The next challenges for primary care in Ontario

Over the last year, reports have suggested some of Ontario’s new primary care models, which are significantly more expensive than older practice models, have had limited success in improving access and quality.

In response, the Ministry of Health and Long Term Care is conducting a review of these models, and had recently instituted a temporary freeze on the hiring of new physicians for group practices.

This review, along with a current lack of plans to create new Family Health Teams (one of the new primary care models), raises questions about how best to realize benefits of significant investments made in primary care and to continue the important progress that has been made.

Over more than a decade, Ontario has made significant changes to its primary care system in order to improve quality and access, while also improving the recruitment and retention of family doctors.  Where in the past family doctors often practiced alone or in very small groups, more than two thirds now practice in some kind of group model and millions of Ontarians participate in these models.  Also, while most family doctors used to be paid for each service they provided to patients, many are now primarily paid based on the number of patients enrolled in their practice (known as capitation).

Among several goals, group practice models were intended to improve access to primary care during evenings and weekends and to encourage physicians to accept new patients.

Group models were also designed to address the shrinking number of family doctors providing comprehensive primary care.  When the models were introduced, morale was low, burnout was high, and the number of medical graduates going into family medicine was on the decline. David Tannenbaum, president of the Ontario College of Family Physicians believes these efforts have been largely successful, saying “there’s a sense in primary care that things have gotten much better… career satisfaction is much higher and we are bringing top-quality docs into family medicine.”

Ontario’s 200 Family Health Teams

Ontario created several new group models of primary care delivery. Among the highest profile was the implementation of 200 Family Health Teams across the province.  Many of these were located in teaching centres.  In Family Health Teams, family doctors work together with government funded nurse practitioners, dieticians, psychologists and others to provide more comprehensive care than any of them could provide on their own.

Despite hopes among the primary care community that Family Health Teams would become the standard in Ontario, the government originally planned to create only 200 for the whole province.  According to Angie Heydon, executive director of the Association of Family Health Teams of Ontario, Family Health Teams currently serve just over 2.8 million Ontarians, about 21% of the population.

All of these changes to Ontario’s primary care system involved a large financial investment. Primary care payments to physicians increased by 32% from 2006 to 2010. In 2010, payments to family doctors accounted for $3.7 billion; roughly 1 out of every 12 dollars spent by the Ministry of Health and Long-Term Care. This increase was intended, in part, to address long-standing inequity in payment between family doctors and other physicians in Ontario.

Bumps in the road

While Ontario’s new group practice models, especially Family Health Teams, have been hailed as a success, reports from researchers and Ontario’s Auditor General suggest there remains significant room for improvement.

Recent studies from the Institute for Clinical Evaluative Sciences report that while more Ontarians now have a family doctor, many still cannot see their doctor in a timely way.  As a result, these models do not appear to have had a significant impact on walk-in clinic or emergency room visits.

It also appears that while many more Ontarians now have a family doctor, Family Health Teams have tended to enroll healthier and wealthier patients. This has raised concerns that those who could benefit the most from the interdisciplinary care provided by Family Health Teams are not accessing it. The exact cause is not known, but it is likely due in part to the current capitation payment system, which adjusts financial compensation for the age and sex of patients, but not other factors that affect medical complexity.

Ontario’s Auditor General has also raised concerns about accountability, having found that many new group practices were not providing the evening and weekend services required in their contracts.  Also of concern to the Auditor was the lack of ongoing analysis of whether the significantly higher cost of group practices over traditional fee for service are justified by superior outcomes.

The Auditor General made a number of recommendations to the Ministry of Health and Long Term Care, including regular analyses of patient enrollment in group practices and ongoing review to ensure group practices provide after hours services.

Primary care models under review

In response to the Auditor General’s report, the Ministry of Health and Long Term Care began to review group practice models this past summer.

During the first part of this review, the Ministry froze new applications for group practices with capitated payment systems, except in cases where group practices needed to replace a doctor who was retiring.  This freeze led to some confusion within the medical community, particularly among new doctors who found themselves working on fee-for-service and worried they would not be able join the type of group practices they had been trained to work in.

The review is ongoing, but some details have been released by the ministry.

At the beginning of October the Ministry lifted the freeze on approving new hiring for existing group practices, and announced that it would now approve a maximum of 25 applications a month, down from 50 prior to the freeze (replacements for retiring physicians will not count against this cap).  This limit of 25 now applies to all of the new group models (the limit of 50 applied only to capitated models).   These approvals will now be based on a scoring system, meant to ensure new group practice spots go to communities with the greatest need for new doctors.

Zita Astravas, a spokesperson for Ontario’s Minister of Health and Long-Term Care, Deb Matthews says “the scoring system will be based on a number of factors, including the number of people in a region registered with Health Care Connect and the number of doctors per capita in each region.”  The Ministry also plans to work with the LHINs to identify communities with the greatest need.

While all the details of this new scoring system are not yet known, and may change after public consultation, its current emphasis on underserved communities could go a long way to improve access to primary care. The government also looks to other primary care models like Community Health Centres and Nurse Practitioner Led Clinics to help meet the needs of underserviced communities.

Other details of the review have not yet been released, including how the Ministry plans to improve required access to evening and weekend services as well as the availability of same-day and next-day appointments.

No plans for more Family Health Teams

While the Ministry has lifted the hiring freeze for existing captitated group practices, it has no current intention of creating any new Family Health Teams.  “The government committed to create 200 Family Health Teams and it has done that,” says Astravas, “now we’re just looking to expand them.”

The plan to create only 200 Family Health Teams raises concerns about potential inequities within Ontario’s health care system.  Patients enrolled with these models have access to services from health care professionals, such as dieticians and psychologists, not usually covered by the public system, while the rest of Ontarians must continue to pay for these services themselves.

The cap on new Family Health Teams is also a cause of concern for some primary care groups.  Heydon believes the government should not be restricting the number of Family Health Teams.  Rather, she argues “we need to make interdisciplinary care the standard.”

Tannenbaum agrees.  “The model of care, of inter-professional team-based collaborative practice is the future of family medicine and primary care,” he says.  While he acknowledges that “that Family Health Teams are an expensive model,” he says “what we’re seeing with this team-based model is that family doctors feel like they provide better care… that they have the resources to manage complex chronic diseases in the community.”

Which way forward?

More than a decade of change in primary care has meant a more stable practice environment for family doctors, millions of people participating in the new models and an entrenchment of the appreciation for team based care.

It is clear, however, that not all of the goals of primary care reform have been achieved.  The challenges for the next decade of reform will be to increase after hours and same-day access for participating patients, improved health care outcomes and achieve equitable access for all.

The comments section is closed.

