Reconsidering care at the “margins:”Rural and remote services as the frontlines of health care reform in B.C.

Dr. Neil Hanlon Geography Program

Presentation to the BC Rural and Remote Health Research Network 18 November 2005

OUTLINE

• Care at the “margins”• Case studies in northern B.C.

– Regional & local responses to population aging

– Emerging roles for the voluntary sector– Community-based health & social care

networks

• Discussion• Concluding remarks• Acknowledgements

Care at the margins

• Major provincial health policy issues since mid 1990s

– Funding Levels and Priorities– Regionalization– Wait Lists – Health Human Resources

Care at the margins

• “CORE CONCERNS”

– Metro/Urban– Health Care– Formal– Autonomy /

Independence– Human Capital

• “MARGINAL ISSUES”

– Rural/Remote– Social Care– Informal– Dependency /

Support– Social Capital

Case Studies

• (1) Local and Regional Adaptations to Population Aging

• (2) Emerging Roles and Challenges for the Voluntary Sector

• (3) Mapping Community-Based Care Networks

Local and Regional Adaptations to Population Aging

• Restructuring Welfare, Remaking Place: The Territoriality of Health Care Reform in ‘Remote’ British Columbia Communities (SSHRC Operating Grant #410-2003-0142)

• Improve our understanding of change in the health sector through the interaction of provincial and regional directives and the more local exercises of planning, administration and service delivery

– E.g., responding to population aging in northern BC

Population aging in northern BC

Pop’n aged 65+ (2001) / Pop’n aged 65+ (1991)*

*Source: Adapted from BC Stats

“Red” = 1.40+

BC mean = 1.26

Annualized Growth Rate, 1991-2001, by Age Group

Local Health Area 25-44 45-64 65-79 80+

Prince Rupert -0.9% 2.1% 1.2% 1.5%

Terrace 0.9% 4.0% 4.8% 5.2%

Smithers 0.5% 5.2% 3.9% 4.7%

Burns Lake -0.2% 3.6% 4.3% 7.8%

Nechako 0.8% 4.1% 3.6% 4.9%

Prince George 0.4% 4.5% 4.6% 6.0%

Quesnel 0.1% 4.0% 3.5% 6.3%

Peace River South -1.5% 1.7% 3.0% 2.1%

Peace River North 2.0% 4.0% 3.3% 4.9%

Fort Nelson 2.4% 5.8% 3.5% -0.4%

NORTHERN REGION 0.2% 3.8% 4.0% 4.4%

BC TOTAL 1.1% 4.2% 1.6% 4.7%

Population aging in northern BC

Source: Hanlon and Halseth, 2005

Central directives: continuing care reform / rationing

• (1) Redefining levels of care

• (2) Case management: assessment and entitlement

• (3) Population benchmarks and spatial allocation

Central directives: continuing care reform / rationing

Local Health Area Assisted Living Units

Complex Care Beds

Net Impact on Residential

Beds

Net Impact on Service Units

Quesnel 37 75 -40 -3

Prince Rupert 18 39 -34 -16

Smithers 18 36 -14 4

Burns Lake 11 22 -8 3

Nechako 20 38 -4 16

Prince George 101 185 -101 0

Peace R. South 35 72 -86 -51

Peace R. North 27 54 -41 -14

Kitimat 14 22 -13 1

Terrace 25 46 -29 -4

NHA 324 619 -363 -39

Distribution of Continuing Care Capacity in Northern BC (Based on 2001 population and Provincial Benchmarks)

Source: Hanlon and Halseth, 2005

Regional Responses: Network of Excellence in Rural and Remote Geriatric Services

• Objectives: increase and improve geriatric services in northern BC

• A collaborative approach– Frontline staff (e.g., nurses in

LTC facilities)– Outreach educators– Visiting specialists– Planning staff / consultants– Regional administrators

• A work in progress … Source: NHA, n.d.

Regional Responses: Network of Excellence in Rural and Remote Geriatric Services

• Enabled by regionalization– Issues of critical mass– Rationalization– Coordination / integration

• Fueled by social capital– Networks and partnerships– “Trust”

Emerging Roles and Challenges for the Voluntary Sector

• Aging Across Canada: Comparing Service Rich and Service Poor Communities (PI: Dr Mark Rosenberg, Queen’s University)

• Identifying how and why communities age differently and what it takes to create a healthy and service rich community

• BC study site:

– 21 key informant interviews with service providers (health care, housing, transportation, seniors’ centres, service organizations)

• 10 formal sector– 5 in 2004

• 11 voluntary sector– 10 in 2004

Emerging Roles and Challenges for the Voluntary Sector

• Themes emerging in first round of interviews (2002):– Issues around lack of coordination of

activities and services– Under-recognition of role of voluntary

sector services

Emerging Roles and Challenges for the Voluntary Sector

• Themes emerging in second round of interviews (2004):– (1) role of voluntary sector services– (2) experience of institutional pressures on

voluntary sector– (3) changes to voluntary organizations and

service provision

Emerging Roles and Challenges for the Voluntary Sector

• Role of voluntary sector– Complement or substitute? – Provision of instrumental and informational

forms of support– Emerging advocacy roles

Emerging Roles and Challenges for the Voluntary Sector

• Experience of institutional pressures– Voluntary sector absorbing offloaded

responsibilities• E.g., help with IADLs

– Volunteer strain– Funding squeeze

• Changes in provincial funding• Greater emphasis on project-based funding

Figure 1. BC Provincial Government Gaming Revenues Redistributed to Voluntary Organizations

