Code Grey: Rural health shortages began long before pandemic

Written By Spencer Hall, Energeticcity.ca
Published

Special from Energeticcity.ca, part two of Code Grey, a series on the state of health care in northeast B.C.


The critical shortage of health care staff affecting the province doesn’t just include nurses and hospital staff and it began in rural communities long before the pandemic.

While some suggest staffing shortages in Northern B.C. are primarily due to the COVID-19 pandemic, this is not a new issue in rural communities. In fact, staffing challenges have pervaded rural areas for decades.

Humble beginnings

The first hospital in the Fort St. John area opened in 1930 with two beds – the Grandhaven Red Cross Outpost Hospital. The second was opened a year later by the Sisters of Providence in a two-storey, 10-bed, 30 by 50 feet building. A third story was added during the construction of the Alaska Highway. 

Initially, the Providence Hospital had one doctor and two registered nurses. The need for care was so strong, it began admitting patients before the hospital officially opened. In 1962, the Sisters, along with the Peace Liard Regional Hospital District, built a new 44-bed facility, which became a public hospital in 1973 and was renamed the Fort St. John General Hospital.

Shortly after the hospital became a public facility, the first official records of staff shortages were reported.

Historical health care shortages

A review of the public archives at the Fort St. John North Peace Museum by Energeticcity.ca revealed that health care staffing shortages have been —at the very least—an intermittent issue within the community.

In August 1974, the Alaska Highway News reported that the Fort St. John Hospital was in the midst of a nursing shortage, with over a quarter of the hospital’s 32 nurses away on holidays, resulting in a loss of services at the hospital and a drop in personal attention paid to an average of 65 patients daily.

A hospital administrator at the time, Rick Wilson, said the issue was one the hospital regularly experienced at that time of year, claiming it would likely be solved in the fall.

At that time, the hospital was reportedly having difficulty finding specialty nurses, particularly those to work in the ICU, which at the time was being staffed by two “regular” nurses — one full-time nurse who planned to leave in the fall and one part-time. In the major surgery ward, there were 35 patients —nine of which needed special care — being looked after by four nurses each shift.

In a 1975 article discussing a then-new policy requiring doctors immigrating to B.C. to practice in the north of the province for five years, Garth Wortman, an administrator of Fort St. John’s medical clinic, told the Alaska Highway News that there wasn’t a shortage of doctors in the city, adding there were no problems in recruiting doctors to the region.

However, Wortman admitted to a high turnover rate of physicians. He said there had been brief periods when “there had been problems,” but he did not elaborate further.

But, recruiting and retaining doctors in rural communities like Fort St. John has been a long-standing issue for decades.

In 1995, the patient-to-physician ratio in Fort St. John was five times the provincial average.

In May of 1995, the city of Fort St. John found itself in the midst of a dire doctor shortage, with Dr. Mike Wright telling the Alaska Highway News that doctors in the region were working with a patient-to-physician ratio of 3,500 to one — about fives times the provincial standard at the time.

Wright said that Fort St. John doctors had been “burdened for years with an overwhelming work schedule,” one that is typically temporarily reserved for training physicians.

Earlier that same month, Fort St. John mayor Steve Thorlakson reportedly said despite paying doctors a substantially higher rate than their counterparts in the lower mainland, the province had been unable to encourage an adequate amount of physicians to practice in the city.

The population in Fort St. John grew from 14,156 in 1991 to 21,465 in 2021. About $7.7 million has been invested in the Fort St. John Hospital in the past decade, yet the B.C. Nurses Union says nurses in Fort St. John have reported increased negative patient outcomes due to a lack of nursing staff.

Fort St. John is not the only rural area to have problems with high turnover rates when it comes to physicians. Studies dating back to at least 1971 have illustrated the issues when it comes to the recruitment and retention of rural physicians.

Rural doctors hard to hold

A 2000 study of recruitment and retention of doctors in 78 B.C. communities over the previous 21-year period showed the towns with the lowest populations had the highest recruitment rates.

Conducted by Dr. Harvey Thommasen, a now-retired professor from both the University of Northern BC and the University of BC, the study showed typical year-to-year retention rates in places with less than 7,000 people was between 70 and 80 per cent. Whereas in communities with a population larger than 7,000, retention was 85 to 90 per cent.

“For example, a community of less than 7,000 people that has two or more physicians who have stayed 5 or more years can consider themselves very fortunate,” Thommasen wrote.

“Policies designed to force urban doctors to “do their time” in rural communities have not yet worked.”

