Focus on Ontario
Can J Rural Med 1996 1(1): 27
Other legislation in Ontario has had an impact on medically underserved communities. Bill 50[2] has been in place since 1993. It limits the flow of doctors into the province unless they go to areas designated as underserviced. There has been a brisk traffic of physicians contacting rural communities; however, it is difficult to say whether Bill 50 has increased rural physician numbers.
The Scott Report[3] is now a year old. It has not been possible for the Ontario Medical Association (OMA) to create any of the rural initiatives called for in this Report. The impasse hinged around the fact that the OMA was unwilling to implement the suggested initiatives within the confines of its capped budget, and the Ontario Ministry of Health was unwilling to bring forth new funding. Nothing more was heard of the Scott Report until December 1995, when the Ontario Ministry of Health announced unilaterally that it was offering a $70/h stipend for low-volume (rural) emergency departments, as recommended in the Report. Surprisingly, this was to be "new" money to the system.
This seemed to be a breakthrough, but many communities were not convinced that they wanted to take the package. Some feared the administrative burden of shadow billing. Dispensing and possible clawing back of the fund was perceived to be a potential problem, particularly in areas where there are frequent locums. Some doctors, especially those practising in areas that are seasonably extremely busy, feel that they should only have to take the stipend for low-volume times and that they should be permitted to continue billing fee-for-service for their high-volume work.
Some communities have said that the introduction of the stipend has made it more difficult to staff their hospitals' emergency departments. Locums who used to come from urban centres to more isolated communities are now able to do paid emergency shifts in small hospitals that are closer to their home base. This is because the $70/h stipend has been applied broadly over the 69 hospitals in northern and southern Ontario.
Another change likely to have an impact in the near future is the Ministry's decision to discontinue its co-payment for Canadian Medical Protective Association (CMPA) fees to Ontario doctors. Formerly, the Ministry gave this co-payment annually to defray the incremental costs of CMPA coverage. This is scheduled to stop next year. The burden will be felt most by those in more technically demanding practices, including rural physicians who do emergency room work, anesthesia and obstetrics. More troubling is the possibility that some of the secondary referral centres that support rural communities will also stop doing obstetrics, leaving us with even less back-up than we have now.
Jim Rourke's recent small-hospital survey found fewer small hospitals provided obstetrics in 1995 than in 1988. At 37 small hospitals still actively providing obstetrics in 1995, there were 227 rural doctors doing deliveries, compared with 266 in 1988. Furthermore, there were 74 GP anesthetists compared to 95 in 1988.[4]
Finally, there is a change in how medical business will be conducted in Ontario. Prior to the passage of Bill 26 the OMA had sole representation rights for all Ontario physicians. The government has now stated its willingness to enter into discussion with groups of physicians, breaking the OMA monopoly. The OMA graciously yielded the Rand formula, stating that "in the absence of representation rights, we had a moral obligation to suspend mandatory collection of dues."[5] Some physicians see this as a divide-and-conquer tactic that will have a negative effect. Many see it as a positive step toward breaking the dominance of the larger sections within the OMA.
In order to clarify what Ontario rural physicians' attitudes are to these impending changes, a survey was undertaken by the Society of Rural Physicians of Canada (SRPC) in January 1996. From the 440 doctors who were registered as "rural" with the OMA Section of Rural Practice, we received 143 responses. The most notable findings were that a significant number of respondents (69.2%) feel that the SRPC should represent their interests. An even greater proportion (90.9%) would like to see the Society at least as an advisory agent for negotiations with the Ministry of Health.
There has been ongoing discussion regarding the continuing medical education budget for rural physicians, which is currently administered by the OMA. Consideration was being given to the transfer of responsibility for CME and its funding to the academic health science centres. When asked what they thought of this, 29.4% of the survey respondents thought the OMA should continue to administer the program, 1.4% thought that the academic health science centres should be entrusted with the task, and a surprising 74.8% of respondents wanted the SRPC to manage the program. Results of this survey will be forwarded to the Ontario Ministry of Health and the OMA for further discussion.
A final few points. November 1995 saw the first-ever Rural Forum at an annual meeting of the Ontario College of Family Practice. The annual meeting of the OMA Section of Rural Practice followed this. The Section Chairman, Jim Rumball, requested a closer working relationship between the OMA Section of Rural Practice and the SRPC, and called for two SRPC members to sit on the executive of the OMA Section of Rural Practice. A resulting statement of cooperation was published in the SRPC's most recent newsletter.6 It is hoped that this will clarify the relationship between other provincial medical associations and societies and the SRPC.
References