ONTARIO COLLEGE OF FAMILY PHYSICIANS

Transcription

1 Summary of the Proceedings from the Think Tank on Stabilizing Health Services in Rural Communities Contact: M. Janet Kasperski, RN, MHSc, CHE Chief Executive Officer ONTARIO COLLEGE OF FAMILY PHYSICIANS 340 Richmond Street West Toronto, Ontario M5V 1X2 Tel: (416) ϖ Fax: (416) ϖ Website: May 2009

2 Think Tank on Stabilizing Health Services in Rural Communities May 11, A Call for a Moratorium The OCFP and our partners are calling for a moratorium on the reduction in services in rural/small communities. We are not calling for the status quo but rather a planned approach to service delivery in these communities based on the evidence and the needs and expectations of the public we serve. Recent reports on rural healthcare use quality concerns based on volumes as a rationale for decreasing services in rural communities. Quantity does not equal quality. CIHI reports that there are only three procedures in which high volumes have been found to improve health outcomes. A growing body of research demonstrates that travelling to care is associated with high rates of morbidity and mortality. Hospitals with the lowest morbidity and mortality rates are those with the most involvement of family physicians in inpatient care. Rural and small hospitals heavily depend upon family doctors to provide hospital based care and throughout the community. Starfield showed that the higher the ratio of family doctors to the population, the better the outcomes. If decisions are anchored in the evidence and in public needs and expectations, the focus of the Rural and Northern Expert Panel will be on the recruitment and retention of family physicians, nurses and other healthcare professionals in rural/small communities.

3 Think Tank on Stabilizing Health Services in Rural Communities May 11, RURAL SECTION Preamble CALL FOR A MORATORIUM ON REDUCING HEALTHCARE SERVICES IN RURAL AND SMALL COMMUNITIES: A Call for a Review of Emergency Services in Ontario The health of rural Ontarians has been shown to be worse than that of their urban counterparts. Since there is strong evidence to support that local access to the majority of healthcare services has a positive impact on health, the Ontario government should increase access to services in rural/small communities to ensure equal health outcomes for all of its citizens. The restructuring of the healthcare system in the 1990s, resulting in hospital closures, mergers and downsizing, had major negative consequences. The system has yet to recover from these efforts to downsize the system. The attempt to close small hospitals in the 1990s demonstrated how valued these hospitals are by their communities. Ontarians recognized that the inability to receive care close to home would negatively impact on their care and, in particular, would impact on the elderly and those requiring palliative care. The potential impact on the local economy and all three levels of government demonstrated that the closures would cost more than the savings that might accrue. Policy decisions in the 1990s also created an outright shortage of family doctors in the province. The government has invested extensively in the recruitment and retention of family doctors throughout Ontario, especially in smaller, rural and remote communities; however, these communities remain relatively unstable and fragile. The impact of reducing services in these communities will increase their difficulties in recruiting and retaining physicians, further destabilizing them. Current discussions regarding the decrease in service to rural/small communities such as the transformation of Emergency Departments into 18 hour Urgent Care Centres or complete hospital closures is not seen to be evidence-based but rather driven by the need to balance budgets. The lack of a detailed evaluation of the unintended consequences of decreasing services in these communities needs to be undertaken prior to final decisions being made.

4 Think Tank on Stabilizing Health Services in Rural Communities May 11, A Moratorium on reducing healthcare services in rural and small communities should be imposed in each Local Health Integration Network until such time as a province-wide review process has been conducted that result in the following: 1) The urgent establishment of a Think Tank with broad and knowledgeable representation, similar to those involved in the Rural and Northern Health Care Framework, to provide recommendations to the LHINs regarding the role and future of emergency departments and small hospitals; 2) The adoption of the standards that have been developed identifying the services that are required to provide emergency care; 3) The identification of how many emergency departments are needed in each community and in each LHIN; 4) The adoption of standards regarding the level of services that should be available in local hospitals to support the health care needs of the local population; 5) The adoption of standards regarding the level of services that should be available to local communities to provide the non-hospital based services that are required to meet the healthcare needs of the local population; 6) The adoption of standards regarding the regional services that need to be in place to support local delivery systems; 7) The implementation of a system to ensure accessibility to regional services that are deemed necessary to support local delivery systems; 8) The implementation of standards regarding EMS availability in the event of a closure of an emergency department; 9) The development of a comprehensive educational program to prepare and support physicians and nurses to provide exemplary care in every emergency department/urgent care in the province; and, 10) A review of the research papers developed to date to evaluate the effects of any reduction in services in communities on both the quality of care provided and the overall cost to the healthcare system and further research to fill in identified gaps in knowledge. The Ontario College of Family Physicians The Canadian Association of Emergency Physicians The Society of Rural Physicians Ontario Chapter Ontario Medical Association Section of Rural Medicine

5 Think Tank on Stabilizing Health Services in Rural Communities May 11, Table of Contents Think Tank Agenda Executive Summary Welcoming Remarks: Dr. Robert Algie Keynote Address: a Day in Life of a Rural Physician Dr. Sean Moore Quality of Care in Rural Communities: Lessons Learned Dr. Ray Dawes/Dr. Peter Hutten-Czapski Regional Organization of Services: Facts and Fantasy Dr. Alan Drummond/Dr. Jim Ducharme Adopting Standards of Care in Emergency Services Dr. Alan Drummond Quick Facts Small Group Discussion/Debate: Services should be Centralized into Regional Centres of Excellence Small Group Discussion: Designing a System to Enhance Care in Rural/Small Communities Summary Remarks: Dr. Robert Algie...21 Appendix A: Speaker Biographies Appendix B: PowerPoint Presentation Keynote Speaker/Dr. Sean Moore Appendix C: PowerPoint Presentation Dr. Ray Dawes Appendix D: Rural Hospital Service Closures Document Appendix E: PowerPoint Presentation Dr. Peter Hutten-Czapski Appendix F: PowerPoint Presentation #1 Dr. Alan Drummond Appendix G: PowerPoint Presentation #2 Dr. Alan Drummond Appendix H: Bibliography

