One of the most dramatic demographic trends in the world today is the ageing of the population: an increase in the proportion of senior citizens relative to the youth and working age population. The reasons for this trend are often complex. Some of the reasons could be the tremendous impact of the "baby boomer" generation, increases in life expectancy, changes in fertility patterns and for many geographical locations, out-migration of the younger members of society. This population change is evident in rural Canada where there is a higher ratio of seniors to youth. With this change in composition of the rural population, the needs for services are increasing; in particular, primary health care services are especially important for senior citizens in rural areas. This includes more focus on prevention and treatment of common diseases and injuries, basic emergency services and health promotion. In this essay, I will be analysing Canada's ageing population, primary health care services, initiatives taken by LHIN's in Ontario to tackle the issue and also European strategies.
Canada's Ageing Population
Canada faces significant ageing of its population as the proportion of seniors increases more rapidly than all other age groups. Seniors can be defined as those above the age of 65. In 2001, one in eight Canadians were aged 65 years or over. By 2026, one Canadian in five will have reached age 65. The challenges of an ageing Canadian society will require: continued efforts to improve health, well-being and independence in later life; facilitate the participation of older Canadians in economic and social life; strengthen the supportive environments within communities; and, sustain government programs benefiting Canadians of all ages. Canada's seniors are a diverse population. Issues related to their overall health and well-being may vary depending on their place of residence (urban, rural, or northern areas), their gender, and their ethno-cultural background as well as if they are among Canada's Aboriginal people.
Primary Health Care Services
Primary health care refers to an approach to health and a spectrum of services beyond the traditional health care system. It includes all services that play a part in health, such as income, housing, education, and environment. Primary care is the element within primary health care that focuses on health care services, including health promotion, illness and injury prevention, and the diagnosis and treatment of illness and injury. Primary Health Care is also relevant to secondary and tertiary care. The Primary Health Care approach focuses on promoting health and preventing illness. The Primary Health Care approach means being attentive to and addressing the many factors in the social, economic and physical environments that affect heath - from diet, income and schooling, to relationships, housing, workplaces, culture and environmental quality. In addition, the Primary Health Care approach places citizens and patients on the same level with health professionals when it comes to making decisions about health issues that concern them. The five principles usually associated with the Primary Health Care approach are accessibility, public participation, health promotion, appropriate technology and intersectoral cooperation. Accessibility refers to a continuing and organized supply of essential health services available to all people with no unreasonable geographic or financial barriers. Public participation means individuals and communities have the right and responsibility to be active partners in making decisions about their health care and the health of their communities. Health Promotion is the process of enabling people to increase control over and to improve their health. Appropriate technology includes methods of care, service delivery, procedures and equipment that are socially acceptable and affordable. Inter-sectoral cooperation is the commitment from all sectors (government, community and health) is essential for meaningful action on health determinants.
Health Care in Rural Canada
The challenge of providing good quality health care close to home in a country as vast and sparsely populated as Canada is not new. In spite of major scientific advancements and a health care system that is rated amongst the top in the world, the challenge remains. A number of factors play a role in the availability of, and access to, good quality care for rural residents.
Distribution of Physicians
The uneven rural-urban distribution of physicians has been at the centre of discussion for a number of years. Less than 10% of all physicians are known to be practicing in rural Canada where approximately 20% of the Canadian population resides. When the data is broken down between family physicians general practitioners and specialists, it is clear that specialists are even more under-represented in rural regions.
Rural regions encounter difficulties in recruiting and retaining physicians. Many factors play a role in a physician's decision to enter rural practice, including both personal and professional dimensions. Physicians most interested in working in rural areas often come from rural backgrounds and are committed to working in this environment. Physicians' decisions to leave rural practice are usually influenced by non-monetary factors, such as a shortage of professional back-up, long hours of work, limited opportunities for further medical training, insufficient job opportunities for partners, and concerns over children's educational opportunities. Levels of satisfaction with rural work appear to rise with proximity to large urban centres. Several incentives are being implemented to encourage and retain physicians in rural regions by most provinces and new strategies are always being discussed.
