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But 11 years after the government promised new regional health agencies would trim waste and deliver better care, the opposite has happened too often, and how patients fare depends upon where they live.

Last year alone, Ontario’s Health Ministry funnelled $25 billion through the networks to hospitals, nursing homes and community agencies. But while the networks oversee more than half the health-care budget, the ministry does little to hold them to account, even when the care they oversee becomes worse.

The ministry instead monitors hospitals, tracking wait times and how often patients quickly return to the ER or a ward — and the verdict isn’t pretty. On most measures, performance has stagnated or worsened.

But those near the front lines are less confident — only one in five health service providers say the LHINs are on track.

The government promised LHINs would chip away inequity in access to health care but the opposite has occurred, Lysek found. In 2012, patients in the worst-performing region waited five times as long for semi-urgent cataract surgery as those in the best performing region. That gap has grown to 31-fold.

KEY FINDINGS Key findings In the auditor general’s report: Many LHINS didn’t establish quantifiable targets or performance measures. The performance gap among LHINs is increasing. Health Ministry takes little action to hold networks accountable. The networks don’t consistently monitor the quality of health services. Some networks don’t track patient complaints at all. Too little has been done to cut wasteful spending by providers who duplicate office work and fail to work together to lower costs of purchases.

Dr. Isabelle Leblanc, president of the pro-medicare group Médecins québécois pour le régime public, said the survey results show that radiologists in Quebec are increasingly choosing to work in the private sector to the detriment of the public system. "For us, this is the best example of how mixing the public and private systems can lead to decreased accessibility for most patients and increased accessibility for those who have the money to pay," Leblanc said. "Radiologists have no incentive to increase access in the public system, and in fact, they're draining resources from the public system." Leblanc explained that radiologists can earn more money charging patients for scans in private clinics than they would if they worked exclusively in hospital and billed the Régie de l'assurance maladie du Québec. Leblanc's group warned in a report three years ago that wait times for MRIs in hospital would increase.

"We're the province that has the highest number of MRI and CT scan machines per capita in the country - with a third of the machines in the private sector - and yet our public wait times are going up," Leblanc added. Health Minister Gaétan Barrette, a radiologist by profession who had worked in a private clinic before entering politics, was unavailable for comment. Officials with the Association des radiologistes du Québec could not be reached for comment, either. The Fraser Institute report observed little progress in cutting wait times for medically necessary surgery or treatments. The median wait time in Canada for treatment inched up to 18.3 weeks from 18.2 weeks last year. In Quebec, the median wait time for treatment by a specialist rose to 16.4 weeks from 7.3 weeks in 1993, when the Fraser Institute first started compiling such data. The median wait time denotes the midpoint for those waiting, as opposed to an average. In Quebec, the median wait time to see a medical specialist following referral from a general practitioner rose to 7.3 weeks from 7.1 weeks last year. The survey found that the longest median waits in Canada were for orthopedic surgery at 35.7 weeks, or almost nine months.

"These protracted wait times are not the result of insufficient spending but because of poor policy," Bacchus Barua, the author of the Fraser survey, said in a statement. "In fact, it's possible to reduce wait times without higher spending or abandoning universality. The key is to better understand the health policy experiences of other more successful universal healthcare systems around the developed world." aderfel@montrealgazette.com Twitter.com/Aaron_Derfel

The median wait time in hospital for a magnetic resonance imaging (MRI) scan in Quebec jumped to 12 weeks this year from eight in 2014, a survey has revealed. Wait times also increased slightly for other medical imaging. ALLEN McINNIS-MONTREAL GAZETTE FILES • MONTREAL GAZETTE / Source: Fraser Institute

"All provinces and cities will likely be saying, 'We think we can play a role here and we want to have a chance to do so.' " Manitoba Premier Greg Selinger added that his province would like to welcome up to 8 per cent of the Syrian asylum seekers - about twice Manitoba's proportion of the overall Canadian population. "We know that Manitobans want to do their part in welcoming these innocent victims of war [and helping them] find a better life," he said.

In a conference call with reporters, Immigration Minister John McCallum said he's aware that officials in places from Victoria to Halifax are working to rejuvenate their population. "We would like to see these refugees spread fairly evenly across the country. We do not want to concentrate them all in three or four big cities," he said, adding that Ottawa does not "control exactly where they will go." Mr. McCallum said the government will be leasing planes from Royal Jordanian Airways to fly many of the refugees to Canada, stating the first trip could occur as early as next week.

"We want to have a certain number built up before we begin the process," Mr. McCallum said, adding the government will soon be able to process 500 cases a day at a centre in Jordan. Still, there have been concerns about whether small-town Canada can handle government-sponsored Syrian refugees, who will be the most vulnerable and traumatized newcomers. Governments are preparing an assessment checklist that can help them determine whether smaller towns have the necessary minimum services such as health, mental-health and education workers.