  • Suzie Queue says:

    I experienced the Group model first hand in Sault Ste Marie. After waiting a couple of months for Health Care Connect to assign me a family physician, they finally assigned me a doctor. However, I found it was impossible to get a timely appointment, within a day or two. On several occasions, I was told it would be weeks before I could be seen by my GP. I was also informed that I should not use the walkin clinic or I would risk being cutoff from my GP. Too bad because the walkin clinic was good if you don’t mind waiting most of the day. So, hospital emergency department is the only option. Seems like a poor use of resources. Access to docs in a timely manner is a big issue in the north. It’s smoke and mirrors on the governments part and a lot of beauracracy fora very bad outcome. As we are retired and need access to health care, we moved back to Toronto as we have the resources to do so. Unfortunately many people in northern Ontario don’t have that option. It’s a shame!

  • James Beard says:

    I was particularly intrigued with you statement “Patients enrolled with these models have access to services from health care professionals, such as dieticians and psychologists, not usually covered by the public system, while the rest of Ontarians must continue to pay for these services themselves.” What it doesn’t address is the inequity created by these “free” clinics/services to the surrounding existing clinics. I’m a Chiropodist (College Regulated Foot Specialist) in Lindsay Ontario. I’ve practiced in Lindsay for over ten years, investing in my clinic to offer the best care possible. In the last several years the FHT set up a nursing foot clinic. Although the my training far exceeds the nurse, how do I compete with FREE? All the physicians within the FHT now NEVER refer to my office (they did in the past)! I pay taxes, as does my business – why can’t I access those same dollars allocated to foot care as the FHT does?

  • mjd says:

    As promised, I said I would let you know how my doctor search in Sault Ste. Marie went having moved here from Toronto in May 2014. Its now Sep 1, 2014.The first thing you have to is register with Ontario Governments Health Care Connect program. The catch …. You have to delist your current doctor (in Toronto) and roll the dice hoping you get a new Doc and are not left without one at all (many wait years) Okay, so I thought let me see if I call every single GP in Sault Ste. Marie and beg, will they take me? NOPE. They all said the same thing. I have to register with Health Care Connect and there is nothing they can do. That is code for “we the government are trying to get rid of GPs so you better get rid of yours or you will get no help from us”. Health Care Connect refused to allow me to keep my GP until they found me a new one. Their answer is “well you can call around yourself to find a doctor if you don’t want to delist your current one first” but of course they know that this is a pointless and futile excercise as when I did that, I am told the same thing, I have to be registered with Health Care Connect first. So that was a waste of time. Health care connect also says walkin clinics and hospital emergency rooms can be used until i have a doc. So I caved, having no choice. I reluctantly filled in the form to delist my Toronto doc. Then you wait, wait, wait. Finally, 2 months later some form arrives in the mail from Health Care Connect saying somebody will get in touch with me and my Toronto doc is now delisted. Then you wait some more. Still nobody calls. So I start calling. Let’s start with Health Care Connect. They give me a list of supposed doctors and phone numbers who are taking new patients. The list is sadly less than useful with doctors no longer practicing, numbers that don’t exist, duplicate numbers. Zero help at all. I finally figure out that there is only really one place in sault ste mare, a group clinic, where there a doctors. I call the group clinic. I beg. I get someone who listens and seems to care. I followup with a letter to them. Finally a call. Not sure from who. I have been assigned a doctor. Then another call. I have been assigned a different doctor. Hurray. Many phone calls and persistence is paying off. The catch – the next available appointment. Two months. October. Okay, thanks to someone who cared in the Group Clinic, 5 months later I might get to see a doc. Meanwhile, I needed I doc. Okay, let’s try out the Walkin Clinic. First Walkin clinic – CLOSED permanently. The one and only walkin in clinic is Sault ste Marie, city of 75,000e dos not even have a doctor. Waited 3 hours. Got a GP in training. Hooked me up via teleconference to a Toronto specialist. Everything was great!!!! I got some help. Everyone in the walkin was great. It was just very slow. I have to wonder what is Health Care Connect (ie. ministry of health) doing anyway? Totally ineffective, slow, paper process driven and nobody helping the client to find a doctor. Health Care Connect – Please get out of they way with your stupid administrivia which takes months and nobody does anything anyway to help you. I’ve paid my taxes, been a lifelong resident of Ontario and I deserve to have health care. Your policies are completely ridiculous.

  • Mary-Jo Dodds says:

    I support the group model and seems good conceptually. In reality, my experience so far with the Health Care Connect program is less than stellar! A lot of money spent so far. Have to wonder what they accomplished. Still no doctors in remote areas. The formula for how doctors are incented to practice in remote areas has got me puzzled. Based on my experience with Health Care Connect I would advise everyone who is looking for a Doctor to never delist your current doctor (if you have one) as they require you to do, holding you ransome under the disguise of maybe finding you a new doctor, or more likely, a nurse practioner (no offense to NPs everywhere). In my case, a senior with a heart condition, who just retired and moved from Toronto to a remote area north of Sault Ste. Marie would rather make the 8 hour to Toronto for an appointment with my doctor than risk not having a doctor at all. Their answer – walkin clinics and emergency! Having made several calls to the local doctors, they all say the same thing – 1) I have to go through health care connect. 2) nobody is taking new patients
    So how is this helping. Plus it cost me $50 to get my doctors records and my Toronto GP refused assist in any referral process! I think the whole delivery system got lost in models and formulas and forgot about the real people out there. Longer hours and fewer doctors in a group practice doesn’t address remote needs for doctors.

  • Patient advocate says:

    If physicians in an FHT are required to roster patients but unlike hospitals, are not required to see them in a timely and reportable manner, then patient care suffers – Patients suffer. If FHT’s can interview patients and refuse complex patients who really NEED care, because bonuses aren’t offered for “those kinds of sick people” – then patients and indeed our entire universal health care system is at risk.

    In small communities when doctors in an FHT are also working in the ER, seeing inpatients and operating a walk-in clinic, ACCESS to a physician becomes a problem for the patient. One real example- A patient has a physician in a FHT, but cannot see that physician for weeks because their physician is busy. Then, when they get an appointment, the doctor tells them they can only discuss ONE problem as they only have six minutes with them. That patient, who waited three weeks and sat in the clinic for 35 minutes, feels devalued and does not feel that better care was delivered. This true example is one of the reasons the government SHOULD be doing a review and putting some requirements in place.

    We know that having more than one primary care giver can create problems – patients seeing several doctors in walk-ins, emerg, doctors in different towns. So seeing a nurse practitioner within the doctor’s office – FHT- is supposed to provide access to a primary care in a seamless continuity of care. However, sometimes the NP doesn’t have the same approach or training and things are missed or tests have to re-ordered at the next appointment.

    The majority of physicians will deliver the same level of compassion and skill no matter what model of care they are in, but when their time is restricted because of capitation requirements or when they are busy making additional money in other ventures (ER and Walk in) patients are the losers. The government created this system with obvious flaws. They threw a lot of money into the FHT models and should have written more accountability into the requirements. One comment alluded to the fact that accountability used to be between patient and physician where a bond of trust was expected. Now doctors have to answer to the government for non-clinical outcomes and that can dilute the care.

    Yes we need to be fiscally responsible. When the FHT models were created it was all about patient care. Has that focus shifted? or is COST of care the most important thing now? Perhaps it is both, value for money.

