Organizing Primary Care for an Integrated System
During the past decade, many changes have occurred in the Canadian healthcare delivery system but few, if any, of these changes have specifically addressed the role of the family physician.
This paper proposes a number of changes to the infrastructure that supports the role of family physicians, including family physician accountability for delivering twenty-four-hour, seven-days-per-week services to a defined population of patients. The infrastructure needed to support family physicians as the coordinators of care across the continuum of healthcare services includes family-medicine group practices or practice networks linked by electronic networks. Family medicine is the key to health-system integration. Systems to integrate family medicine with other primary healthcare providers and with secondary- and tertiary-care systems are proposed, as well as quality-improvement systems for family medicine.
Implementation of these strategies is essential in the transition to a fully integrated healthcare system and is an important part of making the Canadian system of healthcare sustainable.
During the past few years, there has been a great deal of rhetoric about the importance of primary care as the cornerstone of the healthcare system. The recognition of the importance of primary care has led to a variety of reviews suggesting reform and integration to strengthen the role of primary healthcare. Nine reports over the past five years have discussed various strategies for reform (PCCCAR 1996). There has been a surprising level of agreement in all nine reports regarding the changes needed. In spite of a growing consensus, little action has been taken to modify and improve primary-healthcare delivery in any province. This is not to say that change has not happened. There have been major impacts on family physicians and their patients as a "side effect" of rationalization, regionalization and hospital restructuring, which have been the main focus of reform to date. In Ontario, hospital restructuring and subsequent lack of community-based services have directly affected the delivery of family-medicine services. Hospital reform was not planned carefully enough to prevent this negative impact, and the changes have tended to go in the opposite direction to the strategies presented in the nine primary-care reform reports (OCFP 1999a).
This lack of attention to primary care, and family medicine in particular, is somewhat surprising given the importance of family physicians in the Canadian healthcare system. Canada is highly regarded internationally for the strength of its primary-care system (Starfield 1998). Compared to most developed countries, Canada has one of the highest percentages of family doctors relative to consultants. Family physicians are the principal healthcare providers of medical care at the primary-care level; 50% of Canada's physicians are family physicians. The most likely reason for delays in reforming the primarycare system is lack of political will, for any change in healthcare delivery at the primary level will affect the entire population. The scope of family practice means that even minor changes will be likely to raise the ire of various interest groups and will be politically risky. These are risks that need to be taken, however, for the maintenance and improvement of healthcare delivery in Canada (OCFP 1999b).
2. Problems Identified with the Delivery of Primary Care
Although the government continues to deny there is any shortage of physicians, there is a growing shortage throughout the province of Ontario. Most other provinces are also experiencing shortages. The supply of family physicians in Ontario has been dramatically reduced since the early 1980s when over 1000 new family practitioners were licensed to practise annually. Fewer than 190 family physicians were licensed in 1997 (CPSO 1999).
The hospital-based system has traditionally provided back-up whenever service needs overwhelm the primary-care delivery system. This is no longer the case. Rather, the primary-care system is now providing back-up for a down-sizing hospital system, with an everexpanding number of community-based organizations trying to fill the gap. The current climate is one of accelerating fragmentation in the delivery of care as the number of agencies increase without any coordination or organizational structure to support primary-care delivery. Although some steps have been taken to integrate key components of the system, namely, home care and long-term care through Community Care Access Centres, there remain few incentives to overcome the fragmentation that exists among community-based care providers and between the community and hospital sectors.
The essence of family medicine is the doctor/patient relationship. Table 1 demonstrates that the current fragmented healthcare system diminishes that relationship, with other providers of care delivering services in the absence of this vital therapeutic relationship. A prime example of the disconnection between family physicians and their patients in the current system can be seen in reviewing a patient's health record, which may reside in part with five to ten different organizations. In spite of high investments in information technology in the hospital sector, there are only one or two isolated examples of hospital systems providing outreach into the community (OCFP 1999c).
|Table 1: Current Non-Integrated Health Care System
|PROVIDER OF CARE
|MAINTENANCE OF DOCTOR/ PATIENT RELATIONSHIP
|Family practice visit
|• FP/patient relationship is maintained and enhanced.
|• FP coordinates access to specialist.
• FP/patient relationship may be splintered as patient develops relationship with specialist; relationship with specialist is usually for one condition/health problem only.
|• FP/patient relationship is splintered.
