LEADING FOR PATIENTS
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LEADING

FOR PATIENTS

Union Presidents Roundtable

7 October, 1:00 – 2:00PM

Facilitator TSH: Robert Biron

Facilitator RVHS: Rik Ganderton

General Comments

  • Concern that engagement is not reaching front-line staff
  • Need to address job security concerns of general staff

Benefits

  • Economy of scale

Risks

  • Patients don’t know where to access service
  • Accessibility to mental health services
  • Merging hospital cultures
  • Lack of metrics or financial information associated with merging
  • Funds spent on merging, rather than patient care
  • Cost of merging programs
  • Mobility of workforce
  • Hospitals “taking on” each others’ deficits
  • Job Security
  • Retaining quality of service
  • Fear that promises will be broken by a merged Board

Transcript

Facilitator:

What do you perceive are the benefits and/or risks?

Community Member:

Strength in numbers has always been cited as a benefit – but honestly, I’m more interested in talking about the risks. I’ve seen a lot of your slides which say that a bigger hospital can raise more funds, hopefully get better programs – and it’s addressed in your accessibility slide, that with larger numbers, you get more funding, etc. I didn’t see any mention about accessibility for residents to get to a hospital service or health service. I’ve seen a lot of programs transition from the hospital to the community, and the concern and risk is that patients don’t know where to go for services – they’re used to going to the hospital for a particular service or clinic, and now they may have to go 12km away for that same service. For Scarborough, where there are not any subways, people have to take the bus – not everyone has a car. I didn’t see that accessibility addressed, and I see that as a risk.

Community Member:

Actually, I don’t see that as a risk. I think integration in a rural setting would have a more significant impact on people, in terms of transportation – there’s less transport services. But we saw the radius between the three hospital sites, and the federal government just pledged money to a subway system where we might have a subway stop right next to our hospital. In terms of accessibility and transportation, they’re so close that I don’t think it would be a problem. An extra kilometer or two here or there wouldn’t be a huge risk.

Community Member:

Transportation-wise, we’ve already moved mental health out of Ajax into Centenary. Would you be looking to move things to one site? Mental health is at Birchmount and Centenary. Would mental health end up at one site?

Facilitator:

We don’t know. Those types of decisions would rest with the future Board and administration of a merged hospital, should we merge. It would require detailed program planning and stakeholder engagement to make substantive changes as you have described.

Community Member:

It’s already a sore spot, given that mental health got moved out of Ajax to Centenary. When that happened, accessibility dropped. When people are in crisis and need to get care, they don’t need extra transport time on public service. A patient out on the street in crisis doesn’t always go to the emergency department – they are often transporting themselves on a bus while in crisis.

Facilitator:

Ajax has crisis supports available. The patient would be transported at our cost. So the issue that you see is that treatment is not as close to home as people might prefer.

Community Member:

Yes. And if they do go, they have to travel farther, on public transport.

Facilitator:

Our emergency departments are equipped for transporting patients in crisis. You don’t necessarily have better or faster access by going to the facility with mental health beds, because all of the hospitals are triaged in terms of accessing those beds, regardless of the entry point.

Community Member:

People in a mental health state don’t want to be far away from the services they are used to.

Community Member:

I think one problem with Ajax in particular is that transit is not well linked between Durham and Scarborough.

Facilitator:

That is why we won’t move services between the communities.

Community Member:

You need to look at siting in the long term – that remains a concern for people who are not well connected. Rouge Valley is a big gulf for a lot of people.

Facilitator:

So your risk is the uncertainty of what impact a merger might have to a service. The reality is that the two communities we serve are distinct, in many ways. The other thing you should note is any changes in service would be planned out by the future merged Board. Opportunities to create Centres of Excellence and consolidate services – would be a future action which wouldn’t be done immediately. It would involve an exercise of planning and engagement.

Community Member:

At the Scarborough Hospital during the Strategic Refresh, we had an expert panel at the Scarborough Civic Centre. What was clear there was that when General and Grace [TSH Birchmount site] merged in 1998, they weren’t successful in amalgamating their cultures. They were extremely different in the way that they thought. Now that we are potentially getting bigger, how will you address the culture?

