The Role And Value Of Primary Care Practice
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  • 1. À LA RECHERCHE D’UN CONSENSUS POUR LA RÉFORME DES SOINS DE SANTÉ AU CANADA BUILDING CONSENSUS FOR HEALTH CARE RE- FORM IN CANADA 2002/02/14-16 MONTRÉAL, QUÉBEC, CANADA The Role and Value Marie-Dominique Beaulieu of Primary Care As requested by the organisers of the conference, I will first present what, in my Practice view, primary care is - or should be- and raise some of the issues we are facing as we are to develop a strong primary care sector in Canada. I will then address some questions related to the primary care team: What significant changes to Rôle et valuer des professional practices should occur as such an approach develops? Then, as soins de première requested by the organisers of the Conference, and with much humility, I will ligne make some “prescriptions for changes”. I bear particularly on Barbara Starfield’s work on primary care as well as on WHO definition of primary care; added to this, the richness of information we have Chair/Président: from abroad. For, as you all know, some industrialised countries are trying to solve Clermont Racine similar problems. Approaches What is primary care ? What is the “plus value “ of primary care, from the communautaires et perspective of citizens ? Primary care is “person-oriented care”. It is where 80% of inégalites de santé, health care needs of individuals could be dealt with. Hence, it means that primary Université de Montréal care practices and services must effectively deal with the full spectrum of care : preventive, curative, readaptation and palliative care. Primary care is not “gate keeping care”. It is not either “population care”. Participants Although accessibility is the corner stone of primary care, primary care cannot be reduced to accessibility. Continuity and coordination are the two other Dr. Marie-Dominique key functions of primary care, equally important if primary care is to play its role Beaulieu fully. Coordination and continuity within primary care, but also between primary Centre de Recherche care and referral and hospital care. Primary care can only play its role if it is CHUM et groupe de adequately linked to the whole system - referral and public health care. Primary recherche interdis- care is not “revolving doors” care. ciplinaire en sante What is the plus value of having a developed and responsible primary care system ? I see two major gains for citizens. First, a system that functions better, Dr. Howard Bergman more efficiently, for it is proven that the whole system works better where there is Division of Geriatric a strong and responsible primary care system. This means : easier access to Medicine, McGill Univer- specialty care when needed, less crowded emergency rooms, more care close to sity and Jewish General home. Second , it means more equity in health care. This has been shown par- Hospital ticularly by Starfield in her comparative international work. We must not forget that the health care system is one of the determinants of health. Where are we at with our primary care system in Canada ? What are the stakes ? We still have a health care system driven by “secondary and tertiary” care. This is where the money is, this is where the power is. “They call the shots”, pardon the expression. There are no “Primary care system’s advocates” - except in Québec, to a certain extent, because of the CLSCs network. What are the risks Transcripts of the 7th annual conference of Conference principal partner Actes de la 7ieme conférence annuelle du Partenaire principal de la conférence McGill Institute for the Study of Canada L’Institut d’études canadiennes de McGill 3463, rue Peel, Montréal, Québec, Canada, H3A 1W7 (514) 398-8346 fax: (514) 398-7336 w w w. a r t s . m c g i l l . c a / p r o g r a m s / m i s c /
  • 2. of a primary care reform driven by the current existing forces within our system? The risks are that we will propose “secondary care solutions” for primary care problems. Two examples : the attractiveness for “inte- grated health care networks” which bear on the disease management model and can, at one point, jeopardise longitudinal, person oriented care. Also, the way information technologies are developed : I am yet to see a genuine commitment to develop information technology which will address the need of primary care practition- ers. We are also mesmerised by “accessibility” problems. I dare to say that we do not have an accessibility problem. We have a problem of accessibility to personal, coordinated and longitudinal care. There are very interesting data from Québec, where a variety of financial incentives and constraints have been included in the physicians’ payment scheme during the last 10 years. General practitioners do cover all the points of services (hospital, emergency, CLSCs) … in the same week, still citizens cannot find a family physician. We call this “pratique papillonante” (“butterfly practice”). Is this what we want ? The primary care team In order to meet our goal, professionals must change the way they practice. Still, physicians are not the only ones who will have to change. How will my work change ? I would work closely with a primary care nurse practitioner. She/he, will be a “Jack of all trades” like me. We will share the care of the same patients. We will be able to increase the services to our patients. She will be able to manage common acute problems, such as otitis media. She will also have time to offer preventive care and