​Primary Health Care: one of a few key building blocks of Health Care Reform

Far too many New Brunswick residents do not have access to effective primary care services; over 43,000 of them and growing, not getting better.  Just when you think it could not get worse, it does.  My Facebook timeline had a post describing the tragedy presented to good, hard-working people when they got a letter, as did nearly 2000 others, that said the doctor “is retiring, no replacement in sight, you will have to get your name on the provincial wait list for a doctor.”   She expressed in that same letter her disappointment with the state of primary care services in New Brunswick.  The doctor is a highly respected practitioner but based on the trends in recent years with medical education and the profile of graduates, it would take two physicians to manage this practice.  And the traditional practice of a new doctor “buying a practice” is long gone.  Why buy a practice when there are so many other options to earn professional income without the expense and burden of an office practice.

The Minister of Health, feeling some of the distress of the thousands of taxpayers who are disgusted with the current status of Primary Care in New Brunswick, did issue a press release outlining some options and relatively minor changes to primary care service.  To this, I say it is a noble baby step in fixing a much larger problem that has been on the radar for a decade.

Empowering pharmacists to play a larger role in prescription filling and treatment for minor ailments has been recommended for decades.  Indeed, other developed countries implemented this measure and more many decades ago.

Empowering EMTs to more fully use their skills us a great initiative having been debated now for a few years.  This is a good initiative.  Walk-in clinics gets mixed reviews in the province and are not part of a permanent resolution to primary care access.  Virtual Care has been birthed during the pandemic and gets great reviews by most who have been service recipients (including me!).  Tele-Care may be able to help to an extent although signs of overload with Covid calls seem evident.  Speaking with someone who has no chart and cannot know any history or physical presentation can only be a stop gap if useful at all.

Addiction and mental health clinics will need further attention if their role is to be expanded, based on early feedback that is purely anecdotal.  The proposed service model of one-at-a-time is not described yet in any material available to the public.  Hopefully it will prove to be a model that will yield results.  This is an incredibly serious area of health care and honestly needs a serious overhaul and strong leadership.

What would a full plan for primary care entail?  If we were serious about dealing with the people who, constitutionally, have grounds for class action citing the Canada Health Act violation of inaccessible essential primary health care.  A full plan would show precisely the methods by which the wait list for access to primary care will be eliminated.

These columns and other columns have put solutions forward and no assembly of planners is complete without getting the informed, wise counsel of seasoned, experienced family physicians.  There are many great physicians in this province, but I was thrilled to be given an advance copy of a plan, Access to Primary Healthcare in New Brunswick, written by four physicians that are held in exceptionally high regard in the province:  Dr. Russell King, former school teacher, popular family physician, Minister of Health and Community Services during the tumultuous years of Phase 1 of Health Reform in the 1990’s.  Dr. Stephen Hart, family physician who was prominent in leading the introduction of seatbelt legislation in New Brunswick in 1982, one of the first four provinces to do so.  Dr. Ian MacDonald has been a very popular, busy family doctor, prominent member of the NB Council on Aging in 2016.  Dr. Robert Tingley was, for decades, a highly respected, very popular family physician in Fredericton and first Site Director of the Dalhousie Medical School Family Medicine Teaching Unit in Fredericton.

The plan that they assembled says all the things that these columns have been saying for three years!  What you have here is four leading recently-retired, highly respected physicians presenting an approach that is hard to criticize.  Taking this plan, assembling the right planning group that must have nurse leaders at the table, and you could have a plan to change the face of primary care in New Brunswick in weeks!

Highlights of the plan start with the acknowledgement that whereas family doctors who practiced when they were in their prime carried 2500 or more patients on their roster while noting that practitioners now prefer to carry a roster of 1000 or less with great emphasis on work/life balance.  A variety of styles of practice have evolved within the broad scope of primary care medicine, man of which do not involve maintaining an office practice per se but are necessary element of primary care.

A strong point of emphasis in the plan is the priority given to team-based practice.  A practice that has, in its staff mix, a nurse, a specialty family practice nurse, or a nurse practitioner can absorb much larger numbers into the patient roster because of the primary care skills of these professionals working as a team.
The model presented by the NB Medical Society, referred to as Family MedicineNB, is a solid model that can be made even better with the addition of a family practice nurse or Nurse Practitioner to the staff mix.  The issue, of course, is how do these people get paid, so a new funding formula needs to be adopted if government is serious about encouraging integrated primary health clinics.

The plan makes reference to the need for medical schools and faculties of nursing to think a bit differently in order to respond to the issue of essential new directions for primary care.  It also encourages some better approaches to physician recruitment, and in so doing, it illustrates the difference between urban areas and rural communities in terms of recruitment issues and challenges.  But having physicians themselves engaged in recruitment is pretty important.

In the 1992 Health Reforms, government introduced a physician manpower plan that was directed by a special committee, the Physician Resources Advisory Committee.  This provided some valuable tools and data as a basis for recruiting and appointing physicians.  The objects of that plan need to be dusted off and refreshed in light of current practice and knowledge.

Does this plan answer all that is needed to implement province-wide change?  It does not profess to be a plan that has all the financial and demographic detail that Treasury board budget people will want.  What it does do is present a vision supported by 4 dedicated, enthusiastic, highly-respected family doctors, one with the ultimate political experience in system change, that can then be taken by an informed, experienced planning group for detailed work and implementation.  Based on feedback I have received over three years of writing commentaries, I am confident that once seen by the physician and nursing community, the persons of influence will come alongside and help to champion change.

“In preparing for battle I have always found that plans are useless, but planning is indispensable.” General Dwight D. Eisenhower.

Simply stated:  take a plan like this as a jumping off point, assemble the right people with the right knowledge, the right experience and the right motivation; give them a month with the right leader and we can resolve this primary care access issue.

Ken McGeorge,BS,DHA,CHE  is a retired CEO in major teaching hospitals and long-term-care facilities. He was co-chair of the New Brunswick Council on Aging and is a columnist with Brunswick News. His email address is [email protected].​