Facilitator:

That question has been raised before. I want to respond to the Birchmount and General merger – my impression is that there have been many success stories in terms of integration between the two sites; but there are some departments that struggled with it. The performance of both sites are exceptional; the eye centre; mental health programming in general is integrated very successfully; and staff rotate between the two sites in some departments like Emergency Department physicians. However, the point is taken that ‘culture eats strategy’. We need to pay attention to that.

Facilitator:

We have had similar experiences between the two Rouge sites as well – and between TSH and RVHS already. We have good examples of merged services – radiology, for example – so we already have an example of cross-organizational services. That does exist. Mental health is another good example, as psychiatrists function across sites.

Community Member:

In the workbooks I’ve looked at and in the example of Scarborough General and Birchmount merger, we have identified that there have been mergers in the past. What hasn’t been clear is how those mergers benefited the community, the bottom line, etc. We seem to be addressing this in the sense of: can we merge? Is it physically possible to merge? Rather than, if we merge, this is what the benefits could be, and this would be the cost. Everything is all about how we can’t make these decisions until we actually merge; so we don’t actually know if it’s a good idea to merge. I’m struggling about whether it’s a smart idea, because I don’t know what the end result would be. There’s a risk associated with anything like this – and I don’t know if it’s worth the risk.

Community Member:

Let me put it another way. The rumors in the hospital between medical practitioners and coworkers is that we will merge, and will take a one-time amount of funds to facilitate the merger, and then after the merger we will still have the same fiscal challenge, same funding formula changes. If we’ve spent all of our money on merging, there will be service cuts.

Facilitator:

I think your point is totally valid. You also need to look at it in terms of what would happen if there was no merger. Those constraints exist whether we merge or not – the funding constraints, the growth, the inflation. The question is, can we weather the storm better together, rather than as individual hospitals?

Facilitator:

Just to build on that, when we look at some of these issues we need to look at them longer term. We know we have a new funding formula which has introduced a level of competition among hospitals. Essentially it’s a fee schedule which encourages you to capture the volume of patients. The downtown core is particularly well positioned to capture market share. We also have a very fast growing Durham community. The hospitals are competing for the same funding envelope; and right now we are competing with each other for the same community. Does that make sense, when we are servicing the same community? Can we better position ourselves longer term to get our fair share for our community? They are going to continue to constrain hospitals in terms of funding; we will continue to see a growth and aging of the population, and we need to absorb those costs. Can we do that more successfully together?

Community Member:

The workbooks seem to be focused on standardization of policies between sites, which you can do merged or not. That’s not even the right answer. Instead of standardization, you need to look at best practices. The other thing I’m seeing a lot of is that we don’t even know if things are possible to do – if staff will be able to go across the four sites, for example. There’s so much uncertainty. The only thing I’m seeing is increased transportation costs. I’m not seeing anything in the workbooks that says: if we do this, we can reduce costs by this amount; therefore we should do it.

Community Member:

I saw a lot of, ‘if we merge child/adolescent programs, we will need $X in capital costs to merge.” I’ve seen more examples of the cost of merging rather than the savings which would be accrued. The clerical union president at Scarborough is concerned that there would be fewer clerks, fewer secretaries, fewer management staff. We’ve seen other hospitals when they merge, they have a CEO and a ‘site vice president’ – so the CEO still makes more than he did before. And there’s still site vice presidents as well.

Facilitator:

Those are all risks that you’re raising. I think the environment is a lot different than when the Restructuring Committee merged hospitals in the 1990s. This is a different exercise; we are going into this voluntarily, and we are looking at all of the options. It will involve the hospitals looking at quality improvement, access to care, and positioning our communities for long term success. A lot of these operational things will have to work themselves out program-by-program. The workbooks were intended to provide some value proposition from a high level. They look at opportunities, best practices, and cost out what it might look like. The savings are calculations that still have to be worked through, and they will still be estimates at the end of the day.

Community Member:

I think we can assume that strength in numbers – upcoming capital projects and consolidation – will be a good thing. One thing I have also taken from the workbooks is that more than one working group recognizes that Scarborough demographics need a lot of healthcare. I haven’t seen so far either hospital publicly saying to either the Ministry or LHIN that we have a lot of people who need healthcare dollars in our community. We have more diabetics, more hypertensive patients; and all we have read so far is that we have to cut money and combine to compete. There’s no proposition that I’ve seen that says we need to combine in order to treat our sicker patients, better.

