Tinkering at the margins of primary care

Ontario’s Minister of Health is promising that people will soon have more timely access to their family physicians.  The province’s 200 family health teams will come under the control of Ontario’s 14 local health integration networks (LHINs), the regional authorities that currently oversee the system. The goal is to give citizens speedier access to primary care, and it is assumed that these changes mean that people will make rational choices; in particular that they will not go to an emergency room if a visit to a family doctor can be arranged.

I am in awe of this assumption on several fronts.  Some residents of Ontario still do not have the luxury of a family physician. It seems unlikely that the limited supply of doctors will automatically grow just because LHINs will be responsible for family health teams.  It also seems unlikely that this will mean patients who do have family doctors will suddenly be able to get same-day appointments.

I believe we currently spend more than enough on health care, but it is not properly deployed and not provided in a seamless manner.  Scope of practice concerns often keep nurses and therapists and other care providers from working to their full potential.  When will we make courageous and bold decisions to address how health care teams work together and make sensible choices about who can provide care and when? Frequently I don’t need to see a physician and could function well with a nurse practitioner who could perform wellness consultation and prescription renewal.  At least I think I could function well, and I would certainly be happy to try.

Deb Matthews’s website mentions that Ontario is moving forward with 25 nurse practitioner-led clinics across the province. That might be an answer. This is an admirable step and needs to be followed up quickly by many more.

We need to totally reset the expectations of care providers and recipients.  The people of Ontario have not designed the system that they now struggle to access; rather it has grown up around them.  It is time to eliminate barriers to sharing resources and to deploying them in a manner that will provide the results that are required. Merely tinkering with the system in its current form will not utilize the knowledge, talents and abilities of all those who provide health care, nor will it help us to use our money more effectively or efficiently.  Until we redesign the delivery service model and the goals and objectives of the Canadian healthcare system, emergency rooms will still be overflowing.  Until we start to work toward a common vision for all Canadians, I’ll remain skeptical about the chances of getting a same-day appointment with a family physician.

The comments section is closed.

  • Richard Janson says:

    I cringe when I hear people say they think there is enough money in the system if only it were better organized. It’s true all of us could point to ways in which the system could be more efficient, but does that mean there is enough money?

    I have never seen any evidence to support the idea that simple reorganization would answer all our prayers and provide sufficient funding for health care. But I hear it all the time.

    And let’s not forget that among OECD nations, Canada has had one of the slowest levels of growth in health spending — something that rarely gets talked about.

    Any kind of transition to a new system is going to take money, but we buy into these reorganization schemes trying to reap the savings before we complete the investments.

    For example, Health Minister Deb Matthews appears to be holding the line on new long term care beds, following Denmark’s model of no new beds since 1987. However, Denmark spends about six times more per capita on home care. It also has more residential facilities per capita that provide around the clock care. Does Matthews honestly believe a 4 per cent increase to home care funding is going to get us there? We’re not even in the ballpark. See http://dialbogue.org

    • Mark MacLeod says:

      This is the best comment I think I’ve read on this site – it should be carved into the walls of our government.

      There is simply not enough money in the system right now. If we pay 47 cents of every program dollar for health and estimates are that it will rise to 60 to 80 cents by 2030, that means, that by efficiency alone we would need to become 30 percent more efficient just to stay where we are, let alone address increased/unmet need.

      That 30 percent might be there – but it will take an immense amount of investment to unlock it. Magical thinking gets us no where.

  • Aaron Medd says:

    As a practicing nurse practitioner (NP) in primary care for the past 11 years and current Communications Specialist for the Nurse Practitioners’ Association of Ontario, I would like to respond to Jennifer Dee’s blog titled “Tinkering at the margins of primary care”. I appreciate the title of this blog entry but take a slightly different interpretation in regards to nurse practitioners than the author or subsequent responses.

    Nurse practitioners represent an exceptional opportunity to achieve better value from our existing health care. Employed in all sectors of the health care system we have the knowledge, skill and judgement to care for complex clients in CV units and Complex Continuing Care departments, as well as in the community for those with co-morbid conditions, consulting as appropriate for patient care. NPs also treat common illnesses and injuries (not just complete wellness exams), treat and discharge patients from hospitals, as well as prescribe (not just renew) almost all medications.

    Paralleling Jennifer’s comment, both Ontario’s Action Plan for Health Care and the recent Drummond Commission highlight the need to better recognize the full scope of practice of our health care professionals by maximizing the contributions they can make in improving marginal health outcomes the system is currently achieving at a very high cost.

