Doctors across the country are cautiously optimistic about the condition of primary care, but realize more work needs to be done, especially with reform models and collaboration

TORONTO | It’s a no-lose proposition. After getting somewhat contradictory reports over the past several months, Medical Post editors wanted to know how family doctors feel about major issues facing them these days.

In late November, the Boston-based Physicians’ Foundation released a survey expressing “widespread frustration and concern” among U.S. primary-care physicians.

Around the same time, the College of Family Physicians of Canada released a troubling report card on the status of the family medicine workforce. The report assigned a D grade to health human resource planning, “a fact that alarmingly underlines the priority for a pan-Canadian co-ordinated approach,” the college’s news release indicated.

We asked four high-profile representatives from across the country about the current “state of the union,” primary-care reform, collaborative care, fee relativity and what they think the future holds.

We expected one of two equally interesting things: Either the responses would be similar, reflecting remarkable solidarity among what the country’s GPs are experiencing, or their substantively different answers would indicate a concerning fragmentation among the provinces toward primary-care policy-making.

We hope our results encourage debate about where Canadian family practice is going.

1. What is the “state of the union” of family practice in your province now?

• Dr. Goodchild (B.C.): Cautious optimism. For the first time in years, things seem to be looking up for family practice in B.C.

We have a strong working relationship with the ministry through the GP services committee (GPSC), and there have been many positive steps taken toward valuing the key role of GPs in providing continuity and co-ordination of care. More than three-quarters of B.C.’s GPs have taken advantage of new GPSC fee initiatives, which have motivated older GPs to stay in practice longer. The recent global financial crisis might keep them practising even longer! It looks like more grads may also be settling into practices earlier.

• Dr. Brox (Alberta): I don’t have numbers as to how many new GP licences and retired GPs there are, but it feels like there are probably a few more (new GPs) out there right now.

Family practice is no longer a fallback where if you can’t do something better, you go into family practice. Even in medical school, where various bits and pieces used to be taught by specialists, it’s GPs who are now the very core of teaching models.

GPs are still finding it tough to support themselves financially in community family medicine because of oppressive overhead. We need more community-supported practices, or patients just aren’t going to get the care they need.

• Dr. Arnold (Ontario): In Ontario’s 2004 contract, and the most recent one, we made great progress in improving the attractiveness of family medicine with the assistance of our section on general and family practice (SGFP).

We’ve also been successful in getting other sections more involved in providing input into where funds are allocated. This should allow the SGFP to actively participate in resolving outstanding issues. This will be a difficult process, but we’ve put resources aside to help our sections as much as possible.

We’ve also made significant progress getting more patients access to family doctors. Over the past four years, physicians in Ontario have worked hard to treat more patients and help fill gaps left by the doctor shortage. Doctors across the province have taken on 630,000 patients who previously didn’t have a family doctor.

There’s much more work to do, and we’ve agreed to take steps over the next few years to get every patient a family physician and ensure they receive the care they need and deserve. Initiatives in our new contract, such as providing funding for 500 nurses to work in physician offices, will help us move in the right direction.

• Dr. Hatcher (Newfoundland and Labrador): Things are reasonable in terms of supply in urban areas. The biggest challenges remain access to specialists, diagnostics and waiting times.

The same may or may not be strongly felt by our rural colleagues. (Problems like these) make it less likely someone will want to start a practice in these areas. It’s a chronic problem.

We didn’t do well during our last negotiations and were assured we’d do better in the next round, which starts next year when we had hoped things would be better. Now, we know there will be another downturn, so we’re concerned all the things we were promised four years ago won’t materialize. The province is already involved in hardball negotiations with the nurses.

2. Has your government done enough to encourage development of primary-care reform models?

• Dr. Goodchild: B.C.’s initial approach to primary-care renewal was not very successful. It wasn’t grassroots-driven.

There are only a few of the initial “primary-care reform” projects still functioning here. More recently, the approach through the GP services committee has been community-focused. Incentives to encourage changes in practice styles rather than penalties have encouraged GPs to approach chronic disease and complex care management in a more organized fashion.

If we’ve learned anything from our experience, it’s that there is no single correct model for how to deliver primary care, as long as it achieves the key elements of access, continuity, co-ordination and comprehensiveness.

• Dr. Brox: Alberta government officials have said a lot of words, but haven’t put enough money behind them and haven’t really provided any supporting legislation that would help primary-care reform models work more effectively, such as a better position on liability. The buck always seems to be stopping on our desks.

• Dr. Arnold: We’re encouraged by the provincial government’s efforts to develop family health teams (FHTs) and other collaborative-care models in Ontario. FHTs are staffed by full-time physicians, nurses, and dietitians, among other health-care providers.

We’re dually encouraged by the introduction of shared care pilots a few years ago, and by the funding in this contract for 500 nurses to work in physician offices. It’s important all doctors and all their patients have access to comparable levels of services. Our focus has been to enable as many physicians interested in getting access to other providers, incentives and, of course, information technology.

We have, however, been concerned with new initiatives such as nurse-led clinics. Collaboration and partnership in models that have been tested and are proving to provide quality care to patients is the best way forward.

• Dr. Hatcher: They may think they have, but I don’t think so. There’s been absolutely no support for electronic medical records (EMRs) in our province. Some reports show progress, but it’s hospital-based and not really an EMR.

Newfoundland is in the forefront of developing a pharmacy network, however. We expect a pilot project linking both professions in one region sometime in 2009. That promises to have a significant positive impact on patient safety and will help minimize errors. The intention is to go live across the province in 2010 with all pharmacies on board and online prescribing.

