Controversy over closing rural hospitals

Hymns, protests, and arrests – that’s what happened when the Fort Erie, Ont. community rallied against a planned conversion of their local hospital’s emergency room to an urgent-care centre. It didn’t work, and in 2009, it seemed their fears were realized when a teenager died after she was in a car crash and had to be transported to Welland – twice as far as it would have been to Fort Erie’s Douglas Memorial.

At the time, then-health minister Deb Matthews defended the decision, saying the hospital had not been able to handle serious emergencies and had to send critically ill patients to other hospitals. (A coroner’s inquest into the death also made no recommendations around ER services.) And this January, she announced that the government would close five hospitals within the area, the Niagara Health System.

The plan is for patients to go to two new, larger hospitals and two new urgent-care centres instead. The closures are the result of recommendations from the 2012 report by Kevin Smith, now CEO of Niagara Health System, which outlined the challenges faced by the region, including the community’s loss of confidence in the health leaders.

The report says there are advantages to consolidating services, arguing that doctors in the remaining hospitals would see enough patients to develop and maintain their skills. It also says it would reduce staff turnover in the larger sites and lower costs. But the idea that volume equals quality is controversial. And small towns are often fiercely protective of their hospitals.

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“Communities – and I mean everybody in the community – absolutely loves their hospital and will defend it to the nth degree,” says Jack Kitts, president and CEO of The Ottawa Hospital who reviewed the Niagara plan, including the Fort Erie changes.

It’s especially important that the rural health care system functions well, since the health of rural Canadians doesn’t measure up to that of urban dwellers. They tend to have less healthy habits, are more likely to be overweight, and have a shorter life expectancy than their city counterparts. They also make up a significant portion of the population, at 20% of Canadians.

Cutbacks and closures

Alberta is currently reviewing rural health care, including facilities usage. Though Premier Jim Prentice told the Calgary Herald the review “is not about closing rural hospitals,” other recent reviews have come to that conclusion. And the U.S. is also seeing a rise in rural hospital closures, thanks in part to funding changes that came with the Affordable Care Act. Twenty-four rural hospitals have closed since the beginning of 2013, twice as many as in the 20 months before that.

Rural hospitals closing isn’t a new issue in Canada. The Ontario government closed and merged hospitals amid the recession of the 1990s. At the same time, Saskatchewan stopped funding 52 rural hospitals, which all had an average occupancy of less than eight patients a day. Many of them turned into health centres.

Many in the community were against it, as Rein Lepnurm found out first hand. The professor of management and scientific director at the University of Saskatchewan was a principal investigator for a government commission on the issue at the time, and held hearings in small towns across Saskatchewan about the proposed changes in the late ’80s. “We had hearings where we wanted to see four people: the chief executive officer, the head nurse, the chief physician and the board chair,” he says. “Half the town showed up – they found out about the meetings and they were all there. They were practically yelling at us.”

Could closing hospitals make quality of care better?

A follow up survey of more than 5,000 Saskatchewan residents at the time found that while most people contacted thought their health and the health of those in their family would be negatively affected by the hospital closures, after the fact, nearly 90% said the closures had had no effect on their health. The report also found that the mortality rates had declined in Saskatchewan since the closures.

Some credit this to the practice-makes-perfect idea that closing smaller hospitals leads to higher volumes – which gives doctors the critical mass they need for better outcomes.

David Urbach, a researcher for the University Health Network, reviewed over 300 analyses on the issue in a report commissioned by the Canadian Institute for Health Information. He found that high-volume hospitals had better outcomes 67% of the time. But he also found most of the studies were American, and many looked at specific procedures.“The studies show that generally, high volume is always better – for surgery, medical care, you name it,” says Urbach.

“At the end of the day, we know that what you do more of you do more efficiently and with better quality,” says Kitts, adding that most of the public doesn’t know what the quality of care is at their local hospital. “I believe very strongly that if you don’t have critical mass, you don’t have quality.”

