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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Avatar Thomas Ungar | December 11, 2019
Thank you for this but can the RCPSC please consider for item 5" Models of care and remuneration must support sustainable practice" to expand the concept of under-served populations beyond just "rural and remote areas" . The very ill Inner City population where I work is not conducive to Fee for Service as they often do not have their health card and often do not show for appointments due to mental illness, addiction, and other socioeconomic factors. Also the providers need allied health staff support beyond solo specialist care. I can't easily recruit or retain physicians to work with this highly acutely ill population of significant cost and impact to society due to lack of a sustainable specialist model of care and remuneration, even though they are in the centre of the country's largest city. When there are alternate funding models offered they are less attractive and non-competitive to specialists out of keeping with a population of higher risk and acuity needs.
Royal College - College royal Communications Royal College - College royal Communications | December 20, 2019
Thomas, you raise an excellent point. We will be more deliberate to clarify in our future communications on this topic that under-served patient populations are not exclusive to rural and remote areas. – Royal College Communications on behalf of the Royal College Health Policy and Advocacy Team
Avatar Naomi Miller | December 11, 2019
Now retired, I previously worked at Princess Margaret Hospital / University Health Network Toronto and I recall a patient discharge discussion to try to arrive consensus about discharging patients from Princess Margaret Hospital follow up in order to free up more time for new patients. The advantage of this is to free up more time for new patients The disadvantages may include: - patients wish to continue follow up in higher acuity centre than they need - remuneration for follow up may be overall greater for institution than new patient clinics ( as a pathologist I have no personal knowledge of how clinic funding words but I heard this ) - more stressful for health care professionals to have greater percentage of new patients - more expensive for institution with more investigations per new patient than follow up Regardless - patients who do not need to receive specialist care should not monopolize services at the expense of new patients who do need this
Avatar Lesley Barron | December 11, 2019
While I agree with these points, I think centralized referrals are a critical aspect of access to care to decrease wait times.
Avatar Mark Etkin | December 11, 2019
Just a comment on your mention of nimble and responsive licensing. I am a psychiatrist, and recently applied to the BC College of Physicians and Surgeons. Their process was slow, had significant red tape, and time-consuming; the College employees responsible for working with me were poor communicators, not transparent, and seemingly intentionally non-responsive and unhelpful. The process seemed like applying for probation while in jail for a capital crime. Perhaps that's too harsh, but the process was so frustrating that I was tempted at several points to drop out. My application had nothing outstanding about it, and was eventually approved. Then I had to go through a further somewhat lengthy process to gain approval to be employed by the Vancouver Island Health Authority, then another process to be able to obtain a MSP (medical services plan) billing number, then another process to be able to bill for "sessional work". Then I spent 2 days learning the VIHA EMR system, which is quite good, but required extensive learning in areas that I had no subsequent requirement to use. Then I had to learn another EMR to work at the community clinic I worked at. Then, as there is no easy way to actually bill MSP, I had to figure out how to do that - with no help provided by the MSP itself. This response is merely to let you know that "nimble and responsive" doesn't quite describe the process. -Mark Etkin MD FRCPC
Andrew Padmos Andrew Padmos | December 20, 2019
Hi Mark, I agree and I’ve heard similar concerns expressed by many Fellows. True nimbleness and responsiveness is the objective. As you’ve outlined so clearly, there are many obstacles and a lot of work has yet to be done to clear them! - Andrew
Avatar Tad Pierscianowski | December 10, 2019
All the above is a desirable objective but let us face the reality that universal access to all levels of medical care is a pipe dream in a country not only as large as Canada but one with such isolted and at times extemes of weather. To suggest otherwie is dishonest and in itself an impediment to attaining improvement over what is available presently. A more realistic approach would be to set minimum standards of available medical services related to identified regions within the country. It would then be the decision of individuals to reside in those regions that are able to provide the level of care that they need or wish to have access to. Rural and isolated areas come with advantages and disadvantages. When one makes a decision where to live one has to be cognizant and accepting of these issues.
Andrew Padmos Andrew Padmos | December 20, 2019
Hi Tad, I agree that we will always face limitations but, in my experience, we constantly strive to overcome them. We need to if we hope to serve patients with unexpected health care needs for those who, for any number of reasons, cannot move to more resource-rich areas. I still believe, despite Canada’s climate and land mass, that we can leverage human and technological resources to the advantage of patient populations in all under-served areas (including those in urban centres). - Andrew
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