Criticall and Emergency Care Access in Ontario
One of our regular contributors had posted an informative post on the previous journal entry regarding accessing beds in Ontario hospitals for emergency cases using Criticall, particularly neurosurgical cases. It indicates a true lack of access in 2010. This is not something new but it is easy to be hoodwinked by the science of studying wait times and the systems designed to deal with lack of capacity in a system that is likely to get much worse before we come to our collective senses.
Of course, tens of millions were thrown at neurosurgical cases in the past couple years in an effort to create an improvement but in my own estimation, nothing has really changed. I still wait for months...a year in some cases...for a neurosurgical consult in cases with positive MRI findings. I still have referrals rejected because the fax back reads "due to focus on cancer cases, cervical and lumbosacral cases will not be seen".
I do note that what did change after some money flowed was that neurosurgeons were suddenly quiet.
Looking ahead to an aging population and a population with increasing obesity, diabetes and cardiovascular disease, with all the inherent cerebrovascular complications such as stroke and MIs, it doesn't take a rocket scientist, or even a LHIN administrator, to figure out that things are going to get nastier.
I have copied the post almost in its entirety and hope that it provides a deeper understanding of how poorly our system is equipped to meet the needs of the future, not to mention now.
I will also have a look for Mr. Smitherman's comment.
Here is the post from eklimek:
"I am grateful the discussion is in the press about the shortcoming and unsustainability in providing service.
As some of you probably know there is a telephone communication system called Criticall in Ontario. It is used when an emergency requires treatment not locally available.
In years gone by, when there was surge capacity, it was very helpful in connecting the sending and receiving clinicians and assisted in finding emergent care somewhere in the province. Now with no excess capacity pretty well anywhere clinicians begin to view it as becoming just one more hoop.
Here is how it works. Since Criticall does not know the actual provincial bed availability for the needs of the patient (e.g neurosurgery) , it literally telephonically hopscotchs across the province sequentially ringing up on call neurosurgical services.
Reflect for a second on this. Say you are on call as at the potential receiving end. You also know there is no ICU /NICU or surgical capacity on site because you just took the last bed with the last case. Nevertheless you get called. You are obliged to respond, listen to the story, may choose to give telephonic advice for which shared liability is engendered and still must refuse to accept the case because you lack the capacity to treat the problem. All this, let's say, at 3 or 4 in the morninng.
Meanwhile, on the sending end, typically after 3 or 4 refusals for "no beds" over a similar number of hours of repetition and telephone tag with serial oncall services, the conversation turns to out-of-province care. Of course the alternative is to start over from the beginning, just to see if the bed situation has changed in the last 6 hours.
The new wrinkle is interposition of a medical director near the outset of the process if the patient is to leave the home LHIN. Who knew we really needed another noncare provider in this process?"
Thanks for putting it so plainly, eklimek. As health care in Canada sinks, the band leaders play on....except of course when they are trying to enter the life-rafts destined for the US.
Merrilee Fullerton
84 Comments
Reader Comments (84)
But I did find this post from 2007..yes, three years ago...and despite the millions and millions and even billions, no significant improvement:
September 08, 2007
Tanya Talaga
Health Reporter
A shortage of neurosurgeons and hospital beds meant 36 severely ill Ontario
patients had to travel to the United States for urgent surgery over five
months ending in August.
A summer spike in emergency cases left no choice but to send the patients to
Buffalo, Ann Arbor and Detroit to ensure the quickest and most appropriate
care, according to CritiCall, the referral service in charge of tracking
available beds in the Ontario health system.
From April through to August, 564 patients needed to be transferred to
another hospital to receive neurological treatment. Of that group, 36 were
sent south of the border, said Kris Bailey, executive director of CritiCall.
"This last quarter has been quite high," she said.
The problem is blamed on shortages of trained doctors and nurses as well as
critical care beds and available operating rooms.
When no bed can be found for Greater Toronto patients needing urgent
treatment for sudden bleeding in the brain or traumatic head injuries, they
may get sent to an Ottawa or a Kingston hospital.
But if there are no beds anywhere in Ontario, patients can get sent to the
U.S. It is an expensive option for taxpayers, and potentially devastating
for patients and their families. The health ministry said while the
aggregate costs of sending this summer's 36 patients for American care have
not been finalized, the tally for three particular transfers totalled
$97,921. The transfer referral system is working as it should, said Bailey.
