LEADING FOR PATIENTS
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LEADING

FOR PATIENTS

Friends of Ajax Pickering Community Roundtable

 October 7, 2013: 7:30-8:30PM

Facilitator TSH: Robert Biron

Facilitator RVHS: Rik Ganderton

RVHS = Rouge Valley Health System

TSH = The Scarborough Hospital

LHIN – Local Health Integration Network

General Observations

  • Serious concerns about the 2008 move of inpatient mental health beds out of Rouge Valley Ajax Pickering into Rouge Valley Centenary
  • There is mistrust as a result of previous merger experiences (Ajax-Pickering with Centenary in 1998)
  • Inquiries about how funds would be allocated under a merged entity
  • Interest in meeting with the Friends of Scarborough Hospital group to gain their perspective on the proposed merger

Risks

  • Fear that a Scarborough-dominated Board would favour Scarborough campuses and neglect Rouge Valley Ajax and Pickering hospital site
  • Concern of loss of services at Rouge Valley Ajax and Pickering site

Transcript

Friends Member:

I’m going to start with a few questions I had from listening in to the telephone town hall (Sept. 24, 2013). There was a comment mentioned that performance metrics that the two Scarborough hospitals do very well; I’d like to know why Ajax-Pickering isn’t up there with the performance metrics mentioned?

Facilitator:

The performance metrics are measured on a corporate basis – across the two hospital sites for Rouge Valley Health System. The public reporting is also done across the two sites. It’s done by corporation rather than site, so the metrics were done that way.

Friends Member:

So when you talk about the Scarborough hospital, it included Ajax -Pickering?

Facilitator:

When we talk about Rouge Valley, we are talking about Ajax-Pickering hospital site and Centenary hospital site.

Friends Member:

That’s my first point – you talk about Scarborough, not Ajax-Pickering. I was also concerned that when funds are raised within Ajax Pickering, will that funding stay in our area?

Facilitator:

Yes. The law is that if the fundraising campaign is for a specific hospital site. So in the MRI fundraising campaign that our Foundation ran for Ajax-Pickering, any funds raised must be associated with that hospital. If there was a general fundraising campaign for RVHS, without a specific target for fundraising, which is very rare, then the money could move around within the corporation. The fundraising we have done has always been associated with a specific campus.

Facilitator:

A donor can also always designate where they want it to go, and it is honored. That’s a legal requirement.

Friends Member:

Does property owned by Ajax-Pickering (hospital site) fall under that umbrella too?

Facilitator:

That is owned by the Rouge Valley Health System Corporation. The hospital corporation owns the lands at Centenary and Ajax Pickering sites.

Friends Member:

If the lands were sold, where would the profits go?

Facilitator:

They couldn’t be sold without the permission of the Minister of Health.

Friends Member:

Originally, if that land were sold, the funds would remain with Ajax-Pickering. Now, if the funds are sold, that wouldn’t necessarily be the case.

Facilitator:

Surplus lands would belong to the hospital corporation, which was formed in 1998.

Friends Member:

If the corporation wanted to raise funds by selling land, because the other hospitals are in trouble, the money would go out of the region.

Facilitator:

There is no intention to sell the land.

Friends Member:

When it comes to future funding from the government, where is Ajax-Pickering going to rate in comparison to the other Scarborough sites? You have a teaching hospital and Centenary – we are like the country cousin.

Facilitator:

Funding doesn’t come to individual hospital sites. It goes to the hospital corporation. (There is no “teaching hospital” among the four sites of RVHS and TSH.)

Friends Member:

That is still my concern.

Facilitator:

It doesn’t ever go to the physical individual hospital site. Funds are allocated based on the activity carried out on the sites.

Friends Member:

Teaching hospitals use more funds.

Facilitator:

There is no teaching hospital in the corporation. Scarborough has a community teaching affiliation, but neither hospital is a “teaching hospital.”

Friends Member:

What is the difference in the language?

Facilitator:

Teaching hospitals have a full affiliation with a university, and are responsible for both undergrad and post-grad education. A teaching affiliation means that we help those who have already qualified as physicians to gain practical experience. It’s more than a practicum, rather than a formal part of the education. It’s post-initial MD.

