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My main beef is that there's a lack of specialists in the more isolated communities - as I found out this summer with my ENT crisis. It gets worse as you go north. Much more funding in the Canada Health Plan might help to recruit more specialists - but is that the problem? Maybe medical folks don't want to live in tiny far off communities? Comments welcome.
That's been an issue as long as I can remember (and it's not just specialists). Thirty plus years ago when I was a student med-school applicants automatically got interviews if they were from "remote" areas - forget where the cutoff points were but the areas in question were truly in the booneys.
Problem was that after spending several years in "the big city" going to university and med school after that most of the new doctors I knew didn't want to go "home". They'd been in Southern Ontario for so long that that was home, not the small town they grew up in. And in a lot of cases they were married, or at least in long term relationships, with people they'd met at school who were simply not willing to move to small town nowhere.
We get a nursing rotation here - we were lucky to have the same nurse for about three years, then she left. This year it's been one nurse after another, most just stay on a month or two. Our community is just 100 people, and no road connection to the mainland, and nothing to really attract someone to remain here for the duration - other than a good income and really nice accomodations. Our physician usually flies in for a few days every two or three weeks. The dentist is here for a couple days every two months, and the ENT specialist is here for just two hours twice a year - total of four hours in the year.
A hearing aid specialist is here one afternoon twice a year, and an optometrist is here for an afternoon four times a year. The opthamalogist (eye doctor) is here one afternoon in the year.
If there are difficult or extreme cases (such as kidney stones) requiring hospital care we get airlifted out on a regular passenger flight. If it's a life-threatening situation (heart attack), we have a helicopter medevac on standby in the next community 44 km away that responds quickly if the weather is good for flying - and makes the connection to an air ambulance that flies in from either Blanc Sablon or Sept-Iles (both over 400 km away so it takes well over an hour before boarding).
Trouble is, I don't think even a properly-funded health care system would be able to provide local care to all people living in remote areas. Canada is just too spread out, its tax base too sparse, to support the availability of specialists everywhere. And depending on the speciality, you wouldn't want that. For more sophisticated medical procedures, you'd want your provider to be doing a certain minimum number of them per year to stay practiced up.
Under the Canada Health Act, we all have the right to accessibility to care. But practically speaking, there can't be tertiary care centres in every remote area. It's too expensive, and there's also the problem of your high-end providers not getting enough practice on the lower frequency higher skill requiring procedures, like I mentioned in the 1st paragraph.
That said, a proactive approach could be taken by ministries of health, defining a certain level of care depending on population, so that we can determine where the needs are, and allocate health care workers there rather than waiting until there's a crisis of no care in some communities.
Instead of just one specialist to cover that speciality spread out in a huge territory, why not two?
First you've got to find that other specialist that's willing to visit the territory in question. Using Ontario as an example, there really is a shortage of doctors which is why there are so many "Urgent Care" centres scattered around the province.
I guess the only solution to providing adequate medicare to the entire population - scattered as we are across this huge country - is a large influx of funding to encourage more medical personnel, then. Dumping these idiotic neocon F35s, mega-prisons, massive corporate tax breaks, and other wasteful stuff would provide funding for a while. It's a matter of prioritizing.
from: Canada's Medicare System: It's all about equality for Canadians with disabilities (.pdf format)
The problem with respect to inadequate access to health support services in the community has existed for decades but reached a crisis point in the mid-1990’s when provincial governments began to restructure health care in Canada. The health care buzz words of ‘closer to home’ health care and the ‘continuing care model’ of health care were to be heard in every jurisdiction across the country giving rise to the closure of close to 300 hospitals and the elimination of thousands of acute care beds in the last decade. Unfortunately when it came to implementing a community-based health care model, our politicians failed to provide an adequate infrastructure and resources to community care – the less expensive preventative side of our health care system. The result has created an overburden Medicare system that provides less equal access for persons with disabilities and seniors.
Canada’s ability to promote equality should be measured by the degree to which our most vulnerable citizens can fully participate in all aspects of society. An important vehicle to achieve this is through the provision of a range of public services that supports the integration and participation of our disadvantaged citizens. Most of these services support and form a community-based health care system.
