It's estimated that roughly five
million Canadians don't have a family physician. But
does that really matter? Does everyone really need an
FP to call their own?
HAZARD
OR HYPE?
It's widely accepted by the public and most in the medical
establishment that not having an FP to look after you
is a very bad thing indeed. "There are some really disturbing
stories about diabetics going to the ER to get their
insulin scripts renewed," says Dr William Hogg, Director
of Research for the Department of Family Medicine at
the University of Ottawa. "I find it shocking that in
this civilized society some patients have had to resort
to this."
But what about the healthy Canadian,
with no chronic illnesses who rarely needs medical care?
Does she need her very own FP?
One radical solution to keep both
these groups of patients healthy is to throw out the
idea that each patient should have a single family physician
who handles their cases and whom they have to book an
appointment with months in advance. Would primary care
then be able to open up, absorb orphaned sick patients
and make the massive changes that need to take place
so it doesn't burst at the seams?
SCRIPT
FOR CHANGE
"If you were to start from scratch and ask: 'what kind
of primary healthcare should we create?'" says Dr Michael
Rachlis, a health policy analyst who has consulted for
both the federal and provincial governments as well
as two royal commissions, "you'd be talking about creating
patient-centered care," or needs-based care. He says
we need to abandon the one-size-fits-all approach and
base care on the specific needs of specific communities.
Downtown Toronto has very different primary care needs
than Kapuskasing, for instance.
Family Health Teams (FHTs), like
those in Ontario and Alberta, are a step forward, he
says. "But a lot of these new models are not necessarily
being driven by the best evidence." He says many FHTs
follow a set recipe when putting their teams together
instead of looking at what their community really needs
— maybe one FHT needs a full-time nurse practitioner
and a part-time pharmacist, while another needs a nurse
and a social worker, for instance.
Needs-based teams, he says, should
be made up of two physicians and roughly three other
staff, like a pharmacist, NP or physiotherapist, depending
on the community's population. Patients would still
have an FP who handled their file, but they would only
manage the patient's chronic diseases and other major
illnesses.
"Every Canadian could have a family
physician if FPs were working in an interdisciplinary
team with other physicians and healthcare staff," says
Dr Rachlis. "The federal government knows they should
make a move. They need to think big and begin asking
questions that a business person might ask like 'What
is the best way of organizing all the people who are
providing healthcare?'"
A
SECOND OPINION
Dr Hogg's a little more sceptical about team-based care
saving the system. "The presence of nurse practitioners
improves access for those who are already a member of
the practice," says Dr Hogg. "But as yet, there's no
evidence that multi-disciplinary teams allow doctors
to take on any new patients."
All the words that are spoken about
teams so far only 'hope' that FHTs will allow doctors
to take on more patients, he says. Ontario's FHTs have
been running since about 2006 and studies to gather
numbers are just getting underway.
Dr Hogg does, however, believe
that major structural reforms are necessary, and that
those reforms should rely heavily on multi-disciplinary
teams. But there is no magic bullet, he says.
STRATEGIES
AND SCHEMES
Dr Rachlis and Dr Hogg both stress that a number of
other strategies should go hand-in-hand with interdisciplinary
teams to make them work.
There is evidence, says Dr Hogg,
that advanced access, the practice of seeing patients
as soon as possible — preferably same day —
is helpful. But it's hard to set up, and change moves
slowly in medical practice.
Tough, says Dr Rachlis, it's do
or die time. "We have the legacy of a private system
where individuals were getting paid to do piece work.
Fee-for-service is not good and it's part of the problem.
It makes it really messy for physicians to integrate
other health professionals into their practice."
FFS payment shaves off extra things
that need doing during visits too, like educational
and preventative measures, he says. "You need some kind
of mixed system. In the UK they've concluded that you
need a majority payment under capitation. And only then
you can add on outcome payments and FFS payments."
A wholesale, government funded
move to EMRs couldn't hurt either, he adds. It helped
streamline the system in England.
PATIENTS
IN PERIL
Dr Hogg and Dr Rachlis agree that many of the millions
of patients who are actively looking for an FP are in
peril, and many who actually have an FP aren't getting
the service they need. Patients can still visit a family
physician in their community regularly, they say. But
the system that these patients approach has got to be
reconfigured drastically.
"To anyone who says that a physician
shortage has put healthcare in crisis," says Dr Rachlis,
"I would ask, is it bad enough to make changes that
would introduce advanced access, interdisciplinary teams,
and electronic health records across the board? If the
answer is 'no,' then stop saying there's a crisis!"
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