The May 1 report on Nova Scotians who can’t find family doctors (Need a Family Practice Registry Monthly Report – May 2018) is pretty routine. The total for the province is up a couple of thousand or so and Metro Halifax is up about 1,200. These are raw numbers and, as always, Halifax has the worst problem.
Annapolis and Kings counties continue their slow increase in doctor-less citizens but, as you can see below, have by far the greatest percentage of residents in this situation.
Antigonish and Guysborough continue to be in the best shape and Cape Breton County’s situation is actually improving, a fact that some of Turpin Labs associates adamantly refuse to believe.
It doesn’t matter. We’ve gone in a blink of the eye from assuming everyone who wanted a doctor would have one, to a day when a one per cent shortage (see below) looks good.
Viewing the stats as a percent of community population going without doctors offers a different picture. Things have become dramatically worse in the counties of Annapolis and Kings since March 1. Halifax and the province as a whole show a similar trend.
Antigonish and Guysborough are holding steady and, as noted, Cape Breton County is improving.
No doubt there are many reasons for the problem, but one of them has to be that Nova Scotia is the lowest-paying province in Canada for family doctors.
Barb Johnson, of Doctors Nova Scotia, offers this comparison for Atlantic Canada:
PEI ~ $326,000;
NL ~ $311,000;
NB ~ $290,000
NS ~ $275,000
This includes the recent increase announced by the premier and comes before expenses, which are considerable. Really, if you were carrying hundreds of thousands in debt by the time you’re allowed to practice, would you set up your life’s work in Canada’s worst-paying jurisdiction?
A lot of folks have trouble getting numbers right, including yours truly, who transposes digits more often than a concert pianist. So it’s best not to get too righteous when people speaking off the cuff fumble the figures.
Nonetheless, the family doctor crisis in Metro Halifax is so serious it’s worth setting the record straight. Fifty-two per cent of Nova Scotians who need but cannot find a family doctor live in the heart of Halifax, not 40 per cent, as Health Minister Randy Delorey told Allnovascotia.com this week. A department spokesperson says Delorey was speaking from memory in the House and later corrected his error.
While Delorey came in low, PC backbencher Pat Dunn came in high, stating that 100,000 Nova Scotians are without family doctors. His interim party leader, Karla MacFarlane, told CTV: “We have a crisis happening in rural Nova Scotia and we know there are 100,000 people without a doctor,” she said.
In fact, 45,555 Nova Scotians cannot find doctors. And the worst crisis is in the heart of HRM, where 23,754 people are doctor-less. That’s 52.1% of the provincial problem visited upon 40% of the population. If you include all of HRM, the numbers become 53% and 42% respectively.
“Oversight” left Halifax out in the cold without enough docs
Health authority came to the rescue
The family doctor crisis in Metro Halifax occurred because government assumed that the capital city didn’t require its attention as it set about managing the MD supply in rural Nova Scotia.
Wendy Walters, Senior Communications Advisor, Physician Relations for the NSHA, describes it as a bureaucratic “oversight”. I can think of less charitable words, but people do make mistakes (I may have made a mistake once, but the details have grown fuzzy.)
Political interference, on the other hand, would have been be unacceptable. Walters says it didn’t occur: “(The direction was) a policy decision from the Department of Health and Wellness which at the time hosted the New MD approval committee. It was in response to perceived challenges in recruiting to rural areas and came from a reasonable place with the data available at the time.”
In fact, the information was there, but you had to dig for it.
The family doctor issue acquired a public profile sometime around 2009, but was assumed to be a strictly rural issue until 2016, when the Nova Scotia Health Authority brought Halifax in from the cold.
The deliverance of Metro Halifax (along with the rest of the Central Zone) began in 2011, when the Department of Health and Wellness created the “New MD” committee.
Halifax remained off the committee’s radar until 2016, when the freshly minted NSHA joined the group. The NSHA was handed “accountability” for the province-wide physician supply problem. (See Turpin’s Law, Section 33 subsection 9(a),(1),(ii),(ab), which states “Woe unto whosoever is last to join a committee, for surely he will be assigned the heavy lifting.”)
