient flow, healthy equity, and health quality planning. Interviews with LHIN leadership revealed that there are often many more advisory committees than even those publicly posted on websites; for example, Mississauga Halton LHIN identified four committees, but a member of the leadership team, when interviewed, estimated that they have “probably upwards of twenty-­five to thirty different committees,” because “there’s a lot of work to do.”81 Many of the advisory committees at the LHINs presented in table 6.1 consist of health service providers, though usually there is patient representation on each of them when relevant. But these advisory committees appear to be more focused upon assisting with implementation than democracy and representation, per se. The line here blurs, as many deliberative democracy theorists speak of “those affected” by decisions as ideally being involved in the process, and that is certainly true of health service providers. They have knowledge of parts of the system that they are assisting to govern, but also will be required to implement reforms and thus must buy in to policy agendas and programs for them to be faithfully executed on the ground. Why are advisory or working groups initiated in this context? According to Stewart Sutley from the Central East LHIN, in some cases, “we will strike them because we’re starting a new piece of work that requires leadership [carrying a message to the system] and thought leadership [around design] from the system.”82 Much of this work is thus focused on “build[ing] legitimacy for that approach” by designing the initiative appropriately and with buy-­in from the service providers. In other cases, committees can be struck that are more like working groups, which are tasked with producing something concrete. He cited the example of a population health working group to actually “look at the data, and [discuss] how to use and shape the data in a way that becomes a tool for us to be able to do effective needs-­based assessments … in our catchment area.”83 One might think that this type of work is typically done by staff of the organization, but it is important

134  Distributed Democracy Table 6.1.  Advisory Committees for Each LHIN, from Publicly Posted Information (2016) LHIN Central

Ad hoc governance groups and advisory committees/councils

Primary Care Council Health Links System Planning Committee eHealth Council Emergency Department Working Group Central Hospice Care Program Council Regional Chronic Disease Prevention and Management committees Wait Time Strategic Planning Group Regional Diabetes Committee Engagement of Indigenous People Engagement of Francophone Community Central East eHealth Steering Committee Information Management/Information Technology Advisory Committee Wait Time Strategy Working Group Maternal, Neonatal, and Paediatric Advisory Committee Vice President and Chief Nursing Steering Committee Central West Telemedicine and Telehomecare Advisory Steering Committee Mental Health and Addictions Core Action Group Services to Seniors Core Action Group Diversity and Equity Core Action Group Women and Children’s Health Core Action Group Chronic Disease Prevention and Management Core Action Group Champlain CEO Performance Evaluation and Compensation French Language Services Committee Erie St Clair Leadership Council CEO Performance Evaluation and Compensation Committee Primary Care Council Hamilton Quality Guidance Council Niagara Health Links Steering Committee, Operations Committee, and Working Haldimand Groups Brant Diagnostic Imaging Steering Committee Ophthalmology Leadership Committee Orthopedic Leadership Steering Committee Patient Flow Steering Committee Emergency Services Steering Committee LHIN Laboratory Council Hospice Palliative Care Council Mississauga Primary Health Care Steering Committee Halton Health Equity Planning Advisory Committee Health System Funding Reform Local Partnership Committee Critical Care Committee North East eHealth Advisory Council Diabetes Advisory Committee Emergency Department/Alternate Level of Care Leadership Committee Telemedicine Advisory Committee North Simcoe Complex and Chronic Health Needs Coordinating Council Muskoka In Home and Community Capacity Coordinating Council Maternal, Newborn, Child, and Youth Health Coordinating Council Medicine Coordinating Council

LHIN Advisory Committees and Public Engagement  135 LHIN

North West

South East

South West

Toronto Central

Waterloo Wellington

Ad hoc governance groups and advisory committees/councils Mental Health and Addictions Coordinating Council Surgery Coordinating Council Communications and Community Engagement Coordinating Council Health Coordinating Council Integrated Health Human Resources Coordinating Council Indigenous Health Services Advisory Committee Primary Care Council Health Integration Leadership Council Emergency Department and Critical Care Advisory Committee Primary Health Care Council Hospice Palliative Care Steering Committee Francophone Advisory Committee Regional Patient Advisory Council Hospital Patient Advisory Council Community Support Services Support and Development Council Long-­Term Care Home Network Council Indigenous Health Committee Board to Board Reference Group Palliative Care Council Health Link Council Strategic Advisory Council Toronto Indigenous Health Advisory Circle French Language Services Advisory Group Mental Health and Addictions Advisory Group Children and Youth Advisory Group Integrated Health System Emergency Response Advisory Group Community Council Primary Care Advisory Committee Local Quality Partnership

Source: Tabulated by the author

to keep in mind that most LHINs have about thirty staff, yet have enormous responsibility to manage the health system in their areas, and thus there is often limited internal capacity. At other LHINs, staff leaders suggest that they need “that input to say, ‘Does this make sense? How do you tweak it? How do you best meet their needs?’ They’re the ones that can best inform you.”84 So advisory committees can be venues for generating ideas, working groups, and sounding boards for initiatives that are more driven from the top-­down, depending on the nature of issue at hand. But LHIN staff cautioned, “You’re never going to please 100 per cent. And that’s not your mandate.”85 By 2014, when the formal legislative review was underway, much of the criticism by stakeholders regarding the vague community engagement provisions had become muted, in part because many reported

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positive experiences with their LHINs in this regard. One deputant, Sue Hillis, who participated in several planning and engagement activities, some of which provided recommendations on investments in South West LHIN reported, “I believe I have given more input and, I feel, have even had a small amount of influence on some decisions made by the LHIN, much more so than I ever had working with the regional office,” the previous model of governance in the late 1990s and early 2000s.86 Another stakeholder, Heather Cranney of the Canadian Red Cross, involved in advisory committees of the North East LHIN, reflected that “we are looking at relationships I didn’t see possible. There weren’t conversations, I think, that occurred five or six years ago. That’s because the LHINs fostered this trust within our agencies.”87 This view was echoed by the Victorian Order of Nurses, who “remain very supportive of the principles that were laid out by the government when establishing the LHINs through legislation. It’s all about local planning and accountability, community integration and co-­operation,”88 and the Independence Centre and Network (assisted living services for high-­ risk seniors), involved with the North West LHIN, whose representative said that they “would not want to see it [the LHIN governance framework] replaced with something else that does not have local control or input.”89 Thus there was a strong sense among many of those involved in community engagement at the LHIN level that this was a positive element of the reforms, and that there were real opportunities to influence decisions. In many of these arenas, on the measure of empowered inclusion and collective will formation democratic functions, there is evidence of robust design and procedures. The Health Professionals Advisory Committee (HPAC), recall, was the only mandated committee in legislation, which was a demand of (mainly) physician groups in response to the reform efforts in 2006. Physicians are, of course, not the only regulated profession in the health sector, and the regulations allowed for more than twenty regulated health professions to be involved in HPAC.90 Given these numbers, some physicians and other professions requested their own mandated committees to influence the LHINs in their area.91 But the argument for separate health professional advisory bodies was rejected by the Liberal government, as the primary purpose of the legislation was to encourage integration and collaboration among those in the system, which siloed committees would only make more difficult.92 On this the government was correct to assert that separated committees for each category of health professional was completely contrary to the spirit of the legislation and reform effort, and that the HPAC venues are precisely where the various actors in the sector ought to be structurally

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convened together to work towards integration, knowledge exchange, and mutual understanding. HPAC was thus considered necessary, in light of the reforms, as “prior to the LHIN there does not exist a formal structure where hospitals and other providers sit at a table and talk about how to best integrate the system. We do not sit down at a formal table and talk, particularly with the physicians, as to how to integrate the services,” according to Chris Carruthers, chief of staff at the Ottawa Hospital.93 One doctor, Rob Annis, who engaged with the South West LHIN as primary care lead, spoke favourably about how the LHIN structure “has enabled front-­ line primary caregivers to have a say in regional planning, from a voice that puts the system first as opposed to any particular viewpoint.”94 He also noted that prior to the LHINs, “many decisions were made in Toronto [at the ministry level]; we didn’t really have a voice in that at the ground level.”95 For many health care practitioners, meeting regularly to offer advice on regional program planning, and also communicating planning objectives and challenges to the other physicians in the field, has “paid off and has become more structured.”96 One LHIN staffer claimed that her HPAC “worked very well” but acknowledged that “some of the LHINs had some more difficulty making it a useful group,” but suggested that it comes down to having good leaders who are interested in system work and collaboration.97 Thus, not all of those involved with LHINs reported value from the mandated HPAC. Paul Huras, CEO of the SE LHIN, reported during the legislative review that “we’re all sorting out the role of HPAC. The role probably varies in each LHIN, and some LHINs have it meet more often than not. It is an area to be reviewed, I think, and to really look into the value.”98 This testimony and other lessons filtered up from LHINs to lawmakers in the government such that by 2016 in the proposed Patients First Act, language was changed from LHINs “shall” to “may” form a HPAC. This was met with fierce resistance among physician groups in particular, who were simultaneously in a fee dispute with the provincial government, convinced this was another way to undermine them. It is important to note that a relaxation in the requirement for each LHIN to have a HPAC since 2016, and the fact that many have since dissolved theirs, does not mean that health professionals are not involved in LHIN policymaking and deliberations. They remain deeply embedded in many of the advisory committees and working groups detailed in table 6.1. The shift is simply away from an exclusive health professionals advisory committee, which did not include any other stakeholders or citizen representatives. Thus, health professionals are part of working groups and advisory committees that include others now, which is generally a

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positive development, as they add perspective to those conversations that at one time excluded them, and likewise they are exposed to perspectives from other stakeholders and citizens they were once siloed from in their HPAC context. This development contributes the collective will formation democratic function, in particular the building of intersubjective consistency, common agendas, and metaconsensus, by reasoning, rather than raw interest group power through the OMA or OHA. Further, in place of mandatory HPACs at the LHIN level, the provincial government created the Integrated Clinical Care Council working out of the provincial Health Quality Ontario agency, as a “better way for LHINs to engage health care professionals,” according to Liberal MPP Sophie Kiwala, for high-­level, system-­wide policy discussions.99 Citizens Panels Undoubtedly, LHINs have historically engaged more systematically with health-­service providers and advocates than they have with so-­ called ordinary citizens, but this has changed in recent years with the growth of citizens panels in various LHINs. There is considerable evidence of representative panels of ten to twenty members, who are provided a small honorarium, as being among the most effective means to involve the public in sophisticated priority setting via deliberative engagement.100 For example, the Central LHIN created the Citizens Health and Advisory Panel in 2013, consisting of nine members randomly selected from hundreds of applicants, which meets four times annually to provide advice to the LHIN on a variety of issues. The panel is subject to regular turnover, as each member is normally appointed to a three-­year term, as a way to inject new perspectives while building up capacity to engage within their term of service. Central LHIN panel members largely report positive perceptions of the process, commenting that they can see their group’s work reflected in the IHSP and other smaller initiatives advanced or supported by the LHIN.101 The Toronto Central (TC) LHIN has also created a citizens panel in recent years, consisting of residents with experience interacting with the health system, with particular attention to vulnerable groups, as well as those who have (or a family member has) received care in hospital, LTC, home care, and beyond. The ages of panel members in 2019 range from nineteen to seventy-­seven. All TC LHIN citizens panel members were approached for an interview about their experience, and six agreed to share their perspectives. With such diverse participants, age ranges, and experience with the health system, it is perhaps not surprising that those interviewed had mixed reactions about the

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value of the citizens panel. One member, Alies Maybee, felt that she has had some influence on LHIN decisions, reporting that “some of the ideas I had around subregion structure for patient engagement were adopted,” but she struggled to find additional examples of insights emerging from their group that were directly adopted by the LHIN. Peter Cresswell, another member of the TC Citizens Panel, also noted a problem that “they engaged [with us] after they’d already had their plans together.”102 This is clearly a problem, identified earlier in the citizen engagement literature, of the importance of establishing clearly the expectations of these venues, including their expected tasks and the scope of their activity. When the objectives of citizens panels are not clearly understood, participants can be left confused about what they can expect to result from their work. Another panellist, Aditya Muralidhar, was a bit more blunt when asked if she feels that the citizens panel is making a contribution: “No. I hate being blunt about it, but no. Because nothing I’ve even said has been undertaken.”103 Where does the feedback from the citizens panel go, she was asked, and she replied that their points are heard “but then filed away for the national archives. That’s about it.” Another panellist, Alies Maybee, saw it as critical that the LHIN report back to the citizens panel about how their input was used or not, or where it was channelled. “Otherwise people will walk.”104 Alexander Zsager suggested that “we get regular updates. Not as much as I’d like to … sometimes if I have a question I’ll call in but may not get a response for a week or two weeks down the line.”105 Ultimately, Barbara Fallon, another member of the panel, remarked that “to me, the purpose of the citizens panel was one thing. And that’s to say they had a citizens panel. Which they did.”106 This is clearly not feedback that the conveners would like to hear, but it reflects the lack of preparation and scoping that was done by the LHIN in the relationship between the citizens panel and the broader work of the TC LHIN. In representation and structure at the citizen’s panel, Aditya Muralidhar would like to see some health care professionals on the citizens panel, as “it would be nice to have someone who knows about medicine to be involved in that process as well,” suggesting that actor circulation and venue coupling are a gap in this LHIN engagement framework.107 Muralidhar was not advocating for health professionals to be literal members of the citizens panel, as it would no longer be a “citizens panel” in the strict sense, but rather that health professionals engage with their work through presentations and information exchange so that the citizens panel is not estranged from the broader work of the LHIN advisory committees. Alies Maybee was also a member of a citizens panel for a local hospital, in addition to the TC

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LHIN panel, and noted that the TC LHIN panel did not meet frequently enough to keep the momentum going. She noted, “If you’re going to have a meaningful council that’s actually sticking their oar in, then you need to meet once a month.”108 Another common complaint among the TC LHIN citizens panellists about progress was that the staff turnover at the LHIN was seriously disruptive to their work, as in some cases new LHIN staff were in charge. Whenever facilitating staff turnover, “it just felt like we’re starting over again every single time,” noted panellist Sandra Dalziel.109 This observation emphasizes that the importance of stable LHIN metagovernance of advisory bodies was just as critical as balancing representation and inclusion. Peter Cresswell, also a member of the TC LHIN Citizens Panel, called the panel a “total failure,” in part because the LHINs operate on a system level, yet citizens panels are best equipped to handle smaller, but still important tasks.110 At such a high level, Cresswell noted, “I have no idea what you’d talk about at that level. We’re not even at the 30,000 foot level now, but with this I’m on Space X flight intercontinental, crazy high up there. At what practical level could I influence or what am I going to talk about?”111 He noted his experience on the St Michael’s Hospital citizens panel, which he awarded plaudits because it focused on practical reforms in the hospital that could be changed or prioritized with relative ease, not system-­ wide changes for which the LHIN was responsible. Asked why he went to a panel that he deemed a total failure, he suggested, “I mostly go because I’m just curious to know what’s going on in the system, not because I feel my input would be particularly useful.”112 Barbara Fallon also labelled it a “total failure.” And “I thought at one point I was on Candid Camera, it was so absurd.”113 She also balked at the tasks they were asked to perform, such as revise the health care system: “I’m like what? In two hours, for people who are totally inexpert? That’s not how you are supposed to access their experience and expertise.”114 The feedback from Fallon and Cresswell is perfectly consistent with what the research on deliberative citizens panels tells us: small, concrete, actionable tasks are ideal in scope for harnessing that knowledge sharing and mutual understanding – not enormous and difficult questions of health-­system redesign. Cresswell thus thought they would be more effective if they “zoned in on a very small geographic region and take a sub-­LHIN or take a project or something. Don’t try and grow outside of those. Try and just get something actionable here.”115 Other LHINs have used their citizens panels to work on program or policy design, rather than priority setting, and have found success. The Central East panel was given the option to pick one project per year, a co-­design project, which they identified as a

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need in the system. In one year, the panel co-­designed a patient’s handbook and patient complaints process in the LHIN. This was a practical task that leveraged citizens’ experience and insights to create concrete change.116 The TC citizens panel went on an extended hiatus in 2017–18 as staff re-­visioned its role, and panel member Sandra Dalziel was “hoping with the reconstituted citizens panel that we get to obviously things that are more specific, more tangible – there’s follow-­up for the people who are involved, and we get assigned to things.”117 Barbara Fallon, the most critical member, was likewise hopeful that “the scale of focus” in the new citizens panel(s) would better match how the citizens can contribute to setting priorities and “where the impact is clearer to the person and to the government.”118 For example, other LHINs, such as Central East, developed “resident councils” at the sub-­LHIN level after a successful pilot test in one neighbourhood in which they sent a mailer to one of five households in the area inviting people to apply to a resident council and got 300 responses back. A lottery selected twenty-­seven of them to come together in educational sessions (first) and priority-­setting sessions and advice-­giving to the hospital on specific initiatives.119 This was perceived as successful by LHIN staff and citizens alike, and there was interest in replicating the process in all Central East sub-­LHINs and beyond. Recall that the 2016 Patients First Act mandates the creation of a Patients and Families Advisory Committee for each LHIN. But that is not the same as a traditional citizens panel, which is characterized by a lottery selection of interested participants. Advisory committees in LHINs tend to be populated after an application and interview, are expected to meet more frequently, and advise on more system-­wide reform in partnership with stakeholders and LHIN staff. Alternative Public Engagement Mechanisms One lesson from fifteen years of LHINs vis-­à-­vis standing advisory committees (not including the citizens panels) was that many committees were created in response to a pent-­up desire to become involved in local health planning. But LHINs are “trying to back away from having these set tables because … it just became these committees without end … and they got captured by a few voices. And we found they weren’t really representative of the population,” according to one LHIN official.120 Another LHIN staffer echoed that sentiment, suggesting that “we found when you have advisory councils or panels, it tends to be the same voices, and they’re not necessarily representative of the community, or necessarily the people whose needs you want to address.”121

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In place of a default position on a plethora of ongoing advisory committees, various LHINs have started to focus on who is affected by a decision, and found different strategies to hear from myriad voices, in particular those most affected by the proposed reforms. Thus through more targeted or tailored approaches to engagement, particularly with non-­English-­speaking populations, Indigenous communities, etc., that are hard to reach, “We’ve really tried to improve our methodologies around reducing barriers to participation,” according to a Toronto area LHIN official.122 Some of those strategies included reaching out to community leaders and groups to facilitate engagement, scheduling meetings in evenings, and attaching LHIN engagement to cultural or community events.123 This development is surely positive, particularly given democracy theorists’ long-­standing concern that passive recruitment to committees and panels will typically result in exclusionary representation consisting mostly of highly activated citizens. Surveys, webinars, and social media are among alternative methods to engage the community used in more recent years as LHINs have worked through the best ways reach larger swathes of the population they serve. For example, Central West LHIN used public polling within their area to “assess our local residents’ overall satisfaction on a number of important areas, including access, quality, sustainability and equity,” according to Maria Britto, board chair of the Central West LHIN.124 A 2014 poll noted an 11 per cent increase in satisfaction with the quality of the health care services among the population from a similar survey in 2009 (up to 88 per cent from 77 per cent).125 They also discovered lower satisfaction in the system’s ability to provide fair and equitable services for all, and thus have focused on that area in recent years. The Champlain LHIN in 2015 had a survey with over 4,000 responses on areas of needed change in the health system, and discovered that helping people with chronic illnesses and/or disabilities to live better was a clear first priority among the population. Other LHINs, such as the Mississauga Halton LHIN, have also employed online surveys, but also leave paper copies at key service providers for those with no access or ability to go online.126 In fact, meeting minutes and annual reports suggest that nearly all LHINs use public polling or web-­based survey tools to reach out to their populations. The downside with these engagement alternatives is that they are often one-­time events or engagements and seldom deliberative, in that they do not challenge citizens or stakeholders to look at the system from alternative perspectives. Other online tools used are what North West LHIN calls an “online hub” for input and feedback into the Integrated Health Service Plan (i.e., the priorities of the LHIN over the next three years), which they