    Bottom line, the government needs to do a review. However, it should consider that many clinics may have agreed to hire residents and now will not be able to do so. Where does the government think the new docs are going to go? The Liberal government has promoted and encouraged med schools to TEACH the group model of care and now …?

    Already we are hearing that the cost of health care is because of high payouts to physicians. What is next? the NDP plan of the 90s which reduced residency spots?

    This government had big plans. Many people predicted the FHTs were not finincially sustainable. Expensive systems were put in place in which SOME physicians have tripled their incomes and not delivered better care, but don’t tar all doctors and certainly don’t blame them for models and bonuses put in place by the government.

    • mj says:

      I agree with your comments. There is no accountability to see patients in a timely manner. It took me 5 months to get a physician assigned to me in the Sault Ste. Marie group health clinic through Health Care Connect following a lot of effort on my part. When I tried to make an appointment with Dr. Patterson I was told by the group clinic there was nothing available for 2 months to see Dr. Patterson. There is only one Walkin clinic that was available to me prior to being assigned to Dr. Patterson and I waited 5 hrs. And they didn’t even have a doctor. I am told now that I cannot use the walkin clinic or I risk not being seen by the group health clinic. They can cut me off and take away the doctor they assigned me who I can’t see for 2 months. They told me I have to use the same day clinic run by the group health clinic but be prepared to be frustrated playing the phone game. The group clinic same day clinic is closed on weekends and holidays and is to be used for non emergencies. I have multiple items that I need to see a Dr. And 6 minutes after waiting months is inadequate. Do I really have to go to hospital emerg to get a doctor. I will but I feel it’s a waste of their time and resources. But I will if I have to.

  • John Burke says:

    Agreed Gerald, but his attitude does reflect a popular but ill-considered opinion.
    Putting docs on salary would lead to an extraordinary increase in expenses , dilute the care of the patient, drive physicians out of the province and compromise the independence of physicians as patient care advocates.
    As a rural physician i have several roles from admitting patients, office visits, ER shifts, obstetrics, So-called “orphan call, and hospital committee work. Yesterday I saw about 60 patients in an 11 hr shift in the ER, rounded on my inpatients, did a house call to a patient dying at home, supervised a resident and got called back ay midnight for a new admission.
    This is a fairly typical day for docs I know. We do this out of a sense of responsibility to our patients first and our community second. Payment is way down the list. For example, when I am called back at 2 am to see a patient my pay will be considerably less than the x-ray tech who is called in and bills an automatic 4 hours whether she is there for an hour or less as her contract demands. I do this because of a sense of commitment to my patients, I would not be wiling to sacrifice family life and leisure time out of a sense of commitment to my employer.
    Since I am self-employed i do not have any benefits that many govt employees take for granted. I have to save for my retirement, I do not get sick leave or paid vacation and I do not get medical or dental benefits. Neither do the 3 employees that are on my staff. I have to buy my own supplies and have to buy or rent an office. Costs for my EMR this year will amount to $20,000 of which the govt , for now, will reimburse me $3,600.
    I assume that on salary I will have access to the same generous benefits as other govt employees , that my current employees will be hired by the govt and have those same benefits and that someone will be hired to administer the practice, do the accounting and payroll and day to day bookkeeping ( things that I now do myself). Based on my experience with govt workers I can expect an enormous increase in sick days for my staff and myself and almost certainly someone will take 6 months off for ‘stress leave’.

    You will not save money by making the state involved, you are living in a fantasy world if you think you will. I would expect and predict increased cost and degraded service.

    Faced with the prospect of working for a political-driven “community governed” organization I would anticipate a significant loss of professional independence. Sacrificing for my patients in whom I have a personal/professional investment is one thing ; sacrificing for and anonymous bureaucratic employer is quite another. For the first time in my career i would consider leaving for greener pastures. It would also compromise my ability to speak against the govt and hospitals in defence of my patients’ need. While I am sure the state would like this, it would compromise my ability to freely advocate for my patients.

  • Gerry Goldlist says:

    The survey on this page is a good example of a biased survey that begs for a specific answer. The choices do not take into account all of the possibilities

    -Yes, more Ontarians should have access to inter-professional care. (50%, 115 Votes)
    -Only if new research shows their outcomes justify the costs. (32%, 75 Votes)
    -No, they are too expensive and haven’t been proved to produce better outcomes – (18%, 41 Votes)

    The survey does not give the option of Ontarians having access to inter-professional care BUT that they are expensive.

    I believe they should have access but maybe not in the form presented.Possibly the system where the doctor feels the need for other professionals but not having them under the same roof. This may well be the most efficient use of other professionals’ time.

    Design of surveys is very important to truly accurate findings.

  • John Burke says:

    It is clear to me that in its haste to replace the medical model of care with something (anything) else the govt implemented a shot gun of alternatives under the rubric of being “patient-centred. Predictably, these have been incredibly expensive, burdened with increase administrative costs, and have not achieved the desired goals and outcomes and in an Orwellian twist have become “institution centred” not “patient centred”. The truth is that there never was any evidence that so called team based care would do anything other than elute a dumbing down of the system and interfere with the doctor patient relationship. That relationship is empiric and based on 300 years of trial and error.
    The govt has now retroactively recognized this and is backtracking. Their next and predictable move will be to blame the docs and allied health professionals that their magnificent central planning has not worked. They will then , with language inscrutable ( see TapOff), create even more complex and doomed to failure reform.
    The problem is that the medical model, like Churchill said about democracy, is the worst system except for all the others.
    What is needed is to supply the family doc with immediate access to allied health care workers and support to apply directly to the patient in front of us. This reduction of the system to its most essential interaction would be efficient, epistemologically sound and save a ton of money for the govt. Instead the dilution of care presented by govt- created institution-centred models (FHTs, CCCs etc) is wasteful of time , money and expertise.

  • TapOff says:

    I read the Dorval evaluation methods….all 125 pages.
    It is an ambitious project. It is terrific that the history and methods are available in a mostly transparent manner. The adaptation of an existing evaluation system is also a useful evaluative base.
    Your most recent comment about evaluating things alone will not fix THE SYSTEM.
    I agree, given the primary care (etc.) access dearth in Ontario across the board seems to indicate a need for more help, at least to clear backlogs.

    Evaluating vs. “studying” using established scientific method are a continuous debate. If you meant administrative ‘study” with minimally availing the administrative body of the rigor gained over the years from publicly funded, peer reviewed scientific research results for the synthesis of an administrative “study” and the conclusions from those “studies” may very well be less than effective in “fixing” a Provinces Health care system. Understanding the value of valid measurement seems to help those who want continuous, satisfying results. One might want to consider larger critical thought baskets and their available tools for a larger understanding for effective outcomes similar to some of those outlined in the Dorval method.
    A concerted commitment to change large integrated portions of a system using proven methods and a full commitment to evaluating those changes for a scientifically accepted timeline to understand more than “just costs” are bold but necessary actions.

