Transforming the practice of family medicine
Doctor networks designed to give continuous care But primary-care reform not yet taking hold

THERESA BOYLE
QUEEN'S PARK BUREAU

In the waiting room of Dr. Bob Henderson's office in Campbellford is a sign welcoming patients to one of Ontario's new family health networks.

Henderson is one of a minority of family doctors in Ontario who took the plunge into "primary-care reform" — bureaucratic lingo for changing the way family medicine is practised.

Despite Henderson's enthusiasm, reform is happening slower than he'd like. Engaging patients in the changes has turned out to be a time-consuming process and involving other health practitioners is contingent on more government support.

The aim of primary-care reform is to provide round-the-clock care by a team of health professionals, including doctors and nurse practitioners. The way doctors are paid would change to encourage them to focus more on quality of care rather than on high patient volume.

Henderson says patients as well as physicians benefit, because patients have full-time access to co-ordinated care and physicians have more back-up and more time off. As well, he says, "the value of comprehensive care — hospital, office, house calls, obstetrics and other services — (is) recognized as important and paid accordingly."

Despite such advantages and despite the fact that governments have touted primary-care reform for three decades, there is little progress.

The Ontario government wants to make family health networks the mainstream model for primary-care delivery and hopes 80 per cent of family physicians will participate in such practices by next year. Eventually, the government wants 600 networks to be in operation.

But, as Premier Ernie Eves was forced to admit this week, only 4 or 5 per cent of family doctors have joined networks.

On Wednesday, Canada's first ministers reached an agreement on the creation of a $16 billion health-reform fund, part of which would be used to "immediately accelerate primary-care initiatives."

The deal calls for 50 per cent of residents to have access to "an appropriate health-care provider" around the clock within eight years. (This is a watered-down version of Ottawa's previous goal of having 50 per cent enrolled in "multidisciplinary primary health-care organizations within five years.")

Curiously, Ontario Health Minister Tony Clement continues to boast that Ontario is a national "trailblazer" in reform. On Monday, he announced the opening of a new family health network in Toronto, the 10th in the province. Added to 14 pilot networks, that means there are only 24 such reformed practices in Ontario.

Even where doctors agreed to the concept, reform has been slow. Except for the new sign in Henderson's waiting room, there is little evidence of change.

The Campbellford network has about 800 patients signed up from a potential pool of about 2,000 in the town northwest of Belleville.

Henderson and his five colleagues in the network are trying to enrol patients from their pre-existing practices.

"The plan was to have them all signed up by now. We thought three or four months would do it," Henderson says.

"The process has taken longer than I think the planners had anticipated, but we are moving forward."

Each patient must sign a contract agreeing to roster with the network that compels them to see their family health network doctor first when they have a health need, rather than, for example, going to a walk-in clinic. They're still encouraged to go to hospital in cases of emergency.

Patients must also sign release forms, allowing the health ministry to let the network know if they receive health care outside the network.

The release also gives other health professionals in the network access to relevant parts of a patient's medical records.

Once enough patients are signed up, the practice can begin to function like a network.

When it does, the doctors will no longer be paid primarily on a fee-for-service basis, a piecemeal system that reimburses them for each procedure performed.

The criticism of fee-for-service is that it encourages doctors to see large numbers of patients rather than spend quality time with each one. Henderson's dissatisfaction with this is the main reason he agreed to sign onto a network.

Under the network system, physicians are essentially paid a salary, with the amount based on client caseload. They get bonuses for preventative care services such as flu-shot clinics.

Generally speaking, it's not financially feasible for doctors to switch to the network system of payment until they have 50 to 60 per cent of patients signed up from their pre-existing practices. Henderson now hopes he can make the switch in the spring.

To date, only the family health network in Guelph has changed payment systems.

Henderson says his practice doesn't look much different now than it did prior to becoming a network.

"The big changes, as I see it, will likely come in the future because, by changing the way physicians are paid, it provides a new way of delivering care."

In the future, Henderson hopes to add a nurse practitioner to the practice, but the government has not earmarked any funding for the hiring of nurse practitioners in his area of the province.

A central premise of primary-care reform is having other health-care providers work alongside doctors. There are only 10 nurse practitioners in the pilot networks and none in the others.

The government is expected to soon announce that funding will be made available to some networks to hire nurse practitioners.

The province has not provided much special support to health networks. For example, a special telephone health advisory service is not yet established, and there is a lack of information-technology support.

And an "e-physician project" is still being evaluated at the Chatham-Kent network. The idea is to connect physicians to local hospitals by computers and to store patient records electronically. Part of the hold-up is that the government has not passed legislation to protect patient privacy.

Henderson hopes the first ministers' deal, and the creation of a health-reform fund, will give reform a much-needed boost.

"If you step back and look at it from a business sense, a proposal has been made and the uptake has been slow. Therefore, the proposal wasn't good enough.

"Clearly, if they made it more advantageous, financially or in other ways for the physicians, then the uptake would be faster."

Against this backdrop, a group of doctors in Ontario is actively organizing against reform.

The Coalition of Family Physicians argues that the proposed changes aren't financially rewarding for doctors and exposes them to undue legal risk.

"Primary care is not in need of major reform," says coalition president Doug Mark. He says a survey conducted by his group found 98 per cent of 1,350 Ontario physicians are not interested in participating in family health networks.

What's needed is "family practice enhancement," Mark says, including "more doctors, less bureaucracy, more resources and adequate funding."