Rural Hospital Emergency Services: what happened to the consultation prior to final decision?
The discussion at the Horizon Health Authority Virtual AGM this week suggested that even though the Premier has not been able to conclude the consultations with municipalities that he promised, thanks to the Pandemic issues and distress, the CEO remains convinced that the plan needs to go ahead as originally announced. This, now, has raised the hackles of persons in rural communities and has now created strong pushback from some.
Having now had 5 months to ruminate on what was announced and how it was announced, and having consulted with some knowledgeable people in the field, what appears obvious is the classic stalemate! Rural Health Care thinking versus Urban Health Care thinking. What appears obvious is that the rurals were handed a plan that took them by surprise and did what they should do…push back!
They were absolutely correct in pushing back because they felt disrespected in the process and you cannot do that to otherwise good people and expect them to cooperate.
These columns have called for a Rural Health Strategy for nearly two years! But the plea seems to fall on deaf ears for reasons that are clear; health services are planned in urban centres in organizations in which a serious urban bias is prevalent. I confess I was part of that thinking for a long time, actually until I actually worked in real rural Canada. It is a numbers game; the majority of those who provide advice and provide essential clinical service are from urban areas.
What a difference when you are living two hours drive from the nearest regional hospital, it takes the ambulance a minimum of ½ hour to get to you then two hours to get you to the regional hospital emergency department.
Or what if you live only ninety minutes from the regional hospital and you know that when you get there with your child or your frail mother, you face a minimum 2 hour wait for care, possibly much more, unless it is major trauma or heart attack.
The Emergency Departments in the urban hospitals still have wait times (or “time to care”) that is totally unacceptable by the standards of 2020, as noted in the Daily Gleaner on Saturday, June 27, 2020. The article said the wait times are getting worse not better. People in the urban centres are not well served by these long waits and now the same organization that oversees deteriorating urban wait times asks rural New Brunswick to forego what works well for them? There is something missing in the logic here.
Now it undoubtedly is true that the volume of service, particularly at night, in rural “emergency departments” is be very low. It would be totally inappropriate and, in fact, unnecessary to pay doctors and nurses to “sit and wait” in order to see one or two patients, however ill or badly mangled they may be on arrival. But it is possible to provide superb night time, low volume emergency service without having people sitting and waiting. Duty nurses in the hospital can and should be trained at the level that they can provide first contact care while executing an on-call roster that has a physician and nurse on stand-by.
That is the way it is done in many small, rural hospitals in other provinces and it works in those areas very well.
The plan announced in February made some assumptions that just do not stand scrutiny. First, the Oromocto/Fredericton relationship was cited as an illustration of how nighttime coverage in low volume areas can work. The flaw in the analogy is that there is 4 lane, high speed highway from Oromocto to Fredericton that requires a fifteen-minute drive at most.
The second assumption was that the ambulance can get to the victim promptly and consistently. Stories from the field do not support that assumption with recent illustrations causing public concern. The public still has issues of confidence in the timeliness of First Responder service, rightly or wrongly.
The third assumption is that it is perfectly safe, clinically, for a person to experience up to 2 hours of transport in order to get to emergency care. Practically speaking, this creates real concerns for persons with heart attack or stroke in which cases “time to care” is absolutely critical. Well trained EMTs can administer some initial stabilizing therapy but in both cases, hospital care with experienced physician and nurse support is critical.
A fourth assumption is equally flawed, that being that getting to the nearest full-service emergency department is the better option. If that “better option” is being transported to a department known for long lineups and waits, regardless of accuracy of the Triage System, patients and the public have every right to be apprehensive.
What is the way forward out of this messy situation? We cannot go on running low volume rural emergency departments based on urban standards and thinking. But the rural populations, albeit shrinking, are still here to stay as long as we have fishing, agriculture, logging and lumber as staples of the economy. Government cannot just foist an urban plan on this important population and expect tranquility.
Create a proper Rural Health Strategy. This is a rural province and while a large percentage of the population, according to the Finn Report, live within 50 km of an urban centre, those who do not still must be served. Our health system is based on universality.
The first element of such a strategy is the recognition that rural and urban is different in the same way that government recognizes that health services on northern reserves is different from downtown Toronto. This huge divide has resulted, for decades, in health care services adapted to the local communities, not some urban model created in the cities and imposed on the locals.
Small rural communities are ideal centres in which to engage various health professionals, give them advanced training and enable them to function at full scope of practice. That actually used to happen in New Brunswick many years ago before we became so conscious of turf!
It is probably time to re-visit the models used to compensate physicians and health professionals in rural areas. In one jurisdiction of note in Canada, the conventional fee for service method, with its flaws, was replaced by an Alternate Payment Plan, or APP. This model can be tailored to both the needs of the physicians and the paying agency (Medicare) in order to create fairness and equity while having a system that attracts physicians to rural practice.
In the skirmish in February, some who supported the plan as announced made the observation that it has come to the time when we must “think out of the box” and not a soul would disagree with that. But if thinking out of the box means reducing the quality and accessibility of essential service, rurals will not buy that, nor should they. If it means having intelligent conversation about how health and long-term care services can be stabilized and improved in rural areas, chances are they will come to the table.
But they will not come to the table as long as the mental image of the alternative is a 3-5 hour wait in an Emergency Department 90 minutes’ drive from their children.
The promised consultations need to take place, there needs to be some open-mindedness about rural health needs, and a sincere engagement of the local leaders.
Ken McGeorge,BS,DHA,CHE is a retired veteran health care CEO, part time consultant and columnist with Brunswick News and can be reached at firstname.lastname@example.org
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Ken McGeorge, BS,DHA,CHE is a career health care executive based in Fredericton, NB, Canada.