Case 6: Shared challenge, shared solution: Northumberland hills hospital's collaborative budget strategy

Citizen Engagement in Health Casebook

Robert Biron, President & CEO, Northumberland Hills Hospital
Jennifer Gillard, Director, Communications and Community Engagement

Photo: Northumberland Hills Hospital - Citizens' Advisory Panel


Located in Cobourg, Ontario, 100 km east of Toronto, Northumberland Hills Hospital (NHH) faced difficult choices during the 2010 fiscal year. Although efficient by most key measures, the 110-bed hospital had run three years of operating deficits in order to maintain the 23 services that its community had come to expect. This was not sustainable, and the long-term viability of the hospital was at risk. Furthermore, Ontario's hospitals are required, by law, to balance their budgets.

Why citizen engagement?

Recognizing the fiscal realities and the tough choices they faced, the NHH Board embarked on a public consultation focused on the challenging — and potentially controversial — issue of service prioritization. It did so in the context of a small community that was heavily invested in — and supportive of — its hospital, both as a leading employer and the focus of considerable donor and volunteer commitment.

The objectives of NHH's engagement process were threefold:

  1. to receive public input through a genuine process that would inform the NHH's Board of its options;
  2. to maintain or enhance the trust felt towards NHH within the community; and
  3. to achieve Local Health Integration Network Board approval for the ultimate choices made by the NHH Board regarding service adjustments that were necessary to balance the budget.

Conducted over a 10-month period, Northumberland Hills Hospital's collaborative budget strategy, Shared Challenge, Shared Solution (SCSS), offers a unique case study for effectively engaging the community served around a subject facing many hospitals in Canada.


NHH's community engagement initiative was partly triggered by a requirement in the Local Health System Integration Act of 2006, which requires that Ontario's health service providers "engage the community of diverse persons and entities in the area where it provides health services when developing plans and setting priorities for the delivery of health services."

Regardless of the requirements of the Act, NHH strongly believed that there was significant value to engaging its community prior to making decisions relating to service changes. As such, the engagement initiative was anchored on three fundamental principles, namely that the hospital would be:

SCSS aimed to involve external stakeholders in the decision making process to help identify and prioritize the core services of the hospital while maintaining the community's expectations for quality patient care. The challenge was to deploy an engagement process that would be effective and viewed as legitimate by the broader public.

To support the design and process of public input, NHH followed a number of resources. A framework document published by Dalhousie University, entitled A Framework for Involving the Public in Healthcare Coverage and Resource Allocation Decisions, was used to map out the overall process.1 NHH also followed the International Association of Public Participation's spectrum of participation while implementing the SCSS strategy, informing, consulting, involving and, finally, collaborating with the community served.

Inform and consult

The first stage of the plan — the "inform" portion — commenced in April 2009 with community presentations by the CEO being delivered to community groups, including municipal councils, service clubs, and other health service providers. Within each group was a distinct set of community thought leaders. The focus of the presentations was a financial update on NHH and context on the funding challenges facing NHH and hospitals throughout Ontario.

Running parallel to this outreach — which was designed to get community members thinking and talking about both the fiscal challenges faced by NHH and the prospect of change — was a telephone survey.

Conducted by an independent polling company on NHH's behalf, the survey was carried out in April 2009.The survey focused on whether the public wanted to be involved and, further, how they wanted to be involved in budget deliberations, preparing the way for the future public engagement exercise.

A total of 510 telephone interviews were completed. In line with NHH's "inclusive" promise, interviews were collected from a representative sample from across the community served. Phone interviews were also conducted with representatives from the First Nations of Alderville, ensuring that their representation in the survey was proportional to their percentage of the overall population. Results were weighted by region and gender (based on the most recent census data) to ensure representative results.

Following a recommendation from the Northumberland Poverty Reduction Action Committee (one of the many community groups visited by the CEO), face-to-face surveys were subsequently added to solicit input from lower-income individuals who might not have been reached by the telephone survey. A total of 36 face-to-face surveys were completed, bringing the overall total of citizens polled to 546.

Close to half of the residents surveyed stated that they wanted to be more informed about hospital services (49%), as well as key decisions and plans related to the hospital's future and priorities (47%). One in five residents surveyed said that they wanted to be "much more informed."

