During the reign of the Liberals in Ontario (2003-18), the number of health-related civil servants soared to 13,000 from 6,000.

Coming up with that number requires a lot of sleuthing and some unpacking but ultimately tells us a lot about the morass in Canadian health care.

While the number of health “bureaucrats” rose sharply, paradoxically, the number of employees of the Ministry of Health and Long-Term Care actually fell, by almost half, to about 3,000.

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But almost all of that reduction was due to “divestment” of psychiatric hospitals. Owing to a quirk of history, staff of psychiatric hospitals were employed by the ministry; when oversight of the hospitals was transferred to other institutions, staff kept their jobs but had new employers.

So, the ministry staff doing administrative work stayed roughly the same while the budget swelled to $54-billion from $28-billion. The number of senior officials (deputy minister, associate or assistant deputy ministers and executive directors) stayed roughly the same.

What all these new bosses did, apparently, was spend a lot of time dreaming up new administrative structures.

During 15 years in power, the Liberals carried out 15 significant restructuring exercises, centralizing and decentralizing and creating new layers of regional administration such as LHINs (local health integration networks) and CCACs (community care access centres), before settling on the current bloated structure of 14 LHINs (each of which has a CEO and six vice-presidents) and 78 sub-LHINs. (The CCACs were rolled into the LHINs after a damning Auditor-General’s report showing they spent almost 40 per cent of home-care dollars on administration.)

The other trend that has received little attention is the penchant for creating arm’s-length provincial health agencies. There are now 94 of those, up from 67 back in 2003.

These agencies include well-known entities such as Cancer Care Ontario, ehealth Ontario and Ornge, and less-known ones such as the Autism Spectrum Disorders Clinical Expert Committee and Personal Support Services Ontario.

The government should probably not be directly involved in delivery of services but that doesn’t mean it should be creating para-public agencies willy-nilly. Nor can it have it both ways by routinely interfering in “independent” agencies.

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As Ontario premier-designate Doug Ford aims to put a mark on health care, one of the places he can start is by bringing some order to the administration of health care in the province.

But he has to be careful not to repeat the mistakes of his predecessors.

Complex systems such as health care don’t run themselves. Oversight and management is required.

The biggest sin of the previous Liberal government was micromanaging everything to death. No policy could be put in place without every assistant deputy minister putting her/his stamp on it, and without the approval of the minister’s and the premier’s office.

As much as anything, the new Conservative government needs to establish broad policies and priorities and then get out of the way – let health administrators administer, and hold them accountable.

There is a lot of rhetoric about “bloated bureaucracy” and calls to spend more money on “front-line care” rather than administration.

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Anecdotally, there is a sense the system is getting fat around the middle, with new layers of middle management creating lethargy and waste. But there is little concrete data.

We know how many health workers there are – 31,017 physicians and 151,026 regulated nurses in Ontario (up roughly 10,000 and 25,000 respectively since 2003) – but the Canadian Institute for Health Information does not have a mandate to collect similar data for administrators.

The figure cited at the outset – 13,000 health administrators on the public payroll in Ontario – was compiled independently by a consulting group, and it had to go through the annual reports of each health-related agency, one by one, and count how many people they employ.

Health spending is the single biggest public expense, gobbling up $54-billion a year, or 42 per cent of Ontario’s budget.

We know the big-ticket items – hospitals, $17-billion; physician payments, $12-billion; prescription drugs, $5-billion; long-term care, $4-billion; home care, $3-billion; and so on.

But while we know how much is paid to individual administrators, we don’t know how much is spent over all on salaries or administration, or even the precise number of employees on the public payroll – directly and indirectly.

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Dealing with that troubling lack of transparency needs to be the first step in getting a handle on the bloat.

Editor’s note: Between 2003-18, the number of employees of the Ontario Ministry of Health and Long-Term Care fell by half but the number of associate and assistant deputy ministers and executive directors remained roughly the same. Incorrect information appeared in an earlier version of this column.



