Home News Hospitals & Health Care Open Letter To NSM LHIN From Dr. McNamara
Open Letter To NSM LHIN From Dr. McNamara

Open Letter To NSM LHIN From Dr. McNamara


February 15, 2016

Ms. Jill Tettman
CEO,North Simcoe Muskoka Local Health Integration Network,
210 Memorial Avenue, Suite 127-130
Orillia, Ontario
L3V 7V1

Dear Ms. Jill Tettman:

Re: GBGH Operational Review Final Report dated December 19, 2015

It has been some time since I have had the pleasure of writing you regarding issues at the Georgian Bay General Hospital (GBGH) in Midland. I recently had the opportunity of reviewing the 108 recommendations generated by your consultants and I would like to share with you the practical implications of these clinical recommendations. Please forgive the length of my response as there is much material to comment on.

I would further like to use this forum to include a formal request that the review be reopened to include consultations with Beausoleil First Nations, the Metis community, the Director of Woman’s shelters and the health care providers of both Waypoint and CNCC patients.

While some of the consultants’ recommendations dealing with civility and behavior are welcome, it is the clinical conclusions and their accuracy that concerns both myself and many of the physicians of GBGH. I fear for the future of our hospital and I fear for the care (and lack thereof) that we will be able to offer our patients.

Downsize the ICU and acute care beds

The decision to downsize our ICU and to delegate it to a Level 2 is a poor decision for a number of reasons. This change alone will increase mortality and morbidity significantly in our hospital.

Changing to level 2 status means that our ICU can no longer take care of persons with more than one issue. If the patient has a heart attack and goes into cardiac arrest and is a diabetic, he/she must be transferred out. Once the Level 2 designation is put into effect, temporary ventilation assistance of less than 24 hours only can be provided. If a patient needs ventilation following an operation until the body heals sufficiently to breathe on its own, the patient will have to be transferred out. Transfer fragile patients without due cause adds to their risks as well as acting to separate them from families and friends. This is particularly difficult for us as caregivers when we know that this service could have been safely and capably provided at GBGH.

At present, GBGH ICU has the capacity for 2 critically ill patients requiring ventilation. For the past 1.5 years, we cared for a patient with chronic ventilation needs which reduced our vent capacity to 50%. During this time, we transferred out more than 100 patients requiring ventilation – patients who could have been treated in our own ICU. Since that patient’s tragic demise, we are back to full capacity, yet still must transfer out patients when our two ventilators are being used. This suggests that our capacity for ventilation is lower than our need. Your consultants still strangely concluded that we require fewer, not more ICU beds.

Strangely, the LIHN also not provided a viable plan to treat and house our next chronic vent patient, in all of Simcoe County. Why is this?

I work 15 days per month in our ER. I begin almost every evening or night shift with a pleasant nursing supervisor informing me that there are no beds in our ICU. I and other physicians currently spend hours on the phone trying to find appropriate beds for critically ill patients, usually at other hospitals facing the same pressures. Many of these are patients are well within our scope of practice and expertise but for the lack of ICU beds. A calculation of the costs (and loss of hospital revenue) for all of the patients transferred out of our ER, not actually having made it to our ICU, would be an interesting exercise and one that I am certain would speak to a need to increase our ICU capacity, not decrease it.

Changing our ICU designation will therefore sentence my colleagues to hours of phone time through “Criticall”, speaking with multiple consultants regarding the severity of our patient’s condition. The “life or limb” designation, while a reasonable concept on paper, takes on a new dimension when applied to clinical practice. For example, a patient recently presented to our ER with multiple comorbidities and vital signs absent. The patient was successfully resuscitated, had a temporary pacemaker inserted in our ER and then was turned down as being “life or limb” as the cardiologist felt that the patient was now “stable” having been successfully resuscitated. She advised us to continue caring for the patient and call her back if anything changed. Well intentioned policies at your level do not always translate into expected outcomes at our level (upon implementation). This is our reality.

The recommendation to add four step down beds is a reasonable, welcome and logical recommendation, but not at the expense of our ICU capacity. Changing our ICU designation to a Level 2 means that we will transfer out all “multisystem” complex patients and keep only patients with single system disease. However, there are no ICU patients with single system diseases. All are complex, take multiple medications, have multiple associated illnesses since this is what led their need for the ICU

We must have the capacity and equipment to care for our own. Other hospitals are facing tremendous pressures to not accept patients from us. We can care for our own quite adequately. We simply need the funding to do. I note that the report fails to do a proper cost analysis comparing the costs of transportation, EMS utilization, nursing and physician costs to accompany the patient, costs of Ornge compared to local care? Simcoe County EMS assigns two ambulances per day to cover inter hospital transfers. The Geyer and Associates review team has made no recommendations regarding what ER physicians are to do with our next emergency patient requiring ventilation when ambulance capacity is exceeded, as it surely will be.

