Family Physicians, Hospital and Community Care Connections
For the past several years, there has been heightened awareness of the difficulties Canadians are having in finding a family physician. The primary care crisis in the community is having a ripple effect on hospital and emergency department capacity across the country and notably in Ontario. This was predictable given the growing and aging population and given the interconnectedness between acute care and community care.
There is no doubt that Canadian health care is in crisis generally. It has been in crisis for many years largely due to efforts of provincial and federal governments attempting to control costs to a single payer system and putting off the difficult decisions until later for the next government to deal with. Now the crisis is escalating. Patients are dying in emergency departments. Babies are going without access to primary care. Patients are dying on wait lists. There can be no denying the seriousness of these realities.
Critical to improving health care access is the recognition that health care is like a balloon. When one area is squeezed, another area bulges. Meaningful heath care reform requires a comprehensive approach to our health care system, from hospitals to all the various community care connections. Pivotal to effective reform is to properly consider the role of family physicians within the system.
Tinkering around the edges for the past forty years as many governments have repeatedly done hasn’t worked to control costs or to provide timely access. We are where we are today because multi-billion-dollar solutions proposed to date by health care bureaucrats, consultants, lobbyists, representative physician groups, and political campaign strategists haven’t worked to create the access to care to meet demand. Neither have a myriad of regulatory changes and task forces.
It’s fair to acknowledge that rising health care costs threaten other important programs that could make a positive difference in people’s lives. Efforts to keep a lid on growing health care expenditures may be well intended but a growing and aging population needing more complex care than ever before is increasingly faced with lack of access to timely care.
So, let’s consider how family physicians factor into the equation. Relatively low per capita physician numbers compared to other developed countries is part of the problem but even as more medical students graduate, the problem persists. This issue must be thoroughly understood. Not only do more family physicians need to be trained, but they also need to be retained in family practice.
Unfortunately, health human resources have not been seen as the health care system’s greatest asset. Physicians are seen as cost drivers to the system and so the efforts to limit their numbers have been consistent. More physicians are needed in many areas but even so, there have been attempts to claim an oversupply in some jurisdictions. The difficulty patients are having in finding access to primary care paints a very different picture. The refrain of “we have too many doctors costing the system too much!” has been replaced by “make them see more!”.
The confused narrative and the blaming of family physicians for the access problems is misplaced and damaging. In the past decade, family physicians in Ontario have seen the levels of administration become intolerable. The efforts to create greater efficiencies in primary care have had the unintended consequence of driving medical students to choose other areas of practice and for current family physicians to look for relief elsewhere.
During the pandemic, family physicians were blamed for rising numbers of patients seeking care in hospital emergency departments. The claim was that providing virtual care was driving patients to the emergency departments. Further analysis of this situation published in the Journal of American Medical Association refutes speculation that patients were visiting emergency departments more frequently because family physicians were providing too much virtual care. The data does not support this allegation.
Despite very significant amounts of data and many government-funded agencies creating it, the current data collection either does not adequately show the dynamics of hospital and community interaction or is not being communicated and translated into solutions. It does not assess the lynchpin role of family physicians within the health care system.
For example, hundreds of family physicians have been hired across Ontario to assist with patients in hospital, “hospitalists”, effectively removing them from their community family practice settings. In hospital, they may care for the growing number of Alternate Level of Care patients who occupy on average 15-20% of all hospital beds. They may care for complex patients on surgical services where increased productivity has meant a greater volume of patients receiving services and requiring additional physicians.
This is not to fault hospitals for their efforts to provide quality care nor to fault family physicians for choosing a hospital setting in which to work. The benefits may be attractive as well as predictable hours with potentially less administrative tasks and more flexibility in hours. However, when this phenomenon is failed to be recognized by decision-makers then solutions to the primary care crisis will go unmet. The health care system experts have squeezed the balloon only to create pressure in the system elsewhere.
The unintended consequence of family physicians leaving their community offices to work as hospitalists means more unattached patients struggling to get the care they need when they need it.
Moreover, the productivity with respect to the increased number of elective procedures performed in hospital and the increasing complexity of in-hospital patients is contributing to draining family doctors from the community. Those entities and individuals responsible for measuring and monitoring should not miss this dynamic. It lends itself to identifiable solutions both short-term and long-term which will inevitably require more physicians and more infrastructure. Doing more with the status quo is no longer tenable.
Effective reform of the health care system demands an approach that considers the importance of the community / hospital dynamic in terms of flow of patients, staff, services provided, and funding. Hospitals have an effect on the community of care and services that surround it, including long-term care homes and family physicians’ offices. What happens in the community (or what doesn’t happen in the community) has, in turn, an impact on hospitals and the patients they serve.
Key to health care reform are family physicians. Their role in the community including primary care, long-term care, palliative care, and increasingly intermediate levels of care must be understood in the context of increased demand for family physicians in hospitals. Training and retaining family physicians in the community is an imperative for a properly functioning health care system.
There are immediate steps to be taken that could achieve short- to medium-term results and begin to build towards a more sustainable health care system. To be continued…
References:
JAMA Network, Virtual Care and Emergency Department Use During the COVID-19 Pandemic Among Patients of Family Physicians in Ontario, Canada, April 28, 2023
Artificial Intelligence in Point-of-Care Testing, Annals of Laboratory Medicine, September 1, 2023
Reconceptualizing Primary Care: From Cost Center to Value Center, NEJM Catalyst, October 3, 2023
Dr. Merrilee Fullerton will be publishing a book that will provide an account from someone who experienced the early pandemic years as Ontario’s Minister of Long-Term Care.