Because the Keewatin communities are small and far away from major centres, some medical services cannot be based there. Over the years, arrangements were made to have these services provided by organizations in Manitoba. One example is the contract between the Keewatin Regional Health Board and the J.A. Hildes Northern Medical Unit (NMU) at the University of Manitoba.

Health Canada negotiated the first contract with the NMU in 1971. The contract provided general practitioners (GPs) and specialist services. One GP (family doctor) was based in Rankin Inlet and two in Churchill, Man. The Churchill based GPs regularly visited Keewatin communities. Specialists from Winnipeg visited the Keewatin on a regular schedule.

The NMU was responsible for hiring the GPs. From time to time, there were vacant positions, but for the most part, contract provisions were fulfilled. Turnover of doctors was frequent, as is the case in all isolated parts of the country.

The contract included:

• interpreter services based in Churchill and Winnipeg for Keewatin patients travelling to those places.
• a patient care co-ordinator and a patient referral clerk based in Winnipeg. Working with the Winnipeg interpreter, these people formed the Patient Referral Unit which provided support to patients while they travelled to and from Winnipeg and while they were in the city.

Although not specifically mentioned in the contract, the NMU also provided 24-hour telephone advice for community health nurses and occasional medevac consultation and support.

Service Changes

The board is maintaining the historical connection that it has held with Manitoba. The board has ended the contractual relationship with NMU and is planning to contract directly with GPs and specialists for service delivery. It is felt that this will eliminate adminstation costs and allow more service days to be provided in the Keewatin.

Proposed are three GPs in Rankin, one in Arviat and one in Baker Lake and visiting specialists on a similar schedule to the NMU contract. The patient referral unit in Winnipeg has been transferred to board control. Churchill interpreter services remain unchanged at this time.

Planning/Board Support

In 1993, the Keewatin Regional Health Board accepted the Keewatin Regional Health Services Plan prepared by a consulting company (Resource Planning Group Inc). One of the recommendations in this report was to have family doctors live in the Keewatin. The expectation was that resident doctors would be able to provide more service. Another report, Medical Services Audit and Future Options, which was prepared in 1994 by K.R. Mansen, made the same recommendation.

The goal of the board has clearly been to bring as many services as appropriate to the Keewatin. For example, in partnership with the department, a birthing centre has recently expanded from community to regional service. Colposcopy, laboratory services and ultrasound services are now available in the region.

The NMU was aware of the board's desire to base more services in the Keewatin. In fact, the NMU had submitted proposals in the early '90s that were similar to the plans the board is following today. The NMU had expected that doctors would eventually live in the region and had indicated to the board that they were willing to help achieve this.

In January 1996, the department issued a report that questioned the high administrative costs of the NMU contract. The report set up a framework for a subsequent review of the contract. The responsibility to review the contract was passed to the board.

Assessment

The board started negoitations with the NMU to renew their contract in the fall of 1996. The board hired a negotiator to represent it because relations were strained between the board's executive director and the director of NMU. In January 1997, NMU and the board signed an Agreement in Principle which provided a long-term vision of moving contract services to the board. It was to cover operations from April 1, 1997 to Sept. 30, 1997 until a longer contract could be developed.

Negotiations continued over several meetings but ended on April 30, 1997. The board broke off the negotiations despite being close to a settlement. While negotiations were still going on, the board had been trying to hire other doctors to work in the Keewatin under contract with the board. Med-Emerg Inc. had also been contracted by the board to assist in the recruitment of doctors.

After negotiations ended, NMU continued to work under the terms of the old contract. The board increased its efforts to recruit new doctors. No documented plan exists to bridge the services provided by NMU to those to be provided by the board. The board knows what has to be provided and is working toward putting these services in place.

The status of these services as of Oct. 1 1997 is:

General Practitioner Services:

The board proposes to have three GPs in Rankin Inlet and one each in Arviat and Baker Lake. This would create a higher level of service than the NMU had provided. As of Sept. 29, 1997, one doctor's position in Rankin Inlet has been filled on a locum basis for about the next six months. The board is trying to have another doctor registered to work in the NWT, starting in mid-October. A third doctor has expressed interest but would not be available until November or December at the earliest.

The shortage of GPs in the region will mean an increase in medical transportaion of Keewatin residents. This being said, most Keewatin communities only received visiting services from a GP under a NMU contract. Medevacs were always used for emergencies and other urgent cases.

Specialist Services

Under the NMU contract, specialists visited the Keewatin on a regular schedule. The board intends to maintain the same schedules. To date, a psychiatrist and a pediatrician have been hired to cover off the immediate visits. Recruitment for OBS/Gyne and orthopedic specialists is continuing. There will be no immediate disruption in services.

Most of the visiting specialists have had long-standing relationships with the Keewatin. Depending on the board's success at recruiting the existing specialists, there is some risk of loss of history with turnover.

Patient Referral Unit

The Patient Referral Unit has been successfully transferred to Ublivik, the Winniped Boarding Home, through collaborative efforts of the board and the NMU.

General Practitioner Consultation

Phone consultation for health care staff will be provided until the end of December by GPs at the Churchill Health Centre. By that time the board intends to have hired doctors who will be able to provide the service in the Keewatin.

Communications

The board has been heavily criticized in recent months. They have responded to this criticism, but largely in reaction. No formal communication plan exists at this time, although the development of such a plan would have better prepared the board for both proactive and reactive information sharing. The omission has turned what could have been a straighforward change in service providers into a major regional issue.

Recommedations

That the Keewatin Regional Health Board:

• advise the minister immediately of how many GPs are currently available to people in the Keewatin, along with details of how it plans to recruit their complement of GPs.
• report monthly to the department on the number of GPs and the action taken or planned to address vacancies.
• submit to the department within 30 days, a schedule detailing visiting specialist services to the Keewatin. Any change from the previously developed schedule under the Northern Medical Unit must be reported publicly to residents of the Keewatin.
• Report monthly to the department any changes from the previous schedule and actions taken or to be taken to address vacancies.
• Prepare and implement immediately, a complete communication plan that informs residents and caregivers of the intentions and actions of the board.
• In conjunction with the department, document the new service arrangements and identify outstanding transition issues. This should be completed within two months.