Harvey Thommasen

Training more doctors likely won’t correct the issue of poor staffing in rural areas, according to Thommasen, who practiced family medicine in Bella Coola, Masset, Dease Lake, Tumbler Ridge and Houston, B.C.

Call of the city

“The problem is primarily one of poor distribution—doctors recruited from urban centres, trained in urban centres, not surprisingly, want to work in urban centres,” wrote Thommasen. “Policies designed to force urban doctors to “do their time’ in rural communities have not yet worked.”

The 22 year-old study findings still ring true for Paul Adams, the B.C. Rural Health Network administrator, who says there needs to be a focus on training rural medical students to serve rural communities.

“Rural B.C. has been in a healthcare crisis for decades.”

Paul Adams

“[The province] is in a health care crisis, but rural B.C. has been in a health care crisis for decades. You could probably take that back 100 years if you want to look at it from that perspective,” Adams said.

“We need to have more equity in who’s going to come back to rural communities. So we need to train more rural people if we wanna see that intended result.”

Adams said that while a lot of things have changed over the past 100 years in regard to health care, it has always been challenging to recruit and retain physicians to work in rural communities.

Northern Health is born

In December 2001, the provincial government announced a new structure of delivery for health care services. The new system included 15 health service delivery areas governed by five health authorities —Interior, Vancouver Island, Vancouver Coastal, Interior, and Northern.

Northern Health Authority covers 70 per cent of B.C.’s land mass while serving less than seven per cent of its population.

The health authorities replaced the previous health care delivery system in the province, which comprised 52 separate health authorities and approximately 600 appointees to health boards, health councils and societies.

The ministry of health said the 2001 system reduced jurisdictional overlap and duplication of costs.

“Under the previous system, huge budgetary discrepancies between small rural community councils and large urban boards led to disparities between urban and rural communities while impeding the efficient delivery and planning of health care services,” the ministry stated at the time.

Establishing Northern Health brought improvements in care closer to residents of the North.

Ministry of Health

Northern Health is the largest of five health authorities. It covers about 70 per cent of the land area and less than seven per cent of the province’s population – most of whom live in rural and remote communities.

High hopes

The establishment of Northern Health facilitated a “critical” partnership bringing improvements in care closer to residents of the North, according to a Ministry of Health email to Energeticcity.ca

“Collaboration has resulted in the replacement of Fort St. John Hospital in 2012, the upcoming replacement of Dawson Creek and District Hospital and many other investments and improvements.”

Some of these improvements include increased diagnostics capacity including additional MRI machines and CT scanners (Northern Health went from 174,000 scans in 2016-17 to almost 300,000 during the pandemic). As well, there are more long-term care beds and renal services in Fort St. John; increased assisted living capacity in Fort St. John and the South Peace; and established Fort St. John and Dawson Creek-based community oncology clinics.

The ministry email acknowledged health care in the North faces “unique challenges” due to the remote nature of the communities it covers, and committed to working closely with Northern Health to solve issues related to staffing and retention.

Where are we now?

According to a 2022 survey completed on behalf of the B.C. College of Physicians, nearly one million British Columbians don’t have access to a family doctor, while 40 per cent of residents with a family physician are concerned their doctor will soon retire or close their practice. 

Residents surveyed in Northern Health fare better than residents elsewhere with 94 per cent saying they have access to a family doctor —the highest of any health authority — that doesn’t mean there are no shortages for those who live in the Peace region.

In one Fort St. John clinic, three doctors arrived as five left.

There has been movement in Fort St. John’s number of physicians, with one local clinic welcoming three new doctors just as five leave the practice.

Earlier this month, Taylor’s only medical clinic closed its doors after it switched to a fee-for-service payment model, leaving residents —11 per cent of whom are 65 and older— without access to a doctor in their community. 

The Fort St. John Hospital has been closed since 2020 and staffing shortages have been reported throughout the health care system.

“We’re short of nurses, doctors, lab techs, and not just in the Northern Rockies [formerly Fort Nelson] or in British Columbia, but in fact, all across Canada,” said District of Taylor mayor Gary Foster.

Foster, along with the mayors of Tumbler Ridge, Mackenzie and Fort Nelson, have asked for an audit of Northern Health. The mayors have said until they understand how the health authority operates, they are unsure how to assist with recruitment and retention of health care staff and practitioners.

“Our health care system was pretty much in shambles before COVID hit.”

Lori Ackerman

“We need to acknowledge that our health care system was pretty much in shambles before COVID hit. We need to be brave and ask the questions,” said Fort St. John mayor Lori Ackerman.

