Impact of rural hospital closures in Saskatchewan, Canada

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Abstract

Canada's health care system has undergone major changes since 1990. In Saskatchewan, 52 small rural hospitals funded for less than eight beds stopped receiving funding for acute care services in 1993. Most were subsequently converted to primary health care centers. Since then, concerns have been raised about the impact of the changes on rural residents’ access to care, their health status, and the viability of rural communities. To assess the impact of hospital closures on the affected communities, we conducted a multi-faceted, province-wide study. We looked at hospital use patterns, health status, rural residents’ perceptions of the impact of these hospital closures, and how communities responded to the changes. We found the hospital closures did not adversely affect rural residents’ health status or their access to inpatient hospital services. Despite widespread fears that health status would decline, residents in these communities reported that hospital closures did not adversely affect their own health. Although some communities continue to struggle with changes to health care delivery, others appear to have adapted as a result of strong community leadership, the development of widely accepted alternative services, and local support for creating innovative solutions. Good rural health care does not depend on the presence of a very small hospital that cannot, in today's environment, provide genuinely acute care. It requires creative approaches to the provision of primary care, good emergency services, and good communication with the public on the intent and outcomes of change.

Introduction

Saskatchewan has been a leader in health care in Canada for almost 50 years. The province pioneered universal hospital care insurance in 1947 and comprehensive medical coverage in 1962. Saskatchewan began a major reform process designed to renew the health system in 1992. The conceptual cornerstone of the new approach was the wellness model and a shift from institutional to community care. The wellness model emphasizes preventive care and innovative service delivery within a system of 33 health districts. The need for this shift in emphasis and structure is best illustrated by the fact that in 1992, Saskatchewan had 134 hospitals for a population of one million people — more than in Quebec, for example, with a population seven times larger. As a consequence, utilization rates were high and the populace identified strongly with a brick-and-mortar approach to health care.

Fiscal circumstances in the 1990s also increased pressures for change. In 1982 the province had no accumulated operating debt. By 1991, after two terms of Progressive Conservative government, the cumulated deficit had reached nearly $9 billion (Canadian). The province's credit rating declined steadily through the 1980s. When the New Democratic Party resumed power in 1991 it faced a daunting situation: there were threats of further downgrading of the credit rating, raising the possibility that the province could no longer borrow money to cover any operating deficit. Since health care consumed a third of the provincial budget, it was an obvious target for restraint.

To accelerate the shift from institutional to community care and as a cost-containment measure, the Saskatchewan government announced the conversion of 52 small rural hospitals to health centers in 1992. All of these affected hospitals but two had less than 25 beds; none received funding in 1992 for more than eight beds. These hospitals were located in towns with about 500 people. They did not perform surgery. Of the 52 hospitals, 23 were integrated facilities with both acute and long-term care beds. These 23 continued to receive funding to operate as long-term care facilities. The remaining 29 hospitals were given one-time only funding to convert to wellness centers. Many of these wellness centers operate five days a week with full-time staffing by nurses and part-time physician visits. In addition to the conversion to wellness centres, the withdrawal of acute care funding was counterbalanced by the expansion of primary care, emergency, physiotherapy, home care, and long-term care services. Since the funding cuts, concerns have been raised about the impact of these changes on rural residents’ access to care and health status. In addition, the health care providers and the public worried about the potential loss of local jobs, a further decline in the economy, and out-migration of some rural residents (James, 1999).