No Obstetrical or Gynecological Surgeries

Many of the consultants’ recommendations speak to improving dialogue and partnerships with other hospitals for our Obstetrical needs, gynecological needs, pediatric needs, ICU needs while cutting these services from our hospital. From personal experience, other hospitals are not in the least bit interested in caring for and housing our patients.

To build a partnership with other hospitals suggests that we have something to barter. We have neither a carrot nor a stick to ensure that our patients will receive the same consideration from these providers as do their own patients. Our experience with Mental Health and Orthopedic patients suggests that transferring out patients will be a very difficult and troublesome process, adding to the risk for fragile patients. We often encounter hospitals that refuse our patients, even when they have “regional beds” available. This problem will only be exacerbated by the current recommendations.

I have attached a copy of a recent article from the Canadian Journal of Rural Medicine, which speaks to the relationship between maternal and infant safety and distance travelled for maternity care. The Journal articles review the EVIDENCE backing up the practice of providing services such as obstetrics closest to home. I would suggest providing a copy to the LHIN board members for their perusal.

The team from Geyer and Associates suggests that the model currently employed in Owen Sound is the first choice for us. They report is as working well there. Personal discussions with physicians working in the small, surrounding towns suggest that these claims have been somewhat exaggerated. Secondly, the population of the Owen Sound area differs dramatically from the demographics of our local population. Distances are also very different. Residents from Christian Island, for instance, face a trip of one hour to GBGH on good days. Having served the Island residents for 10 years as the “Island Doctor”, I can assure you that on inclement days, trips to the mainland can be very difficult, lengthy and dangerous. On occasion, the travel is impossible.

No Pediatric Surgeries

It is very misleading and somewhat slanderous to suggest that the care for pediatric surgical patients at GBGH is higher risk and less safe. Your consultants state that we do not perform enough pediatric surgeries to be safe. They tell us that tonsillectomies and tympanostomy tubes would best be done in a larger center where volumes are higher.

The patients receiving tonsillectomies and tympanostomy tubes at GBGH are, for the most part, lower-income patients who do not have the means to make the journey to a larger centre. This is why the same consultant who performs the procedures in the higher volume centre, comes to Midland to provide this same service. That consultant, in fact, rents a local office in which to see these patients who would otherwise receive no care due to their socioeconomic status. If this ENT specialist is losing IQ points by crossing the Tay township line, perhaps he should be notified of this fact before more patients are endangered.

The consultants furthermore, did not provide an accounting of the emergency appendectomies and other basic procedures being done quite competently by our own surgeons. As for the recommended cut of all pediatric surgery, is there really a difference between an appendectomy on a 17 year old versus a 16 year old? One is “pediatric”; the other is not? Again, there is no costing of the impact of transferring out all patients under 16 years of age with right lower quadrant pain for assessment at neighboring centres.

Another sad downside to the recommendation to end all pediatric surgeries is the effect on anaesthetists. They will no longer handle the volumes necessary to maintain comfort when a patient presents with a serious and difficult airway problem. Strangely, our anaesthetists see more pediatric patients individually than do the anaesthetists at OSMH, putting in doubt the conclusions of your consultants that we don’t have a “critical mass” necessary to maintain our skills.

No Dental Surgeries

Your consultants tell us that we should not be in the dental business. These cases involve, for the most part, patients of lower socioeconomic status, who are unable to access dental care in any other way. Admittedly, we do have some cases of wisdom teeth extractions which could be done in an office setting, however, many of these patients suffer from anxiety and panic such that these procedures would not work in an outpatient setting. An analysis of the patient demographics shows that, once again, the populations served are those with limited access to dental services: low income families, the working poor, and our First Nations patients. To remove even a fraction of this service is unconscionable given the effect of dental health on overall health. These patients would either continue being treated with antibiotics and narcotics in our ER, or would have to find some means of travelling to Barrie or Orillia for the same OR procedure to be done.