LHIN Advisory Committees and Public Engagement  143 Table 6.2.  Comparative Social Media Engagement for All LHINs, as of 27 June 2018

LHIN

Tweets

Followers

Account age (years)

WW HNHB CE SW SE CW ESC TC MH CH NE NW NSM Central

9,419 6,816 1,965 12,229 1,582 428 2,139 731 3,180 1,734 2,531 1,136 1,878 258

4,871 3,454 3,285 5,334 2,893 1,577 3,138 3,681 2,461 2,329 3,184 711 1,550 633

7.07 8.05 8.38 8.42 5.96 6.01 8.25 6.35 6.59 7.30 7.82 3.27 8.02 2.53

Social authority (Twitter)

Facebook followers

54 49 46 44 37 37 35 34 34 34 31 29 28 27

399 0 134 756 463 0 0 0 0 0 691 145 0 0

Source: Tabulated by the author

viewed as an accessible way for Northwestern Ontarians to offer their opinions to the LHIN. And like most organizations in the current era, all LHINs have some social media presence, primarily as a track for the outward flow of information, but purport to be willing to hear feedback through these means. Table 6.2 presents comparative data for all fourteen LHINs for their Twitter presence and engagement, as well as their number of Facebook followers. The table reveals that most LHINs have had Twitter accounts for many years, with the exception of Central and North West, and most have a few thousand followers. There are proprietary metrics to track engagement on Twitter, one of them is called “Social Authority,” an amalgamation of follower count, Tweets, age of the account, and influence of followers, and aims to be a measure of influential activity. Extracting the Social Authority score for each LHIN, we see that only one LHIN, Waterloo Wellington, breaches the 50 threshold (maximum is 100). By comparison, top pop stars tend to have scores of 100, Prime Minister Justin Trudeau has 91, Premier Doug Ford has 78, and the Ministry of Health and Long-­Term Care has 64. Overall, the same LHINs have reasonably large followers and engagement on Twitter for the size of their constituencies. Yet surprisingly, only six of the fourteen LHINs have Facebook pages, and their followers are much less numerous than those on Twitter. The final type of engagement relevant to this analysis of a systemic account of the democratic avenues and public engagement in the LHIN

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environment surrounds protests. In traditional deliberative democratic theory, protests are typically not a type of discourse and action that is normatively privileged, but in the systemic account there is acknowledgment that protests can have a deliberative function because, as Mark Warren writes, “If angry demonstration is necessary to persuade others that they should notice unpleasant facts, that is a contribution to deliberation.”127 And the controversial nature of LHINs has certainly prompted targeted protests among stakeholders and citizens since they were created in 2004. The key measure on their contribution to a deliberative system is whether they moved decision-­makers towards a fairer process or more defensible or equitable outcome. For example, citizens in the HNHB LHIN assembled to protest a hospital restructuring plan in 2008 – which involved closing the Emergency Department and removing day surgeries – that was by any objective evaluation a violation in the spirit of open and transparent process, as described in chapter 5. The LHIN itself was not legally required to conduct its own consultations on this plan, but the hospital was. Nevertheless, the LHIN is the funder of the hospital and ultimately accountable for the decisions in the region in this regard. The LHIN also held “secret” meetings in which they learned about the hospital restructuring plans and chose not to halt the process or ask the hospital to conduct further community consultation. Media reported that 4,000 showed up one evening at the local arena in the very small community of Fort Erie, assisted by businesses closing early to allow their employees to attend.128 Sustained protests outside the hospital, LHIN offices, and in the broader community (nearly 20,000 signed a petition) prompted an investigation by Ontario’s ombudsman, who issued a blistering report on the failures of the process from a democratic view. That resulted in a public scolding by the ministry and a change in policy to prevent secret meetings at LHINs when information was being discussed on a substantive decision. In this sense, the protests were an essential ignition to creating a fairer and more democratic process (and prompted the firing of the hospital system CEO, and the board chair resigned), despite being characterized by a relatively small group of people shouting – not always conceived as a deliberative democratic principle. Another example of protests that contributed to enhancements in process was in the Erie St Clair LHIN in 2009, which again was around the closure of an Emergency Department in Petrolia and prompted “months of protest, petitions and threats by local physicians.”129 The LHIN ultimately consulted further with stakeholders and citizens in the area and signed a five-­year agreement to keep the department open. In London in 2011 protestors gathered outside the LHIN offices during a board meeting to protest their “reducing the number of beds available

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for the mentally ill in the London area” (twenty mental-­health workers were laid off at the Regional Mental Health Centre as the result of budget restraint), and then marched to the Minister of Health Deb Matthews’s constituency office.130 Another example in the Erie St Clair LHIN area in 2015 showed how protests can prompt an improvement on process and more equitable outcomes. The Leamington hospital was going to close its Obstetrics Unit and expectant mothers and families would need to go to Windsor for these services, but this controversial decision attracted hundreds of protestors, prompting the LHIN to hold more public meetings and later appoint an expert panel to come up with a solution, which ultimately included saving the OB unit and enhancing services, after learning about the unique challenges of rural women in the area.131 These are all examples whereby protests, though not normally considered part of deliberative ideals, pried open the space of decision-­making to reveal a fairer process and hearing, regardless of the outcome or final decision by the LHIN board. Another example of protests in the LHIN context, which should not be characterized as contributing to a more deliberative system, occurred when legislation was introduced in 2006. Nurses and other unions launched a $1 million ad campaign and mobilized protests around the province in workplaces and in the public, to resist the reforms.132 Yet these protests were based largely on unfounded claims that reform was secretly about privatization and thus were concerned with ginning up false but powerful fears that polluted debate on the real issues at stake in the reforms. Another example of protests that do not meet the standard of legitimacy in a deliberative system was in 2013 in Perth, Ontario (covered by the South East LHIN), where the hospital – and, by extension the LHIN – faced protests from the Ontario Health Coalition on the false premise that bed closures in the hospital meant “cuts to the hospital.” Instead the beds were no longer being used, as the previous problems of getting patients into LTC homes were lessened, thanks to the work of the hospital and LHIN.133 A final example of a protest that did not meet the standard of deliberative systems occurred when a few dozen citizens in the North Simcoe Muskoka LHIN area used public meetings to hear patient stories to make health care better to protest a decision earlier in the year, which was subject to an open and transparent process, to close the Georgian Bay General Hospital’s Penetanguishene location.134 These examples illustrate that while all peaceful protests are legitimate in a liberal democracy, not all contribute to the deliberative ideal (i.e., build intersubjective consistency or common agendas), which rests upon a foundation of good faith, sharing of information and perspectives from diverse actors, to arrive at a mutual understanding within a fair process.

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Conclusion This chapter presented and analysed public engagement in the LHIN system in the third sphere of the DAF focused on citizens and public space, depicted in figure 6.1 at the beginning of this chapter. The chapter revealed how different types of consultation and engagement are used at different stages of the policy process, with different actors and towards specific purposes, exploring metadeliberation (citizens helping to design governance structures), advisory committees, citizens panels, surveys, and protests, all as opportunities for the public to be engaged. And how did the citizens and public space fare in the democratic function dimensions and measures outlined in chapter 2 in table 2.1? Recall that the functions were differentiated by empowered inclusion, communication and collective will formation, and collective decision-­ making capacity, each with several dimensions and associated measures. And in the DAF not every arena at every level needs to satisfy every dimension, as theory suggests certain democratic functions will be met at some arenas and less so at others; the important test is whether the collection of arenas, when layered on each other, sufficiently satisfy all of the democratic functions and their dimensions, as a whole. Most analysis of the democratic dimensions in relation to each other must wait until the next and final chapter, but we can establish a few brief takeaways from the citizen and public space arenas here. So where do the citizen and public space venues exhibit strength on the democratic arenas dimensions? In contrast to what was observed in the procedural and mandated decision-­making arenas in the previous chapters, this realm is marked by significantly more inclusive and representative actors within the numerous advisory committees within each LHIN. Though typically populated by local stakeholders, these advisory committees received overall positive feedback from participant testimony in legislative hearings and from interviews of participants and LHIN officials in this study. Likewise, in more recent years, many LHINs are experimenting with more varied methods for reaching affected citizens, particularly those for whom an advisory committee role is not feasible or desirable, such as targeted focus groups, surveys, online forums, and webinars, among others. LHIN staff report that these methods have engaged more than the “usual suspects” who are most eager to be part of public engagement events and bodies. These efforts are strong on the deliberative criteria of publicity, given the need to use various methods to reach their diverse constituencies, as well as transparency, given the effort to report the results of much of this engagement in annual community engagement reporting, which has become standard practice across all LHINs in recent years.

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Areas of weakness or a more mixed record in citizen and public space arenas in the democratic dimensions are metadeliberation and citizens panels. When contemplating reform of the governance framework, the Ontario government has never taken seriously the fact that citizens ought to have a role in the basic construction of governance, the scope of authority for LHINs, and the accountability relationships within the system. Instead, much of this reform has been driven from the top down by the state, with consternation from stakeholders and interested citizens who are presented with mega-­reform packages with little direct input. This approach is especially problematic, given that in none of the provincial election campaigns during the existence of LHINs was health care reform litigated specifically in the public realm. Furthermore, while it is admirable that many LHINs have been experimenting with citizens panels as a core part of their public engagement frameworks, the record on their impact and sense of purpose from participants has been mixed. The most successful ones have been given discrete tasks at the implementation or program development stage, rather than system-­wide visioning, a task that is too broad for them to tackle or see their work reflected in positive change. As such, on measures of consequentiality, several citizens panels have underperformed when their work is too broadly and vaguely defined, such that participants report few tangible results emanating from them. It is important to examine each type of public engagement mechanism individually, as done in this chapter, but the democratic systems approach demands that we view venues and actors in relation to one another. That is, while we may find that elements of certain public engagement mechanisms are weak, those weaknesses may be addressed by strengths in other parts of the system, provided there are sustained links across venues in the system. The next and final chapter of this book focuses on the connections between the various venues and actors described in the preceding three chapters, looking for synergies across them, as well as areas where connections could be enhanced. Viewed through a systemic democratic lens, some LHINs are indeed conducting public engagement with sophisticated mechanisms that link to decision-­making “up the chain,” while others suffer from broken links to other venues across the system, seriously undermining democracy and accountability.

Chapter 7

A Democratic Arenas Analysis of LHINs

Introduction The big questions in this book that frame the examination of LHINs, but also any other policy domain in which governance arrangements attempt to inject more public engagement and deliberative components, relate to democracy and accountability. Jonathan Guss, former CEO of the OMA, notes that “in health care, there are a range of decisions; a critical question is, Where should various classes of decisions be taken: Which at the centre? Which at the regional level? Which at the local level? Which in the hospital? Which in the doctor’s office by the caregiver or by the caregiver and patient working together? And which by the patient alone or by the citizen pre-­illness?”1 A further question one might ask is, What are the relationships between these numerous and overlapping decision arenas, and how is accountability conceptualized and operationalized? That is, how do we try to disentangle the web of institutions and relationships in order to examine their democratic attributes, but also see them as an entangled web – part of a broader system that has been incrementally modified over decades – to examine the connections and interrelationships to assess democracy and accountability? In this final chapter, we take stock of what we have discovered from the examination of LHINs in terms of democracy and accountability, and look more broadly at how complex governance institutions are designed and put into practice. Recall the big-­picture question posed at the beginning of the book: How do we know if a complex, multi-­level, and networked governance system enhances or undermines democracy? The preceding three chapters represent a segmented form of analysis of the constituent parts of the democratic arenas of LHIN system in order to clearly articulate the key institutions and actors that comprise those parts, but in the

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democratic systems approach advanced in this book, it is necessary to go beyond the study of individual institutions and processes, and instead we must examine their interaction in the system as a whole. This approach enables scholars and practitioners to think about decisions being made in the context of a plurality of arenas and institutions – as has been demonstrated in the case of LHINs in Ontario – interacting together to ideally produce a healthy democratic system, but can also expose shortcomings in meeting this ideal. Let’s revisit the specific research questions posed at the beginning of this book that help answer the big-­picture question: 1. What is the role of metagovernance (steering and oversight) by the state and metadeliberation (citizen influence) in devising a governance subsystem? 2. How do we reconcile our understanding of democratic accountability with the complex institutional relationships that have been created that involve various actors (e.g., elected officials, stakeholders, experts, citizens), most of whom have no clear electoral-­democratic mandate? 3. What kind of institutional and interpersonal links between governance arenas produce an interconnected and responsive system? To answer these questions, the democratic arenas framework (DAF) was devised in chapter 2 to specify the actors, institutions, and relationships that exist in any complex and multi-­level governance subsystem, as well as the democratic functions each arena is best equipped to perform, the measurement strategies we can use to evaluate the functions, and how arenas ought to be linked to each other in a governance subsystem. The DAF thus holds that various actors, many of whom have no clear electoral-­democratic mandate, can enhance the democratic character of a governance subsystem, and that each arena need not meet all democratic functions, provided the component arenas of that system are institutionally linked through venue coupling and actor circulation. This book thus set forth a systematic approach to evaluate the numerous venues, actors, and dynamics in a multi-­level governance space, while also articulating the arenas in the system where key democratic criteria and functions ought to be privileged (e.g., transparency, consequentiality, inclusion, etc.).2 A normative analytical framework holds that responsibility and authority must come with commensurate accountability (although it may not be the same mechanism of accountability in all parts of the system), that categories of representatives (e.g., elected officials, bureaucrats, stakeholders, citizens, advocacy groups)

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must be activated at the right time and for the right purpose. It thus presents an ideal against which real world governance patterns can be evaluated. The case of LHINs is particularly well suited to illustrate the value of the DAF in evaluating complex governance systems in terms of democracy and accountability because the fourteen LHINs exhibit variation on the dimensions specified in the framework. LHINs provide a unique opportunity to analyse governance institutions that were all created at the same time, in the same legislative and regulatory context, yet were permitted latitude to design governance patterns and policy priorities attuned to their local area. We thus gain analytical leverage by studying the LHINs in relation to each other and over time, as it allows for us to identify parts of a particular system that are performing well and those that are weak and need to be improved. This final chapter synthesizes the empirical findings from the preceding chapters through the prism of the DAF, identifying strengths and weaknesses in the democratic subsystem by focusing on the relationship between institutions and actors against the normative criteria of democratic systems, such as inclusiveness, representation, transparency, and accountability. The analysis in this chapter reveals that there are indeed thoughtfully designed governance mechanisms within this system that promote democracy and accountability, but also areas where those linkages and relationships are underdeveloped, undermining confidence in the process and outcomes among elected officials, stakeholders, and citizens. The final section of the book will examine the implications for the design and practice of governance of democratic subsystems beyond the health care policy realm. Revisiting the DAF Figure 7.1 is the analytical framework articulated in chapter 2 based on drawing together concepts from the literatures of governance-­driven democratization, metagovernance, and democratic theory. The paragraph below summarizes the idealized framework prior to overlaying the empirical findings from this study to identify areas of strengths and weaknesses in the current LHIN system and extracting lessons that can be drawn to answer the main research questions of this book. Beginning from the left side of figure 7.1, the two central steering mechanisms of a deliberative system emanate from the top down via metagovernance (largely state actors) and from the bottom up via metadeliberation (largely citizens and civil society), which ideally repredevelopment of institutional design of any democratic sent the co-­

Figure 7.1.  Democratic Arenas Framework

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subsystem. Within this context, there are three general levels of formal and informal bodies: procedural, mandated, and citizens/public space. An ideal democratic subsystem would see circulation (of actors) and venue coupling (institutional links) across the levels – where people and activities from one part feed into another. Figure 7.1 also articulates several important features of each level of any system in typical venues, actors, their democratic functions, and the ideal mechanisms of accountability. The variation within these levels across the articulated features brings into clear view the key principle behind the systemic account of democratic institutions: component parts may be more equipped to handle certain tasks, involve different policy actors, and are held accountable in ways matched to their characteristics. The true test of a democratic arenas approach in a particular governance context is whether the collection of arenas, when layered on each other, sufficiently satisfy all of the democratic functions and dimensions as a whole. With the purpose of the DAF framework rearticulated, we can proceed to synthesize the empirical findings from LHINs in Ontario to identify the areas where the system meets these normative, though flexible standards and where the system is deficient in democracy and accountability in the context of the three main research questions guiding this book. Whereas figure 7.1 is an abstract representation of the DAF that can be applied in any policy context, figure 7.2 charts a simplified account of authorities and ideal relationships in the LHIN context. There is enormous complexity involved in health care governance in Ontario, but for the purposes of this analysis, key actors and institutions in this context include the minister (of health) and ministry bureaucracy, LHIN boards, LHIN advisory committees (of which there are dozens per LHIN), citizens panels as mini-­publics, and the broader interested public, each with different responsibilities and/or expectations in this realm. There are formal and informal relationships between the layers of arenas in this realm. For example, as presented in figure 7.2, the minister of health has a metagoverning relationship to LHIN boards by specifying the delegated authority and ultimately evaluating their performance, and the LHINs formally report regularly to the minister, including with their annual business plan (how they intend to spend the public dollars transferred to them by the ministry) and the annual report (summarizing activities, initiatives, and performance). Further down the institutional chain is the relationship between LHINs and their stakeholder and citizen advisory groups, which is mutually influential: the committees and panels provide advice and information to the LHIN

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Figure 7.2.  Authorities and Ideal Relationships in the LHIN Source: Produced by author

board, and stakeholders in the health system are ultimately responsible to help implement the agenda decided by the LHIN. Finally, a governance framework from the normative position of a democratic system would have dual tracks of influence in its basic design, from the state (metagovernance) and from the stakeholders and citizens (metadeliberation), as well as transparency and publicity flowing downward from every institution to the interested public. In figure 7.2 we also see how venue coupling and actor circulation as normative concepts can become operationalized in the LHIN subsystem, with solid-­line arrows indicating the substantive nature of the coupling link across venues,