Friends Member:

So this is an opportunity for foreign-born medical professionals?

Facilitator:

It is, as well as for Canadian-born professionals. It’s an opportunity for them already today. All four are community based hospitals, and the affiliation we have is with general practitioners. Most community hospitals today have common practice in which medical students train not only at medical centres, but also at smaller real communities to medium-sized hospitals. It’s post-MD – not undergraduate.

So TSH is not an academic centre. They are two community hospitals.

Friends Member:

Post MD – you mean internships?

Facilitator:

They have their MD so they are doing some form of specialty or community training – family practice or something like that.

Friends Member:

When the merger of the Boards takes place and there is just one board, what will be the composition of the Board?

Facilitator:

We don’t know yet.

Friends Member:

It will mostly be Scarborough people.

Facilitator:

We don’t know that.

Friends Member:

You’re dodging the question. I worked in Scarborough, and I know that they will want to constitute the majority of the Board.

Facilitator:

No decision has been made about how the board will be comprised – and no decision has been made as to what composition the Board will have, if there is a merger. We have received your letter which identifies a concern around constituency, and that will be taken into consideration. But we don’t have the answer now.

Friends Member:

So who has the answer?

Facilitator:

Nobody yet.

Friends Member:

The LHIN and the Ministry of Health will have the answer, because they will put the board together. You can’t tell me that the composition of that Board with three Scarborough hospitals and one Durham hospital won’t have a majority of people from Scarborough on it. In our experience with the situation of the Rouge Valley Health System, once we were amalgamated with Rouge Valley, they tried to take obstetrics away from us, and they took our mental health away from us. So my level of trust is extremely low. Going into this, you should know that my level of trust of the Board and the LHIN is extremely low. The LHIN should be sponsoring public discussion but they don’t. We know who is driving this – the LHIN and the Ministry. As far as I’m concerned, I don’t trust what’s happening and I don’t trust what’s going to happen to Ajax-Pickering down the road.

Facilitator:

Message received.

Friends Member:

Between the two sites, what’s the ratio of the Board composition right now?

Facilitator:

There is nothing in the bylaws which dictates how many people come from any jurisdiction. What we have is a ‘skills-based board’ in which we select board members based on the skills we need on the board to govern the corporation. There are currently 15 elected directors, and I think it’s about 50/50, maybe 60/40 Scarborough/Ajax. But that can change at any time. There is no policy of residential representation.

Friends Member:

What about department heads within the hospital structure? Where do most of the department heads work?

Facilitator:

We have cross-site departmental heads.

Friends Member:

Will we continue to have department heads in Ajax-Pickering?

Facilitator:

We don’t know.

Friends Member:

That is one of the concerns we have.

Facilitator:

We have managers who operate across both hospital campuses (of RVHS) at the moment.

Friends Member:

One of our concerns is, will that remain? Will Ajax-Pickering managers have to run to Scarborough to make decisions around things that are done in Ajax Pickering?

Facilitator:

Arguably that happens today, and vice versa. We have managers responsible for both sites, and local manager.

Friends Member:

It depends on the balance that will be struck.

Friends Member:

The history of the associations of the two corporations shows an exchange of information over the years. In this process of consultation with the communities, other than the phone outreach enterprises, which I think are a good stroke, are there any plans to try to get a nucleus such as this group from west Durham to get together with an associated group from Scarborough? There is a very interested community group dealing with Scarborough concerns like we do here.

Facilitator:

There were a number of community agencies that we have engaged with. We have laid out a set of engagement tactics which include roundtables such as this, where we tried to ensure we have a good representation for the conversations we’ve needed to have, and we’ve had the telephone town halls, we have our website – that’s how we mapped out our outreach.

Friends Member:

I appreciate that from the point of view of the two of you as executive members of the organizations. But has any of the consultation process included some sort of effort to get the citizens of the community talking to each other? That may give you a much bigger picture of how they view our concerns, and how we view theirs.

