On Tuesday, the New Brunswick Health Authorities issued a document that is mostly aspirational in terms of future directions for health care services. The document did, however, get specific as it relates to rural “hospitals” and noted the conversion of beds to “chronic care” and announced changes to the way emergency health services will be offered in small, rural facilities. Understandably, those living in rural communities are expressing visible concern if not anger.
And why not? They, for the most part, enjoy a level of primary care services that exceeds the expectations of those of us living in urban New Brunswick. The family doctors who provide care in many of these local communities offer their patients a totally personal level of care without the significant delays that are typical in urban health care. With access already to a level of superb primary health care services, the thought of losing some elements of that service is too much for them.
If I were driving health care reform, this would not be the hill on which I would want to die because the actual cost savings, relatively speaking, are not significant.
Most of these small rural hospitals ceased to be full service hospitals years ago as specialists retired and demographics have changed. But for people living in the rural areas these facilities are the centre of health care services. So a perceived attack on them is seen as an attack on what they believe to be essential service. For the most part, major interventional clinical services have, however, gravitated, to the larger urban centres either by design or happenstance.
In the eyes of residents of rural New Brunswick, those in Urban Areas live in the lap of health care luxury with the doctor’s office a block away and a hospital a couple of miles away, and everything else readily available. The perception, I would add, is far better than the reality although there is a serious convenience factor in urban health care despite long waits in Emergency Departments.
To the urban dwellers, the understanding of rural health care is that of hospitals filled with people who could either be at home or in a long term care facility and an emergency service that operates with very low volumes. So the urban planners would be tempted to say that there is no business case for small volume operations and they would be right! What the rural dwellers have that urban dwellers do not is almost instant access to good primary care.
While the population in rural New Brunswick has been declining and may continue to decline, there will always be a rural population. Thousands of people live off the land, the forest, the sea, or in mining and to one extent or another, those populations will always be there and proudly so. What is not feasible, nor is it even desirable, is to maintain full service hospitals and full service emergency departments in all rural areas. Interventional secondary and tertiary care, and excellent trauma care, is best provided in facilities where there is sufficient volume to attract and retain great clinical skills.
But with a proper Rural Health Strategy, it is possible to provide superb emergency service appropriate to the rural area. It cannot nor should it be the level of service that involves complex fractures, major stroke diagnosis and treatment, major trauma with surgical intervention.
But, as other parts of Canada have demonstrated, family doctors, nurse practitioners and physician assistants can do remarkable work in small volume areas as long as they have advanced emergency service training and access to back up consultation albeit electronically. Part of the support system must be a flawless emergency transport system that operates without some of the hiccups that have been covered in the press in New Brunswick in recent years.
I actually had the honor of serving as CEO in one such rural centre located in Northwestern Ontario exactly 7 hours from a Regional facility and 3 hours from a secondary hospital. So in that environment our doctors, all 5 Family doctors, had skills that were incredible resulting in many lives saved at point of care. They all took additional training to equip them to do much on site to avoid transporting to the major centre. But when the major centre was needed, it was a phone call and ambulance or helicopter ride away. No muss, no fuss.
But we did all this without pretending to operate a full Emergency Department or a full specialty support system. All the staff tended to be trained and skilled at the same level so care was consistent.
A Rural Health Strategy starts with the planners making a serious effort to understand the issues of health care services in rural settings. That there is a rural/urban divide is without question; what is also without question is that it will not go away so those who would lead change need to invest in understanding the issues which is the first step to successfully working with rural populations.
By the same token, those who live in rural areas, and their medical and political leaders, need to play a major role in helping the local populations understand that it is not possible to have on-site clinical expertise in every hamlet. Looking across the country and across the border to Maine, one sees that major clinical programming has, long since, been consolidated into a few regional referral centres.
A Rural Health Strategy starts with clinical leaders in the regional referral centres using the best of marketing and customer service skills in dealing with doctors and patients from rural areas. This means being sensitive to the distances to be travelled and the lack of comprehensive diagnostic tools in small rural facilities. What I saw in the North was that when a GP needed to speak with a specialist at the referral centre, there was an accessibility and respect that enabled timely communication about patients that presented with concerns.
The referral centre has to work creatively to make the consultation with specialists seamless and efficient including access to overnight accommodation if required. The post acute follow up care can be efficiently and effectively delivered in the smaller rural facilities but only if the specialist staff function as leaders and enablers.
Mobile diagnostics were used in our Northern Ontario model that allowed people in remote areas to have CT Scans and breast clinics on a mobile unit making a tour of small, rural communities. The widespread use of Skype and telehealth facilities can bring specialist consults and exchange of information to a whole new level for health care professionals working in rural areas.
There is, as well, much continuing medical and healthcare continuing education that can be done for the rural areas by the referral centres that enables health care professionals throughout the system to function with a common base of knowledge.
Helping the rural communities develop and maintain health care services that are appropriate for their communities need not be subject to trench warfare and great angst. The health care services of remote centres with which I have been familiar are second to none; not a duplicate of urban health care but high quality and appropriate to the circumstances and environment. But the conversation cannot start out with take-away language.
Ken McGeorge, BS,DHA,CHE is a retired health care CEO, one of the leadership team in the 1992 initial reform of health care in NB, and columnist with Brunswick News; he can be reached at email@example.com
Ken McGeorge, BS,DHA,CHE is a career health care executive based in Fredericton, NB, Canada.