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and the dotted-­line arrows indicating where actor circulation ought to be observed to promote cross-­pollination of ideas and perspectives. Figure 7.2 specifies what we are looking for in a democratic subsystem, normatively speaking, in terms of venue coupling and actor circulation across the various arenas. Figure 7.3 provides a summary of what we actually find when we examine most LHINs in practice and reveals that important arenas and actors, while present in the field, are not always meaningfully integrated or even connected, thus revealing venues that operate in isolation from each other and thus fail to exhibit that connective tissue that systemic theorists advocate. Examining governance contexts in this manner can not only identify democratic shortcomings but also allows for reflection on what type of

Figure 7.3.  Authorities and Relationships in the LHIN, in Practice Source: Produced by author

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connections we ought to expect across arenas. The sections below are devoted to synthesizing the data gathered from the analysis of LHINs from 2004 to 2019 to identify patterns in governance subsystems in relation to the severed connections summarized in figure 7.3 and the main research questions examined in this book. Research Question 1: What is the role of metagovernance (steering and oversight) by the state and metadeliberation (citizen influence) in devising a governance subsystem? A governance framework from the normative position of a democratic system informed by deliberative principles has dual tracks of influence in its construction, from the state (metagovernance) and from the citizens (metadeliberation). When LHINs are measured against this ideal, the balance tilts heavily – almost entirely – to metagovernance, with very little citizen involvement in the debate or design of the LHIN governance framework (as depicted by the X over metadeliberation in figure 7.3). Recall that the earliest conceptualization of LHINs was subject to little public debate, as it was not presented to the public as part of health system reform in the 2003 election, and its design was principally driven by a small “dream team” in the minister’s office. Critical decisions such as the proposed authority to be devolved from the provincial to the local-­level LHINs, their geographical boundaries, and the appointment process of LHIN board members, among others, were debated and decided internally within the state, with no substantial pre-­consultation with stakeholders or citizens. And notably, all of this was done in 2004 by executive order – without a legislative foundation that would prompt at least some form of institutionalized opportunity for public comment. One example emblematic of the problems that can develop when the metagovernance-­metadeliberation balance is skewed is on the determination of LHIN boundaries. The minister did not seek citizen, stakeholder, or local government input on his drawing of LHIN boundaries, but rather used an analysis of referral patterns between various services (family physicians to hospitals, etc.). Yet under a data-­driven process to draw boundaries using referral patterns and no public or local government level input, the boundaries lack political coherence to some, which led to confusion among citizens and stakeholders and contributed to suspicion that this was not a locally sensitive reform effort. The local governments, service providers, and stakeholders in some districts are pushed together despite having no historical relationships, did not overlap with local public health planning agencies, municipal

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boundaries, and other regional planning authorities, thus lacking co-­ terminosity. Coletta McGrath from the Niagara region remarked that “the average person, quite frankly, does not identify with the HNHB LHIN. People identify with municipalities.”3 In short, these new LHINs had little coherence with existing regional governance structures, which meant that policy players would be thrust together (or alternatively torn apart) by the drawing of these new boundaries. The LHIN boundaries controversy is but one example of the heavy hand of metagovernance by the state and the comparative lack of mechanisms of metadeliberation in the design of LHINs. Legislative committee testimony and media coverage, documented in chapter 4, reveals that citizens and stakeholders were caught off guard by the sudden introduction of LHINs and found it difficult to comment on them in front of legislators because they knew very little about what they were. This finding is critical, because from the beginning the LHINs have suffered a legitimacy deficit as birthed from the shadows with no substantive stakeholder or public input into their design or purpose, with little transparency and publicity that ought to accompany significant reform efforts. The government maintained that they “consulted” the public through town halls, online feedback, etc., but many described this as not a generative exercise (for ideas) but rather about receiving feedback on what was already proposed and set to be put in place. Colleta McGrath from the Quest Community Health Centre identified the political importance of metadeliberation when she said, “No matter how good a new health system paradigm is, for it to work effectively and be supported by residents, people must identify with some component of the paradigm.”4 The overwhelming evidence gathered from legislative testimony and interviews with LHIN and ministry staff suggest that the original process of introduction of LHINs without sufficient metadeliberation left major local stakeholders and citizens alienated from the reform effort. Whereas metadeliberation is perhaps the weakest component of this democratic system in its origins and basic design, and metagovernance overly dominant in some respects, there are also areas where state direction to the LHINs was needed, such as a provincial strategic plan, which was chronically delayed and underspecified, or the weakly enforced performance management of LHINs (as depicted by the X over “performance management” in figure 7.3). The basic policy premise of this reform effort was that the province would set the broad goals for health care in Ontario via a strategic plan, and the LHINs would be charged with devising local strategies and programs, suited to their context, to meet those goals, and would be held accountable to meet

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these goals by the province. But a comprehensive strategic plan did not arrive until 2014 – ten years after the introduction of LHINs. Until that point LHINs had been pursuing objectives in various directions. And once a more comprehensive strategy was in development, it was criticized for lacking elements of metadeliberation: it was mostly done in insular, state-­driven fashion, without substantive involvement by the public – or even LHINs! – in a systematic process, according to consultants KPMG.5 With the provincial strategy development the critique is thus two-­fold: a near complete absence of metagovernance of policy objectives for a period, and then once it was devised, it lacked the balance of metadeliberation in order to draw in citizen and stakeholder perspectives on what those larger goals ought to be. Recent changes, however, suggest the metagovernance-­metadeliberation balance is closer to being achieved, in some respects, in the LHIN environment. The Patients First Act, 2016, was the result of more substantive public and stakeholder input on further modifications to the design and operation of LHINs, and clearly responsive to several problems identified from the first decade of their existence. First, LHINs were granted more authority, namely over primary care, public health and home care, which stakeholders identified as problematically outside the earlier authority of LHINs, making integration more difficult. Likewise, members of the public – as well as Ontario’s ombudsman and the auditor general – expressed concern that LHINs were not as inclusive and transparent with their activities as expected by the legislative language and that that ought to be more clearly and explicitly mandated, such as the newly mandated Patient and Family Advisory Councils (PFACs) for each LHIN. So in these respects, the provincial government was responsive to community concerns when making major institutional design amendments to the legislation in 2016. Furthermore, on an ongoing basis, the province has established more opportunities for metadeliberation to contribute to the provincial strategy development and evolution, via institutions like the minister’s Patient and Family Advisory Council (province-­wide), with the mandate to drive meaningful changes to provincial programs and policies and help inform health care plans in Ontario.6 There are fifteen members and one chair, selected from over 1,200 applicants, signifying great interest among the public to metadeliberative institutions that may contribute to institutional design reforms in the future. But it remains too early to evaluate its contributions and influence. Furthermore, the province introduced an initiative in 2018 whereby residents of Ontario can sign up to be “patient advisors” to the province, which will ask them for continuing feedback on their experience in the system and how programs and policies are meeting patient needs.7 Thus while the

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metadeliberation piece was perhaps the greatest weakness in the deliberative system in the first decade of LHINs, there are reasons to believe this is improving, to better balance state and citizen influence in the design of the system – at least before the Ford government’s major governance overhaul plans announced in early 2019, which we will reflect upon after summarizing the main findings on LHINs. Research Question 2: How do we reconcile our understanding of democratic accountability with the complex institutional relationships that have been created that involve various actors (e.g., elected officials, stakeholders, experts, citizens), most of whom have no clear electoral-­democratic mandate? The middle portion of figure 7.1 differentiates the levels of governance in any governance subsystem, from those parts governed by elected officials (procedural decision-­making bodies), appointed officials (mandated decision-­making bodies), and citizens/public space, where we see outreach, advocacy, and protests in less structured manifestations. The previous three chapters examined these domains separately to drill down into their development and evolution in the context of LHINs, but it is critical to examine the relationships between these levels and the principal actors therein to evaluate their democratic character. Elected officials remain critical policy actors, even in this analytical construction that normatively emphasizes much broader participation in politics in governance beyond elected officials. So what has been the role of elected officials, namely MPPs, and their relationships with LHIN development and operations? MPP involvement in LHINs is primarily manifested in two ways: (1) collectively evaluating, revising, and endorsing the enabling legislation for LHINs, and (2) individually as political actors with whom LHINs engage regularly as a geographic link to electoral representation. On the role of MPPs as legislators, they have been involved in the LHIN environment during moments of legislative change, including travelling the province to hear testimony about proposed bills and questioning the government’s design choices. This role was undermined by the OLP government routinely delaying a promised review of the LHIN legislation for six years. The first substantive review of the legislation occurred in 2014 but did not result in changes until 2016, despite significant feedback about problems in the system. Additionally, during this period the Liberals had a majority government and rejected most proposed amendments to the legislation from opposition parties, and Liberal MPPs, as is common practice in Canadian party politics, dutifully adhered to the party position

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on these issues, regardless of what local actors in their constituencies claimed were areas that ought to be considered for reform. The other primary role for MPPs in the LHIN environment is the ongoing relationship most have with the LHIN(s) in the geographically defined constituency they represent. In legislative committee testimony, MPPs reported that they have regular meetings (a few times per year) with LHIN board chairs and members to share mutual feedback about initiatives under way by the LHIN, but also to learn from MPPs about what they are hearing from constituents or stakeholders. It is an important loop of exchange between elected officials and LHINs that is not often recognized by observers critical of LHINs for being completely unaccountable and detached from democratic institutions. Yet some MPPs also report that this relationship is strong for some and nearly absent for others, with some LHINs being less than proactive about nurturing this relationship, so it is important that all LHINs establish relationships with the MPPs in their territory, and across all political parties. Another dimension in the relationship between procedural decision-­ making bodies (i.e., those that involve elected officials) and mandated decision-­making bodies (i.e., LHINs), as described in figure 7.1, concerns the minister and the LHIN. A major finding from chapter 4 is that the minister (and, by extension, ministry officials) has at times meddled in LHIN affairs in ways that seem to violate the spirit of the enabling legislation. From sometimes arbitrary interventions that in essence overturn LHIN decisions, to attempts to reach in to shape LHIN decision-­making (recall that some LHINs reported that their staff spend at least 30 per cent of their time responding to ministry inquiries), ministers who oversee LHINs have had a strong presence. More recently, in an effort to provide more structure and predictability for both the minister and the LHINs, mandate letters have been issued to more clearly set out the expectations of LHINs from the perspective of the main procedural decision-­making body (i.e., Cabinet), a development not resisted by LHINs, as it is hoped that this would reduce the minister’s ad hoc interventions. The relationship between procedural decision-­making bodies (and their members) and the citizens/public space in the LHIN environment is evolving away from limited connections to more developed and sustained interactions, particularly in recent years. In the early years, some MPPs were suspicious of LHINs because, as Crown agencies, they are shielded from inquiries from MPPs acting as representatives of their citizens. For example, the MOU between the ministry and LHINs specifies that for “contentious issues” raised by those – including MPPs – who

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ask for information, LHINs must “await any required approvals from the Minister’s Office before proceeding”8 – that is, do not answer. Furthermore, some types of information are more difficult to access if the LHIN is not prepared to share, and rules on what can be discussed in the legislature may inhibit the connection between citizens and their MPPs on this issue.9 On the other hand, from the perspective of citizens and stakeholders, MPPs have been the target of protest and lobbying when LHINs have made or been implicated in controversial decisions, knowing that MPPs carry special legitimacy that LHINs will feel compelled to listen to in these contexts. MPPs can also be brokers between citizens and LHINs, charting out paths to reconcile competing visions, a key democratic function articulated in the DAF. The final pair of relationships to examine in the democratic system specified in figure 7.1 is among the mandated decision-­making bodies (i.e., LHINs) and citizens and public space. Chapter 6 was devoted to ways in which the public is engaged with LHINs, and for what purposes, so that will not be reviewed here. But in the view of how it fits with the DAF to evaluate democratic accountability, the major finding is that public engagement is a widespread practice among the LHINs, but there have been challenges associated with deciding how each piece contributes to the broader goals and activities of LHINs. There are opportunities for LHINs to intersect with the broader public, including at the board level, advisory committees, and citizens panels. At the board level, some LHINs have open-­mic opportunities at board meetings, where citizens can raise their unfiltered concerns to LHIN leadership; some have regularized media availability after public board meetings; and others use webinars or webcast technology to allow the public to watch proceedings. In times where LHIN decisions have generated controversy among the public, the LHIN board has been the target of protests, usually outside of their meeting locations. Many of these protests were focused on expanding the nature of ongoing debates, or lack of inclusion, or about making decision-­making a fairer process – all of which represent contributions to the normative ideals embedded in the DAF. We saw that, despite LHINs not having a direct electoral connection to local citizens, they are generally responsive to them, as their dual accountability mechanisms squeeze them “from above” by the minister and legislature and “from below” in terms of citizen engagement (cooperative or protest-­oriented), as depicted by the dotted-­line arrow connecting the “interested public” and LHIN boards in figure 7.3. Beyond the LHIN board-­ level interactions with citizens and in the broader public space, numerous advisory committees created by

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LHINs involve stakeholders and citizens. Yet the research and analysis revealed that these are often focused on the design, development, and monitoring of programs, not idea generation or reform. But it is important to note that stakeholders are generally content with their inclusion and involvement in advisory committees and councils, certainly compared to the period before LHINs existed. Stakeholders such as doctors or other health professionals can contribute to discussions by giving voice to their patients in these advisory committee settings. Yet stakeholders, who are the ones largely represented on these advisory committees, are not the same as citizens. Adrianna Tetley, CEO of the Association of Ontario Health Centres, noted that a critical part of engagement involves “planning from a person’s perspective, not the provider perspective.”10 This has led to the growth of citizens panels, sometimes called resident councils, for all sorts of purposes in the LHINs, from the strategic to the operational level, with mixed success, as revealed in chapter 6. Most of those interviewed from the TC LHIN citizens panel suggest that the tasks of these venues should be more operational or practical, and indeed some LHIN citizens panels are experimenting with co-­ design of initiatives or small-­scale programs. A trend identified in this research is a shift from numerous ongoing advisory committees to more focused engagement and targeted to particular parts of planning and system integration. Some LHINs suggest they are now trying to focus on engaging those affected by the decision, rather than the public writ large for certain issues or programs under consideration. A key lesson from public engagement by LHINs is that managing citizens’ expectations of their involvement is clearly important, and they often fail to do so in this context. While there should be no deterministic relationship between involvement and the resulting policy or program choices of LHINs, there must be more transparency and disclosure about how involvement and public engagement have fed into the policy process in order to give citizens and stakeholders confidence that their efforts were a piece of the process, not just window-­dressing, as depicted by the X over “report on activity” from citizens panels to the “interested public” in figure 7.3. Research Question 3: What kinds of institutional and interpersonal links between governance arenas produce an interconnected and responsive system? A democratic subsystem requires design in order to ensure appropriate actor circulation and venue coupling across the levels – that is, interpersonal and institutional links across venues, where activities and

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by-­products from one arena feed into another (e.g., societal goals determined at procedural decision-­making bodies are structurally linked into deliberations on the means to achieve those goals at the mandated decision-­making bodies). Actor circulation and venue coupling are critical pieces of any complex democratic governance subsystem, but there must be a balance to these features: too much circulation of the same actors limits the diversity and representation in the system, as does coupling among venues that is too tight, contributing to group-­think. What emerges from the study of LHINs in Ontario since their creation in 2004 is that circulation tends to happen with information, not people, and that venue coupling is stronger than it may appear from the outside, with various institutionalized linkages, forming a ladder of sorts, that build out initiatives from the ground level to influence higher-­level provincial policymaking. In circulation of actors across venues, some LHINs have had participants in their citizens panels present findings or outcomes from their work to the respective LHIN board, thus representing actors from one venue bringing lessons to other venues to influence their work. More often, circulation takes the form of information, not people, flowing from one venue to the next. While this is, of course, better than simply not circulating the information, circulation of actors is a more effective approach, as evidenced by the overwhelming impression given in interviews with citizens panel members from Toronto who did not get this opportunity: they had virtually no idea where their work went and what influence it had on “higher-­level” decision-­makers. To Alies Maybee, a citizen panel member, “we’ll have a focus group on X, and then nothing comes back to the focus group and people say, ‘Well I never know if it makes any difference or not, so why should I bother?’ So you break trust.”11 This is depicted by the X over “priority setting” from citizens panels to LHIN boards in figure 7.3. By carrying their own ideas and outputs to other venues, rather than relying on LHIN staff, confidence in their work and trust in the process would be enhanced. Whereas circulation is concerned primarily with the movement of people across venues, venue-­coupling is related, but distinct, in the sense that it is concerned with fostering institutional links across venues, where outputs or products from one venue feed into other venues. This could mean recommendations for action are taken up for consideration by a “higher-­level” body, or draft ideas of priority areas for funding are sent “down” to the public for consideration and ranking, or any other mechanism through which the products of one venue are institutionally linked to another, ideally building on the work from the other. There are numerous examples, particularly in recent years, of venue

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coupling in the LHIN context, such as “governance-­to-­governance” (G2G) meetings, the LHIN board chair-­ministry group, and the HSSO, which was formerly the LHIN Collaborative, a venue created by LHINs to share learnings but also present a united front on certain issues to the provincial government. For example, G2G bodies and working groups typically involve the leadership of the LHIN board, CEO, executive directors of hospitals, long-­term care homes, mental health and addictions agencies, community health centres, and senior officials from the ministry to gather the leadership of the main players in the health system in the region to reflect, learn, and share how governance practices in their organizations can be improved to work towards the objectives defined in the LHIN’s IHSP. The chair of the WW LHIN stated that “we host meetings and events that bring people from different boards together so they can learn from one another, better understand their role within the system, and provide ongoing input to the LHIN.”12 In recent years, observers in the health system think the LHINs have turned a corner on these efforts, and after resistance, learning, and trust-­building, “a lot of the providers at a local level are working together, sharing information about the population, deciding together with community input what are the priorities in their area, figuring out the best ways to deliver services, and starting to share referrals and coordinate a lot better,” according to a LHIN official.13 G2G is practised differently at each LHIN but is viewed as essential to unite the venues of representation and operations in the system and contribute to mutual understanding, system planning, and shared action. Despite these highlights, there are several areas where circulation and venue-­coupling could be enhanced in the LHIN environment to further promote learning, mutual understanding, and trust-­building. One suggestion to better link the public engagement work, which at any LHIN is extensive and varied, with higher-­level decision-­making is to have a “public engagement broker” who physically traverses various venues in the LHIN system, ensuring that the public engagement learnings are embedded in higher-­level deliberations and discussions, but also whose job it is to report back to the public and participants on how their ideas and work was (or was not) integrated into the agenda. This approach responds to a significant problem identified in the interviews with citizens panel members: consultation and engagement must “feed” into LHIN operations and planning must be routinized and contribute to choices made or priorities selected or programs funded. Paul Huras, CEO of the NE LHIN, was clear that “listening to input doesn’t mean we do everything we’re told. If we did that, we would be