No Emergency After Hours Endoscopies

Your consultant consistently refers to a “scope after hours” program at our hospital. No such program exists. Our five specialists do, on occasion come in after hours to scope patients with foreign bodies in their esophagus. While many of these patients could potentially wait until morning, they would be very uncomfortable and run the risk of esophageal perforation and other complications leaving the patient, the institution and the care team at risk. Many of these patients are from Waypoint and suffer concomitant mental illness, which led to their swallowing said objects. In the last 6 weeks, I have seen, after hours, four cases of foreign body ingestions: a battery, a toonie, an earring (opened) and a bolus of liver. I would challenge you that any of these could have safely waited until morning. Transferring these patients out would surely incur a greater cost than simply treating them off hours. (If we can find someone to accept them)

Surge Capacity

Your consultants are touting that they will increase our beds and return us to a 115 acute care hospital. I have corrected this fallacy on their part and plan to continue doing so. We are a 105 bed hospital with 69 acute care beds (soon to be 62 if your consultants have their way). We generally run at between 95 to 103% capacity. While those with acute mental health issues will benefit from the planned move of 20 beds to our hospital, one must point out that these beds don’t actually increase our acute care bed designation as it would be unusual to place a post operative patient in a bed between someone with acute schizophrenia and another with a bipolar illness. These are, in fact, specialized beds, not general community beds. I repeat that we therefore have 69 acute care beds.

The European Commonwealth countries have made it a priority that their hospitals never exceed 85% capacity at their busiest, ensuring some surge capacity for outbreaks such as SARS and other emergencies. We have absolutely no surge capacity now and cutting another six beds will worsen the situation.

Length of Stay {LOS}

Patients are regularly housed in our hallways now, in spite of LEAN methodologies improving flow. The consultants tell us that our Length Of Stay (LOS) is too long, as though we somehow have some control over those agencies caring for our patients post discharge. Nursing homes in outbreak, homecare delays, retirement homes not accepting patients, waiting lists for CCC and Rehab all contribute to the problem of worsening LOS. We have no leverage with these organizations, other than to beg their assistance, yet we are penalized if we do not discharge these patient within the provincial guidelines.

Consultation with Physicans

I have been quite amused at some of the strategies employed by your consultants. For instance, were you aware that they made recommendations to cut obstetrics and ICU without actually speaking to the Chiefs of those departments to see if improvements could be made to secure the service? I find this appalling and insulting to the physicians who have spent more than 30 years each providing this service.

It is also interesting that the consultants suggest that the cuts are due to “safety issues”, yet, strangely, GBGH’s services recently passed a MOHLTC accreditation with flying colors. Something is clearly amiss with one of these services. Could it be the MOHLTC or your consultants? In addition, they have suggested publicly and repeatedly that our program suffers from a high index of litigation. A review of the physicians providing this service reveals that, in more than 130 years of care on the part of our four providers, three lawsuits have been generated. This in a discipline that is noted to be second highest in Canada in terms of litigation. Are we really unsafe? I would suggest that publicly stating so is slanderous in the extreme.

We recently changed our hospital credentialing bylaws to allow for midwives to deliver their patients at our hospital. In addition, we’ve recruited a new family physician to provide obstetrical services. Our links with NOSM also suggest that their work with us hinges on our provision of CORE rotations for their learners. Our recruitment strategy is heavily dependent on our teaching services. We are in the process of rebuilding obstetrics and have had inquiries from a number of new, young gynecologists expressing interest in coming here. What we need is a commitment on the part of LHIN and the hospital to support these providers and to offer them meaningful OR and AM care time. What we don’t need are cuts to our CORE clinical services.

Opthalmology services

The recommendations provided by your consultants in this area of care are particularly interesting in that they clearly show that there is little understanding of rural medicine or the needs of our providers in our particular setting. “Best Practice” as expounded by your consultants, is for ophthalmology procedures such as cataracts, to be done in an AM care setting, rather than our OR as is currently the practice at GBGH. Our ophthalmologist provides “regional call” every 5th week. He reports performing between 4-10 operative procedures during that week of call; procedures such as repair of ruptured globes, enucleations and others. The equipment is fragile and requires calibration each time it is moved. The distance from our OR to AM care is 440 yards, (or ¼ mile). The equipment currently is dated and has one broken caster. The OR currently used for ophthalmology is out 3rd OR and is not used for any other procedures. How can adopting the practice of moving equipment that weighs close to 500 lbs, every fifth week be more cost effective than our current practice? The geographical location of the equipment is irrelevant to the procedures being done. It is surely more cost effective to have the equipment on one location (OR) than to move it every fifth week or every procedure, recalibrate it, move it back, ad nauseam? Who will perform this work at 3 am? Perhaps the “private” maintenance people we’ve contracted to work for us, based on earlier LHIN“efficiency reviews”?