"I believe we are achieving the Ontario mandate – we find the safest, best
spot for (patients') care and the most appropriate transfer."
Ministry spokesperson David Spencer said efforts are underway to boost
capacity here. Last year it launched a $90 million critical care strategy
that by next month should have added 86 beds to the system.
Ontario has also introduced 31 critical care response teams able to deliver
intensive care quickly anywhere inside a hospital.
Dr. Naveed Mohammad, corporate chief of emergency services at William Osler
Health Centre, said if CritiCall can't find a bed, a hospital's entire ER
feels the strain. "Resources are tied up with the patient, the doctors and
nurses spend a lot of time on them," he said.
Another major problem is retaining surgeons, said Dr. Janice Willett,
president of the Ontario Medical Association.
Nearly half of new neurosurgery graduates, about seven out of 15 every year,
leave Ontario to practise elsewhere, according to 2005 figures, she said.
The province's neurosurgeons work 70 hours a week and are on call, she said.
"It's hard to maintain job satisfaction."
Ontario's neurosurgeons are also getting older. About 23 per cent of those
practising are over age 55.
One recent Tuesday near the end of August was particularly frustrating for
doctors.
"We had three cases that needed a neurosurgeon," said Dr. Alan Kruger, an
emergency room physician at the Osler Centre's west end hospital. His own
hospital hasn't the capability to handle these types of cases and "there
wasn't a bed (elsewhere) in Ontario."
CritiCall confirmed handling 14 neurosurgery requests for transfers across
Ontario on Aug. 28.
Two of the cases were resolved without a transfer, but half the 12 patients
who did get moved were sent to the U.S.: five to Buffalo and one to Detroit.
"This one day was really quite unusual," Bailey said.
"Ministry spokesperson David Spencer said efforts are underway to boost
capacity here. Last year it launched a $90 million critical care strategy
that by next month should have added 86 beds to the system."
in 2010, beds will be cut because of government's inability to pay for its health care system...what happens to the patients then?
http://www.kaiserhealthnews.org/Stories/2010/February/04/cms-government-insurance.aspx
Some economists say they would help lower costs, but Steve Heffler, director of the National Health Statistics Group, which helped provide information for the report, said, "We do not project that any of those provisions… are going to have a noticeable impact on the rate of growth [of health spending].""
I located this (below) from 2006-2007. I remind your readers that Criticall deals with more than neurosurgery, but that happens to be the source of my professional issues. I am sure other clincians in other fields may have similar concerns about their respective infrastructural shortcoming.
But, as the CMPA says, it is sometimes inadequate to do your best. You must also inform those in a position of authority if you have noted a potentially remediable and preventable problem. The Rutka report (URL below) was a response by the MOHLTC to this particlular problem.
--------------------------------------
http://www.health.gov.on.ca/transformation/wait_times/providers/reports/neuro_rep_20071201.pdf
---------------------------------------
September 6, 2007 | eklimek
Followup Case number 2 below has since expired.
---------------------------
September 19, 2006
Hon. George Smitherman
Minister Health and Longterm Care
Hepburn Block
10th Flr
80 Grosvenor St
Toronto ON M7A2C4
Phone: 416-327-4300 Fax: 416-326-1571
Sir:
This letter is directed to several who may be in a position of authority to correct a remediable and forseeable problem, and the Minister of Health and Longterm Care of Ontario specifically. It is unclear to me who has the greatest burden for shared responsibility (hospital, LHIN, province) in the neurosurgical infrastructure of Ontario.
Vignette 1
----------------
On July 5, 2006, Mr X, a 47 year old, arrived 10 am in the office with an overt spastic paraparesis of subacute onset. He used a cane and was barely ambulatory. A symptomatic navel level was noted with sphincter involvement.
The required emergent MRI scan was scheduled for noon after telephone solicitation. Unable to lie adequately motionless due to pain, he was sedated in ER. A second effort proved diagnostic by 2:30 of a thoracic spine central posterior disc herniation with a lunate crescent of residual spinal cord visible.
After engaging Critical in futile hours of canvasssing the province for emergent neurosurgical assistance, the case was transferred out-of-country by 8 pm for definitive immediate neurosurgical management. Faxing of paper work for out of country treatment approval occurs at 9 pm. Homeland security required documentation of citizenship without a criminal record.