6 Think Tank on Stabilizing Health Services in Rural Communities May 11, Stabilizing Health Services in Rural Communities THINK TANK May :30 AM 3:30 PM Metropolitan Hotel (108 Chestnut St) Toronto Ballroom, Second Floor AGENDA 08:00 08:30 Continental Breakfast and Registration Toronto Ballroom 08:30 08:45 Welcoming Remarks Dr. Robert Algie President Elect, OCFP 08:45 09:15 Keynote Speaker: A Day in the Life of a Rural Physician Dr. Sean Moore 09:15 09:45 Quality of Care in Rural Communities: Lessons Learned Dr. Ray Dawes Dr. Peter Hutten-Czapski 09:45 10:15 Regional Organization of Services: Fact or Fiction Dr. Jim Ducharme Dr. Alan Drummond 10:15 10:45 Adopting Standards of Care in Emergency Services Dr. Alan Drummond 10:45 11:00 BREAK 11:00 12:00 SMALL GROUP DISCUSSION: Preparation for the Debate.. Services should be Centralized into Regional Centres of Excellence Group 1: Pros; Group 2: Cons Moderated by: Dr. Robert Algie President Elect, OCFP 12:00 13:00 LUNCH Preparation of Debaters.. 13:00 13:35 DEBATE and Summary Dr. Jim Ducharme 13:45 14:45 SMALL GROUP DISCUSSION: Designing a System to Enhance Care in Rural/Small Communities Dr. Robert Algie 14:45 15:15 Reports from Small Group Discussion Dr. Peter Hutten-Czapski 15:15 15:30 Summary of Next Steps Dr. Robert Algie

7 Think Tank on Stabilizing Health Services in Rural Communities May 11, Executive Summary In the fall of 2008, the Ontario College of Family Physicians (OCFP) convened an interorganizational Task Force to review and identify solutions to the growing problems facing rural and small communities in maintaining healthcare services for their patients. In collaboration with the Canadian Association of Emergency Physicians, the Ontario Division of the Society of Rural Physicians and the Ontario Medical Association s Rural Section, the Task Force members discussed the problems and reviewed the many reports that had been written over the course of last twenty years on rural health issues. In spite of years of creative thinking about the issues, few of the recommendations in these well-regarded reports have ever been implemented and rural healthcare remains a neglected area of practice in Ontario. Task Force members identified the fact that we understood the problems facing rural and small communities. Like many others before us, we had identified most of the potential solutions; however, we needed a robust process to solidify recommendations for government that would overcome the barriers to implementation previously seen over the years. We began to envision a Think Tank that would include rural and emergency physicians, hospital administrators, LHIN CEOs, HealthForceOntario staff and Ministry of Health and Long Term Care representatives; however, at that very time, hospital corporations began to arbitrarily announce service closures in small rural communities in southern Ontario. These closures did not seem to be part of master LHIN plan. They seem to be the individual hospital s response to budgetary restrictions. As one physician expressed it, they were seen as easy made, rather than well-thought out action plans that benefit people in the affected communities, as well as people throughout the LHINs. Task Force members were pleased when the MOHLTC announced the establishment of a Rural and Northern Expert Panel. We knew that our Think Tank would contribute significantly to the work of the Panel; however, we were concerned that hospitals would remove services from the targeted hospitals before the Panel had completed its work and called for a Moratorium on the reduction of services in any rural/small hospital until the MOHLTC s Rural and Northern Expert Panel had completed its review and the government and LHINs were able to implement a solid plan for rural health in the various regions of Ontario. (see the Moratorium document) Given the discussions and the recommendations from the participants at the May 11, 2009 Think Tank on Stabilizing Health Services in Rural Communities, our priority recommendation to government is as follows: A Moratorium on decreasing services in rural and small communities should be enforced until such time as the MOHLTC s Rural and Northern Expert Panel develops two separate strategies for equitable healthcare services delivery in rural communities (one for rural northern communities and one for southern rural/small communities). Both strategies need to address the changing face of healthcare from the delivery of acute care services to chronic disease prevention and management. The plans should take into account the unattached patient population, as well as, the need to ensure surge capacity throughout the system in keeping with the ED/ALC wait-time strategy. Moreover, the Moratorium should be in place until each LHIN utilizes these strategies to develop and implement a LHIN specific plan to ensure that every citizen in their LHIN has equitable access to core services particularly primary care and emergency services. The plan should be in

8 Think Tank on Stabilizing Health Services in Rural Communities May 11, recognition of the fact that LHINs should be accountable for health outcomes in population served with funding accountabilities seen as means to that end. Other recommendations are as follows: 1. The MOHLTC and the LHINs should ensure that investments are made to provide more services in rural and small communities. Given the reduced health status of rural citizens compared with their urban counterparts and in keeping with the principle of equity (i.e. the most care for those most in need) more services, not less are required in these settings. 2. The LHINs should map patient needs and public expectations in each rural/small community. Citizens and front-line provider engagement is required in rural and small communities to determine the core services that should be provided to meet local needs and to ensure that a patient-centred system is established that aims to improve health outcomes for each rural/small community citizen.. Research shows that the top-down/imposed approach usually results in negative unintended consequences. 3. The Rural and Northern Expert Panel and LHIN specific planning should focus on realignment of services, rather than centralization. Centralization usually results in a shift of services to larger centres with a further decrease in access to services to rural/small communities. Regionalization, on the other hand, affords the best opportunity to develop a system with an equitable access for all citizens. This may include developing and enhancing Centres of Excellence in rural/small communities with a much needed shift in resources from large centres to smaller ones. 4. The Rural and Northern Expert Panel should call upon the expertise for planning excellence in the delivery of healthcare in rural/small communities from the many communities across Ontario that are recognized as examples of rural healthcare. Rural expertise is required to address rural issues. 5. The Rural and Northern Expert Panel should not re-invent the wheel. It should review documents developed over the course of the past 20 years and use those to develop its plans. 6. The MOHLTC should develop an inventory of the innovations and effective processes that work best in rural and small communities and should develop a plan to share them throughout the province. 7. The LHINs should overcome the tendency to respond to individual organizational budgetary concerns by developing a strong regional governance structure that bases decisions on the evidence of how to improve health outcomes rather than financial expediencies. 8. The MOHLTC and LHINs should recognize that communities need both strong primary care/community-based services and emergency services. Both are required and neither one cannot substitute for the other. The LHINs should concentrate on building strong primary care/community-based services in rural/small communities and ensure that they are effectively linked to emergency service providers locally and regionally. 9. The LHINs should focus on the establishment of collaborative, interdependent interprofessional teams in the community, in light of the changing needs of our growing and aging population with chronic diseases especially for patients with multiple comorbidities to relieve pressures on emergency departments and inpatient beds. 10. The MOHLTC should redefine the meaning of interprofessional teams to include a virtual team composed of members from the continuum of care in a community/region (primary care, community service organizations including public health, emergency services, inpatient care, home care and long term care).

