LEADING FOR PATIENTS
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LEADING

FOR PATIENTS

Friends of TSH and Friends of Ajax Pickering Joint Roundtable

Friends of TSH and Friends of Ajax Pickering Joint Meeting

November 4, 2013: 6:30-8:30PM

Facilitators: Rik Ganderton, Marla Fryers

Transcript

Facilitator:

We are just finalizing the draft report. We are going back and forth on the usual edits required on these things to get them into the final form, and we are working with the Integration Leadership Committee (ILC) to come up with a final recommendation that will go to the Boards. The plan is to formally email the document to the Boards on Thursday or Friday, and then the Boards are meeting in an open session to consider the Report on Tuesday, November 12th. Scarborough’s meeting is at 4, and RVHS’s is at 6:30. A draft document has been submitted to the LHIN – they have been part of the ILC so they have seen the draft and we understand that it’s gone to the Ministry but we haven’t had specific feedback yet, and there’s a meeting with the Minister of Health this week. That’s where we are in terms of the process.

The benefits and risks that have been raised through this process are outlined in front of you, and I don’t think any of them will be particularly surprising to you. We are trying to take risks raised in the roundtables into account through the process.

Friends Member:

A couple of questions.  I didn’t attend any of the previous meetings so I am hoping you can clarify things. First of all, on the merger, will changes to the service programs be designed by population or demand? Take for example mental health. Currently, Scarborough’s services are centralized at Birchmount. There has been an ongoing concern that there is no children’s and youth services at Scarborough General at all. Would that be addressed?

My second question is that transportation is linked to accessibility. Language and cultural accessibility is difficult, and Scarborough has cut interpreters. Family members have to translate for patients, which is unacceptable. Will that be dealt with?

Facilitator:

I’m not aware of any cuts to interpreter services.

Friends Member:

There wasn’t much before, but as late as two weeks ago, certain programs were still using family members for interpretation.

Facilitator:

Both hospitals use volunteers to assist with interpretation. We have a telephone language line – Lifeline – which functions to do live translations, and both hospitals continue to use those services. I’m not aware of any changes in the interpretation services.

Friends Member:

Yes, but using Lifeline is not effective. That’s what I’m trying to say. Our recommendation as part of the collaboration is to put together another task force with Central East LHIN to not use Lifeline, particularly for mental health.

Facilitator:

I’m not aware whether we use Lifeline in mental health.

Friends Member:

The population at Centenary is so different than at Birchmount. How much of the planning will be based on population and culture?

Facilitator:

The objective is to provide culturally sensitive programming, regardless of whether we merge or not. We try to provide culturally appropriate services.

Friends Member:

Personally I’ve gone through that experience at Birchmount. I acted as the interpreter one day when I happened to be at the emergency room.

Friends Member:

We have many staff who work in the organization and live in the community who speak many different languages. We use staff for interpretation services frequently.

Friends Member:

That’s something that the LHIN’s attention should be drawn to. This is an opportunity to look at community needs, particularly if funding is cut.

Facilitator:

I’m going to correct a few things. The cuts in funding are not related to the merger. The funding cuts are related to the ongoing restructuring of the health system by the government. They will happen irrespective of whether there is a merger. That is important to understand.

Friends Member:

I understand that. The percentage growth of the population in Scarborough, Ajax and Pickering has never been factored into the funding – they just want to automatically cut funding. Does that really make sense? My point is that the smaller fringe programs will be cut in the process of the overall system cutback.

Facilitator:

To be clear, we are not going through an operational planning or budgeting exercise at the moment. We are trying to understand whether there is an order of magnitude benefit to merging in improving or maintaining access, finance and quality. We haven’t done any detailed operational planning, and that wouldn’t be done until, if there is a new corporation, the mid-to-late next year.

Friends Member:

If I can ask, what have been the criteria in terms of trying to make the decision at a high level? Without making some base assumptions, what are you using as criteria?

Facilitator:

The basis on which we are doing the evaluation is: what are the benefits and risks associated with a merger? There are four criteria that we used: collaboration, accessibility, sustainability and excellence. We’ve judged or are judging the various opportunities based on those four criteria. The fundamental question we are trying to answer is: are we going to be able to weather the storm better together or on our own? The storm is here already – the funding restraint is in place for the hospital system. That will continue for at least three to five years.

