Transcript Rurality from a country perspective

Rurality from a Country Perspective
SR PC
Dr. Peter Hutten-Czapski
Haileybury Ontario
[email protected]
“We Care for the Country”
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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.
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“Every citizen in Canada should have
equal access to health care regardless
of where they live.” .
- Mr. Justice Emmet Hall
Rural in 30 min or less
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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
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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
1.8
1.6
1.4
1.2
1
0.8
0.6
0.4
0.2
0
MDs/1000
Urban
Rural
GP/FP
Psych
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Fewer docs… and sicker people
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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
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In Manitoba city
citizens frequent
specialists more
City consultation
rates are only 30%
more but follow up
visits occur over
twice as frequently
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3.5
3
2.5
2
1.5
1
0.5
0
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 7
POPULIS Project, MCHPE 1999
Practice Style - Emergency
60
50
40
30
20
<8K
8-37
0
37-114
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114-559
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As community size
decreases the
percentage of
physicians providing
ER coverage
increases
maximal effect of
58% at under 8,000
pop
>560K
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%GP in ER
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>87Km
%GP OB
17-87
40
35
30
25
20
15
10
5
0
5-17
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As distance from a
city hospital
increases the
percentage of
physicians attending
births increases
maximal effect of
37% at under
>87Km
2-5
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<2Km
Practice Style - Obstetrics
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Practice Style - 22 procedures
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10
8
6
4
>185Km
#Procedures
45-184
0
14-44
2
7-14
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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
<7Km
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Professional Satisfaction
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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
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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
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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 Transparent
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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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Existing Rurality Scales
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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)
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Discontinuous 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
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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
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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
yr to yr tenure %
Rural Retention
100
90
80
70
60
50
40
30
20
10
0
20-30K
11-20K
7-11K
<7K
1 2 3 4 5 6
year
H.V. Thommasen Physician retention and recruitment outside urban
British Columbia BCMJ 42(6) 2000, p304-8
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Continuous Scales
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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”
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RIO = [(Tb-Tbm)/Tbm]x10 + [(TaTaM)/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
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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
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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
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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
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Option B: Simpler (sub)Scale for
retention incentives such as CME etc
– RIO A = TIMEb + TIMEa + POP + SOC +
WTHR
– RIO C = TIMEb + TIMEa + POP
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Relatively stable over time unless there
is a large population shift (mine
closure/opening)
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Mitigation of RIO Limitations
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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)
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Would require catchment data and real
time doctor numbers on a per case
basis
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Mitigation of RIO Limitations
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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


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

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...
www.srpc.ca
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