9 Think Tank on Stabilizing Health Services in Rural Communities May 11, The MOHLTC and the LHINs should ensure that person-to-person connects amongst virtual team members are enabled by effective telecommunication systems including telehealth and interconnected EMRs/EHRs. 12. The MOHLTC should implement the recommendations in the Underserviced Area Review Report to provide the needed incentives to recruit and retain physicians to rural/small communities. 13. MOHLTC/OMA should ensure that the funding models for physicians do not result in discentives to practice in these communities compared with suburban/urban centres. Funding models should recognize the multiple roles that family physicians play in rural/small communities that compensate for the lack of specialists by addressing the discentives in on-call programs. 14. The teaching roles of rural physicians needs to be recognized as the emphasis shifts to distributed learning sites. Medical Universities should ensure that every medical student and Royal College specialty resident is required to practice in a rural community under the supervision of a comprehensive rural physician. Family residency programs should strengthen the ED/procedural components of their programs. 15. The MOHLTC should develop incentives to recruit and retain nurses and other healthcare professionals to rural/small communities. Student nurses and other healthcare learners should be provided with opportunities to practice in rural sites. 16. The Rural and Northern Expert Panel should recognize and strengthen those communities with a population of 5000 or more who have been able to recruit and retain 5 or more physicians. These communities should provide primary care, emergency and inpatient care if the community is more than 30 minutes from another centre. 17. The Rural and Northern Expert Panel, using the model of regionalization rather than centralization, should ensure that equal access for all citizens to core services is provided in each LHIN (i.e. 24/7/365 for minor, major and emergent conditions). Inconsistent hours of operation in various communities increase confusion amongst the population and deaths have been associated with such models of practices. 18. Each LHIN should ensure consistent quality of care throughout their region based on the following means: A single Medical Advisory Committee in each LHIN with common credentials and shared responsibilities for care amongst the physicians in a LHIN. Compulsory acceptance of patients from smaller centres by the on-call specialist in regional or academic health centres. Implementation of minimum standards of care in emergency departments and care maps and medical directives that are implemented consistently throughout the LHIN/province. Easy access to comprehensive, affordable education programs for physicians and nurses to ensure the knowledge, skills and confidence to meet those standards. An emergency services team-building strategy modeling best practices/standards of care similar to the MORE-OB programs. Effective linkages between community-based family doctors and emergency service providers to ensure two-way transfer of information about individual patients. Effective linkages between rural/small hospitals and larger centres to ensure that consultations and advice is available 24/7/365. Point-of-care diagnostic technology, telemedicine and PACs. 19. Collect data on an ongoing basis to measure primary care and ED access, ICU capacity, diagnostic turnaround times and EMS response time. Inventory the equipment and document the mechanisms/processes needed to provide excellence in healthcare services in

10 Think Tank on Stabilizing Health Services in Rural Communities May 11, every community with a focus first and foremost on improving health outcomes for the 15% of citizens in Ontario living in rural/small communities. In summary, the OCFP and our partners look forward to supporting the MOHLTC s Rural and Northern Expert Panel and moving forward with the recommendations from our Think Tank Participants. We thank each one of them for generously contributing their time and wisdom to making the Think Tank an overwhelming success. 2.0 Welcoming Remarks: Dr. Robert Algie Dr. Robert Algie, President-Elect of the Ontario College of Family Physicians (OCFP) welcomed the participants to the Think Tank. Dr. Algie noted that Dr. Stephen Wetmore, the OCFP President, sent his regrets and wished the participants his very best. Dr. Algie noted that he had been the Chair of an OCFP Task Force that included representatives from the Ontario Medical Association s Rural Section, the Ontario Division of the Society of Rural Physicians of Canada and the Canadian Association of Emergency Physicians. During the six months that the Task Force was meeting, its members identified the challenges in rural medicine; however, they were not able to find all of the answers that face rural and small communizes in the provision of healthcare services, especially emergency services. They decided to convene the Think Tank to bring together a variety of healthcare leaders who could help to identify the solutions. Dr. Algie presented the following comments to the participants: Kenora, Dryden, Red Lake, Fort Frances, Geraldton, Kirkland Lake these are some of the remote, rural communities that are having great difficulties in staffing their emergency departments. Since these communities are so isolated, they need to be open 24/7/365. As a result, HealthForceOntario funds southern Ontario physicians, indeed, physicians from as far away as Vancouver, to travel to these communities to work in their emergency departments. The cost to do so is exorbitant and would be better spent on recruiting, retaining and supporting local physicians to provide care in their own emergency departments. Petrolia, Leamington, Wallaceburg, Fort Erie, Port Colborne, Trenton, Picton, Richards Landing these are few of the communities that seem to be at risk of having their emergency departments closed or, in some cases, a full-out hospital closure. HealthForceOntario doesn t support their physician needs in the same way that it does the previously mentioned communities in the far north. As a result, their financially strapped hospitals have to dig deeply into their global budget to pay locums directly or to hire organizations like MedEmerg to provide the necessary physician resources to keep their EDs open. MOHLTC budget increases to the LHINs are well below inflationary rates and the wage settlements that are negotiated centrally. It seems as if the only possible response is service reductions. With the advent of hospital restructuring resulting in amalgamated hospital corporations, the already hard pressed smaller hospitals are an easy prey. Here is what we know about rural and small communities: The health status of people living in rural communities is worse than their urban counterparts. They need more care, not less. There are fewer family physicians per 1000 population in rural settings and dramatically fewer specialists. Rural physicians are older and work more hours per week than their urban counterparts. As a result, they are at higher risk of burnout.

11 Think Tank on Stabilizing Health Services in Rural Communities May 11, They have a broader scope of practice than urban physicians and by and large make up for the lack of specialists. There are fewer nurses and other healthcare professionals to assist them with patient care, so many demands besides medical care are made upon them. Indeed, in the 27 years that I have been practicing family medicine in a remote, rural setting, I can honesty say that the number of physicians and nurses working in our community emergency departments has never been so low. Staffing our rural EDs is extremely difficult and it is safe to say that, once again, rural medicine is in crisis. But the solution to this human resource crisis, to reduce services, doesn t make much sense. Our patients need more services, not fewer. We need more physicians and nurses, not less. Our patients are being told that Centres of Excellence in other communities will provide them with better care but I would like to remind you that there are not any studies that show that medical care in rural hospitals is inferior. Quantity does not always equal quality. Indeed, the studies show that travelling to care is a variable associated with higher morbidity and mortality. While we respect the need for trauma and stroke centres, these small hospital EDs can hold their own against the majority of larger community hospitals and community hospitals of each size have the advantage of heavily involving the patient s own family doctor in care while in hospitals. We know from Canadian research that the hospitals with the lowest mortality and morbidity rates are those with the most involvement of the family doctor in the patient s hospital care. With these factors in mind, we have asked for a Moratorium on any further reductions in the services provided in rural communities until we have a province-wide plan in place. We believe that the recommendations made in recent months have been made on the basis of financial considerations and not necessarily on what is best for the population in rural communities. Reducing services in these communities and shifting the resources to large hospitals may look good in short-term but may not be in the best interest of the communities they serve. In addition to the potential loss of even more doctors and nurses from these communities and a further negative impact on the health status of rural citizens, the uncalculated costs associated with these closures are likely to be substantial. Some are tangible such as the increased costs for upgraded ambulance services. Others, such as the cost born by families having to travel to care, are not so tangible and likely fall below the radar of consultants. The loss of an emergency department usually spells the loss of the majority of the acute care services in a community. In addition, the loss of a hospital, usually the largest employee in a community, may be the death knell of the community. The costs of employment insurance, welfare and the ODB are all significant but not likely taken into account by the hospital corporations or the LHINs that support the closures. As we see, time and again, silo thinking rather than system thinking prevents a complete analysis of the costs associated with service reductions in a community. Urgent Care Centres are being proposed as replacements for some EDs and we have heard about a CHC plus an Urgent Care Centre as a model to replace a small hospital. Under normal circumstances, the MOHLTC would set up pilots and carefully evaluate them before moving forward. At this point, we do not even have an acceptable definition of an Urgent Care Centre or government approved standards in place. As far as the CHC + urgent care model, I forecast an exodus of family doctors from those communities - and this potential worries us. So, we need your guidance and advice to help us prevent further erosion in healthcare in these communities. The goals for this meeting are as follows: To explore these issues further;