education for chronic diseases. I would more a little bit more on the phone, like her. I will assume more complex responsibilities; will do more “curative” work. Somehow the patients will have figured out that we both care for them. They would know for what kind of problem she is in charge, and for which one I am. For sure : we would not have an hour-a-day team meeting. We must beware of creating professional battle fields within the primary care teams, as we have often experienced with the CLSCs when they were created. We should not but professionals in situations where they will have to chose between allegiance to their professional autonomy, their team and their employer. What are the arrangements which will permit the development of a strong feeling of belonging to a team responsible of a “clientèle” ? Can you work as an equal if you are kept in an employee-employer relationship ? What does “being followed by a team” mean to citizens ? Is it what they want ? How do they want this to unfold ? Building trust will be the cornerstone of the success of the team approach. Between professions. But also, within professions. Between specialists and family physicians. Between secondary care nurses and primary care nurses. We were asked to consider two questions : What can be done immediately to improve the quality of primary care ? What organisational / funding incentive changes would you make immediately to improve better integration of care. I refuse to address those two questions separately, for I think, as Journalist Jean-Claude Leclerc from Le Devoir said this week, that the organisation of the system is as important as professional deontology when quality of care is concerned. I prescribe : 1. The deployment of information systems developed to meet the needs of the practitioners : without good information you are limited in your capacity to reflect on your practice, to identify your weakness and correct them, to organise your services in response to your clientèle’s characteristics. I see simple things that can be done now with the information we produce delivering services : I could receive feedback on the number of my patients aged 50 to 69 who are reached by the breast screening program, for example. I think that Public Health can help us with this. There is the issue of confidentiality, but I think that it can be worked out. 2. The consolidation of the “core primary care team”. An interesting study published in the BMJ last year showed that effectiveness of team functioning is a key determinant of quality in primary care. 3. About financial incentives for physicians : we have to pay for “responsibility”, that is to pay not only for services given or time spent on site, but for assuming the basic functions of primary care : longitudinality and coordination. Capitation and inscription of clientèles can be means of doing this. But they can only be if the primary care system is given the means of assuming its responsibilities. 4. We need to create a primary care organisation which can relate efficiently to the rest of the system and make it accountable to the primary care needs. I do not see how this would be possible without decentralisa- tion of the “bargaining power” to local authorities who will have not only the money to give primary care serv- ices but also to “sub-contract” for referral care services. I am in a “Groupe de médecine familiale”. We are told that we have to develop “corridors of services” with referral care for our registered patients. Can anybody in there right mind think that we will be able to do such a thing the way the system is organised and funded now ? I often wonder if the worst think Michel Clair did was to say that “If there was only one recommendation to apply, it should be the one on the “Groupe de médecine familiale” 2- The Role and Value of Primary Care Practice
  • 3. I will conclude with one question : can we change primary care without changing the health care system as a whole ? If your answer is “No,” then it means that all the goodwill of the individuals and organisations involved will not be able to overcome the huge barriers on our way if the politicians do not have the courage to do their part in order to change some of the rules. And when we say the politicians, we mean the population. Indeed, if politicians do not “feel” that the population want that kind of health care, they will not do it. When I see the pile of reports that have accumulated on shelves for the last 25 years, saying basically the same things, I must say that my prognosis is reserved. Howard Bergman (French in beginning to come) Primary care is the foundation of our healthcare system and I think that means that we need to both strengthen and transform primary care. I think also we need an evidence-based approach to health prevention and disease management and I think there again primary care is the key to an integrated system and a coher- ent system of care. I just want to give the example of diabetes, because it will come back and I can give the example for congestive heart failure as well. We know that in diabetes, we know that if we invest in primary care, in terms of population and patient education, in detection of diabetes, in treatment and ensuring compli- ance in diabetes, we know from many studies that we are going to have more positive health outcomes. We also know that there are going to be less complications as the result of diabetes and there are going to be less utilization of secondary and even tertiary care at some point. We