Or is quality of care the same in rural hospitals?

But the evidence may not be as strong as some believe. A 2005 Canadian Institute for Health Information study looked at mortality rates from 10 procedures and found that for three, higher volumes meant lower death rates. However,  for the rest, the number of procedures performed didn’t seem to matter. Other studies have also pointed out that the effect of volume varies widely by procedure.

“It sounds like a very easy thing to look at, volume and outcome, but when you start to get into this analysis, it’s not,” says Kira Leeb, director of health system performance at the institute. “[Volume] matters, but I think it’s a misconception if it’s a blanket statement.”

Many of those studies are on rural American hospitals, which perform a wider variety and complexity of procedures than those in rural Canada. For more common procedures, like Cesarean sections, appendectomies and colonoscopies, outcomes from family physicians seem to be similar to those from specialists in larger hospitals. One aspect of that may be that the family doctors are good at recognizing and referring more complicated cases.

Urbach thinks rural hospitals are a matter of trade-offs: between a rural lifestyle, being geographically close to the hospital, and top-notch care. A common community concern is the increased hassle and costs that come with travelling further to a hospital for patients and visitors.

Driving patients away from hospitals by routing them to larger hospitals isn’t a long-term solution, Urbach says, because it will only exacerbate the imbalances between smaller and larger hospitals, and doesn’t address issues like lack of resources.

“Ultimately if rural hospitals are going to continue to exist, then you have two options: to give them more resources, or leave the status quo and accept that there are going to be these differences in the quality of care,” he says.

Sizing up the issue

An important question in this issue is, how small is too small? The Ontario government’s Rural and Northern Health Care report defines rural as a town of less than 30,000, more than 30 minutes away from any town of more than 30,000. (Remote hospitals, which are further from the nearest town and may not have year-round road access, face a different set of issues.)

A suggested formula by Stefan Grzybowski for maternity service needs in rural communities also recommended including social vulnerability in this mix. And some have suggested that towns with over 5,000 people who are over half an hour away from other centres should have primary care, an emergency department and inpatient care.

That’s because travelling longer distances to emergency centres also increases the chance of mortality. Distance to emergency care is a common concern of residents, and one reason why hospitals are often replaced by urgent-care centres. “One the anxieties of the community remains, what if I need urgent services, what should I do?” says Smith. He believes travelling further to larger centres isn’t necessarily negative. “If you’re acutely ill, you want to be in a site that has all of the technology to support you, and those [smaller] sites have never had that capability,” he says.

Kitts believes the goal should be for hospitals to work within the system to deliver quality care, in the most appropriate setting, as close to home as possible. “It’s about figuring out that sweet spot between access and quality,” says Mark Rochon, consultant with KPMG’s Global Health Care Centre of Excellence and ex-CEO of the ’90s Ontario Health Services Restructuring Commission. “We need to make sure that rural hospitals are part of a larger approach to providing health, and that what they do provide is within their capabilities.”

Impacts on the region

A key reason for consolidation is often costs, though there isn’t much evidence around how much the closings themselves save. A report on rural hospitals in Alberta report found most extra-small hospitals had higher costs – about 15% more than larger ones – and that they were more likely to operate below 75% capacity. Costs were also a driver behind the Niagara Health System changes. In his report on the Niagara Health System, Smith noted the consolidation plan should save $9.5 million in operating costs.

But while closing hospitals may lower health care costs, it may also have a negative economic impact on the region, reducing the number of health care jobs as well as others in the community. In many of these communities, the hospital is the biggest employer, says Smith, adding that in Niagara, many towns have also “suffered a tremendous amount of loss” after heavy industry and other jobs have left. A 1991 survey of mayors of small towns in the U.S. who had lost their hospitals found that more than 90 percent believed it had a significant, negative impact on the local economy.