12 Think Tank on Stabilizing Health Services in Rural Communities May 11, To inform Provincial, LHIN and Municipal Leaders about these issues; and, To try to set a course to explore these issues in a more systematic way to support the MOHLTC s plan to establish an Expert Panel on Rural Health. While there have been multiple reports on Rural Health in the past, we still need to determine what is in the best interest of people in these communities. The financial pressures within LHINs need to be addressed but not at the expense of those most in need. 15% of Ontario s population lives in rural communities that equates to almost 2 million people and it represents 30% of Canada s rural population. This is a significant constituency that needs healthcare. They deserve an informed and well-thought out response to the problems we face in providing effective healthcare as close to home as possible in these communities. The call for a Moratorium is supported by all of us but we are not in support of maintaining the status quo. Later this morning, you will hear about rational rationalization strategies and the implementation of standards in our EDs. We will debate such issues and later in the day explore potential solutions to the challenges facing rural communities. I know that this will be a most productive day, given the great minds in this room. This is a day to debate, to focus on issues and to come to consensus on next steps. 3.0 Keynote Address: A Day in the Life of a Rural Physician Dr. Sean Moore Dr. Sean Moore identified the fact that he had been the Chief of Staff and Chief of Emergency Medicine in Kenora until recently. He is now practicing in Ottawa but returned to Kenora to facilitate the Ontario College of Family Physicians Primer in Emergency Medicine for Family Physicians. He described the activities he was involved in that day, noting that the locum physician working the night shift needed to leave early so he agreed to cover the rest of the shift until the day shift emergency physician arrived on site. As he was getting ready to leave for the hospital, he noted that the ambulance had arrived at the hotel to transport a 19 year old woman in full cardiac arrest to the hospital. He asked if he could assist them and then headed to the hospital arriving two minutes after the ambulance. Dr. Moore described the skill sets of the team that arrived to engage in the resuscitation, in the care of the family and the immediate feedback provided by the pathologist. During the OCFP Primer in Emergency Medicine course, local family physicians left briefly to perform anesthesia, C-sections, and to stabilize cardiac patients awaiting transfer to tertiary care. There activities were used to describe some advanced medical services that develop in small communities given the need, interest and the talent of the practitioners. As another example, Dr. Moore described Kenora s cataract surgical program that was developed to retain OR nurses, which in turn was key to the retention of their talented local general surgeon. Dr. Moore suggested that each LHIN needs to inventory the unique services available in rural communities, as well as the reasons why physicians and nurses are attracted to rural communities to ensure that changes in service delivery make working in these communities more attractive, not less. Many of the patients attended to during this day may not have survived were immediate emergency care unavailable to them. Dr. Moore closed by emphasizing the gratitude of people in small communities and the dedication of providers to meet the needs of their families, friends and neighbours (see Appendix B).

13 Think Tank on Stabilizing Health Services in Rural Communities May 11, Quality of Care in Rural Communities: Lessons Learned - Dr. Ray Dawes/Dr. Peter Hutten-Czapski Dr. Ray Dawes representing the Ontario Medical Association s Rural Section began his presentation by noting the state of healthcare in the United States. Dr. Dawes noted that the new USA administration intends to address the following issues. 40 million uninsured in the USA and those with insurance having a difficult time attaining care due to high up-front co-payments. The USA ranks 15 th to 40 th on key health measures such as life expectancy and years of life lost due to preventable causes. $7000 per capita vs. $3500 in Canada $700 billion per year spent on services that do not improve outcomes. Dr. Dawes noted that the Academy of Family Medicine in the USA has developed the concept of a Medical Home whose core features include a physician-directed medical practice; a personal physician for each patient; the capacity to co-ordinate high quality, accessible care and payments that recognize the medical home s added value for patients. It was noted that family physicians help patients to understand a more constructive path that is likely to be as safe as more intensive and higher cost care pathways, resulting in decreased costs with same or improved outcomes. It is for this reason that there is such an emphasis in the USA, in Canada and globally on strengthening primary care. Rural communities with the close alignment of family practices and the local hospital provides the medical home that people require to address the majority of their healthcare needs. Rather than supporting models of care in which specialists provide primary care and specialist clinics are funded in large centres, the medical home in rural communities should be supported by the LHINs. While acknowledging that many complex services cannot be provided in small hospitals, Dr. Dawes emphasized that small hospitals are Centres of Excellence in the care of the elderly, palliative care, convalescence from illness or surgery and chronic disease prevention and management. The problem in small hospitals is not related to quality or level of care, rather to physician and hospital funding models that disadvantage small Emergency Departments. Physicians in rural EDs are paid less due to a flawed system that financially rewards volume rather than acuity and lack of back-up. In addition, the underserviced area program has not changed significantly in 40 years despite several efforts to improve it. The rural CME and locum programs have also lost their value to a point where most rural physicians do not even bother to apply. Moreover, the 2008 negotiations between the MOHLTC and the OMA resulted in little, if any, support for rural physicians for the very first time. Dr. Dawes closed by noting the words: Every citizen in Canada should have equal access to healthcare regardless of where they live. (See Appendix C) Dr. Peter Hutten-Czapski presented on behalf of the Ontario Division of the Society of Rural Physicians of Canada. Dr. Hutten-Czapski referred the participants to the document recently released by the SRPC on Rural Hospital Service Closures (see Appendix D). He referred to the comments of Roy Romanow in his report on the Future of Healthcare in Canada. There is an inverse care law in operation. People in rural health have poorer health status and greater need for services and have more difficulty accessing healthcare services than people in urban centres.