  • Mark Wakefield Nurse Practitioner says:

    I think that while the FHT model offers many positive advantages for primary care delivery such as improved patient access to a multidisciplinary team of health professionals, the model suffers from some of the fundamental problems that the Fee for Service model does. Whenever a health service delivery model offers opportunities to increase income by altering one’s practice behavior, providers will always find a way to make more money and often to the detriment to the patient’s needs. Its human nature, especially when you have spent substantial amounts of time & money getting educated and shoulder an immense level of responsibility and liability and you believe that you are entitled to make a certain dollar amount relative to others out there. Unfortunately, I think that the FHT system that currently exists rewards maximizing roster size and as a result several things happen; access to timely appointments diminishes, quality of care diminishes, referrals to ER’s/specialists increases, and “cream skimming” occurs. FHT have no accountability to the community and are free to populate their rosters with whomever they choose. So I am not surprised to hear that reports are indicating that FHTs are perhaps not as effective as the government had hoped, the model was flawed from the outset. Privatized health care is no solution either because exactly the same thing happens, making more money drives the priorities. I think if governments wish to truly ensure that all of its constituents get the best quality patient centric primary health care for the least amount of expenditure , the model has to be community governed & salary based. Any monetary incentives and bonuses for providers need to be given for measurable health related outcomes, patient satisfaction, and adherence to access indicators.

    • George Southey, Dorval Medical Lead Physician and Medical Director says:

      I agree 100% that performance transparency and accountability are needed if we want our system to survive and flourish.

      My preliminary look at CHCs suggest that their achievement of quality is quite good but comes at a cost of reduced capacity and increased cost. For disadvantaged populations this is an appropriate trade-off, but for the province, it would require substantially more resources than we currently have.

      My observations are not robust enough to base any decisions on. What we really need is standard performance measurement which can compare all models. Then we can have the real conversations.

    • Duff Sprague says:

      Hi Mark

      I am the Executive Director of a physician governed FHT (Board of 5 physicians, 1 NP and 1 community member) and a champion of the physician governed model. I have also worked for many community governed organizations. In my experience, too often a deficit in the community governed model is that the Board receives almost 100% of its information from the organizations senior executive – therefore one person pretty much controls the communication flow. I have no such luxury. We provide a large number of clinics and programs to our community but unlike most Boards, the physician governance board has many avenues of information regarding those programs and services and their efficacy at their fingertips. Patients, colleagues, our interdisciplinary providers and our electronic medical records all reveal the quality, efficiency and effectiveness of our services and have access to my Board five days of every week. So unless ones hypothesizes that family docs don’t care what their patients think of our services one could conclude that the physician governance model has even a higher level of service accountability.

    • Gerald I. Goldlist, MD says:

      I find Mark Wakefield Nurse Practitioner’s remarks very offensive. Maybe he projects his own personal motivations on others when he says, ” Whenever a health service delivery model offers opportunities to increase income by altering one’s practice behavior, providers will always find a way to make more money and often to the detriment to the patient’s needs. Its human nature, especially when you have spent substantial amounts of time & money getting educated and shoulder an immense level of responsibility and liability and you believe that you are entitled to make a certain dollar amount relative to others out there.”

      He should not assume because HE thinks of HIS OWN needs over those of his patients that OTHERS practice the same way.

  • TapOff says:

    Gerald I. Goldlist
    Team based not usually a subjective term. See any organizational behaviour literature…or Hockey
    Gaming has been defined in a Canadian context (e.g. see any of Michael Rachlis’ work)
    Good administration within and without “Front line” . (perhaps also subjectively defined)
    …. of *private* practise (perhaps also subjectively defined)
    administration of practise
    administration of regulations–(legislation)
    Guidelines and best practices for both sectors exist.
    Also a great deal of evidence on publicly funded, single payer health care system reform with a great number of different model and composition mixes that offer ways make changes for the satisfaction of “the user” (Human Beings and citizens of all stripes, including clinicians) and “the provider” and “the regulators/legislators”.

    There is a great possibility that some combinations of the evidence available will work better than assuming any of the quoted words noted are “slanderous”???
    Assuming that quality assurance and **continuous** evaluation of any sort is outside the purview of either legislators or **any** group or person on the “front lines” may not be very helpful.

    • Gerald I. Goldlist, MD says:

      Although he graduated from medical school in 1975, Dr. Rachlis practices as a private consultant in health policy analysis. I garnered this information from his website. I am not sure when he stopped practicing full-time clinical medicine. Although Dr. Rachlis is a physician, I am confident (but not positive) that he has not PRACTICED medicine in the 21st century.

      If you would point me to a specific article that defines “patient-centred” I will read it. Better still please define “patient-centred” yourself. Defining terms will help us communicate. You should appreciate that the words “patient-centred” taken literally by an unsophisticated newspaper reader would imply that those physicians working in other types of environments are NOT patient centred.

      The following words and phrases certainly imply doing things in a disgraceful and immoral way:

      core attitudes
      primary motivations
      quality care

      • TapOff says:

        “. . . I agree that there is an association between primary care and a good health care system.

        “I **believe** that the problem today is that the Health Care System itself is broken.
        The relationships between patient and family doctor are not functioning well for many Ontarians. Many Ontarians do not have a family doctor at all. There is no continuity of care for them and as well these patients without a family doctor have difficulty getting access to other necessary elements of the Health Care System.
        With an **aging population there is an increased need for treatment of chronic illnesses*** and thus need of more time from family doctors. The family doctors have to spend more visits with individual patients and more time at each visit. . . ”
        There is a great possibility that some combinations of the **evidence** available will work better than assuming any of the quoted words noted are “slanderous”???
        Assuming that quality assurance and **continuous** evaluation of any sort is outside the purview of either legislators or **any** group or person on the “front lines” may not be very helpful.
        The assignment will be forthcoming before October 9, 2012

      • Gerald I. Goldlist, MD says:

        I see that you highlighted my word “believe” in:

        “I **believe** that the problem today is that the Health Care System itself is broken”

        I used the word believe because I try to keep an open mind to being corrected. As well many of my facts are anecdotal or hearsay (e.g. journal articles that I have not personally read) and so I temper my statements. Here are the facts as I have see them:

        -Hundreds of thousands (at least) Ontarians without family doctors. The gatekeepers for most of secondary and tertiary care
        -10 family doctors that I have heard about retiring in the last 6 months.
        -a group of 3 family doctors shutting down with 3 months notice. I heard 2nd hand that the local LHIN had put some onerous condition on their hours so they retired. This has left thousands of elderly patients scrambling for new doctors. I know this as these doctors used to refer me patients.
        -ludicrous waiting times in emergency departments
        -2 ophthalmologists retiring 3 years ago leaving thousands of patients looking for care. I stopped taking new glaucoma patients a few months after that happened. Very quickly after that I stopped new patients.
        -patients BEGGING my secretary for appointments. I am booked 6 months ahead and have been trying to slow down for several years.
        -phone calls at home asking me to do favours for friends and relatives by seeing them in a more timely manner. Of course, jumping the queue is illegal in Ontario. It was made illegal to make it fair so that everyone has to wait a long time.
        -patients telling me that they have to wait months and months for knee and hip surgery because they wait months or longer to see an orthopedic surgeon and wait again for an OR time.
        -Waiting in pain is subjective and difficult to measure
        -cutting fees for absolutely necessary imaging tests and assuming that physicians will continue to do the tests at a loss
        -hospitals currently shutting cataract ORs for months in order to balance their budgets. Some hospitals even closing their eye surgeries down completely.
        -patients losing their drivers licenses and having to wait to get them back because of the cataract wait times
        -patients waiting months for tertiary glaucoma care
        -doctors buying testing equipment for their offices because hospitals will not fund them e.g. visual field machines, OCT machines
        -patients waiting hours in my office because my older patients have often have 4 issues now instead of 1. I can’t bring them back because my next appointment is in 6 months.
        -a friend having serious problems at work had to wait a year for a cornea transplant. Problem was lack of OR time.

