While Doug McGregor makes some great points and other previous articles about team-based delivery propose an encouraging step forward, there are alternative ways of looking at both the problem and the possible solutions.
To begin, let’s first identify the real problem we are trying to solve. How we define the issue impacts the solutions. While the symptom is identified as people not having a family doctor, the key problem is not having access to a health-care professional when you need one.
Today, if you don’t have a family doctor you visit a walk-in clinic or Urgent Care Centre, if you can find one, or you go to your local emergency department. As a patient, you want treatment and who gives it to you initially is immaterial. If it turns out to be the emergency department, the end result is higher costs to the system and, for the patient, delays and frustration. It makes it seem like the system is broken.
Further complicating the situation is that the fight for family doctors has started to impact municipal budgets as municipalities post bounties of several hundred thousand dollars per position to attract new doctors to their towns, each trying to outbid the other with the taxpayer ultimately on the hook yet again. In the coming years, as more family doctors retire this situation is only going to get worse. Furthermore, the number of people wanting to practice family medicine is decreasing for a variety of reasons, including cost. This cycle of outbidding has to stop as there is no winner and municipalities should not be involved in a provincial issue.
The question that is not being asked, but should be, is why primary care delivery is focused on the doctor. You don’t hire a master carpenter to build a birdhouse so why must doctors be the central focus. We are historically handcuffed. We claim we need family doctors because that is the way it has always been. But why? Today’s Registered Nurse or Nurse Practitioner is far more skilled than the doctor of 75 years ago and is capable of so much more. Since 95 per cent of patients presenting at the family doctor can be dealt with by someone other than the doctor, isn’t it time we re-evaluate how we provide primary care and by whom.
We concur that within the system there is a shortage of health-care professionals, but we have to look at providing service differently. So, let’s examine the solutions offered to eliminate the staffing issue so we can fix that underlying problem.
OPTION #1 – Import health-care professionals, from other provinces or internationally. While this may seem like a good temporary solution, it only shifts the problem to the other jurisdictions and solves nothing in the long term. We should not be encouraging professionals from underdeveloped countries to come here. They are badly needed where they currently reside, to say nothing about the challenges of equating their credentials within our system.
OPTION #2 – Pay more; higher wages. Well, the unions would have you believe that this is the solution, but it does nothing to address the shortage of staff. Appropriate pay for expertise and experience shows the respect that professionals are due. Higher pay, however, does little to change the number of professionals. Claiming that higher pay will bring back retired professionals is more hopeful than realistic. It also does not account for any retraining or recertification required. I will leave the reader to judge the motivations of the unions in their assertions that higher pay is the solution. What I do not understand is why the unions and associations are not advocating to expand the scope of service being delivered. Their members are capable, so why are they not seeking to expand the value that they can provide. Added value is the fastest way to an increased paycheque.
OPTION #3 – Increase the schools. This is, of course, the ideal solution as it directly addresses the issue but it is a solution that will take a long time to arrive. It takes a decade or more to grow a doctor, six-seven years for a Nurse Practitioner, five-six years for a Pharmacist, four years for an RN, and one-two for a Paramedic or RPN.
Given these extended timelines, we must examine the potential to accelerate these courses. Clearly some cannot be modified as there must be clinical experience to accompany the classroom work. However, we must examine whether there are ways to extend the training day, shrink the time between semesters or otherwise find ways to graduate individuals faster without compromising quality. Consider, for example, the huge potential impact of having another 1,000 paramedics added to the system within a year.
We must also consider what incentives can be made to encourage people to take up these careers. Free training with a commitment to a number of years of service afterward would seem to be a reasonable compromise. Look at the military colleges: four years of university and in return a number of years of service. If it turns out not to be for you, then you pay back the full amount like any student loan.
OPTION #4 – Better usage of existing professionals. The current cadre of health-care professionals are skilled, experienced people. Doug McGregor and others have correctly pointed out that there is an opportunity for increased efficiency by having them do less administrative work.