14 Think Tank on Stabilizing Health Services in Rural Communities May 11, This statement was backed up by the following statistics: Rural Canadians live three years shorter than urban counterparts Per capita health expenditure reflects 18.4% under spending for rural patients. Physician service expenditure for rural patients is $490 annually compared with $580 for urban patients. Dr. Hutten-Czapski referred to the myth that rural care is inferior to urban care, noting that there is little or no evidence to support this claim; indeed, the evidence that is available supports equal or better outcomes in small hospitals. Maternity care in small rural hospital is as safe as that provided in largest specialist run centres and travelling for obstetrical care results in higher costs and worse outcomes. Procedures such as appendectomies, colonoscopies and other endoscopic procedures have been shown to be as high quality as those done by specialists; indeed, fewer complications were noted. CIHI had identified all but three rare and highly specialized procedures that are done as well in low volume centres compared with high volume centres. A review of savings due to service closures revealed that medium size rural hospitals ( beds) were more efficient than large city teaching hospitals and that the indirect costs such as ambulance, personal transportation, hotel accommodations, meals away from home and accidents during transportation result in increases to the overall costs. These costs are rarely captured in consultant reports. As an example, closing 52 hospitals in Saskatchewan saved $30 millions to the hospital system; however, the added costs have yet to be described. Dr. Hutten-Czapski noted any plans to distribute hospital services should take into account the need to balance equity of access for rural patients, provide alternative care services, the economics impact on the community, the geography (northern vs. southern) and the impact on the recruitment and retention of practitioners, especially doctors and nurses. There is scant evidence to guide policy so government has tended to use precedents, such as 40 kms between hospitals with 24/7/365 emergency departments. Dr. Hutten-Czapski suggested that a population base of 5000 with 5 or more physicians should result in a hospital that is of the size to be sufficient in providing emergency care, inpatients and obstetrics. Smaller communities may also need a hospital/ed if the next community is more than a half hour away. The evidence demonstrates that the closure of a rural hospital results in lower quality of care, decreased access to physician servicers, fewer employment possibilities and increased per capita healthcare expenditure. When compared with a community with a hospital, per capita income drops by 4% and the unemployment rate increased by 1.6%; however, the greatest impact on imposed hospital closures is the inability to recruit and retain medical and nursing staff. Dr. Hutten-Czapski provided examples of the results of imposed closures and concluded that closures of hospitals where the travel distance is less than ½ hour may be reasonable if the existing healthcare providers join together to form a larger group to share the burden of care; however, the case for improved efficiency/cost savings is not at all clear. Dr. Hutten-Czapski closed by stating that the evidence, where it exists, suggests that without local input, it is most likely that costs will go up, access will decrease and there will be negative ramification for the recruitment and retention of physicians and nurses and a negative impact on the local economy. (See Appendix E)

15 Think Tank on Stabilizing Health Services in Rural Communities May 11, Regional Organization of Services: Facts and Fantasy Dr. Alan Drummond Dr. Alan Drummond, representing the Canadian Association of Emergency Physicians, noted the regionalization of rural emergency services has been considered since the early 1990s when physician and nursing shortages become a major issue. The problems facing hospitals in addressing emergency staff shortages continued throughout the 1990s and 2000s and may be even worse in fact today. Dr. Drummond noted that service disruptions are unacceptable and threaten the public s confidence in the entire healthcare system. Dr. Drummond noted that there seems to be a general acceptance that emergency care is more expensive than primary care. Noting that the emergency department infrastructure required to deal with level 1, 2 and 3 patient problems needs to be in place and once those costs are covered, any additional patient costs are minimal amounts compared with the costs of diverting them to primary care. Rural hospital care is often thought to be inefficient; however, in actual fact, costs escalate when patients are sent to larger centres and indirect costs are rarely taken into account. He noting that emergency rationalization has been linked to primary care reform; however, both emergency and primary care are needed. They complement but do not replace one another. Dr. Drummond noted that regionalization in the Ontario context has never been done before and, as a result, careful planning is needed. In moving forward, Dr. Drummond stated that the following was needed: 1. categorization and standardization of regional emergency departments; 2. development of a comprehensive regional plan for emergency service delivery; 3. broad public consultation to ensure that the payer of the system (i.e. tax payers vs. government) agrees with the plan; 4. provincial oversight to guarantee adherence to minimal standards of care; 5. an effective communication system; and, 6. services that are cultural sensitive. Noting that none of the above would happen without leadership, Dr. Drummond stressed the need for the participants to find ways to provide the leadership needed to move forward (see Appendix F). Dr. Jim Ducharme noted that our first obligation is to keep the patient first and foremost in our minds. Emphasizing that the greatest rise in health costs in our healthcare budgets is from drugs, while hospital costs actually decreasing, Dr. Ducharme emphasized that LHINs need to look at the big picture and noted the following: 1. All major hospital sites have crowded EDs now. If the smaller sites close, how will the larger sites absorb the increased volume? 2. The transfer of critically ill patients is currently delayed due to bed shortages. How will the larger sites handle an increased volume of critically ill patients? 3. If patients are admitted to hospital in distant communities, how will continuity of care be maintained? Will all patients end up being unattached patients needed to be assigned family doctors? 4. Where will nursing home patients end up if the local hospital is closed?

16 Think Tank on Stabilizing Health Services in Rural Communities May 11, Dr. Ducharme identified some of major unintended consequences already in place in EDs. He described the reduced level of care for MI patients that occur when a multiple trauma patient presents. Dr. Ducharme evoked a response from the participants when he asked how budgets that are too small to support care in rural communities but seemed to be able to support expensive prehospital systems such as direct-to-the-cath-lab system. Dr. Ducharme asked how many will die because of lack of care required in the first ten minutes when the care needs override the skill sets of paramedics, firemen and police combined. Hospitals and LHINs were asked to reflect on whether rural communities were the best places to cut costs with the least consequences or simply the easiest? Dr. Ducharme also asked how many hospital or LHIN administrators have training in Emergency Medicine and ended by requesting that we redesign the system first and then make appropriate changes to move towards the redesigned system, rather than arbitrary cuts to meet budget limits. 6.0 Adopting Standards of Care in Emergency Services Dr. Alan Drummond Dr. Alan Drummond presented a whirlwind view of the way in which standards have been adopted in emergency departments. Dr. Drummond noted that standards have been developed over the course of time; however, governments usually only acted to implement them after a patient death and/or an inquest. Dr. Drummond reported on the death of a Quebec patient from an MI who had lived minutes away from the nearest hospital. Several physicians had resigned from the ED citing poor working conditions and lack of back-up support. As a result of the physician shortage, the ED had closed at 9:00pm and the patient was transported to the next nearest hospital but died on route. Rather than fixing the problems in the ED, Bill 114 was passed. The Bill forced physicians to provide coverage in hospital EDs or face major fines. Having physicians who may have lacked emergency skills in poorly managed EDs many have been an expedient thing to do to keep the doors open but did nothing to reduce the stress that resulted in the physician shortage in the first place. Several other patient scenarios were presented with each describing a patient death that led to implementation of standards of ED care. Dr. Drummond then provided a cross country review of hospital ED physician and nursing shortages. Some of shortages have resulted in the type of after hour closures that led to Bill 114. He noted that governments are held responsible by the public when such closures occur. Dr. Drummond spoke to the rationale for regionalization of Emergency Departments noting the inverse relationship between complications and mortality with certain conditions and patient volumes as a result of physicians gaining substantial experience in managing conditions such as trauma, PCI, stoke and possibly thromboembolic disease. Rural ED with lower volumes and less exposure to critical illnesses and major trauma lack the back-ups needed to deal with these conditions making regionalization a necessity which has been called upon for over 20 years and never acted upon. Dr. Drummond cited seven separate reports from 1992 to 2001 calling for rationalization of services. Details were presented from the following reports: The OMA/OHA Guidelines or Hospital On Call Services (1992); The Report of the Fact Finder or the Issue of Small/Rural Emergency Department Physician Services (Scott Report 1995); The PCCCAR Report: A New Approach to Rural Emergency Care for Small Rural Hospitals (1995); The Recommendations for the Management of Rural, Remote and Isolated Emergency Health Care Facilities in Canada (CAEP 1997); The Health Services Restructuring Commission of Ontario ( ); The Rural and Northern Health Care Framework (MOH 1997); and,