        The system must be hundreds of times worse as I am just an ophthalmologist and can only see a tiny fraction of the broken system.

      • TapOff says:

        by Ishani Ganguli
        BLOG: Patients and doctors benefit from shared notes | Oct 16, 2012
        –Possibly subjective notes on patient centred care–and the need for greater EMR infrastructure

      • George Southey, Dorval Medical Lead Physician and Medical Director says:

        The term “patient-centred” is not clearly defined and the resulting ambiguity risks turning any discussion into miscommunication.

        The OMA adopted a narrow definition in its June 2010 policy paper;

        “A patient-centred care system is one where patients can move freely along a care pathway without regard to which physician, other health-care provider, institution or community resource they need at that moment in time. The system is one that considers the individual needs of patients and treats them with respect and dignity.”

        This definition appears to limit the term “Patient-centred” to mean services that the patient can access themselves.

        The Institute of Medicine defines the term as “Health care that establishes a partnership among practitioners, patients, and their families (when appropriate) to ensure that decisions respect patients’ wants, needs, and preferences and that patients have the education and support they need to make decisions and participate in their own care”

        The Institute for Health Improvement defines “patient centred” as “The experience (to the extent the informed, individual patient desires it) of transparency, individualization, recognition, respect, dignity, and choice in all matters, without exception, related to one’s person, circumstances, and relationships in health care”.

        All definitions appear to vary in the degree to which patient opinion governs care, and there are BIG differences with the different definitions.

        It looks like this might be an area in which political leadership would help by clarifying what the term means in Ontario.

      • Andrew Holt says:

        Maybe it is best to focus on the intent of the term ‘patient centred’ as a starting point for establishing a working definition that can be used.

        My first introduction to the term ‘patient centred care’ was through a large American based consulting firm during a cost cutting (‘re-engineering’) phase of health care in the 1990’s. In the age of consumerism and branding such slogans tend to confuse versus illuminate any meaningful debate.

        Do we really mean our health systems could be better organized to serve the needs of patients and would benefit from increasing the rigor that professional engineers could bring to health systems design?

        Jargon only serves to confuse the actual intent of all concerned – blocking communication and progress.

      • TapOff says:

        well said. I am inspired about the mention of professional engineers bringing rigor to evaluating a health care SYSTEM. It is not necessarily just engineers as professionals. Those who have worked in health care and are veteran quality evaluators who look at their well known system and evaluate root causes from project management perspectives.
        One who goes to the rigors of health evidence from the scientific literature for definitions has a good systematic investigative base. This is a reasonable way to gather high quality and valid information from which to use as basic definitions for model evaluation and improvement. How would these valid definitions be used to evaluate the several ‘real life’ systems? Using rigorous root cause assessments? Although a system within a particular controlled study is narrower than an entire [integrated, patient centred ] system within or across even the several Ontario models currently available for administering Primary Care, it would facilitate well defined, systematic investigation methods. The definitions are relatively consistent (reliable and valid) . This mitigates physician-only administrative boards, regulators and support systems and facilitates evaluation and problem solving from well described and more concise yet broadly accepted definitions from which to move forward in a concrete, systematic manner. The goals first would be to understand areas of organizational behaviours and ineffective system components driving less than effective system issues and feedback loops. Systems approaches to understanding complex problems are most useful in continuous problem solving.

      • Andrew Holt says:

        I agree that although professional engineers can provide rigor to system evaluations there are other necessary professional groups with valuable evaluative expertise. Could we do a much more effective job establishing greater inter-professional collaboration when undertaking such evaluations and use the results to drive evidence based clinical program developments and health policies?

  • Christine Navarro says:

    What is your take on the PC’s white paper “Paths to Prosperity”? They propose striking the LHINs in favour of health hubs. The hospital corporation is at the centre of this hub, and I would think this doesn’t bode well for either primary care or public health.

    • George Southey, Dorval Medical Lead Physician and Medical Director says:

      Last time I checked, a hub was a mechanical device on a wheel.

      If people want to use the term as a metaphore for a management reporting structure, they should use plain language and state what they mean with regard to the authority and responsibility related to the “hub”.

      Once there is clarity on the terms, you can determine if the concept has merit.

      • Gerald I. Goldlist, MD says:

        “clarity on the terms”

        That would bring a breath of fresh air to all discussions.

      • Gerald I. Goldlist, MD says:

        I read the white paper “Paths to Prosperity” and I was pleasantly surprised. There appear to be some good ideas.

  • Gerald I. Goldlist, MD says:

    I guess we are speaking of different things.You are talking about measuring while I am talking about what we can do right now to manage the crisis is in delivery of health care right now. Thus we can both be right.

    • George Southey, Dorval Medical Lead Physician and Medical Director says:

      Yes, both initiatives are valuable.

      I have just posted “A Brief Introduction to the Dorval Model” on our website. It might help orient a reader to the main document.

  • Gerald I. Goldlist, MD says:

    Why is there the assumption that doctors on fee for service don’t care about giving quality care? The vast majority of doctors, on salary, capitation or otherwise, all serve their patients as best they can. I hate to use ad hominem comments but I point it out first so you can take it with a grain of salt. Do physicians who go on salary really believe they would not put their patients’ care ahead of their own?

    I do not devalue the team model. It may well be ideal but we don’t have the resources, both manpower and financial, to make it available to all Ontarians in the present. We must deal with the realities that face us now. “Ideal” systems in the future do not help our patients right now.

    • Michael Eden-Walker says:

      The irony it seems exists in the structure. If patients paid directly for the service and there was enough choice then it would seem that the market place would manage the rest (with some added controls). In the present system, the distortions and resultant much larger beaurocracy add a layer which threatens unsustainability due to cost and loss of morale.

      • George Southey, Dorval Medical Lead Physician and Medical Director says:

        A market requires choice and knowledge in order to operate efficiently. Neither factors are sufficiently present in our primary care system.

        Most economists would argue that shifting cost from public to private payment does little to mitigate the negative impact of a poorly functioning system.