Around the time that health care was being restructured across the country towards a community-based model of health care, our federal government, through their war of the deficit, cut back on its funding of health care and eliminated its funding for the many support services that support a community-based health care system. The biggest single factor in this regard was the 1995 federal budget of former Finance Minister Paul Martin, which reduced federal funding for health care and eliminated an important public policy instrument that promoted greater equality in Canada – the Canada Assistance Plan (CAP). CAP would have also gone a long way in providing financial resources to support a community care model of health within Canada. CAP was a federal/provincial fiscal arrangement dating back to 1966 whereby the federal government provided provincial governments with fifty cents for every dollar they spent on community-based health and social services. These federal ‘50¢ dollars‘ provided provincial governments with a significant incentive to expand services and programs to allow our more vulnerable citizens like people with disabilities to fully participate in the lives of their communities. The elimination of CAP has affected the lives of persons with disabilities disproportionately to other Canadians since the national standards of CAP ensured that they had access to many of the vital services that relied on for independent living in their communities. CAP ensured that the sharing and caring values of Canadians formed a part of our country’s overall prosperity. CAP also provided a strong signal that the state had a collective responsibility for the associated costs related to an individual’s disabilities. Since the elimination of CAP, provincial governments have failed to provide adequate funding for the necessary support services to sustain a community-based health care system. Although spending on community-based services has increased by over 200%, most of that spending has come from private sources. The increased demand for health support services has greatly outstripped the increases in public spending.
- snip -
This instability in funding for these vital support services has greatly attracted 'for-profit' interests and thus spread the growth a two-tier health care. The growth of 'for profit' private services in community health will always hit hardest at those with the lowest incomes resulting in less access to health care services for them compared to those who can afford to pay directly for health care. People with disabilities are disproportionately poor, and as a result their access to health services will decrease as a result of increased fees and privatization.
Conservative MP Shelley Glover on P&P to Rosemary Barton said the Harper Conservatives would never cut health care like the Liberals did.
How many medical helicopters could we buy for the price of one F35 jet?
Rural and remote areas health policy is about access-- not just putting more people in -- and that can be done in part with high bonuses as there are people that might find that a good way to pay of tuition fees etc...
But also there is infrastructure access to make the best out of available staffing which means transportation and facilities.
Transportation is a fact of life in remote communities. But it takes investments.
Here on the Lower North Shore of Quebec the air transport infrastructure is actually in place, but we're using antiquated DH Twin Otters from the 1960s and 1970s as our primary aircraft in the smaller communities along with more recent small helicopters - the larger (paved) airstrips in the bigger communities are served by more modern Beech Craft turboprops. Our air ambulance is actually a turboprop, but it can not land in the smaller communities such as mine (Kegaska). A constant refrain here on the LNS is the lack of finances to do all the things that need to get done - and medical transport is a priority; but even so, there's still not enough money in the system.
Boom boom, though I doubt its as bad here, Windsor is less than half the average for doctors and we are a metropolitan area. OUr average doctor patient load is approx 4,300, ontario average is 2,200 and in toronto its about 1,300 we are only 3 hours from Toronto and just across the river from detroit. We are lacking in so many specialists and even though we had the numbers to jusitify a 1 million angioplasty(sp) care center it took 15 years and an addition of a medical school to our university to get one. We use to send over 100 people a year to beaumont hospital in detroit at 100,000 a pop but they couldn't justify the 1,000,000 required for our own center. Bad economics and the wait at the border could kill a person if we had to rely on detroit solely for cardiac care. Our medical professional also are not interested in more doctors being trained-if it means it cuts into their pay)
I would like to see doctors with a salary instead of per customer billing as we currently have. Better care and reduced cost(per doc) are likely to happen(Oh I know the docs would fight it same as they are leading the charge against universal healthcare) . Nurse practitioners could help too.
Border areas are especially hard hit because doctors cross over and stay there. People in a border area get used to crossing and are more familiar with the other side...