Let’s take this a step further and let the health-care professionals focus solely on the work they are capable of performing and trained to do. In reality, most patients don’t need to see a doctor. We are already seeing minor ailments being handled by pharmacists. Let’s expand that concept.
In reality, most patients don’t need to see a doctor. Let’s expand that concept.
Walk-in clinics are a great way of providing coverage to a larger population. By greatly expanding the number of paramedics, it is possible to do triage and assessment from essentially mobile clinics. For the elderly and shut-in population, this would be a huge benefit. The concept of a house call disappeared decades ago but could be quickly reinstated by having an increased number of dedicated paramedics providing this service. It would also take enormous pressure off hospital emergency rooms. Paramedics can be trained relatively quickly and could be in the system in significant numbers within a couple of years. Programs like these are already in place in places like Renfrew County with its Virtual Triage and Assessment Centre.
Properly compensated video/telemedicine services could easily provide service to large numbers of people, especially to those in remote and rural areas where travelling to a physician can be difficult. This service is also cost effective when you consider the recruiting fees and travel costs avoided, but for it to work it must be accompanied by an appropriate funding model.
And consider expanding the use of health-system navigators to direct people to the care they need. This would help alleviate the administrative burden that health-care professionals have today, letting them focus on delivering actual medically necessary service as they have been trained to do. Have doctors see only those patients who have been triaged to screen out the ones that can be handled by others. As long as they get access to treatment, most people do not care if they have a family doctor or get seen by one.
What about privatization?
We should first ask, “Does the patient care?” In most cases no, but with some caveats.
Firstly, the service must be delivered without additional payment by the patient. Guarantees have to be in place so that this cannot happen.
Secondly, the cost structure has to be supportable and equivalent to services provided elsewhere in the system. For example, if a hospital is paid $Y per X-ray or other defined procedure, then the private provider should only be paid the same amount. The system should not pay more. There is one caution in calculating this amount – from experience we know that private clinics will try to take the easier, uncomplicated cases and leave the complicated ones for hospitals. This must be factored in so that either a private clinic takes all cases, complicated and uncomplicated, or the costing takes that into account and the privatized fee is lower than what hospitals get because of the difference in the complexity of cases overall.
Those against privatization will argue that health care will cost more, but it should not if we set fees properly. In addition to lower facility and overhead costs compared to the public domain, by creating specialized centres that can optimize staffing and workflows, private clinics can operate at higher capacity and likely with less staffing cost. The unions want to fight privatization because the jobs of their members will not be protected. They say it will drain staff from hospitals, but it won’t. An RN is a highly trained individual who has a wide range of skills and is capable of doing many jobs. Much of that training is wasted when the work is repetitive and specialized. It can often be handled equally well by a specialized clinician or an RPN with specialized training. For a private clinic, using a specialized individual is a cost saving and hence part of the equation in making a profit. The clinic must accept the liability for the procedures and staff itself accordingly. If the business case does not work, then the clinic does not open – privatization should not mean it costs the system more.
As an alternative, the Ministry of Health could choose to implement a cap on profits. In the absence of true competition, the CRTC used to do this with the telecom companies. It set rates of return to ensure that customers were not gouged. While not the optimum solution, it would be another way of ensuring that excess profits are not made on the backs of the public.
Summary
To be clear, I am not against having family doctors or that we should do away with them but I am suggesting there are multiple solutions to today’s challenges; more family physicians is not the only approach we should consider.
Team-based delivery and squeezing administrative inefficiencies from the system are useful and will help us move forward but they are incremental approaches to our current problems. It is time to be bold, to move faster. By thinking a little out of the box, we can find solutions to our current challenges.
The future health-care system may not look like what we used to have but if the goal is to get access for the patient when they need it without excess cost, we can achieve that by significantly restructuring how the players in the system provide that service as we work to quickly train more. This approach will also limit the longer-term growth of system costs by ensuring more optimal usage of its human resources.
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