Friends Member:

So could you talk a bit more about the benefits of consolidation (Benefit point: “Consolidation may lead to increased quality of care”) – just to have that context? Different communities have different needs – the same service would maybe need to be provided in different ways. What informed the list of benefits and risks?

Facilitator:

These benefits and risks were identified through various consultations.  The point you’re referring to (“consolidation may lead to increased quality of care”) talks to the issue of critical mass. There is strong research evidence to support if you do larger volumes of particular types of care on a consolidated basis, then you have a greater chance of being better at it and doing it more cost effectively. Recently when we transferred cataract services from Centenary to Birchmount, we improved service because were delivering cataract services inefficiently beforehand.

Friends Member:

So how does that fit into patient care? That sounds like an institutional impact.  How is that better for the patient?

Facilitator:

Greater access and reduced wait times. As well, when you bring large groups of physicians together, they standardize equipment and procedures, which results in a more efficient and high quality operation. We spend less money per case, and we can do more cases.

Friends Member:

Under institutional impacts, you have “the reduced duplication of services” as a benefit. What informed that point, and how does it relate to the patient perspective?

Facilitator:

There are services that we are providing at each of the campuses which are low volume and not necessarily accessible for patients. There are greater opportunities to provide some of those services on a consolidated basis and improve access. Vascular is an example. Each institution used to have part time vascular surgery. That wasn’t a very good way of providing that high quality, repeatable quality service. Having aggregated the critical mass of services, the volume of activity, and having surgeons dedicated to providing vascular surgery, has improved the quality of service provided. The outcomes are better and the quality is better.

Another example could be the back office functions. Accounting and finance.

Facilitator:

There’s no question that as we are getting more specialized, give that a lot of services cannot be provided at every hospital – both in terms of manpower and the technology needed. These services require specialized units. It only makes sense to consolidate services to get better units and technology.

Friends Member:

In terms of the Report that you discussed, which will be going to the Boards, what would be the headings already covered in that?

Facilitator:

There’s an executive summary, a background, a description of what the current state is, there is a description of each of the risks and benefits –there’s a whole chapter on that – identifying the challenges and some of the mitigation strategies. There’s eight or nine sections – a description of the value proposition, a financial section, etc. There’s about 70-odd pages, plus lots of appendices.

Friends Member:

Thanks for that. It helps my understanding of what has been initiated through the LHIN and directed from the Ministry to provide a background in which financial cuts can be made and justified in this process. I think in my thinking, we have to place that against the background in which these two hospital corporations were first put together, with objections in both cases, and the failure on the part of government to come up with a plan to meld the different cultures of the two campuses for each corporation.

Facilitator:

First of all, this plan is not about funding cuts. It’s not about cutting service or programs – it’s about a way of managing with the changes in funding that we see. The second point is that it doesn’t matter how big the cheques are. Cultures are merged and created by leadership. In the absence of good leadership you will have cultures that don’t work, and in the presence of good leadership you will have cultures that do. Funding has nothing to do with whether the two cultures initially worked well together, but had more to do with how leadership was applied in bringing those cultures together.

Friends Member:

I accept those points. There were umbrella statements made by the Ministry when these two hospital corporations were initially put together, and as much as the communities tried to protect themselves, different governments, ministries and people took the directions of making their own decisions, regardless of what had been said originally. We have the community of Scarborough and West Durham with a very high level of suspicion with regards to anything the government initiates in our hospitals. That doesn’t have direct impact on what you folks have attempted to do, but it is a background for you to understand that we are suspicious. To expand that line of thinking, for a citizen like me I do not wish to see Rouge Valley and Scarborough either combined or remain separate and have the same kind of results that have been spread across the province from Niagara to Sudbury – cutbacks have been severe and have impacted the delivery of medical services in almost every community in Ontario. I don’t think it will come as much of a surprise that there is going to be a request from our two Friends groups that this process be extended in time, so that there can be a fuller discussion. I’m hoping that other people will make their opinions known – I don’t care whether they differ from mine or not. But having experienced the kinds of processes that have been set upon us in the past, which were not good – from a historical perspective, they influenced what could have been a very beneficial amalgamation of hospitals in dire financial situations. We need to see that there is actually a plan in place that people have looked at in detail.

