Ontario 2024 Pre-budget Consultation Submission:
Reclaiming Public Health
This pre-budget submission presents strategic priorities for the 2024 fiscal year to re-balance Ontario’s public healthcare system across all settings. These priorities are developed in response to Ontario’s increasingly evident financial management, board governance, and community engagement issues in healthcare planning and provision.
The financial state of Ontario’s public healthcare system, particularly concerning hospital funding, is facing considerable challenges, as highlighted by the significant deficits experienced by numerous healthcare institutions across the province.
Our analysis shows that 33 healthcare systems in Ontario reported a deficit for FY22. The average deficit was approximately ($540,000), and the total deficit was roughly ($17,900,000). For FY23, 102 healthcare systems in Ontario reported a deficit. The average deficit was approximately ($5,900,000) and the total deficit was roughly ($610,000,000).
This situation represents a marked increase from 2022, with the total deficit escalating by about ($831,024,296) for the same group of 102 healthcare systems. On average, Ontario healthcare systems that posted a deficit in FY23 saw a 992% increase ($5,900,000 compared to $545,000) compared to those who reported a deficit in FY22.
This alarming financial scenario in Ontario’s healthcare systems indicates a broader issue within the healthcare funding framework. The growing deficits reflect an urgent need to reassess funding strategies and allocation.
The current financial challenges stem from a combination of factors, including rising operational costs, particularly in staffing, and inconsistencies in provincial funding. The reliance on temporary staffing solutions, such as private nursing agencies, has further exacerbated these financial pressures.
Haliburton Highlands Health Services (HHHS) permanent closure of Minden ED exemplifies these challenges, illustrating the need for a comprehensive approach to re-establish our public healthcare system and, at the very least, prevent further closures.
In this pre-budget submission, we draw on the lessons learned from the Minden ED closure and apply them broadly across budget priorities and corresponding recommendations.
Summary of Recommendations
- Financial Stability and Infrastructure Enhancement
- Allocate specific funding to stabilize finances and improve healthcare infrastructure.
- Eliminate dependence on temporary private nursing agencies.
- Legislative Changes for Transparent and Accountable Governance
- Implement legislative reforms for transparency in healthcare decisions, particularly regarding staffing and employment practices.
- Development and Retention of Public Healthcare Workforce
- Invest in training, education, and incentive programs to attract and retain healthcare professionals within the public healthcare system.
- Holistic Healthcare with Social Determinants of Health
- Integrate strategies addressing social determinants of health into healthcare planning and provision.
- Enhanced Community Engagement and Participation
- Establish effective channels for community involvement in healthcare planning, with a focus on staffing decisions.
- Data-Driven Healthcare
- Conduct research to collect data on healthcare needs and evaluate the effectiveness of current staffing models.
- Governance Oversight
- Implement review mechanisms for healthcare leadership to ensure responsible management and strategic decision-making.
- Active Ministry of Health Involvement in Public Healthcare
- Enhance the Ministry of Health’s role in overseeing public healthcare, focusing on policy development and maintenance.
Overview of the Minden ED Closure
The permanent closure of Minden ED, which occurred with six weeks’ notice and no public consultation, highlights systemic issues within Ontario’s healthcare system. This section discusses the challenges faced by HHHS in financial management, governance, and community engagement, underscoring the multifaceted failures that must be addressed.
Detailed Financial Struggles and Systemic Issues
Withheld Funding: The Ministry of Health withheld nearly two million dollars in funding for almost two years between FY21 and FY22, a situation not mirrored in their Long-Term-Care (LTC). This is reflected in HHHS’ board meeting minutes as harming the organization.
Overreliance on Private Nurses: HHHS board meeting minutes and local news coverage from the time reflect concerns about the increasing costs and utilization of private nurse agencies. A month before the closure announcement, HHHS’ Finance Chair cited deficit stress and stated that financial and staffing pressure informed every decision the organization made.
Surging Deficit: HHHS’ deficit escalated from $200,000 to approximately $4,100,000 in FY23, including a monthly accumulation of $700,000 each of the final two months. After an adjustment for the sale of a house, the average monthly deficit was $360,000 for FY23.
Underestimation of Deficit: HHHS’ underestimated its deficit by $1 million eight days before its fiscal year-end (FY23). They projected a $3,000,000 deficit on March 23rd, 2023; at their June 22nd, 2023, Annual General Meeting (AGM), they revealed a $4,100,000 deficit.
Denial of Financial Motivations: Despite clear evidence of financial challenges, HHHS and provincial government officials publicly stated the closure was not about money or funding.
Line of Credit: HHHS opened a line of credit due to the funding delays, accruing roughly the equivalent of a nurse’s monthly salary in interest alone.
Asset Liquidation: HHHS sold a house it had originally purchased for a non-profit and their organization’s future growth.
Failure to Write Off Payroll: HHHS applied a different accounting treatment than other healthcare systems regarding the potential impact of Bill 124, placing further financial strain on the organization.
Bankruptcy Risk: As per their recent board meetings, HHHS faces bankruptcy in FY24 without intervention.
Lack of Transparency in Decision-Making: The decision-making process surrounding the closure was marked by a lack of public disclosure. This absence of transparency led to widespread dissatisfaction and distrust among community members and stakeholders. Minden Mayor Carter clarified that HHHS did not consult virtually any stakeholders regarding the closure beforehand.
Inadequate Stakeholder Consultation: Essential stakeholders, including healthcare professionals, community members, and local government representatives, were not consulted or involved in the decision-making process. This failure in stakeholder engagement breached the principles of inclusive governance.
Board’s Limited Engagement with Community Concerns: The HHHS board demonstrated a limited capacity or willingness to engage with and address the concerns raised by the community. This disconnect between the board’s decisions and the community’s needs undermined the efficacy and responsiveness of the healthcare governance system. The Ombudsman’s report underscores the importance of community engagement in health care governance.
Non-Compliance with Governance Best Practices: The approach taken by the HHHS board in handling the closure of the Minden ED raised concerns regarding the board’s adherence to governance best practices. These best practices are outlined in frameworks such as the Ontario Not-for-Profit Corporations Act (ONCA) and the Excellent Care for All Act (ECFAA). The Ombudsman’s report calls for adherence to such guidelines to ensure responsible and ethical governance.
Resistance to External Scrutiny: The board displayed a noticeable resistance to engaging in open dialogue, particularly highlighted in its Annual General Meeting (AGM), where questions about the ED closure were not permitted. This resistance to external scrutiny contradicts HHHS’ accountability and transparency principles.
Community Engagement Issues
Lack of Effective Communication Channels: There was a notable absence of communication between HHHS management and Haliburton County. Information about the ED closure and other critical decisions was not shared with the public before or during the closure, leading to the distribution of unreliable, contentious information and increasing community dissatisfaction and hostility.
Unfulfilled Promises of Communication Strategy: Despite HHHS’ assurances of a “robust” communication strategy for the closure, the actual efforts fell short. This was further compounded by the vacancy in their Communications Officer role during this crucial period. The lack of a dedicated communications professional before, during and after the closure significantly hindered the effective dissemination of information and left key questions unanswered.
Inadequate Communication Effort: HHHS’ approach to communicating the Minden ED closure was markedly unprofessional and demonstrated a lack of understanding of the region’s characteristics, including its traffic patterns and the primary sources of information for its residents. This gap in understanding further alienated the community.
