Recently hundreds of people lined up for hours outside a new medical clinic near Ottawa, all hoping to get a family doctor.
Those people knew intrinsically what research shows: people with family doctors stay healthier and get more appropriate medical care. And, moreover, they cost the health care system less, too -- mostly because family doctors help prevent hospitalizations.
Some 4.5 million Canadians are without a family doctor. The reasons for this are many, including the training of too few doctors in the 1990s, more doctors working part time hours, more doctors retiring, and fewer graduating doctors choosing family medicine.
Provinces have been attempting ambitious and far-reaching reforms with new impetus over the last decade. Ontario, Quebec and Alberta have largely embraced structural reform, changing how services are delivered, creating community health clinics or family health teams with other allied health professionals like nurse practitioners, and putting doctors on salary or other payments models rather than traditional fee-for-service payments. Many of these changes have been to encourage doctors to leave solo or small group practices to join allied health teams and to change the way they are paid.
B.C. takes a different path
British Columbia has chosen a different route, opting to focus on operational reforms rather than structural reforms, through an active dialogue with physicians, patients, and other stakeholders to better align physician reimbursement with the provision of care to patients with complex health conditions and by supporting family doctors (also called General Practitioners or GPs) to feel better equipped both clinically and practically to do their job.
At the heart of B.C.'s approach is the conviction that the doctor-patient relationship -- that long term bond forged over time -- is the critical attribute that promotes healthier patients and more appropriate, cost-effective care, a relationship that is not typically matched by episodic or specialist care providers.
Since 2002, a committee of doctors and government representatives called the General Practice Services Committee (GPSC) has been overseeing the reform of B.C.'s family medicine services. Prior to this, B.C.'s relationship between doctors and government had been marked by more than three decades of rancour. The two sides, however, came together by focusing not on what is best for doctors or government, but on what is best for patients.
Incentive payments improve efficiency, increase capacity
The GPSC has introduced an array of programs into the province's fee-for-service system, open to all GPs but completely voluntary. A wide variety of incentive payments are now being given for managing patients with various chronic conditions or complex health needs. These incentives encourage doctors to take on sicker patients rather than to self-select healthier patients.
Generous maternity care bonuses are designed to encourage more doctors to deliver babies and significant recruitment incentives are designed to lure new doctors to underserved areas. New fees for group visits and telephone and email consultations with patients are enabling doctors to increase their capacity to treat patients and to improve office efficiency.
Training doctors, staff improves care and wait times
In addition to financial incentives, the GPSC is supporting family doctors with clinical and office management training through its Practice Support Program. Doctors and their office staff are paid to attend a series of training modules that address skill sets doctors say they need.
For example in a 2008 survey, B.C. family physicians said mental health conditions were their highest need for further training and support. The Practice Support Program launched an Adult Mental Health module in 2009 using GP "champions" to teach screening tools, diagnostic assessment, treatment options and care planning to their GP colleagues.
Medical office assistants are trained in patient scheduling, billing and interpersonal office skills. Of the GPs who took the mental health training, 94 per cent said it resulted in improved patient care. Another training model on more efficient patient scheduling has enabled doctors to significantly reduce wait times, enabling urgent patients to be seen on the same day and shortening the time for regular appointments by four to five days.
Cooperative networks foster innovative solutions
One of B.C.'s most unique initiatives is the creation of "Divisions of Family Practice." The divisions are local cooperative networks for formerly isolated family doctors that increase their influence on health care delivery and policy in their community, and make them better able to work together with regional health authorities to address gaps in patient care.
One of the gaps that divisions will address is the estimated 200,000 people in B.C. without family doctors by developing remedies, such as incentives for doctors to accept orphaned patients or as a group hiring other allied health professionals to help meet patients' needs.
B.C.'s model is not without its weaknesses, but it is showing so far that the unprecedented co-operation between government and doctors has been a critical attribute for success and is leading to better patient care, increased job satisfaction among family doctors, and contributing to fewer hospitalizations and lower system costs -- all without radically restructuring the existing system.
Dr. Garey Mazowita is the Chair of the Department of Family and Community Medicine at Providence Health Care in Vancouver, BC and a member of the GPSC.
Marcus J. Hollander, PhD, is a national health services and policy researcher and an expert Advisor for EvidenceNetwork.ca, a comprehensive and non-partisan online resource designed to help journalists covering health policy issues in Canada. His firm is conducting a comprehensive evaluation of fee incentives and training modules for the GPSC.