Q&A: The future of providing healthcare in the North

Changes in NWT rheumatology care are one example of how healthcare leaders are trying to join a complicated set of dots to offer the best treatment they can.

The people making decisions about healthcare in the territory have to balance a complex funding system with the needs of northerners and the availability of people to do the work.

In the case of rheumatology, the loss of one person who had offered the service in Yellowknife for a long time started a months-long dialogue between the NWT and Alberta about how to preserve care for patients.

Ultimately, in December, patients were told rheumatology is no longer being offered in the territory. Almost 400 people were referred instead to Alberta and must travel to Edmonton for treatment.

Alberta rheumatologist Dr Steven Katz subsequently told Cabin Radio the territory’s health authority had missed opportunities to preserve a program that allowed patients to be seen in Yellowknife.

But in an extensive interview, Dr Claudia Kraft – the NWT’s medical director – said the health authority had chosen the option that provided the highest-quality care while continuing to work on a solution that will allow treatment in Yellowknife.

Dr Kraft said she felt “quite optimistic” that an approach can be found that will return rheumatology service to Yellowknife in future, citing past examples where services were temporarily moved to Alberta before resuming in the NWT.

More broadly, Kraft said the territory and its residents have to be “prepared to make some tough decisions” about the future of northern healthcare.

“We can’t have it all and expect to do that with zero incremental cost,” she said.

“At some point, citizens in the Territories and across the country have to decide where to prioritize the limited funds that are available. Is it all of healthcare? is it primary healthcare? Is it subspecialty healthcare? How do we fit that puzzle together?

“And for those of us in the North, which parts do we want to make sure we definitely have access to, all of us within the territory? And which types of care could we live with if we had to accept that they couldn’t be close to home?”

Read the full interview below.

This interview was recorded on December 23, 2022. The transcript has been lightly edited for clarity.

Ollie Williams: How do we get to a situation like this, where we lose a rheumatology service?

Claudia Kraft: I’m not entirely sure I’d characterize it as losing a service, in as much as our patients ultimately still need to get their rheumatologic care and they’re still going to get that. What they’re losing is a really valuable piece, from our vantage, which is care close to home. What they’re gaining right now is access to continuity of care, so appropriate quality of care, that we just didn’t have a pathway to delivering here with our current circumstances and the options available to us.

How that arises is a complicated story that to a certain extent touches on funding, but the reality is that in a lot of services, we have an inherent vulnerability because we’re small. We don’t easily maintain a lot of redundancy for many services.

Our situation with rheumatology was sort-of an organic arrangement in which we had a longtime rheumatologist willing and able to visit the Northwest Territories for many years. When that individual’s circumstances changed, we really struggled over the past several years to find equivalent continuity of care. We’ve been lucky to have a series of people willing to provide that service for short periods of time, but what we’ve really struggled to find is somebody – or a group of people, ideally – willing to provide us with a comprehensive package of care that is appropriate rheumatology care.

That means not just visits to Yellowknife to meet with patients from around the territory, but also that in-between care that is so critical: following up on results, triaging referrals and answering questions that arise about the care of those patients. That’s the whole package that’s required in order to call a service a real service. It’s been really difficult to find one or more people willing to do that whole package with the resources that we have available.

That sounds like the package Dr Katz was describing. He seemed to think that package was achievable.

I think we have a very similar vision because we’ve been working really closely together for the last two and a half years. It may well be possible that we will be able to achieve a package in which we have consistent providers willing to partner with us to provide comprehensive rheumatology care close to home.

A timeline for that is hard to predict. I can say with certainty that if I had a clear pathway to that comprehensive service, without a solution where people have to access care that they need in Alberta, then I would have taken that for sure. But as you can imagine, it’s more than just saying, ‘This is the vision that we have.’ We actually have to put quite a few pieces together in order to make that vision into a reality, into a real package.

