Northumberland Hills Hospital in Cobourg, Ontario was facing a significant deficit.

The hospital convened a citizens’ panel to advise the board about which services could be removed from the hospital.

The experiment was successful – should it be used by other hospitals? took to the street in December 2010 to gather some opinions about whether citizens should be involved in hospital budgeting and restructuring, check out people’s responses in the video link below.

Northumberland Hills Hospital (NHH) did something radical in the fall of 2009 when the CEO brought together a group of citizens to help the hospital’s board make some tough choices.  This process was a unique approach to budgeting in the current era of fiscal restraint and health system restructuring. Is the NHH experience a one-off project or a model for other Ontario hospitals to follow?

Why participatory budgeting for NHH

Many of Ontario’s hospitals are increasingly having to make tough choices about how to balance their budgets, and possibly cutting some services.

By March 2010, NHH had run three straight years of operating deficits in order to sustain the range, and level of services, available at the hospital. The NHH Board chair, John Hudson, said “like any business or household, we simply cannot keep spending more money than we receive.” NHH’s leadership decided that they could not pursue hospital restructuring without enlisting in the help of community members

To our knowledge, participatory budgeting, meaning a collaborative process involving citizens in budgeting decisions of an organization, has never been done before in a Canadian health care organization. Budgeting is usually left to hospital staff who bring their recommendations to their Board of Directors for a final decision. In NHH there has a long history of community involvement, evident in the strong volunteer presence, active auxiliary and foundation. Therefore, the CEO, Robert Biron, felt that the budgetary process should not be done behind closed board room doors.

The citizen’s advisory panel process

Mr. Biron knew that the community had to be engaged, and that the process had to be legitimate – “Putting a mic in the back and front of room and yelling at each other is not community engagement.”

Mr. Biron and his team worked with experts in community engagement to develop a process that was guided by 3 core principles: it had to be proactive, legitimate and transparent.  Letters of invitation were mailed to 5000 households in the hospitals’ catchment area and asked that a household member be nominated to participate in a Citizen’s Advisory Panel. Twenty-eight citizen volunteers were selected based upon age, gender and geography. The Citizen’s Advisory Panel met for five, day-long weekend meetings held over three months. The entire process cost about $50,000.

The citizens heard from, and asked questions of, speakers expressing a wide-range of perspectives, including community health workers, hospital front-line staff, as well as executive staff from NHH, the Local Health Integration Network (LHIN) and the Community Care Access Center (CCAC). Citizens were also taken for a behind-the-scenes tour of the hospital, and visited all the hospital departments and laboratories. The Citizen’s Advisory Panel also had the opportunity to get input from the wider community, and held an open “Roundtable” meeting for interested community members to attend and learn about the challenges facing NHH, and the CAP process.

Following the presentations and tours, the citizens began to discuss, deliberate and make recommendations through a series of facilitated exercises. Citizens were asked to recommend which, if any of the 23 services offered by the hospital, needed to be cut in order to balance the budget. These were serious decisions, which not only influenced where people in the community could access health care, but also the jobs of health care providers and hospital staff.

The outcomes of the citizen’s advisory panel and lessons for Ontario

Ultimately, the Citizens Advisory Panel decided that complex continuing care, interim long-term care, a diabetes clinic, palliative care and outpatient rehabilitation services being offered at the hospital were not core services, and could be shifted from the hospital to the community. Part of their reasoning was that these services could be delivered more effectively and efficiently outside the hospital setting, and that the hospital should focus on providing acute care services.   The Citizens Advisory Panel provided recommendations to the hospitals’ Board of Governors, who considered the citizen’s recommendations, along with advice from other key groups including hospital staff, physicians and the senior leadership team. The board made the final decisions about the re-allocation of services; and their decisions included the majority of the Citizen’s Advisory Panel recommendations.

There was a great deal of apprehension at the outset of the process. Mr.Biron admitted that “I was very anxious at the beginning of our engagement process and I didn’t know how to approach the challenges of structuring a meaningful, constructive dialogue with our community.”  However, through a well designed process, which followed key principles, a group of citizens representing their community were able to come together and provide the Board informed and insightful advice relating to some tough decisions that would influence the future of their hospital.

Ontario is still in the midst of a recession, and tough decisions need to be made by many Ontario hospitals about what services they can provide. Could the Citizen’s Advisory Panel be a model for other Ontario’s hospitals to follow?

Do you think that Ontario's hospitals should have a Citizen's Advisory Panel to help with restructuring decisions?

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To learn more about the Northumberland Hills Hospital Citizen’s Advisory Panel process click here.

To access the final Citizen’s Advisory Panel report click here.

To read an independent evaluation of the Citizen’s Advisory Panel, click here.