Rural health under attack/La sante rurale attaquee.(Editorial)

I've handled highway trauma, difficult deliveries and heart attacks by the score, but, as a rural doctor, nothing drives fear into my heart more than a threat to my tools of the trade--the nurses, equipment and support that a hospital represents. Yet, throughout this country, whenever the budgets need trimming, rural hospitals are being closed.

If we envision the health care system as a wheel, and narrowly focus on the region without looking at the whole picture, getting rid of one of the spokes takes money from the powerless and uses it to spare the powerful hub. However, from the point of view of a patient out on the spoke, out-of-pocket costs for the patient and his or her family are always increased with service closure. The community often loses its first or second largest employer. Unemployment increases as support jobs go. (1)

Is there any real money saved? The car collision, the pneumonia and the birth will still occur somewhere. When the per capita cost of health care for rural patients is already lower than that in the specialist- and equipment-rich city--the full-service rural hospital is a very efficient beast(2)--how exactly do you save money by moving care to the city? Savings will only occur by denying care.

Even when the smallest, least efficient 2 doctor-type hospitals are closed on a massive scale, the actual money saved is insignificant on a provincial ministry level. The former Saskatchewan minister of finance, Janice MacKinnon, reflecting back on the 1993 closure of 52 rural hospitals, conceded that at best $40 million was saved. (3)

Can city hospitals give better quality care? Of a vast number of procedures that the Canadian Institute for Health Information studied, only 3 rare and specialized surgeries that rural hospitals don't do (such as a Whipple procedure) require volume for best outcome. (4) Quality measures, including care for labouring mothers and their infants, studied in both Northern Ontario and British Columbia show first-class outcomes occur when teams of caring professionals provide care in a small local hospital. (5) The question that really needs to be asked is whether transferring patients, even to an excellent city centre, improves rural outcomes. American studies show that if women have to travel to give birth (even to excellent centres) outcomes are worse and costs double. (5)

Closing rural hospitals is a mean-spirited substitute for system reform. The work out here is already hard enough. Don't make it any harder than it needs to be.

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