        The old adage of management is central to our challenge, “if you don’t measure it, you can’t manage it”.

        It is time to measure and then see what we can do.

    • George Southey, Dorval Medical Lead Physician and Medical Director says:

      Agree 100%. All evidence from CPSO audits suggest that there are excellent practitioners in all models of care. There is also evidence that some practitioners need to pull their socks up in all models.

      Once there is agreement on a uniform method of measurement, excellence will be easier to see and support. The Dorval Model is nothing more than a framework which allows such observation. It is rooted in accountability to patient expectation and is intentionally dynamic to allow changing perspectives as our world changes.

      • TapOff says:

        Gerald I. Goldlist,::
        “Why is there the assumption that doctors on fee for service don’t care about giving quality care? ”
        It is not directly related to “caring about giving” quality care.
        It is a system that does not fit the reality of where patient centred care should be in Canada and in the 21st century.
        Unfortunately models that use FFS feedback on the archaic reimbursement systems that seem to incentive-ize ‘gaming’ an inappropriate/unsophisticated system over changing things to a point where quality and team based patient centred care can align with core attitudes. It has more to do with obsessing over *maintaining* an infrastructure rather than re-arranging infrastructures **at all levels ** of the provider system to align with providing comprehensive primary care in a way that is in line with a clinician’s primary motivations of patient centred-care; good acute care, good administration, and really good prevention care, and eventually good public health then overall lowering waste, dissatisfaction, and improving the giving of quality care.

      • Gerald I. Goldlist, MD says:

        “It is a system that does not fit the reality of where patient centred care should be”

        Why would you imply that not all doctors practice patient-centred medicine. Patient care has been and will always be about the patient. Are you defining the words “patient-centred” in some way that is different from what I feel it is.

        “Archaic”, “gaming”,”unsophisticated”, “quality and team based”, “core attitudes”, “obsessing”,”primary motivations”,”dissatisfaction”,”quality care” are subjective terms. They can be interpreted differently by different people including both patients and practitioners. Because people have different interpretations of these terms many feel that these terms are being used slanderously against those who have a different way of doing things than what the “authorities” feel is the “correct” way.

        “Good administration” by those who are not on the front lines of private practice “lowering waste” seem to be oxymorons. That statement may interpreted as slanderous but many of us have been slandered over and over by good administrators.

  • Scott Wooder says:

    Thanks for looking into it Jeremy.

  • dr merrilee fullerton says:

    You may also want to read or view Thomas Homer-Dixon’s Mannion Lecture 2010 to Canada’s Public Service. It is well worth understanding concepts surrounding Complex Systems.

    We are headed for a more co-ordinated but more brittle system prone to collapse

  • Gerald I. Goldlist, MD says:

    I agree that there is an association between primary care and a good health care system. I believe that the problem today is that the Health Care System itself is broken. The relationships between patient and family doctor are not functioning well for many Ontarians. Many Ontarians do not have a family doctor at all. There is no continuity of care for them and as well these patients without a family doctor have difficulty getting access to other necessary elements of the Health Care System.

    With an aging population there is an increased need for treatment of chronic illnesses and thus need of more time from family doctors. The family doctors have to spend more visits with individual patients and more time at each visit.

    Another disaster that is accelerating is the loss of long term patient-doctor relationships as family doctors retire. There are many family doctors in their 50’s, 60’s and 70’s. This problem can only get worse.

    It has taken many years to get where we are and I fear that it will take a long time to turn this around. Ontario will have to live with the issue of providing medical care. I think one of the big questions is how we will ration the available care. There is no question there are big problems with our Health Care System and we have to figure out how to make it less bad. To go for very good or excellent is hopeless.

    Sorry to be a pessimist but I feel that I am being a realist.

  • Gerald I. Goldlist, MD says:

    It seems that “overall the new primary care models are significantly more expensive than older practice models [and] have had limited success in improving access and quality.” It is upsetting that prior to their innovation these new health care models hailed as a way to “save health care” and in fact, make it better. The powers that be have increased spending and created more administration.

    According to the article, the president of the Ontario College of Family Physicians believed that the changes in health care models had increased family doctors’ morale. With the May, 2012 regulation imposition by the Ontario Health Minister, morale has plummeted again. All the money and work of the last few years has been wasted as frustrated and demoralized doctors are retiring and moving out of the province. I have been made aware of 10 family doctors in this position. I am a medical consultant and most of my knowledge about the retiring doctors has been learned from my patients. I feel that by extrapolating what little I know there are probably 100’s of family doctors who have retired or will imminently.

    I wish I had better news but politicians have overpromised and underdelivered. By wasting all this time and money they have left the health care system bankrupt in dollars, morale and patient care.

  • George Southey, Dorval Medical Lead Physician and Medical Director says:

    Only results really matter. If primary care is to deliver in its role as the foundation of the health system we all need to be able to see where performance exists, and to follow successes by incorporating them into our practices.

    A uniform performance measurement method is required which can evaluate all practice models committed to comprehensive care including Fee-For Service, FHG, FHO, FHN, FHT, CHC, and nurse practitioner lead clinics. Such an evaluation method has been proposed by AFHTO and a similar method has been in operation for 3 years at Dorval Medical – see

    Evidence is now present which demonstrates the ability to assure quality across the spectrum of services in comprehensive primary care, increase primary capacity so that there is a choice of primary care practice for all people in Ontario, and to aggressively reduce costs.

    It is time to leave anecdotes and embrace reproducible evidence of good performance. Our health system depends on us to succeed in our search for high performance achievement.

    • dr merrilee fullerton says:

      If it were as simple as measuring and monitoring performance indicators and acting on them then all could be well. However, health care provision is NOT as simple as that.

      We can create and monitor all kinds of performance indicators but because patients and providers are complex and the system even more complex, there are many, many unintended consequences which cannot be anticipated. These have costs associated with them.

      Just look at the failure of the diabetes registry and the billions being poured into ehealth so we can all be more “efficient” while patients languish waiting for care or being denied care or medications.

      I’m not saying that we don’t need EHR, ehealth….we do because of the growing complexity of health care….but the same complexity makes many unintended consequences that have costs elsewhere in the system and that do not translate into cost savings eventually taking away from front line care.

      The complexity that is being created needlessly in primary health care will only serve to create more bureaucratic expense.

      Measuring primary care performance indicators does nothing to address the overall issues associated with longevity and our ability as a society to fund all the care and social entitlements that are required now and in the future.

      Looking at primary care transformation as some kind of overarching solution to health care system sustainability is myopic.

      • George Southey says:

        Correct, there is nothing simple about the problem or the solutions, however I’m confident that solutions exist. We have demonstrated results for over 3 years and I’m quite certain that the model will work in other practices.

        As for primary care’s role in health system sustainability, the work of Barbara Starfield makes the case for the association between primary care and an efficient and effective system. While some feel that the association is related to higher quality, I suspect that the association is due to solid patient/provider relationships which allow patients to safely engage in the stewardship of their cherished system.

