Accessible Primary Care in Times of Scarcity

I argue in this short article that the current design of primary care services is not able to provide the care needed by the population. We need to consider a more population needs based design which provides effective care and work/life balance for the healthcare providers.

Environmental Scan

First let's gather some of what I see happening. The College of Family Physicians of Canada wants to increase the residency for Family Practice to three years, quoting the complexity of family physicians' work. Health Authorities are struggling to recruit family physicians to provide coverage for the whole population. There is somewhere between 20 and 30 percent of the population without a family physician access. 75+ population will continue to increase each year another 15 years until 2039. A recent report from OurCare presented the same problems and came up with same/similar expectations: solve attachment crisis, expand team-based care, expand virtual health, grow the primary care workforce, enable patient access to health records, extend primary care coverage including dental, eye care, prescription medications, and allied health professionals, improve accountability in the health system, bring strong equity focus. I agree with all of these wishes.

New options for physician compensation are introduced with the 2022 Physician Master Agreement (PMA). The Primary Care Networks (PCN) brought a new view to the primary care services. We can see a lot of similarities in programs developed under PCNs for selected patient groups across communities. Multidisciplinary teams are the norm for most of them. Health Authorities built Urgent Primary Care Centres (UPCC) and Community Health clinics. The College of Physicians and Surgeons of BC allowed for international medical graduates to be recruited under physician associate category. Nurses, social workers, nurse practitioners are recruited to support primary care services and physician assistants are on the way. The perception of the crisis in primary care by strong physician advocacy in 2022 subsided with the new PMA and news coverage tapered down.

Attachment levels did not budge significantly, citizens still have challenges in accessing primary care services, emergency units are still full.

Family Physicians told us what they want

Survey conducted in Vancouver by Hedden et al in 2021 shows that new-to-practice physicians prefer to be clinic employee (58%), work in teams (84%), direct funding for clinical roles (77%), direct clinic funding (72%), part-time work options (68%), and ability to take planned vacations and parental leave (83%). Established physicians on the other hand do not have the same sentiments regarding alternative payment plans - only 40% agree that it is required versus 64% of new-to-practice physicians. In short, Family Physicians want to have a satisfying work and life that provides them flexibility and vacation, don't we all? They don't want to carry the risk of managing a business. A fee-for-service model with individual practices will not be a direction for the majority of them. This is not good news for established physicians, they may not be able to find new graduates to sell their practices (see Dr. Alex Duong's take) and naturally, they may resist a change in status quo. This, however, a great news for health authorities because it offers ample opportunities for developing new models of primary care.

A side-bar here. Individuals have three fundamental needs at work: meaning, membership and mastery (and fair compensation, which is given). A health organization who can provide this to family physicians will recruit and retain them. Family Physicians want to involve work that they care (meaning) as a team member (membership) where they can build competency (mastery). They prefer to become hospitalist because they help patients in great need, they are a team member with co-workers and specialists, and they are able to build competency in a defined patient population and they have a set schedule which allows them to have work/life balance. If we want to recruit and retain primary care physicians and if we want hospitalist to move to primary care, we need to create a similar environment in primary care.

Our efforts focussed on improving the current system. We are constantly making changes on the edges to prop up the current system and prevent it from collapsing. What if we came to a point that upgrades cannot support this system anymore, and we need a new system.

Objectives

All healthcare leaders' first priority, from the Minister of Health to each executive in health authorities, is ensuring timely access. That is why the attachment rates are at the top of their minds. While it is aspirational to have 100% attachment, it is not feasible in the current design.

Increasing primary care workforce is a long term and also accurate strategy, it will take years to increase capacity, train people and provide them jobs. In the short term and also for the long term, increasing productivity per primary care worker is the necessary action to enable the first objective.

Considering that the providers are the backbone of the primary care services, in order to recruit new providers, achieve a move from hospital services to primary care services and more importantly retain them in primary care, providing opportunities to develop mastery and competency and to maintain work/life balance is absolutely necessary.

Efficiency has been the name of the game for the healthcare system, we are finding ways of reducing average length of stay, moving services to ambulatory care, seeking methods to increase throughput. While this aligns well with the intent to increase productivity, efficiency without effectiveness results in more harm than benefit. A rhetorical question: which is a better indicator for health system effectiveness, average length of stay for heart failure patients or median of total number of days in hospital in a year? Providing telemonitoring upon discharge from hospital after congestive heart failure attack or before patient crashes. Measuring efficiency without effectiveness (patient outcomes) guides the system into a hamster wheel, we are running as hard as we can but really not going anywhere.