Facilitator:

The status quo cannot stay – we know that. It’s unsustainable. I’m from Ajax, and I worked there for 40 years. This is an opportunity to really develop a health system – we don’t have a system right now. This is an opportunity for us to be leaders. All of the hospitals have guaranteed that they will provide a certain standard of services locally. This will allow us to amalgamate tertiary services – service will be standardized across all four sites, which will improve the services to the community, access to quality, and will make it more sustainable too. A lot of the tertiary services cannot be provided at all of the hospitals due to manpower and the technology needed. But 95% of services can be provided locally – it’s no different than sending someone to St Mike’s for neurosurgery then bringing them back here. All hospitals should have a Centre of Excellence that they should be proud of. This is why it is important to divide services fairly evenly across the sites.

Friends Member:

Would you say that it would be fair for the Friends groups and hospitals to ensure that there is a written request to that effect, regarding having a Centre of Excellence in all the hospitals?

Facilitator:

By all means, if that’s what you want to write that’s fine. I think it’s a belief that we generally have – to help to make each site viable and vibrant, you need something that differentiates it from the others beyond just being a routine community hospital.

Friends Member:

I want to echo what [X] is saying, even though we are in a different location. All of us around this table will agree with you that business can’t continue as usual, given funding. This process is a good one. It is such a speedy push, however, and there is a discomfort level in only having a few roundtable discussions – maybe the community doesn’t even have the questions out there, in order to feel more comfortable and be able to assist in the process. From my perspective, this kind of “shotgun wedding” is too rushed. We do see value in the integration, but it’s how you do it. Some of the questions you raised about the services – we understand that. But the questions that we have, maybe we need more debate and more answers. We don’t feel we have adequate answers.

Facilitator:

That is fair, because we certainly don’t have all the answers put in place. So that is a fair comment. I would ask, though, what your view of the timetable is and what your view of what you would like to see through that timetable. What are you envisioning in terms of time and content? What would you see the process being in that extra time?

Friends Member:

All I’m hearing, based on the concept you are working on, is that you aren’t looking at the current status of the program and feedback from the community. Where would that fit in? We aren’t objecting to the integration. The reality is that this is related to funding, but how do we do this process while being accountable? The transparency process is what we are hoping to see. I agree with a lot of the points you raise, but how do you implement them practically, within the budget and resources? We want to hear that you looked at population and service needs and demands – how much cardio and nephrology is needed at Scarborough site compared to the Ajax site. Has transportation been addressed? Those are the practical things we want to see addressed.

Friends Member:

I’m going to say that you’ve probably done an awful lot of work on this consolidation of services, for you to be analyzing risks and benefits and whatnot. You ultimately must have a vision of what the health system is going to look like; where the Centres of Excellence will reside. A draft vision should be made available so that the communities can see how the changes are going to come and they can develop the questions they may have for you. If we had an idea as to how everything is going to roll out –because ultimately this kind of work, you know what kind of services are going to be at which sites, where the Centres of Excellence will be.

Facilitator:

Actually we don’t.

Friends Member:

I find that hard to believe. You have to know where the services are going to be.

Facilitator:

I’m sorry. We have not done the planning to the service level. We have not looked at where we are going yet.

Friends Member:

I find that really hard to believe, for business acumen. You’d better have a goal, you can’t get all this done without the goal.

Facilitator:

We have a goal, but we have not done the planning as to where individual services will go.

Friends Member:

You have to have a vision as to how the system will roll out.

Facilitator:

We’ve said we will commit to 24/7 ERs. The four campuses will continue for the foreseeable future, because there is not the physical capacity for any one hospital to close. We’ve also said that the detailed planning will come later. We believe there needs to be a full engagement of the community in the detailed planning of the siting. We are committed to having the community involved in those discussions and participating fully. What we’ve done is, looking at a high level, finding order of magnitude opportunities to improve services, maintain services or reduce costs. We’ve quantified those – but we haven’t said that we are going to provide service X here and service Y there. That detailed analysis is the next step post-merger.

Friends Member:

But why would you do that post merger?

Facilitator:

Let me speak about how our clinical teams came together. Our clinical teams looked at which clinical services were offered at our sites. As much as our organizations should be working together due to our geographical closeness, we aren’t right now. We brought physicians together from all campuses to find the possibilities of working together. That’s the level of conversation we’ve gotten to with our clinical services. It’s not about where we place cardiac services – it’s about how we could come together to reduce duplication, increase quality. What would be the benefits of cardiology coming together? What would be the risk? It’s really the beginning of the work.

Friends Member:

So ultimately this whole merger should be a lot longer in a time-span. Right now the impression is: ‘we’re consolidating, we’re merging’ – but you have no idea what the end result will look like. So you shouldn’t merge until you have a vision.