If a rheumatologist and a nurse rocked up in Yellowknife tomorrow and said they were ready to start a program, it sounds like the money would not be a problem.

The funding picture is a little bit complex. The health authority was funded from within, so without any explicit funding, for rheumatology services for a long time. That means the funds used to pay the physicians’ component of the work have come out of the budget for other core physician services. The additional supports, clinic support staff when those visiting rheumatologists came, were also not explicitly funded. They, again, were funded from within. They came out of the resources assigned to other services.

If a comprehensive package – in partnership with a group of rheumatologists and some additional allied health personnel – required more than what we’ve funded from within traditionally, then we would need to seek additional funds through the Department of Health and Social Services and the Government of the Northwest Territories to fund that budget item. You can imagine that it’s likely to be achievable, because the cost of providing the care plus the medical travel in Alberta is likely to be able to help us make the case to fund those additional resources.

What I’ve really learned from the rheumatologists that we’ve partnered with over the past few years is that the status quo of just having rheumatologists willing to come, and the resources that we’ve been able to fund from within as far as program assistance support, nursing support, isn’t enough to make it viable for them. So we don’t have anyone willing to do the in-between care without additional resources now, and to have those additional resources would require some additional incremental funding to NTHSSA. That’s not to say that it couldn’t or wouldn’t happen. I think that there’s a very strong likelihood that it would, but it would have to go through the usual funding cycle, that process. That’s not an overnight or tomorrow type of solution.

You mentioned that the funding setup is complex. Does it sometimes get in the way?

I think there’s no question that there is a certain nimbleness that a 24/7 health system requires, and that is difficult to reconcile at times with an 18-month funding cycle that is the norm for government. Absolutely, there are times when it would be useful to be able to make decisions more nimbly and more quickly. It’s also, I think, important to provide good value for the funds that we spend, because these are public funds. That oversight is built into the system, I’m quite sure for a reason. But if I could make it happen in the timescales of months rather than years, I’m sure that would be an advantage for problem-solving on some of these types of complex issues.

It sounds like the door is not closed on the idea of rheumatology reemerging as a service that is provided in Yellowknife. Can you see a future where rheumatology is provided here again, and provided as a funded service?

I absolutely hope that that is the future before us. I’m still working closely with our Alberta Health Services partners, both on the logistics of the immediate solution – which is care for these patients in Alberta – and with ongoing discussion about how we get to the longer-term plan, which I hope is care close to home that is of high quality. We don’t want to cut corners and have low-quality care just because it’s close to home. That’s just not acceptable. And so for that reason, we do have to do this two-solution approach of first ensuring that patients do get timely access to continuity of care that they need for these complex illnesses, and then picking back up – hopefully close to where we left off – in working toward a more comprehensive arrangement.

And we have other examples. Part of my optimism is that we’ve done this before within the Northwest Territories. Two good examples have been the colonoscopy program – which at one point was temporarily shifted back to Alberta while we built back a more effective and higher-quality program here, and then we once again resumed that full service – and the medical oncology program. At one point in recent history, patients who required chemotherapy in the territory, were not able to receive that service in Yellowknife any longer and they were temporarily moved to Alberta while we put together what I think, by most accounts, is a very successful program with Cancer Care Alberta.

Because of those two recent examples, in which we’ve been able to successfully build and fund programs that are both high quality and close to home, I feel quite optimistic that a similar solution is possible.

We’ve done it before, might we have to do it again? Would you characterize any other services that we currently enjoy in Yellowknife as being similarly vulnerable?

I think there are a number of services that have been delivered without any explicit funding or mandate, and I think there’s an inherent vulnerability to most of those programs. Where we have one or two providers that have chosen to provide services in the NWT, it’s easy to imagine a life change – changes in their circumstances – that would lead them to stop being able to deliver that service. In that case, we would once again find ourselves looking for a solution.

