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Under the existing fee for
service payment scheme, it is said that there is insufficient coordination
to ensure that the right services are provided by the right
providers in the right places. It is evident that there are problems
with primary care in many urban environments. The city dweller has a choice
between walk in, ED, the family doctor, midwife, paediatrician, and gynaecologist
for elements of their primary care. The providers offer fragmented and
therefore expensive and often uncoordinated care. Furthermore, with the
exception of the ED, there is limited dependable access to care on a 24
hour, 7 day a week basis. It has been suggested that with primary care
reform (PCR), we could provide accessible high quality integrated and coordinated
care. As an additional benefit, some have even claimed that this will also
improve access for primary health care for the 1.6 million rural Ontarians
To date, in Ontario there
have been at least ten major models, and several large PCR pilot projects.
There has been considerable discussion about PCR and its promises,
and between proponents for each of the plans. Who are we to believe?
To this simple rural doc, I think that most models of primary care reform can be characterized in three sentences
1) Patients are enrolled to a provider
2) The provider is accountable for a defined basket of ambulatory services
3) A group of providers will
provide 24 hour access 7 days a week
Rural physicians, find it
hard to understand the controversy over these tenets as the vast majority
of rural docs, defacto have their patients enrolled to them (the patients
have nowhere else to go), they provide all the listed ambulatory services
as a matter of course (there is no one else in town to provide them), and
they work in virtual groups to provide 24 hour 7 day a week coverage.
Furthermore, in the country
we have to do much more than just provide ambulatory care. A good third
or more of our time is spent at the hospital. In fact the existing fragile
rural hospital is a model for coordinated community based services. Each
of the proposed PCR models is significantly flawed by failing to take this
into account.
The lack of sufficient flexibility
in the PCR pilots to allow for hospital services, is the reason why the
only rural hospital pilot, Wawa, dropped out. This failure to accommodate
the rural context is a graphic example on why rural input into the design
is essential for formulating a successful PCR model for rural communities.
While most PCR models are
quiet on rural implementation, the strength of the Health Services Restructuring
Commission (HSRC) plan is that it has some specific suggestions. It starts
well with suggestions for additional support for hospital services in rural
areas to include specifically obstetrical deliveries, ED work, anaesthetic
services, surgery assists and visits as most responsible doctor to homes
hospitals and long-term care facilities. But rural doctors have been left
scratching their heads on how the HSRC expects a rural or remote hospital
in a town of 5,000 to provide all these services plus primary care with
only 1 or 2 physicians, no matter how many nurse practitioners get hired..
Take Blind River. It has
a population of 3,200 and draws from nearby Algoma Mills and Iron Bridge
for another 1600 population. Currently it has 4 doctors who are trying
to recruit a fifth, as they are overworked and doing too much call. Its
doctor to population ratio is 1:1250 which means they make do with a third
less GP's than the Ontario average, but this is better than the rural norm.
In the HSRC model 2 or 3 of the existing doctors will become redundant
and you would hire 2 or 3 nurse practitioners to replace them. To cover
the hospital you will have to convince a doctor to carry the beeper every
minute and never leave town. Not stated in the report but you could hire
2 extra doctors as hospitalists. There wouldn't be enough work to hire
any more, but by trying to run a call schedule for the hospital with half
the number of doctors will increase already high burn out rates.
Nonetheless, we need reform
in the country as much as people do in the city. Fee for service in its
current implementation is not working for us. By the government's own numbers,
underserviced areas are looking for 415 doctors this year, over a four
fold increase from 1996. The problem lies not in the needs of the primary
care side but in the need to provide those more difficult hospital duties.
In rural Ontario there is
no getting away from the fact that you need doctors to run the hospital.
To make them stay you have to remunerate them well, especially for the
difficult services in remote areas, and provide sufficient numbers so that
they don't burn out. To introduce nurse practitioners doesn't make sense
unless there are at least five doctors sharing call for the hospital. Above
this number, you can introduce Nurse Practitioners for the ambulatory work
without risking the hospital. To encourage cooperation between providers,
it is essential that the payment schemes for each provider doesn't engender
competition.
Dealing with the entire picture
of the rural medical crisis has become forced the Society of Rural Physicians
to think outside the existing box, and to seek natural allies at the grass
roots levels, so that we can find solutions.
In early 1998 we organized
a national policy conference with and about nurse practitioners, to help
define the issues and roles. Not surprising, issues of isolation and need
for professional support are as important to rural NP's as rural doctors.
In 1998 the Ontario Region
coconvened with PAIRO an expert group that developed "From Education to
Sustainability - A Blueprint for addressing physician recruitment and retention
in rural and remote Ontario." This provides a comprehensive guide from
highschool through retirement to address rural physician shortages.
In 1999 the Ontario Region,
in conjunction with the OMA Section on Rural Practice, and building on
the blueprint, developed an implementation plan for Rural Medical Practice
support called "A Fair Share for Rural Health"
In 2000 the Ontario region
has joined with community, business and labour leaders to form the Negotiating
Ontario's Well Being Alliance. The NOW Alliance has a 12 point Rural Health
Action Plan which we know can be applied to FFS or other funding mechanism,
including those proposed under PCR. These proposals are needed to support
services such as inpatients, emergency, obstetrics, surgery and anaesthetics
that, in one person can only be delivered by that swiss army knife of clinicians,
the rural doctor.
Lets take obstetrics as an
example. In Ontario in 1986 there were 460 rural generalists who attended
births. Now there are less than 250 FP/GP's left who provide this service.
Because there is practically no one else in rural Ontario to provide this
service, there are at least 30 hospitals who have closed their obstetrical
wards because of lack of medical personnel. There are at least 3 more hospitals
in Northern Ontario that are down to one MD who does all the deliveries
at the hospital (Manitouwadge, Chapleau, Kirkland Lake) When the remaining
Family Doc who provides this service leaves Kirkland Lake this spring,
170 women will have to travel two hours in good weather to Timmins
for delivery.
The NOW Alliance suggests
that the province provide community based funding to hospitals for this
service in a way so that the most vulnerable hospitals with the greatest
personnel shortage, have the greatest incentive to attract new or existing
physicians to provide the service. This can be accomplished for all rural
hospitals in Ontario with under 0.1% of the physician services budget as
detailed in the "A Fair Share for Rural Health" document.
Plans to deal with inpatient
care, anaesthetics, and surgery are provided with full costing, in similar
manner, as well as other specific recruitment and retention measures. We
know that with these measures, not only will we be able to get PCR to work,
but we will also be able to provide needed services to many rural citizens.
However, unless we can recognize and act on the fact that rural medicine is distinct, and needs specific and flexible grass roots solutions, we can reform primary care all we want and still not provide equitably access to primary care for all the citizens of Ontario.