Walters wouldn’t say so, but I think the NSHA is the hero of the piece, leaning into the task to discover there was a problem in Metro Halifax, too. So, in fiscal 2017, Metro and the rest of the Central Zone received a physician recruiter and incentives matching those enjoyed by the other zones.
The beleaguered Western Zone got a recruiter, too.
Bottom line, Metro was left twisting in the wind for five years or so while government was busy implementing policy for the rest of the province. Today we have 23,709 people who cannot find a doctor.
I combed DHW publications for the origin of the “oversight” and I believe I have found it.
DHW had reports noting “… almost 60 per cent of physicians (are) located in Halifax.” True, but that number included specialists, and NS had 30 per cent more specialists than the Canadian average (see Physician Supply, Environmental Scan, Page 14, and Shaping our Physician Workforce, Page 4). I’m guessing that no one thought to ask how many of those doctors in Halifax were specialists and how many were family MDs.
If I may borrow a medical term, we had an “occult” family doctor shortage in Halifax, i.e., hidden by all the specialists and clouded by the exhaust from their Porsches.
I am Halifax-centric, but I do not minimize the effect all this has had outside Metro; it’s just that the worst problem is here in the middle of the Central Zone. For example, an acquaintance in Musquodoboit with a life-threatening disease has no family doctor to tell him whether a new symptom is benign or possibly something more dangerous.
Note to insiders: The NSHA’s Walters says the accreditation and privileging system was never used to control the number of doctors. That was accomplished simply by managing the number of available positions. However, the NSHA took over physician supply management at about the same time it got responsibility for accreditation and privileging, and I think the two activities became associated in the public mind.
2,280 Haligonians lose their family physicians in two months
The number of citizens in Metro who want but cannot find a family doctor has passed the 23k mark, a notable but dubious achievement.
The March accountability report from the NS Health Authority showed 23,007 metro-dwellers without a family doctor, an increase of 2,280 from 20,727 in January. The NSHA says that kind of increase is not necessarily unusual. The next update is expected soon.
The provincial total rose to 44,158 from 41,877, an increase of 2,281. That means Metro Halifax effectively took the whole hit and now accounts for 52% of the entire family doctor shortage in the province. No NSHA zone or Community Health Network even approaches that number. (For these purposes I’m defining Metro as Bedford/Sackville, Dartmouth/Southest, and the Peninsulas of Halifax and Chebucto.)
In percentage terms, Metro citizens without doctors are 6.2% of its population, up from 5.6% in January. It’s the second-worst area by this measure after the hapless counties of Annapolis and Kings at 8.1% (6,390 out of a population of 78,507). But in raw numbers, Metro is the worst disaster in the province.
This is consistent with the instinct of successive governments to put rural Nova Scotia votes ahead of all else. Meanwhile, local MLAs and councillors stand around with their thumbs in their pockets.
Below is a chart highlighting the changes in Metro Halifax (yellow and red), the four NSHA management zones (white), and the Community Health Networks found in each (blue).
Negative numbers on the chart mean fewer people in the area are without family doctors, which is good; positive numbers mean the opposite. The problem seems to be that, likely at the end of the 2017 tax year, a lot of doctors jumped ship or retired.
There is a belief in some quarters the cause of Halifax’s misery was a government decision to steer new doctors toward the countryside and away from Halifax by making it impossible to work here. In other words, government may have gone beyond mere rural incentives to actually barring new doctors from the capital city.
Are Haligonians too haughty to get involved in finding family doctors? Almost 21,000 people within an easy drive from City Hall want a doctor but can’t find one. City council is doing nothing.
By contrast, in Liverpool, the Queens General Hospital Foundation has created an attractive website about the advantages of practising medicine there.
Is Halifax Council too proud to admit we have a medical problem here? Is meeting in secret to discuss secret complaints apparently levelled against public Councillor Matt Whitman a diversion? Is their plan to distract prospective businesses from noticing that if they come here they won’t be able to get a doctor?
I ask because 6.3 per cent of Haligonians on the western side of the harbour can’t find one, the second-worst rate in the province. The rate on the Dartmouth side of the Harbour is 5.7 per cent, and Bedford-Sackville is 4.0%. Taken together, the rate for these communities (metro Halifax, really) is 5.6 per cent, or 21,000 people. And these are people who WANT doctors, not healthy-as-a-horse twenty-somethings.