-----------------
Vignette 2
------------------
Mr. X, a 39 year old man, experiences an injury to the neck and is confirmed to have a fractured spine. The emergency room seeks advice on management and is advised that patient needs surgical stabilization at regional spine centre, but there are no beds. Patient is heldover. He is found on the morning of the 3rd day awaiting transfer in hospital "not moving legs".
-----------------
These vignettees taken from professional practice in St. Catharines demonstrate that patients suffer from neurosurgical infrastructural inadequacies in Ontario and this results in transfer of patients to the United States. By any estimate, the cost of long term care of the latter unfortunate man exceeds the cost of the definitive care he was denied. Surely, either individual's loss of societal contribution alone should persuade anyone the current inadequate neurosurgical infrastructure is not in society's best interest.
Please forward this matter appropriately.
E. Klimek MD FRCPC
145 Queenston Street, Suite 301
St. Catharines, Ontario, Canada L2R 2Z9
Telephone (905) 688-2066
Fax 688-9335
cc:
Michael G. Fehlings MD PhD FRCSC
Professor of Neurosurgery
Krembil Chair in Neural Repair and Regeneration
McLaughlin Scholar in Molecular Medicine
University of Toronto
Medical Director, Krembil Neuroscience Center
Head Spine and Spinal Cord Injury Program
Toronto Western Hospital, University Health Network
Tel: 416-603-5627
Fax: 416-603-5298
Suite 4WW-446
399 Bathurst St. Toronto Ontario M5T 2S8
-------------------------------------
Hamilton Niagara Haldimand Brant
Local Health Integration Network
Chair – Juanita Gledhill
270 Main Street East
Units1-6
Grimsby, ON
L3M 1P8
----------------------------------------
Niagara Health System
Betty-Lou Souter - Chair
NHS Corporate Office
155 Ontario Street
St. Catharines, ON
L2R 5K3
September 6, 2007 | eklime
Criticall is accessed thousands of times.
Does the pattern of transfer correlate with the inequity of LHIN per capita funding?
It's funny how London (outside my LHIN)will accept an unstable leaking AAA regardless of their bed situation most of the time. Hamilton on the other hand (the much closer hospital within the LHIN) Sorry no beds - click. They should be stripped of their tertiary care status - an absolute disgrace.
Globe and Mail | Jan 19, 2008
http://www.freerepublic.com/focus/f-news/1956732/posts
Sorry for dragging this quote forward but I thought, in fairness, clarity might be of interest to someone.
Accountants would have an opinion on this indeed. It would typically be based on something they call 'Activity Based Costing' principles (ABC) I suspect.
ABC recognizes that operations require indirect and direct inputs which in turn are charged against indirect and direct outputs respectively. They get snippy when indirect costs are found to be out of wack with outputs generated and this is as it should be.
When mfo refers to the NHS budget figures to assert (I think) that only 50% of spending goes to direct outputs (medical services/goods), I confess confusion.
According tomtheir financial reports, NHS expenditure figures for 2009 were $397M vs $380M (or so) budgeted. Yes a deficit.
NHS reports that 77.9% of expense went to 'DIRECT patient care'.
An additional 9% is reported as going to 'administration' (administration, HR, Finance, Info & communications.
'Support Services' are in at 13% and includes housekeeping, food, mtce., biomedical, registration, records and education services.
So my question is this: Which of the indirect inputs (support or admin. services)can be dispensed with or curtailed without compromising direct outputs patients seek? How do you arrive at the answer you arrive at?
I'll leave this alone now and apologioze again for dragging the subject forward.
Certainly the discussions about "fun with numbers" is cute but, as DrK points out, virtually useless, in that it's all manipulated to serve a political need. It is bizarre that one can move from a position that 2% of costs (apple to apples) comparsion, to a position of 50% of costs being non direct care in the space of days.
The reality is that the overall comparsions used are just 'gross" estimates of overall costs, and they aren't really comparable because of different items contained in the comparisons.
drKs suugestion of comparison could be a new approach - actaully structure the year end acconuts using an agreed accounting standard, which shoes how much money was given out and what expenses removed funds that get to the bedside. This would allow the public to measure the "efficiency" of their institutes.
Reality is most don't care - the service is free.
The reality is quite likely that nobody knows how much is being spent on overhead and bureaucratic costs in Canada's health care system. I suspect many don't want to know. It is often convenient to spin numbers in one way or another when discussing health care since stats can be twisted depending on the desired goal.
