5 key factors to consider for improving access to specialty care for underserved populations

Andrew Padmos
December 9, 2019 | Author: Dr. Andrew Padmos

Dear colleagues,

Recent legislative efforts to improve access to health care services for underserved communities have met with varying degrees of success. While the intent of these policies is terrific, sustainable solutions must take a range of complex factors into consideration. The Royal College is engaged in reaching out to health system stakeholders, patients and communities to encourage evidence-informed discussions and thoughtful action.

Legislative support to bring health care services to underserved populations

You have probably seen in the news that several provincial governments are at various stages of developing and implementing legislation, policies and procedures that are aimed at ensuring physicians practice in underserved communities:

  • Alberta is developing legislation that, among other changes, would enable the provincial government to exercise greater control over where physicians and other health care providers practise, and the type of practice they can establish (Section 28.3 of Bill 21, 2019).
  • Quebec is operationalizing its “plans régionaux d’effectifs médicaux” (PREM) and “plans d’effectifs médicaux” (PEM) that endeavour to regulate the respective supply and distribution of family and specialist physicians.

While these and other provincial efforts bring much-needed attention to the health care needs of underserved communities, the plans are not clear on how (or if) they take into account the successes or lessons learned from other jurisdictions.

Considerations for critical conversations, collective efforts

There is an urgent need to bring key perspectives together and learn from one another. These conversations should draw on health workforce research and evidence, including data resources the Royal College is developing with stakeholder organizations. Efforts must lead to shared commitments and actions, to nurture sustainable and effective health system improvements.

The Royal College is asking system planners and decision-makers to consider the following five points as they work to improve access to specialized care for rural, remote and underserved communities:

  • Many resources are required to provide specialized care: Health care facilities need unique infrastructures, equipment and teams to deliver specialized surgical and medical care. Such resources need to be in place in rural and remote communities; otherwise, specialists who practise in these areas will be limited in the care they can provide to their patients.
  • Indigenous communities have unique health care needs: Many Indigenous communities are rural, remote and underserved. It is critically important that all health care providers receive training that enables them to provide culturally safe care. Guided by the Indigenous Health Committee, and in the spirit of Indigenous self-determination, the Royal College is in the midst of developing new cultural safety resources for educators, learners and physicians.
  • Health providers need access to ongoing learning/training: Health care providers in rural, remote and underserved communities are often called upon to provide broad and distinct care for patients. As a result, these providers must have access to ongoing development opportunities to support their skills for the range and scope of specialized care required.
  • Foundational learning in rural, remote and underserved communities is essential: Newly certified physicians have been the target of past — and proposed future — legislative efforts to encourage work in underserved communities. Canada’s undergraduate and postgraduate training programs have taken great strides in distributed medical education; however, ongoing (and possibly additional) experiential learning is needed to prepare and embolden physicians to practise in underserved communities.
  • Models of care and remuneration must support sustainable practice: Models of care must progress to better address on-call demands and provide locum services for physicians who need relief. This includes the continued development of fee-for-service and alternative payment programs that will sustain medical careers in underserved and under-staffed regions. The Royal College has formed an Access to Specialty Care Working Group to identify tangible solutions to some of the problems that lead to shortages in rural and remote areas.

Innovative policies and programs can bring specialty care where it’s needed

As this five-point list suggests, we need multi-pronged, multi-stakeholder solutions to properly address the unmet needs of underserviced communities. For example, I’m encouraged that Canada is reviewing its regulatory systems to enable more nimble and responsive licensing across multiple jurisdictions, which will reduce barriers for physicians willing to visit underserved areas. As well, communities of practice are also evolving, stimulated by eConsult, eReferral and telemedicine programs that are connecting physicians and patients in new and creative ways. These are equally important factors to consider in our future critical conversations and collective action.

All people in Canada deserve timely access to quality specialty medical care. The challenges facing underserved communities, I fear, will persist if we do not come together and strategize beyond potentially short-sighted and simplistic legislative and regulatory actions.

If you have any thoughts on this issue or suggestions, I’d love to hear them. Please leave a comment.


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Andrew Padmos Andrew Padmos | December 20, 2019
Thank you, everyone, for your engagement with this important topic and thoughtful feedback. I have read through all of your comments and have shared them with our Health Policy and Advocacy team, who will continue to lead knowledge-informed dialogue on health human resources, physician distribution and access to specialty care, working alongside various other Royal College offices and partners in health care. Sincerely, Andrew
Avatar Ken Foster | December 14, 2019
As a practitioner in a small town the most helpful thing to me in this context is having an expert that I can get advice from. It is a little different from referring a patient onwards to be taken care of by the new specialist. It also usually results in a teaching moment result of significant learning that does not usually happen in the same way with referral onwards. If there were some way to connect teaching specialists with rural and remote practitioners when some question arises it would provide tremendous benefit and support. Another example of this was the textbook in paediatric orthopedics which I bought when I was working in Afghanistan. It listed the email addresses of each chapter author and so I was able to write some of these authors about weird and wonderful cases and they gave very helpful replies and support.
Andrew Padmos Andrew Padmos | December 20, 2019
Hi Ken, I will share your comment with our Office of Professional Practice and Membership. Sincerely, Andrew
Avatar Maria Filyk | December 12, 2019
I am a specialist in psychiatry and child psychiatry. I practice in Calgary. The challenge I currently face since leaving a nearly FT AHS outpatient clinic is finding affordable space in my community to rent. I am approaching the many medical clinics within walking distance of home. I can work part-time, not full, because I live with a chronic health condition. Part of caring for myself and my condition is movement hence looking for space nearby. So far the people I have spoken to have asked alot more than I want to pay given my time-determined income. Space is another challenge: most family practice clinics are not designed for group work such as I do with either families or groups of adults/adolescents. There are other spaces I may have to explore such as local churches or my community centre. And the mentally ill are an underserved population.
Avatar G Robert La Roche | December 12, 2019
A follow up to andrew’s message should be a CEO update of the RC advocacy efforts before AND after the federal elections, especially around access to care through improved high speed wide band internet services across the country and pharmacare . Also a point to consider is the aging demographic of our rural non indigenous communities as a point of concern in access of care issues
Royal College - College royal Communications Royal College - College royal Communications | December 20, 2019
We will pass on your suggestion to our new CEO, Dr. Susan Moffatt-Bruce, who starts in January. We look forward to your continued leadership on the advocacy work of the Royal College. – Royal College Communications
Avatar Paul A. Galbraith M.D.(Hons.),B.Sc.(Med), M.Sc.( Med), FRCPC, D.A.B.I.M. ,F.A.C.P.,Professor of Medicine (Retd) | December 11, 2019
Dear Dr Padmos,, The aforementioned says all the right things and for this the College is to be commended. Remember a statement made by Henry Kissinger in 2011. “ A turbulent history has taught Chinese leaders that not every problem has a solution and that too great an emphasis on total mastery over specific events could upset the harmony of the universal”. Canada has a huge landmass and many very isolated communities. It is unrealistic to believe that these isolated communities can ever enjoy the quality of health care available in large centres. For example when a stent must be inserted into a vessel within an hour of the onset of symptoms to prevent infarction it is unrealistic to expect that this clinical action could be available in many remote communities.. Moreover professional in site services, cultural differences, family interests and governmental financial support will never be able to support the ideal situation. In my career I have seen Indigenous specialist professionals relocate to California after completion of their education. I wish the College every success in its endeavours. Paul A. Galbraith M.D.
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