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changing things constantly. As many people tell us one thing, we have people telling us another thing. Listening and engaging does not negate our responsibility to make a decision. We use that information to help put the data in context, and it helps us understand the system and it often helps us make the changes that are good for the system.”14 Thus a deterministic “use” of consultation and engagement should not be the standard by which we evaluate it. Rather we should look to whether there were opportunities to be heard and whether these contributions flowed through the system to make it to other arenas, including decision arenas. This can be facilitated by a “public engagement broker,” whose job is also to communicate back to participants on the reach of their work into the larger policymaking process. There was also a suggestion that, given the growth of citizens panels (or resident councils, as they are called in some LHINs) in recent years, they need to be more thoughtfully created and linked to other local actors and arenas. One idea was to have some overlapping representation on a citizens panel with health professionals, who often have their own committee or working groups, and have these bodies intersect from time to time to jointly puzzle through issues. The absence of this dynamic in most LHINs is depicted by the X in between “stakeholder committees” and “citizens panels” in figure 7.3. Citizen-­identified issues in the health system could then be partially explained or put in context by health professionals, and likewise health professionals could gain a better understanding of a typical citizen’s view of the health system. Creating structured opportunities like this, where committees within LHINs are brought together for joint planning or deliberations on specific issues, would be a way to further enhance circulation and venue-­coupling. With the three primary research questions answered by synthesizing the empirical findings from LHINs, using the democratic arenas framework, we now can step back to evaluate the big-­picture question at the heart of this book: How do we know if a complex, multi-­level, and networked governance ecosystem enhances or undermines democracy? To find the answer, we return to the core democratic functions of any governance context and examine the division of labour between arenas and the connections among them. Does the Governance Subsystem Fulfil Core Democratic Functions? Recall that the core democratic functions in any governance subsystem were differentiated as empowered inclusion, communication and

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collective will formation, and collective decision-­making capacity, each with several dimensions and associated measures and linked to various venues. Empowered inclusion includes dimensions such as equality, diversity, and dynamics of participation, measured by the share of relevant and affected actors approached and accommodated for involvement, the breadth of accommodations made to provide a culturally safe and inviting context for participation, and the extent to which there are structured and balanced opportunities for involvement, speaking, and dissenting, and the equality of voice (stemming from one’s perspective, experience, and/or credentials). Communication and collective will formation captures the discourse and procedures inside venues, with dimensions such as reciprocity, and the extent of consensus-­driven procedures, measured by identifying and tracking exchanges of mutual benefit, the extent of reasoning or persuasion (rather than coercion) to build common agendas and metaconsensus on issues, as well as the extent of transparency and publicity in venues and actions. The capacity for collective decision-­making captures the connection between venues to authoritative decision-­making and thus is concerned with consequentiality (i.e., to policymaking and implementation) and accountability, measured by venue placement in the institutional mix and how actors are answerable for their actions, and the adherence to these mechanisms in practice. Table 7.1 summarizes the strengths and weaknesses of the three democratic arenas alongside the core democratic functions of governance. In the empowered inclusion dimension for evaluating democratic subsystems, committees, and other forms of participation in the LHIN, we see inclusion interpreted to mean different things in different venues. For example, membership on LHIN boards (i.e., mandated decision-­ making bodies) is not “inclusive” in the sense of political or epistemic inclusion, as they tend to be made up of professionals from the private or public sector. They have been largely skill-­based boards in recent years, in comparison with the first few years of LHINs when the aims were to achieve political and epistemic inclusion. Instead, LHIN boards tend to emphasize leadership skills and experience, at times not accumulated in the health care realm, but in public or private sector management. Our traditional understandings of inclusion, however, are key goals of advisory committees, citizens panels, town halls, etc. that have been designed to be quite inclusive and contribute to more equality of voice from a political and epistemic point of view, as described in chapter 6. There is also a recognition that, particularly when trying to engage citizens, proactive steps must be taken to foster inclusivity, as LHINs do by offering honoraria, bus tickets, and catering, but also by

166  Distributed Democracy Table 7.1.  Strengths and Weaknesses of the Democratic Arenas, and Core Democratic Functions of Governance Democratic arenas

Democratic functions of governance

Procedural decision-­ making bodies

Mandated decision-­ Citizens and public making bodies space

Empowered inclusion

Mixed: diversity, equality

Weak: equality of voice

Strong: diversity, equality, affected populations

Communication and collective will formation

Weak: common agendas, metaconsensus

Strong: common agendas, metaconsensus

Mixed: common agendas, metaconsensus

Collective decision-­ making capacity

Strong: consequentiality and accountability

Mixed: Weak: consequentiality consequentiality and accountability and accountability

recruiting via lotteries rather than by the “usual suspects” who often attend public engagement opportunities. In communication and collective will formation, we see in table 7.1 that LHINs are important sites in the democratic subsystem that have built intersubjective consistency, while forming common agendas and metaconsensus. Prior to LHINs, the health system in Ontario was siloed, competitive, and distinctly adversarial, and while there remain problems in this regard, LHINs have bridged divides in the health system by structurally bringing actors together to work more cooperatively. This process has also been aided by the ministry. But most of this activity has been driven fundamentally at the LHIN level as part of their mandate to integrate the health system and engage with the community. A high-­level concrete example of common agendas and metaconsensus is the LHIN Collaborative (now known as HSSO), which has worked to establish strategic focus amidst diversity of localities, share knowledge and data, and diffuse innovation, from dispersed venues into the core, building consensus and common agendas as a result. For the collective decision-­ making capacity of democratic functions, consequentiality and accountability are measures of how tasks are divided and linked in this complex policymaking context. Consequentiality refers to the roles of venues being meaningful in the policy development process and have weight in the definition of public problems, discussing possible alternatives, deliberating solutions, and implementing those choices. Procedural decision-­making bodies, namely the legislature and Cabinet, are strong on consequentiality, as

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they have clear authority to make collective decisions, as shown in table 7.1. Yet other sets of arenas are undermined when the consequentiality of their function is constrained. This was observed most acutely in the citizens panels that have emerged in recent years in LHINs, which have received mixed reviews from participants. Advisory committees have been more successful in this regard, as they have been typically involved in implementation and monitoring, where they can see the concrete results of their efforts put into practice. Accountability is one of the most important dimensions of governance and is especially critical when evaluating a system like LHINs when authority is distributed and clear lines of accountability are elusive – all for laudable purposes to achieve the benefits of collaboration, but is nonetheless more difficult to measure and track. It was discovered in this research that traditional ministerial accountability between the ministry and LHINs is formalized, strong, and systematic. There were problems in the first decade of LHINs with their being held responsible for performance in the health system in areas for which they had no authority, but this changed after 2016, when LHINs were given more authority and an appropriate level of enhanced oversight by the province. The accountability relationship between LHINs and their advisory committees and citizens panels is much weaker, in part because it is unlike the principal–agent relationship they have with the ministry. LHINs are not formally accountable to their communities. Instead discursive accountability is manifested. Recall that discursive accountability privileges trust and reputation as the basis for cooperation and involves actors justifying intentions and behaviours to the satisfaction of their peers. Instead they are held accountable not for their actions and results, as elected and bureaucratic officials are, but instead by their intentions, as good or bad in the context of their organization or community goals, evaluated by peers via mutual monitoring and reputational sanctioning.15 In this vein, LHINs’ discursive accountability relationships have been undermined in this regard by poor management of citizens panels (involving routine staff turnover, which confuses participants), as well as LHINs halting deliberative engagements when not happy with them, such as the TC LHIN Citizens Panel at the time of writing. Furthermore, the “board education” meetings, in which a few LHIN boards went in camera to avoid scrutiny, were hugely damaging to the reputation of LHINs, even though there was infrequent resort to this device. Part of building and maintaining discursive accountability involves LHINs having their presence in communities felt more broadly, especially by citizens, and that is very much

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a work in progress as of 2019. Among stakeholders, LHINs are building trust and reputations through the governance-­to-­governance opportunities, which interviewees suggested was an important tool to demonstrate accountability to the broader community. Notwithstanding the variable performance of the democratic functions of governance across the three main arenas depicted in table 7.1, it is critical to remember that a democratic systems approach posits a division of labour in arenas that meet the core democratic functions. That is, whereas mandated decision-­making sites may be weak in empowered inclusion, citizens and public space are strong, and provided there is venue coupling and actor circulation among them, the core democratic function of empowered inclusion can be satisfied. Likewise, for collective will formation, we see mandated decision-­making bodies as strong in this function and procedural decision-­making bodies weaker, and further for collective decision-­making capacity we see citizens and public space as comparatively weak on this function, but procedural decision-­making bodies are strong. No single arena can fulfil the core democratic functions on its own, but through venue coupling and actor circulation this division of labour can be assembled to create an integrated and responsive governance system. Broader Lessons for Democratic Governance from LHINs The creation of LHINs in 2004 was marked by excitement among some in the health-­policy community and nearly universal suspicion and criticism by media commentators, as well as by many citizens. Yet by diving deeper through the research in this book, it is evident that that excitement ought to be muted in some respects and that the suspicion of some observers is unwarranted in other respects. LHINs are very much a mixed bag: an innovative attempt to create a governance framework that structurally incentivizes integration and coordination of services, while opening up the policy process to more local influence. But there are key weaknesses in the LHIN system that undermine its democratic accountability. It is also important to keep in mind that health care governance and reform is inherently difficult to execute. Ed Castro from the Mississauga Halton LHIN reminded me that “it’s extremely complex. We don’t fix Ferraris. That’s easy. We work with organizations and groups and people, in a complex environment.”16 And people like Robert Morton of the LHIN Leadership Council, who has led changes in complex environments, unlike media commentators, know that “when we look at the principles of complex adaptive change, we know that you’ll never get it right the first time. If you did, you probably didn’t go

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far enough.”17 And while the empirical contributions of this book are drawn exclusively from LHINs in Ontario, the lessons from this study are relevant for policy domains that are characterized by complex, networked governance institutions that struggle with how to link public consultation or deliberative engagements with the broader policy process, as well as whom to include, at what critical points in time, what we expect of them, and how this relates to accountability. In that vein, it is essential to step back and distil the central successes of LHINs that policy actors in other fields ought to recognize and replicate, as well as ongoing weaknesses or failures they should avoid. We have observed several strengths in the governance of LHINs, most of which are under-­recognized or dismissed amid the torrent of criticism afforded to them in the media. First, there are many opportunities for citizens and stakeholders to participate and provide input into LHIN policy planning and decision-­making. With over ten years of experimentation with public engagement, most LHINs have developed systematic community engagement strategies to engage their publics in planning and implementation, as well as methods – ranging from advisory committees, to town halls, polling, webinars, community events, citizens panels, and more – to recognize the diverse schedules and willingness of citizens and stakeholders to get involved. With these more sophisticated and systematic community engagement frameworks, LHINs also maintain an inventory of all formal engagement to elicit input into strategic planning, initiative-­specific activities, and priority-­ setting, as well as gain feedback on the appropriateness of their engagement techniques and participant satisfaction with the process. As such, no one can fairly accuse LHINs of merely conducting consultations and public engagement for the sake of saying they did so – it is increasingly embedded as a core function of policy planning and decision-­making.18 Second, recent efforts to enhance metadeliberation opportunities – involving citizens in the actual design of governance frameworks, not just on substantive policy discussion – are positive and encouraging, with province-­wide advisory committees made up of citizens to advise the minister, and “patient advisors” who are continuously asked to submit feedback to the province on their experience in the health system, to contribute to its design and reform. A third area of strength in LHINs that similar governance frameworks in other domains ought to model is transparency. This was certainly not always so, but at the time of writing, LHINs are among the most transparent organizations this researcher has ever studied, with open board meetings, sometimes webcasted, as well as meeting agendas posted online in advance, meeting minutes posted shortly thereafter, and laudable media access to

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board members after monthly meetings. Some of this transparency is mandated by legislation, but in other cases it has emerged as an important tool for LHINs to enhance their legitimacy and presence in their communities. Along with the successes discovered in this governance context, there remain failures that policy actors in other domains ought to avoid to build a healthy democratic and accountable system of governance. First, there has been a pattern of engagement without clarity of purpose or outcome. To some, it has the appearance of throwing the kitchen sink at public engagement, with lack of strategic objectives and without care to establish feedback loops with those engaged on how their involvement mattered to the process. The most obvious example is the bumpy roll-­out of citizens panels in LHINs, in which, while they are a welcome deviation from the otherwise-­heavy stakeholder bias in public engagement vis-­à-­vis LHINs, there has been dissatisfaction among participants. To Alies Maybee, a member of the TC LHIN citizens panel, “there needs to be a huge cultural change, system change, [and] at the micro level on the ground. And those can really only be driven by the citizenry, because the powers that be certainly don’t have any way of getting through the logjam that is the mess of our health care system.”19 Citizens panels can be a very effective way to engage the public in a deliberative setting, but organizations must have clear objectives of their focus, otherwise they can feel directionless and ineffective to participants, undermining the legitimacy they purport to afford to policy planning and implementation. So what are the lessons on how and when to involve citizens? Citizens ought to be involved throughout all stages of policymaking, but particularly in the early stages of institutional design and reform visioning, as well as the latter stages of implementation of program design. Thus, citizens ought to be involved in shaping societal goals, alongside the means to achieve those goals in decision settings. Citizens panels can be a powerful mechanism to bring together a “mini-­public” of citizens to consider policy issues, but they cannot be the only or the principal mechanism of public engagement, given their small scale. They must supplement, not replace, broader civic deliberations and engagement. Likewise, in order to generate diverse engagement from citizens, passive efforts such as posting information about town halls, social media updates, or even email addresses made available for citizen feedback are not sufficient. There must be active efforts, targeted and purposeful, to recruit and incentivize participation among less-­activated citizens, which can include enclave deliberations (i.e., in-­group gatherings only), holding events and forums where people already are (i.e., cultural and

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community events, neighbourhood councils, among others), and via interactive online settings. A second area of weakness from a democratic systems point of view is venue coupling. It is not always clear how efforts at one level of governance contribute to developments and debates in other levels, and that threatens sustained participation and substantive gains that can result from engaging different policy actors at different points, for particular purposes. In some sense, outputs from various venues in the broader system have to “go somewhere” and systematically feed into policymaking processes up and down the chain of decision-­ making for accountability to be infused across the system. This can be achieved by inserting formal reporting procedures from one venue into another, but also in the circulation of actors from one venue into another. Several people interviewed recommended that LHINs and similar organizations employ a public engagement broker, whose sole task is to travel across venues, injecting their outputs throughout the system, and report back to lower-­level venues about how their work became embedded in the larger system of planning. Ideally outputs or decisions must be carried “up the chain” for consideration as well. In this vein, political scientist Genevieve Fuji-­Johnson also concluded from her case studies in Canada that policy requirements that bind policymakers to the outputs of deliberative venues ought to be institutionalized.20 So what are the lessons on venue coupling and actor circulation? When there is a plurality of legitimate actors and institutions working in a complex governance environment, there must be clarity on their role in the division of labour and linkages between them. There is an enormous number of islands in this policy subsystem, and the key task of governance is to devise an efficient and responsive ferry system to connect the islands. Venues must be coupled: outputs from one must feed to another, matched to their point of engagement in the policy cycle, either in the form of reporting (i.e., this is what we discussed and the position[s] we arrived at) or formal recommendations that must be taken up by the other venue. Linkages between venues can also be reinforced by the circulation of actors within the system. This can involve a member of a citizens panel appearing at a stakeholder committee, agency board meeting, or even a legislative committee hearing, to connect the work conducted in particular venues to the other parts of the system. This does not imply a deterministic “use” of deliberations, recommendations, or decisions, but rather that the outputs from venues are shared, considered, and built upon, as decisions make their way through a complex governance system.

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A third area of weakness surrounds accountability in this environment. In terms of traditional political-­administrative accountability, LHINs are formally linked to the bureaucracy, which is linked to the minister and Cabinet, who govern with the confidence of the legislature. LHINs are required to report regularly to the ministry on their performance, the minister approves their annual business plans, and their powers are constrained by legislation and regulation. In this context, ministers have the incentive to monitor the activities of LHINs to ensure that they are operating in defensible ways and to correct and intervene when appropriate. Yet in the DAF presented in this book, there is another form of accountability, which speaks to how LHINs are accountable not just “upwards” to the minister, but also “downwards” to the community. Through this lens, accountability relationships look different, as LHINs do not hold authority over the “community” (or vice versa), but instead there is a discursive accountability, whereby LHINs must justify intentions and behaviours to the satisfaction of their partners and citizens in the community, privileging trust and reputation as the basis for cooperation. A common complaint in the early days of LHINs was that they were not “accountable to the community,” and this was true in a strict sense of traditional accountability relationships. But accountability scholarship suggests that accountability at this level is cultivated when the community sees itself in the leadership and behaviour of LHINs at the board level. LHIN boards today tend to be skills based, not representation based, and that can lead to biases in their agendas, with many claiming “efficiency” as the primary lens through which issues are viewed and debated. Extending and democratizing the community appointment process to LHIN boards could strength representation so that there is more direct community investment in those decision-­ makers. Across the country, elections have seldom worked for health authorities, but nomination of board members that engages a larger share of the community would enhance the accountability of LHINs to their communities. Healthy tension between boards and the province would be welcome, as boards must feel they can resist the province at times, engendering community trust when local needs conflict with provincial objectives. What is the key lesson on how to conceptualize and enhance accountability? Formal linkage “upwards” to elected officials for decisions made in a democratic system is central to accountability by ensuring that those for whom legitimacy is granted via election are incentivized to be involved in the process. Yet this accountability link is not the only one to privilege in a complex governance context characterized by

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inclusion of citizens and stakeholders in decisions. Discursive accountability that flows outwards to the community – not upwards to elected officials – must be facilitated, enabled by transparency and publicity within the system. In practice this means that the outputs from citizen forums, panels, and surveys, among other modes of engagement, must be transmitted to the broader interested public for review and analysis, to ensure that this work is in conversation with the larger citizenry not directly involved in this work. The People’s Health Care Act Abandons the People? Just as we build a knowledge base to reflect on the major strengths and weaknesses of the LHIN system of governance, Ontario is once again entering a period of major change in health care governance. The recent health care governance overhaul in Ontario advanced by the Ford government has not been analysed in depth in this book because of its recency and corresponding uncertainty at the time of writing. Recall, however, from chapter 3 that these governance reforms will ultimately dissolve the fourteen LHINs examined in this book and recentralize authority in an agency called Ontario Health, while promoting the voluntary assembly of up to fifty Ontario Health Teams consisting of hospitals, primary-­care physicians, and home-­care providers to jointly coordinate their services. Much additional information is unknown or not publicly disclosed at the time of writing about how this will work in practice, and most LHINs are not poised to be dismantled until 2022. But there is value in viewing the anticipated governance reforms through the DAF established in these pages to contemplate the significance of the changes, as well as to explore what may be gained and lost from this reform effort. Governance reforms in the People’s Health Care Act, 2019, can still be laid over the DAF’s procedural decision-­making bodies, mandated decision-­making bodies, and citizens and public space realm. In fact, the analytical framework helps to reveal where reforms shift the balance of authority and relationships among arenas. In short, the reforms shift considerable authority to procedural decision-­making bodies, in particular Cabinet and the health minister, at the expense of the mandate decision-­making bodies and citizens and public space. Mandated decision-­ making bodies remain in the presumably policy-­ focused “super agency” Ontario Health and the operationally focused “Ontario Health Teams.” Citizens and public space is undefined at the time of writing but will be sacrificed almost certainly from their privileged status in the LHIN context, as locally oriented policy and program

