The Current - Should some rural ERs be closed permanently?

Episode Date: July 14, 2025

Canada’s small-town ERs are in crisis, facing routine closures and severe staffing shortages. Globe and Mail health columnist André Picard argues some of those ERs might need to close, so scarce resources can be used more effectively.

Welcome to the Dudes Club, a brotherhood supporting men's health and wellness. Established in the Vancouver downtown Eastside in 2010, the Dudes Club is a community-based organization that focuses on indigenous men's health, many of whom are struggling with intergenerational trauma, addiction, poverty, homelessness, and chronic diseases. The aim is to reduce isolation and loneliness and for the men to regain a sense of pride and purpose in their lives. As a global health care company, Novo Nordisk is dedicated to driving change for a healthy world. It's what we've been doing since 1923. It also takes the strength and determination of the communities around us, whether it's through disease

awareness, fighting stigmas and loneliness, education, or empowering people to become more active. Novo Nordisk is supporting local changemakers because it takes more than medicine to live a healthy life. Leave your armor at the door. Watch this paid content on CBC Gem. This is a CBC Podcast. Hello, I'm Matt Galloway and this is The Current Podcast. When was the last time you had to go to the emergency room? Having to make that trip is never good, but if I asked you what comes to mind when you think about Canadian ERs, chances are many of you would say packed rooms, hours of waiting,

hoping someone will at last see you. But for Canadians in rural places, the image that may come to mind is that of a closed sign. The Globe and Mail has compiled national data that show that since 2019, emergency rooms in Canada have been closed for more than a million hours. And Andre Picard is a health columnist with the Globe and Mail. The headline for his latest column is, should every small town hospital have its own emergency room? Andre, good morning. Good morning.

Andre, what constitutes a small town ER? Well, I think, you know, the line is not entirely clear, but when we did our series, we tried to look at more rural and remote areas. We know that most Canadians, about 80%, live in urban areas, but once you get outside that number, it's very sparse services of all sorts, including hospitals, including ERs. And nationally, what do we know about how often these types of emergency rooms are shut? What did the Globe study show you?

Yeah, my colleagues, you know, months of work took them to find out just how bad the situation was. We know anecdotally there's a lot of closures, but what we found overall is about one-third of ERs closed unexpectedly at some point, so that's disturbing in itself. More than half of them were closed, or some of them are closed more than half the time. We found some ERs that were closed 80% of the time. One that stuck out for me was closed 323 nights of the year out of 365. So these are quite disturbing numbers. So I ask the question I say, if something is never open, is it really an ER? To me, an ER has to be available 24-7, and if not, it's something else. I think we need services in small towns,

but does it have to be an emergency room? What are the main reasons that the ERs are closed? There's one reason, it's staffing. Staffing, staffing, staffing is an issue all across Canadian health care, but it's much worse in rural areas, much worse in ERs, just because the work is difficult, really demanding, hard to get people to small towns.

So it's mostly about staffing by nurses to a lesser extent doctors. Does pay come into it at all? Everybody gets paid essentially the same in most provinces. Provinces negotiate contracts provincially. The pay is the same whether you work in a rural or urban area.

I think the work is different. Sometimes in rural areas, everybody knows you. You never get a break. You're a nurse. in rural or urban area. But I think the work is different. Sometimes in rural areas, everybody knows you. You never get really a break. You're a nurse if you're in the ER, but you're also a nurse if you're in the supermarket. So it's a different style of living.

And a lot of them burn out. They just end up doing these endless amounts of overtime because there's no one to fill out in for them. And that's why the ER is closed. Right. Now, you write about this, to fill out in for them. And that's why the ERs close. Right, right. Now, you're right about this, of course, in your column. Can you tell us your argument for why

some of these small town hospitals might be better off just shutting these ERs down, which, as you point out, aren't really ERs if they're not open all the time? Well, that's it. I think they're ERs in name only. So I think we have to have a serious discussion in Canada. What is an emergency room, right? So an emergency room in Canada has become just a walk-in clinic for many people.