17 Think Tank on Stabilizing Health Services in Rural Communities May 11, The Submission to the Commission on the Future of Health Care (The Romanow Commission 2001). In addition, Dr. Drummond reviewed findings from three provincial reports that called for regionalization of emergency services; namely: the Fyke Report for Saskatchewan (2001); the Corpus Sanchez Report from Nova Scotia (2007); and, the McKinsey Report (Alberta 2009). Dr. Drummond noted that regionalization does not necessarily mean consolidation of services in large emergency departments and the closure of small ones; however, some closures can take place without adversely affecting health outcomes. He cited the closures of 52 very small (8-10 bed) hospitals in rural Saskatchewan. The development of primary health centres met the needs of the population. The Fyke Report also called for primary health centres to support primary health care teams; noting that the primary care teams need to be supported by a network that included enhanced emergency services in fewer centres. The Corpus Sanchez Report was presented as an example of broad-based citizen engagement; however, the public remained emotional about their local hospital. As a result, little has been done to provide alternatives; however, a Task Force has developed recommendations to refocus EDs on true emergency care through the provision of alternative, non-emergent service mechanisms. Community involvement will include a public education program to explain how local healthcare needs can be met in other settings besides the ED. The McKinsey Report called for investments in ambulatory care centres, telehealth, and emergency medical services in selected rural hospitals to improve quality and cost-effectiveness. Dr. Drummond ended by presenting a Primer on the myths contained in the McKinsey Report regarding emergency medicine (see Appendix G). 6.1 Quick Facts Re the Quality of ED Care Quality improvement results most frequently from inquest or media attention. Surely, there must be a better way: Seven regional critical care hotlines announced following the Stella Lacroix Inquest. Canadian ED Triage and Acuity Scale implemented after the Kyle Martyn Inquest. Ambulance Division System developed after the Joshua Fleuelling Inquest. 50% of hospitals surveyed did not satisfy the basic minimum standards set in the ED guidelines. A Paediatric Inquest revealed the basic paediatric equipment was unavailable in high number of EDs across Canada. Only one Ontario hospital out of 179 was adequately stocked with 10 essential antidotes possibly jeopardizing the survival of acutely poisoned patients. Even in academic ED s difficult airway devices were not available in a significant number of cases.

18 Think Tank on Stabilizing Health Services in Rural Communities May 11, Compliance of asthma guidelines was found to be suboptimal (ranged from 41% for severe asthma, 67% for moderate asthma and 89% for mild asthma. No significant reduction in ankle x-rays following educational sessions to improve compliance with the Ottawa Ankle Rules. Number of physicians providing coverage in the ED decreased from 2525 in 1993 to 1987 in No standardization of ED physician qualifications. Emergency physicians can be: FRCP (EM) X 447 physicians CCFP (EM) X 1603 physicians CCFP with interest/experience GP/FP forced to work in the ED to maintain hospital privileges X 4,000 physicians Moonlighting dermatology resident. 23% of Canadians live in rural communities. Up to 70% trauma fatalities occur in rural areas. (NE Ontario = 23.4 MVA deaths/100,000 and Ontario = 13.9 MVA deaths/100,000) 7.0 Small Group Discussion/Debate: Services should be Centralized into Regional Centres of Excellence The participants were broken up into four groups. Two groups were assigned to prepare to debate the pro side of question and two other groups were assigned to the con side of the question: Should services should be centralized into Regional Centres of Excellence. After an hour long discussion in the small groups, Dr. Ducharme led four of the participants through a lively debate. The pro side of the debate was represented by an emergency physician and a LHIN CEO, while the con side chose a rural family physician and a LHIN Emergency Physician lead to represent their point of view. The first pro side of the debate noted that two strategies are needed one for the rural northern communities and one for rural close. While northern and southern strategies were important, it was just as important to find a local solution for each community. While regionalization of services into Centres of Excellence might be the result of good planning, the Pro side recommended a common governance structure to include one Medical Advisory Committee for each region, as well as, common funding and a sharing of regional assets to maximize those assets. While small hospitals might not be needed in every community, investments in multipurpose clinics were needed. The view that needs to be taken by providers and the public is not what is best for my hospital but what is best for my community and the region, in general. From a planning perspective, the view that needs to be taken should address the continuum of care from primary care to ED services to hospital to CCAC/home care to long term care. The second pro debater noted that he was assigned to be on the pro side and did not necessarily agree with the need to centralize services! He stated that we should concentrate on what is best for patients rather than debating the pros and cons of Centers of Excellence. Prior to further changing the system, we need to work on making care delivered now in the system seamless. Physicians

