THE NEED TO REBUILD PRIMARY CARE IN ONTARIO.

Issue:

Over the past years, the number of individuals without regular access to a family doctor as a primary care provider (PCP), has been reported to be over 4.6 million Canadians?(1), and this has put additional pressure on local emergency departments (ED) as the main option to seek medical attention at, straining this healthcare resource by serving patients with low-acuity conditions that could be treated by a PCP at 1/5 of the cost of an ED visit?(2).

To maximize the use of the ED for high-complexity cases, there must be a network of health resources available to serve those in need of non-urgent medical attention, which could be through expanding local and provincial alternatives to ED services by creating new Rapid Referral Clinics (RCR), urgent care centers or expanding the PCP network and its hours?(2). Family medicine is considered the foundation of all these strategies and also of the Canadian healthcare system (3).?

Therefore, it is necessary to evaluate, from a leadership position, the primary care health system, as well as the path that patients navigate to access health care services for non-urgent medical causes in Canada. This can be done by using systems thinking to understand the dynamic interaction, synchronization and integration of people, processes, and technologies at this level of care to identify the critical relationships that can be utilized for a successful implementation effort?(3).

Background:

Canada has one of the most expensive per capita health care systems around the world and yet, this does not prevent user dissatisfaction and complaints about obstacles, lengthy waits and difficulty accessing healthcare services, which often relate to the reduced number of family doctors available to serve the growing population?(4). This scenario is even worse in rural Canadian communities, where less than 10% of all Canada’s family doctors work?(5).

To solve this, federal initiatives have included remote recruiting of international medical graduates (IMG) through provisional licensing or return of service agreements, both of which have failed to lower the turnover rates, and the costs of this strategy have surpassed the benefits in the long run?(5). Besides obstacles such as lack of support for family members, fewer educational opportunities, and limited resources?(5), there is also the fact that family doctors are under immense pressure in each of their physician-patient encounters, mainly driven by the number of administrative tasks, filling medical forms, and coordination of care?(4).?

For this reason, some hospitals in Ontario have created Rapid Referral Clinics (RRC), as a way to provide and improve care for individuals with less complex health conditions that need ED attention and also, to reduce wait times for those who need immediate care, through the ED?(2). From a financial standpoint, an RRC in Toronto has shown to be a cost-effective intervention, freeing approximately $1 million per year, with increased patient satisfaction and contributing to improved healthcare outcomes?(2).

Nonetheless, over the past months, patients have faced even more challenges in finding a family doctor across Canada, which has pushed institutions like the Canadian Medical Association to propose action plans to address the health human resources crisis that Canada is experiencing?(6).

From a leadership standpoint, it is imperative to consider that behind every backlog, with every delay in the provision of care and accompanying every Canadian without a PCP, there is an individual in need of medical attention, and all this is mostly coordinated and regulated under federal and provincial laws and regulations?(7)which needs to be examined and replanned.?There is a need to rethink PCPs’ work and contribution to the healthcare system?(8).

Key Considerations:

The current situation of the healthcare system in Ontario differs from the quadruple aim framework to which its new vision is aligned, which considers improving patient experience, improving the health of populations, reducing the per capita cost of health care and improving the work-life of providers?(9).

To overcome this situation and guarantee equal access to healthcare services, the provincial government is called to develop a human resources plan to rebuild the healthcare workforce sustainably, by considering and adopting the following three-step plan:

Immediate plan (up to six months)

In almost every province, services provided by family doctors are less paid than all other specialties and subspecialties, for example, in British Columbia, family physicians are paid as low as $30 per encounter, regardless of the complexity of the situation?(4). This pushes many family physicians to work in hospitals, long-term care facilities or specialize in other areas of practice, all of which increase the need for family doctors as front-liners for all non-urgent medical consults?(8).

By reviewing the provincial fee schedule, the ongoing shortage of family doctors would not be a problem, the first line of attention for non-urgent medical concerns will be enhanced, and the reduction of 30% of the patients that use ED for these concerns would alleviate this level of care, reducing the costs associated to it and redirecting the funds to a better paid PCP network?(2,4). It will also align with the Ontario Ministry of Health vision, which considers improving the work-life of providers?(9).

