What Rural Communities are Talking About on Their Health Across BC
September 15, 2023
BCRHN is a non-partisan organization dedicated to ensuring equitable health access and outcomes for all rural BC residents. We work closely with various levels of government, health authorities, and community members to create community-driven solutions. This briefing will outline key challenges faced by rural BC communities and propose evidence-based solutions. Detailed information is available on the subjects listed and evidence either exists or research is underway for each of the stated items. Full policy positions are developed through our committee work and research projects.
Challenges and Proposed Solutions
A. Core Funding
Challenge: The BCRHN requires consistent funding to foster relationships at all government levels and promote bi-directional communication between communities and health authorities.
Solution: Obtain sustainable government funding that ensures a strong foundation for these vital activities.
B. Community Engagement
Challenge: Centralization of services in the 2000s diminished local community engagement, causing a disconnect between community needs and healthcare provisions.
Solution: Restore local community engagement and health tables, focusing on community-centric solutions and ensuring community involvement in policy development.
C. Team-Based Care
Challenge: Recruiting and retaining healthcare workers in rural BC is challenging due to inadequate team-based models of care.
Solution: Implement and promote the Community Health Centre model supported by BCACHC for more sustainable and comprehensive healthcare.
D. Travel Assistance
Challenge: High costs associated with traveling for healthcare services.
Solution: Revise and expand the current TAPs program, emphasizing personal facilitation and partnering with organizations like Hope Air and the United Way.
E. Research and Evidence
Challenge: The need for research-backed policy recommendations.
Solution: Partner with institutions like UBC’s Centre for Rural Health Research to gather and utilize community-based data.
F. Decentralizing Low Acuity Care
Challenge: Many basic healthcare services have been moved to urban centers, harming rural healthcare outcomes and recruitment.
Solution: Return low acuity services, like basic surgical care and maternity services, to rural communities where they are more cost-effective and maintain high-quality outcomes.
G. Physician Assistants
Challenge: Declining number of rural healthcare workers.
Solution: Integrate and regulate Physician Assistants, providing valuable support in rural areas.
H. Expanding Educational Seats
Challenge: Rural students face educational disparities, making it challenging to enter healthcare professions.
Solution: Reserve and create educational seats specifically for rural students in nursing, medicine, and other healthcare programs.
I. Living in Place
Challenge: Elderly rural residents are often moved to urban centers, diminishing the social fabric of rural communities.
Solution: Reinforce community services such as ‘Meals on Wheels’ and in-home nursing in rural areas. While organizations like BC United Way are making strides, enhanced support with a rural focus can significantly reduce costs by preventing relocation from rural to urban settings.
J. Agency Nursing Impacts
Challenge: Over-reliance on temporary agency nurses from private companies affects the morale and retention of resident nursing staff.
Solution: Improve working conditions for resident nurses, prioritizing their employment over temporary staff.
K. Employment and Economic Development
Challenge: Health disparities affect local economies and deter families and businesses from settling in rural areas.
Solution: Study and highlight the economic impacts of healthcare disparities. Utilize regional centers for healthcare to boost local economies.
Recommendations
- Engage the government for sustained funding to support rural health initiatives.
- Revitalize community engagement.
- Promote and implement the Community Health Centre model.
- Overhaul the TAPs program to better address rural residents’ travel needs.
- Collaborate with academic institutions for evidence-backed policy.
- Decentralize low acuity care back to rural settings.
- Develop regulatory pathways for Physician Assistants.
- Establish reserved educational seats for rural students in healthcare disciplines.
- Strengthen community health services for the elderly.
- Reduce reliance on travel nurses and improve conditions for resident staff.
- Commission studies to understand the economic impacts of rural healthcare disparities.
Conclusion
To enhance the healthcare outcomes of rural BC residents, a multifaceted approach is essential. With appropriate funding, evidence-backed policy, and community-driven solutions, BCRHN believes that a brighter, healthier future is attainable for all rural communities in British Columbia.
Our Board and all our volunteers across BC are the foundation and our grounding in rural life and rural lived experience. The BCRHN is a rural knowledge resource. We wish to share and collaborate with others. Join us at www.bcruralhealth.org
Expansion on Challenges and Solutions
Introduction
This document is not intended to represent the full and complete positions of the BC Rural Health Network but is intended to expand on the snapshot document on challenges and solutions brought forward by rural communities pan provincially.
