REDIRECTING CARE FROM WINNIPEG HOSPITALS TO TEN LARGE RURAL FACILITIESMoving health care from high-cost institutions to more appropriate community-based settings is one of the goals of Manitoba Health's reform process. This includes providing more services in large regional hospitals, so rural residents would not have to travel to Winnipeg for hospital care. To get an idea of how much hospital care could be moved, Manitoba Health asked the Manitoba Centre for Health Policy (MCHP) to study the question.
Overall, we found that redirecting care from Winnipeg facilities to large rural hospitals would have a fairly small impact on both rural and Winnipeg facilities. The rural hospitals currently have enough empty beds to accommodate most of the increased volume.
MCHP considered ten "target" facilities in the following towns: Brandon, Dauphin, Flin Flon, Morden-Winkler, Portage la Prairie, Selkirk, Steinbach, Swan River, The Pas and Thompson. These facilities were chosen because they each have the potential to become regional centres in rural health reform. Morden and Winkler were studied together since planning for a new amalgamated hospital was already underway.
In estimating the number of cases which might be moved from Winnipeg to rural hospitals, the report used Dauphin General Hospital as a benchmark - Dauphin already functions well as a regional hospital. How many additional cases would need to be handled locally for each target hospital to reach the same level of regional service as Dauphin?Findings
The size of the population served by the hospital is important for estimating the number of hospital cases that may be expected in that area. In comparison to Brandon hospital, which serves almost 100,000 persons, the other centres serve much smaller populations: The Pas, Swan River and Flin Flon serve populations of less than 20,000 persons; Morden-Winkler, Steinbach, and Dauphin between 20,000 and 30,000; Portage and Selkirk between 30,000 and 40,000. For hospitals in the three areas closest to Winnipeg (Selkirk, Portage and Steinbach), from 33% to 63% of cases currently treated in Winnipeg facilities could be shifted back to large regional hospitals (fig. 1). Approximately 34% of cases from the Thompson area could be redirected. At most, 810 obstetric cases, 786 paediatric cases and 1180 adult medical cases could be relocated to large rural hospitals (table 1). Because these patients would be spread over 10 hospitals, most of which have low occupancy rates, the impact at each hospital would likely be small. Over all ten hospitals, 9 beds would be required for obstetrics, 9 beds for paediatrics, and about 28 beds for adult medical. Selkirk would be the largest recipient, requiring 3 more beds for obstetrics, 3 for paediatrics and 11 for adult medical. The redirection of obstetric, paediatric and adult medical cases would reduce the caseload of Winnipeg hospitals by 4% for obstetrical, 8% for paediatric and 4% for adult medical cases (fig. 2). Across the different types of hospital care, the largest proportion of people come to Winnipeg hospitals for surgery. Although 1100 cases could theoretically be redirected to four rural hospitals, this would lead to only a 2% reduction in adult surgical cases treated in Winnipeg (table 1). Rural facilities likely would need significant investment in surgical facilities and staff training, as well as recruitment of surgical specialists. Furthermore, there would likely be a low volume of specific types of surgical cases in each hospital, so that there may be problems with quality of care. While Selkirk, Thompson and Portage could theoretically care for a large number of surgical cases in order to achieve the Dauphin benchmark, Brandon is the only non-Winnipeg service area with the facilities and surgeons to provide a wide range of specialized surgical services. The potential for shifting care needs to be assessed from a practical perspective. Selkirk, Steinbach, Portage and Thompson are the service areas with the highest reliance on Winnipeg hospitals. For communities close to Winnipeg, if the large percentage of cases treated in the city is the result of patient choice, these patterns may be difficult to change. For the Thompson region, shifting care may mean a reorganization of transportation and medical care systems. Significant decentralization of specialized services in rural areas must be considered cautiously. Providing care closer to where people live reduces travel costs and personal hardship. However, the number of specialized cases in each facility would be small, so there are concerns about quality and efficiency. Quality of surgical care is related to the number of procedures that an institution performs, so less common procedures should be centralized. Efficiency is decreased when smaller numbers of specialized types of care are provided in multiple locations.Conclusions
The findings of this report are significant for rural health reform. To function best, a regional hospital has to treat a large number of specialized cases. To generate these cases, the population should be approximately 100,000 to 150,000 persons. The population in all of the target hospital service areas except Brandon appears to be too small to support a regional centre that is capable of providing specialized care. Even using proposed Rural Health Association boundaries, the population numbers fall short.
The assumptions made to estimate the numbers of cases that might be redirected were deliberately optimistic and probably overestimate the actual numbers of cases that can be shifted. Despite these deliberately optimistic assumptions, the total number of cases available for redirection was much smaller than had been anticipated in discussion with many groups.
While the idea of delivering care closer to home is appealing, the impact of redirecting such care to rural areas would be small for most of the facilities studied. Since most of them currently have occupancy rates under 70%, they could accept many of the additional medical, paediatric and obstetric cases without requiring additional hospital beds. Considerations for surgical care are very different: while theoretically possible, shifting such care would require major investments in capital and training. Instead, there may be potential to increase the numbers of certain types of surgical procedures provided in specific large rural facilities.
Summary written by Carolyn De Coster, based on the report: Redirecting Care from Winnipeg Hospitals to Ten Large Rural Facilities: Estimated Number of Cases, Feasibility and Implications: by Charlyn Black and Charles Burchill.
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