When other industries face a human resource shortage, a low customer approval rating, a decreasing profit margin (decreasing effectiveness in public healthcare), they redesign their systems, reinvent workers tasks and bring in technology and fast.

Another side bar here: The Ministry of Health of BC has a health system matrix (data dictionary) that divides population into 13 healthcare needs groups. Chronic condition groups are quite broad which may require further division to aggregate similar chronic diseases into one category (Let's say Vascular biomedicine - Integrated Practice Unit - IPU) and aggregate cardiovascular conditions such as hypertension, heart failure and stroke, renal diseases and cardiometabolic conditions such as diabetes under one umbrella because they all require the same biomedical knowledge and experience). This population segmentation by health care needs would provide us an opportunity to think about the needs of each group separately and design our systems to satisfy the needs of each group effectively. "Patients are not diseases, they are people" some argues. I wanted to highlight that if we can provide reliable health care access to those unattached 20-30% of the population who have limited access to care, they feel supported and at ease. I also wanted to highlight that cancer care services focus on a particular type of population and treat them as people, not disease. And yes, there will be people who would not fit into any bucket; let's provide reliable, consistent care for the majority of the population and I am sure we can find a good solution for them too.

New Old Design

Approximately 30 to 50% of the population is considered healthy and needs only episodic care and regular monitoring of risks. We need to design high throughput episodic care for them. The facility needs to be designed for this purpose. After triage, nurse, nurse practitioner, and physician sees the patient and provides the necessary care. In order to increase throughput, onsite lab and possibly onsite diagnostic imaging is necessary. Timely access and immediate decision making is the primary objective. There are possibly two supportive technologies needed; an algorithm to review the delayed labs and flag ones with possible problems or unexplainable findings, and the other is automatic reminders for healthy person preventive tracking (+ patient centred outcome measures), my vet does it, my mechanic does it, cancer care does it, why couldn't we do for primary care. Let's say I got a message to measure my blood pressure and enter into a system and let's say the guideline requires three day consecutive morning measurements and one of my measurements are 130/85 mmHg. Well obviously I need to be further checked.

If you are diagnosed or have a suspicion of a chronic disease, you are now referred to the chronic disease team. This is not a new concept, in Victoria, BC, Canada we have RebalanceMD and Pacific Digestive Health where if you have a musculosketelal problem or gastrointestinal problem you would receive full care, I can even call end-to-end care from these clinics where all specialists are together. In Rebalance's case, there are nurse practitioners, nurses, physiotherapists, kinesiologist in their team. There is a standard pathway for patients and regular monitoring.

You remember that my blood pressure was 130/85 mmHg, I got a message saying that I have an appointment with a nurse about my high blood pressure at the Vascular Biomedicine clinic. Using the guidelines, the nurse evaluates, requisitions necessary further investigations, decides, prescribes and puts me into a monitoring program. 60-70% of the population is now covered. I will see the nurse practitioner when I start to develop kidney problems, and I will see the doctor when I have hypertension, chronic kidney disease and psoriasis. We can employ foreign graduate internists or cardiologists as primary care team members in these clinics because it has a particular and a narrow focus.

We can have a maternity clinic that provides care for women from the beginning of their pregnancy to baby's first birthday, staffed with midwives, nurses, family physicians, obstetricians, psychologists, pediatricians, lactation consultants, public health nurses, and peer-to-peer support programs,...etc.; one stop shop. This design ensures early diagnosis of problems, continuity of care, and enables measuring the outcomes of care and constant improvement to provide everybody the most effective care.

Now the next stage. Institute for Health Improvement states that the objective is to keep the variation from patients and reduce the variation from providers for higher quality care. We will need to create networks (in this case let's say Vascular biomedicine network) across geography in order to provide same effective care to all patients regardless of their residence. Most primary care networks developed similar programs but they are not linked, each creates their own design, processes, and their own guidelines. I am confident that they look the same but they are not integrated, they are not discussing the best way to provide care, they are not evaluating their results to see what works the best.

Large scale change is not easy and would take years. But a long journey will start with a single step. Let's take this step, put together a blueprint of a well designed system and start changing it bit by bit. We already have components, we are already talking about scope of practices, we are already talking about integrated programs and teams.