174  Distributed Democracy

decision-­making shifts (and likely disappears) in favour of streamlined provincial decision-­making in these reforms. At this point we do not know how the estimated fifty Ontario Health Teams will operate – they may turn into miniature LHINs in their engagement with their patient constituencies, but that would simply reproduce the “bureaucracy” that the Ford government cites as the motivation to dismantle LHINs in the first place. But frankly it will almost certainly happen; for the Ontario Health Teams to work, they will need administrative capacity of their own to decide how to allocate resources, initiate programming, and evaluate the performance of their efforts. It is clear from these reforms that the idea that local communities and citizens ought to have a role in shaping services in their area has been mostly abandoned in favour of streamlining decision-­making at a broader level of authority, Ontario Health, which in the view of the Ford government will allow more health dollars to flow to patient care rather than public administration. Whether these savings in administration materialize will not be known for many years, but experiences from other provinces that recentralized administration of health care suggest that this will not happen. For example, Alberta recentralized in 2008 and “instead of the hoped-­for bureaucratic efficiency, Albertans got bureaucratic chaos and worsening health care results,” according to Randell Denley.21 Premier Kenney in Alberta has committed to a performance review of Alberta Health Services, given that Alberta has the highest age-­adjusted health costs in Canada yet is among the weakest in standard performance metrics like open-­heart surgery and emergency room wait times.22 Meaningful savings on administration are thus unlikely to materialize merely because fourteen LHINs, their boards, and their senior executives are collapsed into one mega-­organization. But what about the potential gains in accountability by recentralizing authority? The Ontario Health agency will now be accountable for health care in Ontario, compared to the fourteen LHINs, but of course the minister of health is ultimately responsible for the file in electoral politics (which was true with LHINs as well). At this time, we do not know what the relationship will be between the Ministry of Health and the new Ontario Health agency, whether it will truly be an independent agency in the way some LHINs were, or if it will be merely an extension of the ministry. It will be singularly accountable for health care in Ontario, but it will also be a monolithic and comparatively impenetrable, less responsive bureaucracy – precisely the critique in the pre-­LHIN era. Gone will be the open mics at board meetings, and the accessibility of board proceedings to locally interested citizens. Lost will be the institutionalized

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linkages, forming a ladder, that build out initiatives from the ground level to influence higher-­level provincial policymaking. We also do not yet know the criteria for the appointment of the board of directors for the province-­wide Ontario Health agency, in particular how geography, expertise, and representation will factor into the appointments. We do know that this agency will be in Toronto and thus likely not nearly as accessible to citizens and local stakeholders in the way the fourteen LHINs are. And it remains to be seen how much latitude the Ontario Health Teams will be given from Ontario Health to devise locally sensitive services. Potentially lost will be the dual accountability mechanisms squeezing them “from above” by the minister and legislature, and “from below” in terms of citizen engagement (cooperative or protest-­oriented). If the intent of these reforms is to eliminate “bureaucracy” in health care, this will change the way community engagement and civic involvement in health care planning is conducted. To conduct high-­ quality and sustained public engagement, administrative capacity is required, and all indications are that the Ford government is motivated to minimize administration that in its view takes away investment from “front-­line care.” The most effective public engagement by LHINs in their experience, as documented in this book, was not broad-­based open forums, but targeted, specific, and ongoing engagement in particular and locally specific matters. The reforms will lose much of this public engagement, and almost certainly return to such large-­scale and generally ineffective engagement. The minister’s Patient and Family Advisory Council will remain, but the local processes that occurred in communities across Ontario are open to question in their place in the new governance framework. The enabling legislation, unlike the legislation it replaces that foregrounded community engagement as a pillar of the health system, is conspicuously silent on what this will look like in the future Ontario Health universe. Thus, when we look at the upcoming reforms in health care in Ontario through the lens of the core democratic functions – empowered inclusion, collective will formation, and collective decision-­making – we see a shift in the balance of functions, however imperfect, that was observed in the LHIN universe. Collective will formation functions of LHINs will likely proceed as now, but via Ontario Health Teams. The biggest change in expected functions will be in favour of streamlined collective decision-­making in Ontario Health at the expense of empowered inclusion. Recall that empowered inclusion involves equality, diversity, and dynamics of participation, measured by the share of relevant and affected actors approached and accommodated for involvement,

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the breadth of accommodations made to provide a culturally safe and inviting context for participation, and the extent to which there are structured and balanced opportunities for involvement, speaking, and dissenting, and the equality of voice (stemming from one’s perspective, experience, and/or credentials). Thus from a democratic perspective, the Ford reforms to health care governance do not inspire confidence, as they are silent on the bulk of the health care management literature that asserts the importance of connecting an engaged public with the considerations of health care practitioners and stakeholders.23 No single arena can fulfil the core democratic functions on its own, but through venue coupling and actor circulation this division of labour can be assembled to create an integrated and responsive governance system. This reform effort is imbalanced on the core democratic functions we must demand for our governance institutions. While singular accountability for health care in Ontario Health may sound appealing, it is naive to hold a single agency accountable for the performance of the broader health system. In LHINs, this distributed and shared accountability was acknowledged and brought into the open to be managed. In Ontario Health they will be stuffed back into a black box to give the appearance of streamlined accountability, but none of the actual accountability issues in a very complex system go away. It obscures rather than resolves accountability in this context. In some sense these reforms represent the worst of both worlds: at least citizens and stakeholders could get issues on the local LHIN agenda, and they showed evidence of being responsive to them; but a local issue or group is unlikely to be able to provoke a response from the superagency, Ontario Health. Ultimately, the reform effort undermines the strengths of LHINs (in particular the multiple pathways of citizen engagement in health), and does not address the weaknesses of LHINs, which, as documented in this book, include weakly representative boards, simplistic use of citizen panels, and insufficient coupling of policy planning across decision-­ making venues. Essentially, the Ford reforms, as far as known at the time of writing, amount to putting everything into a giant pot and hoping it all gets coordinated, while obscuring the real accountability pressures and demands in the system. Final Thoughts This inquiry into LHINs in Ontario sought to demonstrate the utility of a democratic arenas framework (DAF), which can be applied in other policy domains and jurisdictions to evaluate the democratic and

A Democratic Arenas Analysis of LHINs  177

accountability dimensions of complex governance institutions from a systemic perspective. Through this approach, it was revealed that many criticisms of LHINs are focused on the wrong areas – there are indeed weaknesses in democracy and accountability, but just not where most of the popular criticism locates them. That is, the problem with LHINs is not that they create additional layers of bureaucracy or allow the minister to dodge accountability, as are the main lines in the media and among critics, but rather that the plurality of new institutions and decision-­making venues created in the LHIN context are seldom coupled or sufficiently connected to each other. Getting the critique right is the first step to contemplating reforms that may improve their structure and function. The DAF helped to systematically evaluate the component parts and how they are (or are not) connected to each other and to core democratic functions to present a more sophisticated critique of the broad democratic character of the LHIN universe. For policy practitioners in Canada, particularly in the health care sector, the research and analysis of LHINs contributes to debates on the evolution of regionalization of health care delivery in Canada. Provincial government variation in the regionalization of health care governance is really a struggle to reconcile who should set policy objectives, how much policy variation ought to be permitted to meet the needs of the local context, and what is the appropriate role of stakeholders, experts, and citizens in policy development and implementation. That is, regardless of a province’s position on the centralization-­regionalization spectrum for health care governance today or in the future, the questions that this book tackles – those associated with ministerial–agency relationships, interest group and stakeholder advisory mechanisms, and increasingly demanding citizen participation and deliberation – are universal. And while this book did not aim to recommend an ideal type of regionalization, it offered an analytical framework suitable for all configurations of health authorities in Canada to evaluate the relationships between elected officials, agencies, stakeholders, and citizens against core democratic functions we ought to expect in any governance model. Future research that applies the DAF to compare more centralized versions of health care governance, such as what is unrolling in Ontario at the time of writing, may reveal strengths and weaknesses different from those identified in the analysis of the decentralized LHINs, presenting system reformers with a clearer vision of the trade-­ offs at stake for democracy and accountability along the centralization-­ regionalization continuum. This is what governance-­driven democratization looks like; it can appear muddled, at times be frustrating for those involved, and often

178  Distributed Democracy

lacks a direct relationship between inputs to outputs that media commentators or opposition critics demand. But one thing that is clear is that the LHIN type of governance is fundamentally more democratic, broadly speaking, than previous systems of health care governance in Ontario. In the LHIN universe, there have never been more opportunities for citizens, stakeholders, experts, and the like to be involved to shape health care planning and decision-­making, and while at times it can appear (or is!) messy or fuzzy, it is more responsive and inclusive to diverse perspectives and input than past models. My hope for lessons that emerge from this book is that we can devote ourselves to improving these more inclusive and deliberative models of governance, rather than tossing them out in favour of an ill-­defined return to clear lines of accountability, as traditionally understood. That previous models of governance, with centralized ministerial control, fostered greater accountability is a fallacy, simply creating the illusion of accountability when clarity and hierarchy are privileged. Distributed democracy and accountability that recognizes the complexity of modern governance systems is simply facing reality, and our frameworks to analyse them must reflect that when we evaluate them and contemplate the governance alternatives.

Appendix

Interviews Conducted as Part of Research Name

Organization

Position

Liane Fernandes Narenda Shah Ed Castro Stewart Sutley

LHIN: MH LHIN: MH LHIN: MH LHIN: CE

Ian Dawe

LHIN: CE

James Meloche John Lorenz

LHIN: CE LHIN: CE

Jai Mills Tess Romain

LHIN: CE LHIN: TC

Georgina Veldhorst

LHIN: TC

Alison Blair Annie Tam

MOHLTC MOHLTC

Jane Sager Vivian Ng Barbara Fallon Peter Cresswell Alies Maybee Sandra Dalziel Jonathan Guss Anonymous (11)

MOHLTC Minister’s Office LHIN Citizens Panel LHIN Citizens Panel LHIN Citizens Panel LHIN Citizens Panel OMA –

Senior director, Health System COO Senior lead, Health Development Team Senior director, System Finance and Performance Lead physician, Mental Health and Addictions Senior director Team lead, Performance and Accountability, acting director Lead, System Design and Integration Senior director, Strategy, Community Engagement, and Corporate Affairs Senior director, Planning, Integration, and Community Engagement Director, LHIN Renewal Branch Implementation lead, LHIN Renewal Branch Director, LHIN Liaison Branch Ministry of Health and Long-­Term Care Citizen representative Citizen representative Citizen representative Citizen representative CEO –

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Notes

1. Introduction 1 Citizen in this context is referring not to formal legal status in Canada, but rather those with political standing to give voice and consent to public decisions that affect them, as used by A. Fung (2006), Varieties of participation in complex governance, Public Administration Review, 66(Suppl. 1), 66–75, and others. 2 See T. Talaga (2010, 16 August), Ontario’s local health networks must go, opposition says, Toronto Star, www.thestar.com/news/ontario/2010 /08/16/ontarios_local_health_networks_must_go_opposition_says .html. 3 See Ontario Newsroom (2005, 28 June), McGuinty government announces leadership of local health integration networks, https://news.ontario.ca /archive/en/2005/06/28/McGuinty-­Government-­Announces-­Leadership -­Of-­Local-­Health-­Integration-­Networks.html. 4 See B. Hepburn (2015, 27 September), Urgent need for Ontario home-­care task force: Hepburn, Toronto Star, www.thestar.com/opinion/commentary /2015/09/27/urgent-­need-­for-­ontario-­home-­care-­task-­force-­hepburn .html. 5 See T. Boyle (2014, 6 June), Health care, the forgotten issue in Ontario’s election, Toronto Star, www.thestar.com/news/ontario_election /2014/06/06/health_care_the_forgotten_issue_in_ontarios_election .html. 6 See J. Sher (2014, 25 February), CCAC official fends off criticism, saying the centres are well run and have kept people from needing costly hospital care, Chatham Daily News, www.chathamdailynews.ca/2014/02/24/ccac -­official-­fends-­off-­criticism-­saying-­the-­centres-­are-­well-­run-­and-­have-­kept -­people-­from-­needing-­costly-­hospital-­care.

182  Notes to pages 5–6 7 See R. Ferguson & R. Benzie (2010, 20 October), Ontario tightens lobbying rules after scathing report, Toronto Star, https://www.thestar.com/news /ontario/2010/10/20/ontario_tightens_lobbying_rules_after_scathing _report.html. 8 See D. Glynn (2014, 9 April), Mayors want answers from LHIN, Simcoe .com, www.simcoe.com/news-­story/4454724-­mayors-­want-­answers -­from-­lhin. 9 See Boyle (2014, 6 June). 10 See T. Talaga (2010, 30 January), Ontario government praises LHINs as critics call them a waste of money, Toronto Star, https://www.thestar.com /news/canada/2012/01/30/ontario_government_praises_lhins_as _critics_call_them_a_waste_of_money.html. 11 See Boyle (2014, 6 June). 12 See Glynn (2014, 9 April). 13 See M. Gandhi (2010, 24 October), Inside Ontario’s bloated health-­care bureaucracy, Toronto Sun, http://torontosun.com/2015/10/24/inside -­ontarios-­bloated-­health-­care-­bureaucracy/wcm/8154 8c36-­bedd-­4834 -­be5a-­2fe0048aa8a7. 14 See Talaga (2010, 16 August). 15 See K. Leslie (2016, 2 June), Ontario bill would overhaul $50 billion health-­care system, close CCACs, City News, www.citynews.ca/2016 /06/02/ontario-­bill-­would-­overhaul-­50-­billion-­health-­care-­system-­close -­ccacs/. 16 See B. Kelly (2017, 5 February), Brown would axe Ontario’s LHINs, Sudbury Star, www.thesudburystar.com/2017/02/05/brown-­would -­axe-­ontarios-­lhins. 17 See M. Crawley (2019, 17 January), Ford government poised to dissolve regional health agencies, sources say, CBC News, www.cbc.ca/news /canada/toronto/lhin-­ontario-­doug-­ford-­local-­health-­integration -­networks-­1.4980509. 18 See Talaga (2010, 16 August). 19 Ibid. 20 Toronto Star (2010, 23 August), How to heal health delivery, www.thestar .com/opinion/editorialopinion/2010/08/23/how_to_heal_health _delivery.html (site discontinued). 21 See Gandhi (2010, 24 October). 22 Sudbury Star (2012, 6 October), Nurses’ tough medicine; HEALTH CARE: Eliminate bureaucracy, association says , www.thesudburystar. com/2012/10/06/dissolve-­ccacs-­nurses-­association (site discontinued). 23 See Peterborough Examiner (8 April 2009), New doctor waitlist, www .thepeterboroughexaminer.com/news-­story/3710204-­new-­doctor -­wait-­list/.

Notes to pages 6–16  183 24 Sudbury Star (2017, 18 March), LHIN expands “culturally appropriate care,” https://www.thesudburystar.com/2017/03/16/lhin-­expands -­culturally-­appropriate-­care/wcm/1e327f0e-­e83c-­bf3c-­ff4a-­1bc40d7d3544 (site discontinued). 25 See Conference Board of Canada (2015, 1 February), Provincial and territorial ranking: Health, www.conferenceboard.ca/hcp/provincial /health.aspx?AspxAutoDetectCookie Support=1. 26 See Boyle (2014, 6 June). 27 P. Barker (2014, 27–9 May), An assessment of local health integration networks in Ontario, paper presented at the 2014 Canadian Political Science Association Conference, Brock University, St Catharines, ON. 28 See A. Marin (2010a, 10 August), The LHIN Spin: Ombudsman remarks, Ombudsman Ontario, www.ombudsman.on.ca/Files/sitemedia /Documents/Investigations/SORT%20Investigations/lhin-­remarks -­en_1.pdf. 29 Y. Papadopoulos (2012), On the embeddedness of deliberative systems: Why elitist innovations matter more, in J. Parkinson & J. Mansbridge (Eds), Deliberative systems: Deliberative democracy at the large scale (pp. 125–150), Cambridge: Cambridge University Press. 30 J. Mansbridge, J. Bohman, S. Chambers, T. Christiano, A. Fung, J. Parkinson, D.F. Thompson, & M.E. Warren (2012), A systemic approach to deliberative democracy, in Parkinson & Mansbridge, Deliberative systems, 1–26. 31 In 2019 the Ministry of Health and Long-­Term Care (MOHLTC) was split into the Ministry of Health (MOH) and Ministry of Long-­Term Care (MoLTC). 32 D. Osborne (1993), Reinventing government, Public Productivity & Management Review, 16(4), 349–356. 33 Local Health System Integration Act, 2006, S.O. 2006, section 14 (1). 34 See J. Ronson (2011, 1 June), LHINs at five years – What now? Longwoods. com, www.longwoods.com/content/22432/print. 35 L. Fernandes, senior director, Mississauga Halton LHIN (2017, 1 December), interview. 36 P. Barker (2007, May), Local health integration networks: The arrival of regional health authorities in Ontario, paper presented at the Canadian Political Science Association conference, Regina, SK. 37 J. Abelson, S. Montesanti, K. Li, F-­P Gauvin, & E. Martin (2010), Effective strategies for interactive public engagement in the development of healthcare policies and programs, Ottawa: Canadian Health Services Research Foundation; J. Grant, N. Sears, & K. Born (2008, December), Public engagement and the changing face of health system planning, Healthcare Management Forum, 21(4), 22–26.

184  Notes to pages 16–22 38 P. Barker (2015), Health system performance reporting in Canada: Bridging theory and practice at pan-Canadian level, Canadian Public Administration, 58(1), 15–38. 39 C. Fooks & S. Hylmar (2015), Are LHINs influencing the patient experience in Ontario? Healthcare Management Forum, 28(6), 251–254. 40 K. Moat, K. Waddell, M. Wilson, & J. Lavis (2016), Addressing health-­ system sustainability in Ontario, paper presented at McMaster Health Forum. 41 M.E. Warren (2009), Governance-­driven democratization, Critical Policy Studies, 3(1), 3–13. 42 Mansbridge et al. (2012). 43 C. Doberstein (2016a), Building a collaborative advantage: Network governance and homelessness policy-­making in Canada, Vancouver: UBC Press; Doberstein (2016b), Designing collaborative governance decision-­making in search of a “collaborative advantage,” Public Management Review, 18(6), 819–841; Doberstein & H. Millar (2014), Balancing a house of cards: Throughput legitimacy in Canadian governance networks, Canadian Journal of Political Science, 47(2), 259–280; Doberstein (2013), Metagovernance of urban governance networks in Canada: In pursuit of legitimacy and accountability, Canadian Public Administration, 56(4), 584–609. 44 C. Conteh & I. Roberge (Eds) (2013), Canadian public administration in the 21st century, Toronto: CRC Press; R.P. Leone & F.L.K. Ohemeng (Eds) (2011), Approaching public administration: Core debates and emerging issues, Toronto: Emond Montgomery Publications. 2. The Democratic Arenas Framework 1 J. Parkinson (2006), Deliberating in the real world: Problems of legitimacy in deliberative democracy, Oxford: Oxford University Press. 2 D.J. Savoie (2008), Court government and the collapse of accountability in Canada and the United Kingdom, Toronto: University of Toronto Press; Savoie (1999), Governing from the centre: The concentration of power in Canadian politics, Toronto: University of Toronto Press. 3 E.H. Kljin & J.F. Koopenjan (2000), Public management and policy networks: Foundations of a network approach to governance, Public Management: An International Journal of Research and Theory, 2(2), 135–158; J. Kooiman (Ed.) (1993),  Modern governance: New government-­society interactions, London: Sage; R.A.W. Rhodes (1996), The new governance: Governing without government, Political Studies, 44(4), 652–667. 4 Warren (2009). 5 N. Bradford (2004), Place matters and multi-­level governance: Perspectives on a new urban policy paradigm, Policy Options, 25(2), 39–44.

