The are lots of rumours floating around about what the Ontario Government is going to do about regional health governance. It seems clear that the current LIHNs or Local Health Integration Networks are in for some kind of change.
I don’t know if that’s a good or a bad thing, but I do hope that it is a chance to take a fresh look at how primary care is organized in this province. More accurately it is a chance to improve on the almost total lack of organization and put a true primary care system in place.
Whatever the local governance model, we need to establish a set of principles that will define the core elements of a true system. Once we have those principles in place each community should be given permission and direction to create a system that works for the people who live in that community. As always in this vast, geographically unique province, no one solution will work everywhere. But the principles of a good system should be the same in Toronto and Little Current.
I have some suggestions about what some of those principles should be.
Every person needs to have access to a family physician, a primary care nurse practitioner or even better, an integrated team of professionals all working in collaboration to provide the best possible care to a community. Each professional should work to their full scope of practice and people should have some choice as to who they see for a particular issue.
Professionals within a community need to make a commitment to work cooperatively with others to service the needs of the community as a whole, not just a subset of people.
In return the government needs to put sufficient resources in place to make sure that no individual physician or other profession faces an unreasonable burden of work. Burnout is real. None of us is superhuman and we need to acknowledge this.
People are not always available to see a health professional during business hours. Best efforts must be made to accommodate people’s work, school and family obligations. This is not to say that any individual needs to be available 24/7. We do need to be flexible. As professionals we should be expected to work together to establish a plan to provide care outside the traditional 8-5 office hours.
Quality is important. Groups need to have tools and protected time to define and implement quality improvement plans. Quality improvement is not work that can be done on the fly or during meal breaks.
Professionals in a community should commit to having a shared electronic medical record. It should be available to other providers and to patients. This sounds expensive. The government is going to have to fund this like any other public utility. It’s like roads and hydro lines. Don’t expect small businesses to fund this alone.
Practices cannot develop their own IT systems. Come to them with workable, affordable solutions.
Primary Care must integrate with Public Health, Home Care, long term care and hospitals. We must work with social agencies and schools. And visa-versa. There is only one tax-payer and only one patient. They don’t become someone new when their provider changes hats.
We need to work more formally with families of very ill people. We all know what a crucial role families play. Let’s involve them in system decision making.
Professionals need to be paid appropriately for their clinical work. At a provincial level, we need to review primary care payment models to remove any barriers to good care. We need to reward people for all of their work. Lets reward excellence and innovation.
Leadership in primary care is important. Let’s pay people to lead. Each hospital pays VPs Medical, Chiefs of Staff and Chiefs of Departments. Universities pay Deans, Department Heads and Program Directors. I expect that they get real value in return. Why on earth would we expect family doctors and other community based professionals to do similar work pro bono.
Leadership should be local. Don’t put some know-it-all from University Avenue or Stoney Creek in charge of primary care in Peterborough. Let the folks who live in a community choose their own leaders.
Finally let’s agree that any changes have to be focused on making patient care better. We’ve seen what happens when we focus on institutions and providers. It ain’t pretty.
This is one list of principles. It’s my list and I like it. I expect others would loath this list. I don’t care. Make your own list. What matters is setting goals, establishing principles and getting on with building a primary care system.
Right now we have no principles and no system. We need to put energy into building. It will not happen spontaneously.
And it’s long overdue.
Scott Wooder, MDRe