Non-Compliance with Accessibility Standards: The HHHS website, a crucial platform for information dissemination before, during, and after the closure, failed to meet several basic compliance measures of the Accessibility for Ontarians with Disabilities Act (AODA) and the Web Content Accessibility Guidelines (WCAG) during the closure period. This non-compliance not only restricted access to information for individuals with disabilities but also reflected a disregard for mandatory accessibility standards.
Failure to Incorporate Community Feedback: The concerns and feedback from the community, which were critical in understanding the impact of the ED closure, appeared to be largely ignored or insufficiently considered in the decision-making process. This lack of inclusion of community viewpoints in decisions led to outcomes that did not align with the community’s needs and interests.
Impact on Public Trust and Neglect of Elected Official’s Role: How the Minden ED closure was executed significantly eroded public trust in HHHS. Contributing to this deterioration was the perceived lack of responsiveness from both the healthcare management and elected representatives like MPP Laurie Scott, whose support and advocacy for her constituents were notably absent during this critical period. This has led to a strained relationship between HHHS, the community it is meant to reflect and serve, and their elected representatives.
Budget Priorities and Rationale
Allocate Funds for Financial and Infrastructure Stability
Priority: Designate an adequate portion of the healthcare budget specifically for stabilizing the financial health and enhancing the infrastructure of public healthcare systems across all settings.
Rationale: Dedicated funding will directly address the fiscal challenges seen in the Minden ED case, facilitating the transition to more reliable and cost-effective public healthcare delivery models.
Fund Legislative Initiatives for Transparent and Accountable Governance
Priority: Allocate resources towards legislative initiatives that reinforce transparency and accountability in healthcare governance.
Rationale: By financially supporting these legislative reforms, the government can ensure that all public healthcare institutions adhere to high governance standards, as the lack thereof was a critical issue in the HHHS case.
Invest in Public Healthcare Workforce Development Programs
Priority: Earmark funds for programs aimed at training, educating, and incentivizing healthcare professionals to work in the public sector, especially in underserved areas such as but not limited to northern and remote communities.
Rationale: Investment in workforce development will mitigate the reliance on costly external staffing sources and foster a sustainable healthcare workforce.
Budget for Integrating Social Determinants into Healthcare
Priority: Dedicate funds to initiatives that integrate social determinants of health, such as housing, education, civic engagement and food security into healthcare planning and policy.
Rationale: Financially supporting these initiatives will enable a more holistic approach to healthcare, addressing broader factors that impact health outcomes across all settings.
Fund Community Engagement Initiatives in Healthcare
Priority: Set aside budgetary provisions for programs and platforms that facilitate community involvement in healthcare planning.
Rationale: Investing in community engagement mechanisms will ensure healthcare services are more aligned with the specific needs and concerns of populations, rebuilding trust and enhancing service effectiveness.
Support Data Collection and Analysis in Healthcare
Priority: Increase funding for advanced and patient-centered data collection and analysis systems in healthcare, focusing on real-time health data gathering methods that are more relevant and timely than traditional census data.
Rationale: Enhancing budget allocations for modern data collection and analysis will enable healthcare providers to make more informed, patient-centric decisions. Access to real-time, detailed patient data offers a deeper understanding of evolving healthcare needs, particularly in rural areas, leading to tailored healthcare solutions and efficient resource management. This approach fosters a proactive healthcare system that can respond quickly and effectively to changing health trends and patient requirements.
Budget for Oversight and Review Mechanisms in Healthcare Governance
Priority: Allocate funds for establishing and maintaining oversight and review mechanisms for public healthcare institutions.
Rationale: Financial support for these mechanisms will promote responsible management and decision-making, particularly in staffing and resource utilization.
These budget priorities are designed to address the challenges and lessons learned from the Minden ED closure, ensuring a strategic allocation of resources to foster a robust and equitable healthcare system across Ontario, particularly in rural communities.
Financial Stability and Infrastructure Enhancement
Recommendation: Allocate specific funding to stabilize finances and improve healthcare infrastructure, emphasizing the reduction of dependence on temporary private nursing agencies.
Rationale: Stable financial support is crucial for transitioning from temporary, costly staffing solutions to a more sustainable, permanent workforce. This approach will enhance service continuity and efficiency in rural healthcare settings, directly addressing issues underscored by the Minden ED closure.
Legislative Changes for Transparent and Accountable Governance
Recommendation: Implement legislative reforms mandating transparency in healthcare decisions, especially regarding staffing and employment practices.
Rationale: By enforcing transparent decision-making processes, healthcare systems can ensure that staffing decisions are made considering long-term sustainability and community needs. This approach addresses the governance challenges identified in the HHHS case, promoting accountability and ethical management.
Development and Retention of Public Healthcare Workforce
Recommendation: Invest in training, education, and incentive programs to attract and retain healthcare professionals within our public healthcare system.
Rationale: A robust local healthcare workforce is essential for addressing the unique challenges in all settings. Eliminating reliance on external private agencies, as witnessed in the Minden ED scenario, will contribute to a more stable and responsive healthcare system.
Holistic Healthcare with Social Determinants of Health
Recommendation: Integrate strategies that address social determinants of health, including housing, education, and employment, into healthcare planning and provision.
Rationale: Addressing social determinants is vital for improving overall health outcomes in rural communities. Considering the broader context of patients’ lives, this holistic approach to healthcare aligns with the goal of creating a more equitable and comprehensive healthcare system.
Enhanced Community Engagement and Participation
Recommendation: Establish effective channels for community involvement in healthcare planning, specifically focusing on staffing decisions.
Rationale: Community engagement ensures that healthcare services are aligned with the specific needs and preferences of local populations. This approach is crucial for rebuilding trust and ensuring the responsiveness of healthcare services, as evidenced by the community response to the Minden ED closure.
Recommendation: Conduct targeted research to collect data on healthcare needs and evaluate the effectiveness of current staffing models.
Rationale: Data-driven insights will inform strategic decisions, optimizing healthcare delivery and workforce management. This approach aligns with the need for evidence-based policy-making highlighted in the Minden ED case.
Recommendation: Implement review mechanisms for healthcare leadership.
Rationale: Effective oversight ensures responsible management and strategic decision-making, which is crucial for eliminating reliance on temporary staffing solutions, a significant issue in the Minden ED closure.
Active Ministry of Health Involvement in Public Healthcare
Recommendation: Enhance the Ministry of Health’s role in overseeing public healthcare, focusing on developing and maintaining public healthcare.
Rationale: Active involvement by the Ministry of Health in staffing policies will ensure that healthcare services in areas like Haliburton County align with the community’s long-term needs and sustainability goals.
These recommendations aim to address the key issues identified in the Minden ED closure case, focusing on creating a more sustainable, accountable, and community-oriented healthcare system in Ontario.
This pre-budget submission for the 2024 fiscal year represents a focused and strategic approach to addressing the pressing issues within Ontario’s public healthcare system. Drawing on the Minden Emergency Department closure, we have highlighted the need for systemic reforms in financial management, governance, and community engagement practices.
The permanent closure of Minden ED has provided valuable insights into the vulnerabilities and shortcomings of the current healthcare system, especially in rural areas. Our detailed analysis and subsequent recommendations aim to directly address these challenges, paving the way for a healthcare system in Ontario that is more accessible, sustainable, equitable, and responsive to the needs of all its residents.
