Editors note: This is a long letter and packed full of information. It appears to be well cited with links at the bottom. Informal fact checks we have undertaken confirm that this is far more than an opinion piece. It has been published in its entirety since editing it any way could dilute the message that the author is trying to convey.
To the residents of the area,
On the evening of January 21, 2016, in the crowded Community Hall of the North Simcoe Recreation Centre, the residents of Midland learned about the future of Georgian Bay General Hospital (GBGH). Chief Executive Officer of GBGH, Karen McGrath, and the members of the hospital’s Board of Directors held a public meeting to discuss the recent findings of the Operational Review of GBGH and to allow the public to ask questions about the content of the report. The two-hour meeting was filled with emotion as citizens learned that several of the services currently offered by the hospital will soon either exist in an altered form or cease to exists altogether. The topic of the cancelling of all obstetrical and gynaecological services was the most heated. Throughout the evening, many in the audience expressed their anger with the perceived mismanagement by the hospital administration and asked about possible courses of actions to reverse the recommendations of the report. With three more public meetings slated for Penetanguishene, Tay and Tiny this week, it is vital that the public have a better understanding what caused the hospital to end up in this situation and to have information required to ask the questions that really need to be answered.
Whenever changes occur within a publicly funded organization, cost-savings is often one of the major motivating factors. GBGH’s financial woes have been well documented throughout recent years. The hospital finds itself in millions of dollars in debt and several years of financial mismanagement has lead to crisis. The purpose of the report was to help make recommendations to ensure GBGH is sustainable for the future. Financial viability has become a problem for many small, rural hospitals in Ontario, due in large part to changes to the way that hospitals in Ontario are funded.
In 2012, the government of Ontario recognized that healthcare costs were skyrocketing. At that time, $0.42 of every tax dollar was spent on health care. As our population continues to age, by 2030, it was estimated that 70% of taxes would be spent on health care. Knowing that this would be untenable, the province released Ontario’s Action Plan for Health Care, a document outlining measures to help ensure the long-term viability of publicly funded healthcare in the province. Part of this document included changes to be made in how healthcare would be funded. No longer would Ontario hospitals receive global funds based on past funding requirements (with included inflationary increases). Funding would now shift from being provider-centered to being patient-centered. This would mean that hospital funding would be determined by patient outcomes.
The new funding formula is comprised of three parts. The first part is Global Funding, a lump sum of base funding equal to 30% of the budget. The second is Health Based Allocation Methodology (HBAM). This represents 40% of the budget for a hospital. It is intended to fairly distribute available provincial health care money to all Ontario hospitals based on health care needs and population growth in each community. The remaining 30% of the budget is funded through Quality-Based Procedures (QBP). The province has agreed to provide funds for certain services at a set price for a LHIN-determined required volume. Failing to complete the requisite volume at the pre-determined price will result in partial or complete loss of future funding for those procedures. Originally limited to treatment of chronic kidney disease, knee and hip replacement and cataracts, the province continues to add to list of procedures that fall under QBP funding.
HOW DOES ALL THIS RELATE TO GBGH BOTH NOW AND IN THE FUTURE?
There were some very key pieces of information that were left out or not fully explained during the first public meeting related to GBGH’s Operational Review. Many of the audience appeared to be under the impression that this was a public consultation about the recommendations. Several members felt that there were actions that could be taken to prevent some of the recommendations from being enacted, particularly with regards to those found in Recommendations 100-108 related to reductions or losses in clinical services. Within the report, it was made clear by the consultants that the recommendations were to be accepted or rejected as a package, not in an à la Carte manner. As well, some in the audience were unaware that the hospital’s Board of Directors has already accepted all 108 recommendations. The report contains a timeline for implementation of the recommendations, some of which are effective immediately. The Board and CEO were not there to seek public input on whether or not to accept them, but rather how to implement them. Had this been better understood, the emotions undoubtedly would have gone past the breaking point for some.