19 Think Tank on Stabilizing Health Services in Rural Communities May 11, should not have to fight to get care for their complex patients at larger centres, nor should they have to fight to have them returned home when care requirements in the community are adequate. The system should require the On-Call Specialist/ED Physician to accept patients in the same way they do when a patient enters their hospital directly. Every patient in the province deserves equal access to care. The pro side pointed to the Centres of Excellence in Cataract Surgery in Kenora, as an example of the fact the Centres of Excellence can be managed in small hospitals and not just in major teaching or regional hospitals. He noted that the meat and potatoes for all emergency departments are 3s, 4s and 5s with a small percentage of 1s and 2s in each ED. If we are to save lives, we need standards of practice, education regarding those standards and effective care delivery systems. It will be important to set priorities based on our understanding of how the system works when all is going well, as well as when things are going poorly so that we will know how to function in a crisis. In order to maximize expertise and the regional assets, core centralization may be needed but it must be within the context of an overall plan. The con side reminded us that people in rural communities have higher healthcare needs but poorer access to services now. A strong statement was made that hospital closures/service reduction in these communities is a proxy for lack of thinking. Emphasizing that core services are needed as close to home as possible, it is was identified that it is the HR problem that needs to be solved. The con side recommended that we need to find practical ways to provide care in the rural/small communities. The Hub and Spoke model was described. The model has two components one inside the community and the other connecting the community to the rest of the regional system. This system is almost working in most communities; however, we need to work together to improve it throughout the province. Noting that the pro side had stated that there was a need for administrative consolidations, a single MAC and regionalization in each LHIN rather than centralization of health services, the con side called for better collaboration amongst local hospitals to increase services in the smaller communities rather than close them. The following rationale was given for keeping local hospitals open: 1. Transportation issues 2. Patients want services close to home. The prime reason for moving to a community, especially in retirement, was close proximity to ED services. 3. The ripple effect on family doctors/nurses with job loss and the economic downturn in the community. Noting that core services need to be available in every community such as diagnostic services and that without an ED, a hospital becomes a chronic care facility, the Con side called for better collaboration between primary care and emergency care. In addition, the increased remuneration for family doctors in the new models of care has drawn family doctors away form emergency services so the Con side called for the funding model to be fixed. To make EDs more effective and efficient, higher levels of care by RNs and NPs could be provided resulting on less pressure on the ED physicians. The Con side concluded their remarks by describing the change from acute care to an emphasis on reducing ALC days in hospital with more care in the community. A global approach is needed but more study is not. At least nine reports have been generated without any implementation being executed. In rebuttal, the Pro side described a paediatric standardization process developed by CHEO using standardized care maps and patient/provider education. Mandatory acceptance of referrals from orthopedics and psychiatric referrals had also been implemented in the LHIN. CT scans were being reviewed by the neurosurgeon on call prior to transport resulting in 35% decease in the

20 Think Tank on Stabilizing Health Services in Rural Communities May 11, number of trauma patients needing to be transported. Lastly, a database of the services available in each ED/hospital has also been undertaken. In summary, the Con side described access to emergency care as an essential service and, while proximity to care does not equate to quality, consistency in care does. We were reminded that we need to skate to where the puck is going and not to where it is. With the impending tsunami in senior care, we need to redefine service delivery in order to meet current and future population needs vs. budget driven service cuts. Dr. Ducharme, in summarizing the debate, concluded that both sides had basically presented the same message, resulting in a great message to government but a poor debate!!! 8.0 Small Group Discussion: Designing a System to Enhance Care in Rural/Small Communities Dr. Algie led the small groups in a discussion of how to design a system to enhance care in rural/small communities. Dr. Peter Hutten-Czapski collected the top two issues from each table and presented them to the large group of participants. The top issues identified are as follows: Both a northern rural strategy and a southern one are needed due to the diverse issues in the northern and southern parts of the province. Small, rural communities need to work in a team-based model but we need multiple definitions of what we mean by teams since virtual teams working together in the community and throughout the LHIN should be the norm. Seamless access to care was identified as a priority including the automatic acceptance of patients needing care in larger communities as well as care maps describing the patient journey in the community, in the ED/hospital and throughout the LHIN. Surge capacity was identified as a need to ensure that regional centres and, indeed, all hospitals have the resources to deal with sudden influxes of patients or unusual situations such as a pandemic. A team-building strategy based on modeling best standards such as the MORE-OB process was seen as something vitally important. A policy framework for addressing the needs of patients with chronic disorders especially those with multiple co-morbidities so that they do not end up in the emergency department. The orphan patient population needs to be dealt with effectively but we do not need to reinvent the wheel LHIN by LHIN. We need to find ways that work best and implement them throughout the LHIN in a manner that respects local needs and approaches. Accountability for outcomes was seen as needing to be first priority in each LHIN. It was noted that LHINs are held accountable for the money spent and collect data on funding and providers but not on the outcomes of care. System integration should begin by mapping patient needs and their expectations for care. The system needs to be patient-centric. Data needs to be collected to measure ED access, ICU capability, Diagnostic and EMS resources, as well as equipment and documentation of the mechanisms that are needed to provide care in a systematic manner. Regional planning needs to include a no refusal policy, improvements in governance and the elimination of silo governance thinking in LHINs to be replaced with LHINbased mechanisms to move towards a more systematic approach to healthcare.

21 Think Tank on Stabilizing Health Services in Rural Communities May 11, Summary Remarks: Dr. Robert Algie Dr. Robert Algie concluded the day s proceedings with the following remarks regarding the next steps we need to take: There have been a number of studies on rural communities and health care. Most recently the Romanow commission made a recommendation of a 1.5 billion dollar fund to look at solutions to address the inequities in health status between rural and urban. Recently McGuinty has announced a task force on Rural and Northern health care. The composition of this group has yet to be announced. Hopefully the bedtime reading of this group will be the host of studies already written regarding this problem. Although OMA represents physician interests well, they reflect the wants and needs of the majority of physicians, i.e. the urban physician. The new models of care are an improvement for doctors in large population areas. There was little in the last contract to further encourage rural practice. Manitoba and BC both have quite significant fee differentials that seem to be effective at recruiting and retaining doctors in rural communities. The incentives to go rural have been eroded due to time and taxation. The underserviced area grant I received 27 years ago is the same dollar amount and now is taxable. They need to be increased and particularly for the hard to serve communities. Northern and Rural municipalities are struggling. The forestry sector has virtually disappeared in Northern Ontario. Health care and education are the major sources of economic activity. Trying to encourage young doctors to come north and buy a house in a failing community is a tough sell. New and experienced rural doctors need to have relief from the obligation to own and operate businesses. In the past, Northern Development and Mines had a program to build clinical facilities to address this issue. It needs to move to the larger rural communities. I suggest that rural municipalities need provincial money and potentially federal money to construct turn key facilities for primary care. The new interdisciplinary setting of today s primary care requires a different clinic space configuration. We, as well, have to be aware of the space needs of distributed learning models being forced on rural communities. In rural communities family doctors and GP s provide many functions that are provided by different physicians in larger communities. Some of our physicians provide care in anaesthesia, ER, hospital acute care, long term care, intrapartum care and primary care clinic. In these small communities it doesn t make sense to have 4 different doctors on call to provide all of these functions, but increasingly we are having a hard time finding young doctors to replace rural doctors. The incentives in the new models of care are inadequate to really reward the truly comprehensive broad scope family doctor. There was an attempt to do this through a program last year (rural enhancement fund), but it was confusing and not evenly applied. Some of these incentives are hidden and not apparent when recruiting new doctors. One of the major problems is the lack of responsiveness from our regional hospital colleagues. There needs to be a much greater feeling of a true system of care. When I phone Thunder Bay and advise them I have a patient that is beyond either my ability or the ability of the institution, I shouldn t get a run around. I know doctors that have left ER practice because they often feel abandoned by their colleagues in the larger communities.

