I very much appreciated the piece in the Healthcare Quarterly (8(1):89) "Primary Healthcare: The All-Too- Quiet-Revolution in Waiting."

My problem is that the examples quoted are isolated. The Use Health Centre's project in Halifax addresses one narrow topic. The Hamilton Project also addresses only specifically mental health and nutrition. They are not a broad range of services. They are very directed to narrow targets. The BC Nurse Line answered approximately 16 calls for each physician visit that was preempted. I doubt that this is a very efficient system. Even as a specialist, I only receive $25 for a visit. I doubt very much that a nurse-line service can handle telephone calls at $1.61 per telephone call. Maybe the Saskatchewan system works better with a range of healthcare professionals. I do agree that the system described in Northern England may be better. I, as a specialist, would very much like to have electronic health records system with a smart card containing all information on a patient but neither the privacy advocates nor the cost of implementation make such an undertaking feasible.

I am very strongly in favour of a nurse practitioner program and have supported them very strongly in Cornwall. My concern is not displacement of physicians.

You also indicated that change seems faster and more effective across the ocean but the most important part that you omitted is the fact that in Canada we train and have far fewer physicians per population than exist in Europe. An integrated system still demands physician participation and a sudden transition from our patient-oriented system to a multidisciplinary team work requires stepwise establishment. That would dislocate existing physicians and therefore, at least temporarily, services would be curtailed rather than initially expanded. No physician is willing to participate in further curtailment of services even if the horizon is brighter in the future. Maybe governments should not have cut back on medical school enrolment in Ontario 15 years ago but implementation of a changing system is temporarily disruptive which would potentially lead to disaster during the implementation stage, even if the long-term effects are beneficial.

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