Focus on Nova Scotia

Robert F. Martel, MD
Dartmouth, NS

CJRM 1998;3(3):149-51

© 1998 Society of Rural Physicians of Canada

Physicians who practise in rural areas of Nova Scotia received somewhat of a reprieve in 1997 with the introduction of payment for on-call services. This hard-fought recognition was not achieved without some discomfort. Clearly the government saw the need to have rural physicians involved, given the difficulty with recruiting and retention of rural physicians, but the potential for divisiveness was always present when funding of new programs was set aside in the context of a global budget. The final tariff agreement (between the Medical Society of Nova Scotia [MSN] and the Government of Nova Scotia), in which was included a rural stabilization fund, was met with widespread relief, but some fence mending remains. The fact that the government saw fit to set aside new money for the fund further contributed to the impression that government may be too focussed on rural concerns. As a group rural physicians have failed to articulate the differences between rural and urban physicians in a manner that does not invite finger pointing. The omission of a "voting seat" designated as rural at the MSNS Board level points to the lack of understanding of these critical differences. (The current "rural seat" on the Board is 1 of 5 seats designated for general practice.) It is important to recognize the goal of a stable rural physician work force: improved access to evidence-based health care for all Nova Scotians

Two years ago, prior to the incorporation of the Society of Rural Physicians of Nova Scotia (SRPNS), physicians based in rural Nova Scotia were polled to determine the factors that would enhance, not only their quality of life as physicians, but also their quality of life as members of a rural community. Ten concerns were listed, with continuing medical education, locum relief and payment for on call, being the front runners. The MSNS and the Nova Scotia Department of Health (DOH) were asked to present strategies to remove the barriers to both retention and recruitment of rural physicians to Nova Scotia outlined in the survey. Minister of Health Bernie Boudreau invited interested parties to present their views to the government on this issue in February 1997.¹

A "Green Paper" entitled "Securing doctors' services requires a partnership"² was delivered to the minister on Mar. 17, 1997, outlining the SRPNS position. The SRPNS was the only organization to formally respond to the minister's challenges. The DOH, to date, has not responded to this paper. Much of the "Green Paper" dealt with Graham C. Scott's report to the Government of Nova Scotia and the assumptions on which it was built.³ Given that Mr. Scott had been instrumental in brokering a deal for rural physicians in Ontario, the government saw fit to ask Mr. Scott, at the urging of the SRPNS, to assess the problems of securing rural physicians' services in rural Nova Scotia. Unfortunately Mr. Scott's terms of reference (and budgetary parameters for the "solution") in Nova Scotia were outlined without consultation with either the MSNS or the SRPNS. Although Mr. Scott did have wide consultation with some of the stakeholders, as part of the process, the fact that he had to craft a solution within restricted guidelines limited his imagination. The executive of the SRPNS presented vigorous opposition to the Nova Scotia Scott Report in a written dissertation to the minister of health⁴ Despite Scott's recognition of a need to compensate physicians for being on call, a "poison pill" was included in his report: Graham Scott recommended that physicians be made to work in designated emergency rooms to receive compensation for on call and suggested that physicians would serve their patients better if they worked in group practice situations.

In Nova Scotia, as in other provinces, there are solo physicians (some of whom are not affiliated with designated emergency rooms), especially in very rural areas, who continue to offer on-call service to their patients. Although there are many who feel that this is detrimental to the well-being of all concerned, this service needs to be compensated until some other process is in place to serve the needs of those patients. This is particularly critical for those specialties located in rural areas. Internal medicine, surgery, pediatrics, ophthalmology and neurology are only some of the specialties in need of urgent assistance with on-call compensation, to say nothing of manpower planning.

The SRPNS maintains that before manpower issues can be addressed, financial stability must be brought to rural health care. In Nova Scotia rural pediatric specialists are in need of urgent assistance with their practice situations. Pleas for reprieve from unworkable and unsafe work places have fallen on deaf ears. Mr. Scott did not consult with the physicians in question nor did he spend any time discussing the matter with community representatives. It is interesting to note that he made similar recommendations in New Brunswick. All stakeholders recognized the disruption caused by forcing physicians to take call from recognized emergency rooms and they realized that a compromise was required. Like all compromises no one can claim total victory.

After considerable debate, the following was agreed upon: First, all physicians providing on-call service in a registered emergency room would receive compensation based on a formula that factored in volumes of patients seen in the departments. Level III emergency care physicians would be compensated at a rate of Can$85/h. Rural emergency care on-call remuneration would be divided into 3 categories: the larger volume rooms (category A) would compensate their physicians at approximately Can$65/h, mid-volume rooms (category B) would compensate Can$55/h (in lieu of fee-for-service compensation), with solo physicians (category C) receiving a fixed Can$20 000 a year in addition to fee for service.³

Although explicitly prejudicial to the more rural, less supported physicians, it was a compromise needed to gain support from colleagues. The DOH pledged to entertain an alternative remuneration scheme to address the inequities. The issue of compensation for rural specialists would be deferred until a new model of primary health delivery could be implemented and an alternative remuneration mechanism devised.