Lack of Consultation with First Nations, Francophone and Mental Health Patients

Your consultants interviewed many staff, community members, and partners. (200 interviews) The recent Primary Care paper (Putting the Patient First) released by the Ontario government in December 2015 speaks to providing enhanced care to three populations in particular: First Nations, Francophone and mental health patients, all of whom are present in sizeable numbers in our community. NONE of these groups were consulted by the review team. We have one of the largest Metis populations in Ontario. Beausoleil First Nations is also one of the Bands with the longest history of contact with arriving Europeans and were the main partners in the “Penetang Purchase”. They have a distinct and respected history in the area, yet, they were not consulted and were certainly not aware of any planned cuts to services that would directly impact them until contacted by a local physician. Beausoleil First Nations has approximately 800 residents living on Christian Island and dependent on the local hospital for much of their care. They also have more than 1000 Band members residing in neighboring communities. Who speaks for them at the table?

Our newly elected Prime Minister has made it a priority to genuinely consult with our First Nations PRIOR to implementing changes that will affect the health of their people. Your consultants have failed to do this and the Board has failed to call them to task on this. NO ONE at the table spoke either for or to these groups.

Removing access to obstetrical and gynecological services for these groups will be catastrophic. Yet, our Board, guided by your consultants has, in one fell swoop, eliminated local access to hysterectomies, ablations, tubal ligations, colposcopy, endometrial biopsies, IUD insertions, pessaries and a large number of other gynecological services too numerous to mention. I am frankly stunned that none of the female members of the Board resigned. I am also stunned that you and the LHIN Board members, Ms. Tettman, would stand idly by while these recommendations move towards final acceptance.


As the administrative body tasked with providing culturally appropriate services to our entire LHIN, I am asking that you direct the GBGH Board and your consultants to open meaningful consultations and dialogue with our at risk populations – First Nations, Francophone, and others.

Your consultants consistently referred to “best practice” when discussing the planned cuts. Best Practice is quickly becoming synonymous with “cheapest” practice. You can make a pizza so cheap that no one will eat it. By adopting all the 108 recommendations, there is a high likelihood that we will move closer to closing our doors to admissions as no one will use our services (those we have left). Many of the clinical recommendations will actually prove dangerous to implement. I, and other clinicians here, would like an opportunity to work with you to keep our obstetrical unit alive, viable, and growing and would like to work with you to maintain our Level 3 ICU designation and beds. I and other physicians working in rural areas believe that there should be local care for local people, where clinically appropriate.

The above information does not even begin to anticipate the effect these cuts would have on our educational programs such as the NOSM medical student program and our ties to programs such as the Nurse Practitioner, Physician Assistant program, the Medical Clerkship Program, Rural Residency program and recruitment should we find ourselves unable to provide CORE rotations such as obstetrics and gynecology.


Dr. M. McNamara. CCFP/EM

Dr. McNamara
Dr. Martin McNamara Photo Source: Simcoe.com / Metroland



  1. Smarten up Wynne !!! You will be there one day ,see how you will like it! We all worked for these and paid into health care …now it is not available ,SHAME ON YOU!!!

  2. What would happen if it was K Wynne’s family in an emergency, how would she feel if visiting this year and needed the service. Sorry no longer available.. We live in a community and our medical facilities are well used and appreciated. We get young doctors coming to the area and you take them away. You need to rethink your plans

  3. Excellent letter which addresses concerns we never even would have thought. I , for one, have a partner who has heart problems AND has diabetes. That means the “team” is saying that he should be shipped out to another hospital for treatment. We do not have a car or any system that would allow me to visit or take care of him seeing that you are also cutting nurses. This is an aging population here BUT also a tourist area and the summer brings huge influxes of people who are always getting into emergency troubles, boating, snake bites etc. Send the consulting company back and a new one to deal with all the parameters here.

  4. By The Way in addition to all that I said above, he is also First Nations and never even heard of the threat to our hospital and the surrounding areas until this “report” was presented.

  5. What is happening to our once proud Health Care. Many thanks Dr McNamara for penning this and sending it off. We need our local hospital. It serves a wide range of demographics. What it seems to me, is that it is all about taking away much needed money from our hospitals and putting it into all the unnecessary projects that seen to drive this government. Untill more people stand up to this out of touch government we will continue to be on the losing side.

  6. Many of us have paid into OHIP for over fifty years, with little use of the facilities. Now,due to government mismanagement if we do require medical attention, it may be denied. Non delivery of the services we built and paid for with our personal funds in good faith should be a chargeable offence. Only in Ontario would this scam be allowed to occur.

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Open Letter To NSM LHIN From Dr. McNamara

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