In 2009, Andre Picard wrote: “The reality is that there is two-tiered medicine, but it’s not a private-public split, it’s an urban-rural split.”
Thirteen years later, the reality is even worse – access to primary care in many small communities is difficult or lacking altogether; announcements of emergency department closures occur almost daily; adult mental health care, if available at all, is distant in both time and place; mental health-care access for children is worse; increased surgical disruptions creating further issues for those who have traveled from afar; women forced to travel farther and farther to birth their babies. The list goes on.
But does it matter? Indeed, it does.
Rural citizens are generally older, sicker and poorer than the rest of the population, and so have greater need for care if they are to achieve health outcomes equitable to the rest of the population. Greater need … lesser access. We have a system that is failing for rural Canadians, and it must change.
But what if we got it right for rural Canada?
If we get it right, then patients like Caroline in Attawapiskat would be able to see her doctor for culturally safe care and assessment of her newly discovered breast lump. Vivek, a long-haul trucker from Winnipeg, would be able to access the emergency department in The Pas without hesitation when he develops chest pain. Kate, a 30-year-old in Bella Coola, would be able to have her healthy baby in her community, where she and her sisters were born three decades earlier. Pediatric, mental health, surgical and cancer care would be provided locally, regionally and in large urban centres based on urgency and complexity, with the goal of providing high-quality care as close to home as possible.
If we get it right, all doctors working in small communities will have teams with whom they can share the work of treating illness, and of helping people stay healthy. There will be enough doctors, nurses and lab and X-ray staff that services will not shut down if one or two are away because of illness or family emergency. Hospital and clinic administrators will spend their time developing programs that the community needs to stay healthy, rather than on critical staffing issues.
If we get it right, virtually enabled care will connect patients, doctors and other team members to specialists and others in larger centres who can help provide care without having patients leave home. “Virtual doctors” will be a support to, but not a replacement for, the local doctor.
“Virtual doctors” will be a support to, but not a replacement for, the local doctor.
If we get it right, rural and remote health-care settings – particularly those with community hospitals – will be vibrant teaching sites where students in nursing, medicine, physiotherapy and other health-care disciplines will not only learn to provide excellent care, but also to understand the value of the rural health-care system to their communities. Students in health-care administration will help tackle pressing issues in health-care delivery. Rural health systems will not be an afterthought – a poor second cousin – in any health-related training program.
If we get it right, important questions about illness, population needs and health-system solutions will be answered by research that involves rural health-care providers closest to those who will benefit from the answers. That research will be supported by funding and networks of skilled people who can help to inform health policy.
How do we get there?
This will take a commitment to the health of rural, remote and Indigenous Canadians, and indeed for anyone who requires health care while in a rural setting. It will take a commitment to the notion that health equity matters and that access to “core services” like primary care or emergency services should not depend on one’s postal code. It will also take an understanding that the economic vibrancy of rural Canada will depend on being able to access health-care services locally.
The mythical days of the “old country doctor” working on his/her own are long gone. Now, family physicians, nurse practitioners, nurses, physician assistants and other health-care professionals must coordinate their work to wrap care around patients in models like Patient’s Medical Home. These teams should be established in all rural communities. Governments must invest in facilities, staff and comprehensive payment systems. Incentives and support will be required to recruit and retain rural generalist family physicians and the other health-care workers needed for rural/remote/Indigenous communities.
“To address the Truth and Reconciliation Commission calls to action, rural Canadians must be better served.”
Rural and regional hospitals will need to continue to evolve as rural health-care hubs with funding and support for critical access to 24-hour emergency departments staffed by rural generalist family physicians. Select hospitals will need to be organized to provide surgical and obstetrical services, in a network of care, linked to large regional hospitals. To provide as much care as close to home as possible, rural hospitals will need to become support hubs for community services such as specialist clinics, rehabilitation (physiotherapy, occupational therapy), mental health, long-term care and palliative care. This will require substantial government investment in both facilities and staff.
Health-care learners, including medical students, from rural, remote and Indigenous communities are much more likely to choose to practice in those communities. Admissions that reflect Canada’s geographic and cultural diversity would result in many more rural and Indigenous students enrolling in professional health-care programs, and ultimately returning to those settings to work if those settings have the necessary investments to make them attractive work environments.
Most rural generalist family physicians now entering rural practice have done their post-graduate training in a rural stream and got much of their experience in rural communities. These programs can expand with increased funding and support. Rural training is also needed for nursing, nurse practitioner, physiotherapy and occupational therapy programs. There is a particular opportunity to fast-track the expansion of Physician Assistant Programs pathways for International Medical Graduates to focus on placement in rural community health teams.
To support graduates of rural training programs to work where they are most needed, national licensure or functional reciprocal provincial/territorial licence agreements need to be in place for all health professionals.
There is a need to more fully engage rural, remote and Indigenous communities in their health-improvement research. The Canadian Institutes of Health Research has now included rural health research in its priorities. Developing and supporting rural health-research networks linked to rural medical-education networks could scale and spread successful rural education, research and practice models as has been done in Australia, sustaining the rural health-care system into the future.
The Rural Road Map for Action, in 2017 noted “To address the Truth and Reconciliation Commission calls to action, as well as the Canada Health Act mandate to facilitate reasonable access to health services without financial or other barriers, rural Canadians must be better served.”
Let’s get on with it and get it right!