Pay now or pay later: the North End Community Health Centre dilemma

The North End Community Health Centre held outreach sessions in 2015 to learn more about the community. This poster in the waiting room features some of the responses. Wilson says it reminds the staff who they're working for.

Editor’s note: This story was posted in June, before Rod Wilson announced his candidacy in the 2016 provincial byelection. 
When Rod Wilson says the roof is coming down on his head he’s not being metaphorical.
Wilson, a doctor and executive director of the North End Community Health Centre (NECHC), works in a compact office at the top of the centre’s three-storey building at 2169 Gottingen St. The 35-year-old tar and gravel roof is rotting above his head. It has so many leaks it could collapse at any time.
A roofer inspected the structure in January. “He told me we should get someone up there to do the work next week,” he says. “It’s dire.”
This week’s heavy rain only increases the urgency of the situation. While staff and patient safety isn’t compromised, Wilson says he’s “seriously looking at options” for a business continuity plan.
If the roof does fall, the NECHC’s 5,000+ patients will be left without the free medical care of family doctors, nurses, mental-health-care workers, and the other medical and social services it offers. That doesn’t bode well for a municipality where the Nova Scotia Health Authority lists only three practitioners accepting new patients (all of which are off peninsula).

Dr. Rod Wilson and receptionist Tammy Beazley.

Dr. Rod Wilson and receptionist Tammy Beazley.

The roof’s $50,000 to $90,000 price tag is out of reach to the non-profit organization that scrapes by on government grants and private donations. In addition to the roof, the building needs other major upgrades if it’s to last. “I call this building our Sea King,” he says, referring to the navy’s notoriously aged and hard-to-maintain helicopters. “It’s been renovated five times in the last four years.”
He estimates that bringing the building up to spec could run $500,000. That sounds like a lot of money, but fundraising it isn’t insurmountable with help from the community.
Wilson remembers when the methadone clinic nearby, Direction 180, wanted to purchase a building in Fairview to help people outside of the downtown core in 2014. Residents so opposed the idea that they raised the money to buy the building to block the clinic. “So we know that level of public fundraising can be achieved,” he says dryly.
In January, the NECHC submitted a proposal to the Nova Scotia Health Authority to fund the roof repair, but in June it was still under review. The health authority sent engineers to look at the roof, and review the quotes, but the process is slow.
Provincial Minister of Health and Wellness Leo Glavine says he’s visited the NECHC many times. He told Halifax Magazine that it’s the “strongest delivery of primary medicine I’ve seen in the province.” So strong that New Waterford and other jurisdictions are considering its model.
On the subject of the roof proposal Glavine says: “There’s really a bigger question here. We’re encouraging them to put in a proposal to look at a new site. The current proposal is being reviewed. We support it in principle to the fullest but the proposal is currently being reviewed by Nova Scotia Health Authority.”
Moving is an option, Wilson says, but the NECHC would have to find the right location to continue to meet the needs of its clients. Most of them live in the area bordered on the south and north by Cogswell and Duffus streets, and on the east and west by Robie Street and Halifax Harbour.
Today most people pigeonhole the neighbourhood for low-income housing, crime, and the creeping gentrification brought by new condo developments. In the 1950s and ’60s, before the hip bars and eateries that serve the condo crew, Gottingen Street was a bustling business district. But by the tail end of the 1960s it started to decay.
The Vogue Theatre and other businesses on the street closed their doors in the late ’60s and ’70s. In 1966, the population boomed when the city forcibly relocated Africville residents to the newly constructed Uniacke Square public housing community. The area had no health-care services, but suddenly plenty of people who needed them. A group of local women banded together, and in June 1971 opened the first incarnation of the North End Community Health Centre, across the street from its current location.
But it was in the 1980s that the clinic truly came into its own.
Until then, the clinic operated on a traditional fee-for-service model, meaning doctors are paid by the number of patients they see, hence the “one problem, one appointment” rule many Nova Scotians know all too well. Johanna B. Oosterveld, then NECHC executive director, switched the clinic to a collaborative health care model that included specialists as well as doctors. She arranged funding to pay doctors by the number of hours they work, not the number of patients they can cram into an hour.
The NECHC's simple facade doesn't say much about what's happening inside. Wilson says he's constantly surprised by the number of visitors who say they just learned about the clinic, despite its community presence since 1971.