When I am able to refer patients to specialists without significant wait and when I am able to order diagnostics without weeks and months of waiting...and when patients are no longer being bumped from their elective surgeries for cancer dx or other, then I'll know the system has been "fixed". Until then, I won't be trusting the numbers, just what is really happening on the ground.
And in a different twist to efficiency, I still think that eHealth is of questionable benefit....a convenience no doubt in some circumstances but money spent on eHealth is money not spent on direct patient care...
Below is an article on smartphones being used for banking..expected to replace online banking:
http://www.theglobeandmail.com/globe-investor/personal-finance/ready-to-bank-on-your-smart-phone/article1459671/
How can anyone state the problem arises from underfunding (or any spin off) because there is inadequate service (in my opinion) yet use a "fun with numbvrs" accounting system? Does that not mean there is no possible effective accounting?
I thought the esence of the last decade was to "trim the fat". Seems we don't have a grip on what that might be, sine the data is not firm, or kept secret.
"widget monitoring" and required reporting and monitoring for the MOHLTC or other agencies should not be buried under "clinical services" or "patient care" costs. It may be an imposed cost, but frankly Scarlet, I don't give a damn. It is not essential to care.
http://www.google.com/hostednews/canadianpress/article/ALeqM5iwEMcPeTJctzJH_yGz6CgtPc5COA
A good article on optimization but how does one apply it to health care which is very personal and in which perception of quality is often created at a very individual level?
http://www.financialpost.com/executive/smart-shift/story.html?id=2538949
http://www.cbc.ca/smartshift/2010/02/the-growing-fight-over-personal-information.html
the space of days.'-mfo
I don't think I'm the bizarre one on this mfo.
If you care to look at the facts of the matter, the 2% figure cited in one post was the share of total (not health) provincial spending consumed by the provincial civil service itself. That was stated clearly in speaking to the relativly small gain to be realized in going after it alone through clawback.
I never used the 50% figure in any post and it's bizzare to state otherwise I think.
The NHS figures cited are from their website and available for anyone to view or challenge. They, not me, state that 77.9% of 2009 spending goes to direct medical expense. Take it up with the authors if you question their definitions. MFO,using unspecified sources, asserts that only 50% of NHS spending was on direct service delivery. A big difference here worthy of a thought or two.
Simple fact is that in order to expend 'direct' service dollars effectively,some indirect expenditure is required. Seems to me an interested party might attend the next AGM of the NHS (or any other) and ask the 'independant' auditor if they think the indirect:direct spending ratio is way out of wack or not.
Further, I think this might speak,in part,to trends in managing patient access such as the Criticall service.
If MOHLTC can avoid expanding the size/scope of existing facilities to meet demand through micro-managing existing capacities spread over geography, it theoretically avoids overall higher indirect costs since they are largely built into the network. Presumably some sites have better expenditure ratios than others and these can be trapped to some extent. I don't favour this approach due to it's lack of patient friendliness; I just speculate as to motive and method.
Negotiating bulk treatment volume rates with US based facilities accomplishes the same sort of gross saving result. Even though a portion of the bill comprises indirect facility costs (possibly even inflated), it is not budget structural for the ministry and therefore a better deal from a Treasury standpoint. Patients left pondering trade-off re: 'timely' service access vs inconvienence.
Planners know what most Canadians will opt for here as bizzare as some might construe it.
The Ontario civil service consumes 2% of public expenses.
Persuming the provincial civil service consumes proportionately to ministerial overall expenses, at least 1% of all health care exprnses are not and don't reach beyond Queen's Park. That is then the uber overhead in Ontario health care (light).
How much do the next levels of LHIN, and hospital admninistration consume? And how much is attributable to communication, monitoring and reporting to each other?
In the "fun with numbers" game, we actually don't really have any idea.
There really are the two issues:
1. What's the service being delivered and,
2. What's its direct/indirect cost ratio.
In health, the service being delivered is shifting. In the old days, it was fixing broken bones and supply drugs; now a days it's bus transportation, at home social support, and cancer avoidance. we don't know how to cost this anymore.
As for actually costing, by the use of agencies and crown corporation, etc; there is no getting a hold of who's a public servant versus an employee of an agency doing public service of the tax payers funds.
As we've moved from government supporting the requests of the public, to a centralist management and ownership role for the government, we've successfully eliminated the accountability role. It will continue as long as the tax roles can support it.