Notes to pages 22–4  185 6 M.J. Hill & P.L. Hupe (2002), Implementing public policy: Governance in theory and practice, London: Sage; B.G. Peters & J. Pierre (1998), Governance without government? Rethinking public administration, Journal of Public Administration Research and Theory, 8(2), 223–243; G. Stoker (1998), Governance as theory: Five propositions, International Social Science Journal, 50(155), 17–28. 7 E. Sorensen & J. Torfing (2007), Introduction: Governance network research: Towards a second generation, in Sorensen & Torfing (Eds), Theories of democratic network governance (pp. 1–21), London: Palgrave Macmillan; C.M. Hendriks (2008), On inclusion and network governance: The democratic disconnect of Dutch energy transitions, Public Administration, 86(4), 1009–1031. 8 Warren (2009), 4. 9 Parkinson (2006); A. Fung (2003), Survey article: Recipes for public spheres: Eight institutional design choices and their consequences, Journal of Political Philosophy, 11(3), 338–367; M.A. Hajer & H. Wagenaar (Eds) (2003), Deliberative policy analysis: Understanding governance in the network society, Cambridge: Cambridge University Press. 10 Warren (2009), 8. 11 G.F. Johnson (2015), Democratic illusion: Deliberative democracy in Canadian public policy, Toronto: University of Toronto Press, 5. 12 Papadopoulos (2012). 13 Warren (2009). 14 C. Landwehr (2015), Democratic meta-­deliberation: Towards reflective institutional design, Political Studies, 63(Suppl. 1), 38–54; Papadopoulos (2012), 147; V.A. Schmidt (2006), Democracy in Europe: The EU and national polities, Oxford: Oxford University Press. 15 B. Jessop (2002), Governance and meta-­governance in the face of complexity: On the roles of requisite variety, reflexive observation, and romantic irony in participatory governance, in H. Heinelt, P. Getimis, G. Kafkalas, R. Smith, & E. Swyngedouw (Eds), Participatory governance in multi-­level context (pp. 33–58), Wiesbaden: VS Verlag für Sozialwissenschaften. 16 J.S. Dryzek (2007), Networks and democratic ideals: Equality, freedom, and communication, in E. Sorensen & J. Torfing (Eds), Theories of democratic network governance (pp. 262–273), London: Palgrave Macmillan. 17 B. Damgaard (2006), Do policy networks lead to network governing? Public Administration, 84(3): 673–691; J. Torfing (2012), Interactive governance: Advancing the paradigm, Oxford: Oxford University Press. 18 C. Landwehr (2015), Democratic meta-­deliberation: Towards reflective institutional design, Political Studies, 63(Suppl. 1), 38. 19 D.F. Thompson (2008), Deliberative democratic theory and empirical political science, Annual Review of Political Science, 11, 497–520.

186  Notes to pages 25–30 20 C. O’Kelly (2011), Accountability and a theory of representation, in M.J. Dubnick & H.G. Frederickson (Eds), Accountable governance: Problems and promises, New York: Routledge, 265. 21 D. Mathews (2011), Foreword, in Dubnick & Frederickson (2011), xv. 22 Dubnik & Frederickson (2011). 23 Mathews (2011), ix. 24 B. Radin (2011), Does performance measurement actually improve accountability? in Dubnick & Frederickson (2011), (pp. 98–110). 25 R.E. Goodin (2007), Enfranchising all affected interests, and its alternatives, Philosophy & Public Affairs, 35(1), 40–68. 26 R.E. Goodin (2003), Democratic accountability: The distinctiveness of the third sector, European Journal of Sociology, 44(3), 381. See also M.E. Warren (2008), Citizen representatives, in M.E. Warren & H. Pearse (Eds), Designing deliberative democracy: The British Columbia Citizens’ Assembly (pp. 50–69), Cambridge: Cambridge University Press. 27 Mansbridge et al. (2012). 28 J. Parkinson (2006), Deliberating in the real world: Problems of legitimacy in deliberative democracy, Oxford: Oxford University Press, 12. 29 M.E. Warren (2007), Institutionalizing deliberative democracy, in S.W. Rosenberg (Ed.), Deliberation, participation and democracy (pp. 272–288). London: Palgrave Macmillan. 30 L. Bherer & S. Breux (2012), The diversity of public participation tools: Complementing or competing with one another? Canadian Journal of Political Science/Revue canadienne de science politique, 45(2), 379–403. 31 Mansbridge et al. (2012), 2. 32 D. Owen & F. Smith (2015), Survey article: Deliberation, democracy, and the systemic turn, Journal of Political Philosophy, 23(2), 213–234. 33 M.E. Warren (2017), A problem-­based approach to democratic theory, American Political Science Review, 111(1), 39–53. 34 Ibid. 35 J. Bohman (2007), Democracy across borders: From demos to demoi, Cambridge, MA: MIT Press; J.S. Dryzek & H. Stevenson (2011), Global democracy and earth system governance, Ecological Economics, 70(11), 1865–1874; J. Habermas (1996), Between facts and norms, W. Rehg (Trans.), Cambridge, MA: MIT Press. 36 E. Erman (2016), Representation, equality, and inclusion in deliberative systems: Desiderata for a good account, Critical Review of International Social and Political Philosophy, 19(3), 263–282. 37 Landwehr (2015). 38 Erman (2016). 39 Landwehr (2015). 40 Erman (2016).

Notes to pages 31–43  187 4 1 Landwehr (2015). 42 Erman (2016). 43 Landwehr (2015), 44. 44 Ibid. 45 Habermas (1996). 46 C.F. Karpowitz & C. Raphael (2014), Deliberation, democracy, and civic forums: Improving equality and publicity, Cambridge: Cambridge University Press. 47 Erman (2016). 48 N. Curato & M. Böeker, Linking mini-­publics to the deliberative system: A research agenda, Policy Sciences, 49(2), 173–190. 49 A. Knops (2016), Deliberative networks, Critical Policy Studies, 10(3), 308. 50 Curato & Böker (2016). 51 Ibid. 52 C.M. Hendriks (2016), Coupling citizens and elites in deliberative systems: The role of institutional design, European Journal of Political Research, 55(1), 43–60. 53 Mansbridge et al. (2012), 23. 54 Hendriks (2016). 55 R. Mendonça (2013, 29 August), The conditions and dilemmas of deliberative systems, paper presented at the Annual APSA meetings, Chicago. 56 Ibid., 15. 57 K. Li, J. Abelson, M. Giacomini, & D. Contandriopoulos (2015), Conceptualizing the use of public involvement in health policy decision-­ making, Social Science & Medicine, 138(August), 18. 58 Warren (2007). 59 Karpowitz & Raphael (2014). 60 Ibid. 3. The Evolution of Health Care Governance in Ontario 1 See Ministry of Health and Long-­term Care, Ministry History, https:// web.archive.org/web/20180625160443/www.health.gov.on.ca/en /common/ministry/history.aspx. 2 E. Vayda & R.B. Deber (1992), The Canadian health-­care system: A developmental overview, in David Naylor (Ed.), Canadian health care and the state: A century of evolution (pp. 125–140), Montreal and Kingston: McGill-­Queen’s University Press. 3 Ibid. 4 Ibid. 5 Ibid.

188  Notes to pages 44–52 6 Ibid. 7 F.M. Dixon (1982), The organization of district health councils in Ontario, doctoral dissertation, Brunel University. 8 G.P. Marchildon (2015), The crisis of regionalization, Healthcare Management Forum, 28(6), 236–238. 9 C. Donaldson (2010), Fire, aim … ready? Alberta’s big bang approach to healthcare disintegration, Healthcare Policy, 6(1), 22. 10 Ibid. 11 T. Boychuk (2009), After medicare: Regionalization and Canadian health care reform, Canadian Bulletin of Medical History, 26(2), 359. 12 Ibid. 13 S. Lewis & D. Kouri (2004), Regionalization: Making sense of the Canadian experience, Healthcare Papers, 5, 12–33. 14 Marchildon (2015), 237. 15 P. Barker & J. Church (2017), Revisiting health regionalization in Canada: More bark than bite? International Journal of Health Services, 47(2), 333–351. 16 Ibid. 17 Ibid. 18 Lewis & Kouri (2004). 19 Ibid. 20 Dixon (1982). 21 Ibid. 22 Ibid. 23 Ibid. 24 Ibid. 25 Ibid., 14. 26 Ibid. 27 Ibid. 28 Ibid. 29 Ibid. 30 Ibid., 49. 31 E. Castro, senior lead, Mississauga Halton LHIN (2017, 1 December), interview. 32 Barker (2007, May), 7. 33 LHISA, 2006, s. 14 (1). 34 Barker (2007, May), 7. 35 T. Sullivan & K. Born (2011), LHINs and the governance of Ontario’s health care system, Healthy Debate, June, 29. 36 Barker (2007), 6. 37 Ronson (2011), 6–7. 38 Most LHINs have a community nominations committee and process established by which they seek advice and input on board member

Notes to pages 52–60  189 replacements when vacancies arise. They send these recommendations to the minister, who has the ultimate appointment power. 39 Fernandes (2017). 40 LHSIA (2006) s. (5). 41 Fernandes (2017). 42 S. Sutley, senior director, Central East LHIN (2017, 2 December), interview. 43 Barker (2014); see also Change Foundation (2009), Community engagement and the LHINs: Truth and consequences – Summary Report, www.changefoundation.ca/community-­engagement-­lhin/. 44 Sutley (2017). 45 Toronto Central Memorandum of Understanding (MOU) (2017), http:// www.torontocentrallhin.on.ca/~/media/sites/tc/TC%20LHIN%20Docs /Accountability/07%20TC%20MOU%20-­%202017%20English%20 FINAL-­s.pdf?la=en. 46 Auditor General of Ontario (2015), Annual report, 307–308 (1.1.3). 47 Auditor General of Ontario (2015, 5 December), LHINs’ marching orders not clear enough and performance gaps widening, auditor general says, news release, www.auditor.on.ca/en/content/news/15_newsreleases /2015news_3.08.pdf. 48 Ibid. 49 Ibid. 50 Auditor General of Ontario (2015), 322 (4.1.2). 51 Ibid., 333 (4.2.5). 52 Ibid., 317 (3.0). 53 Ibid., 331 (4.2.3). 54 See N. Alam (2017, 7 February), More proof our health care system is broken: Opinion, Toronto Star, www.thestar.com/opinion/commentary /2017/02/07/more-­proof-­our-­health-­care-­system-­is-­broken-­opinion.html. 55 Sutley (2017). 56 Patients First Act (2016), s. 10. 57 See M. Crawley & N. Boisvert (2019, 31 January), Ontario government responds after NDP leaks draft bill to scrap regional health agencies, CBC News, www.cbc.ca/news/canada/toronto/ontario-­health-­system -­efficiency-­act-­1.5000546. 58 People’s Health Care Act (2019), Preamble. 59 See B. Bell (2019, 27 February), Is it too late to reconsider Ontario’s new health care super agency? Toronto Star, www.thestar.com/opinion /contributors/2019/02/27/is-­it-­too-­late-­to-­reconsider-­ontarios-­new -­health-­care-­super-­agency.html. 60 See Editorial: Ontario health care needs major surgery (2019, 13 May), Toronto Sun, https://torontosun.com/opinion/editorials/editorial -­ontario-­health-­care-­needs-­major-­surgery.

190  Notes to pages 60–8 61 N. Nichols & C. Doberstein (2016), Exploring effective systems responses to homelessness, Toronto: Canadian Observatory on Homelessness. 4. Procedural Decision-Making Bodies That Enable and Constrain LHINs 1 J. Lorenz, team lead for Performance and Accountability, Central East LHIN (2017, 12 June), interview. 2 Ibid. 3 Ibid. 4 Sutley (2017). 5 Standing Committee on Social Policy (2006, 13 February), Official Report of Debates (Hansard), Legislative Assembly of Ontario. 6 Standing Committee on Social Policy (2006, 31 January), Official Report of Debates (Hansard), Legislative Assembly of Ontario. 7 D. Drummond & T. Calder (2015), An action plan for reforming health care in Canada, Managing a Canadian Health Care Strategy Working Papers, Monieson Centre for Business Research in Healthcare, Queen’s University; R. Romanow (2002), Building on values: The future of health care in Canada, Ottawa: Government of Canada Publications. 8 Lorenz (2017). 9 Ibid. 10 Ibid. 11 Sutley (2017). 12 Lorenz (2017). 13 Ibid. 14 Ibid. 15 Ibid. 16 G.P. Marchildon (2013), Health systems in transition: Canada, Toronto: University of Toronto Press. 17 Marchildon (2015). 18 Standing Committee on Social Policy (2014, 31 March), Official Report of Debates (Hansard), Legislative Assembly of Ontario. 19 Standing Committee on Social Policy (2006, 30 January), Official Report of Debates (Hansard), Legislative Assembly of Ontario. 20 Ibid. 21 Standing Committee on Social Policy (2006, 31 January), Official Report of Debates (Hansard), Legislative Assembly of Ontario. 22 J. Ronson (2006), Local health integration networks: Will “made in Ontario” work? Healthcare Quarterly, 9(1), 47. 23 Standing Committee on Social Policy (2006, 1 February), Official Report of Debates (Hansard), Legislative Assembly of Ontario.

Notes to pages 69–74  191 24 Standing Committee on Social Policy (2013, 2 December), Official Report of Debates (Hansard), Legislative Assembly of Ontario. 25 Ibid. 26 Standing Committee on Social Policy (2014, 10 February), Official Report of Debates (Hansard), Legislative Assembly of Ontario. 27 Standing Committee on the Legislative Assembly (2016, 14 November), Official Report of Debates (Hansard), Legislative Assembly of Ontario, https://www.ola.org/en/legislative-­business/committees/legislative -­assembly/parliament-­42. 28 J. Meloche, senior director, Central East LHIN (2017, 23 June), interview. 29 Ibid. 30 As part of this effort, KPMG conducted two-­day site visits at all fourteen LHINs and engaged with staff, leadership, and board chairs, as well interviewing MOHLTC senior staff, and health service providers contracted by LHINs – 250 people contributed to the findings within the report. Ultimately the review found that the transition and devolution of authority to the LHINs has been broadly successful but found issues in relationships and trust, clear communications, and effective processes and structures. 31 KMPG (2008, 30 September), MOHLTC-­LHIN effectiveness review final report, Ministry of Health and Long-­term Care, 28. 32 Meloche (2017). 33 J. Guss, former CEO of the Ontario Medical Association (2017, 6 July), interview. 34 Ibid. 35 Standing Committee on Social Policy (2006, 30 January). 36 Ibid. 37 Ibid. 38 Ibid. 39 See Health Authorities Ministerial Regulations made under section 79 of the Health Authorities Act SNS 2014, c. 32. https://novascotia.ca/just /regulations/regs/hamin.htm. 40 Standing Committee on Social Policy (2006, 14 February), Official Report of Debates (Hansard), Legislative Assembly of Ontario. 41 Standing Committee on Social Policy (2006, 30 January). 42 Standing Committee on Social Policy (2006, 7 February), Official Report of Debates (Hansard), Legislative Assembly of Ontario. 43 Ibid. 44 Standing Committee on Social Policy (2006, January). 45 Standing Committee on Social Policy (2013, 2 December). 46 Standing Committee on Social Policy (2006, 14 February). 47 Standing Committee on Social Policy (2013, 2 December).

192  Notes to pages 74–81 4 8 Toronto Central Memorandum of Understanding (MOU), 2017. 49 See Editorial (2010, 23 August). 50 MOHLTC LHIN Renewal Branch Team (2017, 6 November), interview. 51 Meloche (2017). 52 Auditor General of Ontario (2015), Annual report, 312 (1.3.2). 53 Ibid. 54 Standing Committee on Social Policy (2013, 18 November), Official Report of Debates (Hansard), Legislative Assembly of Ontario. 55 Auditor General of Ontario (2015), Annual report. 56 Ibid., 315 (3.0). 57 Ibid., 322 (4.1.2) 58 Auditor General of Ontario (2015), Annual report. 59 Standing Committee on Social Policy (2013, 18 November). 60 Auditor General of Ontario (2015), Annual report, 333 (4.2.5) 61 N. Shah, former COO of Mississauga Halton LHIN (2017, 5 December), interview. 62 Standing Committee on Social Policy (2014, 11 February), Official Report of Debates (Hansard), Legislative Assembly of Ontario. 63 Standing Committee on Social Policy (2006, 2 February), Official Report of Debates (Hansard), Legislative Assembly of Ontario. 64 Standing Committee on Social Policy (2006, 31 January). 65 Standing Committee on Social Policy (2006, 30 January). 66 See Marin (2010b). 67 Standing Committee on Social Policy (2006, 30 January). 68 See CBC News (2017, 23 October), Ontario reopens 2 shuttered Toronto hospital sites to cope with overcrowding crisis, www.cbc.ca/news/canada /toronto/hospital-­beds-­crisis-­flu-­season-­1.4367079. 69 MOHLTC LHIN Renewal Branch Team (2017). 70 Shah (2017). 71 LHIN official, anonymous (2017, 2 December), interview. 72 Standing Committee on Social Policy (2013, 18 November). 73 MOHLTC LHIN Renewal Branch Team (2017). 74 Ibid. 75 Ibid. 76 T. Romain, senior director, Toronto Central LHIN (2017, 22 May), interview. 77 Meloche (2017). 78 Ibid. 79 Romain (2017). 80 Standing Committee on Social Policy (2014, 4 February), Official Report of Debates (Hansard), Legislative Assembly of Ontario. 81 Ibid.