Friends Member:

Maybe we could consider looking at what the LHIN identified as the concerns and how it should be done in a vision. In other words – don’t make the merger decision, but present the issues and look at them properly before we actually make a decision. Find the pieces before you actually make a decision, and that would go towards resolving the timeline issue.

Facilitator:

The integration discussion has been going on for years and years with no results. You need a push to make things happen. In a merger, you will have to make these kinds of decisions.

Friends Member:

I disagree. You’re talking about four hospitals. You’ve committed to the 24/7, but because integration is going on and because of the government push to funding, even though you may not make any decisions based on money saving, as a patient that’s what matters. To have that impetus to force the merger then make things happen, I disagree.

Friends Member:

If you presented a vision outlining the benefits, you would get more support from the community. When they see the advantages out there for the community, they will be able to get on board. I think that will be better supported and received by the community when they can see what’s in it for them. Right now the government wants our money so we have to look t doing what’s best.

Facilitator:

So you’d like to see that level of detail before a merger.

Friends Member:

It doesn’t have to be completely set in stone, but you should be able to tell us where the Centres of Excellence are going to be.

Friends Member:

As someone without a driver’s license, all of this worries me. You need to identify risks and what would need to happen in order to mitigate those risks – and make it truly patient-centered. Being able to say here are the benefits, and being honest about what the risks are and how you will manage them in a way that will still result in patient centered care, will be important. Without the patient focus, it is easy to get lost in a system.

Facilitator:

There is a difference between emergency services and elective services. For elective services, you already have to travel to different hospitals.

Friends Member:

To go down that road just because ‘that’s how it happens already’ isn’t a good answer. Going to Bowmanville or Centenary for cataract surgery when you live near Ajax Pickering isn’t fair, and that’s what happens now.

Facilitator:

If you have an expectation that there will be every service in every hospital, that’s not reasonable.

Friends Member:

But if you are saying that we are going to consolidate, and you have to figure out how to travel to the new site, that’s your problem, isn’t fair.

Facilitator:

The reality is, for elective surgeries, each of us has the responsibility to get to the elective surgery. That’s what happens right now. A lot of this community goes elsewhere for their care. Ajax serves 30% of its catchment area in terms of services. All the rest go west. Scarborough on a service by service basis, our market penetration is anywhere from 30-80% depending on the service, but there are a lot of people getting elective surgeries outside of the local hospital. We can’t site elective surgeries in all local hospitals – it’s not economically feasible or practical. We can’t give everyone absolutely equal access to all services.

Friends Member:

You need to show us where specialized surgeries will be offered, as well as which services will be based at all hospitals.

Facilitator:

So you want a detailed service plan showing where all services will be offered, post-amalgamation?

Friends Member:

Yes. And we want to be able to debate that prior to the merger decision.

Friends Member:

With the Centre of Excellence for cardiac care, if someone has a heart attack and they drive to Birchmount, they have to be stabilized and then brought here. How much use of ambulances are going to go towards transferring patients between these four campuses?

Facilitator:

We don’t use ambulances for inter-facility transports. We have contracts with non-emergency transport services to do inter-facility transfer. We use private ambulances and the hospital pays for it.

Friends Member:

Surely that’s expensive.

Facilitator:

It’s way less expensive than having millions of dollars with of cath-labs in each hospitals, and specialists in all four sites. You wouldn’t have the capacity to accommodate that.

Friends Member:

I want to get back to the point about some of the programs. The Centres of Excellence are a good idea. The reason people go downtown is because the quality of service is not available here. It is much better to go to a local hospital than downtown for a service. We need to delay the process and get more facts to be more comfortable with services. So if you set up the services, we have a duty to tell you what we don’t agree with, or what we think can be improved. Identify where the programs are, and we will be able to give you feedback. Please consider that type of thinking.

Facilitator:

The Centres of Excellence must have a certain volume of patients to make them worthwhile. If you don’t have a certain amount of patients, you won’t have enough resources in terms of physicians to make it a Centre of Excellence. So these Centres of Excellence aren’t just willy nilly – there are standards where there is definite evidence that providing those services are beneficial for the patients.

Friends Member:

Do you have any idea what Centres of Excellence are coming to Ajax Pickering?

Facilitator:

No. As we have already said, we haven’t gotten to that level of detail, it hasn’t been provided.

