Enhanced Skills
Enhanced Skills in Rural and Remote BC
Generalist health care providers can extend their practice to offer more specialized care through enhanced skills. Generalists with enhanced skills are important for rural health services stability and adaptation as meeting the needs of the population can be achieved locally rather than patients having to travel to access services in referral centres or waiting for the periodic visits of specialists doing community visits. The level of enhanced skills that are appropriate and sustainable in a specific rural community depends on the size and demographics of the given population and the expected frequency of the need for the enhanced skills.73
In 1993, BC instituted regionalized care, meaning that intermediary administration structures were now responsible for organizing and delivering health services to a defined population. The move to regionalization was aimed at reducing costs, improving access to and accountability for public health services, and increasing public-involvement in decision-making.74 In the context of rural healthcare provisioning, regionalization has resulted in an increased number of health procedures and services being offered and conducted at regional referral centres. This is especially pronounced in procedural services such as surgery, anesthesia, and maternity care.75,76,77 In association with regionalization, there have been closures of more than 20 small rural maternity service facilities forcing parturient women to travel away from their communities to give birth.75,78 Loss of local caesarean section services in a rural community could result in the proportion of women able to safely deliver locally being reduced from 85% to 40%, if intrapartum services are able to remain open at all.78 Loss of local surgical and anaesthesia services can further compromise local trauma and emergency care.77 This is cause for great concern as climate change and ecosystem disruption progress, increasing the need for sustainable local generalist services and enhanced skills.
Enhanced Skills Competency in Rural Health Care
Enhanced skills training offered to general practitioners are specific and diverse. From geriatrics, Indigenous health, obstetrics, emergency medicine, to anesthesia and surgery, generalists can choose their field of training based on their community’s needs. To ensure quality training, enhanced skills programs are required to meet standards set by The College of Family Physicians of Canada (CFPC). After the acquisition of Certificate of Added Competence (CAC) credentials, maintenance of competency requires adherence to guidelines and continuing professional development.79 At UBC, the Department of Family Practice provides training in Enhanced Skills in two categories:80
- Category 1 includes main specialties with the national curriculum set by CFPC, including family practice anesthesia, geriatric care, obstetrical surgical skills, and palliative medicine.
- Category 2 allows more flexibility for generalists to tailor their training to specific interests. Some of the programs include addiction medicine, global health, HIV/AIDS, and women’s health.
Reflective of these efforts, evidence suggests that generalist practice with enhanced skills provides safe, acceptable, and cost-efficient care, especially to rural communities.81,82,83 Similarly, there has been no evidence suggesting superior outcomes of simple surgical procedures in urban centres over rural hospitals in Canada.84,85 For high-income countries such as Canada, Australia, and the United States, The Lancet Commission, in 2015, found that for basic procedures, such as caesarean delivery and appendectomy treatment, outcomes were as good in rural communities as in urban centres.86 As such, they have recommended “task-sharing” between specialists and generalists with basic skills in surgical, obstetrical, and anesthetic care as a solution to address global shortages of specialists, especially in rural and remote regions. The Commission suggests that this solution will bring quality care and positive outcomes to patients even when specialists are not locally available.86,87
Dr. Stefan Grzybowski discusses what enhanced skills are and how they can play a role in the care provision for a rural patient panel (1:56)
Importance of Locally-Provided Care
With the predicted increases in morbidities and adverse health outcomes associated with worsening climate change and ecosystem disruption, generalists with enhanced skills can support the sustainability and adaptability of local health services and decrease the need for patient transfers. Evidence shows that strong local care may have numerous benefits for patients.
With physical distances and environmental circumstances such as weather hindering a transfer, rural patients can face critical delays until definitive treatment is available. Increased access to local healthcare protects communities’ right to health, which the WHO outlines as accessibility, equitable, and timely quality of care.88 For example, diagnostic services such as ultrasound can be provided locally or even in the emergency department using a portable probe and can be not only cost-effective, but also allow prompt diagnosis of acute presentations.89,90 Locally-provided procedural services, such as colonoscopy, appendectomy, and immediate trauma care, can also significantly decrease delays in treatment and produce comparable or even better outcomes than patients being referred and transferred to a regional referral centre.83,91,92
In addition, displacement from home and familiar care providers can be stressful for patients which can evoke insecurity, anxiety, and miscommunication, leading to additional distress and other negative outcomes. Patients preferred continuity of care from local generalists who understand their needs over specialist care from an unfamiliar hospital. Financial burdens from the cost of transport, missing work, or organizing childcare can also create issues or delay the timing of care.93 Patients are also more likely to experience effective communication and receive culturally-relevant care when it is provided locally.76 Enhanced skills, and consequently, enhanced local services can mitigate this problem significantly in selected situations.
Finally, many rural patients not only end up making several trips to distant hospitals for needed care, but are often required to undertake significant travel on the day of their procedures, which can negatively affect their recovery process.76 Local care allows flexibility in hospital admission and discharge that is tailored towards patient wellbeing, potentially producing better health outcomes.
Identifying Community-Specific Health Needs
Defining a service dependent population and identifying its needs concerning health services is foundational to healthcare planning. Being able to meet the needs of a population efficiently is important for climate-resilient health services.77 Given the wide variety of potential illnesses associated with climate change and ecosystem disruption augmenting an already replete range of clinical conditions that affect rural people, a clear understanding of necessary services and annual estimated patient volumes are essential for generalists to determine the enhanced skills training needed. It is also important for health authorities to determine the sustainability of services, especially when they require additional infrastructure or budget. In order for this planning to be successful, a holistic examination of population size and demographics, burdens of disease, geographic isolation, and trends in the use of referral centres, is necessary on a community-by-community basis.
Visualization of complex data to identify long-term trends and regional disparities within the healthcare system and at a community level is essential. This can also facilitate communication between the pentagram partners, such as the health authorities and the public.94 For example, the Rural Birth Index (RBI) project at the UBC Centre for Rural Health Research (CRHR) actively utilized this approach to determine rural health needs. Through a multidimensional regional analysis combining geospatial mapping with census data, utilization data, and health outcomes, the RBI systematically measures need for local maternity services and parametrizes that need against a projected appropriate and sustainable level of local services.95 More on data and the RBI can be found in Chapter 4.
Quantifying the need for services of a rural population in an objective and systematic way allows health service planners to balance specialist, generalist, and enhanced generalist care to not only plan specific services, but ultimately to enhance rural community health service resilience to climate change and ecosystem disruption. Through appropriately fine-tuning local healthcare, better alternatives for patients and the environment can be provided. Strengthening generalist models of care and enhanced skills are important healthcare adaptation strategies that are central to evolving rural services in the face of the challenges posed by climate change. These issues must be further discussed amongst the pentagram partners for appropriate government support, education for physicians, and increasing the resilience of rural communities.