The fundamental problem we have is 6.5 million Canadians without a doctor. So if you need care, primary care, that should be the priority, getting it. But it doesn't mean you should go to an emergency room. That's an inefficient, not cost- the priority, getting it. But it doesn't mean you should go to an emergency room. That's an inefficient, not cost-effective way of doing it. So I think we have to distinguish this between the need for care and the need for an emergency

room. Real emergencies, trauma, heart attack, stroke, these things are going to have to be treated in a big centre. The only thing that's going to happen in a small town is if we're lucky, people will be stabilized and they'll be moved. So we have to accept that reality that this kind of care goes on in big centers, regardless of where you live. And then we have to work on the other stuff. How do you get a patient stabilized?

I think it's probably better at an urgent care centre where we know the hours are going to be fixed, work on medical transportation, work on having better virtual care. We have some virtual ERs that are not a substitute, but they are a way of dealing with part of the problem. To me it's a suite of things that we have to deal with, have to do, starting with what I

think is the number one issue in Canadian healthcare, making sure every single person has a doctor. have to deal, have to do, starting with what I think is the number one issue in Canadian healthcare, making sure every single person has a doctor. Right. And why, I mean, you talk about urgent care, doing slightly different things from ER rooms. Why would they be easier to staff? Well, they can do the stuff, you know, like stitching, broken arm, things like that. And you're not going to have these

constant, you're not going to necessarily have 12-hour shifts. You're not necessarily going to have to keep a nurse on because there's no one to replace her. It's not the same as a, you know, when we think of ER, we think of trauma. A trauma unit has to be fully staffed at all times. You can't take that risk. If it's for more minor things, you can. If you have much better paramedic, medical transport, then there's not the same worries. All this stuff intermingles. It's all connected.

MODERATOR NATALIE MAYROUX is the executive director of the Ontario Health Coalition. She thinks ERs are critical to maintaining the health of communities. Take a listen to what she says. If you have an anaphylactic reaction that's life threatening, it's your local emergency department that's going to save you.

If you have a farm accident and get injured by a tractor and you're losing lots of blood, there's not enough blood in the world to have blood on every ambulance. You have to have a local emergency department where you can stabilize and transfer to a hospital that can deal with more critical care. For people who have a serious health incident and that hour, that golden hour, as the nurses and doctors call it, is critical to save their lives, their local emergency department is what saves them and without them more people die.

Andre, what do you make of what Natalie Maera says there, that these small ERs are really necessary to saving lives? Well, I think, you know, the golden hour is really important. We have to get people care when they have a traumatic injury within an hour or a heart attack. But the reality is that the data show us that urban ERs or rural ERs are not doing that. There was a study a few years back in Ontario,

they looked at just the most basic minimum standards for ER care. 50% of rural hospitals did not meet them. You know, ER care is a very specialized service. Doctors have to go and they have to do constant training every year. A small town doctor doesn't do that. Most doctors, they're not bad doctors,

they're doing great work in rural ERs, but their job is not to deal with traumatic injury. Life-threatening injury is not what your average doctor can do on an everyday basis. So I think it's a nice fantasy to say everybody should be able to do this, every hospital can do it. But what we get is a lot of second rate care, unfortunately, fantasy to say everybody should be able to do this, every hospital can do it, but what

we get is a lot of second rate care unfortunately and not the focus on getting people well. The other part of it, you know, there's a trade off to living in rural areas. We know that. We shouldn't be afraid of talking about it. You know, I lived in Northern Ontario when I grew up. We traveled an hour by bus to school. People would think that's unthinkable in a city. We have to think about health care in the same way. Not everybody can have every amount of care that's equal. You know, we need equitable care in health care, but that doesn't mean equal care or sameness.

There are differences in where we live. There are still obviously emergencies though. So where would the people in these towns go assuming that some of them shut down? Yeah, the real emergencies, the focus has to be on transport. Things like Orange in Ontario, the helicopter service is very active in the north. That's what they focus on, getting people stabilized, good paramedicine. I think that's where the focus has to be. We heard Natalie say, you know, there's not enough blood for everyone, but the reality is these services, these transport services, they do have blood, they can treat shock, and they can get people in a helicopter a lot faster than transporting to a

local hospital. And then we know they're going to be sent on eventually, right? So we cut out the middle man is what I would say. Right. Now in your piece you wrote that there's a common saying in public policy, if you don't count it, it doesn't count. How did that idea shape your story? Well, I think that's a lot of the shape of this series we're doing at The Globe called Secret Canada. We know, I travel around the world looking at health systems. Canada is obsessive about secrecy.