Friends Member:

When you say ‘we’, who are you referring to?

Facilitator:

Staff here, CEOs, the MPPs, people in general. Everyone agrees with the concept that there should be some Centre of Excellence at each hospital, and that would give them pride and some buy-in to their hospital. What that particular service would be, has yet to be decided.

Friends Member:

What I’m asking is – who makes that decision?

Facilitator:

I would think that would be the decision of the new Board.

Friends Member:

Wouldn’t your team be able to tell the Board what the hospital is good at, what your numbers are, etc. You can’t have so many Centres of Excellence if you want to control your budget.

Facilitator:

The thing is, as I mentioned, if you have one stroke unit that services 300 people, and three other units that service 100 people each, the 300 person unit would be much more efficient, and higher quality, for the patients.

Friends Member:

But you’re looking at it from the system perspective. This community used to be a car-based society and people got around in cars, but in the last forty years people started using public transit to get around Scarborough. It’s becoming more of a criterion for transportation. Any time you talk to community groups, the first thing they will say is: how do my constituents get to the site? Say you do establish a Centre of Excellence in Ajax and a patient in southwest Scarborough has to go by transit to get there – so how do they do that? Not everyone can afford a 60 dollar taxi to get to Ajax. We aren’t concerned about the Centres of Excellence – they are the kinds of things we rely on you to figure out. But I’m out here as an end-user of the hospital saying how are you going to meet my healthcare needs without making it impossible for me to access the service? You are looking at a million people being serviced by 4 sites – first generation immigrants from East Asia, mainland China – not everyone speaks English. These are the realities that we are worried about. If you make a mistake at this stage, how do you go back? Once you say ‘we’re merging’, how do you go back if you’re wrong? We need some kind of agreement on how we are going to get to where we’re going. We all have different concerns, but at least we are talking about it before the decision is made. Just because the Central East LHIN has said ‘thou shalt merge’ – that took me by surprise.

Facilitator:

There’s a different definition of Centres of Excellence for different people. What I was trying to say is that, right now, if a patient comes in for vascular surgery, we have to phone around to different hospitals to find out who has a vascular surgeon available to treat the patient. There’s no process for getting a patient in. If you have a merged organization, you can make sure that someone in your organization has that particular service – whether it’s Scarborough General, and the patient comes into Ajax, we know that there is a service and a surgeon at General who can attend to them. All these different services would be available in our region and in our hospitals. The patients, when they come to Emerg, they will be moved for a particular procedure if needed, and then will be moved back to their local hospital by us. So transportation is not an issue. And the vast majority of the patients don’t need to be moved at all – it’s only for more specialized care. This can provide complete care.

Friends Member:

Can we go back to the community concerns rather than the operational please? Based on what [X] is saying, the history of the lack of trust between the community and the hospitals, and the fear of turning the clock back, is a very serious matter to us. The latest iteration was the Refresh – and there was a gap between the community and the patient care of amalgamating or doing the changes, which we did not support. Again, it comes back to maybe more time. All of us are saying that this is too speedy.

Facilitator:

So you would like to have a more in-depth process for service planning before any decision around merger is taken?

Friends Member:

The first two items of the LHIN directive, in terms of backroom integration and all that, we didn’t have a chance to talk about it with the community.

Facilitator:

So you don’t care if we have one board and one management, one back office function –?

Friends Member:

One board and one administrative staff that cares for all campuses equally – I can see that as a big savings. But “equally” is the operative word.  My husband had to have an angiogram this last summer and we had to drive far to have it done. If we didn’t have a car, that could have been an issue. He didn’t go in through Emerg, which takes care of that issue. So when you are presenting that plan, and someone has to go in for scheduled surgery, it shouldn’t be based on transportation.

Facilitator:

If you are having an elective procedure, the physician has determined that it is not a life threatening situation.

Friends Member:

The point is, you have to get to the hospital on your own.

Facilitator:

You have to go back to the reality: you can’t have every service in every facility.

Friends Member:

I agree with the Centres of Excellence. But you have to be sensitive to the needs of the community.

Facilitator:

The issue of transportation did percolate up through the community roundtables. It is top of mind for everyone at present time, so no one misunderstands the issue of transportation, particularly between Ajax and Scarborough. That is recognized.

Friends Member:

So when will that get fixed? When you have to take an Amtrak train to get to Ajax, that’s a reality.  It’s a problem.