Facilitator:

Through our consultations, we’ve heard concerns both from the Scarborough residents that resources will be hived off out of Scarborough to support Ajax. They have the same concerns about resource allocation that you do. When it comes down to it, we recognize that what we’re trying to propose is a change in the system and how it is governed/managed. You have concerns about how that administration and Board would function to ensure that both communities have the best healthcare available. That has been a loud and clear message from both communities.

Facilitator:

We haven’t created a forum to get the two Friends groups together, for instance.

Friends Member:

I just want to make an observation on structure. I’m surprised and not surprised that Scarborough would be afraid that resources would be ‘hived off’ to the lowest sister of the hospitals – Ajax -Pickering. The attempt at the obstetrics some years ago and the loss of mental health facilities already happened.

Facilitator:

Obstetrics never moved. There’s a birthing centre at each of the four campuses right now. We do 1,700 births a year at Ajax-Pickering.

Friends Member:

I thought there was a regional birthing centre set up at Centenary.

Facilitator:

There was a new birthing centre built at Centenary. It is not designated as a ‘regional’ centre.

All four hospitals provide labour and delivery – that’s part of the bread and butter of a community hospital.

Friends Member:

Unless this group had acted very strongly a number of years ago, that would not be the case today (that Rouge Valley Ajax and Pickering hospital site has an obstetrics program).

Friends Member:

With respect to the birthing centre, Ajax is only allowed to have level 1 and 2 birthings here, and the rest have to go to Centenary.

Facilitator:

That’s incorrect. Ajax is designated as a 2B – which is actually a higher level than most community hospitals. Centenary has an even higher-level designation for high-risk pregnancies in the community, at 2C.  TSH hospital campuses are designated as 2B level.

Friends Member:

My supplementary question would be, since there hasn’t been envisioned as part of the community consultation, is there time to build in such an opportunity before you have to make your report, to have a conversation with the other Friends?

Facilitator:

I don’t see why not. We can connect the two of you. We can make the connection for sure.

Facilitator:

The commonality of concern is quite interesting, and those in Scarborough have similar concerns.

Facilitator:

The questions from Friends of Scarborough Hospital were posted online last week. One of their concerns was also the structure of the board, and ensuring it was representative between the communities. Another concern was strength of leadership, in navigating the concerns before us. You can read the minutes online. We had a two hour meeting and a fulsome discussion. They appreciated the opportunity to provide input. The reality is that we are getting all kinds of good feedback. There’s certainly anxiety – as soon as you hear merger, there’s a negative connotation, and perhaps that comes from our respective histories. The history tells us that prior mergers were difficult, but we are in a different place now. In the case of Birchmount, they had similar stories of attempts to affect core services. We have to rebuild that trust.

Friends Member:

You said ‘impression of loss’. It’s not an impression. We lost our mental health.

Facilitator:

We consolidated inpatient mental health at Centenary, but at the same time we invested in a very significant amount of outpatient mental health, and we now fund Durham mental health crisis beds in the community, to avoid people getting admitted to Centenary. If you look at the number of mental health patients, the number of mental health professionals at Ajax-Pickering is higher. We have extended hours of crisis intervention services at Ajax-Pickering. If someone is admitted, we are responsible for their transportation between the two sites. There is a better service now for mental health patients.

Friends Member:

There is no in-bed/inpatient service at Ajax for mental health patients.

Facilitator:

Correct.

Friends Member:

Do you realize that I don’t know how much money was invested, but it must have been in the nature of at least a million dollars, in the refurbishing of the third floor of the Ajax hospital in state of the art in-bed mental health facilities, where the nurse at the station could know exactly what was happening in each room, etc. etc. and all of that was abandoned after the money had been spent. I think that was a gross waste of taxpayer money and a gross mishandling of the mental health people that are in the community, in Ajax Pickering and Whitby. It was a medical crime. The LHIN was behind it, and I don’t know how much pressure they put on Rouge Valley Board to do this, but it was a terrible waste of a facility. It irks me to no end that these kinds of things go on, and this community loses an excellent facility. And I know that the facility at the old Scarborough General isn’t a patch on what is here at Ajax. These kinds of things – can you trust Boards? Can you trust the LHIN? It just is a shocking situation as far as I’m concerned that we lost a great facility for people in this community who need a hospital bed close to home.