That says something about the "other side". Why do doctors cross over and stay there? And why do patients get used to crossing over so they become familiar with the "other side"? It would suggest that there's something appealing to both doctors and patients "over here". What is it?
I agree on the topic of nurse practioners but have to disagree on the question of doctor's salaries. First and foremost, they do not work for the government. The vast majority are self employed and simply bill the relevant medicare program [and that includes most doctors whose offices are actually in a hospital, not just those that work out of their own offices or private clinics].
I think I've read many times that Canadian doctors are attracted to higher salaries on the American side. The reason Canadian patients go over is lower wait times for some procedures - and those are all either reimbursed or paid directly by the medicare system here. I think the phenomenon of border town health service whereby Canadians flock to the American side will continue until such time that the Canadian system is fully funded.
Well, they don't have to, because the Liberals already did it for them.
And yeah; doctors potentially can make a lot more money state-side, though for the average doc it doesn't net out to massively higher, because their administrative costs are substantially more because it's more complex and time consuming to bill to many insurers rather than the government provider in our single-payor system.
Actually I don't think it is the income alone that is the attraction to the US. Some of the attractions come from some negative influences with some positive side effects. By the way I have talked to doctors in the Brockville area who were thinking about going.
Some docs go over for the high pay but not all. Many people on the other side don't have access to healthcare and overall they have more doctors which makes the system less efficient and costly.What this means is the number of patients to a doctor are lower. They also get paid more for a consult and can afford to spend more time with each patient. That is the upside I guess for a system that leaves millions with no access to medical care. A system that intends to treat everyone based on need will be more pressured, more crowded. There are also docs who leave the US because they don't want to turn people away who don't have coverage or manage the beastly MOs. Some docs go there because they feel they can make the same money but spend more time with each patient and work in better conditions.
On balance I prefer a system that treats everyone based on need but I can see why a doctor might like the less pressurized approach with more time that can be spent on individual patients which happens in a system where the care is delivered to fewer people by more practitioners. The docs office however might spend a lot more money dealing with insurance companies but if the doc is making enough another person can be paid to do that.
Back in Canada in an office where a couple docs have left already, you have an overloaded-high-pressure working environment-- you can't take holidays easily because there is no replacement, work days can be longer and more frustrating and leaving people behind at the end of the day is hard. Docs often speak of the frustration with wait times themselves-- they don't like to refer people to see a doc right away only to have them go in a 2 year waiting list.
Our system is better but wasteful. The lack of investment in homecare, pharmacare, Long term care together with a public hospital care system leads to inefficient use of resources as backlogs and lack of affordable access in the private areas backs people up in to overuse of the public areas. With the proper investments in our system we could avoid this but right now these are realities doctors face and some vote with their feet -- and it is not all greed related.
A similar point-- this happens with nurses as well. When nurses are underpaid in a province, fewer people go in to the profession there. Those who want to leave to make more money do so. The remaining nurses face working conditions that become dangerous and stressful -- low nurse-patient ratios lead to more violent frustrated patients, stressed and tired nurses, more on-the-job injuries, inability to have functional schedules, refused vacation, unpaid and excessive overtime.... The morale drops and more nurses leave because of conditions. No they are not leaving because of low pay even though that was a factor in causing the snowballing cycle.
A lot of attention must be paid to retention of both nurses and doctors. Assuming they are motivated by greed is one way to blow the system up. Recognizing how the system works and how individuals get influenced to leave is critical. There is a lot that can be done to fix those problems. Some of it is competitive pay but that alone won't do it.
Better management of resources (such as building and staffing 24-hour clinics rather than having people all get treated in an ER after 5 pm each day-- and to staff them you need to pay more after hours), better management of referrals is part of the solution (they did this with regional rather than individual physician wait lists in pilots here). A recognition that modest cuts at the front end can produce huge costs at the back end once they have filtered through the system is a realization health care provider organizations are beginning to realize and governments somewhat slower.