The direct/indirect costs as money filters down is about 50/50.
http://www.theglobeandmail.com/news/politics/in-a-season-of-restraint-alberta-opts-to-spend/article1461959/
Well, I'd argue that is exactly what you'll get with this type of spending....at some point, the piper must be paid but I suppose in politicians' usual way, it will be some other generation's problem. Pathetic...but of course, it is the public will that is driving the process. Seems like Easter Island to me.
Nobody keeps track of how many well-off Canadians pay out of their own pockets for American care. Occasionally provincial health plans pay for U.S. care for ordinary people when services aren’t readily available at home. Provinces spent $1.14 million on U.S. care in 2007-08—less than 0.001 per cent of total health spending. But that’s no more precise an indicator of shortcomings in the Canadian system than Williams’ trip is. Dr. Lorne Bellan, chair of the Wait Times Alliance, an organization of Canadian doctors aimed at speeding up access to treatment, said those problems are serious, complex, and likely to get worse as the population ages.
According to Bellan, provinces made quick progress after Paul Martin’s short-lived Liberal government cut a deal with them in 2004 to funnel $5.5 billion over 10 years into cutting wait times. Queues for cataract surgery, joint replacements and other high-demand procedures shrank fast. Then the Conservatives won election in 2006 on a promise of bringing in wait time “guarantees.” In 2007, each province signed on to deliver one health service, from radiation therapy to bypass surgery, within a guaranteed period. But Bellan said these were token gestures in areas where the waits were already reasonably short. Real progress stalled as politicians shifted to focusing on issues like climate change and the economy.
http://www.calgaryherald.com/health/Budget+boost+health+care+what+Albertans+want/2542253/story.html
but it is okay for Canada to spend beyond its means on bottomless pit of health care, all the while denying its citizens participatory health care including paying for care when necessary...go figure....just hope we come to our senses.
Public spending soared and public sector wages practically doubled during that time.
However, as the money flowed out of the government's coffers, tax income was also hit due to widespread tax evasion.
When the global financial downturn hit, Greece was ill-prepared to cope.
Greece's deficit is, at 12.7%, more than four times higher than eurozone rules allow.
EU rules state that no nation in the euro bloc should have an annual budget deficit which is higher than 3% of its gross domestic product"
While Canada is not really comparable to Greece, the difficulties of spending beyond one's means are highlighted.
Perhaps provinces should be required to balance their budgets just as public hospitals are required to do.
http://commoditytradealert.com/blog/?p=5282
The California situation is much more important than Greece,” he says. Greece comprises about 2% of Europe’s gross domestic product, while California—struggling to pay its debts—represents more than 10% of the U.S. economy, he says. “Yet nobody’s talking about California,” he says."
and exactly where does Ontario fit into the comparison? Perhaps not a big player in the world economy, but Ontario must face economic realities at some point or risk having them fester as time goes on....Alberta's spending is not sustainable either although I'll admit the Boom/Bust/Boom scenario is more likely there.
While I'm not an economist, I do think it is important to note what is happening around you...and quite often, economists, despite their training, are wrong anyway.
long term care home problems blamed on nursing shortage...maybe, maybe not, but it is strange that in a time where hospitals are cutting beds and nursing staff to meet budget requirements, other areas are claiming shortages of trained providers. If they could find them to hire, could they afford them?
It would seem that there is understanding of the disaster waiting to happen in health care in Canada. More emphasis on social determinants of health are likely by the federal health minister.
More self-care.
More individual responsibility without laying blame.
http://www.cma.ca/multimedia/CMA/Content_Images/Inside_cma/Media_Release/2010/PAToolkit_en.pdf
http://www.ottawacitizen.com/health/this+troubleshooter/2543741/story.html
Importantly, Hession says any vision must be centred on the patient, which means an electronic record accessible by anyone, from anywhere."
well...hopefully NOT accessible by anyone from anywhere..but we know what he means...
EHR by 2015? Unlikely at best.
Good luck Mr. Hession.
Over my 25 years as a physician, I still jump for joy when a patient actually loses the weight required to improve their blood pressure and serum glucose levels.
Simply creating a system that makes sure a diabetics HgbA1C is checked and that their feet and eye routines are completed and that they receive food instruction will not be enough.
Socioeconomic status has a great deal to do with who develops chronic disease and this will not be solved with more medical care or a diabetes registry.
http://www.physorg.com/news184857117.html
As a kid living in Whitehorse, it was pretty clear to me that the people living in "Whiskey Flats" down by the Yukon River had major problems....whether or not they had nurses and dieticians and social workers visiting them....the real problem was where they lived and their education level....
