The importance of having a local perspective
While reporting results for the province gives a broad idea about how New Brunswick performs overall, when we look at each region or community separately, we see that local values may vary greatly from the provincial ones. This means that average values for N.B. can hide the variability observed at a more local level and do not provide an accurate picture of the health services in each region. This article will describe the differences (either better or worse than the provincial average) that exist among communities and zones related to citizens’ ability to access the health system as well as their experience and outcomes from using health care services.
The New Brunswick Health Council (NBHC) work has increased the availability of local population health and health services data at the community level. These data have helped recognize that there is a wide variability in the quality of health services around the province.
Regardless of where they live or who they are, citizens in N.B. should all be able to experience the same outcomes in terms of health services quality, like receiving accessible and appropriate services that match their needs and enables them to enjoy good health status and quality of life. This is what we consider an equitable health system.
This article will look at equity from a geographic perspective.
Equity, one of the key dimensions of health service quality, is defined as the ability to provide quality care/service to all, regardless of individual characteristics and circumstances. (e.g. place of residence, age, income, disabilities, immigrant, indigenous, etc.)
Planning and delivering services in the absence of understanding local needs does not support the fulfilment of equity as a dimension of quality. Citizens with different health needs will continue to experience gaps in health service quality, and consequently will not achieve the desired health outcomes.
Note: This analysis focuses on family doctors as they currently represent the most common entry point for accessing health services. Indeed, although primary health care providers include a wide range of professionals, with a growing role for nurse practitioners and multi-disciplinary teams, currently 90% of New Brunswickers report that they have a personal family doctor as their primary health care professional and our health system is still family doctor-oriented.
Accessibility: Do all New Brunswickers have a similar ability to receive health services?
In 2017, only 56% of New Brunswickers reported being able to get an appointment within 5 days with their family doctor. While low, this number only demonstrates a provincial average, which may or may not reflect what is actually happening at the local level. At the community level, although 3 in 4 (75%) citizens in the Perth-Andover Area reported being able to get an appointment with their family doctor within 5 days, barely 1 in 5 (19%) in the Kedgwick Area could; in this instance, the numbers at the local level are very different from the 56% in New Brunswick overall.
This variability is also visible when looking at the ability to access hospital services. At the zone level, in 2018, 71% of knee replacement surgeries in Zone 6 (Bathurst and Acadian Peninsula Area) were done within the target of 26 weeks, while only 29% of knee replacement surgeries in Zone 2 (Fundy Shore and Saint John Area) were done within that time frame.
Experience: Do all New Brunswickers have a similar experience using health services?
Even after citizens receive a health service, the way the service is delivered, its appropriateness, effectiveness and safety do not necessarily look the same across the province.
Communication was one aspect of care experience that varied across communities.
When asked if their family doctor gave them enough time to discuss their feelings, fears and concerns about their health, 3 out of 4 (76%) of the citizens in the Oromocto Area said it was always the case, while only 1 of 2 (53%) of the citizens in the Neguac Area felt that way.
There was also variability around how family doctors explained things, where despite the fact 80% of New Brunswickers reported that their family doctor always explained things in a way that they could understand, this answer ranged from 66% to 90% depending on which community citizens lived in.
Outcomes: Do all New Brunswickers have similar results using health services?
This area relates to the effectiveness of health care, whether the desired results are achieved after someone has accessed and experienced health services.
For citizens with chronic health condition(s), confidence in their ability to manage their health condition is an important outcome/result of their primary health services, and it demonstrates how effective those services are.
In New Brunswick, only 2 in 5 (41%) citizens with chronic health condition(s) reported being very confident in controlling and managing their health condition. That result was even poorer for some communities like the Kedgwick Area where only 22% of citizens reported being very confident about managing their health condition, while 47% of citizens living in the New Maryland Area felt this way.
If citizens receive quality health care that can prevent the onset of a certain type of illness or condition, that controls an acute episodic illness or condition, or that manages a chronic disease or condition, their need to be hospitalized will be reduced; in other words, there will be fewer avoidable hospitalizations (also known as ambulatory care sensitive conditions). Each year, on average, there are 48 avoidable hospitalizations per 10,000 of the population younger than age 75 in N.B., but this rate varies from 23 per 10,000 in the Quispamsis Area to 87 per 10,000 in the Campbellton Area.
Planning: Is it based on needs?
When taking a deep dive into a citizen’s journey through health care services, our data has shown that the provincial average blurs the actual picture of what is really going on across the province. Only local numbers really allow us to appreciate how the quality of health services varies across the province and how some communities fare better or worse than others. At the level of needs-based planning, there are some elements that indicate that resources are not the same across the province.
Distribution of family doctors
When looking at the distribution of family doctors throughout the province, there are 12 family doctors per 10,000 citizens in Zone 2 (Fundy Shore and Saint John Area) and Zone 3 (Fredericton and River Valley Area), and 17 per 10,000 citizens in Zone 4 (Madawaska and North-West Area).
Citizens who have a family doctor
However, when we look at who reported having a family doctor, the zones with the most family doctors per population (for example, Zone 4 - Madawaska and North-West Area) are not necessarily the ones where the most citizens have a family doctor (for example, Zone 1- Moncton and South-East Area and Zone 6 – Bathurst and Acadian Peninsula Area).
Timely access to a family doctor
Moreover, having a family doctor does not necessarily translate into being able to see a family doctor in a timely manner. Zone 4 has the highest number of doctors per 10,000 citizens, with 90% of citizens attached to a personal family doctor. Yet only 40% of citizens in this same zone are able to get an appointment with their family doctor within 5 days, compared to 62% for those living in Zone 2, which has the lowest number of doctors per population.
Conclusions
Equity, one of the key dimensions of health service quality, is defined as the ability to provide quality care or service to all, regardless of where they live (and who they are). In this article, we showed that there were wide variabilities depending on where citizens live:
- in their ability to access the health system
- in their experience of the health system
- in the results obtained from using the health system
The variability that exists across communities and regions is a symptom of a health system that needs to be more equitable. Citizens expect to receive a consistent level of health services regardless of where they live.
It is well acknowledged that this variability of health service quality is a challenge across New Brunswick (as well as throughout Canada) and it has now become imperative to address the situation and mitigate the inequity that exists across New Brunswick.
The outcomes of inequitable and poorly performing health services lead to more sickness, poorer quality of life and an increase in demand for hospital services. In the future, the planning and management of primary health services will need to maximise the roles of all primary health professionals in line with the needs of citizens in their respective communities. In 2017-2018, the NBHC recommended that an effective and clear accountability framework be developed to clarify responsibility for the state of primary health services in addressing inequities at the zone and community levels.