What Do We Want From Primary Care, Part Ii

It's Christmas time, so why not put our wish list in writing?

As I argued in my last post, reforming Canada's primary health care system is an endeavor that never lacks for debate and ideas. Unfortunately, those debates tend to narrow all too quickly into all-too-familiar diagnoses of the problem, and all-too-familiar solutions. Fixing or doing away with fee-for-service medicine, instituting or getting rid of bureaucratic micromanagement, changes to the medical school experiences, etc. None of these diagnoses or solutions are wrong by themselves, but they leave the situation largely unfixed. Why? There are a thousand reasons, but it boils down to one of two mendasar issues:

Failure to scrutinize: not enough testing of assumptions; limited attention to implementation; no thought to unintended consequences

Failure to prioritize: inadequate focus on critical problems; overemphasis on issues of secondary concern; dilution and poor allocation of resources

Let's take a look at a small corner of primary care to illustrate. A number of years ago the Community Health Centres (CHCs) in Ontario were using different electronic medical record (EMR) systems. Some EMRs were better than others at providing data to the government. A decision was made to get all CHCs on the same EMR, so proper analysis, metrics, and comparisons could be drawn. What better way to ensure the cost-effectiveness of CHCs, that are relatively expensive (but excellent) primary care facilities?

Except that the new EMR was awful. It was slower, more cumbersome, more prone to crashing, and required much more IT support that its predecessor. Clinicians weren't given guidelines on what their data input was supposed to look like to meet government needs. And why were the needs and productivity of the clinicians made secondary to bureaucrats' desires in the first place? How much money was spent in the name of ensuring how much money was spent? Perfect example of a policy with misplaced priorities and inadequate scrutiny.

Getting back to primary care, there are more than a dozen identifiable aims for the primary health care system in Canada, depending on how you categorize:

• Equitable in access geographically 
• Equitable in access demographically - age, ethnicity, gender
• Equitable in access socioeconomically  
• Offering after-hours coverage
• Comprehensive - reproductive health, preventive care, mental health, chronic disease management, home visits, palliative care
• Modern and evidence-based
• Data-driven, with the aim of continuous quality improvement (CQI) in both safety and outcomes
• Integrated - with public health, home care, and local specialist and diagnostic services
• Nimble and adaptive - responsive to shifting population needs and emergent health issues
• Cost-effective and sustainable - perhaps as a % of the health budget?
• Multidisciplinary, with each professional working to the limits of his or her scope
• Compassionate and fair to health care professionals
• Accountable to the public purse 

For decades, policymakers have failed to set priorities when it comes to primary care. On the one hand, many millions (if not billions) have been spent to expand access to this or that test, recruit doctors to rural areas, entice doctors and nurse practitioners to work in teams, and train health professionals in data mining and CQI. On the other hand, family doctors have pursued specialized skills and avoided obstetrics in ever-increasing numbers (thus reducing comprehensiveness), have been inundated with ever-greater volumes of non-clinical paperwork, and have been stripped of incentives to meet targets in chronic disease management. 

How many noses must be cut off to spite how many faces, before somebody looks around and asks, "what's going on"?

Just about everyone that works or has worked in primary care will have an opinion on what the priority should be: cost containment, reduction of waste, improved after-hours access, every Canadian with a family doctor or nurse practitioner, and so on. I would argue these decisions properly belong in the hands of the public. That means clinicians, academics, advocates for marginal populations, and communities need to educate policymakers, and policymakers need to lay the options out for the public. 

So before we worry about how we should pay family doctors, or how we should reform medical education, or what should be done about incompatible EMRs, there are basic questions Canadians need to answer, whether at the ballot box or through direct engagement with those in power:

1. What do people want in the primary care system?

2. What do people want most, and what are they willing to wait for or do without?

3. What are people willing to pay for, publicly or out of pocket?

4. Are people willing to pay for implementation of reforms?

Why is it so hard to get this right (I mean, apart from the obvious foot-dragging, willful ignorance, or myopia on the part of those in power)? Because setting priorities is only half the job. Scrutinizing the problems and options is just as important, and can go a long way towards deciding what reforms will or won't work in a reasonable time frame or at reasonable cost. Next time.

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Ditulis Unknown — Tuesday, December 12, 2017 — Add Comment — access, Canada, capacity, doctors, economics, education, Family Medicine, health policy, nurses, politics, taxes