22 Think Tank on Stabilizing Health Services in Rural Communities May 11, It seems that the better job you do in rural communities, the less reward there is for the community. Our ER volume has increased 50% due to the lack of primary care. If we recruit doctors and decrease that volume significantly our hourly fee for ER will decrease. This will make it harder to recruit. If we do a better job in Chronic Disease Management, we will decrease our admissions and our re-admission rates. This has a negative effect on community income from health care. We actually undermine the financial stability of the hospital if we decrease activity. Perhaps some key ER departments and some OR facilities in rural communities should be seen as a part of a system of care and their budgets isolated from piracy by the hospital corporation or the LHIN. Perhaps only those designated ER s should get HFO support? Decreasing the availability of rural hospitals will hamper our pandemic preparedness. The first cases of H1N1, in Ontario, presented to a rural hospital. Sadly a number of these ideas are not mine. They are found in documents such as: PCCCAR recommendations in October 1995 A New Approach to Rural Emergency Medical Care for Small/Rural Hospitals, Access to Quality in Health Care in Rural and Northern Ontario (July 1997), Recommendations for the Management of Rural, Remote and Isolated Emergency Health Care Facilities in Canada (March 10997), Economic Impact of Hospitals on Rural and Northern Economies A Summary of Six Ontario Studies (1997), The Effect of Rural Hospital Closures on Community Economic Health (April 2006), and this isn t a comprehensive list of our Task Force s bibliography. Let us commit to forcing government to deal with this issue in a comprehensive way, to fully implement recommendations made by panels commissioned to address these issues. Capital infusion may actually save money in the long run if it can encourage new doctors to locate in rural communities with well equipped primary care clinics, and provide ER services as part of what they do in rural communities.

23 Think Tank on Stabilizing Health Services in Rural Communities May 11, Appendix A: Speakers Biographies

24 Think Tank on Stabilizing Health Services in Rural Communities May 11, Dr. Allan Drummond is a family physician in rural Perth, Ontario. He is the medical director of the emergency department of the Perth and Smiths Falls District Hospital. He is a past president of the Canadian Association of Emergency Physicians ( ) and a past chair of the Section on Emergency Medicine of the Ontario Medical Association ( ). He is interested in the politics of emergency health care and is currently the chair of Public Affairs for CAEP. Dr. James Ducharme CM FRCP DABEM VP Medical Services, Med-Emerg International Clinical Professor, Department of Medicine, McMaster University Editor-in-Chief, Canadian Journal of Emergency Medicine Past President, CAEP Residency Director for Royal College Emergency Medicine training program McGill University , Dalhousie University , Clinical Director, Department of Emergency Medicine: Cambridge Memorial Hospital Atlantic Health Sciences Corporation Royal Victoria Hospital Dr. Sean Moore joined the staff at the Ottawa Hospital's Emergency department in September. Prior to this, he was Chief of Emergency and Chief of Staff in Kenora, Ontario for 7 years, in addition to working for ORNGE as a patch physician, and teaching at University of Manitoba and the Northern Ontario School of Medicine. He trained in the Royal College program at McGill University and worked at the Jewish General Hospital and McGill University before moving to Kenora. He has a strong interest in education, and is a course director for ACLS, teaches ATLS, and has won teaching awards from McGill University and McMaster University. Dr. Peter Hutten-Czapski Society of Rural Physicians of Ontario Peter Hutten-Czapski is a Haileybury-based general practitioner specializing in rural, family medicine. A graduate of Mt. Allison University in Sackville, New Brunswick, Dr. Hutten-Czapski earned his medical degree at Queen's University in Kingston. He has practiced in Northern Ontario since 1989, and has been a preceptor with the Northeastern Ontario Family Medicine Program since 1992 and sits on the board of the Northern Ontario School of Medicine. Politically he has worked at the municipal level to achieve non smoking bylaws locally, provincially he is the chair of the OMA section on Rural Practice, and nationally he has served on

25 Think Tank on Stabilizing Health Services in Rural Communities May 11, committees of both the CFPC and the SRPC. Dr. Hutten-Czapski has written and lectured widely on issues affecting the practice of medicine in rural areas and was chief editor of the book "The Manual of Rural Practice" published last year. He was the 2007 Family Physician of the Year, Northern region OCFP Dr. Robert Algie OCFP President Elect "I have been in group practice in Fort Frances since the fall of Apart from a summer locum in my home town of Sault Ste. Marie, all of my medical career has been in Fort Frances. Over the years I have patched some of the holes left by my rotating internship in Ottawa and my undergraduate training at Queen's. Certification was obtained when I successfully wrote my exams as a practice eligible candidate a number of years ago. My clinical practice has been quite varied over the years. Early on there was obstetrics and ER, more recently in addition to ER and clinic, I attend my inpatients at both the hospital and the local home for aged. Since the summer of 2002, I spend 1 day a week at an aboriginal health centre. Apart from my clinical responsibilities, I have had significant exposure to medical politics, administration, and clinical teaching. My wife Janet has been a steadying force for me and our two children. My extracurricular interests in sailing, cross country skiing, and music (oboe and bagpipes), continue to occupy my free time. North-western Ontario and particularly Fort Frances, has been a great place to practice, grow, and raise our family. I hope to able to represent my colleagues in Family Medicine from NWOntario." Dr. C. Raymond. S. Dawes Dr. Raymond Dawes graduated from Queen s in 1976 and completed his family medicine residency, also at Queen s in He is now in his 30th year of practice as a full service rural family doctor in Barry s Bay.. He has served as Chief of Staff of St. Francis Memorial Hospital, currently is Director of Emergency Services, and has served on many hospital committees. He was Co-Chair of the joint OMA/MOHLTC Physician Human Resource Committee in the early 2000s, and co-wrote several articles and reports providing warnings and solutions to the pending doctor shortage. He was a member of the committee which developed the 1999 Rural and Northern Health Care Framework document which examined and refined the role of small hospitals with in Ontario. He has Chaired committees which reviewed the Underserviced Area Program of Ontario, and also was deeply involved in OMA committees overseeing the Continuing Medical Education Program for Rural physicians and the Locum Program for Rural Physicians. He currently chairs the Section on Rural Practice of the OMA and is on the executive of the Ontario Chapter of the Society of Rural Physicians of Ontario. His passionate advocacy on behalf of rural doctors and those who live in rural areas continues stronger than ever.

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