Chris Friesen, of the Immigrant Services Society of B.C., said that "if those key elements are not in the community," resettlement groups and governments will have to consider whether these support services can be added over time. The alternative is sending these refugees to the 36 longstanding refugee-resettlement centres across Canada. Resettlement groups say they are still waiting to be given the names of the private sponsors who will welcome 10,000 refugees in coming months, to assist them in successfully integrating the newcomers into Canadian society. "A number of these private sponsors will be doing this for the first time and it's critically important for them to have support around them ...," Mr. Friesen said.

He added that Syrians will have a challenge adapting to welfarerate housing. "You're coming from a middle-class family with a nice house in Damascus. Managing expectations may at times be challenging," Mr. Friesen said. Another issue is seeing how many refugees Ottawa plans on bringing to Canada in 2016, not only from Syria but other countries, as well. The "immigration levels" are normally released every fall, and refugee groups say they need to see overall projections to accurately plan for all the newcomers.

"The government has been consistent in promising [Syrian refugees] will be over and above pre-existing refugee targets for other regions," Mr. Friesen said.

Two reports this fall from Ontario Auditor-General Bonnie Lysyk found as little as 61 cents out of every dollar spent by the agencies went to face-to-face client services, and few improvements had been made to correct problems identified years before. Health Minister Eric Hoskins, in a statement Wednesday, said the government "wants to reduce bureaucracy and administration in home and community care."

Even so, the policy paper introduces the idea of a smaller, local organization to co-ordinate the delivery of home care and primary care - something those familiar with the plans have been calling a "sub-LHIN." Several sources stressed that unlike the discredited CCAC model, these organizations would not mean the creation of another layer of bureaucracy. The job could be given to existing organizations such as community health centres, some speculated, and will allow for better planning. There will be no change in the relationship between the government and doctors, who will not report to the new organizations, one source said. "Our goal is to make it easier for patients to find a primary health-care provider when they need one, see that person quickly when they are sick, and find the care they need, closer to home," the Health Minister said in a statement.

There has been widespread speculation about how far the reforms would go and how the province can restructure primary care at a time when it is waging an increasingly bitter battle with doctors, who have been without a fee agreement for more than a year. After the government imposed two across-the-board fee cuts this year, the Ontario Medical Association, which represents the province's doctors, began a public campaign criticizing the measures that it argues are hurting patient care. Senior government officials stressed that the plans mapped out in the paper would be the basis of consultations in the new year, and that no changes would be "imposed" on doctors. An OMA spokeswoman said the organization would not comment until it saw the paper.

The reality is that, when a loved one is in hospital, you cannot schedule your meals at normal hours. You need access to nutritious food, not to mention to the relief from the stress of sitting by the bedside of a loved one who is ill, whenever it is convenient, for example when your ill loved one is being looked after by the medical staff or when they drift off to sleep. It is therefore an important public service to provide the members of the public who have to make use of the hospital with access to good, nutritious food beyond the normal hours when the rest of us have breakfast, lunch, and dinner. These cafeterias are not really "commercial operations" but part of the public service of a hospital; as CUPE local President Norma Robinson pointed out, nutritious food is a necessary part of a patient's recovery. It is also a necessary part of a patient's family members' continuing health.

Alternatively, maybe the smart thing for Horizon Health to do is to accept that food service is part of the public service that our hospitals provide and therefore get on with providing food services to those who use our hospitals as a public service, not as "commercial operations." This means that the health network needs to accept that providing adequate food services, including by investing in new equipment and putting the cafeterias in better locations to increase visitorship, will cost the health network money. The harsh truth is that trying to balance Horizon Health's and the provincial government's books by reducing the hours of cafeterias that, in total, are losing $350,000 a year is the public finance equivalent of trying to get rich by looking for loose change behind your couch cushions.

If the government of New Brunswick wants to have the health care system contribute to reduced government expenditures and a balanced provincial budget, reducing the hours of hospital cafeterias is simply a side-show; it will have no meaningful effect on the provincial budget. If the provincial government wants to reduce expenditures on the health care system in a meaningful way, it and the health networks should engage in real health care reform.