Given that the recommendations have already been decided upon, those that wish to engage in a response ought to be trying to determine three things: which parties ought to bear the burden of responsibility for the loss of services at GBGH, what types of questions should be asked at the three upcoming meetings to ensure accountability, and what actions must be taken by the members of the public to ensure that GBGH’s role does not further diminish.
THE BOARD AND CEO OF GBGH
Much of the anger of those in attendance caused by hearing the recommendations was directed toward the Board of Directors and CEO of GBGH. The report made it clear that there is a dearth of leadership at the hospital, as particularly noted in the report’s key findings. The consultants noted that the Board lacked a strategic plan and were not proactive in their governance role to position the hospital to meet the needs of the people it serves. It was also noted that the focus on quality was obscured by the administration’s focus on financial concerns. While this can be appreciated, given the fiscal crisis of the hospital, the two ought not to be considered mutually exclusive especially now in a funding model that is largely focussed on quality. A full understanding of the implications of patient-based funding should be of utmost importance for leaders of a hospital in today’s Ontario.
Despite this, there is a system that ought to be in place to help seek efficiencies, improve quality, and to brainstorm solutions to problems. The hospital, in an effort to reduce costs, has spent money on training for what is known as LEAN (The Lean Transformation Model). One of the principles of LEAN is to engage all workers and to allow them to have input on solutions to problems. The current culture of fear and reprisal at GBGH, noted by the operational review, is not conducive to allow for such principles to be effective. Staff morale is reported as being low. Management continues to try to solve problems without actively engaging its workers.
The administration does not actively seek alternative solutions as problems arise with any original solutions. For example, one of the reasons given at the presentation for the loss of the obstetrical and gynaecological program was that the hospital was unable to successfully recruit a replacement for the now retired Dr. O’Halloran. Dr. O’Halloran made public his intention to retire a year in advance. It was stated that during the year some recruitment attempts were made, however, none were successful. Instead of seeking alternative models to ensure that a viable, low-risk obstetrical program continued, the administration has elected to close the program altogether. It has been suggested by the consultants that in order to be sustainable, GBGH would need to have volumes high enough to attract at least three obstetrician/gynaecologists. At the public meeting, Dr. Greg Gaffney suggested a potentially feasible solution that included existing physicians and only one obstetrician/gynaecologist; it seemed to fall on deaf ears.
The report seems to illustrate that the Board of Directors and administration of the hospital have been unable to be proactive enough in today’s healthcare climate, to ensure economic viability for GBGH. Local business owner, Colin Pape, an audience member in attendance during the Midland meeting, asked the CEO Karen McGrath if she or anyone else representing hospital leadership felt that an apology was in order. This question drives at the heart of the issue: is this the leadership that the hospital needs moving forward? Are they best suited to navigate GBGH through the shifting landscape of healthcare reform in Ontario?
Questions to Ask the Board of Directors and CEO of Georgian Bay General Hospital:
- As the future of healthcare in Ontario shifts towards more specialization and centralization of services to ensure efficiencies throughout the LHIN, what will GBGH’s area of specialization be? (The report seems to connect the dots to a move towards mental health and perhaps rehabilitation)
- Why was it not made clear that the board has already accepted all 108 recommendations as a package and that these meetings are not looking for public feedback on them?
- Had the board elected to reject any or all of the recommendations, would there have been financial penalization from the LHIN?
- What alternative models for obstetrical care were considered prior to electing to close the service completely?
- What metrics are currently in place to ensure that GBGH receives its full share of patient-based funding? What metrics will be introduced to ensure that GBGH receives its full share of patient-based funding? Why were the yet-to-be-introduced measures not already in place for a hospital that is in dire straits financially?
- Of the job losses caused by the acceptance of these proposals, how many of them will be management positions?
- With senior physicians approaching retirement and some already threatening to leave due to implementation of the recommendations, what plans are in place to enhance physician recruitment efforts as it did not work for finding an obstetrician/gynaecologist. (It will most likely become only more difficult to recruit, as more doctors will want to establish their careers in an area that offers them opportunities to fully utilize their skill sets. Given that educational opportunities seem to be a vital tool in physician recruitment, a decrease in diverse learning environments may threaten the volume of medical residents coming to GBGH to train.)
