Dr. Robert Martel: We can't ignore 'stark reality' of rural health care
Physician-centric delivery model has become an obstacle to change, writes Martel
The shortage of health-care professionals in rural communities is a global problem that poses a serious challenge to equitable health-care delivery.
Both developed and developing countries report geographically skewed distributions of health-care professionals, favouring urban and wealthy areas, despite the fact that people in rural communities experience more health related problems.
In Nova Scotia, where we remain married to the old physician-centric delivery model, this has become an obstacle to change. It really should not be about warm bodies, it should be about health outcomes.
Nova Scotia's dilemma is that we have more physicians per capita — especially in urban areas — than many more affluent areas of the country. It's a paradox which defies logic for a financially challenged province.
Canada's rural population is in decline, dropping from just over 8.6 million people in 1991 to some 6.1 million in 2001. In 2012, it made up only 19 per cent of the total population. The proportion of the population living in rural areas is highest in the Atlantic provinces and in the territories; coincidentally, the most financially challenged area of this country.
No government can ignore such a stark reality and our government is no exception.
Priorities for rural physicians
The recent announcement from the Minister of Health, outlining a financial incentive for physicians interested in committing to rural practice in return for a five-year commitment to stay in the community, is testament to that fact. But is it a case of appearing to do something to appease the masses?
As a past member of the Society of Rural Physicians of Canada and a current associate editor of their journal, it can be stated unequivocally that the evidence for a financial incentive positively influencing recruitment and retention of rural health-care professionals ranks fifth on a list of 10, behind these simple truths:
- Medical students from rural areas are more likely to return to their rural roots.
- Marital partners of those physicians, whose own roots are rural, enhance the chance of rural retention.
- Spouse employment, collegial support and group practice are powerful enablers of both recruitment and retention.
This prioritized list has been known to the rural physician community for over 20 years, so why are we throwing money at rural physicians who already make more than any other professional group? Where is the creativity in that approach?
One wonders whom the minister is consulting for advice.
Baby boomers have expectations, income
In September 2014, a report on the effectiveness of Collaborative Emergency Centres concluded this new model of care — paramedics, nurse practitioners and physicians — was a successful instrument in keeping rural emergency rooms open and providing improved access for rural-based patients.
The report was somewhat thin on the challenges faced by these CECs, especially around administrative support and workload, but the review nevertheless supported moving forward with the strategy.
Successive governments have struggled to provide essential services to rural populations, be it roads, education, communication or health care.
People still want to live in rural Nova Scotia and, indeed, the desire for baby boomers to retire to ancestral lands is on the increase — but at what cost?
Unfortunately for government, the baby boomers bring two things with them: high expectations and disposable income, which they are prepared to use to leverage services. Vocal, educated, networked and technologically savvy, this will be a formidable group to placate with the usual platitudes.
Governments are sensitive to the power of this demographic and since the current government draws much of its life juices from rural Nova Scotia, there is an awareness that the problem with the delivery of health care to this group may be a soft spot in their underbelly.
Why limit CECs to rural areas?
However, the silver lining may rest with this group's problem solving ability — why not harness that?
As medicine has become more complex, team driven and technologically advanced, the struggle to provide timely, evidenced based, cost effective and appropriate health care has become more the expected paradigm than it was in 1985 when I first raised this issue with politicians.
When Dr. John Ross first made the recommendation to transition to CECs, it was prompted by the cry for increased access and basic health care.
If this model is so effective, why do so few exist in Nova Scotia? Why limit them to rural areas?
It cannot be left to current providers to come up with the plan, as they are too invested in legacy practice to be effective, but neither can their input be devalued.
Rural residents of Nova Scotia want access to evidenced based medicine and, I venture, care not who provides it as long as it's up to date, timely and has positive outcomes.
Somebody has got to get out of the way, so let's start by government providing the environment and letting non-government content experts develop a business plan to make it happen.
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