Canadian Journal of Rural Medicine

 

Rural hospitals in jeopardy*

Rick Mann, MD, CCFP, FCFP
Kinhuron Medical Centre, Kincardine, Ont.

Can J Rural Med vol 2 (3):163-65

Correspondence to: Dr. G. Richard Mann, Kinhuron Medical Centre, PO Box 220, Stn. Main, Kincardine ON N2Z 2Y7; tel 519 396-3384; fax 519 396-3199

*This editorial is an abridged version of a Discussion Paper on Rural Hospitals, which was prepared by Dr. Mann for the Ontario Medical Association's Section on Rural Practice.

© 1997 Society of Rural Physicians of Canada

The survival of rural hospitals in Ontario is in jeopardy. The hospitals are threatened by budgetary restraints, government restructuring and attempts to impose urban solutions on rural communities, to name but a few of the issues. The Ontario Medical Association's Section on Rural Practice believes it is imperative for rural Ontarians and for rural health care that these hospitals continue to exist. This paper presents the reasoning that supports this belief.

Rural is different from urban and has its own needs

Rural hospitals play a unique role in the whole spectrum of hospital and health services. They are not merely scaled down versions of their city counterparts, and cannot be viewed as such in the arguments for closure. The ratios and regulations set up for urban hospitals cannot be transposed to the rural setting. For example, bed-to-population ratios and occupancy rates are different in rural and urban hospitals. A universal number cannot be set that is appropriate for both settings. Occupancy rates in small hospitals must be lower to accommodate fluctuations in admissions: in rural settings one is not able to divert the ambulance to the other hospital in town or admit the patient to the hospital down the street.1

Other factors, such as distance and transportation resources, mean that people may have a slightly increased length of stay in a rural hospital. If Mrs. Smith lives 20 km outside town, with no public transit, little support, and it is the middle of winter, she might spend an extra day in hospital recovering from surgery rather than risk the chance of running into a complication and being unable to access care. This is not a common scenario in urban centres, but it is a reality in rural communities. The shift to outpatient care (e.g., outpatient surgery) has an impact on inpatient bed census, but should not and cannot be used to suggest the closure of a rural hospital because its inpatient census is low.

Rural hospitals provide all inclusive medical care in one facility

Rural hospitals provide a menu of basic services tailored to the needs of the community. This includes emergency care, maternity care and inpatient treatment of common medical problems. In a 1990 survey of Ontario hospitals with fewer than 100 beds, Rourke found that these hospitals, which accounted for just over 10% of the total acute care beds in Ontario, in the course of a year had 1 239 085 emergency and outpatient visits, 10 646 deliveries (including 1748 cesarean sections), 33 155 general anesthetics given and 25 008 major general surgery operations done.2 They provide these services within the competence of the local health care providers.3

In his 1995 report,4 Scott stated: "rural medical practice is different from urban and suburban practice." Most rural physicians have active admitting privileges to their community hospital and are responsible for the care of their patients while in hospital. They tend to be generalists, and provide care for a variety of health needs during the patient's lifetime. Many do obstetric deliveries, anesthesia, assist in surgery and work shifts in the emergency department. They provide not only primary care, but selected secondary and tertiary care. They do all this in a cost-effective manner: because they know their patients and their conditions, they can often prevent unnecessary duplication of tests and procedures.

By acting as satellite clinics, rural hospitals look after patients in their own community who would otherwise have to travel to larger centres for care. This is seen today with chemotherapy and dialysis; the care plan is put together in the larger centre but carried out closer to home. The rural hospital usually serves as a focus for physician practices and other health care services.2 Without the hospital these services are not available, because health care professionals and services tend to be located in communities with hospitals.

Rural hospitals attract physicians

Pirani and colleagues noted that rural hospitals provide access to services, equipment and support services that physicians need and would otherwise be unable to provide. They state that a hospital is important in helping communities attract and retain physicians.5 This was borne out in October 1996, when a survey of physicians in Bruce and Grey counties in Ontario showed that 80% of the physicians in those 2 counties would leave if their rural hospital closed. As Henderson6 stated: "Rural communities are best served by family physicians with broad-based skills who reside in those communities and who have active privileges at the local hospital." This fact must be taken into account as the provincial government attempts to modify physician resources. It is not logical to close hospitals so important to the work of the rural physician and, at the same time, try to increase physician numbers in these communities. Nor is it wise, because demographics indicate that more people are moving to rural areas and that the aging baby boomers, with their medical needs, will create more, not less, need for rural hospitals.7

Rural hospitals fire up the economy

Rural hospitals have significant impact on the local economy. They are often one of the town's largest employers. In 1981, Christianson and Faulker reported that rural hospitals contributed on average between $700 000 to $1 000 000 (US) to local economies.8 Hospital employees spend money in the community, and the hospital purchases services from local businesses. Thus, the economic stability of rural communities is affected by hospital closure.

Home care in the country can be too difficult

Rural Canada is sparsely populated and, due to distances, weather and isolation, difficulties arise in providing home care efficiently and cost effectively. The rural hospital inpatient setting may provide more cost-effective and consistent care than home care programs.

Closure may contravene the Canada Health Act

The Canada Health Act contains the concept of equitable access for all Canadians to good health care. Rural patients have the right to expect quality health care and the availability of emergency care within the so-called "golden hour." However, rural communities fall significantly short of the basic tenets, as set out in the Canada Health Act, compared to those in urban communities with immediate access to "high-tech," specialty-oriented emergency care.

