Primary Health Care is the bedrock of any health care system for it is the entry point to getting health and long-term care problems dealt with efficiently and effectively. Without access to either a great interdisciplinary primary health clinic or to a primary health care physician, the patient has no one to advocate for his health care needs. Just try, as too many of my friends are forced to do, having an after-hours clinic as your main source of access to the care you need. It is not at all a pretty picture.
Andrew Waugh’s article in the Telegraph on Friday, April 8, 2022 reported that the family physician wait list has now grown to 55,000; many suggest that is a conservative number when they observe that many who have been on the list for years have just given up. Not exactly a testimonial for a socialized health system in which access to primary health care is enshrined in the Canada Health Act. No wonder the Canadian health care system ranks so low on the OECD list comparing us with other western world countries!
How long, exactly, have we been having this conversation in New Brunswick? Is this a problem of the Tory government? Or of the Liberal government? They both share responsibility for these conversations have been going on for a full 15 years or more.
For over a decade, one of the responses has been that increased numbers of nurse practitioners will take up the slack. That has been touted as a strategy announced even by this government for a couple of years. Yet the numbers of people “on the list” keeps going the wrong way. Why would that be?
As observed in previous columns, the practice of medicine is not what it used to be even a decade or two ago. The practice patterns of family physicians started changing seriously many years ago yet there was no way to make adjustments that would enable adaptation in the marketplace. Even though practice patterns have been changing so dramatically, there has been no accountability mechanism in place to direct and manage primary care regionally or provincially. In the 1990’s government had a Physician Resource Plan with an Advisory Committee that was beginning to sound some warnings but that has all changed.
Strong management of primary care was not so necessary “in the old days” because physicians, once passing licensure requirements, would figure out a practice pattern and make arrangements that suited their professional and economic ambitions. Solo practice? fine; just get an office and start. Part of a group practice? Sure; just find a group of physicians with whom you and your practice ambitions are compatible and make arrangements with them and start work.
In the old days, solo or part of a group, family doctors worked long hard days, well more than 5 days per week, took call as part of a call roster, and did shifts as scheduled in the Emergency Department. This was tough work and placed enormous pressures on family life.
Fast forward to today when there is, with great justification, much more focus on work life balance. Gone are the patient rosters of 3-4,000 people and in come the rosters of 7-800 people. And gone are the days of 24/7 availability.
Since that evolution commenced decades ago, government has been rather derelict in not keeping pace with the evolution by placing a great deal of emphasis on workable practice options. The conventional theory of simply graduating more nurse practitioners, a good strategy in itself, is not the simple answer to filling the void. The gold standard in primary care is not professionals operating in silos competing for caseload. There is, for instance, a clinic in Dieppe that advertises “What can a Nurse Practitioner assess, diagnose, and treat on eVisit NB? Everything a doctor can!” That advertising would convey to the public that the Nurse Practitioner is a substitute for the physician.
Best practice, as evidenced in many places now, is exhibited when physicians, nurse practitioners, nurses, social workers, mental health specialists and other professionals work in an integrated manner in an integrated clinic. None of the professions, if the truth were known, has perfect knowledge and understanding of all matter’s health care but the synergy that is created when professionals collaborate, share expertise, refuse to compete is absolutely powerful.
But someone has to be accountable to direct primary care. Serious reform will not happen; it has to be driven with intentionality and courage. Should it be the mandate of the health authorities to lead this reform? Probably so. In the past, the Medical Society and the Department of Health have collaborated on the fee schedule and high-level policy matters. And as good as that collaboration has been, well over 55,000 New Brunswickers still lack the basics of health care!
So perhaps it is time for the mantle to fall to the health authorities along with a new method of financing primary health care. Some very thoughtful and knowledgeable people in New Brunswick have suggested, for years, that Primary Health Care needs to be funded not on the conventional fee for service model but on a Capitation Model. Fee for service simply reimburses the physician for every office visit and procedure completed. The financial incentive exists to keep the office full of patients, each one representing a claim to Medicare.
Capitation, on the other hand, allows for funds to flow in payment for the health care of a given population group. The principals receive the same volume of funds regardless of how many office visits take place, how many procedures take place. One important goal of some capitation methods is to create a reward to service providers to keep patients out of the Emergency Department or hospital. In other words, the capitation method provides a means of linking dollars to health promotion and disease prevention. For how many decades have we heard the call to make that a priority…but it never happens.
Physicians in mid to late career would probably not be too excited about a capitation method of funding; at this point they have invested their lives in their practice, have grown accustomed to a great practice pattern with all the relationships that entails, lease agreements or real estate ownership. But for Professionals early in their career or just starting out, it may very well be a very attractive way to organize the funding of an interdisciplinary practice. For those whose professional goals are to excel while maintaining work/life balance without the burden of leases, owning equipment, hiring staff this could be a very attractive option up to and including a pension plan!
I am advocating no model of payment; I just observe that new models with new models of compensation must be found now.
As stated in my last column, with the decades of this debate showing so little promise of progress, is it time for a course of action just a bit more radical than may have been on the agenda thus far?
The current situation is not the fault of Dorothy Shepherd nor of some well-intentioned health ministers of the past. Fixing this part of the brokenness in the health system is very difficult if not delicate and political people are well aware of the danger of creating an angry medical or nursing profession. So, progress needs to be careful but resolute.
Ken McGeorge,BS,DHA,CHE is a retired career health care CEO, part time consultant, and columnist with Brunswick News, and author of Health Care Reform in New Brunswick; he can be reached at: firstname.lastname@example.org
Ken McGeorge, BS,DHA,CHE is a career health care executive based in Fredericton, NB, Canada.