Facilitator:

Hospitals don’t manage regional transportation – the City and Province is responsible for that. The point is well taken, and when we look at the example of cardiac, we know we have to work with partners in EMS and have some creative transportation solution.

Friends Member:  

It’s not just about transportation. It needs to be culturally sensitive. If what ends up coming out is Centres of Excellence and I have to move services, that needs to be named – people need to hear that it’s been part of the thought process and discussion.

Facilitator:

That would be a standard service – there would be over the phone translation at all sites. That’s one of the best practices that we would move to all sites.

Friends Member:

It’s not just language. It’s about cultural sensitivity too, which can’t be provided over the phone.

Friends Member:

In terms of what the overall vision and picture would look like, and how we would fill the extension of timelines – in my experience with the LHIN in this area, my recollection is that the LHIN initiates committees to create programs to suggest solutions – and there is only one committee that got completed and selected by the province. Others they ended because there were no more funds available. All the efforts that people were putting into committee work just vanished. I would only guess that you have experienced that kind of thing as well. One of the uneasy portions of this merger process is that I want clarification from the LHIN or ministerial level – it’s not the responsibility of the CEOs of these corporations to provide assurance that the LHIN will follow through. We need some direct contact with the LHIN to get our assurances that they will deliver some responses to our question and suggestions for what we would like to see in a merged corporation.

Friends Member:

You don’t have authority over the LHIN. Do you feel you have a lot of influence, or are we whistling into the wind?

Facilitator:

If you look at it from the points of view of the two hospitals, we have a clear and present danger. The funding is flatlined and costs are escalating. Our challenge is to enhance service availability. We are looking at this as individual hospital corporations and asking if we can do this on our own, or whether the damage is less if we can do it together.

Friends Member:

So you’re being told the parameters, and you’re doing the best with what you have.

Facilitator:

It’s no secret to anyone in this room that the province has a funding problem. Forty two percent of the budget of the province is spent on healthcare. There’s an impact on healthcare which we are seeing at the operational level – we are trying to maintain services within the face of that funding constraint. That is the reality that we face and that clear danger is now. It’s not six months away – it is now.

Friends Member:

The whole issue of funding and withdrawal of services is going to be a big issue. It’s a matter of trust – people will be very concerned with what services will be available. Wait times are a key measurement for you, I’m sure – and it’s a concern of the public. If I have to wait a year and a half for a hip replacement, that’s a problem. Wait times and those kinds of issues are going to be important to patients – what I think you’re hearing from people is that we are conservative, not willing to go out on a limb without assurances – and there is a concern in this room which is reflected in the community that the decision to go right to merger and not look at the other options is a big leap of faith. We’re sitting here thinking ‘I don’t know if merger is the right decision based on the population which is as large and diverse as the one in this community’ – what you’re hearing tonight is that we would like to understand to a deeper degree what you are going to tell the Board on the 12th, and do we agree with that. Right now, we don’t know what you’re going to say to the Board. The Community doesn’t know what’s going to happen.

Facilitator:

Maybe we should talk a bit about that process and timetable, which might impact your thinking. I’m not sharing the bottom line of the report with you, because the ILC hasn’t finalized it. The decision by the hospital boards is not an irreversible one. It will be a decision in principle, to continue with further analysis. The analysis that has been completed does not, at this point, contemplate a more detailed clinical services plan. The rationale for that has been that we need to have more time around the planning for clinical services. We were envisioning that clinical services planning would take place post merger, because the merger gives us the opportunity to streamline back office and administrative services in the next 18 months. The clinical services planning would happen once back office has been merged, because we do want the community involved in the clinical merger planning process.

After the Board decision, there would be another decision as to whether we actually go ahead with it later in this fiscal year – likely in March. That would be the next step. But clinical planning is going to be out 18 months at least beyond that.

Friends Member:

This is taking into consideration what the hospitals want, not what the community wants. If the CEOs and Chiefs of Staff say “YES” to the Board, it won’t matter what the community wants.

Facilitator:

I don’t agree with that. We have deliberately spent a lot of time and effort talking to the community. This is the third meeting we’ve had with you as representatives of the Friends organizations. We take it very seriously, and the Board is going to be cognizant of what the community is saying, and what the concerns are. I will be sharing your comments about timing with them, because I think it is an important point that they should hear, and should factor into their deliberations. They need to hear what the community thinks.