Failing to implement this immediate plan will continue to reduce the number of PCP and overcrowd the ED with low-complexity health concerns, which will increase the cost to maintain this healthcare setting.

Medium-term plan (7-18 months)

It is necessary to improve workforce data collection by establishing a network of local leaders with the combination of skills needed?(10)?to allow them to provide real-time information about the constraints and obstacles that PCP are facing, to analyze and solve them, promptly?(6). This can be facilitated by implementing a systems thinking approach from Ontario Health, supported by Health Quality Ontario and other established institutions. This also aligns with the vision?Ontario Ministry of Health vision, which considers improving the health of populations and the work-life of providers?(9).

Failing to implement this medium-term plan will continue the implementation of improvised plans, without knowing in detail the situations that are happening within the healthcare system and will not allow to plan based on data obtained directly from the source.

Long-term plan (18 months-6 years)

A promising strategy is increasing enrolment at medical schools, with the idea of improving the distribution of physicians in geographical areas and by specialties?(5,6,11). This could be supported by designing a plan to attract international medical graduates to pursue residency training in Canada and creating more seats conditioned by the signing of a return of service agreement that secures their retention for at least 5 years post-graduation?(5).

It is also important in this phase to establish interdisciplinary healthcare teams, where PCP are not seen as isolated service providers but as part of a comprehensive structure where communication between providers and allied services is eased and patient satisfaction is increased, with better healthcare outcomes (8). Collective thoughts and collective ideas are an important value of teamworking?(12).

This could be thought of as considering the model of a community of practices as the basic structure, where professional and organizational boundaries are erased to propitiate knowledge sharing and enhance patient care?(13).

Failing to implement this long-term plan affects the sustainability of any actions taken due to the lack of new individuals trained to increase the workforce.

Conclusion

The future of the healthcare system in Ontario depends in part on the decision to optimize primary care services, by revising the fee schedule, promoting data collection, and increasing the health workforce in the province. Healthcare leaders should be prone to accept and show interest in initiatives that could generate a change to a faced problem?(14). Embracing a change in the actual health care structure means that the Ontario Ministry of Health will be a leading organization in Canada, and will promote a change in other provinces, with the ulterior goal of providing better health care in Canada.??

Recommendation

In the healthcare industry, interventions are usually carried out by two or more disciplines, and this interprofessional approach carries leadership opportunities that could facilitate reaching a proposed goal?(15).?Ontario’s health care system is a complex adaptative system, with a diverse and interconnected structure with multiple variables and forces that cannot be optimized by traditional top-down thinking and approaches?(12). Therefore, the need to create new leaderships that encourage?the free flow of information between agents in the system?(12). Realizing that a flexible approach is an answer to solving complex situations and involving agents in the proposed solution is key to solving the ongoing situation with the provision of non-urgent health care services to individuals in Ontario, with high patient satisfaction, reduction of wait times and contributing to better health outcomes?(14).

References

1.???????Statistics Canada. Health Fact Sheets: Primary health care providers, 2019 [Internet]. 2020 Oct [cited 2022 Feb 5]. Available from: https://www150.statcan.gc.ca/n1/pub/82-625-x/2020001/article/00004-eng.htm

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4.???????Hopper T. Why five million Canadians have no hope of getting a family doctor. National Post. 2022 Jan 25;?

5.???????Canadian Foundation for Healthcare Improvement. Myth: IMGs are the solution to the doctor shortage in underserviced areas. Mythbusters. 2013.?

6.???????Canadian Medical Association. Physicians, and nurses offer solutions to immediately address health human resource crisis. 2022.?

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9.???????Ontario Ministry of Health. Chapter 2: The vision for health care in Ontario [Internet]. A healthy Ontario: Building a sustainable health care system. [cited 2022 Jul 1]. Available from: https://www.ontario.ca/document/healthy-ontario-building-sustainable-health-care-system/chapter-2-vision-health-care-ontario

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