can say the same about congestive heart failure, where by the way we have had a tremendous explosion of excellent medication in the past 15 years, but if you look at the statistics for readmission rates for people with congestive heart failure, over 65 years old, in the past 15 years, they haven’t changed. So for one reason or another, this medication is not getting to the patients in an appropriate way. And again primary care is the key. We’ll come back to what this means to the health care system, because it means that you have to invest in one part of the health care system but you’re not going to get the returns right away, the returns might come back only in 5 or 10 or 15 years. As I worked on the Clair Commission I was surprised that there’s actually quite a large consensus in the medical and non-medical community around what are the problems and the directions for change in the health care system. And what we put forward in the Clair commission wasn’t an invention, it was based on what was being put forward by many organizations in Quebec and Canada, including organizations of primary care physicians. And so, the problem of accessibility, meeting the needs, the problems of the vulnerable population, and I’ll just point out for my constituency that the frail or the elderly with disabilities comprise approximately 15- 20% of all the elderly population, which means 3% of the total population. Well, that 3% of the total population consumes 30% of all the health and social services resources in our health care system. So, sure I’m worried about how we’re going to pay for dialysis for the well elderly, as senator Morin pointed out, but I am particularly concerned with how we are going to organize efficient care meeting the needs for this part of the population. I think here primary care again is essential. The other thing is that we have to realize that nobody can do it alone anymore. The problems are complex, the treatments are complex and our system is terribly complex. So the old concept of the Dr. Welby going out in his car and visiting his patients is not possible, both from having doctors getting together and different professionals getting together and different parts of the health care system getting together. Here is what I think are the key elements of primary care, based on what I have seen here and in other countries. I think that the issue of population and clinical responsibility is an essential issue. I think that a primary care group has to know what population it is dealing with. And that is where the issue of rostering comes into effect, because if you know what population you are dealing with then you can study the population, you can develop programs that are aimed at that particular population. And if you are working with a population, if your practice is in downtown Montreal, or the Cote des Neiges district of Montreal, or the west Island of Montreal, you are going to have quite different populations that are going to be coming to see you, and you have to adjust your intervention in a different way. The notion of clinical responsibility is also essential: what happens to your patient or your groups of patients beyond the moment when they leave the door of your practice or your institution. Our system of care is based on taking good care of people when they are within the four walls of your institution and hoping for the best when they get out. The second thing that we’ve talked about is an interdisciplinary, systemic approach. Marie-Dominique mentioned the question of information technology and I’d like to add general infrastructure as well. She said it very well. You know that we are managing in Quebec a $17 billion enterprise not knowing what happens. Most organizations will not know their financial situation until three or four months later, will have no idea of the utilization of services that their population is using. We need infrastructure because we cannot do it alone. I met a physician who said that he works alone and he doesn’t even have a secretary and it’s a terrific system. Diagnostics & Solutions -3
  • 4. But it is very limited what he can do. We need accountability and incentives for excellence and performance. In other words, we can no longer in the health care system distribute money for primary care, physicians, specialists, CLSCs or hospitals, without having some sort of indication of what the performance is, and having indicators in that performance, giving incentives for people doing an excellent job. And finally, we can’t do things in terms of the fee-for-service for primary care physicians or global budgets for CLSCs because I am including that in remuneration funding mechanisms of primary care we need remuneration that will be able to support these different elements of primary care. What we put forward in the Clair commission was that primary care is the basis of the health and social service system and we said that the two components of primary care are family medicine units and the CLSCs. But we also said that primary care needs to be supported by integrated service networks. There is a whole area of complex and vulnerable populations, the frail elderly, and mental health populations, very com- plex populations that even a well-organized family medicine unit will need to work with others in order to deliver a complex combination of health and social services. We also have complex diseases like congestive heart failure, pulmonary disease, alzheimer’s disease, that need the integrated support of