Recently I re-read a blog article by Dr. Robert C. Bowman, North American Co-Editor of the International Journal of Rural and Remote Health, entitled “Open Season Upon Small Health Care”.
In the article, Dr. Bowman identifies the bias of many health planners, researchers, and system leaders, towards a disproportionate concentration of health care resources, centered in a few locations. As Dr. Bowman states: “A design that concentrates health activities in a few … locations leaves most [citizens] behind in multiple dimensions - local services, health access, local jobs, economic impact, social organization, education, professionals, best insurance, best local resource support, and more.”
Medical education, Dr. Bowman points out, suffers similarly from a concentration in academic centres, resulting in a maldistribution of health care professionals in areas of need: “The major influence upon practice location is residency training location,” Dr. Bowman added.
Although recent data from the Canadian Post-M.D. Education Registry (CAPER) shows that the output from Canada’s residency training programs, concentrated in Canada’s largest cities, has remained remarkably stable in the face of fewer surgical and medical specialty jobs in Canada, the solution is not to put a hospital in every town or try to recruit a physician to every community.
Instead, as the RPAP Board pointed out to the 2015 Rural Health Services Review, what is needed is a realization that the organization and delivery of health services needs to change. Rural Alberta requires a health services plan that specifies health care services that are to be provided (community primary care, continuing care, emergency and acute care); where those services are to be provided; and the resources to be provided over multiple years to nurture them. Only then can we organize the supports to the health care system – including people, buildings, training organizations, funders– to achieve success.
Such an environment would be built upon a number of foundations, which include:
- A sound community primary care system that evolves in line with Alberta’s 2014 Primary Health Care Strategy, and the recommendations regarding funding models that support accountable, comprehensive primary care.
- A system of specialized services, including Telehealth, as a support to the concept of “Close to Home”.
- Rural surgical/rural operative delivery (C-Section) services best delivered in communities of practice or networks of care that include referral hospitals and community hospitals as follows:
“The Networked Model positions surgical care, including operative delivery, as a regional, rather than institutional phenomenon, where small operating rooms are recognized as extensions of core referral hospital programs and therefore care programs can be provided through a well-integrated and balanced surgical team including outreach surgeons and local surgical providers.” (Dr. Robert Woollard, Enhanced Surgical Skills National Steering Committee, April 2015)
So at the end of the day it doesn’t have to be "Big Health" vs "Small Health". What rural and urban Albertans should insist on is:
- Access to the right healthcare provider at the right time and this is not always a physician.
- Better distribution of the health care work force to areas of need
- Healthcare providers being linked into accountable communities of practice, i.e. are “plugged into” the health care system and function positively together.
With that, better outcomes will result.