The big issue in our province is that there have been pilot projects but then they die. It’s a tradition in Newfoundland not to continue the support. We get federal funding for pilots which continue until the money runs out, and government hasn’t been forthcoming with an answer to that question.

3. Do your members support the concept of collaborative care?

• Dr. Goodchild: B.C. GPs do support collaboration. There’s no way to address the increasingly complex needs of patients without it.

But we’ve also come to realize that collaboration without co-ordination is not an efficient use of resources. Every team needs a quarterback. On a medical team that’s the GP.

The GP-patient partnership of trust over time must remain the locus for therapeutic decision-making. So, while we support better use of the expertise of all members of the health-care team, such as pharmacists, we feel expanding their role in prescribing will fragment care, and drive up costs.

• Dr. Brox: Yes, definitely, but while many of our members have already done a fair bit of collaborative care, we still need to encourage them through the way we deal with some of our fees and providing more (liability) protection.

If a public nurse is asked to do something, I’d be responsible for it. We need to look at these sorts of things, especially if we’re going to use EMRs more. Alberta government officials say big things, but don’t go much further than that.

• Dr. Arnold: Ontario’s 25,000 doctors believe collaborative care is the way to go in this province.

The family health team in Kingston, for example, now provides care to 22,500 patients and will soon serve another 6,000. Investments in FHTs are essential in helping solve the doctor shortage.

• Dr. Hatcher: There’s nothing new about collaborative care in our rural practices. It’s always been part of them. Having more of it in our urban areas, though, would be wonderful.

There’s a big disconnect between hospital and community-based programs for GPs in Newfoundland that we will try to close during our next round of negotiations.

4 Is fee relativity still a major concern for GPs?

• Dr. Goodchild: Like everywhere else, fee relativity continues to be an issue in B.C. While the recent macro-allocation arbitration award and targeted funds to the GPSC have lessened the disparity, there’s still more work to be done to adequately compensate GPs for providing comprehensive, co-ordinated care in a partnership over time with their patients.

In addition to the obvious need to train more doctors and ensure more graduates choose family practice as a career by making sure that financial and social incentives are strong, it’s key to focus policy on the importance of continuity of that relationship.

Patients with complex medical problems place a high value on co-ordination of care by a regular provider. Every time a patient sees a different provider, they start from scratch, creating extra work in the system. When continuity is valued, existing human resources go further because there’s less total work in the system to be done. We would be increasing capacity by reducing demand.

We feel our ministry “gets it” and recognizes the importance of relationships and co-ordination of care, and we’re working together to develop new measures to reward family physicians appropriately.

• Dr. Brox: Relativity has had a major impact on our recruitment. You can make more money faster being almost any other kind of doctor (than a GP).

Status and money have always been linked. There’s been a little progress, and we’re getting support from our specialist colleagues—pediatrics, psychiatry and internists—who are in the same boat we are. (In Alberta) we’re united on the issue and encouraged by what’s happened over the past three to five years. A fair degree of positive reaction has built up.

• Dr. Arnold: Relativity was a key issue for Ontario in the last round of negotiations.

It was an issue we heard throughout our extensive consultations in the lead-up to negotiations. We were able to achieve significant funding dedicated specifically to address relativity issues in the coming years. We’ve already initiated this process, and dedicated additional resources to assist our sections in getting through this process.

• Dr. Hatcher: In Newfoundland, fee relativity is less of a concern than it was before. From a national perspective, it’s still an issue, particularly on an interspecialty basis with fees for doing exactly the same thing.

It’s also an issue nationally because of the possibility of more free trade and labour mobility, which will make relativity much more important. If physicians know there will be no relativity concerns, they’ll be more willing to move.

5. What does the future hold for family practice?

• Dr. Goodchild: The future looks brighter, but the crisis is far from over. The first step was government acknowledging the value of family practice. The evidence locally and globally is clear.

Patients with a regular family doctor receive more appropriate preventive care, are more likely to have fewer tests and prescriptions, have fewer hospitalizations and visits to emergency departments, and are more likely to have lower costs of care.

Family doctors are key to a sustainable health-care system.

Things in B.C. are looking up, but more work needs to be done.

• Dr. Brox: Things stand to get better, and family practice will become a much more positive place than it was in the 1990s.

We have a brighter future because there are lots of people working to make it better. Our rural colleagues have done exciting things to push their skills to the maximum. It’s the place to be for those who like a challenge, and the respect we see in these communities seems to be spreading to urban areas.

• Dr. Arnold: For a number of family doctors, family practice has been a challenge for the last decade. Governments have wanted to move from fee-for-service and have favoured incentivizing doctors in collaborative practices. In Ontario, one of our priorities in the most recent contract negotiations was to get as much funding as we could to put toward fees, and we’re confident we made significant progress on that front.

That said, in recent years, thanks in large part to the hard work of our doctors, we’ve been able to see more patients, and in many cases we’re benefitting from the assistance of other providers. Looking ahead, doctors need a balance in providing preventive, acute and chronic care within our practices.

• Dr. Hatcher: We’re going to see some very significant changes—more collaboration and group practice. The biggest risk we face is losing our physicians to other areas of the world.

The primary care wait-time alliance—which I am co-chairing with Dr. Tom Bailey, past-president of the College of Family Physicians of Canada—will develop creative ways to address these issues.

You have to be optimistic. Governments are looking at ways to improve health-care services and delivery with the goal to provide 95% of Canadians with a family doctor by 2012. There are only so many concrete, practical ways to do that that won’t be humongously expensive.