Core Funding – The BC Rural Health Network works pan-provincially both in and with communities to address equity in access to health care and equity in health outcomes for all rural residents in BC. The BCRHN is a solutions-based organization that aims to communicate effectively with rural communities and governments and provide community-driven solutions that are agreed upon and seen as attainable targets for healthcare improvement for all BC residents. Our organization works to hear from our diverse, pan-provincial constituency and raise awareness about rural health concerns and solutions. We strive to increase our membership and our diversity. We are apolitical and focused on improving current systems by working with the Government to ensure that long-lasting relationships are established at all levels of government: Indigenous, Provincial, Municipal, Regional and Federal. We strive to work with Health Authorities and create a renewed relationship with health leaders throughout BC. We inform all political parties of our positions and remain firmly non-partisan in our work. To do this work, we need to be funded by the government and given the resources necessary to effectively communicate in a bi-directional fashion with communities and their authorities.
Community Engagement – When services were regionally centralized in the early 2000s, community engagement diminished significantly. Local hospital boards and health tables were essentially disbanded and a new approach to rural engagement was taken. This approach has failed miserably for the residents in communities across rural BC. The voice of the community has been replaced with a centralized means of engagement that primarily focuses on the involvement of physicians and patients but lacks the community’s perspective, community solutions and community involvement in policy. We know this to be true from our direct experiences as rural residents, but also as community leaders. Our lived and living experiences are rich resources for policy development and this knowledge has been discarded and replaced with urban-centric mechanisms that fail to engage effectively with rural communities. The resulting problems have been exacerbated through the COVID-19 pandemic but have existed for over 20 years. The disconnect between rural residents and the division within communities is now apparent everywhere and getting worse. We are currently engaged in a gap analysis on community engagement and policy development as it is clear from our ongoing daily engagements across our province that folks are disconnected and rejecting expert advice. We seek to put evidence to this statement and to date, we have well over 600 survey responses from all corners of BC.
Parliamentary Secretary for Rural Health – The recent introduction of the role of Parliamentary Secretary for Rural Health by the Ministry of Health was seen as a promising development for the rural health sector. It was anticipated to be a pivotal channel for effective communication between the Ministry of Health, the BC Government, and our rural communities. However, the current status of the role’s utilization is concerning and falls significantly short of its potential.
While the position was envisioned to be an active bridge between various stakeholders and the government, it appears to be under-supported and under-informed at the moment. For this role to be meaningful and influential, it is paramount that it engages actively with rural communities, representing the vital stakeholders in rural health. Yet, the current level of engagement seems to be insufficient. The effectiveness of the Parliamentary Secretary is intrinsically linked to the support and briefings it receives from senior MoH officials and the Minister. Without this, the role remains symbolic rather than functional.
Furthermore, the position’s autonomy is crucial. It is imperative for the Parliamentary Secretary to interact directly with stakeholders, attend relevant events, and answer pressing queries without incessant higher approvals. Such autonomy not only streamlines communication but also instills confidence among stakeholders. Along with this, it’s vital that the Parliamentary Secretary is consistently kept abreast of all updates, changes, and urgent matters within the Ministry to maintain clarity and transparency.
It’s worth noting that MLA Rice, the individual currently occupying this role, comes with an impressive track record, including known rural advocacy, eloquent communication skills, and an inherent ability to engage. Our concerns do not lie with her capabilities, but rather with the systemic barriers that seem to hinder her from maximizing her potential in this role.
In summary, while the BC Government’s creation of the role of Parliamentary Secretary for Rural Health is commendable, the true test lies in its execution and utility. A genuine commitment to this position is essential to truly benefit our rural health communities and the broader BC populace. Symbolic gestures won’t suffice; the need of the hour is an empowered and well-supported Parliamentary Secretary.
Team-Based Care – Evidence has shown and continues to show that team-based models of care are effective means to enhance services in rural and remote communities. Creating work environments that are less stressful and provide the mechanisms to work as a health team is crucial. In BC, the model of care that we see as aligning with these objectives of team-based care is the Community Health Centre model, championed by the BC Association of Community Health Centres (BCACHC). Recruiting and retaining healthcare workers in rural BC has always been challenging and has become unachievable for many communities. The inability to work as a team in traditional health authority-run models of primary care has resulted in a continued lack of attachment or short-term attachment to a primary care provider for rural residents across BC.