As part of these reforms, they should either close or downgrade a number of hospitals to basic health care and triage centres and build the health-care system around a few full-service, high-quality regional hospitals. If the evidence of other provinces that had a plethora of small rural hospitals but rationalized their health care service delivery as part of a health care reform agenda is anything to go by, these reforms will also have valuable side-effect of providing New Brunswickers with better health care and making them healthier. As well as not saving any significant amount of public money, closing cafeterias in hospitals or substantially reducing their hours, on the other hand, will not do anything to make people healthier, either. If it cannot make a serious contribution to either public sector cost containment or health reform and will harm people in the process, why do it?

an Peach has worked in senior positions in federal, provincial, and territorial governments and at universities across Canada; he also served as vice-president, Policy for the New Brunswick NDP between 2012-15. His expertise is in constitutional law, federalism and intergovernmental relations, Aboriginal law and policy, and the policy-making process.

It all started with Opposition critic Trent Wotherspoon, who questioned the logic of government-employed snowplow operators plowing the Trans-Canada Highway having to lift their blades as they approach the 20-kilometre stretch of bypass from Balgonie to Regina.

This is what will happen once the bypass opens in 2018, because all maintenance matters (plowing, grass cutting, pothole and structural repairs, etc.) for 30 years will be the responsibility of the successful bidder - a Paris-based conglomerate. It will hire Saskatchewan crews to do the work. Highways Minister Nancy Heppner was especially indignant, scolding Wotherspoon for not asking enough questions at his technical briefing and thus again bringing information to the assembly "that is not always correct."

The problem, however, is Wotherspoon does appear to be correct. And the Highways Ministry explanation as to why this would be the case was something-lessthan gracious. "So what?" ministry spokesman Doug Wakabayashi told the Leader-Post's Emma Graney, adding he failed to see why this was even an issue because it wasn't like "nobody's plowing" the bypass.

Of course the bypass will get plowed. No one is being so disrespectful as to assume the minister or her departmental officials don't understand their rudimentary maintenance responsibilities ... even if the politicians and their officials seem to have little interest in exchanging the same courtesies.

The question is how much more this approach might cost Saskatchewan taxpayers. It seems it will be substantially more expensive than using government crews ... although no one seems to know how much more. Notwithstanding the government spin-session briefings, that's one of the many things about the P3 bypass project ministers are not telling us. The maintenance costs are a portion of an extra $680 million (essentially, the difference between the previous bypass construction estimate of $1.2 billion and the current $1.8-billion-plus price tag) that is called "risk transfer."

But how much of that extra $680 million taxpayers will shell out during the next 30 years for maintenance of the measly 20-kilometre stretch of highway remains an unknown. What we do know is that the snowplowing budget for the whole province is only $29 million a year. Under the rules of the P3 bidding process, such a detailed breakdown in the bypass contract can't be released for competitive reasons, said SaskBuilds president Rupen Pandya.

But why, then, is the global cost of "risk transfer" so high? Well, risk transfer in P3 contracts is what the government considers to be the cost of replacing or restoring something to brand-new condition. Some in the know don't much like the concept.

Ontario provincial auditor Bonnie Lysak (who used to be Saskatchewan's auditor) criticized the use of risk management in her assessment of Ontario P3s. She concluded risk transfer didn't apply to any accounting reality. After all, it's not likely a school or hospital will have to be replaced because it was swept away by a tornado. It's even less likely this will happen to a bypass.

But it is a good way for a government to hide cost overruns and thus prove its philosophical case that P3s are less expensive than the traditional method of private companies bidding and then building an infrastructure project without taking any long-term ownership of it. By the same token it would also be a very good way of government claiming that a P3 project came in under budget if there were no cost overruns, or only modest ones.

"Risk transfer" may not have ever been a real cost in the P3 process - something the government might not be eager to tell you in a technical briefing. Maybe one day we will get answers. But one guesses the Sask. Party government won't be offering them before the April election.

Researchers identified 8 cases of acute rheumatic fever among 25,000 patients in the region during a recent 18-month period ending in March 1, 2015. That marks an incidence rate of 21.3 per 100,000 or 75 times greater than the overall rate in Canada.

At the same time, nurses who call in sick aren't being replaced, so there are fewer people to deal with aggressive patients, said Linda Clayborne, a forensic psychiatric nurse in Hamilton.

'When you have a patient holding onto your clothes and punching you, 54 seconds is a long time.'

In the last two months, violent incidents in Hamilton included attacks on two nurses who sustained concussions, Clayborne said.

Clayborne witnessed an incident last week and pressed her personal alarm to call for immediate help.

In another incident, a female RPN had hot coffee thrown in her face by a patient. Last week, a male co-worker sustained a black eye and swelling to his cheek and eye, Clayborne said. Now his children fear for him.

In long-term care, the majority of patients are over the age of 85 with Alzheimer's, dementia and other cognitive impairments that require a higher standard of care, Fetterly said. "Cutting back on staff is recipe for disaster," Fetterly said, because when a nurse is slow to answer a call bell, she's the "recipient of displeasure." The Ontario groups are also calling for legislation to protect health-care workers from violence.