We advocate for adopting these recommendations in the 2024 budget as they are not merely responses to a single incident but are geared towards fostering long-term improvements across the healthcare sector in Ontario. We hope that through these measures, we can collectively ensure that the healthcare system in Ontario evolves to become a model of excellence and inclusivity, effectively serving every community and setting a standard for future healthcare reforms.
This submission is a call to action for systemic change driven by the lessons learned from the Minden ED closure. It invites policymakers to collaborate in creating a healthcare system that truly reflects the needs and values of the communities it serves, ensuring a healthier, more resilient future for all Ontarians.
Letter to Ontario’s Auditor General
Shelley Spence, CPA, CA, LPA
Office of the Auditor General of Ontario
20 Dundas St W #1530
Toronto, ON M5G 2C2
Dear Auditor General Shelley Spence, CPA, CA, LPA:
Subject: Audit Request: CEO, Board and Ministry Financial Management and Decision-making Before, During, and After Minden Emergency Department’s (ED) Permanent Closure
We are writing to request an audit of the CEO, Board and Ministry financial management and decision-making processes at Haliburton Highlands Health Services (HHHS) prior to the abrupt and permanent closure of Minden’s Emergency Department (ED) – a successful public health institution and community linchpin for 30 years.
Enclosed are detailed financial charts for FY23 and unapproved net monies owed between HHHS and the Ministry of Health from FY17 to FY23, that indicate alarming trends and raise critical questions that we believe require your attention.
We feel it is important to understand the specific factors leading to HHHS’ $4 million deficit for FY23; the decision-making process and rationale for the permanent closure; and to assess whether measures could have been taken to avoid the loss.
Our team believes we now have a moral and ethical imperative to understand how these decisions affect the provision of essential healthcare services. We believe our request falls under your jurisdiction, considering the significant public dollars associated with the closure.
We believe this audit should focus on financial transparency, the accountability of decision-makers, and the impact of these decisions on public healthcare planning and provision, especially as it concerns vulnerable populations.
Key Areas of Concern
Decision details: Most stakeholders do not know when the decision was made or the details of the vote. A Freedom of Information (FOI) request seeking the business case and decision details was submitted; the business case was not included and the information sent was heavily redacted.
Reported Deficit Fluctuations: The enclosed charts show erratic deficit trends, with the reported deficit increasing from $220,000 to a staggering $4.1 million within a single fiscal year. We question the factors contributing to such fluctuations and the substantial discrepancy between the initial and audited financial statements.
Forecasting and Financial Oversight: HHHS inaccurately projected its FY23 Year End deficit by $1 million eight days beforehand. On March 23rd, 2023, the board projected a $3 million deficit for Year End (March 31st). At its AGM on June 22nd, HHHS reported a $4.1 million deficit for FY23 ending March 31, 2023.
Furthermore, the inability of HHHS to estimate additional monies, indicated in Note 21 of their financial statements, may be cause for concern about the integrity of financial management and reporting practices within HHHS and its ultimate oversight by the Ministry.
Strategies to Address Deficits: There is a concerning lack of information on what measures were taken to control the escalating deficits beyond repeatedly advocating with the Ministry to release approved funds and/or additional funds. This is evidenced and reflected repeatedly within HHHS’ board meeting minutes ahead of the closure and several years prior to it.
- Current HHHS board chair David O’Brien and former finance committee member Kelly Mitchell performed in ad hoc government relations assistance roles on behalf of HHHS beginning in 2018
- HHHS’ board members initiated an advocacy effort (championed by then-chair Jan Walker) condemning Bill 124’s impact on staff and,
- One month ahead of Minden ED’s closure, HHHS’ board meeting minutes specifically state that both financial and staffing pressures inform every decision they make; the minutes also state HHHS’ inability to retain staff due to higher wages elsewhere.
We urge your office to investigate whether appropriate actions were taken and the level of stakeholder engagement in HHHS’ planning and execution of strategies to address its deficit. Our team has identified different accounting and/or financial management practices across different healthcare systems in Ontario. We believe HHHS may have been able to mitigate its deficit and remain operational if it had adopted the best practices of other healthcare systems in Ontario.
FY 24 Budget Projections: It is imperative to ascertain whether HHHS projected continued deficits in the FY 24 budget and if these projections influenced the decision to close the ED. For instance, when did HHHS get access to FY24 budget vs. when was the decision made to close the ED?
Owed Monies and Financial Statements: The significant increase in monies owed to HHHS in FY21 and FY22, and the subsequent changes in FY23, warrant a detailed audit to understand the causative factors and their impact(s) on HHHS’s financial position.
Questions for Audit Investigation
- Why did the monthly deficits reported by HHHS fluctuate so significantly?
- What led to the unexpected rise in the deficit reported in the audited financial statements?
- Why was there a lack of estimation for additional funds as indicated in Note 21 of the financial statements?
- What steps were undertaken to mitigate the rising deficits, and were stakeholders involved in these discussions?
- At what point in the fiscal timeline was the decision to close the Minden ED made, and were the fiscal projections for FY 24 considered in this decision?
- What caused the substantial increase in monies owed to HHHS in FY21 and FY22, and why did this trend not affect the long-term care sector?
- How are the monies owed recorded in the financial statements, and have there been any adjustments by the Ministry of Health?
These questions are crucial in understanding the fiscal management of HHHS and the factors leading to the closure of Minden ED. The patterns reflected in these charts and the subsequent permanent closure decision appear to be symptoms of deeper financial and operational malaise.
The closure of Minden ED stands to affect the well-being and health of our community profoundly, we implore your office to initiate an audit promptly. The findings of such an audit will be instrumental in restoring public trust and ensuring that similar incidents do not occur in other healthcare institutions across the province.
We thank you for your attention to this grave matter and stand ready to provide any further information required for your investigation.
Sincerely, Jeff Nicholls, Adria Scarano, Aurora McGinn, Tracy Klompmaker
On behalf of Minden Paper
Letter to Ontario’s Integrity Commissioner
J. David Wake, K.C.
Office of the Integrity Commissioner of Ontario
2 Bloor Street West, Suite 2100
Toronto, ON M4W 3E2
Dear Integrity Commissioner Wake:
Subject: Request for Integrity Review: Role of Provincial Officials in the Permanent Closure of Minden’s Emergency Department
We are requesting a formal investigation into the conduct of Deputy Premier and Minister of Health Sylvia Jones, MPP, Laurie Scott, MPP and other provincial officials concerning the permanent closure of Minden’s Emergency Department (ED) by Haliburton Highlands Health Services (HHHS).
Our research has uncovered discrepancies in the statements made by Jones and Scott compared to official HHHS documentation, such as board meeting minutes and financial records. Both officials described the closure as a consolidation unrelated to financial issues and in the community’s best interest, despite their close involvement with HHHS. This contradiction suggests potential neglect of oversight responsibilities, failing to represent interests beyond those of HHHS and the Conservative government.
Minden Hills Mayor Bob Carter publicly stated that the closure was decided with no stakeholder consultation, six weeks notice, and hope in place of a plan. Doctors, nurses, EMS, volunteer firefighters, patients, residents, nonprofits, and businesses were not consulted or informed about the closure in advance. Both ED physicians working at Minden ED and HHHS’ former board chairs opposed the decision with written letters. All stakeholders wanted a moratorium. The community responded with over 25,000 signed petitions.