$0

$20,000,000

$40,000,000

$60,000,000

$80,000,000

$100,000,000

$120,000,000

$140,000,000

$160,000,000

$180,000,000

1998/99 1999/00 2000/01 2001/02 2002/03 2003/04

Earned by Organization

Provincial Bingo Funds

Direct Access Program

Emerging Roles and Challenges for the Voluntary Sector

• Change in voluntary service provision – Cautious expansion of roles– Pressures to rationalize, consolidate

locally– Identity fissures (organizational and

individual)

Emerging Roles and Challenges for the Voluntary Sector

• Identity fissures …

– “If we lose gaming money, like Bingo money or anything, that’s big money for us. That keeps us going. That might be $40,000 a year. I would have to make up the deficit somehow.”

– “I’m really afraid that I’m going to have to get into that proposal writing, funding fight thing. I don’t want to go there, but I think it might happen.”

Emerging Roles and Challenges for the Voluntary Sector

• Identity fissures (cont.)

– “We’re starting to compete within ourselves for … gaming funds, volunteers, space, city grants … . And this is going to get worse. As our needs increase, we’re going to start biting at each other.”

Emerging Roles and Challenges for the Voluntary Sector

• Identity fissures (cont.)

– “Last year, we only got [an amount less than one-quarter requested] from Direct Access because they said we didn’t qualify. We don’t have enough programs.”

Emerging Roles and Challenges for the Voluntary Sector

• Summary of key findings: voluntary sector– Potential erosion of flexibility and

personalization– Increasing pressures for consolidation– Emerging emphasis on competition,

accountability and efficiency

– Governance and accountability mismatch

Mapping Community-Based Networks of Care

• Understanding Systems of Supports for Households Under Stress in Remote BC Communities

– New Emerging Team for Health in Rural and Northern BC, CIHR Northern and Rural NET Competition (P.I.s: Dr Clyde Hertzman and Dr Aleck Ostry, UBC)

• Where do individuals and families in remote communities turn for help if they experience a stressful event, such as job loss or a serious illness? What sorts of support networks are available for families with very young children, especially if these households are headed by a single parent?

• Study sites: Fort St. John, Mackenzie, Terrace, Williams Lake

• Methods (year one): key informant interviews (n=83) with service providers, site inventories, census data profiles

Mapping Community-Based Networks of Care

• Organizations deeming themselves under-funded:– women’s resource centres – public health nursing – service providers for the disabled – mental health – addictions programs

Mapping Community-Based Networks of Care

• Organizations deeming themselves adequately funded:– child development centres – community health programs – employment centres – aboriginal programs

Mapping Community-Based Networks of Care

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100

% of Respondents

Mackenzie Williams Lake Fort St. John Terrace

Community

Service providers with sufficient resources

Mapping Community-Based Networks of Care

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60

70

% of Respondents

Mackenzie Williams Lake Fort St. John Terrace

Community

Staff shortage by community

Mapping Community-Based Networks of Care

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10

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% of Respondents

Mackenzie Williams Lake Fort St. John Terrace

Community

Partnerships with local volunteer groups by community

Mapping Community-Based Networks of Care

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10

20

30

40

50

60

% of Respondents

Mackenzie Williams Lake Fort St. John Terrace

Community

Unsuccessful partnerships with local volunteer groups by community

Mapping Community-Based Networks of Care

• Success in partnering– Complimentary models work best

• General expressions of positive cohesion– Among formal sector providers (small town

advantage) – Positive ‘bridging’ with voluntary groups enabled by

funding adequacy

• Diversity of experiences within and between sites

• Next steps – experiences of service users

Discussion

• Attention to “marginal issues” reveals much about the frontlines of health care reform

• Grounded research• Unique research and training

opportunities– “Leveraging”

– Networking

Concluding Remarks

• Care and care research:– Relationship building

• Across sectors• Across disciplines• Across institutions

– “Bridging” form of social capital– Resources for living / community

capacity

Acknowledgements

• SSHRC Standard Research Grant– Restructuring Welfare, Remaking Place: The

Territoriality of Health Care Reform in ‘Remote’ British Columbia Communities

– PI: N. Hanlon (UNBC)

• CIHR Operating Grant No. YYI44646 – Aging Across Canada: Comparing Service Rich

and Service Poor Communities – PI: M. Rosenberg (Queen’s)

• CIHR NET Grant – Integrated Study of the Social Dimensions of Rural

Health – PIs: A. Ostry (UBC) and C. Hertzman (UBC)

Acknowledgements

• Anne Burrill• Rachael Clasby• Mollie Cudmore• Rebecca Goodenough• Greg Halseth• Regine Halseth• Martha MacLeod• Tom MacLeod• Carla Martin• Jessica McGregor• Aleck Ostry• Virginia Pow• Andrea Procyk• Mark Rosenberg• Pam Tobin