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| Société de la médecine rurale du Canada |
Central Region
2001, May 15
Hon. John Nilson
Minister of Health
Saskatchewan
Dear Sir:
Re Fyke Report
I am writing to you to offer you our observations and insights
on the Fyke report. I am writing on behalf of the Society of Rural
Physicians of Canada. The Society is a voice for rural physicians
in Canada. The Central Region of the Society represents the Prairie
Provinces.
Canadian rural physicians have found themselves on the front
line of change in the health care system. We see the need for and
support changes that improve the quality and access to health care for
our patients. We also see the need for and support changes that improve
the sustainability of services to rural Canadians.
We would like to be seen as partners in the process of change.
We do not consider ourselves to be impediments to, or victims of change.
Many rural physicians throughout the country practice in teams with other
health care professionals, work with alternative systems of health care
delivery, and participate in alternative payment mechanisms.
The Good Things about Rural Health Care:
Statistics Canada figures show that rural people are on average
older and poorer. In spite of this, recent statistics from BC and
Ontario show that rural people cost medicare substantially less than urban
people. It is tempting to attribute this to difficulty in accessing
the system. It is, however more likely that this is due to the following
reasons:
· Rural people get a larger portion of their total health care
from their local physician than urban patients. Urban patients get their
emergency and secondary care from physicians other than their primary providers.
Urban patients have easier access to specialists. Multiple providers
increase redundancy and costs. Rural physicians are not only primary care
providers but secondary and occasionally tertiary care providers.
The cost differences are dramatic. It should be possible to generate
these statistics for Saskatchewan also.
· There is a rural culture that includes careful use of public
resources.
By applying specialist-based secondary services to rural Saskatchewan, you are applying an urban solution to a rural problem. This will probably generate urban costs.
Quality:
A restricted definition of quality is offered in the executive
summary. It is “the best job possible with the resources available”.
The public would see this as a definition of “efficiency” If we are unable
to deliver quality services as the public understands the word, we should
do the best we can with what we have and not solve the problem by redefining
quality.
As is mentioned in the report, there is an erroneous public perception
of quality in the system. A common source of stress at the primary
care level is the collision of patients’ expectations of quality with the
realities of the system. We should be clear to the public on what
the system can and cannot do for them.
Hospital Closures:
It is unlikely that further wholesale hospital closures will
save any more money than the first round did several years ago. The
unit cost of the community hospitals is usually less than that of regional
hospitals. When a patient is in a hospital at a significant distance
from home, there is a tendency to keep the patient in hospital longer as
the patient cannot get back as quickly or easily if complications develop.
The greater distances also make homecare more expensive and less available.
Regional hospitals will have to be expanded appropriately. Patients
will not stop getting sick if the hospital is farther away.
If adequately staffed and equipped, smaller hospitals can generate
better outcomes. It has been shown that with obstetrics, better outcomes
are achieved overall when obstetric services are provided in the community.
The community care centers will be faced with drop-in emergencies no matter
how extensive the public education campaigns are. It will be impossible
to ethically refuse these patients and make them travel to a regional emergency
department. This will create an untenable situation for the providers
as our second greatest source of litigation is emergency work. It
will be an even greater source if this care is provided in the absence
of resources.
Talk of hospital closure becomes a self-fulfilling prophecy.
Closure is publicly considered, major maintenance stops, services stop
being improved, the hospital provides less services, patients start going
elsewhere, physicians leave and the hospital can no longer be economically
justified. You should appropriately space the community care centers
in communities of adequate size. They should be adequately equipped
to provide emergency services, low risk obstetrical services and short
stay medical services in addition to the inpatient services proposed.
They should supplement and complement services provided at the regional
hospital as part of a process of regionalization, but not centralization.
Primary Care Networks and Teams:
Rural physicians are, for the most part, team players and would
look forward to formalizing the relationships. Unfortunately, in
the report the roles of the primary care providers and the composition
of the teams are not defined. The report does not recognize that rural
physicians are multi level care level providers, not just primary care
providers. Because of this, rural physicians have difficulty seeing
how or if they will fit into these networks and teams.
The fee for service system for remuneration of physicians may
be equally suitable with some modifications. For example: it would
need to recognize committee work and consultations with non-physician providers.
Those of us that have been practicing in primary health care
teams recognize that the teams require leadership by someone with a broad
base of knowledge, otherwise the activities of the team degenerate into
each provider advocating for their narrow focus of skill and interest.
In a rural environment, it is more appropriate to have the team
members practice to the greatest breadth of their abilities. Although
they should also work to the maximum of their abilities, exclusively emphasizing
this would make the team larger and more inefficient. Large teams
with each specialized member practicing to the pinnacle of their skillset
might work in an urban setting, but would be inefficient in a rural setting.
To use their full skillsets to maximum efficiency and quality, nurse practitioners
need physicians handy and physicians need acute care and emergency services
handy.
Regional Hospitals:
It is unlikely that you would be able to get sustainable complements
of specialists for these centers. There are many rural physicians
who have acquired additional skills in surgery, obstetrics, anesthesia,
and aspects of internal medicine. They would not be able to provide
the full range of specialist services, but would be able to provide the
more common procedures.. Saskatchewan is well known for the advanced
training that it provides for family physicians to provide cesarean section
services. With such capacity rural hospitals have shown that they
are able to keep 99% of their maternity cases and have outcomes equal to
those of specialty centers.
The Society is working with the College of Family Physicians of Canada
and with specialist organizations to standardize training and maintenance
of competence in these additional skills.
These physicians with additional skills are and will be a valuable
resource to you. These physicians do not see a role for themselves
in the system that is proposed. You should take steps to be sure
that you do not loose them to other provinces.
Emergency Services:
Statistics are provided in the report to demonstrate the effectiveness
of a telephone triage system. What the report fails to note is that
telephone triage is already being provided free by rural hospitals.
Most patients who are unsure of their needs do call their local hospital
for advice and get the benefit of a nurse’s opinion and that of a physician
if the nurse feels it is appropriate. For that reason we expect that the
proposed system will not demonstrate any savings in rural Saskatchewan,
even though it has demonstrated effectiveness in urban settings.
Our members from Northern Ontario noticed that such a system actually increased
referrals to the emergency department. That is understandable because
someone who is unaware of local resources, customs and personalities is
now giving the advice.
Wellness, Illness and Aging:
Wellness efforts prevent some diseases, delay others and detect
others earlier. They have less effect on the more expensive and chronic
diseases such as dementias, cancer and arthritis. By allowing people
to live longer, wellness efforts will increase the incidence of these diseases.
We fully support wellness as part of the primary care team’s mandate, but
you should not expect to see cost savings from it. Illness and old age
will continue to be with us.
The report gives, as evidence of poor quality in the system, the fact
that most of our health care activities do not improve the health of the
population. Caring for the ill and the old will not improve the health
of the population. It is likely to worsen the overall health of the
population by keeping the old and the ill alive and functioning longer.
We cannot abandon these people because our care for them fails to improve
the health of the population. The ill and the old are us, or will
be us, regardless of how healthy we can be now. How well we care
for these disadvantaged people is a measure of how socially advanced our
society is. It is also a measure of the quality of our health care
system.
Yours truly,
David P O’Neil
The Central Committee
Society of Rural Physicians of Canada
Cc: Hon. Lorne Calvert, Premier
-This document may also be viewed at www.srpc.ca