We urge your office to investigate this matter as a potential failure of public health governance at the levels of the CEO, the Board, and especially the Ministry. The circumstances surrounding the closure may be indicative of larger systemic problems.
Board Governance: Evidence suggests that HHHS’s board did not adhere to its responsibilities of leadership, fiscal responsibility, and community representation. There is also an indication of possible conflicts of interest regarding David O’Brien and Kelly Mitchell, who both performed in “ad hoc government relations” beginning in 2018. Mitchell was expressed as regrets for three board meetings ahead of Minden ER’s closure while simultaneously working on the Eastern Ontario Warden’s Caucus (EOWC) Seven by Seven Regional Housing Plan (a 28,000-unit regional housing plan).
Financial Management: Our analysis has revealed significant financial mismanagement within HHHS, including a $4.1 million deficit amidst excessive spending on agency nurses (calculated at 2.5x the cost of public nurses). We have detailed these findings to Ontario’s Acting Auditor General, and believe they warrant a forensic audit for the fiscal period 2017 to 2023.
Community Engagement: The failure to consult stakeholders before, during, and after the closure contravenes the principles of the Ontario Nonprofit Corporation’s Act (ONCA), the Public Hospital Act and the Members Integrity Act. It has also destroyed the publics trust, torn apart the social fabric of our County and planted a seed of doubt regarding public institutions and those who administer them.
Sociopolitical Landscape: Public statements provided by MPPs Scott and Jones conflict with documented internal discussions about financial pressures. This discrepancy is concerning, given their professed intimate involvement in the process.
- Less than one month before the closure: HHHS board minutes capture Finance Chair Irene Odell’s assertion that “the deficit pressures have added a tremendous amount of stress. Staffing pressures and financial pressures were at top of mind and have a significant impact on every decision made”
- NDP Health Critic France Gélinas and MPP Chris Glover: Joined by the Ontario Health Coalition, criticized Premier Doug Ford and Health Minister Sylvia Jones for their inaction on this issue. Gélinas argued that Minister Jones has the responsibility and authority to intervene in the closure, which she believes is financially driven. She called for a minimum one-year moratorium on the closure.
- Criticism of MPP Laurie Scott: Gélinas criticized Scott for not being the “voice of the community” and for not fighting the closure. Scott had previously stated that the decision is a matter for the health board.
- Ministry of Health’s Stance: A spokesperson for the Ministry of Health, Hannah Jensen, stated that MPP Scott has been a strong advocate for her riding and remains in contact with the health board. Jensen emphasized that the decision is not a closure but a consolidation, aimed at providing better emergency care at the location best equipped for urgent acute care. She also noted that the Minden site would remain open for some services.
- Natalie Mehra’s Remarks: Natalie Mehra, executive director of the Ontario Health Coalition, expressed concern that the closure might signal future closures of other small, rural emergency departments. She criticized the Health Minister for a lack of action in addressing the staffing crisis affecting emergency departments.
- Official Party Visits: The NDP’s Marit Stiles and Chris Glover visited Minden to hear residents’ concerns, expressing support for the local community in their fight to keep the ER open. Dr. Adil Shamji, MPP and Stephanie Bowman, MPP also visited Minden.
- Conservative government rebuffs: Despite numerous constituent visits to the Legislative Assembly and calls for an audience, no Conservative government official would meet with patients, residents or the community.
An individual submitted a Freedom of Information (FOI) request seeking HHHS’ business case. The FOI response inadequately addressed the request, omitting the business case and heavily redacting pertinent information. We still do not know when the decision was made, who voted for it, nor the rationale behind it.
Why is HHHS keeping stakeholders from understanding its rationale for closing an ED that had served for nearly 30 years, despite protests from countless people and organizations?
Given the depth of the issues and concerns we’ve discovered and the potential deviations from core mandates by HHHS, we believe that accountability must be upheld. It is our hope that through your office’s oversight, we can reaffirm the principles of integrity, transparency, and accountability within Ontario’s public service.
We are prepared to present our comprehensive report and discuss our methodology for your review.
Thank you for your time and consideration,
Jeff Nicholls, Adria Scarano, Aurora McGinn, Tracy Klompmaker
On behalf of Minden Paper
Letter from Former HHHS Board Chairs
As past chairs who helped guide the development of HHHS since inception, we strongly disagree with the Minden ED closure. It’s unconscionable and flies in the face of more than two decades of responsible health care developed by the corporation. There are many valid reasons in opposition. The response from citizens, through letters, petitions, signs, and demonstrations provide ample indication of the community’s support for the continuation of the service.
We offer these observations:
A complete lack of transparency: When planning for HHHS began over 25 years ago, many scenarios were considered for the County. These discussions, sometimes passionate and heated, took place at public meetings with extensive press coverage. The community was involved, and when decisions were finalized, while not everyone agreed, the community moved on. Minden hospital ‘gave up’ its argument to retain in-patient beds, in exchange for a commitment to keep full-time, fully-funded emergency, and a range of community programs. This decision ‘betrays’ this understanding and resurrects community division. It also came without consultation with the Minden service area communities most impacted by the action.
- A six-week timeline provides little or no time for careful planning or reasoned community input. We wonder, was this decision deliberately and secretly taken in the hope that, with short notice, it would just slide through? It’s already disrupted the smooth operation of the Minden site. ED doctors and staff have begun looking for other places to work after June 1, even though a full roster of medical professionals through September is in place.
- There is no plan: Other than vague descriptions of amalgamation of services in one locale, there is a disheartening lack of foresight to support the decision. Where is the plan?
- What about the professional staff? We are aware that for the most part, the Minden ED had been able to maintain the level of staffing to deliver services through recent years when the pandemic put maximum stress on the system. Why is this being discontinued when it has demonstrated its resiliency and dedication to providing health care?
- We recommend the board cancel the permanent closure, strengthen the health care for the Highlands, particularly emergency, focus on the partially completed master plan and get it done, and encourage the involvement of citizens, all governments, and the Ontario Health Team in the development of a robust system that meets the needs of all the community HHHS was created to serve.
Jeanne Anthon, Dave Bonham, Jack Brezina, Paul Heffer, and Hugh Nichol
Letter from Physicians of the Minden Emergency Department
As physicians of the Minden emergency department, we would like to express our sincere appreciation and support to the wonderful community we have had the privilege of serving for the past 28 years. It has been an honour to provide emergency medical care to you, our adopted neighbours, friends, and community members during some of your most vulnerable moments. It is with a heavy heart that we must inform you that the decision to close the Minden ED was not ours to make. Despite our best efforts and unwavering commitment to the community, circumstances beyond our control have led to this challenging decision by Haliburton Highlands Health Services.
Our group was informed of this decision a few hours prior to the public media releases on April 20. This emergency department has been a strong and steady presence in many emergency physicians’ careers. The physicians of the Minden ED feel a special attachment to the staff and community. Since the news became public, we have heard from past physicians who have reached out to us to convey their appreciation to your community for the time they were able to serve and provide emergency medical services here.
In 1995, when Dr. David Fiddler heard that the ED was potentially closing due to a shortage of physicians, he recruited his brother Dr. Doug Fiddler to find other emergency physicians from community hospitals to support the Minden ED. The plan was to keep it open for three months while the community found more physicians. That was 27 years ago. The brothers, as many have come to know them, were mainstays in the ED, and the community knew them well. Over time, emergency physicians were selectively recruited to work here. At one point, there were four heads of emergency medicine working in the Minden ED. We took pride in knowing we were able to provide continuous physician coverage, without any gaps, over these years.
