Primary Care: A Bold Revisioning

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Radical reform necessary to respond to crisis

Nationally, the number of medical school graduates who rank family medicine as their first choice is 31.3 percent, down from 38 percent just eight years ago.

The article, Family Medicine in Crisis, delves into the reasons why this may be happening. But are medical schools also pre-selecting a group of students who are less likely to choose family medicine? Dr. Jane Philpott thinks that might be the case. That’s one reason why she’s excited about the potential of a family medicine program at a Durham Region satellite campus, a partnership between the Queen’s University’s School of Medicine and Lakeridge Health.

The program is creating a new standard for admissions that, beyond the usual criteria, prioritizes candidates who are committed to comprehensive general practice. This approach will consider the fit between future doctors and locations across southeastern Ontario. The idea is to graduate practice-ready, community-focused physicians.

It is one solution among many being forward to revision a new much-needed reality.

“We need radical reform to improve what has become a crisis,” says Dr. Tara Kiran.

Several recent studies have examined what’s possible, like the OCFP’s Plan of Action and the Public Policy Forum’s Primary Care for Everyone. An earlier Public Policy Forum paper suggested that primary care emulate the public school model. Everyone should have timely access to a publicly funded primary-care team within 30 minutes of where they live or work, just as public school in a local neighbourhood is automatically available to every child.

To make the progress needed, it will take a combination of bold solutions. Seven that are raised often would enable family doctors to take on more patients, increase the time they can spend with them, reach underserved populations and ultimately improve the quality of care.

1. Improve the efficiency of clinical and administrative support

We need system-level changes to address the inefficiencies in how health care information is shared and communicated,” says Dr. Kamila Premji.

Dr. Kathleen Ross says improved health care data management, and the ability to access timely information and avoid duplication, would alleviate many frustrations. She says family doctors may get 4-5 copies of the same lab result. “If I can look at a patient chart and see all data at once, that decreases my workload. Every click of a button or complicated referral process is taking away time I would otherwise spend on clinical care.”

The OCFP proposed enhancing the effectiveness of digital systems by launching an EMR improvement initiative. It also wants to integrate patient information systems, with family doctors digitally connected across their practices and with other parts of the system (creating an Electronic Patient Record will support this process).

The referral process is another prime opportunity for improvement.

The OCFP proposes a central intake referral system for access to specialists, with cases triaged according to the greatest need and integrated with the current eReferral system. They also want all specialists to participate in eReferral and to expand it to manage referrals for other aspects of care, like medical imaging.

Specialists themselves acknowledge the barriers family doctors face. At a recent Choosing Wisely Canada webinar, Dr. Sacha Bhatia, a cardiologist at Women’s College Hospital, and a Population Health and Value Based Care Executive at Ontario Health, explained a source of frustration for family physicians.

“They send in a referral form and it gets spit back three weeks later with the message that this is an unacceptable referral,” says Dr. Bhatia. “It shouldn’t be on the family physician to have to crack the code. A family doctor can’t know my requirements, and an orthopedic surgeon’s requirements and a cancer surgeon’s requirements. It’s on us, as the specialists, to work with our primary care colleagues to design referral or intake processes that actually help people.”

2. Boost the supply

Given the number of people who are unattached to a family doctor and an average family roster of 1,200-1,500 patients, filling the gap means that Ontario would need another 1,750 primary care practitioners and Canada, as a whole, would need another 5,000. “That’s not realistic,” says Dr. Ross.

Still, any increase in the supply helps. Two pillars are to increase family medicine residency spots and fast-track the certification of foreign-trained doctors to practise in Ontario. These are initiatives with which CPSO is closely acquainted. It has sped up its certification processes, and, over the last year, made it an ongoing priority to review its processes and policies to expand opportunities for physicians to practise independently in Ontario. By the end of June, at least half-a-dozen policies will be amended to reduce barriers for incoming doctors.

“We need to make it easier to start up a practice in Canada,” says Dr. Premji.

Another lever to address pressures is national licensure. This would increase the flexibility of doctors to work across provincial lines and support multidisciplinary, full-service, primary care.

3. Create more teams

It’s not just a matter of the size of the family physician workforce, but making the most of their talents and time. Dr. Danielle Martin is clear: she’d like to see 100 percent of the population with a formal attachment to an interprofessional health team.

“This is a moment for rethinking,” she says. “The answer is teams, with some amount of geographic accountability, and appropriate resourcing of the infrastructure to make it happen and create hubs or clinics to cover off one another.”

