This report has been approved by both Vancouver Island Health Authority and the BC Ministry of Health

CONTEXT:

Planning for primary health care on Gabriola has been occurring in various forms for many years on Gabriola Island. The starting point for this interim report is the townhall meeting held on Gabriola in January 2007. A document entitled “Enhancing Primary Health Care on the Island of Gabriola” (http://www.ghcs.ca/enhancing.html– a proposed plan for Primary Health Care on Gabriola Island) was tabled at themeeting. There was general agreement with the proposed plan from the approximately 200 people that attended, with a desire for a first focus on establishing a clinic that contained an Emergency Treatment Room and was staffed by physicians that would be available for on-call services.

Due to the tremendous response from the community, almost $100,000 was raised within 6 months and an interim clinic, with an Emergency Treatment Room, was built. Two physicians and a physiotherapist were located in the building, together with a room set aside for VIHA purposes, specifically mental health support for island residents.

There were numerous growing pains in the first year, including accessing appropriate supplies for the ETR and eventual decision by VIHA not to use the room set aside for mental health support. However, the biggest area of concern was the lack of on-call funding (MOCAP) for the two physicians providing on-call services. In November 2007, VIHA informed the Gabriola Health Care Society that there was a moratorium on providing MOCAP and a review was underway.

An analysis was carried out regarding the issues facing the physicians doing on-call (providing on-call services) and not receiving MOCAP and was sent to the CEO of VIHA and the Minister of Health, George Abbott. The Ministry recognized the issues facing Gabriola Island and indicated the need for both a short term response as well as a long term action plan that was based on population based planning. The Ministry of Health and VIHA met with the physicians practicing on Gabriola Island and the Gabriola Health Care Society to identify ways to support the community of Gabriola to implement a feasible plan that responded to the specific needs of Gabriola Island.

There were several key short term issues that needed addressing prior to proceeding with planning:

Physician stability: A crucial short term issue facing the community was the potential loss of the only two full time physicians, and the only physicians on Gabriola providing on-call response. They were ready to leave based on the lack of resolution of the on-going request for MOCAP. This was resulting in financial stress on the practice, while at the same time physicians in surrounding, comparable communities were receiving MOCAP and new positions being advertised in those communities were including MOCAP.

Two practices:While GHCS was interested in primary health care on the island as a whole, all of their time and effort had been focused on establishing the interim clinic with the ETR room and then responding to the crisis of lack of MOCAP funding. There was a need to include all physicians working on Gabriola in the planning process.

An MOU was developed between the Ministry of Health, the Gabriola Health Care Society four of the physicians practicing on Gabriola – Dr. Bosman, Dr. Hoffman, Dr. Harding and Dr. MacKenzie. Funding was provided for two components of the MOU. Fifty thousand dollars was provided for planning processes. Planning was defined quite generally in the MOU (see criteria below). There was an understanding, at the time, among those present at the table negotiating the MOU, that there needed to be a monetary response to the issues of physician stability and retention of those currently performing on-call duties. Both the GHCS and the on-call physicians requested that an equivalent to MOCAP amount be placed in the MOU. VIHA indicated to the GHCS board representatives that attended the meeting that the “planning” dollars could be interpreted very broadly.

In determining how the funds from the Ministry of Health were to be distributed, the Gabriola Health Care Society based their decisions on the following:

The importance of following through on all of the criteria outlined in the MOU.
The importance of ensuring stability of physicians currently working on Gabriola in order to proceed with effective future planning.
The importance of ensuring that opportunities were available to all physicians practicing on Gabriola to participate in the planning process.
The potential for using in-kind expertise on Gabriola to ensure that all of the criteria in the MOU, for which the GHCS was responsible, were carried out.
The importance of acknowledging the on-call work and the information that had been gathered regarding primary health care, including emergency care, since the opening of the interim clinic.

PLANNING CRITERIA AND RELATED EXPENSES

The MOU included the following statements and corresponding criteria (all statements from the MOU are in italics):

v A planning process for Gabriola initiated between April and July 2008. Fifty thousand ($50,000) will be granted by the Ministry of Health to Gabriola Health Care Society to support the planning process. The following criteria have to be met… (see a-k in the following table)

v The physicians of Gabriola will, within the next 20 days, provide information for the public planning process and to the MOH/VIHA on the following:

- Statement of physician requirements for Gabriola Island, including anticipated locum needs.

- Prepare a brief information sheet for locums and new physician applicants describing family practice on Gabriola and its attributes.

To enable the physicians to complete this work in such a short time frame $20,000 will be provided by the MOH. (see “l” in the following table)

The following table outlines the actions taken in order to satisfy the criteria outlined in the MOU.

Criteria stated in MOU For Planning Funds	Action taken to date
a. Open invitation to all Gabriola physicians with patients on Gabriola – physicians to be remunerated for their time	All planning activities have included invitations to all Gabriola physicians practicing on Gabriola. Physicians have been remunerated for their time.
b. Other health care providers from ambulance service, home and community care, for example, to be involved in the planning process.	Invitations to ambulance, home and community care and other community organizations for pre-planning & public meeting.
c. Representatives from both VIHA and the MOH need to be at any public planning process	Representatives from VIHA and MOH have attended the public planning meetings to date.
d. Working hours for physicians are sustainable and support and maintain the health and wellbeing of the physicians	Payment for on-call hours required to ensure that physicians working hours are sustainable. Plan developed by physicians providing on-call.
e. Plan must be based upon: population based data, evidence, resident and provider experience (the MOH and VIHA will work will supply relevant data)	a. On-call physicians provided data re: Emergencies and on-call. b. MOH has provided draft information to be used to inform the planning process. MOH has indicated that they will be providing Gabriola with final version. VIHA has indicated they will provide population-based data.
f. MOH will provide examples of successful experiences from comparable communities to GHCS and the plan will be informed by those experiences	MOH has indicated that there are examples of successful communities in BC. GHCS has indicated interest in providing a forum for examples. MOH, VIHA and GHCS are working together to have a forum in early 2009.
g. Plan benefits Gabriola by building upon the current investments and programs in primary health care and physician remuneration	Plan developed builds upon current investments and programs such as IHNs (Integrated Health Networks). Exploration of Division is underway.
h. Plan to include indicators important to the residents and providers on Gabriola to measure progress and success	Information regarding these indicators has been provided to MOH and VIHA. Once information is received from MOH a meeting will be held with community members.
i. It is suggested a facilitator would be helpful for the planning process (MOH will consult with the parties to this MOU and, based upon that input, organize a facilitator – expenses etc. to be paid by MOH)	MOH provided facilitator for pre-planning session and for public session in June, 2008.
j. Public meetings: Not specifically included in MOU but understood to be part of planning processes	Pre-planning session held in May 2008, Public session held June 2008.
k. The agreed upon plan to be submitted to MOH and VIHA before August 1, 2008.	Report from Public planning meeting held in June 2008 provided to the community. The report was provided to MOH and VIHA prior to August 1, 2008 to ensure their commitments were included in report. These were incorporated. Final report was released to the public August 1, 2008.
l. The physicians or GHCS are to provide the MOH and VIHA with: family practice hours on Gabriola, expected changes to physician supply, specific locum requirements, a copy of the information sheet to be provided to prospective physicians coming to Gabriola, and a copy of any press release(s) from GHCS related to this initiative.”	a. Initial information: re: Family practice hours on Gabriola, expected changes to physician supply, specific locum requirements was provided to MOH and VIHA within 20 days. b. Coverage: analysis of options for coverage, overall strategy & process for hiring of Advanced Practice Nurse. c. Recruitment: advertising for a long term physician that is able to do on-call. Brochure developed for all those applying to be a physician on Gabriola and provided to VIHA and MOH for recruitment purposes. Welcoming events to all potential applicants. d. VIHA & Rural Locum program: contact to recruit locums, accommodation for locums, managing schedules for locums, tests, medical labs, etc, follow-up by physician from locum. e. Community members: provided and continue to provide free accommodation for locums.

ALLOCATION OF FUNDING TO DATE

The funding to achieve the preceding criteria was allocated as follows:

(Physicians received $100/hr for participating in meetings as per MOH & VIHA recommendation)

Dr. Daile Hoffman received $25,000 for the following:

Recognition of on-call services provided without remuneration from July 1, 2007 to April, 2008.
Participation in planning meetings related to MOU.
Provision of data re: emergency stats for Emergency Treatment Room.
Provision of document outlining physicians schedules.

Dr. Francois Bosman received $25,000 for the following:

Recognition of on-call services provided without remuneration from July 1, 2007 to September 30, 2008 (equivalent to approximately 40% of what he would have received under MOCAP)

*Dr. Bosman and Dr. Smith participated in planning meetings and decided not to receive funding for that participation.

Dr. Geoff Harding received $2,300 for the following:

Participation in planning meetings related to MOU

Dr. Jim MacKenzie received $1,500 for the following

Participation in planning meetings related to MOU

Public Engagement Meeting Expenses (Pre-planning– community groups, Public meeting, MOH/VIHA/Community groups) - $2,385:

Food & Rental of Rooms
Advertising public meeting
Printing and supplies
Website upgrade for public input

Total allocated to date: $56,185

Remaining funds:��$13,815

In-kind Activities carried out by GHCS board members and Judith Graham (in excess of $20,000)

Consultation re: MOH data for planning purposes
June Planning meeting: Facilitation, transcribing, analysis, review process, publication of report
Organization for meeting, invitations to community groups and to broader community for public meeting
Website to communicate with public (receiving input and providing all documents related to planning process on website)
Design, printing and distribution of brochure advertising FP4BC position on Gabriola
Organization regarding locum stays

In-kind Accomodation provided (equivalent to $5,200)

One week (John and Tawny Capon)
Three weeks (Bea Myers)
Five weeks (Marianne Wunderli
Four weeks (Kathy Peterson)

NEXT STEPS

Gabriola Health Care Society board members recognize that there are many more actions to take in order to fully realize the potential of an effective, stable and exciting primary health care system on Gabriola Island.�There are many components that were identified in the June/July planning document that need to be implemented.�For some of those actions that we are planning to implement, we need both VIHA and MOH to provide the information that they have committed to providing to us in the MOU (see items (e) and (f) above). Both have indicated that this information will be available within the next one to two months.

As can be seen by the in-kind column in the table above, the actions that have been undertaken since the signing of the MOU have taken the volunteer time of many members in the Gabriola community. The $13,815 that is remaining will be used to cover costs for the next steps in our planning stage, recognizing that side by side with those costs will be the in-kind efforts by community members. Those next steps include planning based on comprehensive data from MOH, VIHA and other relevant sources, as well as opportunities for hearing and exploring alternative compensation and structural approaches to primary health care provision.

This report has been approved by both Vancouver Island Health Authority and the BC Ministry of Health

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