Facilitator:

From a physician standpoint, the majority of physicians would much rather just carry on with their practices and the status quo. The fact that a lot of physicians think that the merger is not a bad thing is because they are taking the community need to heart. They see what the services are like now, and they see the potential for the services to improve for patients. That’s why the physicians are, for the most part, onside with a merger, when it would be easier on an individual basis for them to continue on as normal. They aren’t looking at their personal needs – they are looking at the community. And that’s what this is all about.

Facilitator:

As you are all aware, we have a real challenge with facilities – particularly the facility conditions in Scarborough. The three physical facilities in Scarborough are not the greatest, in terms of maintenance. That is an operational challenge which is a big issue. In Ajax, the issue is one of capacity – we can’t grow services in the Ajax facility, because we are at capacity. So one thing we are trying to work through at the present time is: what are the opportunities for renewing facilities and looking at expansion options in this integration process?

The other issue is in regards to market share. Both hospital corporations are under-servicing our communities based on the funding formula, which is based on cost efficiency and ability to service the needs of the community. Both hospitals are on par in terms of cost basis, but are clearly under-servicing our communities. By working together more closely, we could repatriate services so we can service patients more effectively. And if we do that, it would increase our funding. So these two issues – facilities and funding – are important.

Friends Member:

The $27 million shortfall that you have alluded to – how much of that is debt financing?

Facilitator:

Virtually none. Interest rates on debt are, as you know, at historic lows. The amount of money that is spent on interest servicing is minimal – less than a million. The $27 million is the difference in the cost curve and the revenue curve. We have flat-lined revenue and escalating costs, and the $27 million is the difference. 70% of our costs is people – it is what it is. If you have flat revenue and no caps on day to day cost inflations, that gap will grow.

Friends Member:

I understand there is a certain timeline for this. Will you be submitting two separate budgets for the 2014 financial year? The budgets will need to be in by January – will you be submitting two or one?

Facilitator:

Two. We aren’t amalgamated yet. In terms of the timetable, the November 12 meeting would potentially be an approval in principle. There wouldn’t be a final decision until sometime in March. If that decision in March were to say “yes we merge” – then the two separate budgets would be rolled into one on April 1st.

Friends Member:

That is scary. You are talking about three months between the principle and the final sign-off. What we are appealing to you is that, can the timeline be reversed?

Facilitator:

I can take that forward, for sure. These are publicly available notes, and we can take that forward, for sure. What do you think the timeline should be, from your perspective? We won’t be planning for clinical services for 12 to 18 months – if you were to merge the organizations, you would have to put the management teams together, hire a new CEO, appoint a new Chief of Staff, build the medical and management leadership teams, and deal with the back office infrastructure so you have some IT capacity. So you won’t be talking about clinical integration for at least 12 to 18 months post April 1. So what do you want in terms of timetable?

Friends Member:

I don’t know. All we are asking is that we have time in order to have a vision, in a general manner, to better understand what is happening. Maybe not to the level of integration of services, but at least to have the general view, in order to feel more comfortable in supporting or not supporting the merger. You would have a better idea of what the integration would be. I don’t have any answer for timeline –what do other people think? It’s not fair for the Board to make a decision in November.

Facilitator:

They aren’t making a decision – they would be pushing it forward to the LHIN.

Friends Member:

You said something that has been gnawing at me. The physical facilities in Scarborough have not been maintained, and we are at capacity in Ajax. So if you have funding dollars, the budget will go to Scarborough. It certainly won’t be going towards expanding services in Ajax Pickering. That worries me.

Friends Member:

In the past five years, I’ve used facilities at four hospitals – and of the three in Scarborough, Rouge Centenary is the most updated. The word in the community is to not go to the Scarborough sites for care.

Facilitator:

We have spent $50 million in the Rouge sites over the past five years to fix a number of problems. We literally fixed leaks in the roofs. That’s a reality we face. Those sorts of maintenance costs do come out of the operating budget.

Friends Member:

Six months ago, you heard a bunch of docs talking about a super-hospital – and one hospital in the middle of Scarborough isn’t going to be met with happiness by a lot of Scarborough residents. So who knows what will happen in the next ten years. Our hospitals are community hospitals, and they should be maintained.

Facilitator:

But again – the revenue line is flat. The number is not increasing. The question is, what do you do with the money? You have a choice: how do you best spend the money? Sometimes you have to make a choice between keeping the lights on or not.

