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?

Below is the complete tabulation to May 1, 2018.

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Related posts: Boroughs without doctors: checkup

Boroughs without doctors #3

Boroughs without doctors #2

Halifax too haughty?Boroughs without doctors #1

Health minister, PCs get it wrong

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.

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Related posts:

Need a Family Practice Registry, April 1, 2018

Boroughs without doctors #1

Boroughs without doctors #2

Boroughs without doctors #3

Halifax too haughty?

 

 

 

 

“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.

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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.

If true, it would be an act of treachery.

More in a future post.

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Need a doctor?

Then don’t  come to Halifax

(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	Population	% of population seeking doctors
Entire Central Zone	21,531	409,706	5.3%
Halifax Peninsula  / Chebucto	10,502	167,379	6.3%
Dartmouth   / Southeastern	6,720	115,427	5.8%
Bedford  / Sackville	3,505	87,838	4.0%
Eastern  Shore Musquodoboit	484	18,165	2.7%
West Hants	320	20,897	1.5%

Nova Scotia

41,877

919,849

4.6%

The table below shows the big picture.

Percentage of the population currently seeking doctors

Zone/ Community Health Network	Total # Not Yet Placed	Population	% of Population without MDs
Annapolis  and Kings	6,248	78,507	8.00%
Halifax Peninsula  / Chebucto	10,502	167,379	6.30%
Dartmouth   / Southeastern	6,720	115,427	5.80%
Yarmouth  / Shelburne  /Digby	2,809	58,393	4.80%
Pictou County	2,023	45,668	4.40%
Queens  and Lunenburg	2,623	59,384	4.40%
Bedford  / Sackville	3,505	87,838	4.00%
Inverness  / Victoria /   Richmond	944	33,505	2.80%
Colchester  East Hants	1,938	69,991	2.80%
Eastern  Shore Musquodoboit	484	18,165	2.70%
Cape Breton  County	2,487	102,397	2.40%
Cumberland	802	34,750	2.30%
West Hants	320	20,897	1.50%
Antigonish  and Guysborough	322	27,548	1.20%
Unknown	130	–	0.00%
Unknown	20	–	0.00%
Western Zone	11,680	196,284	6.00%
Central Zone	21,531	409,706	5.30%
Northern Zone	4,893	150,409	3.30%
Eastern Zone	3,753	163,450	2.30%

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.)

However, while NSHA seems to have the right idea, the Department of Health and Wellness is still offering physicians agreements worth as much as $60,000 to locate outside Halifax, as it has since as early as 2014.

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.”

DHW has a 2014 web document called “Shaping Our Physician Workforce.” It was updated in December 2017, so it’s current. Here’s an excerpt from the FAQ:

“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.

By the way, NS does indeed have the most physicians per capita in Canada at 258/100,000 (Canadian Institute for Health Information. Physicians in Canada, 2016: Summary Report Figure 3. Ottawa, ON: CIHI; 2017.) The number for Manitoba is 207, where there are 1.2 million people spread over a land area 10 times larger. 

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.

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