Rurality from a Country Perspective

Dr. Peter Hutten-Czapski

Haileybury Ontario

phc@srpc.ca

S R P S R P C C

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“We Care for the Country”

The Society of Rural Physicians of Canada (SRPC) is the national voice of Canadian rural physicians. Founded in 1992, the SRPC’s mission is to provide leadership for rural physicians and to promote sustainable conditions and equitable health care for rural communities.

“Every citizen in Canada should have equal access to health care regardless of where they live.” .

- Mr. Justice Emmet Hall

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Rural in 30 min or less

Rural is Different There is a spectrum of Rural Rurality scales exist in Ontario Transparent indices lead to fair and

easier apolitical program application Careful application will be helpful in

service delivery and policy and maximize effect for minimum dollars

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Inequity in Doc Pop Ratios

Kingston 567 pop to each GP/FP

Rural Ontario 1,562 pop to each GP/FP

Ottawa 2,890 pop per psychiatrist

Northern Ontario 24,074 pop per psychiatrist

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8

GP/FP Psych

MDs/1000

Urban

Rural

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Fewer docs… and sicker people

Compared with urban counterparts rural people are more likely to be: employed in high-risk occupations

farming, fishing, logging, mining

older, poorer and aboriginal higher mortality rates for most illnesses but

especially heart disease, lung cancer and cancer of the cervix

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Division of Labour In Manitoba city

citizens frequent specialists more

City consultation rates are only 30% more but follow up visits occur over twice as frequently

0

0.5

1

1.5

2

2.5

3

3.5

4

Rural Urban

GP visits

Specialist Visits

Black C, Roos N, Fransoo R, Martens P. Comparative Indicators of Population Health and Health Care Use for Manitoba's Regional Health Authorities: A POPULIS Project, MCHPE 1999

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Practice Style - Emergency

As community size decreases the percentage of physicians providing ER coverage increases

maximal effect of 58% at under 8,000 pop

0

10

20

30

40

50

60

>56

0K

114-

559

37-1

14

8-37

<8K

%GP in ER

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Practice Style - Obstetrics

As distance from a city hospital increases the percentage of physicians attending births increases

maximal effect of 37% at under >87Km

0

5

10

15

20

25

30

35

40

<2K

m 2-5

5-17

17-8

7

>87

Km

%GP OB

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Practice Style - 22 procedures

the MD procedural care spectrum almost doubles at 185 km from the city

As distance increases the interprovider variability increases from +/- 3.6 to +/-4.6

0

2

4

6

8

10

12

<7K

m

7-14

14-4

4

45-1

84

>18

5Km

#Procedures

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Professional Satisfaction

Thommasen finds that the vast majority (82%) of rural doctors find rural medicine somewhat or very professionally satisfying

H.V. Thommasen, Marcel Lavanchy, Ian Connelly, Jonathan Berkowitz, Stefan Grzybowski Mental health, job satisfaction, and intention to relocate Can Fam Physician April 2001 Vol 47: 737

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The North IS Different

3/4 of Ontario by area 8% of Ontario by population 51% rural 15% first nations 10% francophone high needs

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Ideal Rurality Scale

Comprehensively pan rural Sufficiently detailed (in terms of

level of application) to avoid aggregating heterogeneous areas;

simple to compute (parsimonious) Transparent and defensible Intuitively plausible in its results stable over time

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Rurality Must Be TransparentTransparent

A transparent definition is easier to apply fairly

Programs must be seen to be geared to social need and not political goals

if the criteria are not transparent then designations are felt to reflect patronage rather than social need

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Rural CME <10,000 pop over 80km from a population center of 50,000

Community sponsored contracts (CSC) for designated 1 and 2 doctor towns

Northern Group Funding Plan (NGFP) for 3 to 7 physician towns

Rurality Incentive OMA-MoHLTC 2000 Blue RIO Family Health Network (FHN)

Existing Rurality Scales

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Advantages Programs must be finite The Post Office delivers door to door or

by rural route delivery NOT both Similarly you can either provide locum

support or not, it is hard to provide a continuum

Discontinuous Scales

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But Rurality is continuous Care must be used with discontinuous

scales to avoid boundary effects By example contract positions have

been generally successful in smaller (up to 7 MD) northern towns.

Communities just over 7 MD’s are in the greatest crisis, eg Dryden Kirkland Lake

Discontinuous Scales

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Rural Retention

Rural Retention rates are poor

The smaller the town the higher the turnover

In BC over 50% of doctors have left town by the 6th year

0102030405060708090

100

1 2 3 4 5 6

yeary

r to

yr

ten

ure

%

20-30K

11-20K

7-11K

<7K

H.V. Thommasen Physician retention and recruitment outside urban British Columbia BCMJ 42(6) 2000, p304-8

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Continuous Scales

Rurality is continuous recruitment and retention difficulty is

related to degree of rurality grading degree of program support to

rurality is a more efficient and fair use of limited resources

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Kralj B PhD, “Rurality Index for Ontario” RIO = [(Tb-Tbm)/Tbm]x10 +

[(Ta-TaM)/Tam]x10 + [25-(P98/PM)] + [5-(PD/16)] + [(Pab/P96)x100] + [(RGP-Rm)/Rm]x10 + (20-GP) + (20-SPEC) + AMB + [EDU + AIR + UI]/3 + [Rain + Snow + Temp] + (GPA+GPOB)

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RIO Issues

Not easy to compute Computation is NOT transparent “Black Box” effect However as the formula is published it

theoretically can be checked and application is straightforward

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RIO issues

Catchment is approximated to Community population

Adjacent communities have significantly different RIO’s

Goederich = 47 Goederich TWP = 59 New Liskeard = 94 Haileybury = 66

Cobalt = 85 ergo: non plausible on the ground

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Mitigation of RIO Limitations

Option A: Use More Relevant Data– catchment computations as currently used

for hospitals (have the population served closely matched to the doctors in the area rather than the municipal boundary)

– contemporous MD data (in small communities 1998 doctor numbers do not even approximate current conditions)

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Mitigation of RIO Limitations

Option B: Simpler (sub)Scale for retention incentives such as CME etc– RIO A = TIMEb + TIMEa + POP + SOC +

WTHR– RIO C = TIMEb + TIMEa + POP

Relatively stable over time unless there is a large population shift (mine closure/opening)

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Mitigation of RIO Limitations

Add in Human Resource stress for recruitment measures such as UAP grant etc– RIO D = (TIMEb + TIMEa + POP ) x

(Doc/Pop avr) / (Doc/Pop actual) Would require catchment data and real

time doctor numbers on a per case basis

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Mitigation of RIO Limitations

Reiterate by checking if the ramping of the incentives is achieving the desired effect

if yes then continue If failing one end ramp more or ramp less if failing everywhere reevaluate program

funding and design

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Rural in 30 min or less

Rural is Different There is a spectrum of Rural Rurality scales exist in Ontario Transparent indices lead to fair and

easier apolitical program application Careful application will be helpful in

service delivery and policy and maximize effect for minimum dollars

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Thank you...

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