Friends Member:

That’s really important. Mental health is one of those illnesses that takes up the beds the longest. If you need someone to get better, quicker, it is impacted by the support of the family and friends. When you have mental health patients in Scarborough and family members in Durham, it makes that support all that much more difficult.

Facilitator:

The current thinking around mental health treatment is that you should be de-institutionalizing patients – putting them in institutions should be a last resort. That’s why we changed the way we deliver that care. I understand the issue – not every community can have everything it wants; we can’t do neurosurgery at every single hospital, for example.

Facilitator:

You may recall that when we changed that service in 2008, we increased the number of hours we have for mental health crisis intervention at Ajax-Pickering.

Friends Member:

As part of this community consultation, and combining the information you get out of these sessions with the recommendations you get from the staff, will there be a five or six year projected program of development for what should happen at each of the sites, so it is based on community growth, which is high in Pickering, Ajax and Whitby, as opposed to Scarborough?

Facilitator:

At this stage, by October 29, the answer is no. One of the things we will be seeking from LHIN and government is support for program planning including capital planning to reflect the growing needs of this community and potentially to reflect rationalization of facilities in Scarborough – after October 29. That is one of the things we are expecting to seek support for, if there is a decision to merge.

Friends Member:

For me, that’s very good news.

Friends Member:

There was mention about a new funding formula based on patients. Would that put Ajax-Pickering in good stead, based on our growing population?

Facilitator:

Yes – provided we can get patients to get treatment at Ajax-Pickering. The majority right now seek services outside of Ajax-Pickering.

Friends Member:

That’s because the best doctor is not in my region. I went to Scarborough General.

Facilitator:

The reality is that this is the patient’s choice. When you look at the data, the referral patterns of where patients travel tends to be west from Ajax. The fact that Ajax and Scarborough are already together through Rouge Valley makes sense.

Facilitator:

There are specialized programs that every hospital can’t afford to run.

Friends Member:

I understand. But for certain services you aren’t in the hospital a long time – unlike when you need extended services, and want your family around you.

Facilitator:

Ajax-Pickering has cancer services, one of the best knee and shoulder replacement services; cardiac services that we have extended; a whole cardiac diagnostic unit that wasn’t available before.

Friends Member:

At Ajax-Pickering? Why hasn’t it been extended to Centenary?

Facilitator:

Because the equipment is at Ajax-Pickering. We do the whole region – Durham and Scarborough – at Ajax. Then you are sent home after a 24 hour stay, and we do all the monitoring and follow up in the local hospital.

Friends Member:

Then how does that affect the funding?

Facilitator:

There are regional services that you want to specialize; and then there are ‘bread and butter’ services that you want at all hospitals – obstetrics, OR, etc. The community care that the hospitals were established for. All four hospitals are keeping their emergency departments – the opportunities that present themselves are more along the lines of integrating back office functions; in terms of pursuing capital dollars for growth in Scarborough and Ajax; there are different reasons for merging. We’ve tried to understand those potential benefits. This is not about closing services or taking them away.

Friends Member:

That’s just something I was going to raise. In all of the propaganda that you guys put out, the one thing you stress (and you are on dangerous ground doing this) is that there will be no change.

Facilitator:

We don’t say that.

Friends Member:

That’s what it sounds like. You won’t lose this, you won’t lose that – that’s what it says to me, that’s how I read it as a citizen. You might not mean it that way, but you have to level with people. The government is giving you less money, so there will be less employees and less services. If you try to portray this in any other way, I don’t envy you.

Facilitator:

We are providing more service today in Ajax Pickering than we were seven years ago, with the same or fewer employees, and a broader range of services. We have to find ways to increase services and we’ve done that. We’ve delivered on that.

Friends Member:

The thing is that if your money is going down and the government is under-funding you, if the government keeps reducing the amount of money you get, you will come to the point where your services will suffer. If you keep emphasizing that ‘nothing is going to happen’, you are putting yourself in a dangerous position. You don’t control government policy or the LHIN – but you should temper your language a little bit in that direction. People will come back and say ‘you said nothing will happen’.