Fortunately this works in reverse as well placed investments could save the system from the pressures it has now. People in Canada are talking about an approach to the continuum of care that if fully implemented would improve our system making US docs want to come here... In Canada we are looking at skills upgrading while people are on the job in a more sophisticated way than there. Problem is you need leadership from government at the federal as well as provincial levels. Political leadership is lacking frustrating the institutional leadership that is struggling with a lower public commitment than they should have.
Put bluntly with the right investments we can make our system work way better than the US one because it is on a better foundation but starved for resources we will fail to compete with the working conditions you get when you only have to care for a better off segment of the population and therefore lose people.
Hope this helps clear up some things because just blaming the people that leave is no way to respond to the challenges and opportunities we face.
This has been a great conversation. I hope it continues.
Indeed
Good points, Sean! Our system can certainly use improvement, like more coordination in the health care system, and maybe more rational allocation of resources rather than just hoping a specialist would choose to live in a remote area. Perhaps partnerships with professional colleges to determine need...
Though we have to be wary of criticism from people who would tear down our health care system; conservatives who speak of improvements but really want to privatize. Change must be motivated by allies of our system, not enemies.
Exactly-- a big part of this is listening to front-line providers like the nurses
...and physicians, pharmacists, physiotherapists, lab technicians, respiratory therapists; anybody who is face-to-face with patients. We tend to be political footballs, the first to be hired or fired, depending on which way the wind blows. Especially the nurses, who are the most numerous health care workers. Beware of shallow promises from politicians to "hire more nurses;" doesn't matter if you have lots of nurses but not beds to put patients in, or specialists to perform the surgery resulting in patients requiring nursing care.
Improving the health care system goes beyond hiring more bodies. One way would be more coordinated care. My patients are marginalized people who often suffer from fragmented care because they are crisis-driven, ending up in the emergency dept when there's a serious problem. If we can go online and see that person's health record, for instance, it would help streamline emergency dept service instead of the doctors having to play detective from square one all the time, and they could provide more targeted care for that person rather than just what is often damage control.
Just heard on CBC Newsworld: Anaesthesiologists in BC make between $100,000.00 and 400,000.00 - half of what an anaesthesiologist makes in Alberta right next door! The BC Anaesthesiologist Society is calling for something like wage parity, while the BC gov't says they don't have the money.
I wonder if this is a consequence of Alberta's oil economy - Alberta can keep highly paid medical personnel because they have to economy to back them up.
Health care spending to top $200B in Canada
excerpt:
While health care spending continues to grow, the pace of the increase is slowing, according to Thursday's report, National Health Expenditure Trends, 1975 to 2011. It forecasts that spending will rise by four per cent in 2011 over last year to $5,811 per Canadian - the lowest annual growth rate in the last 15 years despite a larger and aging population.
excerpt:
Baby boomers, Canada's largest population group in recent history, are beginning to turn 65 years old.
The common belief is that an aging population will fuel demands for health-care services. Yet population aging has been a "very modest cost driver overall," the authors said.
"Is aging a threat to our health care system?" Jean-Marie Berthelot, CIHI's vice president of programs, told reporters. "It's very difficult to answer yes to that question."
The aging population will be a factor for years so there is time to react to it, Berthelot said.
Feds announce new health accord - Mike Harris style!
Actually I should think "accord" is the least appropriate word to describe the fiat it will really be.
The fiscal Frankenteins are at it again. They should cut the amount of private spending in health care and cut the amount of private delivery if they want a more European style health care costing less. The bozos will never learn.
Jim Flaherty's Christmas message to Canada:
excerpt:
Wildrose Party Leader Danielle Smith's news release touting the idea of a "wait-time guarantee" for medically necessary treatments and procedures is heavy on glittering promises ("Alberta families will have peace of mind") and short on technical details, but it boils down to a three-part plan for privatization:
1) Starve the public system of funds.
2) Pump public money into for-profit private health care corporations.
3) Watch a two-tier private system quickly flower as the public sector withers.
It's not a big step from administering public health care in two tiers -- a neglected public system and a pampered private sector -- to an honest-to-gosh two-tier system in which extra payments get you timely care in a private clinic and lack of cash lets you wait longer and suffer more.