This study from 2010 provides some credence to what should be already evident.
"The primary problem is that the federal government’s Canada Health Act prohibits the provinces from experimenting with policies (i.e. competition in the delivery of publicly funded care and cost sharing) that have been implemented in other developed nations with universal access health care. These polices would led to better health care, at substantially lower cost.
Unfortunately, Minister Flaherty has indicated that reductions in federal transfers to other levels of government are off the chopping block. He should reconsider. Transfers can be reduced while improving our provincially delivered programs. Our own history provides the evidence.
excerpt:
Danny Williams’ decision is not unique. According to the most recent Fraser Institute estimate in 2009, Williams would be only one of approximately 41,000 Canadians who annually seek non-emergency medical care outside of Canada. Consider how absurd it is that the only way for Canadians to pay privately for better or quicker medical care is to leave their own country.
Our annual international report comparing Canada to other countries with universal health insurance systems shows that Canada is virtually alone in prohibiting people from spending their own money to get quicker or better health care.
Who is to blame for this? Despite commonly held beliefs, the federal Canada Health Act does not prohibit private insurance for medical services — the act only prohibits user charges under public insurance. It is actually the provinces that prevent ordinary Canadians from doing at home what Premier Williams chose to do in the United States.
In fact, six provinces (accounting for about 84 per cent of the national population) legally ban direct private payment for necessary medical services, and six provinces (accounting for 90 per cent of the national population) legally ban the purchase of private health insurance for necessary medical services.
Most provinces also prohibit parallel billing by health care providers. In these provinces, hospitals and physicians are not allowed to accept private payment or private insurance reimbursement while accepting public payment from the provincial health insurance system. Health care providers must choose to work either for private payment or public payment, but cannot elect both.
Most doctors are not willing to surrender their billing rights in the public system, and therefore do not even make their services available for private payment.
This is how governments effectively ban private health insurance and medical care in Canada.
http://www2.macleans.ca/2010/02/09/coyne-v-wells-on-jim-prentice-danny-williams-and-sacred-cows/
http://www.youtube.com/canadianmedicalassoc#p/u/1/I0QZtoKBeQE
http://www.youtube.com/canadianmedicalassoc#p/u/0/rMV3wAbj9t0
Saäd Rafi as Deputy Minister of Health and Long-Term Care. Mr. Rafi is currently the Deputy Minister of Energy and Infrastructure. Mr. Rafi brings extensive senior executive public and private sector experience to the challenges and opportunities at the Ministry of Health and Long Term Care. Mr. Rafi is a proven results-oriented leader and brings business, policy and operational experience to the ministry as it continues to implement key government priorities and to support the health system in the delivery of better health care in Ontario. Mr. Rafi's previous experience in the Ontario Public Service includes roles as Deputy Minister of Transportation and Deputy Minister of Community Safety. Mr. Rafi has also held several senior economic portfolio roles in the Ontario SuperBuild Corporation, Cabinet Office and Economic Development and Trade. Prior to returning to the Ontario Public Service in September 2008, Mr. Rafi was a Partner and National Leader, Infrastructure Advisory and Project Finance, Deloitte and Touche Canada LLP. Mr. Rafi holds a BA in psychology, an Honours BA in law and criminology and a Master's in public administration from Carleton University.
__________________
Because Ontario has done a stellar job preparing itself for its future energy needs.
Ontario Health Care Light, Dirty and in the Dark.
seems he dabbles in quite a few things
On Feb. 2, at about the same time Matthews was shutting the door on our local member, her staff released this statement quoting her: “Today I met with a representative from the Toronto Grace Health Centre Board of Trustees. . . and a representative of the Canadian Union of Public Employees. I reiterated to them our commitment to a strong future for the hospital. I am more confident than ever a solution can be found to ensure that these vitally important services are maintained at the existing site.”
Hmm. In Parry Sound-Muskoka talking about securing the future of health services would be inappropriate. In Toronto the Minister of Health is only too happy to brag about her interventions to secure services. And then there’s the $15 million to get the deal done.
Are we the only ones seeing a different standard, a different set of rules?
Location, location, location, indeed."
http://www.cottagecountrynow.ca/community/northmuskoka/article/607192
Since Parry-Sound Muskoka was last held by a Liberal in the early 1990s, I sincerely doubt that it will ever receive the same attention.
Riding, riding, riding.