No one can speak for rural physicians on the fundamental issues of remuneration, education and lifestyle better than rural physicians. The MSNS is the only body legally able to negotiate remuneration for physicians. The establishment of the rural stabilization fund in Nova Scotia that eventually led to on-call remuneration and other initiatives was made possible because rural physicians were involved in a meaningful and productive manner. In any negotiation process the players must choose the battles they can win. Success should be measured in quantums that will provide the building blocks of a sound foundation for stable rural health care. In Nova Scotia the first block of the foundation was acceptance of remuneration for call, the second is the creation of an information management infrastructure and the third will be input into the training of medical students for rural practice.

No single measure has served to have a more positive impact on the lives of rural physicians than payment for on call. This compensation has provided physicians with hope: hope that there will soon be an alternative remuneration package that will fairly compensate rural physicians, not only for the long hours they work but, more importantly, for the extraordinary responsibility and skills set these physicians must maintain. Rural physicians will be the first to admit that on-call remuneration is not about increasing physicians' take-home incomes.² Rural physicians have finally come to the realization that compensation for on call is about self-respect and the ability to control their lives. The ability to have locums come to relieve rural physicians for a weekend has confirmed that the help is there if the funds are made available to make it happen.

Payment for on call, the recently signed tariff agreement and the funding of re-entry positions have allowed physicians to take a breath, but the structural anomalies that have contributed to a gradual erosion of confidence in the health care system continue to exist. There are areas of the province with a critical shortage of physicians. Amherst, Yarmouth, L'Ardoise, Port Hawkesbury, Guysborough, Shelbourne, Springhill, Arichat, Digby, Windsor and Liverpool are all looking for 1 or more physicians immediately. Many more communities have a marginal complement when one considers factors such as age, backup, spousal employment, educational concerns and other issues.

Physicians, especially rural physicians, remain outside the planning and implementational levels of the DOH both at the provincial and federal levels. As this article goes to press, there is a Nova Scotia DOH initiative to review primary care. Although rural physicians are clearly at the centre of any current primary care model, they have not been asked to participate at any level. It is clear that a crisis of confidence in the ability of physicians to participate as knowledgeable partners in the reform of health care in this country continues to pervade departments of health. The question that begs an answer is: how meaningful will the recommendations to revamp primary care be, if major stakeholders are not involved?

Realizing objectives as ambitious as those outlined here requires the cooperation of many groups. In the past, the lack of communication among stakeholders has contributed to misinterpretations of motives. The time has come for a new approach to be developed to address our common problems -- an approach where each group will have to realize that some autonomy may have to be relinquished to achieve the greater goal. Rural patients through their representatives are demanding nothing less.

A paradox exists however: The majority of rural physicians do not belong to an organized professional group. Forty percent of the Canadian population lives in rural Canada where the bite of health care reform has had the greatest impact. Individual voices have little impact on those who would have you believe that they know what is best for health care in this country. The SRPNS has been instrumental in articulating the needs of rural physicians.

Many issues remain to be explored. The lack of a comprehensive and universally available locum service remains a priority. There are many reasons why this service (announced Apr. 16, 1997) has not been established. Probably the most critical is the DOH admission that there are not enough warm bodies to make this a reality. The SRPNS believes the problem is more complex: training, fair remuneration, logistics, regulatory issues and overall government funding of health care are unresolved issues affecting the availability of locums; a problem not unique to Nova Scotia. However, we have an opportunity to craft a unique solution to the problem by involving rural physicians who are the major beneficiary of a locum service. Departments of health need to reconsider the value they place on physicians who are prepared to undertake this rather extraordinary roll in health care. The issue of value for locum service does not differ greatly from the issue of value for on call -- it is a matter of facing the reality of market forces. Rural physicians are ready to deal with this subject, but first they need to be asked.

The SRPNS is aware that the other items listed need attention if rural health care is to be regarded as a sustainable resource in this province. The ability to cope with these complex issues is compromised by a lack of interest (demonstrated by the membership) in coming forward to develop strategy to grapple with alternative remuneration, curriculum, work-place stress and spousal factors, to name but a few. It can be said that the SRPNS has not been as communicative as it could have been. It can also be said that many physicians in rural Nova Scotia are busy treading water and have little energy to pursue these goals even though they will be the first to admit that the lack of resolution will eventually lead to their own demise. It can also be said that the MSNS has not been as open to dialogue with the SRPNS as it could have been. There are legitimate reasons for each observation, but in the long run both organizations will do a disservice to the people of Nova Scotia if these common problems are not resolved.

References

1. Nova Scotia Department of Health: Good medicine -- securing doctors' services for Nova Scotians. Halifax: The Department; February 1997.
2. Securing doctors' services requires a partnership [report]. Halifax: Society of Rural Physicians of Nova Scotia, Mar. 17, 1997.
3. Scott GWS. Issues recommendation and recommendations on physicians' services in Nova Scotia to rural hospital emergency departments [special report]. Halifax: Novia Scotia Department of Health; Oct. 1, 1996.
4. Society of Rural Physicians of Nova Scotia, Hon. Bernie Boudreau, minister of health for Nova Scotia. Response to the Scott Report. November 1996.
5. Iglesias S, Grzybowski SCW, Klein, MC, Gagné GP, Lalonde A. Rural obstetrics. Joint position paper on rural maternity care. Can J Rural Med 1998;3(2):75-80.