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Money talks in staffing rural ERs


Nova Scotia has been experiencing difficulties in staffing rural ERs and their approach has been to gradually introduce regional collaborative health centres and to develop a pool of locums physicians available to staff low volume rural Emergency Departments.  These are probably good initiatives but until a comprehensive regional approach is developed for emergency services in rural communities there will continue to be gaps in service. Particularly problematic has been the Soldier’s Memorial Hospital in Middleton, Nova Scotia which has faced a number of unscheduled closures.  Local community leaders have noted that there is a  $55 per hour fee differential for doctors who work in Middleton and doctors who work in the larger regional centre.

Ontario faced a similar problem in staffing rural departments fifteen years ago and found that on the short term money talks. That is to say that if you pay a large enough salary that doctors will work in small town ERs.

Initially it was the Scott report that gave an hourly nighttime rate of $90 to guarantee after midnight coverage in low volume ERs. This figure was frequently but informally topped up by discretionary funds from hospital administrations.

This figure became less competitive with time and was ultimately replaced with the AFA, the Alternate Funding Agreement which paid doctors a global funding amount based on volume and acuity. Not perfect but still raised hourly rates to the $150/hour range in the late 1990’s. This had a remarkable stabilization effect on threatened departments.

With time, this lost some of its sheen as the workforce aged and the ER became a more complex clinical environment.

Three years ago there remained some rural Ontario ERs under threat of service disruption. The Ontario government responded with a locum pool, Health Force Ontario which paid locums significantly increased rates to help staff rural ERs. As a result there have been no ER service disruptions in Ontario since that time.

This program has its problems as it pits locums against locals with respect to the enhanced fee differential.

Nevertheless the program has staid off any unanticipated ER closures.

To sum up, by throwing increasingly more money at the problem, Ontario has prevented any disruptions in service.

It is obviously not a long term solution; that lies in regionalization. Nevertheless, it does indicate that rural ERs can be continuously staffed if the price is right.

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