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Objective: To describe the essential components of well-resourced and high-functioning multidisciplinary networks that support high-quality anesthesia, surgery, and maternity care for rural Canadians, delivered as close to home as possible., Composition of the Committee: A volunteer Writers' Group was drawn from the Society of Obstetricians and Gynaecologists of Canada, the Society of Rural Physicians of Canada, the Royal College of Physicians and Surgeons of Canada, the Canadian Association of General Surgeons, the College of Family Physicians of Canada, and the Association of Canadian University Departments of Anesthesia., Methods: A collaborative effort over the past several years among the professional stakeholders has culminated in this consensus statement on networked care designed to integrate and support a specialist and non-specialist, urban and rural, anesthesia, surgery, and maternity work force into high-functioning networks based on the best available evidence., Report: Surgical and maternity triage needs to be embedded within networks to address the tensions between sustainable regional programs and local access to care. Safety and quality must be demonstrated to be equivalent across similar patients and procedures, regardless of network site. Triage of patients across multiple sites is a quality outcome metric requiring continuous iterative scrutiny. Clinical coaching between rural and regional centres can be helpful in building and sustaining high-functioning networks. Maintenance of quality and the provision of continuing professional development in low-volume settings represent a mutual value proposition., Conclusion: The trusting relationships that are foundational to successful networks are built through clinical coaching, continuing professional development, and quality improvement. Currently, a collaborative effort in British Columbia is delivering a provincial program-Rural Surgical Obstetrical Networks-built on the principles and supporting evidence described in this consensus statement., (Copyright © 2022 the College of Family Physicians of Canada.)

Context: Over the past 25 years, the attrition of small volume rural surgery programs across Western Canada has been significant and sustained. The 'Joint position paper on rural surgery and operative delivery' (JPP) offers a consensus policy framework for the sustainability of rural surgical programs by nesting them within larger regional programs. The many recommendations in the JPP coalesce around the recognition that surgical care should be provided as close to home as possible. To achieve this, surgical care should be delivered within rural and regional surgical programs integrated into well-functioning networks staffed by generalist specialist surgeons trained across surgical disciplines and family physicians with enhanced surgical skills (FPESS)., Issues: There are important issues to be addressed in the creation of these networks, not the least of which is the sometimes challenging relationships between the stakeholders in these networks and skepticism about the training of FPESS and the safety and quality of low volume surgical programs. Relationships extend from the patient-provider nexus to include interprofessional relationships and those between the pentagram partners (patients/communities, care providers, administrators, researchers and policymakers). Equally important to resolve is the issue of the minimum threshold volume of local surgical activity required for a sustainable professional workforce in a small rural program., Lessons Learned: A collaborative effort by key stakeholders in British Columbia has produced a program designed to overcome these challenges and build effective networks of rural surgical care, based on the synergistic interplay of five key pillars to support small surgical sites. These five pillars include clinical coaching, continuing quality improvement (CQI), remote presence technology to mitigate geographic challenges, sustainable local surgical capacity, and evaluation of dimensions of network function and clinical outcomes. This is the first time that the integration of these five pillars, each derived from best available evidence, have been positioned together as deliberate strategic policy to improve rural surgical care.

Summary: Rural western Canada relies heavily on family physicians with enhanced surgical skills (ESS) for surgical services. The recent decision by the College of Family Physicians of Canada (CFPC) to recognize ESS as a "community of practice" section offers a potential home akin to family practice anesthesia and emergency medicine. To our knowledge, however, a skill set for ESS in Canada has never been described formally. In this paper the Curriculum Committee of the National ESS Working Group proposes a generic curriculum for the training and evaluation of the ESS skill set.

Our professional organizations have prepared this paper as part of an integrated, multidisciplinary plan to ensure the availability of well-trained practitioner teams to sustain safe, effective and high-quality rural surgical and operative delivery services. Without these robust local (or nearby) surgical services, sustaining rural maternity care is much more difficult. This paper describes the "network model" as a health human resources solution to meet the surgical needs, including operative delivery, of rural residents; outlines necessary policy directions for achieving this solution; and poses a series of enabling recommendations.

Objective: To explore a once successful rural maternity care program and the variables surrounding its closure., Design: Analysis of archived logbook data, reports, and communications with medical staff., Setting: Bella Bella, a Heiltsuk First Nation community on British Columbia's central coast., Participants: Every patient delivering at the Bella Bella hospital since 1928., Methods: We extracted delivery rates, cesarean section rates, and local perinatal and maternal mortality rates from the hospital logbooks. In 2003, a consultant's report reviewed the viability of surgical and maternity care services in Bella Bella; this was also reviewed. Finally, several personal communications with past and present medical staff added to an understanding of the issues that initially sustained and, in the end, closed the local maternity care program., Main Findings: Bella Bella had an intrapartum service with operative backup, and intervention and perinatal mortality rates were comparable to national data. There was only 1 maternal death in 80 years of intrapartum service. In the 1990 s, with sparse cesarean section coverage, more mothers were obliged to travel to referral centres, until an eventual closure of the intrapartum care service in 2001., Conclusion: Bella Bella provided safe and comprehensive maternity care until, in the context of an insufficient supply of family medicine generalists trained in anesthesia, surgery, and maternity care, the service closed.

This paper describes a functional approach to the definition of rural populations for purposes of rural health care research. Rather than define "rural" directly, we created a definition of urban populations and our research target became the non-urban component. Using Geographic Information Systems technology, isochrones (drivetime zones) were created that attached suburban populations to urban centres and mapped non-urban populations into rural hospital catchment areas. For population-based analyses, we have proposed a methodology for constructing catchment areas attached to Rural, Regional and Metropolitan services. We have developed a model for calculation of travel time for patients required to travel for care. We successfully applied these methodologies to the disparate regions of rural Alberta and Northern Ontario in 2 papers that investigated the delivery of rural surgical services. This methodology represents a durable and portable designation of "rural" with potential for research applications in other areas of health research. By defining "urban" rather than "rural," we avoided many of the methodological conundrums in this research field.

Objective: Contrast alternative health delivery systems and the use of differently trained physician providers in the supply of surgical services to rural residents in 2 Canadian provinces., Methods: Four surgical procedures (carpal tunnel release, inguinal herniorrhaphy, appendectomy and cholecystectomy) provided to rural residents of Alberta and Northern Ontario were identified between 1997/98 and 2001/02. Surgical staff were identified as specialists or non-specialists. Rural populations were mapped into the catchment areas of rural acute care facilities. Rural surgical programs were characterized by the level of surgical service available locally., Results: Alberta and Northern Ontario have a similar number of rural surgical programs staffed by Canadian-certified general surgeons (10 and 12, respectively). However, Alberta has 27 smaller rural surgical programs staffed by non-specialist surgeons and Northern Ontario has only 4. These non-specialist surgeons play a significant role in Alberta, often in collaboration with specialist surgeons. In Northern Ontario the non-specialist surgeons play a minor role. The small rural surgical programs in Northern Ontario that are staffed by specialist surgeons are significantly more successful in retaining the local surgical caseload compared with similar programs in Alberta., Conclusions: The principal differences between Alberta and Northern Ontario in the delivery of rural surgical services are the greater number of small rural surgical programs in Alberta, and the substantial role of non-specialist surgical staff in these programs.