Meanwhile, “only” 1.2 per cent of people in Antigonish County can’t find doctors. Cape Breton, mainlanders’ favourite target for derisory comments, is “only” 2.4 per cent.
Here’s a video about Queens County posted by our enterprising Liverpudlians.
Still not worried, councillors? Well, guess which city is doing better than us. That’s right, Moncton. MONCTON!!
Turpin Laboratories asked Halifax’s communications people what we’re doing to attract more doctors. The response: “Physician recruitment and addressing issues of possible physician shortages, is being led by the province as well as the Nova Scotia Health Authority. Although the municipality is not directly involved in these efforts, we aim to contribute to recruitment efforts by attracting potential residents through service and infrastructure improvements.”
Anyway, Liverpool looks like a good place for a doctor to set up a practice. Obviously it’s an engaged community, but there are some other advantages as touted by its website.
For example, they’ve renovated their hospital, the Queens General. The $16m cost was 90% funded by the community.
Did I mention, councillors, that doctors interested in Liverpool have two more provincial incentive options available than they would if they were interested in Halifax? Have you asked the province why?
All that, plus an isolated, kick-ass, white-sand beach half an hour away that Liverpudlians won’t tell you about until you’ve moved there.
Better get moving ladies and gentlemen, before your family doctor sees that website.
MORE GOOD THINGS ABOUT LIVERPOOL
” … an enchanting blend of rich seafaring history, quaint fishing traditions, modern conveniences and services, a thriving arts and culture scene, and numerous recreational areas, all on the shores of the spectacular Atlantic Ocean.
“Known for being kind, open, and generous, Liverpudlians welcome newcomers with enthusiasm. Our community is safe, diverse, and inclusive, featuring people from all walks of life–tradespeople, artists, entrepreneurs, young families, and retirees.”
QGH has a full-service emergency room with 24/7 coverage. Unlike other smaller municipalities, the QGH ER has never closed in the past 64 years. The QGH ER includes features such as monitoring capabilities, a video-laryngoscope, and a FAST ultrasound, a new digital X-ray, and 24-hour laboratory services.
The QGH provides many expert services. These include:
Ambulatory Care area with endoscopy and small procedure operating room.
Mental health services.
Public health services.
Laboratory services, with full lab and point-of-care testing available.
Diagnostic imaging, with on-call technicians available after hours.
COLLABORATIVE PRACTICE AREA
By using a holistic approach, the hospital’s collaborative practice gives patients access to the most appropriate, responsive, and comprehensive care available. Located in QGH, the collaborative practice features:
Room for five physicians.
A Nurse Practitioner, pharmacist, and social worker.
Family practice nurses.
A mental health group.
Visiting clinics, including Medicine, Surgical, Geriatrics, Palliative Care, Pediatrics, and Psychiatry
Opioid replacement clinic.
Liverpool is a training centre for medical students and Family Practice residents from Dalhousie Medical School.
QGH FACILITIES & FEATURES
Notable facilities and features include:
Digital X-ray machine.
22 acute care rooms with private bathrooms.
4 concentrated care suites.
2 bariatric rooms.
2 infectious disease suites with laminar flow.
Ergonomically designed rooms with overhead lifts.
Large windows that maximize the use of natural light.
A rooftop deck and downstairs atrium for ambulatory patients.
(Updated to include a correction on assistance to doctors locating in rural areas.)
That nasty red lesion you see in the middle of the map above is the sore spot of Nova Scotia’s family doctor shortage.
Yep. Half of the people in Nova Scotia who can’t find a family doctor live in the communities surrounding Halifax Harbour.
That’s half the misery resting on the shoulders of 40 per cent of the population.
“We should really get that looked at,” Haligonians say? Well, good, but bear in mind the province still subsidizes new doctors for locating anywhere but Metro Halifax.
And this is a case where raw numbers have more meaning than percentages. Most egregiously, Halifax and Chebucto Peninsulas have 10,502 residents who want a doctor but can’t find one–the worst total of any district. Residents do things like drive to Shubenacadie for care or maintain their own medical records during chemotherapy because they have no family practice to do it for them.