Another suggestion for dealing with the shortage of rural physicians is to make rural health a more important part of the curriculum in medical schools across Canada. The Canadian Medical Association has put forth recommendations that the education of physicians for rural practice deserves special attention to ensure adequacy and appropriateness of learning experiences to meet the unique needs of rural Canada.
Medical specialists are also under-represented in rural areas with, according to the Canadian Medical Association, only 5% of the total number of Canadian specialists practicing in rural areas. In Ontario, only 4% of specialists practice in rural communities. This situation is expected to become worse in the next 20 years, when two-thirds of retiring physicians will be specialists and one-third family physicians/general practitioners. This shortage of specialists will undoubtedly have an impact on the rural community.
It is important to note that there are reasons that one can argue with to rationalize the uneven distribution of physicians. With Canada's rural population being sparsely distributed in small numbers, it is not feasible to have many physicians in rural and remote areas where the population is only a few hundred. Having physicians for such a small number of people is not economically feasible and can take away from other areas that have a greater population. Considering the fact that many heavily populated areas are already lacking physicians, increasing the number of physicians for smaller populations may not be the best decision.
Distribution of other Health Care Professionals
The distribution of physicians is one of the biggest problems in rural Canada and it is also the most widely discussed; however, it is important to note that the availability of and access to, other health care professionals is also of concern. The Canadian Medical Association has found that there is a lack of psychiatric nurses, physical therapists, occupational therapists, speech pathologists and language pathologists in rural areas.
Efforts are being made to compensate for this problem by implementing family health teams. A Family Health Team is an approach to primary health care that brings together different health care providers to give the best possible quality of care for the patient. Family Health Teams consist of doctors, nurses, nurse practitioners and other health care professionals who work together and bring their own unique experiences and skills so that the patient receives the very best care when it is needed. This approach is designed to bring health care as close to home as possible for people living in rural and remote areas as well as urban areas. This approach is also meant to give doctors support from other health care professionals so physicians and general practitioners do not have to bear the burden of dealing with patients alone.
Distribution of Health Care facilities
There is an uneven distribution of hospital services and health care facilities and this reflects the uneven distribution of medical professionals as well. The amount of time and distance it takes for people living in rural areas to get to health care facilities is a major problem. Travelling for a long time for a long distance requires time and money and also adds to the discomfort of the person that is ill. There are no hospitals in many small rural communities. The nearby urban centres may have hospitals with basic medical facilities. However, patients need to be taken to large urban centres when specialized treatment is needed. For example, in Ontario, larger rural communities have hospitals that provide essential services such as 24-hour emergency care, obstetrics, anaesthesia, and general surgery. Smaller hospitals may also provide these facilities; however, these medical facilities can be dependent on specialists who may need to be brought in from different hospitals located in urban centres.
Rural areas have a limited number of hospitals which provide a limited number of services, unlike their urban counterparts. When hospitals do not provide certain services, that can be an issue for people living in those areas, who already have such limited choices on their health care. For example, if the only hospital available in a remote area is operated by religious leaders and followers, then facilities such as abortion cannot be available to the people. Although the option of abortion is available in several urban areas, many rural areas do not have the option and if someone is seeking abortion, then they would have to travel long distances to access such a facility.
It is important to note that similar to physicians, it may not be economically feasible to have a hospital for every remote area where the population is much smaller than many of the urban areas. Hence, alternative options such as family health teams can be a good option for many of the rural areas.
Rural Seniors
Large populations of seniors in Canada live in rural areas. Approximately, one third of Canada's seniors live in rural areas and small towns. Seniors are also the largest consumers of health care. A number of health problems are particularly prevalent among elderly Canadians, including depression, dementia (including Alzheimer's Disease), osteoporosis, malnutrition, and loss of bodily functions (sight, hearing, mobility, continence). All of these may require specialized medical care and support services. Travelling long distances to reach required services is particularly challenging for seniors with mobility problems.