Support from Health Force Ontario was not required until April 2023. Health Force Ontario is a government-funded job board to help get physicians where they are needed in Ontario. These physicians typically have a base hospital they work at and provide coverage to community and rural hospitals on an ad hoc basis.
Prior to the closure being announced, our group had coverage until September 2023, with small support required from Health Force Ontario. In the fall, there were physicians who were expected to fill these gaps, bringing us back to full coverage. We have Dr. Bruno Helt to thank, who has recruited and maintained the emergency physician group for the past decade. Please know we have always been deeply committed to ensuring the highest standard of emergency medical care to the community. As HHHS staffing shortages evolved over the past two years, the Minden physician group became involved in service reduction discussions in November of 2021.
We offered our support to various reduction options that involved partial ED closure scenarios, but we were clear that we could not support a full closure scenario for one of the EDs. The Minden ED physicians knew it would be the end of our ability to provide the highest standard of care to you. Over the years, increasing ED volumes have made these shifts more challenging. However, a 24-hour shift was still feasible to do so and provided a balance that made the long drive from our home bases acceptable. We told the HHHS executive and board in February 2022 that we could not provide physician coverage if one of the EDs were going to close, and it is still the case today.
We will continue to work in our home sites and may see you at one of these locations in the future. Thank you for allowing us to be a part of this wonderful community. Over nearly three decades, it’s been our privilege to serve you. Thank you for the trust you have placed in us, for allowing us to serve you, learn from you and for the memories that will sustain us for years to come.
On behalf of the Minden Physician Group,
Dennis Fiddler, DO, CCFP (EM)
Analysis: Fiscal management and Minden’s unprecedented Emergency Department closure
“In my country, this would not be possible. This could literally not happen.” – Student, Health Informatics, George Brown College, Toronto
As guest lecturers, we heard variations of this many times during and after our presentation about mindenpaper.com, our advocacy effort borne from Haliburton Highlands Health Services’ (HHHS) closure of the Emergency Department (ED) in Minden, Ont. Our audience consisted of many with extensive health-care experience, including dentists, pharmacists, nurses and people who run surgical teams.
We were floored each time we spoke with someone new. They were, too.
Only six weeks’ notice before an ER closure? How? How could this happen? In Canada – Why?
Before HHHS decided to close the Minden ED with just six weeks’ notice, few in Minden would have believed that international health-care professionals/students would view our town as an example of Canada’s health-care challenges.
Now, there’s a steadily increasing number of residents in Minden and surrounding areas who realize that our health-care system is spiralling out of control, and Minden might be a microcosm of the whole thing.
Our team, Minden Paper, has been passionately engaging with people and seeking the return of Minden ED, along with accountability and transparency from the HHHS board. The closure of the ED has become a rallying point for us to address broader issues affecting health-care systems nationwide.
It has allowed us to explore HHHS’s fiscal management, especially during the fiscal year 2023 (FY 23), and to express the urgent need for a province-wide examination of health-care system Chief Executive Officers (CEO) and board performance to determine the current situation and help make informed decisions moving forward.
At George Brown College, we discussed the ethos of mindenpaper.com, the influence of social determinants of health on our analysis to date, and board governance’s impact on the Minden closure. We explored our experiences since the April 20 announcement right up to that moment in class.
However, one thing we did not talk about was the criticality of labelling the x-axis/title when reverse-coding a deficit.
… If you’re reverse-coding a deficit, you need to label your x-axis/title on the chart
Those “reverse-coding a deficit” conversations came up separately, in chats with people who were looking to HHHS’s financial statements to try to ascertain the circumstances of the closure. Specifically, we had started talking with people who wanted to visualize FY 23 based on an analysis of the organization’s Financial Statements and Board Meeting Minutes, amongst other publicly available data.
When you’re talking about reverse coding a deficit for data visualization with people who take their inputs and outputs as seriously as a heart attack, you’re entering the upper echelon of a very particular domain. A world of complexity and precision. Accountability and responsibility. Stakeholder engagement. Continuous learning and adaptability. Ethics and integrity.
A world that is, in our opinion, incredibly analogous to health-care system fiscal management as we’ve come to understand it. Think about it:
The work of data visualization is intricate. It requires meticulous attention to detail to ensure clarity and accuracy in communicating data points, trends and narratives every step of the way. Fiscal management, even in the enormously complicated sense of operating a health-care system, shares these same traits.
Except, beyond the mere numbers and budgets, fiscal management has a profound effect on the lives of individuals and communities. Like the intricacies of data visualization, every step in health-care decision-making demands meticulous attention to detail, accountability and principled approaches.
Just as a mislabeled axis can lead to misinterpretation in data visualization, fiscal management challenges can lead to decisions that have tangible effects on individuals, households and communities, along with entire sectors and industries. The effects can be multigenerational – ask anyone from Fort Erie.
And so, it was with this understanding of what’s at stake that we joined financial analysts in trying to comprehend the larger nuances of health-care fiscal management at HHHS in hopes of understanding both the local and broader challenges facing our health-care system.
The management of HHHS is a joint effort between the CEO and the Board of Directors. Together, they develop a mission statement outlining HHHS’s main objectives, which might include refining services or exploring new areas. This mission translates into a detailed roadmap with specific, measurable milestones. While both the CEO and the board share responsibilities, each plays distinct roles to guarantee the organization’s success.
The CEO handles HHHS’s daily operations, ensuring it meets performance standards and financial benchmarks. If problems arise, the CEO addresses them and, for bigger challenges, collaborates with the board to find solutions.
The board provides oversight, ensuring HHHS aligns with its mission and achieves set goals. It prioritizes financial performance, including staying within approved budgets and ensuring stable cash flows.
The Ministry of Health (MOH) sets fiscal guidelines for HHHS. Though not involved in daily activities, MOH standards significantly influence HHHS’s financial management, demanding transparency and alignment.
In Ontario’s health-care system, the CEO and the board’s financial responsibilities determine the system’s sustainability and effectiveness. The CEO, often collaborating with the Chief Financial Officer, presents financial updates, addressing any deviations or opportunities. CEOs also connect with various external entities like governmental funders and donors to communicate the institution’s financial status and needs.
The board, on the other hand, supervises financial operations and holds the CEO accountable for the institution’s fiscal health. It plays a crucial role in budgeting, reviewing, questioning and endorsing the budgets, ensuring alignment with long-term goals. It also drafts financial guidelines, assesses fiscal threats and ensures risk mitigation strategies are in place. For transparency, a subset of the Board, typically the finance committee, works with external auditors to validate the organization’s financial statements.
While the CEO focuses on daily operations, the Board has a broader perspective, setting large-scale financial objectives in line with the mission and societal demands. Understanding this role distinction is vital as we delve into FY 23 fiscal management at HHHS.
The numbers reflected on the HHHS Reported Deficit for FY 23 chart for the year ending March 31, 2023, are obtained from the posted minutes on the HHHS website.
- On June 30, 2022, financial statements showed a $220,000 deficit, which was reported on Oct. 27, 2022. The deficit averaged $73,000 monthly over April, May and June.