secondary and even tertiary care. Integrated service networks supporting and working together with primary care: this is what things should look like. It’s not rocket science. A lot of other people have been saying it, nursing groups, practitioners. Voluntary rostering makes sense. You want to be allowed to change physicians if you want to, but that can be worked into a voluntary rostering type of system. There is very interesting work in Britain around development of primary care trusts and also community trusts, bringing together primary medical care and community care into trusts that are working together. Change is very difficult to accept and very difficult to understand, because we’ve been doing things this way for many years and how could any other way be possible? I would like to finish by giving some elements of what I consider the vision and strategy for change. Number one, the whole area of governance and man- agement. Unfortunately, our health care system is driven by very short-term objectives and we are plagued by the fact that the chairman of the board of this industry changes about every two years, and the CEO, the deputy minister changes about every year and a half or so. We calculated that Quebec has had 11 or 12 sous- ministres de sante in the past 15 years. So how can you develop a strategy for change and carry it out? We suggested that there may be ways to think of governance in a different way. Number two, I think that we have to work very hard on consensus building. I strongly believe that we can get more done by confidence and incentives than by using the big stick. I think that we can build on leadership as well. The third thing that Marie-Dominique brought as well as other people is that this change towards strengthening primary care as Walter Lutz brought out when he was talking about integrated care, saying it costs before it pays. We have trouble understanding that in our health care system so we are always talking about the run-away costs but we never talk about investing in order to make the changes necessary to control these costs. Also, we need a change in the methods of allocating the resources. To allow for shift in resources from one level to another based on performance. So, in the case of diabetes, if we invest in primary care and there is reduction in utilization of secondary and tertiary care, we need to have a mechanism for that money to come back into the primary care. Otherwise, this investment in primary care is seen as just an additional expense. We are seeing that response to the SIPA project. In other words, something might make sense over overall utilization and the costs of the health care system, but if there is no way of transferring the resources, it just looks like an add-on and people say that it is too expensive. We see the same thing with information technology. My last point is that we need to open up two corridors in the way we govern our health care system. One is the corridor to look after the daily crises, the daily management of the health care system, the over-run ER, the accessability, the crises in a nursing home, etc. But we need another corridor which is separate from that which is going to look at the strategic changes that need to be made in the health care system. And I am concerned that, in terms of our efforts to get a family medicine group going, that if we don’t have those two corridors, we are going to fail because it is going to be the immediate crises which are going to over-run any of the strategic changes. Questions Audience #1: With respect to the idea of performance of different aspects of the health care system, particu- larly hospitals and thinking about what Mr. Legault said recently. How do we look at performance of, for exam- ple a hospital , when so much of it depends on other aspects of the health care system, such as good 4 - The Role and Value of Primary Care Practice
  • 5. primeary care system, home care, a place to discharge patients, because i think that’s really where the difficul- ties in the emergency arise, is that they can’t get their patients bed for acute care and long term care. Also, people arrive at the emergency for primary care which could be received elsewhere. Howard Bergman: I completely agree. As the ER crisis emerged, there are more and more headlines and we say we need to invest more in the ER room, so we pour more money into the Er and then lo and behold, we wonder why 6 months leter people go to the ER Rooms. You go there because that is where all the resources are, that’s where your needs will be responded to very quickly, and it’s an example of where we just look at performance in a very isolated way. We need performance indicators for different types of institutions and we talked a lot about performance indicators for hospitals but we don’t talk about performance indicators for CLSCs, for nursing homes, etc. But the idea of developing integrated performance indicators is fascinating. That comes back to the issue that we can do it if we do it from a patient-centered point of view, or a popula- tion-centered point of view. Marie-Dominique Beaulieu: The question shows the importance of making silos, because you can really see both sides, primary care is not doing what should be done, that’s why there are problems with the hospitals. To have access to the hospital as a primary care practitioner for referral care is to send people to the hospitals. There is a problem there. Referral care has no incentive to collaborate with the primary care