      • dr merrilee fullerton says:

        You may have “demonstrated results over 3 years” but extrapolating that to mean that there will be cost savings overall over many years is an enormous, delirious leap.

        And for primary care’s role in health system sustainability it must show cost savings. Improved outcomes do not necessarily translate into health care sustainability because as patients live longer the cost over their lifetimes increases. Sorry, just fact.

        Anyway, what are your “demonstrated results”?

      • George Southey says:

        Please review the evidence then discuss. Your concerns are all addressed in the document.

      • Gerald I. Goldlist, MD says:

        Continuing to measure a failed health care system cannot fix it because there are not enough resources ie front-line workers, testing equipment, active operating systems, hospital beds, rehabilitation facilties, longterm care beds and there are not enough dollars to fix these shortagess.

        Health care is not delivered by measuring it but by delivering it and only the front-line workers with adequate resources can do this.

        This is the Executive Summary of this report:

        Background: Some perceptive observers have characterized Ontario’s health system as
        displaying uncertain quality, inadequate capacity, and high costs. Costs for health care in the
        province continue to rise, yet residents’ satisfaction with primary health care is low.
        In 2004, the British government implemented a method for measuring quality of
        primary care with multiple indicators – the Quality Outcomes Framework (QOF). Critics claim
        that the QOF is expensive, that it permits easy removal of patients from registries, that its fixed
        indicators distort practice behaviour by encouraging gaming, and that its targets are
        unreasonably easy to achieve.
        None the less the QOF provides an innovative mechanism for
        assessing multiple indicators in comprehensive primary care simultaneously. Dorval Medical
        adapted the QOF mechanism to reflect value in Ontario and further modified it to allow for
        ongoing adjustment to measurement as perception of quality changed over time.
        In 2009, Dorval Medical began a pilot project – the Dorval Model — to try to increase
        patients’ satisfaction and reduce costs by continually measuring the parameters of quality,
        capacity, and cost. To date, its implementation of the Dorval Model has led to cheaper and
        better primary care for its patients.

        1 .7
        The Dorval Model maintains electronic medical records (EMRs) for patients and applies
        a reproducible method to analyse and assess performance. It complies fully with the Canada
        Health Act, is readily adaptable to all comprehensive primary care practices, and could link
        patients, practitioners, and policy-makers (stewards) in feedback loops.
        The Dorval Model’s methods of data collection and analysis focus on relationships
        between groups of doctors and their patients, not on Ontario’s traditional pay-for-individualservice transactions by individual providers. The model allows continuous assessment of
        quality, as well as of capacity and of cost, for primary care in participating practices and
        facilitates comparison and improvements.
        Analysis of Dorval Medical’s practice through the Dorval Model shows that primary care
        physicians maintain a service capacity that, if use spread across the province, could meet
        current needs with current resources. Dorval Medical finds its costs are about $315 per average
        patient per year, probably lower than those for other models and practices in Ontario. In
        addition, Dorval Medical’s patients stay in hospital for 14 per cent less time than the national
        average and 22 per cent less than other practices in the same city (Oakville).
        Widespread adoption of the Dorval Model could transform primary health care in the
        province, improving quality, increasing capacity, and reducing cost.
        This report outlines the Dorval Model and concludes with a recommendation to widen
        the pilot to include other primary health care practices in the province in order to determine
        whether its general adoption could meet both fiscal demands and residents’ expectations.
        The Dorval Model has a number of characteristics that are highly desirable in Ontario’s
        current political and economic environment:8
        ? It is consistent with principles of the Canada Health Act.
        ? It assures the quality of primary care that Ontarians expect.
        ? It has demonstrated the ability to address the province’s needs for capacity (satisfactory
        relationships for all residents) in primary care.
        ? It tracks and reports its own costs.
        ? It encourages patients to conserve health resources (demand-side economics).
        ? It is sustainable and readily adoptable by other practices.
        ? It creates the environment for rapid adoption of electronic medical records (EMRs).
        ? It can generate reports on the population’s health status and physicians’ practice
        ? It creates an environment for ongoing quality improvement in line with Ontarians’
        ? It adapts to people’s changing expectations of quality.
        ? It encourages use of interprofessional health providers (e.g., nurses, nurse
        practitioners, and social workers) wherever possible
        ? It encourages rapid adoption of electronic medical records (EMRs) and their
        mobilization to provide them where they are needed.9
        The report’s seven chapters deal with the following subjects:
        ? elements of performance (chapter 1)
        ? measuring quality (chapter 2)
        ? measuring capacity (chapter 3)
        ? measuring cost (chapter 4)
        ? acquiring, handling, and analysing data (chapter 5)
        ? Dorval Medical’s experience with the model (chapter 6)
        ? applying the model elsewhere (chapt

      • Gerald I. Goldlist, MD says:

        Posted October 4, 2012 at 9:00 PM

        Health care is not delivered by measuring it but by delivering it and only the front-line workers with adequate resources can do this.

        The report’s seven chapters deal with the following subjects:
        ? elements of performance (chapter 1)
        ? measuring quality (chapter 2)
        ? measuring capacity (chapter 3)
        ? measuring cost (chapter 4)
        ? acquiring, handling, and analysing data (chapter 5)
        ? Dorval Medical’s experience with the model (chapter 6)
        ? applying the model elsewhere (chapt
        Continuing to measure a failed health care system cannot fix it because there are not enough resources ie front-line workers, testing equipment, active operating systems, hospital beds, rehabilitation facilties, longterm care beds and there are not enough dollars to fix these shortages.

      • Gerald I. Goldlist, MD says:

        Health care is not delivered by measuring it but by delivering it and only the front-line workers with adequate resources can do this.

        Continuing to measure a failed health care system cannot fix it because there are not enough resources ie front-line workers, testing equipment, active operating systems, hospital beds, rehabilitation facilties, longterm care beds and there are not enough dollars to fix these shortages.

        The report’s seven chapters deal with the following subjects:
        ? elements of performance (chapter 1)
        ? measuring quality (chapter 2)
        ? measuring capacity (chapter 3)
        ? measuring cost (chapter 4)
        ? acquiring, handling, and analysing data (chapter 5)
        ? Dorval Medical’s experience with the model (chapter 6)
        ? applying the model elsewhere (chapt

    • dr merrilee fullerton says:

      Your document is 125 pages. A concise Executive Summary would be helpful.

  • dr merrilee fullerton says:

    I am concerned that the decision-makers in primary care reform are not looking far enough ahead.

    It has taken since the 1990s to get where we are (almost 20 years) with more team based care.

    If it takes that long to make change in primary care, we should be planning now for 2025 when there will be a doubling of our elderly population needing more care BUT at the same time a reduction in workers by about relatively 1/2 of what we have today despite immigration & despite raising the retirement age.

    So not only will there be many more people requiring expensive care and support, there will be a shortage of workers to provide the care and to provide the taxes to fund the care.