• Patient develops relationship with different physician each visit.
|Patient care access coordinator
|Home care/ community services
|• FP/patient relationship usually maintained. but approach to care between FP and providers may not be coordinated effectively.
|Most responsible physician
|• FP may coordinate access to hospitalization, but FP/patient relation ship may be splintered in favour of specialist/patient relationship; specialist may differ for each hospitalization.
|Family physician institution
|• FP/patient relationship may be splintered and approach to care between FP and providers may not be coordinated effectively.
In both the community and hospital sectors, there is a general lack of understanding of the role of the family physician and of his or her value to the system. The four principles of family medicine, developed by the College of Family Physicians of Canada, provide a framework for the delivery of excellent healthcare. Table 2 describes these four principles, which commit each family physician to ensuring continuity of care across the continuum of healthcare services and throughout the life cycle, from birth to grave. The four principles speak to the key role of the family physician in our healthcare system and to the high level of skill needed to deliver comprehensive care to patients and their families.
|Table 2: The Four Principles of Family Medicine
1. THE PATIENT-PHYSICIAN RELATIONSHIP IS CENTRAL TO THE ROLE OF THE FAMILY PHYSICIAN.
Family physicians respect the primacy of the person. The patient-physician relationship has the qualities of a covenant - a promise by physicians to be faithful to their commitment to patients' well-being, whether or not patients are able to follow through on their commitments. Family physicians are cognizant of the power imbalance between doctors and patients and of the potential for abuse of this power.
Family physicians provide continuing care to their patients. They use repeated contacts with patients to build on the patient-physician relationship and to promote the healing power of interactions. Over time, the relationship takes on special importance to patients, their families and physicians. As a result, family physicians become advocates for their patients.
2. THE FAMILY PHYSICIAN IS A SKILLED CLINICIAN.
Family physicians use their understanding of human development and of family and other social systems to develop a comprehensive approach for promoting health and managing disease and illness in patients and their families.
Family physicians are also adept at working with patients to reach common ground on the definition of problems, goals of treatment and roles of physician and patient in management. They are skilled at providing information to patients in a manner that respects their autonomy and empowers them to take charge of their own healthcare and make decisions in their best interests.
Family physicians have an expert knowledge of the wide range of common problems of patients in the community and of less-common, but life-threatening and treatable emergencies in patients of all ages. Their approach to healthcare is based on the best scientific evidence available.
3.THE FAMILY PHYSICIAN IS A RESOURCE TO A DEFINED PRACTICE POPULATION.
Family physicians have effective strategies for self-directed, lifelong learning.
Family physicians have the responsibility to advocate public policy that promotes their patients' health.
Family physicians accept their responsibility in the healthcare system for wise stewardship of scarce resources. They consider the needs of both individuals and the community.
4. FAMILY MEDICINE IS A COMMUNITY-BASED DISCIPLINE.
Clinical problems presenting to a community-based family physician are not pre-selected and are commonly encountered at an undifferentiated stage. Family physicians are skilled in dealing with ambiguity and uncertainty. They will see patients with chronic diseases, emotional problems, acute disorders (ranging from minor and self-limiting to life-threatening) and complex biopsychosocial problems. Finally, family physicians often provide palliative care to people with terminal diseases.
Family physicians care for patients in offices, hospitals (including emergency departments), other healthcare facilities and patients' homes. Family physicians see themselves as part of a community network of healthcare providers and are skilled at collaborating as team members or team leaders. They use referral to specialists and community resources judiciously.
The most important role of the family physician in today's environment is the identification and early diagnosis of problems. This requires a high degree of skill that is neither understood nor appreciated. Few understand that 40% of all new problems presenting to a family physician are undifferentiated and seldom develop into a definable diagnosis or problem (Starfield 1994; Rosser and Shafir 1998). The most efficient way to manage undifferentiated problems is "watchful waiting," which involves minimal investigation or referral. The focus is on reassuring patients and asking them to return for follow-up within an appropriate time period. This model of care only works when administered by an individual whom the patient knows and trusts. Lack of trust of the physician will cause the patient, fearing that he or she has a serious illness, to seek out other advice. Ninety percent of Ontario residents can name their family physician and recent surveys find the family physician to be the most trusted healthcare provider (Decima 1995; HayGroup 1997).