If you are fortunate enough to be attached to a primary care provider, you likely won’t be for long as primary care providers often leave positions due to work constraints and challenges. Longitudinal care, wrap-around services, and attachment to a place of care rather than an individual are not happening for most people in BC. We are creating models of care with low levels of engagement that don’t consider that in rural environments their care centre is likely the only healthcare resource in their community. Most sites under the current models don’t have effective team practices and are not operated by the community or the professionals who work there. Building better models of team-based care that are managed by the community creates responsive structures that provide meaningful work and effectively attract and retain healthcare professionals. These improved models of care also effectively provide ongoing, life-long support to those fortunate enough to have these facilities in their communities. Emergency departments are also often run by primary care providers in rural communities (without a team-based practice) who face the negative effects of continuous on-call schedules, overworked colleagues and non-cohesive care resulting in the rapid departure of many who are recruited. The facilities operated by the Health Authorities with the name ‘community health centre’ are not based on the BCACHC model of excellence. The true Community Health Centre model requires more promotion and focus to be given to the BCACHC model and approach to care. Awareness is important, but funding for these models outside of traditional PCN funding is essential.
Travel Assistance – All insured residents of BC have a RIGHT to equity in accessing services as afforded to them by Section 12(a) of the Canada Health Act. Research demonstrates that the average cost for a rural resident seeking care outside of their community for one specific condition exceeds $2000! Most of this expense is related to out-of-pocket travel costs that are required to access specialized care. Our current TAPs program has not been helpful for most people and voucher programs that don’t have any personal facilitation of the travel are underused and not effective in helping the most vulnerable individuals who desperately need direct assistance. Third-party charities and health groups are trying to fill the void and we work closely with Hope Air, United Way, BC Cancer, and BC Children to bring awareness to programs that can assist in accessing care. These programs are insufficient and additional resourcing is necessary as they are only effective within their limited scope of operations. The equity of who gets travel assistance and who doesn’t also need to be addressed. Although a person with a high income may be able to afford the trip to the specialist or service they need, barriers in access remain a factor during this process as they will likely lose income, employment, and wellness. People of low income are further impacted by the lack of upfront funding available for travel and many have failed to seek care due to the associated costs. Individuals are not the only ones impacted by this lack of assistance. The system is also affected by the trickle-down impact of the lack of acute condition treatment which often results in long-term chronic conditions and disabilities. Mileage and road transport (the primary means of transport for most rural residents) has not been funded and remains a huge barrier and cost for many vulnerable folks. The cost of doing nothing is likely more expensive than investing in getting people to care they need but this requires additional research. Doing nothing is certainly more harmful to individuals as well as the system.
Research and Evidence – The positions that the BCRHN takes are driven by communities and taken through an internal development process. We believe that solutions are needed to address problems and for too long, many have complained about services without presenting positions for adoption and change that are supported by research, data, and evidence. Each position we bring forward to our Board through our Implementation Committee is driven by a panel of experts and community leaders and research is sought to support the positions and solutions suggested. Where evidence doesn’t exist, we find it and are invested in research in collaboration with a variety of partner groups. We work very closely with the Centre for Rural Health Research at UBC. The evidence needs to reflect the lived and living experiences of the community and the residents within them. This data is critical to moving policy forward with a data-rich rationale for making essential investments.
Decentralizing low acuity care – During regional centralization, many services were stripped from rural and remote communities and centralized in larger urban populations. These moves make sense for high-acuity complex care and procedures requiring state-of-the-art equipment and specialists. Unfortunately, we stripped all services including surgical care, maternity care, and procedures from many communities. This has been a contributing factor in the challenges related to recruitment and retention and health outcomes in rural communities. The evidence clearly demonstrates that low acuity services in rural BC (including surgery and maternity) have equitable if not better outcomes than services provided in a larger centre. They are also cheaper. They also attract higher skill sets to communities and create a system that is more likely to retain the existing workforce and recruit new team members. Nobody thinks that small-town open brain surgery is a good idea but being able to have a simple hernia repair, appendectomy or give birth in rural communities are critical items that need to be rethought and re-introduced to rural BC. Population densities have been subjectively created by associating small satellite communities to a large population rather than combining small rural communities to increase the provisions available to them (maternity is a good example.) Having small communities working in collaboration to enhance services locally rather than shipping all residents to a larger centre would enhance services, retention, outcomes, and community engagement. It would also reduce cost, enhance the local economies, and provide more experts in the community to spread good and accurate information. Offering urban residents services in rural communities would also reduce waitlists, improve local economies, and produce lower cost and improved outcomes.