Facilitator:

The socio-economic factors of our patients are factored into the current funding formula, HBAM [Health Based Allocation Methodology]. HBAM takes those socioeconomic factors into consideration when they look at hospital resource needs. We do know that HBAM and “patient based funding” are being phased in, and it will take time for dollars to shift to where the needs are, and that’s the purpose of the new funding formula. What should motivate the hospital is, are we adequately serving the community in terms of market share? It first of all impacts access to quality, because the patients are traveling elsewhere for care, and it also impacts our ability to gain funding as well. We will be motivated to provide high quality, accessible care so that the dollars follow.

Facilitator:

We know right now that we are under-serving our communities. That’s what HBAM shows. The funding formula will sooner or later shift to reflect that under-service.

Facilitator:

There’s enough attention being paid by the hospitals that we hope we can get it right. The results speak for themselves, in terms of whether we are over or under-servicing our community. We know we can do better, in terms of market share. There are also opportunities in terms of looking how we can position our programs for larger provincial programs and services. How can we bring departments together into more cohesive programs?

Facilitator:

One of the risks I’ve heard from you before is the mobility of the workforce –what is the impact of potentially having to work at multiple sites?

Community Member:

It is a long distance having to work between Ajax and Centenary.

Community Member:

And we don’t have cross-site language.

Community Member:

If you spread people too thin you will have quality issues. If you want one X-ray technologist working at all four sites, he will be constantly moving around, constantly traveling. You currently have enough staff to take care of all four sites. What are the benefits of having one person do the job that three people are doing right now?

An integration will create a lot of work for a lot of people over the next few years – and during that time period, we will have to ignore all other issues, because this will be so time consuming.

Community Member:

There is the challenge of disruption going through this process. There were a number of issues parked at a meeting yesterday because things were eclipsed by merger discussions.

Facilitator:

We are still moving forward on patient care. If we don’t move forward with a merger, we will have to move forward in looking at next steps for dealing with these constraints anyways. The problems aren’t going away, nor are the transformations implemented by the Action Plan for Health Care. This agenda of moving dollars away from institutional care into the community is something that any provincial government will continue with, so that policy direction won’t change.

Community Member:

Have you looked at all at the Niagara health system? Because that is a merger that was pretty disastrous from the start.

Facilitator:

The demographics are different – Niagara has a range of rural hospitals to urban hospitals. It is a different geography and a different set of scenarios, with many more small communities. In Scarborough, it’s pretty condensed.

Community Member:

I’ve heard that even if we don’t merge, TSH needs to cut approximately $28M, and Rouge needs to cut $13M. Is that correct?

Facilitator:

What we know is that next year, we do have challenges before us. Those numbers will fluctuate depending on the assumptions you used, and how much we expect to get from the government.

Community Member:

My point is that for our staff, over the years Rouge has worked diligently to get the deficit down, and we have suffered the consequences in terms of cuts – but we have gotten our numbers down. Now if we amalgamate, the numbers will go up again; and our Rouge family will suffer even more than we would have had to suffer if we stayed independent. We will soak up half of the cost of debt that TSH has; and our staff have already worked diligently to bring our number down.

Facilitator:

Both hospitals have gone through significant transformation over the years. We’ve had $17M dollars of change in the current cycle we are in. Both hospitals have had their own journeys, but they have both had significant challenges in meeting these changes. Your impression is that if one hospital has a bigger deficit than the other, the other may have to pick up the slack. I’m not sure if I’d frame it that way. In fact both hospitals have had to implement significant cost reduction programs and both have significant working capital deficits [debt].

Community Member:

Even if we merge, we will still have those cuts.

Community Member:

The combined number for 2014-2015 would be $28M. So the question becomes, if we don’t find enough savings…

Facilitator:

The reality is that the revenue has flat-lined. We know what the revenue will be for the next five years. We know our costs are going up. We know that non-wage inflation is running between 3 and 9 percent, and we know that there is an ongoing growth in demand for services. Whatever the combined budget is, we would have to absorb those changes within the combined budget. We would have to absorb those changes within the individual budgets, if we didn’t merge. Can we minimize the impact and disruption on a larger organization than on a smaller one?