- What plans are in place to enhance physician retention efforts as some have already publicly stated that they will likely be forced to move their practices to communities that offer them opportunities to fully utilize their skill sets?
North Simcoe Muskoka Local Health Integration Network (LHIN)
The NSM LHIN is responsible for planning, integrating and funding local health care in the area. They are accountable to Ministry of Health and Long-Term Care. There has been a tense relationship between the populations served by GBGH and the LHIN. The LHIN has been accused of underfunding GBGH in order to provide more funds to other hospitals under their jurisdiction. Much local vitriol was directed at the LHIN in April 2014, when a proposal made by the LHIN would have seen the loss of cataract surgery at GBGH. In May 2014, the announced closure of the Penetanguishene General Hospital due to funding shortfalls, funding which the LHIN ultimately controls, again raised the ire of the community.
Given the history of the strained relationship with the LHIN and the local community, a LHIN-funded Operational Review is bound to be met with scepticism. The seeming lack of transparency that surrounded the cataract debate is in question again with the release of the review.
The LHIN has failed to realize that the populations served GBGH are unique from those served by any other hospital in the LHIN. The Simcoe Muskoka District Health Unit’s report Community Picture (2011) lists Midland, Penetanguishene, and Tay Township as being three of the four communities in Simcoe County with the highest proportion of low-income families. Some local patients already have difficulty finding suitable transportation to GBGH for treatment. Forcing them to travel much further away is a burden that will turn many away from seeking the health care that they require, simply due to financial hardship. Additionally, the area’s First Nations and Francophone populations are best served by a fully-functioning hospital in close proximity to their homes and communities. The failure by the LHIN to recognize the community’s unique needs is shameful.
Questions to Ask the LHIN:
- In the LHIN-funded operational review, why were only costs overages assumed to be the sole cause of GBGH’s financial crisis? Why wasn’t the level of funding provided by the LHIN examined to ensure that it was both adequate and fair?
- What role does GBGH play in the LHIN’s long-term plans?
- With a provincial move in healthcare towards centralization and specialization, what are does the LHIN see GBGH specializing in?
- What monies will be made available to help offset personal expenses incurred by the loss of local services for those that cannot afford travel and lodging? Will there be travel grants?
- Who will be responsible for any deaths or complications due to a LHIN decision to centralize services?
The Ministry of Health and Long-Term Care
With healthcare costs continuing to escalate, it is understandable that the government would make efforts to reign in expenses to ensure a viable healthcare system both now and in the future. It appears that Ministry of Health and Long-Term Care is attempting maximize quality at the lowest price, which on the surface is admirable. Problems occur, however, through the implementation of plans to achieve this goal.
At the heart of the problems that several small, rural hospitals face in Ontario is the Ministry of Health and Long-Term Care’s funding formula. A move toward specialization and centralization is a feasible model in areas of high density of hospitals, mainly the Greater Toronto Area. Unfortunately, many small hospitals are located outside of the GTA. An urban solution does not work well when applied to rural areas. Several LHINs outside of the GTA are simply too geographically large to apply similar standards as those found in Toronto. Distance between hospitals in many LHINs is often considerable. These areas often lack publicly-funded transportation for patients who would require it to have access to quality care at various healthcare providers It is imperative that the Ministry of Health impress upon LHINs that planning in rural areas must allow for small, rural hospitals to remain “general” hospitals that provide a variety of services to their populations as opposed to specialized centres with limited services.
In order to do so, however, the funds must be made available to function in such a manner. The Ontario government has continued to not increase health care dollars at the same rate as inflationary expenses and population growth. Expenses for hospitals are constantly increasing. Being asked to do more with less is practical when there is waste, but after all the waste is trimmed, budgets must increase. The Operational Review highlights this. The report clearly points out that by 2017-18 GBGH will have a balanced budget but in the years beyond 2018, GBGH will need to increase funding somehow. It is interesting to note, that when the 2012 version of Ontario’s Healthcare Action Plan was released, it noted that: “Funding of small, rural hospitals will continue to be treated uniquely, given their lower patient volumes.” Somehow this recognition of the uniqueness has been lost along the way and it is imperative that the needs of Ontario’s rural populations be treated as such.