In Canada, several other researchers have examined the effect of bed closure (Roos & Shapiro, 1995) and hospital restructuring (Anderson, 1997). None has assessed the impact of hospital closure. In the United States, a few studies have assessed the impacts of hospital closures. Most found little effect on access to hospital care (McKay & Coventry, 1995; Fleming, Williamson, Hicks, & Rife, 1995; Mullner & McNeil (1991a), U.S. Congress (1991b); Mullner & McNeil, 1986; Samuels, Cunningham, & Choi, 1989; Burda, 1992; U.S. Department of Health and Human Services, 1989; Hendricks & Alberts, 1989) and the health of rural residents (McKay & Coventry, 1995; Fleming et al., 1995; Mullner & McNeil (1991a), U.S. Congress (1991b)). Others reported that access (Bindman, Keane, & Lurie, 1990; Rosenbach & Dayhoff, 1995; Hart, Pirani, & Rosenblatt, 1991, American Hospital Association, 1989; Mullner & McNeil (1991a), U.S. Congress (1991b)) and health status (Bindman et al., 1990; Rosenbach and Dayhoff, 1995; Hart et al., 1991) had deteriorated in communities after hospital closure. In particular, the elderly, the poor, and those needing emergency care were disproportionately affected.

Most of these were American studies of rural hospitals two to four times the size of the affected Saskatchewan rural hospitals. The conclusions therefore were of limited applicability to Saskatchewan. We did, however, build our study design on the previous work. Most of the previous studies used hospitalization rates, number of people hospitalized, and episode of care as indicators for access; and used mortality as an indicator for overall health status. We also chose mortality because it is a robust indicator for health status. Mortality has been used by many countries to assess health status across populations, for example, Health For All in the Twenty-First Century (The World Health Organization, 2000) and Healthy People 2010 (U.S. Department of Health and Human Services, 2000). A study from Canada (Cohen & MacWilliam, 1995) concluded “mortality indicators alone appear to be sensitive to differences in health status across populations”. Rosenbach and Dayhoff (1995) used a pre, post-design as well as trend analysis to determine whether rural hospital closures have had a detrimental impact on access to inpatient and outpatient care.

James (1999) has assessed the impact of rural hospital closures by reviewing the history of the Saskatchewan hospital conversion process and the meaning of local hospitals for rural communities. Our study assessed the impact of closures by focusing on health status, hospital utilization, and residents’ perceptions. This report summarizes our findings. We hope this study will stimulate public discussion and inform health care planning at the community, provincial, national, and international levels.

Section snippets

Methods

In 1997, the Health Services Utilization and Research Commission (HSURC) formed a working group of representatives from a number of rural communities. It comprised physicians, a nurse administrator, citizens who have served on rural health boards, and a sociologist and agricultural economist both knowledgeable in rural issues. The working group provided direction to HSURC staff throughout the research project.

To fully examine the impact of the closure of rural Saskatchewan hospitals, we sought

Hospital use and health status — administrative data analysis

We used three rates to measure hospital use: number of people hospitalized, hospitalization rates, and episode of care. They yielded similar results — hospital use has declined throughout the province (Table 1 and Fig. 1). The closure communities had the sharpest decline in rates; communities that still have small rural hospitals continue to have the highest rates of hospital use. The declining trend in the closure group was significantly different from the still group, but not significantly

Strengths and limitations

This study is unique in that it is the only comprehensive assessment of the impacts of rural hospital closure. The study is also strengthened by its pre-, post-comparison, use of four study groups, and the assessment of trends over time. The impacts of hospital closures go beyond measures of access to care and health status. We therefore complemented our administrative data analysis with a telephone survey and focus group discussions to hear rural resident's perspectives.

We excluded the First

Conclusions

Closing very small rural hospitals did not appear to adversely affect rural residents’ health status or access to inpatient hospital services. Whether the hospital closures actually affected community's viability, residents did not perceive it to be a major factor. In this sense the impact of the restructuring of Saskatchewan's hospital system was not as great as anticipated, especially when one considers that these small hospitals, despite severely limited capacity to deliver genuine acute

Acknowledgements

We wish to thank the working group members for their dedication and guidance throughout this project. The working group members are: Jerry Danielson (chair), Marianne Hodgson, James Irvine, Murray Knuttila, Bernice MacDougall, Russ McPherson, M. Rose Olfert, Michael Smith, and Sandy Weseen.

We gratefully acknowledge Greg Basky, Kelly Chessie, Barb Nisbet, and Laurie Thompson from HSURC for their critical reading and helpful suggestions. Also sincere thanks to all the rural residents who

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