Community Member:

I suppose part of the problem is that the people who control the purse strings are not in this room.  A lot of the fear is that even without a merger we will face flat-lined budgets. So I’m not sure either way if that particularly answers the question – there are suggestions about economies of scale, but that’s the struggle that we are seeing. A lot of people here have said that we don’t know if merger is the answer – we have so many obstacles, but the top one is the flat-lined budget, even though over the past five years healthcare spending has gone down in the provincial budget. Another problem is that once the merged hospital divests services into the community, there will be more transportation issues – we don’t know where those services will end up, particularly for communities with high poverty.

Community Member:

In all of the feedback I’ve seen in the workbooks, it’s all about how the hospitals are deficient in certain areas and how they could do more with more money. There’s nothing clearly saying that we can minimize staff- but in doing so we need huge investment in order to get a return.

Facilitator:

Isn’t that the message?

Community Member:

But is it attainable?

Facilitator:

That is the conversation we are having.

Community Member:

The workbooks don’t answer the question of whether it is attainable. If you have five operating rooms at each site, for a total of 20, and you merge, could you cut that 20 back to 15? The only way you could do that is if there is underutilized time, or if there is a technological innovation that speeds things up. If it takes four minutes to book at test under centralized booking, it doesn’t really save any time. But the workbooks don’t reflect that that is the current situation. So to me I’m looking at it and saying ‘it’s kind of a pipe dream’. It could save money, but would take a lot of money to get things going.

Facilitator:

You might be hanging your hat on these workbooks too much. We’ve started a process of asking high level analysis around what are the broad benefits and broad risks associated with a possible merger. The granular type of analysis that you are looking for by program, we don’t have the time to do that in the time given to us by the LHIN. We are trying to get to a point of reasonable analysis. When I look at the workbooks, they provide a lot of a sense of the benefits and risks – and that’s what we have to weigh. If we were to merge today, are those opportunities identified in the workbooks reasonable to pursue, and can we then look at them in the granular detail that you want to see. If I reflect on the Strategic Plan Refresh, that was eight months of heavy lifting exercises. So it gives you a sense of how much effort it would take to restructure a service between hospitals. This can’t happen over weeks; it is a long term exercise of planning.

Community Member:

Where did the funding come from for this planning for amalgamation? Are we spending more than we can recover?

Facilitator:

Both hospitals had restructuring dollars built into our budgets. It was included in our balanced budget for this year, so it’s covered.

Community Member:

But there is no additional money given to us by the government for this as of yet.

Facilitator:

Yes. But we are balanced with it. We didn’t ask for extra money, but that’s not to say we won’t approach the Ministry for this kind of investment. If we weren’t talking about a proper merger, there would still be a question around integration, which we need to do regardless of whether we actually merge or not. The focus of the LHIN was to create a planning cluster which looked at integration of front line, back office and leadership/governance. So they weren’t prescriptive about looking at a merger. When the joint board committee looked at these variations of potential integration, we looked at permutations which made us realize that we ought to take a closer look at the merger option, because at the end of the day we are servicing the same community; we are minutes apart; and we can’t create a shared vision as separate entities. There are various reasons why we wanted to focus on the merger, but if we didn’t merge we would still need to look at different integration options around delivering services more effectively in Scarborough.

Community Member:

I suppose the big surprise was the fact that you went straight to merger, rather than looking at other options first. A lot of other hospitals have shared back office functions, for example.

Facilitator:

There are very few, if any, hospitals that fully share back office functions when they are separate legal corporations. So that’s a myth – it’s only the merged corporations that can fully share back office functions. If you are separate corporations, then they are still responsible to report their finances separately, they have different collective agreements and payroll rules, for example.

Community Member:

Hamilton Health Sciences has contracted out its payroll function. And Plexus does joint purchasing.

Facilitator:

There has been some integration already happening; but the question is, in today’s environment, facing the challenges that we do, can you get more effective and efficient by being together. The other reason for the merger focus was the reality that we only had so much time to look at our options. To do a deep dive on all possible options was impossible given the time constraints. More importantly, we believe that there are some good strategic reasons why we needed to focus on the merger option as we outlined in the presentation today.

Community Member:

By next month, the high level review will be completed. Will we actually see the numbers in terms of benefits and risks? ‘We think there will be so many millions of dollars in benefits, versus so many millions in risks’?

Facilitator:

We intend to have financial analyses of the benefits, risks and investments needed. So we are going to need to summarize that in an “order of magnitude” way.

Community Member:

Has there been any discussion about the change in governance? We would lose a local voice; people in Durham have a split relationship with Centenary, and they would be pitted against three major hospitals in Scarborough. So would that change the board composition?