    Nurse practitioners are independent health professionals with their own professional scope of practice but in no way is the work we do “supervised” by a physician. However, a core value for nurse practitioners is the development of effective collaborative relationships with other health care partners including physicians. This principle is no different in nurse practitioner led clinics where a team of professionals, led by nurse practitioners as the main primary care provider, offer quality care to patients that have been without access to a regular NP or physician for years and, as a result, are at higher risk for chronic disease and disability .

    Not everyone needs to see a physician at all times and nurse practitioners are in a position to provide much of the regular care that is needed while utilizing the advanced training of physicians to provide the specialty care to patients when necessary. Studies have shown that nurse practitioners, when better integrated into primary care, can help reduce wait times, improve patient outcomes and satisfaction, while reducing health care costs.

    While there has been some important progress in the province’s use of Nurse Practitioners, there still remain some significant barriers to their full integration. Until we stop “tinkering at the margins” with the utilization of NPs, we will never recognize the full contribution we can make in the lives of those who do not have appropriate access to care.

    • Mark MacLeod says:

      I don’t think we need more fighting over turf – and emphasizing that NPs are independent practitioners rather than wanting to be part of a team isn’t an answer we need. Much as there is no role for an independent GP, there is no role for independent NPs or independent NP led clinics. Team based care with patients seeing who they need to see at the right time according to their medical conditions is where we need to focus. Carving up the turkey into our own unsupervised chunks isn’t helpful. Perhaps the team isn’t led by a health care practitioner at all unless it’s a medical question – perhaps these teams need drivers who are experienced with business who can make the team perform and ensure the quality demands are met.

  • Mark MacLeod says:

    As in all things, what seems to be a simple organizational problem is really just the tip of the iceberg.
    Switching one provider for another is not the answer. It in fact may compound the problem as although a less expensive provider, seems, to be less expensive, if that provider’s productivity is less than the one replaced, where is the savings and how does that increase access? There is one thing that FFS does, and that is drive volumes – we might not like the resultant distortions associated with FFS but we are also more than aware of the consequence of moving FFS based activity to salary based activity.
    I really thing the major reorganizational move is to move to team based care – and changing expectations of the population. We still have a doctor patient relationship as the cornerstone of health care and patients identify with their doctor or their lack of one. I personally believe that patients should be organized to TEAMS and they are seen by the team member most appropriate for their needs, doctor, nurse, psychologist, dietitian etc. The teams have targets to meet in terms of service and access and remuneration is tied to those targets. Cuba in this is far ahead of us with a polyclinic model that orients patients with teams of providers, and provides essentially outpatient primary care and outpatient specialist surgeries. Polyclinics offer a way to move many services out of hospitals, a way to use providers more effectively, a way to provide after hours services, a way to attract physicians and others to rural environments where no one wants to be the one wolf – all in all it would be a dramatic redesign of all service delivery, not just “primary care”. And perhaps most importantly, it would put more services in places where patients want them – closer to home.
    Yes, adding new non team based clinics is just tinkering, as much political as practical. But quite frankly, it’s all we can expect.

  • Realist says:

    Thanks for the evocative words. Tinkering at the margins is exactly what the implementation of NP clinics represents. NP clinics just replace the doc with the NP. There is still a focus on volume, a limited supply, an unlimited demand and the same “take a number” approach. Yes, NPs are cheaper than docs. The cost of NP salaries along with the required physician supervision has a per diem cost lower than that of a physician clinic.

    NP clinic advocates will suggest patients may receive “better” or “more comprehensive” care as NPs spend longer periods of time with patients, teaching, supporting and engaging patients. But NPs see far fewer patients per day than a doc. And I know this will be controversial, but NPs don’t own their practices. My experience with NPs in this province is they are typically employees. And like all employees, they move around. The career-long commitment to their patients and their practice is simply not the reality.

    The collaborative care team has far more to offer than any clinic comprising of just docs or just NPs. Like it or not, patients in Ontario are most closely alligned with their family doctors – over any other health professionals. A far better strategy is to recognize and celebrate this and provide supports to those doctors to care for the ever-increasing complexity of health care needs and navigation of the health care system. I see the role of NPs better fitting here – as a support. Moreover, I suggest RNs, mental health counsellors and others working along with family docs may, in fact, be more effective and less costly as we try to increase system capacity and better engage patients in primary care.

    That’s not tinkering at the margins: it’s aiming at the heart of the matter.


Jennifer Dee


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