Dartmouth/Southeastern fares almost as badly, with 6,720 doctor-less residents. Together, the Dartmouth/Southeastern, Halifax Peninsula/Chebucto, Bedford and Sackville account for 20,727 of the 41,877 Nova Scotians without a family physician. That’s 49.9% of the entire problem. (NSHA has four zones — Central, Western, Eastern and Northern — each divided into sub-units called Community Health Networks such as Dartmouth/Southeastern in the Central Zone.)
The only record worse than Metro Halifax belongs to the counties of Annapolis and Kings, where eight per cent cannot find a doctor. But, percentages don’t tell the whole story: there are 20,727 people needing docs in Metro vs. 6,720 in Annapolis and Kings.
In percentage terms, Halifax and Dartmouth are the second- and third-worst performers. (This didn’t stop Halifax from attempting to recruit 50,000 Amazon employees to a municipality where already 20,727 people couldn’t find doctors.)
I don’t mean to diminish the problem in Annapolis and Kings. If people in Halifax drive to Shubenacadie to see a doctor, then god knows what you do if you live in one of those counties. Were it not for the misery in Annapolis and Kings in the Western Zone, I would blame this on the rural favouritism baked into our politics.
Percentage of the population currently seeking doctors
Central Zone/ Community Health Network
Total # Not Yet Placed
% of population seeking doctors
Entire Central Zone
Halifax Peninsula / Chebucto
Dartmouth / Southeastern
Bedford / Sackville
Eastern Shore Musquodoboit
The table below shows the big picture.
Percentage of the population currently seeking doctors
Zone/ Community Health Network
Total # Not Yet Placed
% of Population without MDs
Annapolis and Kings
Halifax Peninsula / Chebucto
Dartmouth / Southeastern
Yarmouth / Shelburne /Digby
Queens and Lunenburg
Bedford / Sackville
Inverness / Victoria / Richmond
Colchester East Hants
Eastern Shore Musquodoboit
Cape Breton County
Antigonish and Guysborough
Government gets away with this because most of us have family doctors, so we don’t pay attention. But during your next visit, have a close look at your doctor. Does she look tired, is she nearing retirement? If so, you’d better learn how to keep your own medical records.
In any case, government’s fixation on rural doctor shortages needs to change.
NSHA says it has added a recruitment consultant to the Central Zone, which includes Halifax. (It already had one in Western, which covers Annapolis and Kings.)
The $60,000 is a bursary for locating “in a rural Nova Scotia community outside of the metro Halifax Regional Municipality.” Alternatively, DHW also offers up to $45,000 in debt assistance for docs establishing “in a rural Nova Scotia community.”
I don’t understand the distinction between the rules for the bursary and debt assistance but it doesn’t matter because the message is the same: “We don’t care whether our provincial capital has enough doctors.”
“Q: Isn’t it true that Nova Scotia has more doctors per capita than any other province?
A: Yes, we do have a generous supply of physicians, but as the consultants found, many are concentrated here in metro Halifax . . .”(Emphasis mine).
Sorry, but I call bullroar on this. As we’ve seen, many patients--i.e. people who need doctors—are also “concentrated here in metro Halifax.” Please note the bureaucratic vagueness of the language and how it leads the unwary into mistakenly believing the root of the problem is still too many doctors in Halifax. That misconception seems to be part of DHW dogma, evidence notwithstanding.
I asked NSHA whether it had adjusted its incentives to reflect the evidence. Here’s the answer: “NSHA does own two incentive programs that are for the entire province: site visits and relocation allowance. We have recently doubled the amount available for relocation allowance. All of NSHA’s western zone was already eligible and now the site visit program has been expanded to include areas within NSHA’s central zone, including urban Halifax and Dartmouth.”
So, thanks to NSHA and no thanks to DHW, doctors seeking subsidies are no longer being entirely waved away from Halifax. Sadly, the Western Zone still lags despite having enjoyed recruitment incentives from the get-go.
Here’s a look NSHA’s recruitment strategy. Here is an example of its pitch to physicians.
It’s hard to understand how we got into this mess, but here’s a conjecture. In the ’90s Nova Scotia was one of the provinces that attempted to reduce health-care costs by limiting the number of doctors eligible for payment by medicare. I guess the theory was fewer doctors meant fewer patients and/or less illness. (What could go wrong with that idea, eh?) So, perhaps the policy produced a cohort of doctors too small to replace their retiring colleagues 20 years later.