    I work in a team of MDs which I like very much, but to be honest, I do not see how we are going to manage as a society to provide:

    a) all the bells and whistles of the “transformed primary care” when there is no evidence of improved outcome
    b) the health human resources to provide it
    c) the tax base required to fund more and more care for more and more people while taxing fewer and fewer (old age dependency ratio).

    The primary care system being created is not nimble or quick and will not adapt to the changes that are coming in only a decade or two.

    • TapOff says:

      Marie Fullarton:
      agreed. There may finally (2010?) standard evaluation criteria for ALL FIVE different models, two of which we know do not provide good care, may even be dangerous to patients and certainly siphon off resources for **real primary care**.
      Also it takes up to 20 years to change behaviour in individual practise patterns, all else stable.
      We also have changing demographics that affect the measurement (s) . I am sure these factors were not considered when this SNAPSHOT of “performance” was taken.
      What if we considered reducing the MOHLTC administrative burden of trying to keep track of all the ineffective models and actually do some across the board PUBLIC SERVICE alerts for providers and users and include some disincentives for ‘other than generally healthy’ people accessing either the Walk-In Clinics or Emergency departments.
      Also Emergency dept visits occasionally boost revenue to the OTHER while elephant in our system. So one wonders what other confounders to this “policy”evaluation are identifiable?

  • Michael Eden-Walker says:

    I wonder if someone would be able to explain the difference between the quality of medical care rendered in a fee for service environment verses a capitated one (if in fact there is any)?
    The environment I am currently working in is a FHG. What has changed for me is the incentive to behave in certain ways promoted by the fee structure ( work in the evenings and weekends, provide certain procedures and services etc). What I would like to do in addition (hire dieticians, psychologists, social workers, nurse practitioners etc) I can’t as the funding model does not allow for that. The answer for the latter, it would seem, would be to form a FHO or FHT. Then I would be giving up the financial incentive for seeing and delivering care on a case by case bases, for capitation which would in-cent me to build a large practice it would seem but not necessarily to see these patients personally nor in a timely fashion.
    Personally I have found over the years that medical care provided in a timely fashion is one very important key to providing quality.

  • Duff Sprague says:

    You can’t just expand physician access to existing FHTs. FHTs were intended to be a shared care model WITH family docs, not just a place for them to refer. Physician governed FHTs exist because of local physician leadership and you discount the considerable sweat equity these leaders have invested in this collaborative model, not to mention the importance of a shared EMR – most FHTs are much more than just additional health resources.
    Our physician governed model ensures that programs are developed to meet the priority needs of the physician group investing vision and leadership into the model – and are held to a standard that responds to the needs of those patients.

    Clearly, our universal health care system is at its most vulnerable point since its inception in the 1960s – a fragile economy, an aging demographic, and the increased stress and challenges that accompany both situations.
    Health reform has been a constant part of the narrative surrounding Medicare for decades yet the dialogue has yielded only modest change in spite of volumes of pages of recommendations by health commissions both provincial and national.
    Some themes however have arisen that represent a consensus of ideas, if not of actions. Among the most recurrent themes are primary care reform, multidisciplinary care, service integration and a seamless continuum of care. If outcomes followed the rhetoric, health care would have a very different look than it does currently.
    I was proud to be a part of the strong focus on primary health care reform that the Ministry undertook several years ago, I believe now as I believed then that a strong, responsive primary health care system is the best hope for sustaining and even strengthening our Medicare system. It concerns me when program funding and wage freezes are in place that might discourage many of the best health professionals from continuing in or entering primary health care.

    We are embarking down a slippery slope when we devalue a team based model of care and creating equity without new resources merely brings all communities down to the same level.

  • Jacques Lemelin PC Lead, Champlain LHIN says:

    Thw two main issues are:
    1. Access to interdisciplinary care for all. We do not need to create new FHT’s to accomplish this. The 200 existing FHT’s are seeded throughout the province as are the CHC’s. FHG’s, FHN’s and FHO’s should be linked with their nearest FHT’s and CHC’s and provided with equal access to other PC disciplines through the existing infrastructures. Many FHT’s allied disciplines have capacity to see more patients at the moment and more could be hired as needed. New physical space would not be required because the new hires would see patients in their own practices in the community and the current management structure of FHT’s and CHC’s could adapt to create the appropriate scheduleing systems. In adition, the current PC models are fragmented and work in isolation of one another even within models. This would provide an integrative inflience.
    2. The lack of a primary care sector that is well organized and recognisable as an entity with the four essential components of all successful Primary Care Organization: governance, admin infrastructure, engagement and accountability framework. Each of the 14 LHIN’s in Ontario are working on creating effective PC networks based on the 70 ICES hubs developed by Dr. Theresa Stuker. The PC Physician leads have been given specific targets on access including advanced booking and unattached patients, 30 day re-admission rates, ED pressures and improved chronic illness management. Primary Care will only be able to meet these targets if we welll organised, fully integrated within our own sector and able to interact effectively with other heakth care sectors. An Ontario-wide LHIN-based PC system composed of sub-regional hubs or clusters willallow for full horizantal and virtical care integration in Ontario. The MoHLTC has started investing in this intiative and needs to continue to do so

    • dr merrilee fullerton says:

      Your suggestions are likely to create an administratively heavier entity. This will not save money or reduce human health resources or provide improved outcomes or even access (we only have to look at the transformation to date to understand that reality does not equate to theory).

      Gov’t transformation of primary care should consider a more expanded role in population health where real social change can lead to better health and can occur at lowest cost.

      Attempting to increase co-ordination of primary care will only result in more administrative cost and complexity which will ultimately make the system more prone to collapse.

      I must admit a “seamless continuum of care” sounds great but after this many years, repeating the incantation doesn’t make it real.

  • Scott Wooder says:

    It is mis-leading to say that the number of physicians allowed to enter capitated practice has gone from 50 to 25 per month. The previous limit of 50 per month was for FHN/FHO models only. FHNs and FHOs are capitation based blended payment models. The new limit includes physicians who want to enter FHGs as well. FHGs are a fee for service based blended payment model.

    The restriction is actually a much worse change than the authors imply.

    • Jeremy Petch says:

      Thank you for your comment, Scott. We are looking into this. We did speak to the Minister’s Office, OCFP, and OMA about this. Our understanding based on those conversations was that FHGs were not included. We have contacted the Minister’s Office for clarification and will post a correction if necessary.

    • Jeremy Petch says:

      Scott, thank you for bringing this to our attention. We have confirmed with the Minister’s Office that you are correct. The cap of 25 new applications extends to Family Health Groups (enhanced FFS), as well as Family Health Networks and Family Health Organizations (blended capitation). We have corrected the article to reflect this.


Jeremy Petch


Jeremy is an Assistant Professor at the University of Toronto’s Institute of Health Policy, Management and Evaluation, and has a PhD in Philosophy (Health Policy Ethics) from York University. He is the former managing editor of Healthy Debate and co-founded Faces of Healthcare

Joshua Tepper


Joshua Tepper is a family physician and the President and Chief Executive Officer of North York General Hospital. He is also a member of the Healthy Debate editorial board.

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