We don't publish data. We collect a lot of data, but we don't publish it. We don't use it to improve care. And that's the basis of this whole series we're doing. And right now we're focusing on emergency rooms. You know, there are provinces where the data was just very almost non-existent. If you, you know, if everyone's going around telling you, my emergency room's closed, and what do you do?

You say, well, yeah, that's terrible. But if you actually measure, I think then you can start working on it and you can start looking for solutions. Once you start having a hospital that's closed 50% of the time or 80% of the time, that demands a solution. But unless you have the basic data, there is no, I don't think, any impetus to act.

That is what we hope these stories will do, is get governments to say, yeah, we have to get on this and get this problem solved. MODERATOR Andrei, thanks so much for speaking with us today. Thanks, Megan. Always a pleasure. Andre Picard is a health columnist with the Globe and Mail. Welcome to the Dudes Club, a brotherhood supporting men's health and wellness. Established in the Vancouver downtown Eastside in 2010, the Dudes Club is a community-based organization

that focuses on indigenous men's health, many of whom are struggling with intergenerational trauma, addiction, poverty, homelessness, and chronic diseases. The aim is to reduce isolation and loneliness, and for the men to regain a sense of pride and purpose in their lives. As a global healthcare company, Novo Nordisk

is dedicated to driving change for a healthy world. It's what we've been doing since 1923. It also takes the strength and determination of the communities around us. Whether it's through disease awareness, fighting stigmas and loneliness, education, or empowering people to become more active, Novo Nordisk is supporting local changemakers because it takes more than medicine to live a healthy life. Leave your armor at the door. Watch this paid content on CBC Gem. This message comes from Viking,

committed to exploring the world in comfort. Journey through the heart of Europe on a Viking longship with thoughtful service, destination-focused dining, and cultural enrichment on board and on shore. With a variety of voyages and sailing dates to choose from, now is the time to explore Europe's waterways. Learn more at Viking.com. Tim Vine is the president and CEO of the North Shore Health Network.

He manages the operations of three hospitals in rural Ontario on the north shore of Lake Huron. He's in Blind River, Ontario. Tim, good morning. Good morning, Megan. How often do you actually have to shut down or reduce the hours of your ERs? Far more often than we would like. Andre described, I think, really well

what we're facing in terms of health human resources shortages. For us, it happens to be physicians that are our biggest bottleneck. But we've had several closures already into our beginning of summer, very busy season at both our Thessalon and Richards Landing sites. And we have lots of holes in the calendar. We've got 25 open shifts between now and the end of July across our three emergency departments.

And I gather summer is crunch time. That's when you have more gaps? We have far more gaps in the summer. As you can appreciate, lots of people like to enjoy the weather. Our local physicians that are really at below half complement to support our emergency departments need some well-earned time off to rest and recover and spend time with their families. And of course, we see fewer locums.

And then our demand goes up because we are in prime cottage country for our corner of paradise. So a lot more people coming in and a lot more opportunity for accidents and things. Now, Andre mentioned staffing being the main reason that necessitates shutting the doors. Are there any other reasons that you think it's worth talking about? For us it is really the issue of getting physicians. We're 70% dependent on local, locum, excuse me, those traveling doctors to keep our operations running. And that's our inpatient unit as well as our three emergency departments. So that's our biggest hurdle.

