The recent initiative to form a health co-op in Pictou County has stirred up controversy. The proponents intend to develop a health clinic to provide a range of services. But some patients worry about access to physicians' services and some Nova Scotians are concerned that the initiative signals a further erosion of delivery of public health care.
Dr. Cathy Felderhof working with the Nova Scotia Co-operative Council intends to turn her family practice over to a board of directors elected by her patients who choose to become members of the coop. This could fulfill a goal set by the co-operative movement in Nova Scotia and the Nova Scotia Federation of Community Health Centres some 15 years ago.
Community health co-ops are a good idea and appear to be a natural fit for Nova Scotia, given the history of the Antigonish movement and co-ops. So why the controversy?
To some degree the controversy stems from the fact that we are still dealing with intentions rather than facts as the co-op has yet to be formed. Crucial decisions should be left until after the membership has elected a board of directors. One question is whether there are decisions being made now that will be difficult for members to change later, such as financing and the role of staff.
A central area of concern relates to fees that patients will be charged. In private practices, physicians decide which uninsured medical services they will charge their patients for and how much to charge. Uninsured services include over-the-phone prescription renewals, ear wax removal, and filling out medical forms for insurance and employment purposes. The co-op's plan includes providing access to nurses for patients who pay the fee.
Some community health centres in Nova Scotia, on the other hand, through innovative funding arrangements with the province and health authorities, do not charge fees for uninsured medical services and presumably a similar arrangement is possible for the New Glasgow co-op.
But the promoters of the co-op have already talked about a monthly fee between $10 to $25 - or $120 to $300 per year. There has been some back-peddling on the rate that will be charged but the intention to charge fees is clear. Dr. Felderhof currently charges her patients $8 a visit or $160 per year for uninsured services.
Opting to charge fees could be attributed to the initiative being led by 2 physicians, Dr. Felderhof and Dr. David Zitner, who have worked under the current fee-for-service system that only covers physicians services. Alternate funding arrangements could be explored that provide funding for wider array of services. Presumably a community-led initiative would be focused on minimal, if any, fees and working with the Department of Health on funding arrangements that support such an initiative.
Charging fees is a key issue as fees limit access to health care services for those most vulnerable to ill health -- low-income households. Research shows that low-income is one of the key determinants of poor health and that user fees limit access to medical services.
All patients, I have been told by the promoters of the co-op, will have the option of not paying fees, and still having access to insured services such as visits to the physician. But the image of a community health clinic that provides two levels of services does not sit well. Some patients will get very good treatment, for example access to nurses, while other members of the community, including those most in need, will not have that access and will thus receive a lower level of service. While this may already be the practice in some physicians' offices and clinics, it is contrary to a principle of community health centres in Nova Scotia - "equal access to health for all."
The co-op organizational structure, while democratic, are not inherently community oriented. The orientation of a co-op depends on who the members are and what direction they would like to take the co-op. Just mentioning a monthly fee, at this early stage, screens out low-income folks from becoming members and having a say in the development of the co-op.
The lack of low-income members will influence the future direction and priorities of the co-operative. Rather than a community health co-op we could end up with a clinic for those able to pay the fees. This would fulfill the worst fears of those concerned about the development of two tier health care. In the long term, if the co-op model takes hold, will we be looking at a co-op for well-to-do citizens and another health centre for the less well off?
The co-operative movement in Nova Scotia needs to ensure this initiative adheres to the co-op principles of "open membership" and "concern for community". If the co-op is to become truly community-based it must ensure that community members with limited means become members and influence the development of the co-op and whether it will charge fees. It is also crucial that real decision-making power lies with the board and not with the physician.
The current situation illustrates absence of provincial policy and direction in the support of community-based health centers. The federal government is committed to increased funding and this should contribute to a decrease in uninsured medical services. The Department of Health has indicated a desire to develop more flexible and community based approaches toward health promotion and illness prevention. The development of a true community health co-op would seem to fit well with this approach.
Innovative initiatives in health care need to be explored but they must also be adequately funded and regulated to ensure that they provide equal access to comprehensive health services for all citizens. As the first health co-op in the province, the New Glasgow initiative deserves close scrutiny as it could set a precedent for future delivery of health care in Nova Scotia.
John Jacobs is director of the Nova Scotia office of the Canadian Centre for Policy Alternatives (www.policyalternatives.ca), an independent public policy research institute.