- The deficit was understated by $224,000 due to gains from property, buildings and equipment sales. The adjusted average monthly deficit was $148,000.
- On Sept. 30, 2022, financial statements showed a total deficit of $1.4 million, which was reported on Dec. 22, 2022. The deficit averaged $400,000 monthly over July, August and September.
- On Nov. 30, 2022, financial statements showed a total deficit of $2.4 million, which was reported on Jan. 26, 2023. The deficit averaged $500,000 monthly over the two months covered in that statement.
- On Jan. 31, 2023, financial statements showed a $2.7 million deficit, which was reported on March 23, 2023. The deficit averaged $150,000 monthly over December and January.
- The year-end deficit on March 31, 2023, was anticipated to be $3 million, as mentioned in the March 23, 2023, minutes.
- Audited financial statements presented at the Annual General Meeting on June 22, 2023, reported a $4.1million deficit for the fiscal year ending March 31, 2023.
- The average monthly operating deficit for the final two months of the fiscal year was $700,000.
- After removing gains on sales, the average monthly operating deficit for the fiscal year ended March 31, 2023, was $360,000.
- Why such fluctuations in the monthly deficits?
- Why the big jump in deficit in the audited financial statements?
- Regarding Note 21 from the financial statements: why could HHHS not estimate the additional monies to come?
- What was done to rein in the increasing deficits?
- Were there discussions with various stakeholders to get their input on controlling the deficits?
- Does the FY 24 budget show continued deficits?
- Where on the chart timeframe was the decision made to close Minden?
- Were the 2024 budget numbers available when the decision was made?
The numbers reflected on Unapproved Net Monies Owed: Haliburton Highlands Health Services and Ministry of Health (FY17 to FY23) are obtained from the audited financial statements posted on the HHHS website. In the “Notes” section of these financials, there is a schedule of these monies that is broken out by the various operating grants. The net amounts of monies recoverable (owed to HHHS) and refundable (owed by HHHS) for the hospital and the long-term care were obtained from these schedules and charted accordingly.
- What could cause such a significant increase in monies owed to HHHS in FY21 and FY22?
- Why is the trend only with the hospital and not LTC?
- What changed in FY23 that eliminated the trend?
- Are these reported “owed monies” included in reported revenue for the applicable fiscal year?
- If monies owed by MOH are not included in fiscal year revenue they are claimed for, when are they recorded as revenue?
- Do monies owed to the hospital that are claimed get changed by MOH?
- If yes to 6, where does that get reflected in future fiscal statements?
The numbers, graphs and fiscal details featured herein reveal a complex tale of hardship at HHHS – one that ultimately led to an unprecedented six-week timeframe for the closure of an Emergency Department that stood for nearly 30 years.
Do we know how many of our hospitals might be at risk of having the same outcome of closure?
It’s not just about numbers. Every fiscal challenge, every critical detail, translates into tangible health-care outcomes for real people – our families, friends and communities. The astoundment of our international peers and the passionate, powerful voices from our community indicate what we believe is a pivotal moment for change in Canadian health care.
As patients, residents and communities, we must demand clarity, accountability and a commitment to the highest standards of care. Minden’s experience must serve as a nationwide warning: review the financial management and board governance of your local health-care systems.
And don’t forget: Patients, residents, and community members were not consulted before, during or after the closure of the Minden ED.
Health-care systems nationwide can – and should – learn from that, too.
The authors would like to thank Anna Foat, Laura O’Grady and the people of Minden for their time and insight.
Analysis: We must overhaul how Ontario’s hospitals are governed. Our lives depend on it.
The reckless and rapid closure of the Minden emergency department with barely six-weeks’ notice and no stakeholder consultation is a microcosm of what’s happening across our province and nation.
In an interview with CTV National News correspondent Heather Butts, Alan Drummond, co-chair of the Canadian Association of Emergency Physicians, stated: “We can’t be doing this on an ad-hoc basis nationally; this is a national problem with common root causes that needs national discussion, a national dialogue, a national approach.”
The abrupt closure of Minden ED, a pillar of our community for nearly three decades, meets the very definition of an ad hoc decision. It occurred despite the population being set to at least triple from summer residents, guests and passersby. It also occurred despite intense opposition from former Haliburton Highlands Health Services (HHHS) board chairs, Minden ED physicians (who were staffed through September), local elected officials, most of the legislative assembly, most of the province and more than 25,000 signed petitions gathered over the course of 8 weeks of advocacy.
This is to all to say that the closure of the Minden ED was made with blatant disregard for best practices in board governance. It’s incredibly alarming – terrifying, even – that a CEO and a volunteer board can unilaterally (according to Minister of Health Sylvia Jones) close a public institution without consulting stakeholders.
Such a decision-making process (and the decision itself) blatantly defies best practices of transparency, accountability and stakeholder engagement. In fact, the reason for the closure by the board and CEO has proven to be unfounded.
According to the Ontario Hospital Association’s Physician Leadership Resource Manual: “Great boards are not measured by their rules and regulations, but by their culture and the way people work together.”
The Haliburton Highlands Health Services (HHHS) board’s disregard for its stakeholders was reflected again through its outright refusal to allow questions related to the Minden ED closure at its Annual General Meeting (AGM) June 22, a forum traditionally seen as an opportunity for open dialogue and accountability. In fact, the board failed to inform attendees (who had spent significant time preparing) ahead of time that these questions were not permitted– despite obviously knowing they would not be allowing them at the actual AGM.
By doing so, the board has most likely contravened the Ontario Not-for-Profit Corporations Act (ONCA), which explicitly mandates accountability to members and stakeholders. Given that the Act came into effect in October 2021, one would expect an institution as crucial as HHHS to be fully compliant, particularly in such a critical matter.
The Minden ED closure represents a complete failure in governance because hospital board governance must be held to the highest standard.
Moreover, the Zoom-based nature of the AGM made it impossible to determine which questions went unanswered, and the chat functions were disabled. It was also impossible to determine if questions about Minden ED had come from “members” rather than AGM attendees. If HHHS refused to allow “member” discussion, it is clearly in violation of its own bylaws and ONCA.
On June 29, HHHS held a town hall to discuss the closure of the Minden ED and the path forward. Unfortunately, Board Chair David O’Brien was not in attendance, thereby making many questions that depend on a historical understanding difficult if not impossible to ask.
The Minden ED closure represents a complete failure in governance because hospital board governance must be held to the highest standard. It underscores the necessity for entities like HHHS to surpass the bare minimum in governance.
The HHHS experience indicates it is time to review and overhaul how hospitals are governed in Ontario. Will we continue to allow unequal and inconsistent treatment of communities in their health-care needs by a board of directors?
As afforded in the Excellent Care for All Act, perhaps it is time for Ontario’s Patient Ombudsman to commence an investigation into the HHHS board before it is too late.
The people of Minden and surrounding areas deserve a health-care system that is responsive to their needs. The closure of our Minden ED without adequate consultation is not only a local tragedy; it is indicative of a nationwide emergency that calls for collective resolve and action.
The Minden ED closure serves as a timely wake-up call on how our hospitals are governed. As citizens and stakeholders, it is our responsibility to demand better because our lives, and those of our fellow Canadians, depend on it.
We must demand and ensure more than the bare minimum in board governance, insisting on transparent, accountable and engaged leadership. Only then can we hope for a health-care system that truly reflects the needs and concerns of the patients, residents and communities it serves.
