NWT ‘rejected better answers’ to keep offering rheumatology

An Alberta rheumatologist says the NWT government turned down multiple opportunities to keep the service open in Yellowknife.

Rheumatology is no longer being offered in the territory. Almost 400 patients have been referred instead to Alberta and must travel to Edmonton for treatment, the NWT’s health authority said last week.

While the health authority attributed the closure of rheumatology at Stanton Territorial Hospital to “an inability to find a consistent provider,” Dr Steven Katz said that isn’t the case.

Dr Katz, an Edmonton-based rheumatologist, told Cabin Radio he has spent the past two years trying to reach a solution with the NWT that would preserve in-person treatment in Yellowknife – but authorities in the territory first acted too slowly, then chose an option that Katz believes offers worse care for more money.

The territory’s health authority, in a fresh statement, reiterated its view that sending patients to Alberta is now the only viable way to offer “regular providers and a coordinated program.”

A rheumatology staffing problem arose in Yellowknife after one of Katz’s colleagues retired from the part of their practice that involved regular trips to the NWT, the doctor said. A new rheumatologist had to be found who could take over, but the aim was also to build a sustainable – and even expanded – program that could help reduce a waiting list of hundreds.

“It went slower than I would have liked,” Katz said by phone, attributing some of that to the Covid-19 pandemic.

“We had a plan to start a multidisciplinary arthritis program, identify a rheumatologist to start up and run that program, and the NWT would fund an allied health position that would do a lot of the continuity of care in between visits and handle some of the complexities of practice.”

For example, Katz said, the NWT was looking at creating a nurse position that would help coordinate patient care and the prescription of expensive drugs that slow or stop inflammation.

“We would train them up, that position would help extend care, and we would be able to see more patients with two bodies instead of one,” he said.

According to Katz, by the late fall of 2021, his group of Alberta rheumatologists had identified a candidate who would be able to start the new program, come up to the NWT and provide several weeks of service each year at Stanton.

Katz said the NWT government had committed to the plan at the time – but then waited months to finalize the paperwork that would have activated the deal.

By the time the territory finally made its move, Katz said six months had passed and the rheumatologist initially identified to come north, tired of the uncertainty, had moved on.

A second attempt

This spring, despite that setback, Katz said he came up with a new strategy and pitched it to the NWT’s health authority.

Throughout negotiations with the health authority, Katz and colleagues had continued intermittent visits to Yellowknife to provide rheumatology services. In doing so, he said, the territory’s waitlist had dropped to around 70 patients – but with no continuity of care between visits.

Where previously the plan had been to find a rheumatologist and start a program from scratch, Katz now proposed building the program himself then finding a rheumatologist to step into his shoes.

“What I had proposed to them is that I would personally ensure there were ongoing rheumatology services of some sort, be it through me or these other rheumatologists, for at least the next 18 months – which provides me time, should they fund it, to train up this allied health professional,” he said.

“Then I can go to someone and say, ‘Look, there’s a full program, you don’t have to start it yourself, it’s there and ready to go.’

“That wasn’t good enough for them. They wanted someone to commit, full stop, for five years, now. We got stuck in this chicken-and-egg situation. I would argue, though, that even if the plan failed, 18 more months of service in the NWT? Still we’re better off.”

Health authority ‘would need additional funding’

The NWT’s health authority, in a written statement, stood by its decision-making.

“In the NWT, the services that we are delivering via visiting rheumatologists have become increasingly difficult to organize in a way that would provide continuity for patients,” health authority spokesperson David Maguire wrote.

“Having a provider or group of providers that would be able to travel to the NWT on a regular schedule, and then also follow the patients they have seen here via virtual care, was not something we could secure when working with the team that centrally coordinates rheumatology services in Alberta without significant additional resources that would constitute a program.

“While we do appreciate that providers may be able to provide episodic care via visits to the NWT, the crux of the issue is ensuring that we have consistency in frequency of visiting specialists and, critically, support in between visits.”

That sounds like the kind of service Katz had described, but the health authority said discussions with rheumatology providers – it did not name any – had not “resulted in securing contracts that would ensure continuity of care between on-site visits.”

“Up until this point the NTHSSA has resourced rheumatology services from within,” Maguire wrote. “If there were to be discussions with Alberta about a more cohesive program that provides the continuity and coordination of service and providers that we require, we would need to seek additional funding to support this level of service.

“In addition to an agreement with Alberta about the provision of specialist providers, a coordinated program would also require a suite of on-site resources that would need to be established if we were to be able to deliver this service in the NWT on an ongoing basis.

“I would like to reiterate the decision to move care to Alberta was based on the interest in having regular providers and a coordinated program to support the triage, management and coordination of care for residents in a consistent and ongoing manner.”

Alberta’s waitlist already large

Katz expressed confusion at the health authority’s decision to choose an option involving medical travel for hundreds of people but state “additional funding” is required for the kind of program he had suggested.

“It’s a funding issue, but one that I don’t understand: let’s pay less for the program I’m suggesting but that comes out of one pocket, versus let’s pay an arm and a leg more for the travel,” he said, characterizing the separate arms of government that fund medical travel from one budget and health services at Stanton Territorial Hospital from another.

“People who have joint pain, joint swelling, impairment – who can’t dress themselves, let alone the travel difficulties – to have to spend that much more time coming down to Edmonton, when we’re willing to come up?

“Is the solution ideal today? Sure it’s not. But I feel like we have better answers.”

Katz also worries for the consequences in Alberta, which he said already has a waitlist of more than 600 people for rheumatology services.

“We have wait times longer than they’ve ever been in my time in practice. Another 400 patients on top of that affects everyone,” he said.

“Six hundred people or so in Alberta don’t even have an appointment booked. They’ve been triaged but we don’t have a spot to book them today or tomorrow. Now let’s add 400 to that.

“Rheumatoid arthritis is a systemic, inflammatory disease. If you don’t do it right, the cost to the system over time is huge. And a non-patient-centred approach certainly doesn’t help anyone, either.”