There are also politics. Successive governments have demanded policies to drive doctors to rural areas, but perhaps they failed to also keep an eye on the provincial capital (aka the Devil’s Vestibule.)
Or, maybe they did track Halifax and just didn’t care, assuming we would take care of ourselves.
For far too many Nova Scotia politicians, the interests of their party outweigh those of the people who vote for them. This is why citizens hold them in such low regard. So, if we want see the Halifax’s hospital and outpatient services upgraded to modern standards, we will have to wrestle the project away from our political class.
An independent authority would do, but not the NS Health Authority, which was born wearing the political stink of 2013 campaign politics. Problem is, the task of creating the authority would fall to partisan politicians, who hate to put distance between themselves large amounts of money or power.
A case in point is the Efficiency Nova Scotia Corporation, which lost its legislated independence and revenue stream shortly after the Liberals took over in 2013. The money was about $45 million a year tacked on to electricity bills, where government couldn’t get at it. The corporation’s short-lived independence was the result of consultations in which the public was clear that ENSC should be free of politics.
ENSC had its own Act because, the thinking was, it would be too embarrassing for a government to repeal it. Turns out it wasn’t a problem for Stephen McNeil’s Liberals, who killed the law six months after they were elected and seized control of ENSC.
ENSC’s other problem was that it was an NDP creation and thus inherently unacceptable to Liberals, just as the NDP loathed the Conservative-crafted Environmental Goals and Sustainable Prosperity Act. What saved that act from repeal was its unanimous passage by a House that wasn’t really paying attention. It’s harder to repeal an act you voted for.
The QEII redevelopment project involves hundreds of millions, which presents both an opportunity and a problem for Nova Scotia partisans. The opportunity is obvious: the budget estimate starts at around $714 million, according to a 2009 Capital District Health Authority PowerPoint you can find here. The problem is, no sane politician campaigns on a promise to spend that kind of money in Halifax. You would win more votes by promising a mandatory puppy-cull.
Oh, and all the rooms would be private and have big windows, something proven to pay for itself in shorter recovery times, but nonetheless hard to explain to a certain class of voters.
Why am I so cynical about this? Because all three major parties have had a crack at the project since 2009 and all three have dropped the ball after an election. And self-serving political parties are the reason. In a better world, new governments would pick up important projects where their predecessors left off. But not in NS.
To wit: the PCs got the 2009 plan just months before an election and turned a blind eye. The NDP appears to have ordered the project cut by half (see below) just before the 2013 election, although unlike the other parties, they did consult the public on the plan. The Liberals won’t even discuss the cost, preferring to add up all the bits sometime in the future and THEN tell us. Or they don’t want to be accountable for it. Or it wouldn’t fly in rural NS. Or they have no idea.
And don’t think the Liberals jumped on the job right after they were elected. They announced “their” plan in April 2016, borrowing heavily from earlier work, after wasting 2.5 years amalgamating nine health authorities.
Just for example, this is an excerpt from the “final report” the NDP had in front of them in May 2013. If you’re a lover of detail, here’s the full version, but prepare for a long download. It’s worth your time, though, because it’s the standard we should be aspiring to. (I expect, as with the NDP, whoever is in power will prefer something much cheaper.)
For a quick fix, here is a single page from the report illustrating with a photo of the concept the planners had hoped to emulate, with some explanation.
Or, here’s a cropped version of the picture:
This could have been ours by 2015, if the NDP or Conservatives had been interested.
What happened, you ask? Here’s a clue — just a clue — from a subsequent draft report dated August 2013, two months before a general election, but likely never seen.
"To develop cost reduced scenarios within a fixed budget assumption, several major potential space/ bed capacities were explored ... Project budget is $360m."
In other words, Capital Health had been told to slash the project cost. To see the impact of that budget cut, you can look here. Of download the full document.
What to do? Well, the groundbreaking Environmental Goals and Sustainable Prosperity Act was passed by a Conservative minority government. The power dynamics of such governments often produce creative results. The job of citizens is to persuade the party holding the balance of power that it’s in their partisan interests to force the winners into de-politicizing the hospital project if they want to stay in power.