Wilson is constantly surprised by the number of people who haven’t heard about the clinic, despite its community presence since 1971.

“This model has been shown to work in Medicine Hat, Alberta, and other places,” says Wilson. “It’s been shown to reduce the number of visits to emerg, reduce jail time, reduce hospital admissions and more importantly, treat people with respect.”
Canadian studies are few, but U.S. data shows that one in five community health centre users are low-income earners with no health insurance. Patients are more likely to be a visible minority and more likely to live in poverty than those visiting traditional clinics.
In addition to the indigenous and black communities who lived in the area for generations, the centre sees new refugees, students who moved North for the affordable rent, and newly released federal offenders, who are housed in the Salvation Army building a few blocks away.
“We see a lot of people who are referred to us because they don’t really fit into any other system,” he says. “If you say you’re a former prisoner and you’re on these meds for anxiety and depression, no one will admit it but you’re not welcome in private practice.”
In addition to creating a judgment-free space, the collaborative nature of the clinic means patients aren’t running from office to office to see specialists, and waiting months for referrals. When a doctor decides a patient needs to see a mental health care practitioner or a nutritionist, there’s usually one on-site who can pop her head in to offer real-time advice.
The NECHC employs physicians, nurse practitioners, a nutritionist, and a social worker, plus participates in two mental-health programs that share practitioners with Nova Scotia Health Authority and the IWK Children’s Hospital.
Space is at a premium at the NECHC. Doctors share patient care rooms and desks. When a particularly bad cold circulated in March every member of the staff caught it, some more than once, due to the cramped quarters.

Doctors share patient care rooms and desks. When a bad cold circulated in March every member of the staff caught it, some more than once.

Dalhousie’s dentistry students offer emergency dental care several days a week. For many it’s the only dentist they’ll see this year, or this decade. Wilson worked at a fly-in First Nation reserve in the 1980s and saw huge incidences of dental disease. “I see the exact same issues in the population here,” he says.
All appointments at the NECHC are booked for one hour, longer if the patient is known to have a chronic illness like diabetes that requires a deeper level of care.
“When we break down that stigma and work on all of those barriers, homelessness, mental health, addictions, we can start working on everything at the same time,” says Leigh MacLean, who has worked in Halifax’s social services sector since 2010. “Everything should be a spider web of service.”
This one-stop-service is what makes MacLean a cheerleader for the centre. She’s a transitional support worker at Stepping Stone, a drop-in centre for sex trade workers, and a support worker for Bryony House, which provides 24-hour emergency services to women escaping partner abuse.
“The NECHC is community based and reality based,” she says MacLean. When her clients miss appointments at private doctor’s offices the relationship ends. There will be no next appointment.
“The community health centre knows that people who are experiencing poverty face many different barriers: they don’t have a phone to get a reminder call. They don’t have the bus fare to get over there,” she says. “All of these things come into play and they’re willing to work with the clients to ensure their needs are met.”
Even seemingly simple health care acts become increasingly difficult when the person trying to access them is on social assistance.
Take buying a cane for example. If you’re a social services recipient, you first need a prescription for it. Then you need to collect three written price quotes and submit them to your case worker. In a few weeks, someone will (hopefully) approve the cost and add it to your next social assistance payment.
“We’re looking at people in low socioeconomic situations, facing food and housing instability, medical, mental health, and addiction issues, lower literacy rates,” she says. “How do you get the estimates for that cane if you can’t even read them or Google to find out who sells canes?” MacLean says.
These are the only doctors many NECHC patients have ever seen. “They’ve known me since diapers and now they know my babies from diapers,” says Brittany Loppie, 30, mother of three. “Just to know the staff by name and have them know your name means so much.”
Loppie is a life-long Uniacke Square resident, and having the clinic close by encourages her to take an active role in her health. While pregnant with her first daughter at 22, the staff at the clinic enrolled her in a free pre-natal program that prepared her to become a mother to a healthy baby.
“It’s also fun, there are snacks and checkups during that time so you can get together with other women who are going through pregnancy with you,” she says. “You get to know them; your children grow up together. It builds community.” Loppie admits that without the centre she probably wouldn’t have accessed prenatal care at all.
Lester Carverey, 73, is another long-time patient. He helped renovate the current location when the clinic bought it in the 1970s. He relied on the clinic to learn about his diabetes. “I was away working in P.E.I. after I was first diagnosed,” he says. “They helped me figure out my diet on the phone while I was there so I didn’t have to wait until I got back.”
In addition to the primary and secondary health care offerings, the NECHC is a partner in Mobile Outreach Street Health (MOSH), a bus that delivers frontline medical care to homeless people, and the Housing First project, which helps chronically homeless people find housing and make it a successful long-term solution. The NECHC does all of this and more social programs on a tight budget that gets tighter every year.
According to tax filings, the Nova Scotia Health Authority funded 94 per cent of the centre’s $2.9 million 2015 budget, a figure that’s changed only incrementally since 2012. The NECHC receives a grant from the United Way too, but its 2015 contribution of $30,000 was down $5,000 from the year before. About 80 per cent of budget pays for health care costs, while the rest covers administrative fees and overhead. There’s no money in the budget for the renovations the building desperately requires.
The repaired and redecorated waiting room is a clean, plant-filled space.