Facilitator:

We always try to balance the board to reflect the community in terms of ethnicity, cultural backgrounds, geography, etc. Those things would have to be contemplated in the formation of a new board. Most importantly, the both hospital boards are committed to establishing a “skills-based board” which is a leading governance practice.

Community Member:

Ajax Pickering is a very different community in terms of demographics. So instead of being one of two, they would be one of four. Are there any services at Centenary or Scarborough where patients are referred to Ajax Pickering?

Facilitator:

There’s been strong preference to keep the two RVHS sites together and focus on this merger rather than separating Ajax and having them potentially merge with Lakeridge. The data – referral patterns – shows that Ajax residents migrate towards Scarborough and Toronto for their care, rather than east in getting care.

Community Member:

Because I know the position of the Friends of Ajax Pickering is that they would prefer to merge Ajax with Lakeridge.

Facilitator:

You need to look at the referral patterns of the patients and residents to notice that there is a stronger affiliation with Scarborough and Toronto, than with Lakeridge. If a merged organization comes, it will serve essentially two communities – and there will be a fiduciary duty to ensure that all community hospitals remain relevant and viable. Services in Ajax won’t be moved to Scarborough and vice versa, and those are strong commitments that a future board would have to adhere to. The reality is that you will have to respond to growing needs in Durham.

Community Member:

Is the Centre of Excellence a ministry-term that can give us more funding?

Facilitator:

No. It’s a construct. But it does potentially position you for certain investments in certain areas. If you look at Cancer Care Ontario, they have regional funding. In the long term, if we had a regional centre is something that we have posed. Right now, it’s not as coordinated as it could be – but you can’t get there unless there is a common plan, a common vision.

Community Member:

I’ve started reading the notes from the roundtables of the other 15-16 groups. I think it’s the other CEO [Rik Ganderton] who commented that workers are apprehensive about this talk. I would say that my members are beyond apprehensive – they are worried. But at the same time, some of them have attended staff meetings, looked at the workbooks; and they are saying, ‘well they haven’t said anything yet’. They want to know: what’s going to happen to me? Until next month when you actually make the decision, everyone is still waiting. There are substantial numbers of people – usually at the lower end of the seniority list – who are asking, ‘what’s going to happen to my job? Will I be bumped out of a job?’

Facilitator:

The message I would say is that this is not an operating budget exercise. In November we will not release an operating plan that will delineate in detail how back office and patient services will be reorganized – that’s not what this is about between now and November. We don’t have the capacity to do that level of planning. It has to be carefully planned and we have to engage our stakeholders in a much more rigorous process. However, we can make a ‘big picture’ decision based on the information we’ve been gathering now. I suspect we are frustrating a lot of people right now – however, at the Board level you get a tug of war where you want transparency in how we come up with plans, so we’ve opened up the process as transparently as we can and we are still at the beginning of the process – so that will frustrate front line staff because we won’t know the granular detail for months.

Community Member:

I encourage you to acknowledge that frustration on the part of many workers, in order to allay those frustrations. Otherwise its left to us to tell our union members second hand what you are saying.

Facilitator:

I have been doing that already. I recently attended a nursing huddle meeting and the concerns were all about ‘what does this mean for my job’ – and we are doing our best to alleviate those fears. Those conversations will take place in the fullness of time.

Community Member:

A lot of the frontline staff don’t hear what we are hearing –they can’t get out to town halls. They’re panic stricken. Sure, you can have as many town halls as you want, but the majority of frontline staff can’t get to the town halls.

Facilitator:

In our hospital, there was an expectation that front line managers would give the key messages out to their staff – to have these conversations that we are having today. I’m not sure where you’re at in your hospital on that, but at my hospital they are being rolled out, and we are getting some feedback. There are key messages we want delivered to the front line.

Community Member:

Have you walked around and spoken to a few different departments? I think it needs to come more from the CEO level than from managers.

Facilitator:

Absolutely agree.

Community Member:

Before you provided set messaging, we were hearing some managers  saying ‘half of you will be gone’. This is the first time I’ve heard you say that this is not an operating budget exercise.

Community Member:

This is the most transparent exercise I’ve seen on this topic. This is more information than I’ve even seen, because if you look at the minutes of Board meetings, you’ve only got three pages of notes.