Questions to Ask the Ministry of Health and Long-Term Care:
- How does a uniform, province-wide funding formula ensure equal access to care, when there are major differences between proximity to health care providers for people across the province?
- Should hospitals that operate in areas where low-income families are more highly concentrated receive more funding to ensure these families can have access to care closer to home?
- Will medical travel grants be made available to ALL people in the province when seeking transportation to and from medical care outside their home area?
- What does the Ministry of Health and Long-Term Care see as the role of small, rural hospitals moving forward?
WHAT CAN CITIZENS DO?
Now is the time to engage all three groups mentioned: the GBGH administration and Board of Directors, the North Simcoe Muskoka LHIN and the Ministry of Health and Long-Term Care.
Poignant questions must be asked about the hospital’s current leadership and its ability to make accurate, informed decisions moving forward. Now is the time when small, rural hospitals need leadership that is proactive in problem solving, is willing to actively engage all of their staff in quality improvement measures, and to engage the community in a timely manner to ensure that changes are fully understood by the community. The operational review has cast doubt on the current state of leadership within GBGH. Concerned members of the public are encouraged to attend all meetings of the hospital’s board to get a better understanding of changes to the hospital. Moving forward, the communities need to investigate how recruitment and retention is currently being conducted and look for ways to enhance this to ensure there this does not continue to be a stumbling block for the success of local health care.
LHINs need to be pressured to ensure that all hospitals receive appropriate funding commensurate with their performance. The NSM LHIN needs to acknowledge that the communities served by GBGH are the most unique in the LHIN, given the higher proportion of low-income families and the Aboriginal and Francophone populations that rely on access to healthcare at GBGH. Recently, the hospital in Leamington, Ontario was going to lose its obstetrical program too. Public backlash was so severe that the closure was being reviewed. The public needs to loudly express their concern to the LHIN about their well-founded safety concerns about the transport of patients. Additionally, the LHIN needs to produce financial studies demonstrating how the added costs incurred from transporting patients is a cost saving over current practices. If there are costs savings to be had in transferring, are they significant and justifiable once patient safety, time spent by physicians arranging transport, and the personal financial burden on families for moving services afar is weighed into the equation?
Citizens also need to have their voices heard at Queen’s Park. It is imperative that Health Minister, Dr. Eric Hoskins acknowledges that a one-size-fits-all funding formula is simply not effective for delivering quality healthcare throughout all parts of Ontario. The public needs to take action to have our MPP, Patrick Brown, come to these public meetings, and to meet with hospital administration and the LHIN. Additionally, the public needs to realize that GBGH’s situation is not unique. There are non-profit public interest groups, such as the Ontario Health Care Coalition, that are already lobbying the government for cases similar to what is going on locally. People should petition these groups to take up the GBGH cause.
There is no greater time for all citizens and groups in the community to clearly express their concerns to all three parties discussed. While the GBGH Board and CEO are the easy targets and are not blameless for the current state of affairs, they ought not to bear the full burden of responsibility. A failure to be transparent and a failure to recognize the uniqueness of the communities that GBGH serves is clearly an issue that needs to be directed toward the NSM LHIN. Finally, the Minister of Health needs to be held accountable for assuming a made-in-Toronto solution can be applied to all of Ontario. Dr. Eric Hoskins needs to be reminded of the recognition of the uniqueness of Ontario’s rural hospitals that originally was found the 2012 Ontario Health Care Action Plan. It is crucial that all residents of Ontario that rely on rural hospitals have a much louder voice in Queen’s Park.
I am forming an action group and need members and voices. Watch for details about this group, how to join and what to do next in my publication sent into OurMidland.ca