The majority of senior in Canada live independently and it has repeatedly been proven through studies that independence is a vital influence in seniors' housing choices. The capacity to live independently, however, depends upon a number of factors, including health, financial status, and the availability of support services, which include professional services, such as medical or personal care. Over the years, a number of support services have been developed to help seniors. These services include meals for seniors, special transportation, home-care, visiting home-makers, social and recreational programs, and counselling and information. Although these services are effective, they are for the large part available only in urban areas.
In rural and remote areas there are problems with access to primary health care. The lack of afterhours services can lead to the use of emergency rooms in the hospital for cases that are not so severe such as minor injuries or illness. Also, if primary care providers such as family doctors are not available at all, then patients have no choice but to go to emergency rooms in hospitals for minor injuries and illnesses. These patients who lack the primary care provider and thus have to visit hospitals are known as orphan patients. A majority of the orphan patients are seniors. Also, due to lack of appropriate care, many of the patients that need specialized care have to wait in hospital beds, and occupy a bed, until they can be transported to other medical facilities that offer such care. The patients that occupy hospital beds in such fashion are known as patients who need Alternative level of Care (ALC).
It is important to deal with the lack of primary health services in rural areas in efficient ways because seniors are more concentrated in rural regions and seniors are the largest consumers of health care. An effective way to tackle this would be to apply family health teams as you can have a variety of professionals working together and this can be beneficial to patients as well as the medical professionals. Another effective way to address this issue, especially the issue of ALC, is to use telemedicine. Ontario has one of the largest telemedicine networks in the world and it is known as the Ontario Telemedicine Network. Telemedicine is the delivery of health-related services and information using telecommunications technologies. Through videoconferencing, digital instruments like stethoscopes and patient examination cameras, telemedicine can deliver health care directly to the homes of the patients instead of patients having to travel. This is especially effective in rural areas as the distance required to travel can take a lot of time and money. Cutting down on the travelling can also be very beneficial to seniors as they would save time, money and they would not have to travel while ill. Telemedicine can help with Alternative level of Care patients as the patients now would not have to travel to urban centres and go to specialists as the specialists can now come to them via video-conferencing.
North East LHIN Initiatives
The Ministry of Health and Long-Term Care (MOHLTC) has started the Aging at Home Strategy with an aim to reinforce the ability of community support services to allow seniors to live healthy, independent lives in their own homes. The initiative is being led by the Local Health Integration Networks (LHINs), with each LHIN receiving a specific funding allocation to meet the needs of their local communities. Programs being funded include: enhanced home care and community support services such as meals, transportation, shopping, snow shovelling and care giving supports.
The North East LHIN's initiative can be particularly helpful with primary health care. Their initiative includes enhancing the range of home care services for seniors to avoid unnecessary ER admissions and support timely discharge from ER and hospital. The North East LHIN also looks to do intensive community based case management, in-home primary care, enhanced community supports and enhanced mental health services.
European Primary Health Services Initiatives
Countries in Europe also experience similar issues in primary health care services as Canada does. Looking at the initiatives taken by European countries and comparing it to initiatives taken in Canada can be an effective way to compare and contrast the different health systems and also to look for further improvements in the Canadian health care system.
In Greece, the government has put forth the idea of community centres for the occupation and protection of older people. There are many of these centres, called KAPI, throughout the country. These centres combine the socializing aspect with primary health care facilities as well as other social services. These centres have social clubs and activities as well as primary health care providers including physicians and physiotherapists. Clubs such as these can also perhaps be effective in Canada. The clubs do not necessarily have to be duplicates like those in Greece, but using a similar idea can be helpful in terms of primary health care services for seniors.
Conclusion
With the continuous rise of the ageing population in Canada, the need for primary health care services are increasing. This includes more focus on prevention and treatment of common diseases and injuries, basic emergency services and health promotion. It is important to implement primary health care services in rural Canada as the majority of Canada's seniors live in rural areas and also because seniors are the biggest consumers of health care. Current initiatives such as family health teams, tele-medicine and the Aging at Home Strategy are taking good strides in terms of delivering primary health care services. A combination of such programs along with learning from several program applied around the world can lead to better primary health care services for seniors, as well as the population as a whole.
