[ END OF AN ERA ]

Is Ontario about to say so long to solo?

Stakeholders take target practice at FP aspects of HSRC report

BY CATHERINE TEASDALE

TORONTO - If the Ontario government accepts recommendations from a report about reforming the role of the family doctor, the solo practitioner in Ontario will be history.

The Health Services Restructuring Commission (HSRC), sent to investigate primary care in the province, has recommended that the primary care reform projects currently underway in Ontario be expanded to include doctors’ offices in the rest of the province.

The report, Primary Health Care Strategy, advises that doctors join group practices with nurse practitioners and other healthcare professionals in order to provide one-stop shopping; that services be available 24 hour/7 day a week in urban, rural and remote areas; that 24-hour telephone triage be provided; and that patients enroll in a practice with one family physician, to effectively end the patient practice of "doctor shopping."

"We mainly agree on the basic points," said Dr. David Mathies, president of the Ontario College of Family Physicians. "What is missing here is an acknowledgment that we need more family doctors."

The Ontario Medical Association, too, said that while in agreement on the basic principles, it parts company with HSRC’s plan to rapidly implement the recommendations without evaluation. The commission advises that the recommendations be put in place within six years. The first year would be used to plan for implementation (setting aside funding). The next five years would be used to implement the strategy throughout the province.

"We Need to evaluate what works and what doesn’t work because aspects of this are far more complex than the theoretical application," said Dr. Wendy Graham, who chairs the OMA’s section on Primary Care Reform.

It is a far cry, she said, to write policy in theory as opposed to actually implementing a plan, a statement she has lived for almost three years as the OMA and the Ministry of Health have attempted to launch their 10 primary care projects.

"The success of primary care lies in some key factors," said Dr. Graham. Doctors, she said, have to be confident that "they are going to be paid to do primary care the way we were taught to do it" and the information technology being proposed should be funded appropriately. "It is one thing to buy the equipment - you need to have ongoing support."

Other, such as the Coalition of Family Physicians (COFP) - a 3,000-member splinter group - said that family doctors shouldn’t rush into any of this.

"First of all, we should look at this commission’s tract record. They’ve just recommended pushing through hospital restructuring which the province did and it is clear that that turned into a disaster. We are now in the worst crisis that we have ever been in terms of hospital services," said Dr. Sharla Lichtman, President of the Coalition.

"We should learn from our mistakes and not rush into restructuring the rest of healthcare just because the very same commission that recommended hospital restructuring recommends we [undertake province-wide primary care reform] do so and we do so quickly."

Another point of contention for all three doctors was that the commission recommends physicians be penalized 100% of the cost of the care if patients doctor shop [except in cases of emergency or geographic boundary].

"Negation should be a two-way street and patients should be expected to pay if they are going to be causing a physician to lose income," said Dr. Mathies. "Our position has been to ignore the negation. If it turns out not to be a problem in the province, then the cost and the hard feeling of negation would not be worth it, especially if it remains a small number."

Dr. Lichtman believes that physicians should never be penalized for the behaviour of our patients. And Dr. Graham said that survey after survey shows that patients will seek outside care.

"Two out of seven patients have two family physicians: one for the easy stuff and one for the hard stuff," she said. "People will drive over 100 km to go back to talk over complicated situations with the FP of their choice.

"Patients have always gone where they have thought it necessary to go. To make the physicians 100% responsible - we know that after repeated surveys and discussions that - it is not going to fly with the profession."

The HSRC recommends that within the first year, the extent to which patients seek care outside of their primary care group (PCG) should be monitored and reasons evaluated. In the second year, PCGs should be negated for doctor shopping.

Patient accountability has been a pivotal point of discussion of primary care reform since day one. "The debate," said Dr. Graham, "will be rekindled."

Also announced before Christmas were the finding of Dr. Robert McKendry’s report, Physicians for Ontario: Too Many? Too few? For 2000 and Beyond. The government has committed $71 million to implement the plan’s short-term recommendations ($11 million) and improve access to physician services ($60 million) to help smaller communities provide 24-hour access to doctors in hospital emergency rooms.