Notes to pages 81–95  193 82 Ibid. 83 Sutley (2017). 84 Ibid. 85 LHIN official, anonymous (2017). 86 KPMG (2008). 87 Standing Committee on Social Policy (2006, 31 January). 88 Ibid. 89 Shah (2017). 90 Standing Committee on Social Policy (2013, 18 November). 91 Ibid. 92 Ibid. 93 Shah (2017). 94 Auditor General of Ontario (2015), 317 (3.0). 95 Auditor General of Ontario (2015). 96 Romain (2017). 97 Ibid. 98 Ibid. 99 Ibid. 100 Standing Committee on Social Policy (2006, 15 February), Official Report of Debates (Hansard), Legislative Assembly of Ontario. 101 Standing Committee on Social Policy (2013, 18 November). 102 Standing Committee on the Legislative Assembly (2016, 16 November), Official Report of Debates (Hansard), Legislative Assembly of Ontario. 103 P. Cresswell, citizen participant on TC LHIN Citizens Panel (2018, 8 January), interview. 104 Standing Committee on Social Policy (2014, 11 February). 5. LHINs as Mandated Decision-Making Sites 1 Official Report of Debates (Hansard), Legislative Assembly of Ontario (2016, 24 October), https://www.ola.org/en/legislative-­business/ house-­documents/parliament-­41/session-­2/2016-­10-­24/hansard. 2 Standing Committee on Social Policy (2014, 27 January), Official Report of Debates (Hansard), Legislative Assembly of Ontario. 3 Standing Committee on Social Policy (2014, 10 February). 4 Standing Committee on Social Policy (2006, 7 February). 5 Standing Committee on Social Policy (2006, 2 February). 6 Standing Committee on Social Policy (2006, 31 January), Official Report of Debates (Hansard), Legislative Assembly of Ontario. 7 Sutley (2017). 8 Standing Committee on Social Policy (2006, 31 January). 9 Shah (2017).

194  Notes to pages 95–101 1 0 Standing Committee on Social Policy (2006, 7 February). 11 Standing Committee on Social Policy (2006, 31 January). 12 Standing Committee on Social Policy (2014, 29 January), Official Report of Debates (Hansard), Legislative Assembly of Ontario. 13 Barker (2014), 12. 14 Standing Committee on Social Policy (2006, 6 February), Official Report of Debates (Hansard), Legislative Assembly of Ontario. 15 Standing Committee on Social Policy (2006, 1 February). 16 Ibid. 17 Standing Committee on Social Policy (2006, 2 February). 18 Standing Committee on the Legislative Assembly (2016, 14 November). 19 LHSIA (2006), s. 16 (4). 20 Standing Committee on Social Policy (2006, 6 February). 21 Standing Committee on Social Policy (2006, 1 February). 22 Standing Committee on Social Policy (2006, 31 January). 23 D.J. Philippon & J. Braithwaite (2008), Health system organization and governance in Canada and Australia: A comparison of historical developments, recent policy changes and future implications, Healthcare Policy, 4, e168–e186. 24 Standing Committee on Social Policy (2006, 1 February). 25 Ibid. 26 Standing Committee on Social Policy (2006, 31 January). 27 Phillipon & Braithwaite (2008). 28 Standing Committee on Social Policy (2006, 31 January). 29 Ontario Regulation 417/06: Committees of the Board of Directors of a Local Health Integration Network. Local Health System Integration Act (2006). 30 North West LHIN (2005–6), Annual report. 31 Mississauga Halton LHIN (2005–6), Annual report. 32 Standing Committee on Social Policy (2006, 1 February). 33 Standing Committee on Social Policy (2006, 31 January). 34 Shah (2017). 35 Standing Committee on Social Policy (2013, 25 November), Official Report of Debates (Hansard), Legislative Assembly of Ontario. 36 KPMG (2009), LHIN good governance guide, 10. 37 Ibid., 18. 38 LHIN official who requested anonymity (2017, 1 December). 39 See S. Buist (2011, 22 June), The $68 million question, Hamilton Spectator, www.thespec.com/news-­story/2166695-­the-­68-­million-­question/. 40 South West LHIN (2016–17), Annual report. 41 Standing Committee on Social Policy (2006, 6 February). 42 Standing Committee on Social Policy (2014, 29 January).

Notes to pages 101–6  195 4 3 Standing Committee on the Legislative Assembly (2016, 16 November). 44 Standing Committee on Social Policy (2014, 27 January). 45 See M. Bergsma (2014, 22 January), Health agency to post its info online now, St Catharines Standard, https://web.archive.org/web/2017122400 1547/www.stcatharinesstandard.ca/2014/01/22/health-­agency-­to-­post -­its-­info-­online-­now. 46 Standing Committee on Social Policy (2014, 27 January). 47 See Bergsma (2014, 22 January). 48 Standing Committee on Social Policy (2014, 27 January). 49 See Bergsma (2014, 22 January). 50 Standing Committee on Social Policy (2014, 27 January). 51 Standing Committee on Social Policy (2014, 29 January). 52 Ibid. 53 Standing Committee on Social Policy (2013, 2 December); Standing Committee on Social Policy (2014, 29 January). 54 Standing Committee on Social Policy (2014, 30 January), Official Report of Debates (Hansard), Legislative Assembly of Ontario. 55 Standing Committee on Social Policy (2014, 27 January). 56 A. Marin (2010b, 10 August), The LHIN Spin: Investigation into the Hamilton Niagara Haldimand Brant Local Health Integration Network’s use of community engagement in its decision-­making process, Office of Ontario’s Ombudsman. 57 Standing Committee on Social Policy (2013, 2 December). 58 Standing Committee on Social Policy (2014, 10 February). 59 Standing Committee on Social Policy (2014, 29 January). 60 Ibid.; Marin (2010b). 61 Ibid. 62 Ibid. 63 Ibid. 64 Ibid. 65 Standing Committee on Social Policy (2014, 29 January). 66 See Ottawa East EMC News (2010, 2 September), Opposition blasts province on “illegal” LHIN meetings. 67 See T. Boyle (2013, 13 May), Scarborough Hospital accused of being secretive about service cuts, Toronto Star. 68 Ibid. 69 Standing Committee on Social Policy (2014, 29 January). 70 Marin (2010b). 71 Standing Committee on Social Policy (2014, 29 January). 72 Shah (2017). 73 Standing Committee on Social Policy (2014, 29 January).

196  Notes to pages 106–17 74 Mississauga Halton LHIN (2016), Get LHIN fit: Board boot camp, 39, www.mississaugahaltonlhin.on.ca/~/media/sites/mh/Primary%20 Navigation/BoardandGovernance/GovernancetoGovernance/June 2016/20160627G2GFinal.pdf?la=en. 75 Romain (2017). 76 Ibid. 77 Auditor General of Ontario (2015), Annual report, 315 (3.0) 78 See A. Radwanski (2010, 25 February), Talented CEO’s move is another nail in the coffin of health networks, Globe and Mail, www.theglobeandmail .com/news/politics/talented-­ceos-­move-­is-­another-­nail-­in-­the-­coffin-­of -­health-­networks/article4312139/. 79 Auditor General of Ontario (2015), Annual report, 322, 2–15. 80 Standing Committee on Social Policy (2013, 2 December). 81 Standing Committee on Social Policy (2014, 28 January), Official Report of Debates (Hansard), Legislative Assembly of Ontario. 82 R.M. Walker (2006). Innovation type and diffusion: An empirical analysis of local government, Public administration, 84(2), 311–335. 83 Standing Committee on Social Policy (2014, 3 March), Official Report of Debates (Hansard), Legislative Assembly of Ontario. 84 Ibid. 85 Ibid. 86 Ibid. 87 Ibid. 88 Mississauga Halton LHIN (2012–13), Annual report, 26. 89 MOHLTC LHIN Renewal Branch Team (2017). 90 Ibid. 91 Standing Committee on Social Policy (2013, 18 November). 92 Toronto Central LHIN (2017), Business plan, 55, http://torontocentrallhin .on.ca/~/media/sites/tc/TC%20LHIN%20Docs/Accountability/Annual %20Business%20Plan/ABP%2017-­18.pdf?la=en. 93 Ibid., 55–57. 6. LHIN Advisory Committees and Public Engagement 1 J. Grant, N.A. Sears, & K. Born (2008, December), Public engagement and the changing face of health system planning, Healthcare Management Forum, 21(4), 22–26. 2 B. Checkoway & M. Doyle (1980), Community organizing lessons for health care consumers, Journal of Health Politics, Policy and Law, 5(2), 213–226; C.J. Tuohy & R.G. Evans (1984), Pushing on a string: The decentralisation of health planning in Ontario, in R.T. Gotembiewski & A. Wildavsky (Eds), The costs of federalism (pp. 89–116), New Brunswick, NJ: Transaction Books.

Notes to pages 118–22  197 3 J. Abelson & J. Eyles (2002), Public participation and citizen governance in the Canadian health system. Ottawa: Commission on the Future of Health Care in Canada. 4 K. Rasmussen (2001), Regionalization and collaborative government: A new direction for health system governance, in D. Adams (Ed.), Federalism, democracy and health policy in Canada (pp. 61–106), Montreal and Kingston: McGill-­Queen’s University Press. 5 J. Raeburn & I. Rootman (1998), People-­centred health promotion, Toronto: John Wiley & Sons. 6 H. Dickinson (2002), How can the public be meaningfully involved in developing and maintaining an overall vision for the health care system consistent with its values and principles? Discussion paper prepared for the Commission on the Future of Health Care in Canada. 7 Ibid. 8 J. Abelson, P.G. Forest, J. Eyles, P. Smith, E. Martin, & F.P. Gauvin (2001), Deliberations about deliberative methods: Issues in the design and evaluation of public consultation processes. Centre for Health Economics and Policy Analysis (CHEPA) Working Paper Series, McMaster University, Hamilton. 9 Ibid. 10 R.A. Bruni, A. Laupacis, & D.K. Martin (2008), Public engagement in setting priorities in health care, Canadian Medical Association Journal, 179(1), 15–18. 11 Ibid. 12 KPMG (2009), 18. 13 J. Abelson, P.G. Forest, A. Casebeer, G. Mackean, B. Maloff, R. Musto, & M. Gold (2004), Towards more meaningful, informed and effective public consultation, Canadian Health Services Research Foundation, i. 14 Ibid., 208. 15 Moat et al. (2016), 10. 16 Ibid. 17 Bruni, Laupacis, & Martin (2008), 15. 18 Dickinson (2002), 20. 19 Change Foundation (2009), Engaging communities in health care change in Ontario: Mission impossible? 2–3, www.changefoundation.ca/site/wp -­content/uploads/2016/05/EngagementCommentary-­1.pdf. 20 LHSIA (2006), s. 16 (1). 21 Ibid., s. 16 (4). 22 Grant, Sears, & Born (2018), 22–26. 23 KMPG (2009), 15. 24 Change Foundation (2009). 25 Ibid.

198  Notes to pages 122–7 2 6 Ibid. 27 Ibid. 28 Ibid. 29 Ibid. 30 J. Church, D. Saunders, M. Wanke, R. Pong, C. Spooner, & M. Dorgan (2002), Citizen participation in health decision-­making: Past experience and future prospects, Journal of Public Health Policy, 23(1), 12–32. 31 F.P. Gauvin, J. Abelson, M. Giacomini, J. Eyles, & J.N. Lavis (2010), “It all depends”: Conceptualizing public involvement in the context of health technology assessment agencies, Social Science & Medicine, 70(10), 1518–1526. 32 L. Knaapen & P. Lehoux (2016), Three conceptual models of patient and public involvement in standard-­setting: From abstract principles to complex practice, Science as Culture, 25(2), 239–263. 33 Knaapen & Lehoux (2016), 259. 34 K. Li (2013), Public involvement use in health care decision-­making (Doctoral dissertation, McMaster University, Hamilton, ON). 35 Ibid. 36 K. Li et al. (2015), 14–21. 37 KMPG (2009). 38 Bruni, Laupacis, & Martin (2008), 15. 39 Abelson et al. (2004). 40 C. Mitton, N. Smith, S. Peacock, B. Evoy, & J. Abelson (2009), Public participation in health care priority setting: A scoping review, Health Policy, 91(3), 219–228. 41 J. Abelson, J. Eyles, C.B. McLeod, P. Collins, C. McMullan, & P.G. Forest (2003), Does deliberation make a difference? Results from a citizens panel study of health goals priority setting, Health Policy, 66(1), 95–106. 42 R.F. Rich (1997), Measuring knowledge utilization: Processes and outcomes, Knowledge, Technology & Policy, 10(3), 11–24. 43 Li (2013). 44 G. Walt (1994), Health policy: An introduction to process and power. Johannesburg, South Africa: Witwatersrand University Press. 45 Li (2013), 27. 46 Change Foundation (2006), 13. 47 A.M. Jabbar & J. Abelson (2011), Development of a framework for effective community engagement in Ontario, Canada, Health Policy, 101(1), 59–69. 48 Ibid. 49 Li (2013). 50 Landwehr (2015). 51 Ibid. 52 Standing Committee on Social Policy (2006, 30 January).

Notes to pages 127–37  199 5 3 Standing Committee on Social Policy (2006, 31 January). 54 Standing Committee on Social Policy (2006, 30 January). 55 Ibid. 56 Ibid. 57 Ibid. 58 Ibid. 59 Standing Committee on Social Policy (2006, 7 February). 60 Ibid. 61 Ibid. 62 Ibid. 63 Standing Committee on Social Policy (2006, 2 February). 64 Standing Committee on Social Policy (2006, 6 February). 65 Standing Committee on Social Policy (2006, 2 February). 66 Standing Committee on Social Policy (2006, 31 January). 67 Standing Committee on Social Policy (2006, 1 February). 68 Standing Committee on Social Policy (2006, 2 February). 69 Ibid. 70 Standing Committee on Social Policy (2006, 31 January). 71 Standing Committee on Social Policy (2014, 11 February). 72 Ibid. 73 Standing Committee on the Legislative Assembly (2016, 16 November). 74 MOHLTC LHIN Renewal Branch Team (2017). 75 Standing Committee on Social Policy (2006, 30 January). 76 Standing Committee on Social Policy (2006, 7 February). 77 Standing Committee on Social Policy (2006, 30 January). 78 Ibid. 79 Standing Committee on Social Policy (2006, 31 January). 80 Standing Committee on Social Policy (2006, 30 January). 81 Fernandes (2017). 82 Sutley (2017). 83 Ibid. 84 Fernandes (2017). 85 Ibid. 86 Standing Committee on Social Policy (2014, 29 January). 87 Standing Committee on Social Policy (2014, 4 February). 88 Standing Committee on Social Policy (2014, 30 January). 89 Standing Committee on Social Policy (2014, 4 February). 90 Standing Committee on Social Policy (2006, 1 February). 91 Ibid. 92 Standing Committee on Social Policy (2006, 30 January). 93 Standing Committee on Social Policy (2006, 1 February). 94 Standing Committee on Social Policy (2014, 29 January).

200  Notes to pages 137–44 95 Ibid. 96 Ibid. 97 Romain (2017). 98 Standing Committee on Social Policy (2013, 2 December). 99 Ibid. 100 Dickinson (2002). 101 Central LHIN (2015–16), Community engagement plan, www.centrallhin .on.ca/~/media/sites/central/Primary%20Navigation/Community%20 Engagement/Central%20LHIN%202015-­2016%20Community%20 Engagement%20Plan_ENG.pdf?la=en. 102 Cresswell (2018). 103 A. Muralidhar, citizen participant on TC LHIN Citizens Panel (2018, 4 January), interview. 104 A. Maybee, citizen participant on TC LHIN Citizens Panel (2018, 5 January), interview. 105 A. Zsager, citizen participant on TC LHIN Citizens Panel (2018, 6 January), interview. 106 B. Fallon, citizen participant on TC LHIN Citizens Panel (2018, 6 January), interview. 107 A. Muralidhar, citizen participant on TC LHIN Citizens Panel (2018, 4 January), interview. 108 Maybee (2018). 109 S. Dalziel, citizen participant on TC LHIN Citizens Panel (2018, 6 January), interview. 110 Cresswell (2018). 111 Ibid. 112 Ibid. 113 Fallon (2018). 114 Ibid. 115 Cresswell (2018). 116 Sutley (2017). 117 Dalziel (2018). 118 Fallon (2018). 119 Sutley (2017, 2 December). 120 LHIN official, anonymous (2017, 1 December), interview. 121 Romain (2017). 122 LHIN official, anonymous (2017, 1 December), interview. 123 Romain (2017). 124 Standing Committee on Social Policy (2014, 3 March). 125 Ibid. 126 Fernandes (2017). 127 Warren (2007), 278.

Notes to pages 144–64  201 128 See Niagara This Week (2008, 2 October), Mayor urging all residents to attend Fort Erie rally, www.niagarathisweek.com/news-­story/3284491 -­mayor-­urging-­all-­residents-­to-­attend-­fort-­erie-­rally/. 129 See Niagara This Week (2009, 5 March), Saved Petrolia ER sparks some optimism locally, www.niagarathisweek.com/news-­story/3278499 -­saved-­petrolia-­er-­sparks-­some-­optimism-­locally/. 130 See Canada Newswire (2011, 8 March), Media advisory – walk the talk on mental health: London rally March 9. 131 See Windsor Star (2015, 18 September), Leamington celebrates saving obstetrics unit: “There are no lights going off here, no way!” http:// windsorstar.com/uncategorized/health-­care/leamington-­celebrates -­saving-­ob-­there-­are-­no-­lights-­going-­off-­here-­no-­way. 132 See M. Campbell (2006, 2 March), Even reporters can’t get excited about LHINs, Globe and Mail, www.theglobeandmail.com/news/national /even-­reporters-­cant-­get-­excited-­about-­lhins/article728065/. 133 See Randy Hillier (2013, 31 January), Hillier defends hospital bed closures at testy protest., www.randyhilliermpp.com/emcperth01302013. 134 See J. Dunning (2014, 2 September), Penetanguishene hospital closure off limits at health-­care meeting, Midland-­Penetanguishene Mirror, www .simcoe.com/news-­story/4819310-­penetanguishene-­hospital-­closure -­off-­limits-­at-­health-­care-­meeting/. 7. A Democratic Arenas Analysis of LHINs

1 J. Guss, former CEO Ontario Medical Association (2017, 6 July), interview. 2 Parkinson (2006).  3 Standing Committee on Social Policy (2014, 27 January). 4 Ibid. 5 KPMG (2008). 6 See Ministry of Health, Ministry of Long-­term Care (2018, 11 April), Minister’s Patient and Advisory Council, www.health.gov.on.ca/en /public/programs/pfac/default.aspx/. 7 Ibid. 8 Toronto Central LHIN MoU (2017), 32. 9 A. Tupper & B. Doern (Eds) (1981), Public corporations and public policy in Canada, Montreal: Institute for Research on Public Policy. 10 Standing Committee on Social Policy (2013, 9 December), Official Report of Debates (Hansard), Legislative Assembly of Ontario. 11 Maybe (2018). 12 Standing Committee on Social Policy (2014, 29 January). 13 Romain (2017). 14 Standing Committee on Social Policy (2013, 2 December).

202  Notes to pages 167–76 1 5 Goodin (2007). 16 Castro (2017). 17 Standing Committee on Social Policy (2013, 25 November). 18 Standing Committee on Social Policy (2013, 2 December). 19 Maybee (2018). 20 Johnson (2015). 21 See R. Denley (2019, 14 February), Ontario should learn from Alberta’s example and ditch plans for a health care “super agency,” National Post https://nationalpost.com/opinion/randall-­denley-­ontario-­should-­learn -­from-­albertas-­example-­and-­ditch-­plans-­for-­a-­health-­care-­super-­agency. 22 See D. Cook (2019, 20 February), Jason Kenney calls for Alberta Health Services review, says UCP will not make cuts to health care, Edmonton Journal, https://edmontonjournal.com/news/local-­news/ jason-­kenney-­calls-­for-­alberta-­health-­services-­review. 23 Abelson et al. (2010).