sector because their budget is not looked at that way. We are in a vicious circle. Yes, the primary care sector could be more efficient, but also part of it is that with better collaboration with referrals, we could have a better system. But the hospital has no incentive to do this. You question shows how important it is to change the way the money flows. Audience #2: There is a question of money but also I feel, coming from the hospital setting, the question of la lourdeur du system. There are a lot of people who are very creative, who can do things, change things, but there is and inertia in the system, there are so many levels of administration to get through, that people give up. We need to develop a system that would foster creative solutions from the ground up. (FRENCH TO COME) A lot of people feel they have no power in their own hospital to change things. Audience #3: I have a question of curiosity about the funding mechanism that would be used for these inter- disciplinary teams under the Canada health act, since it does stipulate that its physician and hospital services. I am particularly intrigued, since the primary health care model abdicates the appropriate care by the appropri- ate provider, how this would work for a vulnerable population. I’ll take the example of the aboriginal population. Would a salary mechanism for doctors allow in the interdisciplinary tem, them to hire, for instance, a traditional healer, to work with the team. Do you think that this fits under the Canada Health provisions? Marie-Dominique Beaulieu: I am a practitioner and not a politician so I am not a policy maker. But obviously when we are talking about different levels of governments having to make some decisions, I think that you are giving a good example. I think that one of the things that has to be rethought is what part can be paid and so on, so that you can really, at the level of the field, make that kind of decision. If you make the practionners locked in something they cannot do, like not being able to pay for nurses, under the Canadian Health Act, or things like that, it’s like you are building people who want to change and placing them in situations that they cannot effect change. And I think that’s the same thing for some of the money flow. There needs some political courage to change the money flow because the interest there won’t permit that. I wish that there would be changes that permit us to redefine the services that we give. Howard Bergman: One of our icons is the Canada Health Act. When you say that we have to relook at the Canada Health act, it does mean that the Canada Health Act, which was developed in the late 60s and early 70s, things have changed since then, the whole issue of chronic disease, vulnerable population, the demography has changed. What you raise is an interesting point. Th Canada Health Act was focused on physicians and hospitals. Her is an example of how you could think of funding in a different way. If you had a primary care structure that was funded on a per capita basis, and you said now you are responsible for organizing services, here are the types you have to organize, which leaves that community-based group some leeway as to whether they need 6 nurses, 4 or 10? How many doctors? Do they want traditional healers, etc., based on again a contractual agreement in terms of the services they have to give and the type of per- formance indicators. So one could think of that type of building in more flexibility, and perhaps linked to what somebody was saying of the lourdeur de la systeme, where all decisions have to come from the top. Diagnostics & Solutions -5
  • 6. Audience #4: Now in Ontario, we are reinventing primary care reform or family health networks, which my section feels is a redundancy and I find it kind of unwieldy, whilst the HSO has had some very innovative ones. The one which I think is the best in line with what you’ve just been talking about is in Sault St. Marie, which has a third of the population and once you’ve got big population-based groups you can really do interesting things. It has a non-profit board so you can indeed bring in alternative practitioners. This model got frozen in the 90s by the ministry. I think that rostering should be universal; perhaps we should make it universal registration. Once you’ve registered the population, then rostering is the thing to do next. It is interesting to hear about Denmark where you have the option of derostering yourself. This fulfills everyone’s ideas about choice. I hope that Romanow is going to listen to that. Denmark is a wonderful example. It’s cheaper and it throws in dentistry as well. In Toronto there are lots of people who don’t have insurance, the mentally-ill and the homeless, and unless you have some default mechanism to automatically get people into these settings, you are going to miss many of the sickest, most problematic cases. Dr. Beaulieu: I personally agree with rostering, it is something important, but you have to have the right system. Obviously, the medical profession in Canada is not very agreeable. Rostering by itself is not a solution. It is agreeable when you have the rest to support it. And then we have to walk the Canadian population through it. How will people react. Some people feel that it is an impingement on freedoms. You cannot have engagement where you don’t deliver what you promise. Audience #5 Paul Moreau, Sante Canada, premieres nations: (FRENCH TO COME) Howard Bergman : (FRENCH TO COME) Marie-Dominique Beaulieu: (FRENCH