The OCFP proposed adding primary care team members — an initial 1,000 new social workers, mental health workers, nurses, nurse practitioners, pharmacists, Indigenous healers, physician assistants, etc. — to enable family physicians to take on more patients and improve access to comprehensive care.

“Team-based care, done well, isn’t just having people with overlapping abilities, but means everyone is working to the top of their scope,” says Dr. Sarah Newberry.

4. Create a strategy for under-served populations, including incentives

Another part of the OCFP plan is to ensure Ontarians in the north, rural areas and others in the most underserved populations have equitable access to family physicians.

A Northern and rural strategy could be used to coordinate and expand evidence-based incentives and training/practice supports, such as mentoring, to help attract and retain family physicians (and other specialists). To encourage family physicians to practise in high needs/low access communities, the OCFP suggests offering incentives, such as rent and overhead subsidies, and loan repayment programs.

But other working conditions also need to improve, suggests Dr. Newbery. “Although financial incentives often get people in the door, they often don’t retain people. It is hard to practise in a rural area, if you feel you can’t provide the right care. You’re talking about care for your neighbours.”

She continues, “The currency we need to be talking about isn’t money, but time.” Freeing up time can entail being part of a team-based approach, and having a roster size that’s appropriate for small communities with broad geographies and less access to other resources.

Dr. Newbery hopes more young doctors get a sense of the positives that working in a rural community can offer. She says many of the things that doctors covet, like having close relationships with patients and colleagues, and feeling a sense of purpose and mastery in work, are easier to experience in a rural setting.

“It’s inherently rewarding. When rural practice is well supported, with the right number of physicians in a community and the right number of teammates, there’s nothing better.”

5. Maximize the potential to attach patients

Virtual care and innovative partnerships can extend the reach to unattached patients. Dr. Premji notes the success of the Virtual Triage and Assessment Centre (VTAC) in Renfrew County, created in March 2020 in response to the COVID-19 pandemic. VTAC is a collaboration between the county’s primary care teams, paramedic service, hospitals and District Health Unit, with the support of Ontario Health East. More than 70 percent of the people who access VTAC do not have a family doctor or alternative primary care provider.

The program is a hybrid model of care. Residents call an 800-number to connect to a primary care professional the same day or be referred to paramedics for assessments or in-home visits. To date, VTAC facilitated about 80,000 virtual assessments from family physicians, 70,000 paramedic assessments and 5,500 paramedic home visits.

The head of emergency services for Renfrew County recently said that VTAC has significantly reduced pressure on emergency departments. In March, the Ontario government announced that it would extend funding for the program for 2023-24.

6. Use a “most responsible provider” approach in team-based care

The Primary Care for Everyone paper suggests designating a lead practitioner for each patient using the “most responsible provider” approach, where non-physicians can coordinate care. If we don’t have to rely only on doctors to direct access to care for patients attached to a team, that achieves three goals:

1. It allows other team members to work at their full scope and manage patients;
2. It ensures people have a primary care provider who knows them and looks out for their individual needs; and
3. It increases capacity for the team to serve more patients overall.

7. Invest appropriately

“Although it is the foundation of the health care system and sees the most patients every day, primary care often isn’t given the resources and funding it needs,” says Dr. Michael Green.

When patients are connected with a family doctor, they are more likely to identify and address health issues early, better able to manage chronic conditions and less likely to be admitted to emergency. Investments in primary care “reduce the need for acute care down the road,” says Dr. Mekalai Kumanan.

“Good, quality, primary care costs less,” says Dr. Ross.

Hope for the future

Despite all of the current challenges, “Family medicine is the root of our health care system and, in my mind, there is nothing more rewarding,” says Dr. Ross.

“We’ll see this crisis through and it will get better.”

The range and scale of solutions required can seem immense, but so is the chance to transform primary care.

“This is a moment for re-thinking,” says Dr. Martin. “I’m feeling better now than I was this time last year. We’re seeing signals from the public that they care about the issue, and they’re pushing government and other leaders to figure this out. That’s an antidote to the feeling of being devalued.”

Dr. Philpott also sees a positive sign in that Canadians are talking about the challenges in primary care access and effectiveness, and that policymakers are listening. “There has been a loud public discourse about the importance of family doctors. It is raising alarms and we have to respond. We’ll see this crisis through and it will get better.”