Maclean's 5th Annual Health Care Rankings

WHERE DO CANADIANS get the best health services? The fifth annual Maclean's ranking of the delivery of care across the country points ominously to a big challenge: bringing standards in less populous and rural health regions closer to the levels available in our major cities.

Maclean's 5th Annual Health Care Rankings

WHERE DO CANADIANS get the best health services? The fifth annual Maclean's ranking of the delivery of care across the country points ominously to a big challenge: bringing standards in less populous and rural health regions closer to the levels available in our major cities. Perhaps not surprisingly, 13 of the top 20 communities in this year's ranking are university cities with medical schools - precisely where you'd expect to find superior services. But in fact, that's two more than in the top 20 in the previous two years, and three more than in the 2000 ranking. So if there's a trend there, it's towards centralization, not distribution of resources.

"There's always going to be a difference in services between the bigger centres and the more remote regions," says Jennifer Zelmer, vice-president, research and analysis, for the Canadian Institute for Health Information. "It doesn't make sense to put some of the highly specialized services in communities without the population base to support them." That said, great efforts are in place across the country to help people, even in remoter regions, get better treatment closer to home. "Tele-triage" hotlines are one example, says Zelmer. Now operating in six provinces with more on the way, they put vital health information just a telephone call away. Another growing trend, especially in rural and hard-pressed inner-city settings: bringing nurse practitioners and other health professionals into partnerships with physicians.

Sheila Weatherill, CEO of Edmonton's Capital Health Region, ranked No. 1 this year, sees a bright future for that kind of teamwork. "But when I think of collaborative care now," she says, "I think about how we've put in place a nurse-manned, 24/7 telephone support line." Operating in Edmonton since the fall of 2000, it's going province-wide this month. "In the past, a mom who's got a child screaming with an earache at 1 a.m. would have had to get in her car and drive, then wait in emergency," she says. "Now she can get immediate advice from a registered nurse." And, with luck, avoid joining the lineups in emergency.

What accounts for Edmonton's success? Weatherill gives a lot of credit to the centralized regional structures put in place in Alberta, and all other provinces but Ontario, in the 1990s. "You can pull your senior operational people together, make one request, and everyone hears it and implements it at the same time - every hospital, every public health centre," she says. That's particularly important in the face of threats like SARS, the respiratory disease at the centre of Toronto's continuing health crisis. "You can tell the senior people these are our standards, this is how we will undertake surveillance in our hospitals and with our family physicians," Weatherill notes. "It's a structure that allows flexibility, a nimble approach."

This year's ranking incorporates all 57 health regions with populations over 125,000, representing just over 90 per cent of the national population. That's three more regions than in previous years, due to a redefinition of their boundaries in some provinces. They vary in their makeup from strictly urban (e.g., Vancouver, Toronto and Montreal), to an urban/rural mix (Regina, Fredericton, Halifax) and sprawling, sparsely populated areas (Prince George, B.C., Grande Prairie, Alta., Thunder Bay, Ont.). Regional boundaries have changed so significantly in several provinces, particularly B.C. and Alberta, that comparisons of this year's results with previous rankings are impractical.

The rankings are based on 18 nationally recognized indicators gathered by CIHI and Statistics Canada. The latest numbers available, they generally come from the fiscal year 2000-2001. Maclean's excludes lesser-populated regions because their small numbers can be subject to misleadingly large fluctuations from year to year.

To transform that raw data into a ranking, statistician David Andrews, professor emeritus at the University of Toronto and a specialist in the analysis of medical data, converts the results under each indicator into scores for each region. Grouping those scores into six broader categories with assigned weights representing their relative importance produces the overall ranking. (The weights: outcomes 2; resources 2; community health 2; elderly services 1; prenatal care 1; efficiencies 2.) In rare instances where data is not available from some regions for some indicators, scores are based on available indicators within the same categories.

Two regions illustrate how the boundary changes have produced different results. Take Kelowna, B.C. For the past two years it has finished in the top five - an outstanding performance for an essentially rural region. This year it ranks 14th, still respectable but a significant drop. The reason, says regional CEO Murray Ramsden: its boundaries expanded into "a broader catchment area" of rural B.C., where residents were receiving services that weren't up to the same standards. Edmonton, finishing in first to fourth place in previous rankings, also gained a chunk of territory - again largely rural - to its west. But it has maintained its winner status. That, says Weatherill, is because many of the people in the new territory were already driving into Edmonton for services, so the data now simply includes more people getting the same high level of care.

Headline-grabbing threats such as SARS, the mosquito-borne West Nile disease and Lyme disease, spread by ticks, make Canadians acutely aware of their need for a system that responds to new challenges. Weatherill understands that as well as anyone. "It's nice to know we're hanging in there and we're able to keep the organization moving forward," she says. "But as we're basking in the glory of this great ranking, it doesn't mean everything is fine."

THE TOP 20 HEALTH REGIONS ...

1 Edmonton

2 Victoria

3 Winnipeg

4 Saskatoon

5 Toronto

6 Ottawa

7 Calgary

8 Mississauga/Burlington, Ont.

9 Quebec City

10 Hamilton

11 London, Ont.

12 Montreal

13 Sherbrooke, Que.

14 Kelowna, B.C.

15 Halifax/Dartmouth

16 Regina

17 North Vancouver/Whistler

18 Vancouver

19 Richmond, B.C.

20 Saint John, N.B.

... AND THE OTHER 37

21 St. John's, Nfld.

22 Laval, Que.

23 Moncton, N.B.

24 Lévis, Que.

25 Markham/Richmond Hill, Ont.

26 Kitchener/Waterloo, Ont.

27 Lethbridge, Alta.

28 Surrey, B.C.

29 Rimouski, Que.

30 Burnaby/Coquitlam, B.C.

31 Longueuil/Brossard/Granby, Que.

32 Trois-Rivières/Drummondville, Que.

33 Chicoutimi, Que.

34 Windsor/Sarnia, Ont.

35 St. Catharines/Nigara, Ont.

36 Kingston, Ont.

37 Chilliwack, B.C.

38 St-Jérôme/Ste-Thérèse, Que.

39 Joliette, Que.

40 Gatineau, Que.

41 Peterborough/Oshawa, Ont.

42 Nanaimo, B.C.

43 Brantford, Ont.

44 Owen Sound, Ont.

45 Fredericton

46 Yarmouth/Digby, N.S.

47 Témiscaming, Que.

48 Thunder Bay, Ont.

49 Kamloops, B.C.

50 Cape Breton, N.S.

51 Jasper/Cold Lake, Alta.

52 Sudbury/Sault Ste. Marie, Ont.

53 Prince Edward Island

54 Red Deer, Alta.

55 North Bay/Huntsville, Ont.

56 Prince George, B.C.

57 Grande Prairie, Alta.

Maclean's June 16, 2003