Those losses could include local doctors, who may be turned off by the idea of practice that doesn’t include work at a hospital. “Underneath it all, you close the hospital, the doctor goes away, the local drug store closes … that’s just the sad truth,” says Lepnurm.

Perhaps that’s why the public does not like the idea of closing hospitals. Even those Saskatchewan residents who didn’t feel their health had been affected by the cuts of the ’90s weren’t happy, with satisfaction dropping after the closures from 82% to 54%. “You can’t get away from that fact,” says Lepnurm. “The public doesn’t like it.”

Should Canada close more rural hospitals?

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  1. Bushra Rizwan

    The health sector has become enthralled in examining trends for smaller populations, in particular in rural communities. However, as the denominators get smaller, because of a smaller sample size for example, the confidence in their accuracy is reduced. Perhaps, the reporting of confidence interval may be necessary to fairly assess and compare trends regarding volumes and procedure outcomes, in rural vs. urban setting.

    Although theoretically critical mass may explain the “supposed” disparity in “quality of care”, and by extrapolation the “treatment outcome”, there are several other confounding variables that should be taken into account. For example, both the complexity of the case, and the availability of resources will have a greater impact on treatment outcome. Furthermore, it may not only be heuristic approach to problem solving imparted by critical mass per se, but also a larger sample size in an urban setting that might be providing a buffer when examining treatment outcomes, and quality of care.

  2. David Walker

    The rural or isolated hospital, to exist and be functional and safe, requires a stable and well trained staff of docs and nurses so that it can handle the traumas, heart attacks etc that arrive. To the extent it handles matters in house it will need, for example, sufficient surgeons to cover an on-call roster that is humane, yet there may be insufiicient day surgery work to support that number. An ED is only as strong as what backs it up. Alternatively, stabilization and transfer from a small hospital is an option although that proves problematic when the regional receiving hospital, as is increasingly the case, is in gridlock and cannot easily accept transfers. My view is that there must be a sufficient critical mass of patients and health human resources to provide safe hospital care – some magic cut-off point below which viability fails. Having a mini-hospital with a bright ED sign might provide civic and political pride but it can be dangerous. Good paramedic prehospital care from the field to a large regional facility can achieve very effective care that far outbalances any benefit of in the short run to an ill-equipped small hospital, as Saskatchewan proved beyond doubt.
    As an ED doc for decades in a busy tertiary care centre, I and my colleagues were constantly aware of how vulnerable our skills were to degradation in those areas of rare presentation – and we were awash in volume! How more so in a smaller place such as where I first worked with little back-up and poor transfer capability.

    • Fiona McMurran

      This is an argument that has been used to support the closures of local hospitals here in Niagara. It has merit, of course, but it tends to equate hospitals with surgery, and, even now that the role of the hospital has been reconfigured, that just isn’t true. The closure of maternity/neonatal in Welland and Niagara Falls means that all hospitals births in Niagara occur in the larger and well-equipped facility in St. Catharines. For me, a baby-boomer, that is a step backwards — normal births do not require that. Paediatrics has been centralized in St. Catharines—I would not have wanted my five-year-old with pneumonia half an hour away in a big ward. Welland’s psychiatric ward was also closed. Are mental health patients better served on large wards in big hospitals, far from their community, families and friends? No, they are not. We have a large percentage of seniors in this area. Despite the success of the hospital system in getting rid of , ALC patients, many will be back on hospital wards sooner or later, and sicker than before, too, because of the lack of supports in the community. I dread to think what will happen here when the next pandemic hits, in a region with a single full-service hospital to serve a population of nearly half a million, spread out over a large geographic area—with no regional transit system, I might add.