Jeff Nicholls and Mary Cook
Minden Mayor Bob Carter Facebook Post
Please share this.
The fight to save our emergency department continues.
It was an eventful week.
The highlight was the outpouring of support and the gathering of so many at the Minden Community Centre on Tuesday to sign petitions and pick up signs. Over 3,300 signatures were gathered to deliver to the Provincial Legislature on Wednesday. A shining example of how our community reacts quickly, and works together whenever we are challenged.
On Thursday, Carolyn Plummer and David O’Brien came to the Minden Hills Town Council to make a presentation and to answer questions about their decisions. The two of them also came before Haliburton County Council later in the day.
We needed more information and HHHS told us some things that clarified the situation.
One, this was a decision made by the Board of Directors upon the advice provided to them by the Executive Leadership of HHHS. The decision was not influenced by the Ministry of Health or the Ontario Health Team. We were told that this was strictly a local decision.
Second, HHHS stated that there was prior consultation since they have been discussing the nursing shortages and the potential temporary closures of one of our Emergency Departments. It should be obvious to everybody, that that is not the same as discussing the closure of the Minden Emergency Department, and the fundamental change in the provision of Emergency Services in Haliburton County that has successfully met our needs for the last 25-30 years.
Third, HHHS did not discuss the closure of the Minden Emergency Department with the doctors, nurses, County or Municipal Councillors, or any other stakeholders for fears of starting rumours and stoking fear in the community. HHHS is now starting to meet with the important stakeholders to create the plan and make the alterations necessary before the June 1, 2023 implementation.
Fourth, HHHS was not willing to reconsider their decision or their start date.
The reasonable plea from us, as Councillors and as concerned citizens, to delay the June 1, 2023 date so we can work together to resolve the underlying issues and make proper plans was denied. This week, I, along with Deputy Mayor Schell and all of Council, have worked to broker a reasonable solution.
The public has reached out to us with many ideas, offers of support, and inquiries as to how they can help. Our citizens worked to raise awareness and protest this decision. I have spoken to local, regional and national media. I have spoken, at length, to our MPP and MP. I have spoken to other MPP’s. I have spoken and discussed options with legal counsel and others. I have also spoken to many other organizations and groups asking for their support.
Minden Council is working together and fully committed to leave no stone unturned in our search for answers and options.
One thing is clear. HHHS has the authority to make this decision and decide the timing. Realistically, only HHHS can alter this decision before it is too late. Every moment that goes by sees Minden doctors, and possibly nurses, looking for and finding work elsewhere.
We want to continue to have our Hospital Services managed, overseen and controlled locally. We do not want it run by the Province or Peterborough or Kawartha Lakes.
We need to change the decision and the process by which it was made. We need to ensure that HHHS, perhaps the most important institution in the community, works with us, the stakeholders, to develop the solutions that meet the needs of Haliburton County.
Please continue to write letters and stick together to keep this issue top of mind until it is resolved.
Save the Minden ER
Diane Duff Op Ed: Haliburton County does not need a CT scanner
By Dr. Diane Duff RN PhD
Even a cursory look at the evidence does not support a CT scanner in our community. It will not improve the community’s health or attract a single health care worker. Instead, it will be yet another expensive white elephant in the Haliburton Highlands Health Services arsenal we do not need and can’t afford to operate.
HHHS does not manage its own radiology (X-Ray, ultrasound, and bone density); does not even do routine X-Rays after 8 p.m.; and does not manage most of its essential hospital services. Ross Memorial Hospital in Lindsay manages diagnostic, radiology, IT, pharmacy, sterile processing and supply services on behalf of HHHS. High-level oversight for finance, human resources, and clinical services are also provided by the Ross.
We have access to three CT scanners within 72-98 km, at Muskoka Algonquin Hospital, the Ross and Orillia Soldiers’ Memorial Hospital. All emergency cases requiring a CT scan are seen on an immediate basis and will require care at a regional hospital. Muskoka Algonquin (91 per cent) and Orillia Soldiers’ Memorial (95 per cent) are meeting provincial wait times for CT scans. Even a routine scan at either is taking less than two weeks. At the Ross, the wait time can be up to 45 days.
Ontario has 169 of Canada’s 549 CT scanners, most in cities. The smallest site is Elliot Lake. In 2021, at a cost of $1.8M, St. Joseph’s Hospital was the beneficiary of a $1M donation from the Edward and Suzanne Rogers Foundation. With a population of around 12,000, they may seem to be a reasonable comparator to Haliburton County. However, Elliot Lake is 160 km from Sudbury and 200 km from Sault Ste. Marie, the nearest centres with CT.
St Joseph’s is a 58-bed hospital that provides surgical, ICU, cancer, obstetrical, pediatric, ambulatory care, medical, palliative and alternative level of care in-patient services. While HHHS provides excellent care in its Emergency Departments, patients who need any significant level of ongoing care, even minor surgery and treatments, need to be transferred to affiliate hospitals. Transfers have nothing to do with a lack of a CT scanner.
Transfer is necessary because we do not have specialists, and these common hospital services are not offered at HHHS. Even if we had a CT scanner and someone to operate it, the scan would have to be read by a radiologist at a larger centre. A CT scanner would require extensive building renovations. Would the scanner be sited at the Minden or Haliburton site? Transportation would still be needed, as there is 25 km between the two. Additionally, the fixed capital cost of purchasing and building renovation for a CT scanner is a drop in the bucket compared to the ongoing costs of warranties; maintenance to meet quality standards and accreditation; annual operating costs; and recruitment, training and personnel costs, including salary and benefits.
Unless the scanner could generate revenue in excess of $250,000 per year, it would become a drain on other hospital and community services, as CT scanner costs come out of hospital budgets. According to the current rate of 125 CT exams per 1,000 people in Canada in 2020, we could at best project a rate of 1,250 CT scans per year for Haliburton County. Many would be done on Highlanders being treated at other hospitals due to strokes, cancer, and heart disease.
Even if all of these were done at HHHS, it would only amount to perhaps three CT scans per day, with likely only three per month being required on an emergency or emergent basis. Compare this to the estimated minimum of 25 patients per day needed to justify a CT scanner or that most CT scanners in Canada operate on average 80 hours per week, including weekends, and some 24 hours per day, seven days a week to get a notion of how far we are away from justifying the need for a CT scanner here.
While the Canadian Medical Inventory report notes academic teaching and research- intensive hospitals benefit from access to “cutting-edge” technology to attract specialists and research scientists, this is hardly a benefit for recruitment to HHHS. Instead, “remote or rural centres may face challenges in attracting and retaining highly- trained professionals, or in providing training and continuing education for existing staff”. HHHS has dozens of vacancies, many they have been unable to fill, or retain staff for, over many years.
There are other investments we could make in our communities to improve access to health services and population wellness. I vote for a community recreation and therapy pool, free health appointment transportation, local student scholarships for health and medical studies, and joining HHHS with either the Kawartha Lakes or Muskoka and area Ontario Health Teams…if they will have us.
Diane Duff Op Ed: Accreditation and board responsibility
HHHS has wisely requested to postpone the accreditation that was due this year. According to Accreditation Canada, hospitals must operate with transparency and public consultation. Given the current decision to close the Minden ED without consultation or a robust plan, I agree HHHS would not pass accreditation. The HHHS board still meets only online. With no provincial health restrictions, plainly this is a strategy to prevent public involvement. Additionally, new HHHS board members are reviewed and approved by the current board. Sounds like a country club rather than a hospital. Given the lack of public access to the HHHS board, I am hoping they read their weekly Highlander.
