A famous campaign slogan attributed to U.S. president Herbert Hoover in 1928 promised “a chicken in every pot, a car in every garage.” It was a promise no government could keep.
Recently, Quebec premier Francis Legault and his health minister, Christian Dubé, pivoted away from another unattainable promise: a family doctor for every citizen. They envisioned a more efficient system for primary care, one that could give relatively quick access to the million or so Quebecers waiting to be paired with a family physician.
Now we hear that Ontario is also moving toward a more realistic and achievable goal of providing family physician care by funding more neighbourhood-based clinics like ours.
As talks continue between the federal government and the provinces, it’s clear that the challenge facing patients, politicians and providers is huge and complex.
According to an article published last year in the Canadian Medical Association Journal, “Primary care in Canada is in crisis; 4.6 million people did not have a regular family physician or primary care clinician before the COVID-19 pandemic and the situation is getting worse.”
Just listen to your family members, colleagues, friends and neighbours, many of them without a family doctor, unable to access care beyond walk-in clinics and hospital emergency departments.
As a family physician with 35 years of experience, I recognized how desperate the situation had become and wanted to try something new.
Our original family medicine clinic opened in midtown Montreal nearly 15 years ago, serving residents in the surrounding Notre Dame de Grace (N.D.G.) neighbourhood. Since then, it has grown; in 2015, we applied to the provincial government to become a funded GMF (Groupe de Médecine de Famille). This entitled us to key resources: financial support to enable us to expand physically and staff support in the form of allied health professionals such as nurses, social workers and a pharmacist.
At the start, we were limited because of the legislation surrounding family physicians’ services – that is, individual patients could only be registered to individual family physicians.
But in May 2022, there was a ground-breaking policy change: after negotiations with the Quebec government and the Federation of Primary Care Physicians of Quebec, my colleagues at our medical centre, Clinique GMF-MDCM, brought the province’s new access-to-care proposal to our own family doctors.
More than half of our family docs agreed to take on the added responsibility of providing primary care to an additional 5,500 patients on the Quebec government’s family-physician wait list for the surrounding neighbourhood.
So far, this group registration approach is working: more than 500,000 Quebec residents have been “on-boarded” to clinics like ours.
So how does it work? The government identifies people with the most pressing health needs and sends them a letter with the name and location of a neighbourhood clinic, informing them that they are registered there for care.
The person then calls a central phone number and is triaged and routed to one of approximately 100 reserved spots available each week at our clinic. His or her health information is entered into an electronic charting system, ensuring safety, confidentiality and continuity of care.
Clinic patients also have access to on-site medical specialists as well as nurse practitioners, nurse clinicians, social workers, pharmacists and more. Services may include preventive health care, diagnosis and treatment of mental health problems, urgent health care and chronic disease management.
“‘Who needs a family doctor?’ This is better in so many ways.”
Today, more than 30 family doctors are caring for more than 35,000 registered patients at our clinic. Our patients’ ages span from newborns to centenarians. GMF-MDCM is open seven days a week, 52 weeks a year, 12 hours on weekdays, and four hours daily on weekends and holidays.
After months and years of relying on walk-in clinics or hospital Emergency Departments, our new patients are happy with our care. They say: “Now that I’m registered with your (GMF) clinic, I tell everyone: ‘Who needs a family doctor?’ This is better in so many ways.”
Patients have also noticed that a visit to our clinic feels different than going to a walk-in where the appointments are shorter and are generally focused on urgent-care problems, with rare attention paid to preventive care, mental health or chronic disease management.
When one of our physicians retires, dies or moves out of the system, a registered patient may continue to receive care at Clinique GMF-MDCM.
So, that’s the patient side of the potential solution. But how does it alleviate the strain on family doctors? Why have they been leaving their practices in droves or simply not opening a traditional kind of family practice?
There are currently almost a million people waiting to be paired with a family physician in Quebec alone. Why the shortage? First, fewer medical school graduates are choosing the specialty of family medicine. They have witnessed the rising expectations placed on family practices without appropriate resources and the resulting physician burnout. They don’t want this kind of career.
With insufficient administrative support and stagnant payment models, the costs to maintain a family practice are becoming unsustainable, according to the College of Family Physicians of Canada. And finally, some physicians are choosing to retire from family medicine practice earlier than planned, partly due to the exhaustion resulting from working through the COVID-19 pandemic.
After less than one year of our program, the signs are encouraging. Several of the graduating family doctors we have approached to join our clinic have been eager to sign up.
We have also recruited family physicians who are currently working in hospitals, emergency departments and long-term care or rehabilitation institutes. Some may choose to continue working part-time in these areas but they are willing to commit to part-time family practice at our GMF. This represents an important pool of family doctors who are now able to re-enter the system and provide much-needed care without registering individual patients.
Younger doctors who have joined us are able to consult with each other and have ready access to discussions with consultants and senior colleagues. This doesn’t typically happen in a walk-in clinic setting.
We are convinced that the GMF model (with group registration of patients) that is working so well after a relatively short time could continue to be applied efficiently and successfully throughout Quebec and in other provinces.
In a recent interview, Danielle Martin, chair of the University of Toronto’s department of family and community medicine, asked bluntly: “Why aren’t we funding team-based care for all Ontarians when we know that this is the most effective way to provide health-care services?”
I should emphasize that this model works within the single tier of Canada’s medicare system. There are no additional patient fees for care within our clinic.
We are determined to lobby for ongoing funding from both the provincial and federal governments, so that we can continue taking on new family doctors and more patients into our neighbourhood GMF.
We have been told that in 2024-25, Quebec may introduce some further changes affecting the GMF model. We hope they have noticed our progress and will move closer toward this neighbourhood model rather than expanding funding to walk-ins.
Patients, families, physicians and other players in the health-care system asked for change, for energy and for innovation to solve the huge problems that face us. We are doing this. It’s working. I have to hope that our government partners will continue doing more of what works and less of what doesn’t.