Unfortunately, current healthcare systems do not provide incentives or any support for family physicians to practise according to these four principles. The system today is excessively dependent upon emergency rooms, walk-in clinics and a plethora of potential contacts for care, provided by medical personnel who are unknown to the patient. This leads to undifferentiated problems being investigated extensively with X-rays and laboratory tests and results in unnecessary consultations at an increased cost to the system. Improper problem management causes an unnecessary increase in anxiety for the patient. An understanding of the importance of the doctor/patient relationship and of continuity of care in creating the conditions for "watchful waiting" to manage undifferentiated problems is an essential component of affordable, quality care (Starfield 1998).
Currently, the fee-for-service funding model does not provide incentives for physicians to provide preventative care to a defined population or spend time providing community information or education. The practice population for individual physicians remains undefined and the emphasis has traditionally been on acute disease management. The system is steadily shifting away from institutional care towards increasing the patient's self-care abilities in the system. However, the lack of attention given to the primary-care system and to its role has created incentives that counter the desirable shifts to self-care (White, Williams and Greenburg 1961). Table 3 illustrates that 25% of all people in any given month are seen by a physician or receive home care, long-term care or hospital-based care. The sustainability of the system is dependent upon addressing the determinants of health to maintain and enhance the health status of the population and in-patient education to increase the level of self-care by patients. Incentives and an infrastructure to support health promotion and patient education are missing from the system. The majority of the funding rests with the parts of the healthcare system, namely consultants and hospitals, that are needed by only 1.01% of the people.
There is no current definition of services that patients should expect when attending a family physician.We believe that there needs to be a clearly defined list of services that the patient and physician know about and understand. Table 4 shows the scope of services that patients should expect from their family physician, as developed by the Provincial Coordinating Committee on Community and Academic Health Reform (PCCCAR). They have been adapted in keeping with the four principles of family medicine. It is unrealistic to expect that the defined comprehensive basket of services could be provided by any single physician. Physicians, therefore, need to be working in groups. In eastern Canada, for example, there are relatively few family physicians who practise in groups, and those that do tend to form very small group practices that are not conducive to providing comprehensive services to their practice populations. Current incentives promote a narrower scope of services, since high-volume, minor-problem, feefor- service practices are the most lucrative.
|Table 4: Services to be Provided by all Family Physicians (PCCCAR Report, 1996)
PRINCIPLE I: THE PHYSICIAN/PATIENT RELATIONSHIP IS ESSENTIAL.
PRINCIPLE II: THE FAMILY PHYSICIAN IS A COMPETENT CLINICIAN.
PRINCIPLE III: THE FAMILY PHYSICIAN IS A RESOURCE TO THE PRACTICE POPULATION.
PRINCIPLE IV: THE FAMILY PHYSICIAN IS COMMUNITY-BASED.
Source: Ontario College of Family Physicians
Canada has the best-trained family physician work force in the world and is valued for the scope of comprehensive services that family physicians are trained to provide. European countries tend to exclude general practitioners from functioning in hospitals or even working with other organizations in the community, whereas in Canada their role in in-hospital care and integration with other providers in the system is essential, especially in isolated smaller communities. The extended role that family physicians play is vital to our Canadian health system. Opportunities to practise by the four principles are being further aggravated by the growing rate of physician shortages. Increased workload and disincentives have combined to further demoralize family physicians throughout the province. It is alarming that family physicians are withdrawing from hospital care, long-term care and after-hour care and restricting their involvement in services such as obstetrics and mental health. It is time for actions that will reverse this trend.
3. Proposal to Address Current Deficiencies
The Ontario College of Family Physicians has embarked upon a process to define a more desirable profile for the family physician in the year 2000. This process has involved surveys of our membership and the structuring of a discussion document to address the perceived problems in the system.We believe that the successful implementation of this plan would strengthen the primary-care base of the healthcare system in the province. A stronger, more coordinated primary-care system will facilitate development of an integrated secondary- and tertiary- care system. The desire for a "top down" process has been expressed by a number of groups (Leatt, Pink and Naylor 1996).We feel that family physicians, as the most trusted group of medical professionals, should be providing the leadership for "bottom-up" planning initiatives that will encourage public and stakeholder participation and support.