I think what’s a little bit different about rheumatology is that we have been working toward a longer-term solution for many months with our partners in Alberta. It’s clearer to me what the immediate solution is for this program than for certain others. But our vulnerability has also been greater in this program, because we relied on a single provider for many, many years within rheumatology and so, you know, there was a certain inevitability that eventually that person was likely to stop coming.

Even in our core services, when you’re only two, three, or four people deep for a particular service, we can find ourselves in what seems like an urgent staffing challenge or resourcing challenge. That’s, I think, just the nature of being in the North and being small.

What are the broader conversations that you must have with colleagues across Canada about how we put healthcare on a steady footing here?

It’s one of those really complex problems. We’ve had a lot of rapid disruption, I think, in what we thought was the predictability of the health human resources scene. I think Covid has provided some opportunities, because it’s allowed for in some cases helpful disruption. We got over a lot of humps that had been stagnating for many years regarding remote care. And now remote care is an option as a blended model, or as an exclusive delivery model for a lot of different areas of healthcare. But we also are still reconciling ourselves to the pre-existing conditions in our health human resource planning. So there are in rheumatology, for example, many people that are retiring in a bit of a bubble, and I think for some people Covid has hastened their exit from the profession.

The way forward, I think, is a blend of trying to find some creative technological solutions that allow us to spread the wealth, spread the knowledge, and share scarce expertise more equitably and more efficiently. Some of it is really getting a better handle on who is out there? What is their expected trajectory in the course and what are their expectations? I do find that newly graduating family physicians, for example, have a really different set of expectations about what their work life should look like, as they look forward to the next 10 or 20 years, than some of the physicians that are looking back on 30 or 40 years of their career.

I’m heartened to see that there’s some work happening nationally to get a better handle on what, particularly, physician health human resources look like. I’m heartened to see the Canadian Medical Association advocating for pan-Canadian or national licensure for healthcare professionals. I’m heartened to see more in the public discourse around finding ways to credential international medical graduates. I think these are all parts of the solution.

But I also think that at some point, we have to be prepared to make some tough decisions. “We can’t have it all and expect to do that with zero incremental cost. At some point, citizens in the Territories and across the country have to decide where to prioritize the limited funds that are available. Is it all of healthcare? is it primary healthcare? Is it subspecialty healthcare? How do we fit that puzzle together? And for those of us in the North, which parts do we want to make sure we definitely have access to, all of us within the territory? And which types of care could we live with if we had to accept that they couldn’t be close to home? I think the main challenge, though, is making sure the care we do get is high quality. Care close to home is just one of those pieces, but high-quality care is the foundation. If we can’t do that, then we probably do have to accept some travel, some distance.”

Is the choice going to ultimately be between saying goodbye to some local services or paying more?

Local services are not always more expensive.

In the case of rheumatology, specifically, if it was just about choosing the cheapest option, we might have carried on piecing together individual rheumatologists and accepted that we weren’t going to have appropriate continuity of care in between those visits. Instead, we determined that we must have that proper care, the comprehensive care that includes follow-up of tests and results, and triaging, and what I would consider to be a true program. In order to achieve that, in the short term, that is going to cost us more, because we will be paying for the interprovincial billings – the government will pay for that – as well as the medical travel.

Sometimes, care close to home can also be more cost-effective as long as we figure out exactly what the true costs are, and what resources are needed. But there are times when we just may not be able to achieve it, even if it’s less expensive. Sometimes that comes down to health human resources: who’s available in the pool right now?

I think our partners in Alberta really do understand quite a bit of the nuances of our situation. I think they really understand how important continuity of care is and they understand how valuable care close to home is for us. I’m quite appreciative of their efforts in their advocacy to date. I think we have similar understandings of the incremental resources required to do this, and I think perhaps different realities about how we achieve that, because I appreciate that within Alberta, there’s also likely some advocacy for incremental resources strictly within the AHS system as we try and work toward a solution that that is going to be more sustainable.