Each March, the hockey world is overtaken by the trade deadline. Teams rush to tweak their rosters, but before a team wheels and deals, it must decide whether it is a buyer or a seller. It needs to know its goals.
Health care policy is no different. It demands clarity, vision, consistency and meaning. So why is primary care reform so confusing?
Quebec’s Minister of Health and Social Services recently introduced the idea of “super-clinics” to improve after-hours care and address overcrowded emergency departments. But to many primary care advocates, these new reseau, or network clinics, come with a steep price. They undermine the Family Medicine Group (GMF) project set up only a decade ago in an attempt to solve the chronic family doctor shortage crisis and improve comprehensive care to all Quebecers.
The “Barrette Revolution” began in 2014, when Quebec’s Minister of Health, Gaetan Barrette defiantly presented Bills 10 and 20, legislation meant to radically and rapidly transform the Quebec health care landscape. Boards were scrapped, managers replaced, institutions reorganized and organizations renamed.
Bill 10 took aim at the bloated bureaucracy and forced the consolidation of health and social service facilities across the province (into newly termed “CIUSSS”) with the aim of eliminating middle management positions. Bill 20 focused on physician quotas in an effort to promote access to family medicine and specialized medicine services.
The province’s family doctors retaliated by warning about government meddling and “conveyor-belt” medicine. The Federation of General Practitioners (FMOQ) proposed a ceasefire – a temporary suspension of the contentious patient quotas, to be replaced with a new target of 85 percent of Quebecers having a family doctor by December 31, 2017. If family doctors fail to meet this goal, a penalty of up to 30 percent will be imposed on salaries as initially proposed in Bill 20. Barrette continued to repeat his mantra: “The population demands access to their Family Doctor.”
Barrette also introduced new terms to the Quebec Health lexicon: Taux d’assiduité (attendance rates), taux de fidélisation (loyalty rates), and taux de prise en charge (registration rates). Targets for fidelity (the number of patients seen exclusively by their family doctor) were set at an achievable 80 percent by the same December 31, 2017, deadline, again with penalties for missing the mark.
At this point, the battles were fought, and a plan set in motion with a measurable goal.
Bill 20, in essence, put all the primary care eggs in the Family Medicine Group (GMF) basket — the first-line solution proposed by the Minister’s predecessor, Philippe Couillard, a decade earlier.
Minister Barrette demanded that all GMFs apply for recertification, new terms were imposed, and a plan to integrate with the newly established CIUSSSs negotiated. GMFs offered the promise of comprehensive group care, with extended hours, and access to a multidisciplinary team. The goal, while ambitious, was clear: a family doctor for every Quebecer.
This plan, however, is now being threatened by a new intervention.
Last spring, just as GMFs were being reaffirmed, Barrette presented “super-clinics,” an alternative model of access to frontline care “especially helpful to people who don’t have a family doctor.” These reseau, or network clinics, essentially outfitted GMFs using the same doctors in the same location, but would book 80 percent of their appointments with patients from other clinics, or patients without a family doctor.
GMF and super-clinics, located at the same sites with the same doctors, are mandated to see 80 percent exclusively their own registered patients while booking 80 percent non-registered patients. Confused? It is simply an equation that does not add up.
The Minister again touted the access idea, arguing that super-clinics would help fill the gaps in health care. With them, he says, resources could be diverted from ERs, and patients would have additional coverage in every neighbourhood.
To many of us, the two ideas — GMFs and super-clinics — are confusing and competing concepts. After decades of discussion, we supposedly arrived at the logical conclusion that our health care system needs a robust primary care network, where the family doctor acts as the “doorway” to care. Instead, super-clinics have been introduced, bewildering the public, frustrating family doctors and sabotaging the message. Patients do not know where to go — for prevention, treatment or even the flu.
What remains is a contradictory plan where every Quebecer should exclusively see his or her own family doctor, and yet where the Ministry also promotes clinics where you can see anyone except your own family doctor.
Once and for all we should decide whether we want a strong primary care infrastructure where patients and family physicians assume co-responsibility for care, or whether we prefer to adopt “zone coverage,” where mega-clinics address all front-line concerns.
Our Health Minister should heed the valuable lessons from his colleagues in the hockey world. Understand what you want, articulate what you need, be true to your identity, and be consistent.