Citizens participate in hospital restructuring processes

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?

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.

The comments section is closed.

  • Robert Biron says:

    I am responding to Deborah O’Connor’s post. As the CEO of Northumberland Hills Hospital (NHH), I believe it’s important to correct the false statements made by this individual.

    She states: “I can tell you the advisory group, hand picked by the hospital board and senior administrators, were chosen to reflect their own desires.” This is a false statement. In fact, NHH used a civic lottery process to select a representative group of our community. We randomly invited 5000 households to participate in the Citizens’ Advisory Panel (CAP). From the applicants received, the individuals were randomly selected and balanced for gender, age and geography. The entire selection process was completed independently from the hospital, by our consultants MASS LBP. The Board used this civic lottery process to ensure a legitimate selection process to avoid such accusations that are being made by O’Connor. Neither the Board nor the CEO (or any NHH staff) were involved in the CAP selection process. The full CAP report is available on the hospital’s website ( While the civic lottery process may not be perfect, it was a genuine and honest effort by this hospital board to engage its community before decisions were made on some tough issues.

    In regards to the Hospital’s AGM, she states: “they manipulated the process to avoid adding any new members to the board, and have now designed a process that the current board chooses their replacements instead of allowing democratic elections to these positions.” This is a false statement. The AGM process that was followed adhered to both legislation and the hospital’s by-laws, which were approved by its members. The new by-laws were voted on by the members and passed in a democratic vote by majority. Hospital governance requires a skills-based board. In other words, a broad range of skills, experience and expertise to ensure balance and a range of perspectives. NHH is very fortunate to have 12 volunteer community members of varied backgrounds (including social services, business, law and finance) that serve on our hospital board, who provide countless hours of oversight and represent their community extremely well. These individuals have the interests and long-term viability of their community hospital at heart.

    Finally, the comment that “NHH is a dictatorship” is offensive to say the least. Aside from the implied personal attack, it totally dismisses the work of the hospital Board in a very difficult, economic climate. The NHH Board and I, as the CEO, have taken measures to engage our community in a participatory budget process like no other in this province. We continue with our engagement today through various means. No one claims that the engagement processes or the service plans are perfect. Our goal is to work with ALL stakeholders, including the public, Ministry of Health and Long-Term Care, the Local Health Integration Network, and other service providers in restructuring the health care system so it can be sustainable for future generations.

    The purpose of this website is to provide a “healthy debate” on current health care issues and policy. Let’s have this debate based on facts; not falsehoods or personal attacks. This type of approach is divisive, unproductive and serves no purpose.

  • Deborah O'Connor says:

    I live in Cobourg where the NHH is located. I can tell you the advisory group, hand picked by the hospital board and senior administrators, were chosen to reflect their own desires. They were almost all business people, certainly all middle class and most likely politically conservative. The result was that the services they discontinued, re-hab including physio, and the high risk diabetes clinic for kids and pregnant women, were dumped onto for-profit services for re-hab, and offloaded to a new health care community program that couldn’t deal with the high risk cases. Until the community program went through the process to get funding to hire specialised practitioners, which took almost a year, the high risk cases had to travel out of the area to another hospital in a larger community.

    The Board CEO Robert Biron even acknowledged that low income people and seniors with transportation issues would suffer the most with the cuts, but more or less told them tough cookies. Then, at their AGM they manipulated the process to avoid adding any new members to the board, and have now designed a process that the current board chooses their replacements instead of allowing democratic elections to these positions.

    The NHH is a dictatorship run by highly paid and very slick people who will continue to run the hospital their way without regard for what the community actually needs. It is a disgrace.

    • adlam67 says:

      In response to the posters comment, I would like to challenge her to come up with a better way to run the critical services of a hospital, ANY hospital, with the way the government keeps taking dollars away from these facilities. As a very new member of the community, I am impressed with the fact that the Directors of this hospital would take the opportunity to seek input from the families that live in the area without just making these important decisions behind closed doors, as most organizations typically do. As Mr. Biron pointed out, this website is so we can conduct healthy conversations about our health care system, not use it as your personal source to fling accusations!

      I look forward to raising my family in a community where the health care team members take to heart the opinions of the people they serve!!!

  • Dean P. says:

    Thank you for this website and topical issues. Well done!

    @Emily H. The way I understood the story of Northumberland Hospital is that they asked a representative group of their community to provide advice to their Board. All stakeholders, including patients and public, have inherent biases. And isn’t that the point? It states that the Board also considered other stakeholders in their deliberations. The consultation happened before decisions were made, not after the fact. I think the hospital board should be commended for taking the time to seek out different perspectives (and biases) in their decision making before they made the decisions. I also read into the story that services affected were in fact transferred to other providers in the community. Let’s face it, hospital based care is the most expensive, and if there are services that can be delivered as effectively by a community provider and at a lower cost – how can that be criticized? Hospitals are not known for their public consultation when service changes are made, I think this is a significant step forward. Bravo!

  • Emily H. says:

    The idea of asking highly biased community members which programs to “cut” makes me nervous. Instead, hospitals should be collecting more detailed data on their patients, and enlisting experts to analyze the data to find out what’s really NEEDED.

    However, it sounds as if the slashed NHH programs were “shifted to the community”. Could that really be true? Because as long as resources exist to support the programs in the community (hard to believe!), this makes sense to me. Health care users should have a say in how their care is delivered. But I don’t think it’s appropriate for them to decide what kind of care is available.


Karen Born


Karen is a PhD candidate at the University of Toronto and is currently on maternity leave from her role as a researcher/writer with

Andreas Laupacis

Editor-in-chief Emeritus

Andreas founded Healthy Debate in 2011. He is currently the editor-in-chief of the Canadian Medical Association Journal (CMAJ)

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