One widely accepted proposal is a system of "Patient Choice." We believe that every person in the province should choose one family physician and that the partnership should be formalized (Leopold, Cooper and Clancy 1996). Ninety percent of people in Ontario can identify their family physician of choice; however, owing to a shortage of family physicians throughout the province, many people are without a family physician or are unable to leave their current physician for fear of not finding a replacement. Table 5 demonstrates the strengths and weaknesses of a "Patient Choice System."We believe that there should be an adequate number of family physicians for each resident of the province to have access to a family doctor. Patients should have the right to move within the system if they or the physician feel their partnership is not functioning appropriately.
|Table 5: Strengths/Weaknesses of Patient Choice
STRENGTHS OF FORMAL PATIENT CHOICE
• Discourages double-doctoring
WEAKNESSES OF FORMAL PATIENT CHOICE
• Does not take into account marginalized disadvantaged populations
If family physicians are to provide a comprehensive basket of services, they need to work in group practices or practice networks (virtual groups). Physicians may wish to continue to practise in solo offices, but they would be linked into a group of other physicians ranging in size from seven to thirty who would be jointly responsible to provide the list of services in Table 4. This would mean that any patient who selected a family physician in the province would be linked automatically into a system that would provide the basket of services. Urgent care would be provided by the members of the physician group on a 24-hour-a-day/7-days-per-week basis. This type of organization structure would require the support of excellent information systems so that physicians would have access to the health records of all the patients in the group practice or practice network. Groups should have a minimum of seven physicians (except in isolated areas) to a maximum of thirty physicians. The NHS British general-practice system has recently formed groups of 50 general practitioners to provide service in a region and has over 500 such groups functioning. They are supplied with an interconnected information technology system and each group runs internal quality-assurance programs.
The lack of a coordinated, centralized health record is a major problem of the current system. From a patient perspective, the health record should be held in the family physician's office. The family physician would be responsible for maintaining a comprehensive health record for each patient. All providers in the system with whom the patient had contact would be required to forward copies of all reports and associated information from that contact to the family physician. Information technology will be a necessary tool to support this responsibility. This strategy is now being utilized in the United Kingdom with even social services adding information to the GP group.
The real or virtual group model lends itself to physicians working in collaboration with other healthcare providers. Provision of the basket of services could be greatly enhanced by the use of nurse practitioners and family-practice nurses working in collaboration with family physicians to provide preventative and chronic care, by the use of midwives to augment the provision of obstetrical, prenatal and postnatal care and by the collaboration that could occur with community access and hospital-in-the-home services. By having electronically connected groups, each component could be integrated both at a primary medical- care and community level and with secondary and tertiary levels.
We believe these steps would result in a well-organized, albeit basic, primary-care system that would provide the foundation upon which to build an integrated system.With the key role of the family physician as the coordinator of care throughout the continuum of service delivery recognized, access to affordable quality care will be enhanced and the cost of duplication of services will be reduced (see Table 6).
|Table 6: Proposed Integrated Family Medicine System
|FAMILY PHYSICIAN ACCOUNTABILITY
|FAMILY MEDICINE SYSTEM
|MAINTENANCE OF DOCTOR/ PATIENT RELATIONSHIP
|Chief of Family Medicine monitors quality of care through the continuum of family-medicine services, or there will be a designated Chief of Community Family Physicians Services.
|Family physician provides and co-ordinates access to and monitors care for his/her patients.
|Family practice visit
|FP/patient relationship maintained and care may be enhanced through FP/RN team approach to care delivery.
|FP group or practice network or CHC
|FP or FP/RN team supported by a group or practice network to deliver 24-hour/ 7-day-per-week access to the full continuum of services on a regular or urgentneeds basis. FP/patient relationship maintained.
|FP coordinates access to consultants and maintains records with the relationship being consultant to FP and patient. FP/patient relationship maintained. Shared-care model used.
|INTEGRATED DELIVERY SERVICE
|MAINTENANCE OF THERAPEUTIC RELATIONSHIP
|FP or FP group/network coordinates access to emergency care for urgent/emergent problems. FP/patient relationship maintained.
|Home care/ community services
|FP or FP/RN team works closely with home care/community services to coordinate care.
|FP or FP/RN team works closely with hospital-based consultant and RNs to coordinate inpatient care and develop discharge plan.
|FP or FP/RN team works closely with LTC staff to coordinate care.