  3. Chris Carruthers

    I agree with David Walker. We need to talk about what procedures are to be performed at these hospitals . Many small hospitals cannot provide 24/7 surgery coverage. Days not covered patients transferred. Often these days can not be determined far in advance. In my opinion volume can be an important metric for quality . With improved transportation people can travel for good care. Seriously sick people probably should not stop at a rural hospital and loose precious time but should keep moving to the larger hospital. Having the ‘H’ is important to communities. It is an employer and politicians resist closing it or downsizing its services. However if you ask many of the citizens of the smaller community where they go when they are really sick they will tell you they go to the larger hospital. An integrated network of Academic,community hospitals and rural out patient facilities is the best way.

  4. Duff Sprague

    The closing of rural hospitals is an extremely emotional issue. One can provide all the empirical evidence in the world that centralization of hospital services provides more effective care, yet that changes few minds in rural areas.

    Rural hospitals do provide many things most are intangible – general practitioners and other clinicians who work to the full scope of their training, having a life long relationship with patients that can only come from a family physician delivering your baby and this same physician holding your dying parent’s hand. How do you measure the impact of such a relationship?

    We live in a country of immense size, most of it rural or isolated. Yes, it is more cost effective and provides a greater diversity of skills to move rural healthcare into urban centres. This is also true of other necessary services such as education – we are closing more rural elementary and secondary schools and transporting students away from their communities to urban schools.

    Once upon a time we identified as “citizens” not just “taxpayers”. We had a national railway that reached far into northern and rural communities and a national broadcaster who had local news bureaus in those same communities. It was more expensive but taking precedence was the belief that as Canadians that it benefitted us all to ensure that important services such as healthcare, transportation, education and local news were available to all Canadians. Most of us were prepared to share the cost.

    Quality can be viewed from many angles.

  5. Elizabeth Rankin

    One solution that could be considered for the more rural populations would be to have more & better equipped ambulance service with advanced skills training and seconding a nurse and physician to accompany attendants when it is known the case is difficult & or, may involve more than one patient.

    When a team approach can’t handle or problem-solve difficult issues requiring hospital attention quickly you have the urgent care service of the ambulance attendants and the added qualifications of other needed team members who can actually perform any further stabilization en route to a major centre when there is an accident. The advanced ambulance service could be authorized to call the air ambulance and the patient could be picked up, especially if the time to drive takes too long from the point of care assessment.

  6. James Elliott

    Quality of care, perceived or real, is in my opinion one least important concerns people resistant to rural hospital closures have. Most lay rural Canadians would not argue quality of care is higher at urban tertiary university affiliated hospitals. I would argue the following are more pertinent concerns:

    1. Economic pain. In a rural community the hospital is an important and stable employer. People living in the community are well aware of the direct and indirect benefit a comparatively large scale employer brings in. Many well paying and stable jobs have left rural Canada has been in the past two decades. De-industrialization, off-shoring, weaker commodity markets and de-unionization have made jobs paying above the minimum wage quite scarce. Given that hospitals are often the largest employer in a community, a closure has a real impact on the local economy, tax base and property values.

    2. Weak and expensive non-urgent transportation. Outside of the GTA GO network there is very little regional transportation in Canada. Essentially, you have taxi services, Greyhound/private buses, and a handful of charitable organizations. None of these are free or what I would call cheap. Many of them run infrequent and inconvenient schedules (e.g. once per day). If you have no car you need to rely on friends or family members, if you have some. This might mean scheduling a day off work, using a vacation day and if you have to rely on someone a feeling of being a burden. It also may take more than a day if you have a morning appointment and need to book a hotel the night before. Then of course you have the mortality issue, as this article points out, people are well aware of.

    3. Feeds into the rural abandonment narrative. People outside of the GTA/Ottawa are well aware their roads have more potholes, their salaries are lower and their political power is eroding. There are a lot of factors at play here, most outside of the healthcare sector (e.g. globalization). Many of communities have seen the loss of railway transportation, public transportation, school closures and other public service losses, so a hospital closure can seem like another nail in the coffin.

    My overall point is that it is important to try and understand the viewpoint of someone who has decided to stay in rural Canada. Then, the resistant to hospital closures will seem a lot more logical.

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