The repaired and redecorated waiting room is a clean, plant-filled space.

In 2014, the organization 100 Men Who Give A Damn donated $25,000. Wilson says the money paid to upgrade the waiting room. Originally the paint peeled from water damage, the fan was ready to spin itself out of the ceiling, and everything was 1980s burgundy.
“I was embarrassed,” he says. “Our patients deserved to feel like they weren’t in a church basement. When it looked like that it said to them, ‘This is the best that you deserve.’”
Today the waiting room is bright and clean, and decorated with plants and bright art. Everyone who walks in the door knows someone in the waiting area. Boisterous conversations start, get put on hold as staff call patients in, and restart out on the sidewalk afterward.
Alexis Smith, 56, has relied on the NECHC for 25 years. “The clinic means that there’s a place in our community to restore your health back,” she says. She loves the NECHC, but sees its limitations. “They don’t have enough space there. Doctors and nurses are trying to work around each other, but they’re doing their best.”
Wilson says the closeness of the quarters his team works in was more than evident in March when a nasty cold bug hit every member of the staff. Funding is the key to all of the centre’s challenges, but he admits he hasn’t always been the best at telling the NECHC’s story to outsiders.
“I’d love to collect metrics to convince the bureaucrats, but that takes skill and money,” he says. The board of directors laid-off administrative staff last year to afford to hire someone to collect data and make the case for more provincial funding. Further cuts would mean losing medical staff, which Wilson isn’t willing to do. As it is, the on-call doctor staffing the nighttime emergency phone line works for free.
MacLean, Wilson, and the patients above all say the NECHC closing it would trigger a health care emergency felt across Halifax.
“The North End would erupt without the NECHC. I cannot even fathom what the ER is going to look like,” says MacLean. Health Minister Galvine spoke similarly. “If it were to be absent we’d see a flood of people into the emergency rooms,” he said.
As MacLean sees it, the province is going to pay for the centre whether or not they approve the funding request for the new roof.
“For every dollar we’re spending on the North End Clinic, I know that we’re saving money because we’re helping people before they’re really sick,” she says. “They’re avoiding the hospital, and avoiding the criminal justice system by breaking addiction and dealing with mental health issues.”
You can donate to the NECHC at Donations are recognized with an income tax receipt.

This story was originally published in Halifax Magazine.

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