Community Member:

There is uncertainty in this – anybody who is thinking about this at all realizes there is uncertainty. What the merger process does, is it tends to heighten these concerns. Nothing gets people worked up like a merger in terms of what can happen to their jobs. There are elements of uncertainty because people don’t know what the landscape will look like after a merger.

Facilitator:

Again, there’s no hidden agenda, and as we said earlier, the reality is that all four sites have to remain viable. Emergency departments are going to remain open. We don’t have the infrastructure to close sites. So this is about finding untapped opportunities by merging for the long term.

Community Members:

We’ve seen in other mergers that promises are made and then a few years in they are broken.

Community Member:

Look at Niagara.

Community Member:

I’m comforted to know that between the Friends of Scarborough and Friends of Ajax, there are community groups which will advocate for keeping entire hospitals and programs open. But when you get down to the granular level, we don’t know if anything will stay open. If the leadership can acknowledge the frustration of the front line staff, that will go at least half way to gain recognition from them.

Community Member:

A lot of people just think it’s a done deal now.

Facilitator:

That is a false assumption.

Community Member:

If there was a commitment that people got to see the final recommendation before it goes to the LHIN, then that would be great.

Facilitator:

They will – the recommendation will go to the open board meeting on November 12, before it goes to the LHIN. So be there, because that’s when the boards have the opportunity to deliberate.

Community Member:

Part of the frustration is that people don’t really know what’s on the table, and they won’t see that until the final recommendation. I would think there would be some idea of savings or assumptions on savings that would go into the final report.

Facilitator:

It’s an order of magnitude analysis assessing the risks and the benefits. We aren’t putting together an operating plan. When you talk about governance, you are talking about structural reform – those are high level analysis and decisions being made.

Community Member:

So are you getting a majority of people saying they aren’t in favour? What I see is that more people who are in favour are the board of directors, the upper management, who are paid to go along with it.

Facilitator:

The Board has not made a decision on this, one way or the other – so I don’t know where you’re getting that impression from. In terms of the executive teams, I think we’ve painted a picture as to why we are focusing on the strategic imperatives of merging – but we are getting a better feel for what our stakeholders are saying, which is quite frankly not one way or the other. Some are convinced; some are not; as you would expect on a decision like this. If you want to get a flavor for it, go on the website. It is a stretch to say that only the management is ‘supportive’. A lot of the community is recognizing the benefits.

Community Member:

But the participants of the roundtable aren’t the general public.

Facilitator:

Yes they are. The tele-town hall had 8,000 participants, and some were supportive, some were uncertain and some were against it. It’s premature to say the community is against a merger. People are raising their concerns that we need to consider as we look at this decision, and the roundtables have been very helpful in understanding what the community thinks about this. They are raising good points, both for and against.

Community Member:

When you are meeting with the community, are you getting any sense of frustration with the government? With the law of diminishing returns, we are getting to the point where the amount of money you need to throw at healthcare to get a small amount of savings, isn’t worth it anymore. It’s ridiculous for the government to keep cutting, and keep cutting, and say that we can retain quality. The public will at some point get angry enough at the government to do something about it. Are you getting any sense of that from the community?

Facilitator:

I would recommend that you read the community roundtables.

Community Member:

I get the sense from the roundtables that people think there will be money found as a result of merging – which I don’t see happening.

Facilitator:

We are going to identify risks and benefits in an order of magnitude analysis – and one of the other things we need to identify is, what are the investments that we would need to make in order for the merger to work? That’s another part of work that we need to do.

Community Member:

Has anything surprised you in terms of what you have heard so far?

Facilitator:

Not really. I’m a big believer in engagement, and the fact that we have reached out to the community in the way we have has been insightful and valuable. To me, it proves that you can ask the layperson a very complex question, and you will get very valuable input on what to think about. That’s what this process has demonstrated. I know some of you want a granular analysis, but that was never the purpose of this. I’m not surprised by the kind of feedback – if anything it reinforces my commitment to engagement.

Community Member:

Were there any big ‘aha’ moments that made you think one way or the other?

Facilitator:

There’s been so much going on that it’s hard to identify those things. We need to analyze the responses moving forward.

Community Member:

Is there any sense of the CE LHIN and Ministry saying that this is a reaction to the Strategic Plan Refresh? Because that is an impression that is out there.

Facilitator:

No, I don’t get that sense.

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