The April 2009 survey also endorsed NHH's vision of establishing a mechanism through which it could engage residents to solicit input into changes to services, with 51% of respondents indicating that they wanted input into changes in hospital services.

Another objective of the surveys was to "identify the public's preferred methods for being engaged in budget discussions relating to service options." In this regard, the survey concluded that west Northumberland residents viewed community advisory panels and public meetings as the most effective methods for obtaining their input. In other words, this community preferred "face-to-face" meetings to deliberate and discuss these matters instead of other technologies, such as phone or web surveys. As a result, NHH had clear direction on how to structure its engagement process.

Consult and involve

Northumberland Hills Hospital's Citizens' Advisory Panel ("CAP") would eventually prove to be a new way for community members and NHH to work together to solve the difficult problem of service prioritization. It was essential to strike a Panel that was — and was perceived to be — independent of the Board.

To support the establishment of the CAP and the engagement process, NHH issued a request for proposals for consulting services. MASS LBP, a consulting firm based in Toronto, was selected to work with NHH. Their approach to community engagement and their unique selection process for selecting participants aligned with NHH's engagement principles and core values. MASS LBP deploys an innovative approach to establishing citizen reference panels using a civic lottery, a selection process similar to the way in which a jury is selected in the justice system.

The Hospital Board provided governance oversight of the process, while researchers with expertise in resource allocation decision making and program evaluation from The Monieson Centre at Queen's University's School of Business provided an independent evaluation of the engagement process.

In the fall of 2009, a letter inviting residents to participate in the CAP was sent to 5,000 random households within NHH's catchment area. One in twelve households received the letter, which served as a further communication tool for spreading information on NHH's financial challenges and the tough choices ahead. Signed by the Board Chair and CEO, the letter invited the household to nominate one member over the age of 18 to volunteer to serve on the CAP.

Working with approximately 100 eligible responses received, CAP members were then blindly selected by MASS LBP based on the prescribed attributes of gender, age and geographical location to match the profile of the region. In addition, a minimum of 50% of the CAP participants (or one of their immediate family members) had to have recently used the hospital's services. This was done to ensure that a patient's perspective was also included in the deliberations.

NHH and MASS LBP developed the extensive curriculum for all of the CAP sessions. Over the course of five full-day sessions held between October and December 2009, the

CAP members went through an intensive process. They studied, deliberated and discussed the hospital's 23 patient services. They toured the hospital, heard from experts, stakeholders and service providers, carried input from their neighbours and colleagues back to the CAP through private conversations, and hosted a public roundtable meeting which extended the conversation to the broader community. Through a facilitated process, the CAP was not only able to apply a values-based framework that evaluated and prioritized NHH's core services, but also to prepare their recommendations for the NHH Board.

Collaborate and empower

In January 2010, the CAP delivered its report to the NHH Board. The report included, as requested: an outline of the participants' vision for the future of the hospital; a values-based assessment framework for ranking NHH's 23 services; and a ranking of NHH's services into core and non-core areas, in accordance with the CAP's vision for the future of the hospital, including their rationale and expected impact on NHH's budget.

In keeping with the transparency promise, news that the Board had received the CAP's recommendations was released to the community, but the details of its proposals were not shared until the Board had completed its deliberations two months later. This decision posed considerable challenges from a media perspective, as speculation grew over what the CAP had proposed to excise. This delay, however, was essential to NHH maintaining its initial commitment to the CAP: that while the citizens would collaborate with the Board (i.e., provide recommendations) and inform outcomes, the final tough decisions would remain the responsibility of the hospital Board and, on its approval, the LHIN.

From January to March, the NHH Board deliberated over the CAP's recommendations, combining the input of the citizens with that of other stakeholders, namely the LHIN, hospital staff, physicians and community health service providers.

In March, 2010, the Board released its final plan, which accepted many of the CAP's recommendations. Most importantly, it reflected the CAP's insistence that the hospital should "focus its efforts on acute care services" and divest other, non-core services into the community, where such services could also be effectively delivered.

Outcomes and impact

Shared Challenge, Shared Solution was designed to help develop a plan to place NHH's finances back on sound, long-term footing while retaining trust in the hospital as a valued public institution in west Northumberland that was worthy of ongoing and active donor and volunteer support. It did just that.