Physician Assistants: The inclusion of new team players who have an interest in providing services in rural BC seems like an easy fix to the declining number of rural healthcare workers. Their numbers may be limited, and their application may not be universal, but as we now have many communities that are interested in the inclusion of the PA role, we believe it is a relatively straightforward move to include these practitioners who have played a valuable role in the medical field globally. Once regulated, we believe that a significant number of PAs will have the desire to re-locate to BC and in the future (as the role demonstrates benefit). Creating BC-based training within our universities and colleges would also be seen as a wise step. PAs tend to have an affinity to hands-on rural practice and have demonstrated a benefit in other Provinces as well as in the USA and beyond. Why not here?
Expanding rural student specific nursing and physician seats: creating additional seats in universities for nurses, doctors and healthcare professionals is welcome, needed and should continue to be expanded as rapidly as possible. The challenge faced however is in the selection of students for these programs. In rural BC we often see the brightest of students miss the mark for qualifying for placement in the medical programs in existence. This has nothing to do with their ability, intelligence, or performance but this often simply reflects the lack of program availability and resources available to them in rural high school settings. The need to create seats for rural students is apparent. People who come from rural communities often return to rural communities to practice but if we only select candidates based on their high school qualifications, we are losing many top-level students who have never had an even playing field to demonstrate their capability. If you are unsupported in sciences in high school, you will often have to self-educate at home to leave high school with the necessary qualifications and knowledge and without guidance, the opportunity to compete against a student with full support creates further inequity. If you take post-secondary upgrades to qualify, you will likely score lower than a student who exits high school with all the necessary courses and higher grades from better educational support and not intelligence.
Living in place: Our aging populations in rural BC are not being well cared for and the services often fail to allow people to stay in the community they call home in their later years. This migration of the elderly and sick to larger urban centres requires a massive sacrifice for the individual, the family, and the community they live in. We are losing our elder support for our rural families. We are burdening an overpopulated urban system with rural residents who would prefer to live in their homes and communities throughout their entire lives. We are creating communities that are stripped of their elders, stripped of the services needed to support them and adding to the long-term cost and need to accommodate them in much higher-cost environments. We have also reduced and removed activities and engagements that help folks stay healthy and in place within their communities. Provisions such as ‘Meals on Wheels’, hospice care, in-home nursing support and community services should be reinstated and further enhanced to ensure our community diversity and the community richness remains and is strengthened.
Agency nursing impacts and other private healthcare utilization in a public system: The current ‘stop-gap’ measure of hiring private nursing companies to provide ‘travelling nurses’ has unintended consequences on the existing public healthcare nursing staff and the communities they live in. Filling nursing positions with outside temporary nursing staff has become a mainstay of keeping a broken system barely operational. Ensuring that local nurses are the highest paid and giving them better working conditions and hours would help prevent the migration of public health nurses to the private sector where they will not be required to work for less, work unreasonable overtime or face the level of stress that our resident nursing staff face daily. Often the burden of keeping a facility open in place lies firmly in the hands of these dedicated professionals but their treatment is causing harm and further depleting their numbers and desire to continue.
Surgical care is a similar situation in which we pay to use private clinics and practitioners to increase capacity when capacity exists but is underutilized in the public system in rural areas. Small regional surgical centres could do much more if funded appropriately and supported through the dollars currently flowing to private surgery centres.
Similar issues are apparent with oncology. As we scramble to address a long waiting list, the long-term picture gets bleaker. Not only does the current means of addressing the extended waiting list fail to meet the needs of cancer patients but it also fails to address the many patients who receive non-equitable treatment for conditions which are equally as life-threatening but not equally managed. We have a plan for oncology, but the plan is not transparent and doesn’t give projections on how many more people with oncology needs are likely to enter the system through the combination of the large aging population and the increase in cancer rates in middle-aged people. New oncology centres being planned is good, but not good enough. We need to have ongoing investment in equipment maintenance, routine maintenance that will prevent any loss in capacity with current systems, more smaller radiation centres in a similar fashion to surgical facilities.
We have public facilities in rural areas that must be enhanced and equipped to do more.
Employment and Economic Development: The impact on local economies in rural BC due to diminished healthcare hasn’t been studied to the extent required. We are working on grant funding applications to correct this and ensure that we have the data required to demonstrate the negative impact rural communities face. Many resource companies must hire and pay external medical staff to come from outside of their operational community due to workers not wanting to be in a poor healthcare environment. Young families’ top priority is healthcare followed by recreational opportunities when deciding on relocation. The impact and liability to employers are significant in healthcare-resource-poor communities. The direct economic impact on communities of healthcare employment within their local hospitals and facilities is also a major economic driver in many small communities. The issue is further exacerbated by the failure to use smaller regional centres as treatment areas for larger populations which further benefits these communities through additional consumers supporting local businesses.