Closure would cause hardship on residents

Closure of a rural hospital has documented repercussions in the community. In 1983, Hernandez and Kalnzny9 found that it resulted in lower quality of care, decreased access to physician services, fewer employment possibilities and increased health care expenditure per capita. This last point -- increased health care costs -- is a finding shared by other researchers.10,11 When there are no local alternatives, closure of a rural hospital may result in loss of reasonable access to emergency and acute care.12

The closure of rural hospitals and emergency departments within these facilities "would result in increased time and distance to basic emergency care with a corresponding increase in morbidity and mortality."13 Barriers to care that also affect outcomes include road conditions, terrain, inclement weather, traffic patterns and availability of transportation.14 There is little or no public transportation in rural areas, and what there is has been reduced and threatened by bus-line deregulation. With the recent cutbacks in the Ontario Ministry of Transportation's budget, sanding and salting of roads has been reduced. Taxis are few, if any, and can be expensive.

Rural hospitals are not a drag on provincial budget

If the rationale for closing rural hospitals is economic, there would not be a significant savings if all the rural hospitals were closed because they make up such a small amount of the total hospital budget. The 1995­96 allocation for hospitals with fewer than 50 beds was 5.6% of the total Ontario hospital budget. The allocation for 50- to 100-bed hospitals was 4.3% (Heather Stewart, Small Hospitals Group, Ontario Hospital Association: Personal communication, February 1997). In fact, in closing rural hospitals it is probable that the aggregate costs would rise because patients would be sent to more capital-intensive and expensive urban hospitals. The inpatient diagnostic and procedural mix of rural hospitals demonstrates that they provide inexpensive and cost-effective care for common medical and surgical conditions of low complexity.3 As Hart and coworkers summarized in 1990:3 "Given the fact that they [rural hospitals] are relatively inexpensive, and in the absence of [any] evidence that they provide suboptimal care they should be stabilized" and remain open.

Rural hospitals provide quality care

In terms of quality of care, there is copious evidence that excellent outcomes in areas such as obstetrics can be achieved in rural hospitals and there is no reason to believe this is not the case for other medical interventions.3

Summary

Ontario's rural hospitals are threatened by factors that are mostly economic in nature. Many arguments suggest that the closing of a rural hospital has significant negative economic consequences on the local community and on the provincial health care budget. Demographic data suggest that rural Ontario will see a surge in population over the age of 50 in the next 20 years.7 This sector requires more hospital and health care resources. It therefore makes no sense to close hospitals in rural Ontario. They should perhaps even be expanded. Rural physicians are different from their urban counterparts and are more procedure-oriented, caring for their patients in the hospital setting. They require the appropriate tools; this includes a local hospital.

Finally, rural hospitals are not smaller versions of their urban cousins. The 20% of the Ontario population that has chosen to live in a rural community deserves nothing less than high quality health care. This is provided by rural physicians working in rural hospitals.

References

  1. Rohrer JE. Closing rural hospitals: "Reducing institutional bias" or denial of access? J Publ Health Policy 1989;10(3):353-8.
  2. Rourke J. Small hospital medical services in Ontario. Part 1: Overview. Can Fam Physician 1991;37:1589-94.
  3. Hart LG, Amundson BA, Rosenblatt RA. Is there a role for the small rural hospitals? J Rural Health 1990;6(2):101-18.
  4. Scott GWS. Report of the fact finder on the issue of small/rural hospital emergency department physician services. Toronto: Ontario Ministry of Health, Ontario Hospital Association, Ontario Medical Association. 1995 Mar 22.
  5. Pirani MJ, Hart LG, Rosenblatt RA. Physician perspectives on the cause of rural hospital closure, 1980­1988. J Am Board Fam Pract 1993;6(6):556-62.
  6. Henderson RW. Staffing rural hospitals: strategies for survival [editorial]. Can Fam Physician 1996;42:1057-9.
  7. Foot DK, Stoffman D. The health care crunch. In Boom, bust & echo. Toronto: Macfarlane, Walter & Ross; 1996. p. 163-81.
  8. Christianson J, Faulker L. The contribution of rural hospitals to local economies. Inquiry 1981;18:46-60.
  9. Hernandez SR, Kalnzny AD. Hospital closure: a review of the current and proposed research. Health Serv Res 1983;18(3):419-36.
  10. Welch HG, Larson EB, Welch WP. Can distance be a proxy for severity-of-illness? A comparison of hospital costs in distance and local patients. Health Serv Res 1993;28:441-58.
  11. Merlis M. Rural hospitals. Washington: US Congress Congressional Research Services; 1989. No. 99-296, FPW.
  12. Shreffler MJ. An ecological view of the rural environment: levels of influence on access to health care. Adv Nurs Sci 1996;18(4):49-59.
  13. Rourke J. Small hospital medical services in Ontario. Part 2: Emergency medical services. Can Fam Physician 1991;37:1720-4.
  14. Fleming ST, Williamson HA Jr, Hicks LL, Rife I. Rural hospital closures and access to services. Hosp Health Serv Admin 1995;40(2):247-62.

| CJRM: Fall 1997 / JCMR : automne 1997 |