Friends Member:

You’ve talked about moving services out of the hospitals into private clinics. Then the hospitals won’t require as much capacity once those services have been taken out. Will that affect the amount of money that hospitals receive?

Facilitator:

When services move out, the money moves with it. But that is a very slow process, and quite frankly it is at the margin. It’s not a huge impact that it would have.

Friends Member:

But it will affect your costs.

Facilitator:

It will lower our costs, yes.

Friends Member:

That’s what is happening with our mental health services in Durham. We have emergency functional services at Ajax, but a lot has been moved into community care facilities, right?

Facilitator:

We fund one of the community agencies in Durham to support crisis beds in the community.

Friends Member:

The hospital does?

Facilitator:

Yes.

Friends Member:

So that’s a cost. But you still get the revenue?

Facilitator:

It’s money we’ve chosen not to spend internally – we spend it with a community provider, because they provide the service more effectively and cheaply than we do. We write the cheque, but we also free up beds within the hospital.

Friends Member:

So this whole moving of services from the facility to a community service – is it on a sub-contracter basis?

Facilitator:

In that one specific situation it is. But not in general. The strategy that is being implemented is basically to move procedures and clinics out of the hospitals that can be provided, in theory, more efficiently elsewhere.

Friends Member:

But once it’s in the community, does the hospital cut the tether or provide oversight and budget?

Facilitator:

Generally no. The money comes out of the hospital, and then it is funded directly to the community agency by the LHIN. But this is not significant at present time.

Friends Member:

Would you be able to reverse your decision if you merge?

Facilitator:

It would be very hard to undo after merging. One observation I have is that the work the two organizations did in talking about how to do things at the clinical phase, how to do things at the front of the line, that has really advanced the “shotgun wedding” – that was a really effective ‘dating’ process, and I think that irrespective of what happens, over the next few years the ‘dating’ process between the hospitals has to continue. Personally I believe that the merger is the right thing to do, because it creates a single structure of accountability – you get ‘one throat to choke’ to make things happen. Right now there are a lot of different people with different views. You need the accountability to make things happen, and we don’t have that today.

Friends Member:

I don’t know how to respond to your question about how much time should be added in the request for an extension. What I would suggest is that any comment in the report to the leadership committee group notifies the LHIN that the community is really interested in this issue, and we want to talk to the LHIN in a meaningful way. So if the extension is, for the sake of argument, three months, we would want to talk to the LHIN.

Facilitator:

A few thoughts. Given that November is not a final decision, could that further engagement and discussion be concurrent with the other work that the hospitals would need to do to prepare for a merger? That’s a question for you – could it be concurrent? The second question is, if we addressed the issue of timing as to when and how we would start to approach the discussions around clinical integration post merger, if we put some clarity around that timetable, as well as how we would engage you in the broader community, would that help allay some of your concerns?

Friends Member:

I think so. It would go a long way down the road. What you’re talking about is a memorandum of understanding – as long as we understand the rules of engagement, we could do the engagement in parallel with the post-decision process. What people are saying is that there is a spirit of trust that still needs to be built. If the community is willing to meet halfway, there has to be some kind of document that both sides subscribe to, to ensure that our views aren’t ignored.

Friends Member:

I really commend this process. It is very positive, and I thank you for that. I think you are very sincere about the community engagement, and I thank you for that. And the fact that we have been able to have a ‘date’ between the Friends groups has been very positive. This has been a wonderful process, and please convey that to Robert. Please take our concerns – we have very common concerns between our groups, and they are legitimate – we want things to work, and we don’t want to end up with a divorce down the road.

Facilitator:

It’s about finding a way to do things in a reasonable time frame. The clear and present danger, operationally, is here for the hospitals. We have to deal with these exigencies today, and this is a way of dealing with it. Part of it is administrative and back office restructuring, and the only way to get at that is through a merger. That is the reality. The clinical stuff is down the road.

Friends Member:

The decision on November 12 is imposed by the LHIN, isn’t it?

Facilitator:

Yes.

Friends Member:

Is there any way to push that back?

Facilitator:

What we are saying is that we need to have some more process post-November already.

Friends Member:

Since we are coming into a busy season with December, would it be possible for us to get together and review the Board recommendation that is presented in November?

Facilitator:

I don’t see why not. Absolutely. The LHIN will want to hear from interested parties.

NOVEMBER 18th – JOINT FRIENDS MEETING TO DEBRIEF ON THE REPORT

©2013 Leading For Patients
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