The CAP process brought together personal experience, expert knowledge, and public context to give Panel members the insights that they needed to translate their opinions and ideas into meaningful and credible recommendations for the hospital Board. It respected the hospital's commitments to be proactive, transparent and inclusive. The communication before, during and after the CAP kept the broader public informed and highlighted avenues where everyone could, if they desired, become involved.

The LHIN accepted the Board's proposed service changes without amendment. Implementation of that plan, which involved the closure of several programs, began immediately. As a result of these efforts, on March 31, 2011, NHH achieved its first balanced operating budget in years, and it is on track to sustain the same balance in 2011/2012. Donations, as measured by local participation in ongoing Foundation and Auxiliary fundraising events, have grown or held steady, indicating continued trust in the organization.

In April, 2010, the Hon. Deborah Matthews, Ontario's Minister of Health and Long-TermCare, praised the NHH project as "innovative" during a statement in the provincial legislature, and she encouraged other Ontario hospitals to consider NHH's approach when seeking ways to engage the public:

The Citizens' Advisory Panel [is] something that I think other hospitals may wish to explore because it does actually ask the people in the community what they need to protect and what could be done better outside the hospital.2

On Tuesday, March 1, 2011, The Globe and Mail featured an article highlighting NHH's "novel approach of creating a Citizens' Advisory Panel on Health Service Prioritization…."3

In NHH's 2010 accreditation report, Accreditation Canada acknowledged NHH's community engagement practices as an area of strength:

The NHH is embarking on a transformation journey. It has engaged the community in a meaningful manner with respect to service provision, given its financial imperatives. The community advisory panel, along with perspectives from other stakeholder groups, were considered in the organization's new draft strategic plan and submission of the 2010/2011 operating plan.4

Lessons learned

The CAP process was audited and evaluated by researchers from The Monieson Centre at the Queen's University School of Business. As part of this process, panelists completed a total of eight surveys: one after each of the five sessions, a pre-survey, and two post-CAP surveys. This evaluation not only provided NHH with information for future community engagement processes, but it also enabled facilitators to modify sessions as they received Panel member feedback following each CAP meeting. Baseline, mid-stream and post-event evaluation tools are strongly recommended for organizations planning public engagement, regardless of the participation method selected.

Clear communication around the organization's expectations of participants at the beginning of the exercise is also recommended. In the early stages of planning for the CAP, a detailed Terms of Reference was prepared to outline the roles and responsibilities of the CAP, their reporting relationship, and most importantly, the scope of their mandate. This document, developed in consultation with the NHH Board and senior management team, was made available on the hospital's website at, and it was essential to the CAP's success.

The 185-page evaluation report delivered to the NHH Board from Queen's University concluded that NHH "went far above and beyond the minimum requirements for public consultation" and achieved its goal of engaging the community.5 Before the CAP, 43% of the panelists were satisfied with NHH's method of making decisions about services; this jumped to 83% in the post-CAP survey.

The members of the CAP recognized the significant commitment of the CEO and NHH's Senior Management Team, and they greatly appreciated the hospital's willingness to listen and share information. Survey comments praised NHH's overall facilitation of the CAP, saying the sessions were well organized, the overall curriculum and format were effective, and the facilitators were unbiased. Of particular interest is the fact that the panelists unanimously agreed that NHH should continue to use the CAP model to obtain public input. Given the chance, 92% of the members would participate in a similar process, and 96% felt they had accomplished something important.


Footnote 1

Chafe R., Neville D., Rathwell T., Deber R., et al., A Framework for Involving the Public in Healthcare Coverage and Resource Allocation (Halifax, N.S.: School of Health Services Administration — Dalhousie University, 2007).


Footnote 2

Hon. Deborah Matthews, Ontario Minister of Health and Long-Term Care, Provincial Legislature, April 27, 2010.


Footnote 3

Galloway, Gloria and Lisa Priest, "Health Care Action Plan urged to avert 'looming crisis'," Globe and Mail, February 28, 2011, A4.


Footnote 4

Accreditation Canada, "Accreditation Report: Prepared for Northumberland Hills Hospital" (2010), p. 2 (retrieved January 27, 2012)


Footnote 5

The Monieson Centre, "Report on the Community Engagement Process" (2010), p. 30 (retrieved January 27, 2012)


Date modified: