Auditor General - Health Human Resources Report

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Chapter 3
Ministry of Health and Long-Term Care
Section
3.02 Health Human Resources
care and education systems, and better manage the
Background
supply of health human resources.
Total expenditures for the strategy grew
from $448 million in the 2006/07 fiscal year
Health human resources—physicians, nurses
to $738.5 million in the 2012/13 fiscal year, an
2 and other health-care providers—are crucial to
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3. increase of about 65%. These amounts included
n the delivery of health services. They represent
o $431 million for physician and nursing initiatives in
ti the single greatest asset, as well as cost, to the
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e 2006/07 and $728 million for them in 2012/13, as
M S health-care system. Acting to address concerns over
well as ministry operating expenses of $17 million
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V provincial physician and nursing shortages, long
• in 2006/07 and $10.5 million in 2012/13, as shown
3 wait times and an increasing number of patients
r in Figure 1.
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t without family doctors, the Ministry of Health and
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h Long-Term Care and the Ministry of Training, Col-
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leges and Universities jointly developed a strategy
Audit Objective and Scope
called HealthForceOntario in the 2005/06 fiscal
year. As part of the strategy, the Ministry of Health
and Long-Term Care established the HealthForce-
The objective of our audit was to assess whether the
Ontario Marketing and Recruitment Agency
Ministry of Health and Long-Term Care, in conjunc-
(Agency) in 2007. The Agency’s activities focus on
tion with the Agency, had adequate systems and
recruitment and retention of health professionals.
procedures in place to:
The strategy’s goal is to ensure that Ontarians
• identify and assess the appropriateness of
have access to the right number, mix and distribu-
the mix, supply and distribution of qualified
tion of qualified health-care providers, now and in
health-care professionals to help meet the cur-
the future. Responsibility for its implementation
rent and future needs of Ontarians across the
lies with the Health Human Resources Strategy
province;
Division of the Ministry of Health and Long-Term
• ensure that strategy initiatives were delivered
Care (Ministry), but its Assistant Deputy Minister
in accordance with established regulatory
reports to the Deputy Ministers at both ministries.
requirements, applicable directives and poli-
This is meant to establish a link between the health
cies, and agreements; and
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Health Human Resources 83
to representatives of other jurisdictions—Manitoba,
Figure 1: Health Human Resources Strategy Division
Alberta and British Columbia—to gain an under-
Expenditures, 2006/07–2012/13 ($ million)
standing of how health human resource planning is
Source of data: Ministry of Health and Long-Term Care
done in those provinces.
800
Operating expenses
Physician and nursing initiatives
700
600 Summary
500
400
Over the last six years, the Ministry of Health and
300 Long-Term Care (Ministry) has spent $3.5 billion
200 through its HealthForceOntario strategy to address
the shortages of physicians, nurses and other health
100
professionals across Ontario. In 2012/13 the Min-
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2006/07 2007/08 2008/09 2009/10 2010/11 2011/12 2012/13 i$s5tr0y5 d miriellcitoend f$o7r 3p8h.y5s miciiallnio inn ittoiawtiavreds ,t h$i1s5 s1tr matiellgiyo:n
for nursing initiatives, $72 million for other health
• measure and report regularly on the progress human resource initiatives and the remaining
of the strategy’s objectives. $10.5 million for operating expenses.
The Ministry and Agency senior management Overall, Ontario has seen an 18% increase in 2
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reviewed and agreed to our audit objective and physicians from 2005 to 2012 and a 10% increase n
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criteria. in nurses from 2006 to 2012. While the initiatives ti
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Our audit focused on physician and nurse human increased enrolment, created more postgraduate M S
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resources. In conducting our audit, we reviewed training positions and attracted more doctors and V
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relevant legislation, administrative policies and pro- nurses from other jurisdictions, Ontario has not met 3
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cedures, and interviewed staff at the Ministries of its goal of having the right number, mix and distri- t
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Health and Long-Term Care and Training, Colleges bution of physicians in place across the province to h
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and Universities. We visited three Local Health Inte- meet the population’s future health-care needs.
gration Network (LHIN) offices and three hospitals Specifically, we noted the following:
in the North West and South West regions, and we • The province spends an average of about
contacted two hospitals in the Greater Toronto Area $780,000 (including $375,000 for resident
region to interview staff and obtain relevant docu- salaries and benefits) to educate one special-
ments. We also obtained information related to vari- ist who completes a four-year undergraduate
ous nursing initiatives from Greater Toronto Area degree and up to five years of postgraduate
hospitals. To gain an overall understanding and residency training. For a specialist who
perspective of the health human resources area, we enters Ontario at the postgraduate level from
spoke with a number of external stakeholders such outside the province, this cost is $225,000.
as the College of Family Physicians, the Ontario However, many specialists trained in Ontario
Hospital Association, the Registered Nurses Associa- do not stay and practise here. Retention
tion of Ontario, the Registered Practical Nurses statistics show that, on average, 33% of
Association of Ontario, the Professional Association Ontario-funded surgical specialist graduates
of Residents of Ontario (formerly the Professional left the province each year between 2005
Association of Internes and Residents of Ontario), and 2011. The lack of full-time employment
and the Ontario Medical Association. We also spoke opportunities for graduating residents of
84 2013 Annual Report of the Office of the Auditor General of Ontario
certain surgical specialties may lead to more • Although the physician forecasting model
physicians deciding to leave the province, built in partnership with the Ontario Medical
despite long wait times for these services. For Association was a positive step in determining
example, wait-time data for the three-month physician workforce requirements, it is ham-
period from June to August 2013 showed pered by the limited reliability and availability
waits of 326 days for forefoot surgery and of data. These limitations make planning the
263 days for cervical disc surgery. optimal number, mix and distribution of phys-
• The Agency provides temporary physician icians with appropriate funding, training and
or “locum” coverage in eligible communities deployment difficult. As well, a simulation
across the province to support access to care. model being developed by the Ministry to help
However, vacancy-based locum programs plan for future nursing education positions
meant as short-term measures continued to and to help formulate nursing policies aimed
be used for long periods of time. At the time at recruitment and retention determines only
of our audit there were about 200 specialist what the supply of nurses will be without
vacancies in Northern Ontario, and of those considering how many nurses will be needed
hospitals using locum services, one-third that to meet the population’s needs.
had been using the Emergency Department
Coverage Demonstration Project before Janu- OVERALL MINISTRY RESPONSE
ary 2008 had been continuously using its
The Ministry of Health and Long-Term Care
2 locum services from as early as 2007, and one
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3. (Ministry) and the HealthForceOntario Market-
n hospital had been using them since 2006.
o ing and Recruitment Agency acknowledge and
ti • Over the four fiscal years from 2008/09 to
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e thank the Auditor General for the timely audit
M S 2011/12, $309 million was dedicated to hir-
and the recommendations in this report.
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V ing 9,000 new nurses. Our review showed
• In a Canadian first, the province launched
3 that while the system was unable to hire that
r the HealthForceOntario strategy in May 2006.
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t many nurses in the four years, it had increased
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a This was an innovative response to existing
h the number of nurses by more than 7,300 and
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critical shortages in health human resources,
the Ministry was on track to achieve its goal
and it aimed to ensure that existing gaps would
within five years.
not worsen.
• At the end of 2011, 66.7% of nurses were
The strategy has led to a significant improve-
working full-time in Ontario, which was just
ment in the health human resource capacity of
slightly under the Ministry’s goal of 70% of
Ontario. Shortages of health providers, includ-
nurses working on a full-time basis. However,
ing physicians and nurses, are no longer the
the Ministry needed to improve its oversight
primary barrier to access or cause of wait times.
and assessment of the effectiveness of its nurs-
The strategy has mitigated the shortages and
ing programs and initiatives. For example,
improved the province’s ability to plan, train
funding for the Nursing Graduate Guarantee
and support its health workforce, with some key
Program is provided for up to six months with
results since May 2006 including:
the expectation that organizations will offer
• more than 35,000 new regulated providers,
permanent full-time employment for partici-
including an 18% increase in physician sup-
pating new graduate nurses. However, only
ply and a 10% increase in nurse supply;
about one-quarter of program participants in
• expanded first-year undergraduate enrol-
2010/11 and one-third in 2011/12 actually
ment in medical schools (up by 22%) and
obtained permanent full-time positions.
first-year postgraduate trainees (up by 60%);
Health Human Resources 85
professionals across Ontario. While the province
• 15,644 more nurses working full-time, a
was able to increase the number of physicians, some
23% improvement;
Ontario communities face shortages of health-care
• 25 nurse practitioner-led clinics providing
providers, especially physicians. Primary-care
care to over 36,000 patients;
physicians, also known as family physicians, are
• more than 15,100 employment opportun-
not always available in small, rural or remote com-
ities for new Ontario nursing graduates;
munities. In Northern Ontario, general specialists
• new health-care provider roles including
(for example, in the areas of general surgery, inter-
physician assistants, clinical specialist radia-
nal medicine and psychiatry) also remain in high
tion therapists and five new nursing roles;
demand despite a significantly improved provincial
• creation of evidence capacity to inform
physician supply.
planning;
Although the significant amount of funds that
• legislative and regulatory changes increas-
the Ministry has expended over the last six years
ing the quality and safety of patient care,
has increased the supply of physicians in the prov-
expanding scopes of practice and regulating
ince, shortages remain in certain specialties and
new health professions; and
geographical areas even as physicians in those spe-
• establishment of the HealthForceOntario
cialties are unable to obtain full-time employment.
Marketing and Recruitment Agency.
Ontario is now able to focus health human
resource activities on health-system transforma- Increased Supply of Physicians in Ontario
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tion rather than responding to critical shortages 3.
Medical education is funded jointly by the Min- n
of providers. The Ministry’s work continues o
istry of Training, Colleges and Universities and ti
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to evolve to address today’s challenges. The e
the Ministry of Health and Long-Term Care. The M S
Ministry is renewing the HealthForceOntario
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Ministry of Training, Colleges and Universities V
strategy so that it: •
funds universities for undergraduate positions, 3
• builds on the successes of previous r
e
while the Ministry of Health and Long-Term Care t
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accomplishments; a
funds most aspects of postgraduate training. The h
• aligns with the goals of Ontario’s Action Plan C
majority of the $485 million the Ministry of Health
for Health Care; and
and Long-Term Care spent on physician initiatives
• advances evidence-informed planning and
in the 2011/12 fiscal year was in two areas: total
decision-making.
payments of $315 million to medical schools and
The recommendations in this audit will
hospitals for the salaries and benefits of residents
inform the strategy renewal.
who provide clinical services across Ontario; and
$107 million paid to medical schools to support
academic activities such as teaching, educational
Detailed Audit Observations infrastructure and related administrative costs for
clinical education of medical learners.
From 2005 to 2012, the Ministry of Health and
PHYSICIANS Long-Term Care worked with the Ministry of Train-
ing, Colleges and Universities to increase enrol-
Over the last six years, the Ministry of Health and
ment in physician training programs. First-year
Long-Term Care (Ministry) has spent $3.5 billion
undergraduate enrolment in medical schools went
through its HealthForceOntario strategy to address
up by 22% and first-year postgraduate trainees by
the shortages of physicians, nurses and other health
60%. In family medicine, the number of first-year
86 2013 Annual Report of the Office of the Auditor General of Ontario
postgraduate trainees went up by 67% and spe- north was twice as high. Access has been a long-
cialists by 56%. In addition, the number of inter- standing issue in many rural, remote and northern
national medical graduates who entered residency communities in Ontario with chronic physician
training went up by 48%. As seen in Figure 2, shortages. Geographic isolation, long travel dis-
between 2005 and 2012, the number of physicians tances, low population densities and inclement
increased by 18%, or about 4,100. At the same weather conditions are just some of the challenges
time, the number of family doctors per 100,000 to providing health care in these areas.
people went from 84.9 to 91, and specialists from A 2011 Canadian Institute for Health Informa-
92.9 to 104.3. The total number of doctors per tion report showed that 95% of physicians in
100,000 people went from 177.8 to 195.3. Accord- Ontario practised in urban areas while the remain-
ing to the Canadian Institute for Health Informa- ing 5% practised in rural areas. This number falls
tion, the number of specialists per 100,000 people short of urban-rural population distribution in
in Ontario in 2011 was in line with the Canadian Ontario: according to Statistics Canada’s 2011
average, while the number of family physicians per census, 86% of the population lived in urban areas
100,000 people in Ontario was about 10% below while 14% lived in rural areas. To help assess
the average. the accessibility of health care in rural areas, the
Ministry uses the Rurality Index of Ontario (RIO),
developed by the Ontario Medical Association. The
Sub-optimal Distribution of Physicians in
RIO incorporates data on population and physicians
Ontario
2 practising in rural and northern areas, including
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n Despite the overall increase in primary health-care large urban centres in the north. The RIO indicates
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ti providers and specialists, access to health care is that in 2011, 8.1% of physicians in Ontario prac-
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M S still a problem for some Ontarians. According to the tised in these areas, which contained 11.6% of the
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V Ministry, based on data collected between October province’s population.
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3 2012 and March 2013, 6% of Ontarians lacked a Although the Ministry acknowledged that
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t family physician. Although more recent regional physician distribution across Ontario was still not
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h data is not available, in 2010 the percentage in the optimal, it cited factors that could account for the
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Figure 2: Increase in the Number of Physicians and Physician Trainees in Ontario, 2005–2012
Source of data: Ministry of Health and Long-Term Care
2005 2012 Increase (%)
First-year undergraduate enrolment 797 972* 22
Medical school graduates 663 875 32
First-year postgraduate trainees 757 1,213 60
Family medicine — first-year postgraduate trainees 305 508 67
Specialty — first-year postgraduate trainees 452 705 56
International medical graduates 171 253 48
Family physicians 10,641 12,296 16
Specialists 11,636 14,086 21
Total physicians 22,277 26,382 18
Family medicine physicians per 100,000 population 84.9 91.0 7
Specialists per 100,000 population 92.9 104.3 12
Total physicians per 100,000 population 177.8 195.3 10
* Latest data available for undergraduate enrolment is from 2011.
Health Human Resources 87
way physicians are distributed. For example, some training programs may attract trainees from juris-
highly specialized health-care services are delivered dictions where these programs are not offered, and
in tertiary care units, which means patients in some some may complete residency training in Ontario
communities must travel to large urban centres to and return to their home province afterward.
receive specialized care. However, others may leave Ontario because they
have difficulty finding stable employment after
graduation.
Medical Specialties Facing Employment
The Royal College of Physicians and Surgeons of
Problems
Canada (College) and the National Specialties Soci-
On average, the province invests about $780,000 eties conducted a mini-study from July to Novem-
(including $375,000 for resident salaries and ber 2010 that found physician unemployment and
benefits) to educate one specialist for a four-year underemployment were common in the following
undergraduate degree and up to five years of post- areas: cardiac surgery, nephrology, neurosurgery,
graduate residency training. For a specialist who plastic surgery, public health and preventative
enters Ontario from outside the province at the medicine, otolaryngology (ear, nose and throat
postgraduate training level, this cost is $225,000. specialists) and radiation oncology. In light of these
In 2011, the province spent a total of $438 million results, the College expanded its research in April
on specialist education—a 63% increase since 2011 to conduct a multi-phase national study of
2005, when the amount spent was $269 million. medical specialist employment in Canada. The final
However, many specialists trained in Ontario report was released in October 2013. The report 2
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do not stay and practise here. Figure 3 shows indicated that the specialties affected included n
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that, on average, about 33% of surgical specialist orthopaedic surgery, urology, gastroenterology, ti
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graduates (including neurosurgeons and cardiac, hematology, critical care, general surgery, ophthal- M S
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orthopaedic, paediatric and general surgeons) who mology, neurosurgery, nuclear medicine, otolaryn- V
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were funded by the Ministry left Ontario each year gology and radiation oncology. In our discussions 3
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between 2005 and 2011. with medical associations, we repeatedly heard that t
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Not every graduating specialist who leaves graduating specialists face employment difficulties h
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Ontario does so because of employment difficul- in various surgical specialties, including many of
ties. The size and breadth of Ontario postgraduate the above.
Figure 3: Surgical Specialists Leaving Ontario, 2005–2011
Source of data: Ministry of Health and Long-Term Care retention data extracted from Canadian Post–M.D. Education Registry (CAPER)
Annual Census of Post-M.D. Trainees
Average for
2003 2004 2005 2006 2007 2008 2009 2003–09
Surgical specialists graduating in Ontario 120 122 120 125 111 114 147 123
Average for
2005 2006 2007 2008 2009 2010 2011 2005–11
Surgical specialists practising in Ontario two years
79 79 79 87 73 70 108 82
after graduation
Surgical specialist graduates leaving Ontario (41) (43) (41) (38) (38) (44) (39) (41)
% of surgical specialist graduates leaving Ontario 34 35 34 30 34 39 27 33
Surgical specialists coming into Ontario to practise 22 8 12 19 18 14 9 15
Net number of specialists leaving Ontario 19 35 29 19 20 30 30 26
88 2013 Annual Report of the Office of the Auditor General of Ontario
The College’s 2011–12 study found that about choosing specialties over general practice because
20% of new specialists and subspecialists in Ontario of the perception that specialists have more pres-
(compared to 16% in Canada) could not find a job tige and higher earning potential. According to the
after completing their residency training periods of Future of Medical Education in Canada Postgrad-
two to five years following medical school. It also uate Project funded by Health Canada, a 50/50
noted that employability was impacted by personal balance of generalists and specialists is needed to
factors and preferences such as jobs not being based provide optimal care to patients. In 2011, Ontario
in new graduates’ preferred locations; hospital had about 1,700 more specialists than general-
budgetary restrictions; and delayed retirements. ists. The Ministry has worked with the faculties of
Such factors could result in physicians choosing to medicine to increase the number of family medi-
prolong their studies or make do with contract and cine residency positions by 119% from 2003/04
temporary work, losing skills, leaving Ontario or to 2011/12. Since 2012, the Ministry and medical
having to work in non-surgical practice. At the same schools moved to implement a more structured,
time, there are specialist vacancies in some areas of annual planning cycle to better support decision-
the province. For example, in the north, almost all making and fine-tuning of the size and composition
(99%) of the $13 million spent on temporary special- of the postgraduate training system.
ist coverage in 2011/12 was for covering specialist The Ministry acknowledged that graduating
vacancies while recruitment was being pursued. residents faced a number of employment concerns
The Ontario Medical Association also collected and that unemployment and underemployment
2 employment data in a 2011 survey. It described were concentrated in specific specialties, particu-
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n some of the barriers new graduates face in finding larly those requiring hospital resources. However,
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ti positions in anaesthesiology, cardiac and thoracic we found that it had not collected data from
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M S surgery, general surgery, neurosurgery, orthopaedic hospitals nor analyzed existing data to identify the
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V surgery and vascular surgery: causes or to develop solutions. For example, the
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3 • Many cardiac surgeons were working as Ministry had not examined how hospital funding
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t surgical assistants because they could not find might affect areas such as operating-room capacity,
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h jobs in their specialty; 34% of those graduates and how this in turn might impact employment in
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who were working as cardiac surgeons still some surgical specialties. It also had not collected
considered themselves underemployed. data on factors such as the volume of individual
• More general surgeons were choosing to do physicians’ surgical bookings, the allocation of
fellowships in surgical subspecialties, which surgical bookings among physicians by level of
decreased the number of general surgeons in experience, or the available operating room cap-
the health-care system. acity across the system. The Ministry indicated that
• There was competition among orthopaedic it continues to work with stakeholder partners such
surgeons for operating room time; older as the Ontario Medical Association and the Ontario
surgeons were reluctant to relinquish operat- Hospital Association to better understand how
ing room time to enable new physicians to profession-specific challenges, including hospital
practise. operating practices, affect physician employment
• Senior vascular surgeons were working past and underemployment.
the normal retirement age, which meant they The Ministry told us that once the final results of
were holding on to operating room time and the College’s national study are available with juris-
hospital clinic resources. dictional results, it will help inform it of the current
Naturally, individual job preferences also affect status of and the multiple factors that contribute to
employment patterns. More students may be
Health Human Resources 89
physician unemployment and underemployment as neurosurgery, orthopaedic surgery, psychiatry,
across Canada. paediatrics, obstetrics/gynaecology, geriatrics and
emergency medicine, but had difficulty recruiting
physicians to meet their needs. They indicated
Lengthy Wait Times for Specialist Services
that graduating physicians often prefer to work
Ministry data that we examined for the three- in large urban centres rather than rural, remote
month period from June to August 2013 showed and northern areas. Practising in non-urban areas
long waits for certain surgical services, as shown presents challenges that may be quite different
in Figure 4. We found that some of the procedures from those encountered during physicians’ medical
with long wait times were in the same surgical training or posed by practising in an urban centre.
specialties in which graduating residents faced There are differences in the level of back-up, the
unemployment and underemployment. For extent of on-call work and the types of illnesses that
example, for some orthopaedic surgeries, waits need treating. There may also be fewer social and
following a specialist’s assessment were as long as cultural activities available and limited employment
326 days (forefoot) and 263 days (cervical disc). opportunities for physicians’ partners.
Patients often wait months just to see a specialist
after the family physician’s referral.
Physician Initiatives
Our discussions with hospitals we visited and
the Ontario Medical Association suggested that A number of studies have suggested that one factor
long wait times could be related to factors such affecting a physician’s practice location decision 2
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as hospital funding. Reduced capacity caused by is where he or she receives a significant portion n
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budget constraints could mean long wait times of postgraduate medical training. For this reason, ti
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for some services; if funding is constrained then rural, remote and northern communities may have M S
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operating room hours and/or the resources who more trouble attracting physicians than urban cen- V
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staff them could be cut, resulting in unemployment tres that are close to medical faculties and teaching 3
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and underemployment among the specialists who hospitals. Figure 5 shows a number of programs t
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provide these services. and initiatives the Ministry has funded to help h
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The hospitals we spoke to in rural areas said those communities recruit and retain physicians.
they needed resources in various specialties, such The Ministry also manages a Return of Service
Program that requires international medical gradu-
Figure 4: Provincial Wait Times* in Surgical ates and participants in certain other physician
Specialties with High Unemployment/ postgraduate training programs to practise in
Underemployment, June–August 2013 eligible communities in Ontario, generally for a
Source of data: Ministry of Health and Long-Term Care period of five years. (The program is covered in a
subsequent section of this report.) The Ministry,
Type of Service/Procedure Wait Time (days)
through separate divisions, also funds a number of
Neurosurgery (overall) 134
related initiatives, such as the Northern and Rural
Orthopaedic surgery (overall) 192
Recruitment and Retention Initiative, which offers
Cervical disc 263
financial incentives to physicians who establish a
Forefoot 326
full-time practice in an eligible northern, rural or
Hip replacement 186
remote community.
Knee replacement 220
At the time of our audit, the effectiveness of
Lumbar disc 251
these initiatives had yet to be evaluated. Some of
* Wait time is calculated as the number of days from when 9 out of 10
patients see their specialist to when they undergo surgery. the initiatives had only recently been implemented.
90 2013 Annual Report of the Office of the Auditor General of Ontario
Figure 5: Selected Ministry Initiatives for Physician Recruitment and Retention in Rural and Remote Communities
Source of data: Ministry of Health and Long-Term Care
Funding
Received in
2011/12
Initiative Description ($ million)
Northern Ontario School of Medicine Rural-distributed, community-based medical school that seeks to recruit
students coming from Northern Ontario or rural, remote, aboriginal or 12.7
francophone backgrounds (started 2005)
Distributed Medical Education Organizations co-ordinate clinical teaching placements in small urban
and rural communities for undergraduate and postgraduate learners 11.7
(started 1995)
Northern and Rural Recruitment and Financial incentives to physicians who establish a full-time practice in an
3.4
Retention Initiative eligible community (started 2010)
Hospital Academic and Operating Funding to cover academic and operating costs for hospitals affiliated
Costs for hospitals affiliated with the with the Medical Education Campuses (started 2008) 3.5
medical education campuses
The 2010 evaluation of the Return of Service Physician Locum Programs
Program found that it was not meeting the needs The Agency provides support for temporary phys-
2 of most northern and remote communities. In ician or “locum” coverage in eligible communities
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n response, the Ministry implemented changes to across the province. Locum support targets two
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ti that program, including expanding the eligible geo- specific types of need:
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M S graphic boundaries and providing other targeted • Respite coverage is an ongoing retention sup-
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V funding for certain geographic areas that were port to physicians who work in northern and
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3 underserviced. rural communities. Because there are fewer
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t The Northern Ontario School of Medicine, physicians in these communities, there are
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h opened in September 2005, has not been operating limited options for local replacements. Respite
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long enough for a meaningful evaluation, but a locum coverage provides these rural and
five-year tracking study from 2010/11 to 2014/15 northern physicians with back-up when they
is under way to determine the extent to which the are temporarily away on leave, continuing
school’s undergraduate and postgraduate programs medical education or vacation.
improved the supply and distribution of physicians • Vacancy-based coverage is intended as a
in northern and rural communities. short-term solution to provide access to care
In addition, as noted in Figure 5, the Ministry in areas where there are physician vacancies
funds the Distributed Medical Education Program, while long-term recruitment is pursued.
in which organizations co-ordinate clinical teaching As well as providing access to physician care in
placements in small urban and rural communities communities with temporary physician absences or
for undergraduates and postgraduates. The Min- vacancies, these programs are also meant to sup-
istry informed us that it has been working with port the retention of rural and northern physicians.
medical schools since autumn 2012 on an approach In the 2011/12 fiscal year, the Ministry spent a total
to evaluate this initiative. of about $22 million on three physician locum pro-
grams administered by the Agency.
The programs include the Northern Specialist
Locum Programs, the Emergency Department
Health Human Resources 91
Coverage Demonstration Project and the Rural arium—about four times the average amount paid
Family Medicine Locum Program. for respite coverage. In addition to fees for service,
We focused our audit work on the Northern physicians receive eligible travel and accommoda-
Specialist Locum Programs and the Emergency tion expense reimbursement for respite coverage,
Department Coverage Demonstration Project which amounts to $241 per day on average. In some
because these programs specifically targeted phys- Northern Ontario communities, physician short-
ician vacancies while permanent recruitment was ages and recruitment challenges might have con-
pursued. tributed to the extended use of physician locums
to support ongoing access to care for patients. Our
Costly Long-term Use of Northern Specialist Locum
review showed that using locums has become a
Programs
service delivery model. Almost all (99%) of the
Northern communities can access up to 26 locum
$13 million spent on locum coverage in 2011/12
specialty services. The Northern Specialist Locum
was for covering specialist vacancies.
Programs incurred $13 million in expenditures in
We looked at locum programs in other Canadian
2011/12 to provide temporary physician specialty
jurisdictions and found that they generally provide
coverage through two sub-programs that provide
only respite coverage. The Ministry indicated that
short-term coverage for specialist physician vacan-
Ontario is unique in that it provides large-scale
cies and ongoing respite coverage to support
hospital-based services to five Northern Urban
retention.
Referral Centres and has a medical school based
According to the Agency, the latest available
in the north. The mass of critical services in the 2
0
data at the time of our audit indicated that about 3.
north combined with physician vacancies and n
30% of specialist positions in Northern Ontario o
recruitment challenges in some communities and/ ti
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were vacant. This translates to a total of about 200 e
or specialties creates a need for locum support that M S
specialist vacancies, or 40,000 work days that need
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may not exist in other jurisdictions. The Agency’s V
coverage. Data that we examined for the years •
long-term goal is to transition to a predominantly 3
from 2009 to 2011 showed that the specialties r
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respite program in Ontario and eliminate use of the t
p
requiring the greatest number of locum days in a
locum program as a service delivery model. The h
C
Northern Ontario were internal medicine, diagnos-
Agency indicated that it is working to implement
tic imaging, general surgery and psychiatry. Over
new eligibility criteria, with full implementation by
the past five fiscal years, from 2008/09 to 2012/13,
2014/15.
four large northern cities—Sault Ste. Marie,
We found extensive reliance on locum programs
Thunder Bay, Timmins and Sudbury—received
to deliver needed health-care services to some
more than 80% of specialist locum coverage days.
rural, remote and northern communities. For
According to the Ministry, the four larger northern
example, at a number of the hospitals we visited
city hospitals have the highest usage because they
we reviewed the on-call locum usage for a single
act as critical referral centres to the smaller rural
month in 2012 and found that locum coverage was
northern communities where low population and
as high as 94% for internal medicine at one hospital
other factors would not support specialist practice.
and 72% for diagnostic imaging at another hospital.
Also, they provide teaching and research to the
Although hospitals with specialist vacancies
Northern Ontario School of Medicine.
receiving coverage by the Northern Specialist
In addition to fees for services or claims for
Locum Programs are required to post the positions
work sessionals for daily clinical work, payments to
on the Agency’s HealthForceOntario jobs website,
physicians for vacancy coverage averaged $1,017
they are not required to report on their progress
per day for travel, accommodation and honor-
in recruiting for and filling their vacancies. The