And what has closing the doors of your ER when you have to do it meant for patients? They get redirected and that puts further strain on the system. So we've got fantastic EMS partners, but they're strapped as well. There's only one ambulance operating in each of our communities. So if that ambulance is called away to travel to another emergency department 45 minutes away, that ambulance could be out of service for quite a while, transporting the patient,

getting them into the hospital and then returning to where they originated from. So we know that the risk goes up for folks to be uncovered and lack access to emergency care when they need it the most. So what do you make of Andre's idea of shutting down some small town ERs, ones like the ones that you're currently managing

and having to deal with these temporary closures and shortages? You know, I think André brings up a lot of really important points that needs to be discussed at certainly the policy and the political level. You know, at my end, you know, he brings up a lot of interesting points, but I'm seeing a system that has too many barriers to access. So my concern would be that if we were to shut our doors permanently, too many folks would go without access. So you know, it's not just about, you know, it's certainly not a quality, we can't have

cardiac units and then those sorts of things everywhere. But equitable access is a huge issue and geography plays into that. We cover 160 kilometers of highway 17 along the North shore of Lake Huron. And people have real barriers to getting access because of that geography, getting to a tertiary care center like Syria Hospital,

that sort of thing. So, I'm not sure that we would get to the level of system integration and support that Andre is talking about. We'd certainly need more investment in EMS. We'd certainly need more investment in our tertiary care centers. You know, we have an inpatient unit in Blind River. It's an 18-bed facility, but we were closed to admissions back in March because of a cyber incident and our little inpatient unit effectively ground patient

transfer in Northeastern Ontario to a halt because that capacity was taken out. So we lack any marginal capacity in the system. We need lots more investments, I think, before we can even get to the stage of having that discussion of ED versus urgent care center versus location of services, which is a big, bold discussion to have, and it's going to require a huge investment in our system. Emergency departments, especially in rural Northern Ontario,

have become the backstop of the system. We have held the line until we can hold it no longer, and we catch everything that comes through other areas of the system that have closed or have inadequate access to care. So my concern is if we're not here for the patients that we serve, they will simply not have care. Right, but what do you say to André's argument

that if an ER is not open 24-7, it's not really an ER? You know, I can see that point. When it is open, it is an ER. And without it, it's a very difficult thing for us when we close it. I know ultimately as the president and CEO making that decision, that I might be responsible for somebody's death

because they can't access our service, obviously forced by circumstances and we don't do it capriciously, but we want to be there to serve our communities. And when we are open, we are an ED and we are focused on trying to remain open. Okay. Now, you talked about taking patients to other places. And so in your area, what are the obstacles? I mean, if your ER is no longer an option,

they're transported by ambulance services to a larger centre. And you say that that system really isn't properly set up to deal with a hospital that doesn't have an ER in a rural area. What would that look like, setting that up? I think it starts right from medical transportation all the way up to capacity at the at the tertiary care center. So, you know, our example along the North Shore is Syria Hospital. It's got an emergency department that has pretty long offload delays for the ambulance because they're so busy and backed up. Recent changes in the Physician

Services Agreement actually reduced physician coverage in that emergency department by 11 hours a day, which is causing further delays and further wait time there. So again, equity of access is regularly over 100% capacity in terms of its inpatients. So we have a really difficult time getting inpatients transferred there who might need a higher level of care. If you're chronically running at 105 or 110% capacity, that hallway medicine issue becomes a real barrier to access. So you know, that's where I get concerned about if we're not here for the folks along

the North Shore, they may not get any care at all because there simply is no other capacity anywhere else in the system. So yeah. Sorry, we just a few minutes, but Tim, you're on the front lines of this and personally I'm sure under quite a bit of stress. Very quickly, what's a main solution you'd like to see to tackle the issues that you're facing and then to ensure that the doors to your ER stay open? Well, I think that we need funding stability. open? Well, I think that we need funding stability. Here we are in the middle of July and I still don't know what the operating budget is for the hospital this year, for the fiscal year that started April 1st. I think we need

some direction. You know, I think Andre brings up a lot of good points that need to be looked at at the system level in terms of coordinating some of these services. Those are a little bit longer term. But frankly, I don't know how we solve it in this moment. We have a fundamental supply imbalance in my view of the type of rural generalists that rural medicine has lived on for the last 50 years. And we can't seem to attract people into that sphere of medicine. So I know what we're doing now can't continue. We need to have bold discussions, but we need to ensure that people have equity of access.

Okay. Thank you, Tim Vine. Thank you very much. Tim Vine is the President and CEO of the North Shore Health Network. You've been listening to The Current Podcast. My name is Matt Galloway. Thanks for listening. I'll talk to you soon.