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Index

Page references in bold indicate a table; page references in italics indicate a figure. Abelson, Julia, 117, 119, 120, 121, 125, 126 accountability: bureaucratic, 25; democracy and, 3–4, 11, 41, 92, 148, 158; as dimensions of governance, 167; discursive, 26; evaluation of, 176–7; legal, 26; mechanisms of, 25–6; of non-governmental actors, 26; political, 3, 25–6; professional, 26; in the public sector, 10–11, 25. See also Local Health Integration Networks (LHINs): accountability of actor circulation: definition of, 32, 33, 161–2; in democratic subsystem, 152, 161–2, 171; in the LHIN context, 153, 154, 162, 163, 171 advisory committees: activities of, 53, 133, 135, 136–7, 160–1; health professionals in, 133, 137–8; influence of, 136, 137; mandated, 131; opinion of stakeholders about, 146; overview, 134–5; publicity of, 133; responsibilities of, 141–2 Alberta’s health care governance, 46, 174

alternate level of care (ALC) patients, 80, 108 Annis, Rob, 137 arenas of policymaking: codevelopment mechanisms of, 32; definition of, 29; functions of, 29, 35; levels of, 33, 34. See also democratic arenas framework (DAF) Arnott, Ted, 82 Barker, Paul, 7, 8, 54 Bell, Bob, 59 Bherer, Laurence, 27 Böker, Marit, 32 Boychuk, Terry, 45 Bradford, Neil, 22 Breux, Sandra, 27 Britto, Maria, 142 Brown, Adalsteinn, 66 Brown, Catherine, 111 Brown, Patrick, 5 Bruni, Rebecca, 119, 120 Canadian Centre for Analysis of Regionalization and Health, 118 Cansfield, Donna, 52, 65, 83

212 Index Carruthers, Chris, 137 Castonguay-Nepveu Commission, 45 Castro, Ed, 168 Central East LHIN, 53, 101, 104, 124, 125, 133, 134, 140–1, 143 Central LHIN, 53, 101, 109, 111, 134, 138, 143 Central West LHIN, 53, 110, 134, 142, 143 Champlain LHIN, 53, 102, 103, 104, 134, 142, 143 Charron, Louise, 105 circulation of actors. See actor circulation Citizens Health and Advisory Panel, 138 citizens panels: assessment of, 140; creation of, 138–9; decisionmaking capacity, 138–9, 167; deliberative capacity, 170–1; growth of, 161, 164; meetings of, 140; members of, 138, 139–40; responsibilities of, 140–1; weakness of, 140, 147, 170 collective decision-making capacity, 30, 36, 37, 87, 165, 166, 166–7 collective will formation, 29, 30, 35, 87, 165–6, 166, 175 Community Care Access Centres (CCACs), 57–8, 84, 92, 110, 112, 132 community engagement, 122–3. See also public engagement in health care consequentiality of collective decision-making capacity, 36, 37, 111, 165, 166, 166, 167 Cranney, Heather, 136 Cresswell, Peter, 139, 140 Curato, Nicole, 32 Czukar, Gail, 86

Dale, Anthony, 67 Dalziel, Sandra, 140, 141 decision-making bodies: general levels of, 152. See also mandated decision-making bodies; procedural decision-making bodies deliberation/deliberative system, 17, 27–8, 31, 38, 125, 150. See also metadeliberation democracy: accountability and, 3–4, 11, 41, 92, 148, 158; core problems of, 29; decision-making in, 125; deliberative, 14, 27, 31, 32; functionalist view of, 29; impact on governance, 39, 148, 150, 164 democratic arenas framework (DAF): co-development mechanisms, 32, 33, 77; definition of, 20–1, 29; dimensions of, 35–6, 37; evaluative capacity of, 150, 176–7; focus on citizens and public space, 116, 146; focus on mandated decision-making bodies, 91; focus on procedural decision-making sites, 63, 87–8; functions of, 35–6, 37, 87, 149; overview of, 33–5, 34; principal concepts of, 150, 152; relationships between the layers of, 152, 153, 154; steering mechanisms of, 21, 33, 34; transparency and publicity dimension, 36, 37, 38–9, 100 democratic metadeliberation, 24 democratic systems approach, 28–9, 35, 113, 147, 168 Denley, Randell, 174 Department of Health (Ontario), 41 Department of Hospitals (Ontario), 42 designed coupling, 32. See also venue coupling

Index 213 Dickinson, Harley, 118, 120 distributed democracy, 178 District Health Councils (DHCs): calls for reform, 49; creation of, 7, 46, 47; development of, 60; dismantling of, 66; evaluation of, 48; functions of, 7, 15, 49; interest group support for, 47–8; mandate of, 47; planning and operations of, 48–9; regulations of, 46; review of, 47, 48; tensions within, 48–9 Dixon, Maureen, 47, 48, 49 Douglas, Tommy, 42, 43 Dubnik, Melvin J., 25 elected officials: as policy actors, 158–9, 160 Elliott, Christine, 69 Elliot, Ron, 68 emergency wards closure, 78–9, 144 empowered inclusion, 35, 87, 165, 166, 168, 175–6 enclave deliberation, 31, 38 engagement process: deliberative vs. non-deliberative, 125 Erie St Clair LHIN, 102, 103, 144, 145 Evans, Joanne, 73 Eyles, John, 117 Fallon, Barbara, 139, 140, 141 Ford, Doug: health care policy, 5–6, 9, 59–60; model of governance, 10; social media engagement, 143 Foster, Leonore, 78 Frederickson, H. George, 25 Fuji-Johnson, Genevieve, 23, 171 Gagnon, Ron, 81 Gauvin, Francois-Pierre, 123 Gibson, David, 98 Gonsalves, Aubrey, 95

Goodin, Robert, 26 governance: accountability dimension of, 167; analytical framework for evaluation of, 11–12, 39, 149, 150; characteristics of, 3; democratic functions of, 35–6, 37, 38, 168; post-democratic, 23 governance-driven democratization, 14, 16–17, 21–2, 23, 150, 177 governance subsystems: democratic functions in, 11, 25, 39, 149, 155, 158, 164–5 governance-to-governance (G2G) bodies, 105–7, 163 Gracey, Don, 71 Grant, John, 115, 122 Gunning, Gord, 132 Guss, Jonathan, 148 Habermas, Jürgen, 31 Hall, Barbara, 66 Hall, Emmett, 43 Hall Commission, 43, 44, 46 Hamilton Niagara Haldimand Brant LHIN: controversial decisions, 79, 103–4, 144; criticism of, 104; lack of public engagement and transparency, 102, 114; secret board meetings, 78–9, 101, 103, 104 Havlek, Helena, 72 health care: community-based, 44; in comparative perspective, 6, 45; delivery system, 18, 42, 127; financing, 43–4, 119; future of, 6; idea of universal, 42–3 health care governance: accountability framework, 10, 26; centralization vs. regionalization debate, 177; changes in, 115; citizens engagement, 18–19, 123; complexity of, 152; decentralization

214 Index of, 67; decision arenas, 148; democratization of, 10, 177–8; evolution of, 40; policy planning, 4, 44, 119; provincial differences, 43–4, 67; reforms of, 64–6, 156–7, 173–4, 175, 176; regionalization of, 4–5, 10, 15, 18, 41, 44–6, 67, 118, 127 Health Professionals Advisory Committee (HPAC), 136–7 health service providers, 105–6 Health Shared Services Ontario (HSSO), 112, 163 Hems, Lisa, 129 Hendriks, Carolyn, 32 Hillis, Sue, 136 Home First philosophy, 108, 109 Horwath, Andrea, 5 Hospital Insurance and Diagnostic Services Act (HIDSA), 42 hospitals: performance indicators, 56; protests against closure of, 144–5; reopening of, 79; restructuring of, 103 Hospitals Act, 86 Hudak, Tim, 5 Huras, Paul, 73, 123, 137, 163 Independence Centre and Network, 136 information circulation, 162 Integrated Clinical Care Council, 138 Integrated Health Service Plans (IHSPs), 52, 55, 75, 142–3 Jabbar, Amina, 126 Jaczek, Helena, 83 Kaegi, Gerda, 93 Karpowitz, Christopher, 31 Kenney, Jason, 174 Kiwala, Sophie, 92, 138 Klynveld Peat Marwick Goerdeler consulting firm (KPMG): “Good

Governance Guide,” 122; MOHLTC-LHIN Effectiveness Review, 81–2; reports of, 70, 76, 119, 157 Knappen, Loes, 124 Kormos, Peter, 5 Land, Peggy, 129 Landwehr, Claudia, 24, 30, 127, 128 Lehoux, Pascale, 124 Levis, Bea, 101 LHIN Boards: activities of, 98–100; community-based recruitment, 72, 95–6, 97–8; composition of, 92–8; culture of secrecy, 101, 103–4; directors of, 93; effectiveness study, 99; government appointment to, 71–3, 94–6; interaction with the public, 160–1; as laboratories of democracy, 108, 111; leadership of, 163; meetings of, 13, 92, 100–1, 102, 103, 111, 163; members’ terms of service, 92–3; pay scale, 99; power of, 71; public scrutiny of, 101, 102; responsibilities of, 98–9; size of, 52, 93–4; tension between province and, 172 LHINC Council, 112 LHIN Collaborative (LHINC), 112, 166 LHIN Consistency Workshop, 111 LHIN governance framework: areas of strength of, 169–70; elected officials’ role in, 158–60; metagovernance-metadeliberation balance, 25, 67–8, 155–6, 157, 178; reform of, 173, 176; weaknesses of, 128, 156, 168–72 LHIN Shared Services Office (LSSO), 112 Li, Kathy, 124 Local Health Integration Networks (LHINs): accountability of, 9, 50,

Index 215 62, 78–9, 113, 167–8, 172, 174–5; auditor general oversight of, 55–6, 57, 76, 77, 84, 107–8; authorities and relationships in, 50, 51, 152–5, 153, 154; autonomy of, 69, 71, 85; bureaucracy of, 68, 80; community engagement mechanisms, 7, 53–4, 115, 117, 121–6, 141, 156, 163–4, 169; complexity of, 17, 168–9; creation of, 4, 8, 12, 50, 64–5, 115, 127–8, 129; as Crown agencies, 8, 73, 92; decision-making venues, 20, 62, 68, 87–8, 89, 112–13; democratic arenas analysis of, 6, 7, 50, 57, 148–78; documentation of, 13–14; effectiveness review, 70, 76; geographic distribution of, 52, 53, 65, 155; goals of, 4, 50, 82; health service providers and, 75, 105–7; innovative services, 92, 109, 110; legislative foundations for, 15, 64–5, 67–8, 131–3; legislative oversight of, 82–3, 135; mandate of, 16, 52, 85; metagovernance of, 15, 62, 66–7, 68, 74; micromanagement of, 79–80, 81, 172; Patients First Act and, 57–8; performance targets and evaluation, 56, 76–8, 80, 107–8; pilot initiatives, 108; powers of, 9, 15, 58, 62, 113, 157, 167; public scrutiny of, 5–6, 16, 55, 58–9, 67, 68, 129–30, 168; reforms of, 9, 55–60; regulations of, 58; relationships between, 92, 111–12; reporting regulations, 75, 76; reputation of, 167, 168; resident councils, 141; responsibilities of, 8, 50, 52, 55; social media presence, 142–3, 143; strategic planning, 52, 69–71, 75, 113, 156–7; structural problem of, 56; studies of, 4, 10, 11, 13–14, 16; transparency and publicity of,

100–5, 114, 169–70; weaknesses of, 114; websites of, 100 Local Health System Integration Act (LHSIA), 13, 15, 24, 50, 62, 70, 121–2, 130 MacLeod, Peter, 123 mandated decision-making bodies: characteristics of, 30, 90; definition of, 30; in democratic arenas framework, 91, 151; democratic functions of, 31; evaluation of, 31; governance within LHINs as, 90, 112–13; vs. procedural decisionmaking bodies, 90, 115, 117, 159; relationship between public space and, 151, 160; strengths and weaknesses of, 165–6, 166, 168 Mansbridge, Jane, 7, 17, 27 Marchildon, Greg, 44, 45, 67 Martel, Shelley, 72, 73, 128, 132 Mathews, David, 25 Matthews, Deb, 6 Maund, Jacquie, 69 Maybee, Alies, 139, 140, 162, 170 McCrimmon, Ross, 132 McCulloch, Kathryn, 76 McGrath, Coletta, 156 McGuinty, Dalton, 64 McKenna, Jane, 77 McLeod, Bill, 108, 110 McMaster Health Forum, 120 Medical Care Act, 43 Mendonca, Ricardo, 33 metadeliberation: accountability and, 25; definition of, 65, 127; democratic, 24; in democratic arenas framework, 33, 34, 150, 151; failure of, 129–30; in governance subsystem, role of, 11, 39, 149, 155; in LHIN governance framework, 127–31, 157–8; political importance of, 156

216 Index metagovernance: concept of, 14, 17, 20–1, 127; definition of, 23; in democratic arenas framework, 33, 34, 150, 151; forms of, 24; in governance subsystem, role of, 11, 39, 149, 155; instruments of, 24 Ministry-LHIN Accountability Agreements (MLAAs), 50, 54–5, 73, 74–6 Ministry-LHIN relationships: absence of strategic plan, 69, 79; collaborative approach, 56–7; formal reporting, 75–6; interactions, 79–82; mandate letter mechanism, 85; memorandum of understanding, 50, 54, 74, 75; new development in, 84–6; operational directives, 86; performancetargeting regime, 77–8 Ministry of Health and Long-Term Care (MOHLTC): metagovernance authority of, 62, 66–7; Ontario Health and, 174; regulations of District Health Councils, 46–7; responsibilities of, 7, 8, 46–7 Mississauga Halton LIHN: awards, 109, 110; Caregiver First Strategy, 109–10; Home First philosophy, 108; innovations, 109, 110; performance of, 108–9; Supports for Daily Living service, 109 Mitton, Craig, 125 Moffitt, Rick, 127, 129 MOHLTC-LHIN Effectiveness Review, 81–2 Morton, Robert, 98, 168 Muralidhar, Aditya, 139 Mustard Report, 46 New Democratic Party (NDP), 43 non-governmental actors, 26

North Simcoe Muskoka LHIN, 53, 97, 98, 101, 134, 145 North West LHIN, 53, 97, 104, 109, 122, 135, 136, 142 Nova Scotia’s Community Health Boards (CHBs), 72 O’Brien, John, 129 Ontario: ER wait times reduction, 69; health care governance, 5, 6–7, 46, 57, 60, 64–6; health service providers, 106; hospital services, 42; insured physician services, 43; public health care system, 15, 41–6; universal medicare debates, 42. See also District Health Councils (DHCs) Ontario Council of Health, 46 Ontario Council of Hospital Unions, 59 Ontario Health: accountability of, 174, 176; board of directors, 175; creation of, 5, 59; criticism of, 60; reform of, 173; relationship with Ministry of Health, 174 Ontario Health Coalition, 59 Ontario Health Insurance Plan (OHIP), 43 Ontario Health Teams, 59, 173, 174, 175 Ontario Hospital Association (OHA), 47, 64 Ontario Liberal Party (OLP), 64 Ontario Medical Association (OMA), 47 Ontario Medical Services Insurance Plan (OMSIP), 43 Ontario Nurses Association (ONA), 48 Orridge, Camille, 69 O’Sullivan, Kelly, 127, 128

Index 217 Paech, Gail, 66 Papadopoulos, Yannis, 23 Parkinson, John, 27 Patient and Family Advisory Councils (PFACs), 58, 60, 157, 175 Patient Flow Program in Halton Healthcare Services, 108 Patients Canada, 131 Patients First Act: criticism of, 57, 58, 85; goal of, 84, 86, 130; implementation of, 9, 55; public debates about, 130–2, 157; reform of LHINs under, 13, 57, 79, 93 People’s Health Care Act, 5, 9, 59, 60, 173 Prince Edward Island: health care governance, 46 procedural decision-making bodies: consequentiality, 166–7; definition of, 30; in democratic framework, 62, 63; vs. mandated decisionmaking bodies, 90, 115, 117, 159; vs. public space, 159–60; strengths and weaknesses of, 165–6, 166, 168 Progressive Conservative (PC) Party, 59–60, 64 public administration, 17, 21–2 public engagement broker, 163, 164, 171 public engagement in health care: alternative mechanisms, 141–5; benefits of, 118–19, 126, 146; challenges of, 119–20, 122–3; citizens’ experience in, 120, 170; cross-country comparison, 117–18; deliberative, 125; evaluation of, 126; history of, 117–18; LHIN approaches to, 7, 53–4, 115, 117, 121–6, 141, 156, 163–4, 169; LHSIA provision for, 121–2; nondeliberative, 125; opportunity

for improvement, 170–1; outputs of, 125–6; political debates on, 121–2; protests as form of, 143–5; regionalization of health care administration and, 118; scholarship on, 120; stages of, 123–5; technical expertise vs., 123–4; through social media, 142–3, 143; types of, 124, 147; weaknesses of, 147 public sector boards: vs. private sector boards, 98–9 public space: in democratic arenas framework, 33, 116, 146, 165–6, 166; vs. mandated decisionmaking bodies, 151, 160; primary function of, 31; vs. procedural decision-making bodies, 159–60 Quebec: health care governance, 4, 45–6, 97 Raphael, Chad, 31 regional health authorities (RHAs), 44, 45, 46, 97 Revera Thunder Bay nursing home closure, 104 Rich, Robert, 125 Robarts, John, 43 Ronson, John, 68 Rouse, Shawn, 95 Royal Commission on Health Services, 4 Saskatchewan: debates of universal health care, 42–3; health care governance, 44, 46, 97; Medical Care Insurance Act, 43 Sault, Harold, 129 Shah, Narenda, 83, 95, 105 Shea, Michael, 101

218 Index Smitherman, George: political career, 64, 66; promotion of LHINs, 4, 64, 66, 75, 127, 132, 133; vision of health care governance, 67–8 Sorenson, Eva, 22 South West LHIN, 53, 102, 103, 122, 135, 136, 137 St Michael’s Hospital citizens panel, 140 Supports for Daily Living service, 109 Sutherland, Ross, 68 Sutley, Stewart, 133 Telehomecare program, 110 Tetley, Adrianna, 161 Thompson, Dennis, 24 Torfing, Jacob, 22

Toronto Central LHIN, 9, 53, 110–11, 138, 139, 140, 167 Trudeau, Justin, 143 venue coupling, 31, 33, 152, 153–4, 161–3, 171 Victorian Order of Nurses, 136 Warren, Mark, 21, 22, 29, 144 Waterloo Wellington LHIN, 53, 94, 102, 135, 143 Wong, Florence, 95 Wynne, Kathleen: legislative initiatives, 9, 85; role in implementation of LHINs, 127–8, 129; view of LHIN governance model, 72, 73–4, 94, 97 Zsager, Alexander, 139

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