During a recent visit to the Energetic City, vice president of the BC Nurses Union, Adriane Gear, said members in Fort St. John reported increased negative patient outcomes because there aren’t enough nurses to provide care to those in the community.

“In the emergency room, for example, their baseline ratios are two nurses to 16 patients or one to eight. In any other part of the province, you’re going to see a ratio of one to three or one to four,” Gear explained.

Fort St. John is not alone. Hospitals and ambulance services across the province have reported staffing shortages resulting in rotating emergency room closures and badly needed ambulances sitting vacant.

Staffing strategy

In response to these and other health care pressures around the province, on Sept. 29, Health Minister Adrian Dix, alongside the Minister of Advanced Education and Skills Training, Anne Kang, unveiled B.C.’s five-year health human resources strategy, which looks to address the current challenges facing the province’s health care system.

The plan, consisting of 70 actions under four main pillars — retain, redesign, recruit, and train—includes up to 128 more seats in UBC’s faculty of medicine, with plans for a medical school at Simon Fraser University.

[BC Gov graphic]

Another portion of the announcement involved expanding the scope of practice for pharmacists in the province. Pharmacists gained an expanded ability to refill prescriptions on Oct. 14 and by spring 2023, pharmacists will be able to issue prescriptions for contraception and less acute ailments, Dix said.

New regulations will allow paramedics the ability to provide an extended range of services to their patients, such as expansions in training. This week, Dix announced temporary wage hikes to attract and retain paramedics, and last February added 602 nursing seats to post-secondary schools across B.C.

The province will also develop a new provincial travel resource pool, which is based on a model developed by Northern Health.

Battling the lure of agency nursing

Chief Operating Officer for Northern Health’s northeast region, Angela De Smit, says that the health authority’s travel resource pool program has grown significantly over the past six months, going from 30 nurses to 80.

“It used to be called the travel nurse program, and now it’s called the travel resource pool because we’re also getting sonographers, along with X-ray and lab technicians, so it’s expanded quite a bit,” De Smit said.

She says the program was born out of listening to what staff enjoyed about being agency nurses and has been an effective tool in retaining staff in Northern Health.

“There’s a couple of reasons for that. One is that when they’re a Northern Health Authority employee, then they accrue seniority, which impacts their benefits in terms of paid vacation time, sick time and the job security of being part of a health authority,” said De Smit.

Currently, agency nurses are hired to cover shortages throughout the province. The practice has been criticized for the high cost impact on health authority budgets. Agency nurses get paid twice as much as a public health nurses, which has caused some to leave health authority jobs to work as agency nurses.

A nursing shortage was flagged in a 2018 audit by the Auditor General of B.C. who found the health authority was not doing enough to recruit and retain nurses effectively, noting at the time that Northern Health was short 121 full-time-equivalent registered nurses, approximately 15 per cent of its rural and remote RN workforce and six nurse practitioners. Since then, De Smit says they have implemented most of the office’s recommendations.

Creative solutions

“We’ve had conversations with nurses and health care providers in terms of what brought them here and what they are looking for. We’ve done creative things in terms of changing positions from part-time to full-time in order to have an increased ability to recruit.”

“We’ve contacted over 144 internationally educated health care professionals that live here in the Northeast. Lots come here because they have taken or are enrolled in the Northern Lights College Health Services Management Administration program,” De Smit said.

She adds that being flexible and meeting applicants halfway has been a success for the health authority.

“We had a community kinesiologist position that we hadn’t filled for a year. And then we had a couple of applicants for an occupational therapist position, and we said, why don’t we change these positions?” De Smit began.

“We’ve contacted over 144 internationally educated health care professionals that live here in the Northeast.”

Angela De Smit

“What has been successful is our ability to respond in a reasonable manner, especially when we have qualified staff who come to us or applicants who are seeking employment. We can bring them here, and we’re able to retain them,” she said.

Other recruitment and retention initiatives the health authority has implemented include partnerships with post-secondary institutions such as Northern Lights College, attending specialty conferences throughout Canada and the U.S., and engaging with youth in schools to raise awareness of the variety of health care careers available.

What’s clear is there are many moving parts to the health care crisis unfolding across the province. Despite continual efforts by government and health authorities to relieve pressure on the health care system, long-standing staffing shortages and historic challenges – exacerbated by the pandemic – require creative, innovative and ongoing solutions. 

Read part one of the Energeticcity.ca series Code Grey which investigates the current state of the health care system in northeast B.C.