Facilitator:

We said we will not move services (from Ajax to Scarborough or vice-versa). That does not mean we will be keeping the same workforce to deliver those services.

Friends Member:

When it came up between Scarborough and old Scarborough Grace, this whole thing started about moving services around between the General and Grace.

Facilitator:

I want to build on the point around the ‘change’ if you will. We have been very precise in our language about what this merger can and cannot do. The reality is, it doesn’t matter who is in government – healthcare is going to change, in how we organize and deliver it. The hospitals are essentially being restructured across the province so we focus on what we can do, and everything else is sent to the community. That is why funding has frozen as inflation rises. The question is, knowing that’s what we’re facing, are we better off managing challenges together or separately? We believe there are strong synergies within both of our communities, that currently, we are leaving on the table if we don’t come together. Funding issues will happen with or without a merger.

Facilitator:

That is the message to understand. Rouge Valley, irrespective of the merger, is frozen in terms of funding till at least 2018 – but the costs are not frozen. So we need to restructure, irrespective of merger.

Friends Member:

Do you go to your staff and ask them question about this?

Facilitator:

Every day.

Both hospitals over the past several years have gone over several exercises of quality improvement, and it is engrained in our culture. The challenges before us are much more significant, and this is one opportunity with the new funding formula – we can be a bigger hospital to compete with downtown. A lot of our residents in Scarborough are going downtown or outside our catchment area. We believe we can better service our community based on the new funding formula as a merged entity.

Friends Member:

Why now? We were separate hospitals, we went through a merger before; then the LHIN comes along, the CCAC comes along; so why now?

Facilitator:

We are correcting the past. Fundamentally, this province is the only province that has not dramatically restructured how the services are structured. Frankly, this province is far behind. Our health system is organized to the detriment of patients, and it is inefficient. We need to fix it, and this is one of the processes for fixing it. Closer integration with primary care and community agencies will also happen as a result of merging.

Friends Member:

The other question I have is, why would anyone expect a Scarborough-centric corporation to properly understand Ajax’s needs? I don’t know much about Scarborough Grace – why should they know about us?

Facilitator:

The communities in Scarborough are actually quite different themselves. The community around Grace is very different than that around General and Centenary. Ajax is different as well. If you look at Stats Canada census reporting, the diversity in those communities is getting closer and closer. The difference here (in Ajax and Pickering) is that it is a younger community, which has some implications for the development of Ajax campus in the future. The communities are different and similar, and we have to reflect that. We hear the concern around Scarborough versus Durham. I believe we can find ways to fix that and enshrine it in the governance and bylaws to protect it.

Friends Member:

How would we do that? Obviously the mental health issue still smarts. How do we take away something that says we can ‘veto’ or make people in Ajax feel reassured?

Facilitator:

What do you think the alternative is? If you don’t want to merge with Scarborough, what do you think the alternative is? There is no alternative for being independent. That’s not an option. So what is your alternative?

Friends Member:

Maybe there is none.

Facilitator:

That’s where I’m going with this. We’ve heard people say ‘you should merge with Lakeridge’ – but there are no more guarantees in that direction than in this one. If you look at how patients actually use the system, the vast majority of people in Ajax-Pickering get their services from Ajax-Pickering, Scarborough, or downtown Toronto. They are going where they perceive there is an expert, where (doctor) referrals send them, etc. I’m willing to listen to the concerns.

Friends Member:

The system that exists now has created this environment. It’s not a choice as to where we can go for healthcare – we go where the specialist is.

Facilitator:

Not every community hospital can have every subspecialty available. You do have to consolidate expertise and specialized care – and from a quality perspective, you want that.

Friends Member:

Has Scarborough General had a peer review?

Facilitator:

Yes – in 2008.

Friends Member:

Are the results posted somewhere?

Facilitator:

I believe so. It was dealing with governance issues; it was when they were looking at the two hospitals in terms of how they would allocate resources. I think it’s on our website.

Friends Member:

Just a reflection on the idea that each of you has presented, that local people seem to get referred outside the local hospital support system. As a community user, that’s not our choice. Referrals to specialists are made through family docs.