Dear HHHS board members,
Minden Hospital began as a Red Cross outpost hospital in the 1950s and has served the health needs of our community from birth to death, and everything in between, until today. You are closing an essential service, not just ‘consolidating’… Minden ED treated 13,000 patients in 2022. As board members, you will be responsible for the deaths of CTAS 1 and CTAS 2 patients who live in proximity to the Minden ED, who die enroute to Haliburton ED or who die due to delayed transfer to a tertiary care facility. You are also responsible for people who are old, poor, and living with chronic and life-threatening illnesses who do not have access to transportation or primary care.
The argument that the Haliburton ED needed to remain open due to acute care beds is not true; those patients are managed by the Haliburton Family Health Team doctors, not by the ED. If this responsibility was not what you signed on for when you joined the board as a volunteer, then reverse the decision to close the Minden ED, open the AGM to the public, and hold public consultations on the future of HHHS. The alternative is to resign.
Dr. Diane Duff RN PhD
Dr. Nell Thomas Op Ed: It goes like this…
There were doctors. They were in Minden. But we paid them to leave.
They assessed and triaged 15,000 patients, some years. Sure, they ‘stabilized’ some and sent them out. To Haliburton? Sometimes. Also, to Peterborough and Kingston and Toronto and Lindsay. They also treated patients. And sent them home. And sent some to cardiologists and surgeons and psychiatrists. And coordinated palliative care, wound care, pain care, nursing care, social services, transportation, primary care, homecare, rehab care. Housing shortages are said to challenge recruitment efforts. Never for the Minden emergency doctors. About that 25-minute ride from Minden to Haliburton. By car. A lot longer by foot. Or wait. Wait for an ambulance. Also, a lot longer than 25 minutes when you are north, south, and west of Minden.
Out my office window, the Minden emerg parking lot is full, every day. A steady stream, some on foot. ORNGE comes and goes. And it isn’t even summer cottage country volumes yet. Patients without cars. Elderly who don’t drive. The exponentially growing volume of residents with no local family physician, and the escalating social and environmental stressors making all of us more vulnerable. Extreme heat, fires, floods, pandemics, ice storms, road and power outages, cyber attacks.
Where is our Robin Hood when we need him? He would see the logic of keeping an affordable bird in the hand.
Dr. Nell Thomas Minden
Diane Duff Op Ed: Nurses deserve better
Haliburton Highlands Health Services (HHHS) has, for many years, focused solely on physician recruitment and satisfaction, without valuing or prioritizing hiring full-time nurses and retaining them. Instead of new hires, there has been a reliance on overtime shifts and casual employment to meet nursing labour gaps. One only has to look at the average age of our nurses and the number of hours of overtime that has been increasing year-over-year, as evidenced by the Ontario Sunshine List, and the number of nurses who are off on disability or stress leave, to know that we are on the brink of additional service shutdowns. Word from staff is that the Haliburton emergency department came close to closing this past weekend due to a shortage of nurses.
New nurses join the nursing profession wanting to provide exemplary service and to be part of a satisfying and fulfilling work endeavour… instead they experience exhaustion, fear, and lateral violence due to excessive workloads and lack of mentorship. Dr. Kathleen MacMillan observed that leaders and employers must re-vision and redesign the workplace. Transformational leadership, use of innovation and new knowledge, employee empowerment, continuous quality improvement, and use of outcome data are strategies to create a better workplace.
Closure of the Minden ED was a desperation move and is only a temporary stopgap. HHHS must demonstrate they value their nurses by providing work-life balance and flexibility, sufficient staffing for safe staff-patient ratios, organizational and manager support, autonomy and recognition, new staff on-boarding and transition support, and positions for nurses nearing retirement age. Workplace reform that starts with collaboration, communication, and cherishing our nurses, not slashing essential services, is the approach that is needed.
If doctors are offered perks, such as relocation bonuses and housing, then why not nurses? Maybe with Veronica Nelson from Ross Memorial Hospital at the helm, good things will begin to happen to health care in our County, including hiring full-time nurses.
Diane Duff Minden
Diane Duff Op Ed: Giving HHHS a ‘C’
By Diane Duff
When the Ottawa Hospital wanted to make changes to sites and services, they realized “the people and stakeholders in the process will have different and sometimes conflicting views” and while “conflicts create tensions, they are not irreconcilable…” and that it is possible “to find… win-win rather than win-lose solutions” (Setting the Stage, Turning the Page). The board and senior management realized not engaging with the community would impact everything from trust to fundraising.
Contrast this to Haliburton Highlands Health Services (HHHS) when making changes to hospital sites and services in which the board and CEO announced the closure of the Minden Emergency Department (ED) as “a done deal” with only six weeks’ notice.
Minden ED provided 58 per cent of the total ED visits to HHHS last year. Everyone from the Minden ED, doctors, nurses, and radiology staff, to the Minden council members, to emergency services providers, the media, and the public were in the dark until the announcement was made April 20. Insufficient notice violated the contract between HHHS and the Minden ED doctors, so they needed to be paid 60 days compensation to not work (June and July). This is a waste of human resources, ED services, and more than $250,000 of taxpayers’ money.
While HHHS might argue they cannot be compared to a big city hospital like in Ottawa, there are many other small hospitals that understand the need to engage with their communities and the advantages for doing so. Take the Kemptville Hospital. Like the Minden Hospital, Kemptville Hospital was built after years of “planning and fundraising by a determined group of volunteers.” Kemptville has a population of about 4,000 people. They were awarded perfect scores and exemplary standing for the second time not only due to clinical excellence, but because of dedication to patient-centred care and inclusion of community voices in the way they operate. Campbellford Memorial Hospital, with a local, year-round population of 4,000, that expands by leaps and bounds during the summer season, also achieved an ‘exemplary standing’ award from Accreditation Canada in 2023.
If you think of exemplary standing as an A grade, and accreditation with commendation as a B grade, it is not hard to figure out that HHHS with their award of accreditation in 2019 just managed to scrape a C. Transparency and community engagement involvement is an essential component evaluated by Accreditation Canada. Though HHHS has due for accreditation this year, HHHS has submitted a ‘sick note’ and delayed the process.
I attended the 27th AGM of the HHHS board June 22 via Zoom. After initial problems with the links they provided, which caused late entry to the meeting, many attendees, like me, were restricted from voting due to a flawed application process. During the meeting, vote counts were not read for any of the motions and new board members, chosen by the board, were acclaimed, rather than elected, though other candidates had applied.
In Toronto, where there were 102 candidates for mayor, the slate of candidates was known, and it was the people who chose their mayor in a democratic process, not the sitting politicians. While non-voting members were allowed to pose typed questions following the AGM, not all were read, and many that were read were edited and not asked as they had been written. Responses to the questions were often: “I do not have that information.”
An essential difference between A and C grade hospitals in Ontario is the boards’ and management of the A grades truly believe they work with, and on behalf of, patients, families, and their communities to continuously improve their care, and to create a shared story or narrative. They do not arbitrarily shut essential services without consultation and manipulate board and AGM participation to silence community voices.