TO COME) Audience #6 France Legare, medecin de famille: (FRENCH TO COME) How do you produce evidence, what are the questions that you are asking, which type of design? Most of the evidence that we are working with now has been done in tertiary care. Marie-Dominique Beaulieu: (FRENCH TO COME) Howard Bergman : (FRENCH TO COME) Clermont Racine: (FRENCH TO COME) Audience #7 Isabelle Arsenault, CLSC, du région de Sherbrooke:(FRENCH TO COME) Howard Bergman: (FRENCH TO COME) Marie-Dominique Beaulieu: (FRENCH TO COME) Audience #8 Sonia Samonic, PhD student in nursing at McGill University: I would like to thank Mme. Beaulieu for recognizing the absence of nursing at this table. I am interested in hearing more about the pro- posed role of nurses in the family medicine group. I think there is a lot of concern in nursing that nurses are not used as physician replacements, and that nurses are actually used in recognition of their role in families cope with transitions and health education. I am also interested in how we see family medicine groups interfacing with the CLSC, particularly in my area of expertise, perinatal health, where a large percentage of the primary care is provided by nurses at the CLSCs. Howard Bergman: Just in terms of numbers, what we proposed was 2-3 nurse clinicians or practionners to 6 attendants. I agree with you. We have to carve out s specific role for nurses, which is distinctive but collabora- tive with the physicians. This is going to take time. The same principal from the standpoint of perinatal care applies to the frail and elderly. A nurse practitioner in a family medicine group is probably going to be a generalist, depending on the group. Linked up with the family medicine group are the CLSCs, with their home care program, their professional program and with their nurse practitioner clinicians. This is an example of an integrated group working with the generalists of the family medicine unit. 6 - The Role and Value of Primary Care Practice
  • 7. Dr. Beaulieu: I realize that the word group de médecins de famille carries a message which removes it from nursing. There is a lot of work to do and we don’t have a model in Canada. To create a primary care team, people need to feel that they belong to a team. We as professionals are accountable to our profession, we are accountable to the people who pay for us, and we are accountable to our team. If there is still a division, where nurses are in one organization and doctors in another, we won’t accomplish the team building. Audience #9: I am a family physician and am fortunate to work in a very positive team environment, at St. Michaela’s hospital in downtown Toronto. I am part of a group where about half of our patient population is HIV positive, and this is a practise that has evloved over the recent past. We were formerly of the Welsley hospital, got swallowed by St. Michael’s hospital and so on. The team itself is composed of not only physicians and nurses, but we have pharmacists, physiotherapists, and nutritionists and social workers. And on that team we actually have some of those that are specifically dedicated to a HIV population, and then we have a whole other contingent that are for the rest of our patients. That team meets every week with the residents and the students and we discuss problematic cases and we go through some efforts to try to address not just medical problems but also psyco-social issues and nutritional issues, and so on. There is on-going negotiation in terms of what each member of the team does. It does work. I trained in Ottawa, in an environment where one of my main teachers was a nurse. If I have to think back to the things that made this work is, first, the leadership in the hospital and in the family medicine department. Philip Burger, who is now our chief of family medicine, has been very proactive in making that happen. The other big component has been the community itself. It is not by chance that a lot of that came about because we were dealing with HIV positive patients who are very complicated patients. We need to listen to the communities and let them tell us what they need and from there we’ll be able to develop the system we need. Audience #10: Carl Guttman, Family Medicine College of Canada: Integration amongst all of the players providing primary care and all parts of the system is essential. We are facing major challenges in the renewal of primary care because the rest of the system is not coordinated with this. The role of the family physician in hospitals remains a critical piece of this. Across Canada, the role of the family doctor has been diminishing in hospitals, whether it is active provision of care at the bedside or supportive care, it has dropped to nothing in many instances, particularly in urban and academic hospital settings. This is the link between the hospital and the community at large. The other aspect of integration is the role-modeling and philosophy that has to hap- pen in terms of educating our future health care providers. We are always going to be fighting an uphill battle in terms of trying to change those who have been in practise for years and years. Audience #11: Fernand Montchenie. J (FRENCH TO COME) Howard Bergman (FRENCH TO COME) Marie-Dominique Beaulieu: (FRENCH TO COME) Clermont Racine: (FRENCH TO COME) Audience #12:(FRENCH TO COME) Audience #13: (FRENCH TO COME) Clermont Racine: (FRENCH TO COME) Diagnostics & Solutions -7
  • 8. 8 - The Potentials and Problems of Home Care
  • 9. Diagnostics & Solutions -7