Facilitator:

There is a shortage of family docs in Ajax-Pickering. That is a big part of the problem. How that problem gets reflected, is that younger people in this community are retaining their old allegiances to family docs from where they grew up/where they moved from – so those docs refer downtown or into the old community. It’s a bit of a double edged sword – we are having conversations with the town of Ajax to see if there are opportunities to create incentives to get family docs into the communities, which would create a better referral base and create a better working environment for specialists and subspecialists.

Friends Member:

You mention the Town of Ajax and the City of Pickering. Do you include Whitby?

Facilitator:

Yes – we serve half of Whitby. We treat Whitby council the same as the other two councils. We speak at Whitby council at least yearly, as we do with the other municipalities.

Friends Member:

In the literature you presented here, you emphasize there will be no movement of services if there is a merger. How are the services you alluded to earlier in relationship to mental health issues, about moving certain parts of the services into community-based organizations – if there is a merger, how will that be arranged?

Facilitator:

In terms of linkages with the community? For many of these things, the contact point is typically through the emergency department. If you take a mental health patient in crisis, they will typically show up to the emergency department and may access service through a joint police crisis team which also works with EMS and Durham Mental Health – but typically the contact is through the hospital’s ER. At that point, the patient is assessed, and then if it is deemed by the crisis team that that patient needs institutionalization to manage their mental health disorder at that point, we will arrange for them to be moved to Centenary if they need it. And once that very acute phase of their disease is stabilized, then we move then back to their community with the appropriate linkages with outpatient services here and crisis team here.

That is the way most hospitals function – there are partnerships in place at Rouge Valley which ensure continuity of care as the patient transitions to and from the hospitals. That is true for most programs – whether that’s mental health, cardiac, etc. A patient in north Scarborough living across from Birchmount, if they call EMS with chest pains they get sent straight to Centenary. You are receiving world-class care close to home.

Friends Member:

If a patient is in Ajax and they get referred to Centenary to get the ‘specialist’ then they get sent back to their home community, where would the funding go?

Facilitator:

It would go within the hospital corporation – the funding would be designated to the corporation as a whole.

This comes down to where the patient gets served. We want to serve our immediate communities as our primary focus. We need to recapture patients who go elsewhere. We have good market share for emergency services but not for specialty services.

Friends Member:

Out of curiosity, the last merger brought Rouge Valley Health System. What would the new system be called?

Facilitator:

We don’t know yet.

Friends Member:

I just remembered another service we lost. We lost our kitchen.

Facilitator:

We see this (merger exploration) as more of a strategic opportunity to align ourselves for long-term success. When you look at the funding formula, and population demographics – our aging infrastructure, your growing community – how can we better work together to position ourselves for success?

Friends Member:

There’s talk in Whitby of trying to open a hospital in north Whitby. Couldn’t you convince the Whitby council to be more active and involved in supporting Ajax-Pickering and maybe growing it to meet the needs? I think that’s a big opportunity.

Facilitator:

I do too. The challenge there is that Whitby feels they have lost a hospital and they want one back. That’s the problem there. There’s no doubt when you look at the map, we need a new hospital to serve north Whitby and Seaton and the likely development which will come from the airport lands. That’s a huge growth area, and logically it should be driven through Ajax-Pickering.

Friends Member:

All the more reason to develop this site.

I hope you will consider when you realign services what patient support is required. Cardiac, knees, shoulders – you’re not in the hospital for a long time. But when it comes to long term support for health – you need your family around you.

Friends Member:

What is the respective positions of the budgets for the two corporations – the debt load, what needs to be cut?

Facilitator:

We’re both balanced for this year, and the next cycle starts April 1. We haven’t received any direction as to how that cycle will look. We are waiting for formal direction on that. They’ve essentially told us to plan for zero percent for the hospital sector. What does that mean for us? We still have to work through that. In the current year, Scarborough had to pull $17M out of a $360M budget. RVHS had to cut about five percent. We face that with or without a merger, and we do that every year. For the past two years we have had zero increases in funding and have adjusted the cost structure to meet that challenge.

At some point we will run out of runway. You can only get as efficient as possible; but that is a decision all hospitals will have to face in coming cycles.

©2013 Leading For Patients
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