Integration at a secondary-care level could be achieved by psychiatrists, pediatricians and obstetricians being allocated according to the population base. These consultants would work to support one or more groups of family-physician providers. An excellent model on which to build such integration has been developed in a proposal for shared care in psychiatry (Kates et al. 1997) and could be extended to include the provision of medical, surgical and pediatric services. The secondary-care providers would then be responsible for involvement with tertiary-care providers and for facilitating patient care at tertiarycare centres. Not only would secondary-care providers act as consultants, but they would also work to improve the skills and knowledge of the family physicians and other primary-care providers. The secondary- care model would enhance the concept of the patient moving between caregivers in a "seamless" system.
To encourage integration with the broader healthcare system, every family physician should be an active staff member of his or her local hospital. Evidence from the College of Physicians and Surgeons of Ontario (CPSO) suggests that practising in a group, holding certification or membership at the College of Family Physicians of Canada (CFPC) and being attached to a hospital staff reduces the risk of a physician being judged incompetent in the Peer Assessment Program (McCauley et al. 1990). How quality improvement would be facilitated at the local level is contentious. One suggested model included the hospital Chief of Family Practice being responsible for facilitating/ implementing quality-improvement programs for community physicians. Another suggestion is the formation of a regional health authority that has a family physician as facilitator for the region, responsible for quality improvement. A third suggestion is to appoint a facilitator physician for every 50 physicians, accountable to a provincial supervisory body for quality improvement. A potential model of governance that integrates family medicine with hospital and community-based services is outlined in Table 7. Full horizontal integration of hospital and community-based services with strong linkages to the familymedicine system would be a feasible model in many communities.
To overcome deficiencies in the current system and the lack of incentive to practise the four principles of family medicine, 79% of our membership support the concept of a blended funding model (Table 8). This would modify incentives and provide accountability for a basket of comprehensive services offered to a specific patient population within a "Patient Choice of Physician System."
From the viewpoint of the Ontario College of Family Physicians, the primary medical-care system has been taken for granted for too long. The result is a fairly rapid deterioration in the ability of the primary- care sector to provide appropriate and accessible services to the population. Strong action is necessary to overcome deficiencies identified in the current system. Politicians have been reluctant to take these steps because they carry considerable political risk, in that a number of interest groups are likely to protest loudly. In addition, the public is likely to perceive change as yet a further attack on the healthcare system in order to save money. The proposals outlined in this paper are likely to be revenue-neutral, although some investment in information systems and reorganization will be required. In relative terms, there will be cost savings to the system. This will occur as a result of reduction in the utilization of secondary- and tertiary-care services. However, this may be offset by increased spending in the primary-care sector.With family physicians assuming 24-hour responsibility for urgent primary care, demands on emergency rooms should be sharply reduced, resulting in more savings.
The Ontario College of Family Physicians is embarking upon a process to involve all stakeholders in an open discussion about taking steps to support and strengthen family physicians' abilities to provide excellent primary care. The proposed major reorganization of the primary healthcare system would both benefit the population and provide the basis on which system integration will be feasible. This proposal will go a long way to integrate community and secondary-care services. Implementation of this plan would strengthen what is widely viewed as one of the best healthcare delivery systems in the world.
|TABLE 8: Executive Summary of a Proposal for a Blended Funding Mechanism (The College of Family Physicians of Canada)
|In July 1992, the College of Family Physicians of Canada (CFPC) released the document "A Proposal for a Blended Funding Mechanism." With the rapidly changing economic environment as a result of mounting government debt, it is timely to reassess current methods of physician remuneration. Time is of the essence if we are to avoid being forced into payment mechanisms that are unfair to physicians, lack incentive to improve quality of care and, in the end, discourage physicians from providing an appropriate volume of comprehensive services needed by their patients. The CFPC proposal rewards family physicians more appropriately for the services they provide and, in addition, will improve quality of care through encouragement of continuing medical education (CME), quality-assurance programs, maintenance of certification, research, teaching and maintenance of hospital privileges. The CFPC plan is also less volume-driven, yet provides incentives to maintain appropriate levels of service. With the plan's emphasis on ambulatory care, comprehensive care and continuity of care, a decrease in overall healthcare costs can be achieved by avoiding unnecessary duplication of services and the higher cost of institutional care. The CFPC proposal has four components.
|A base salary would be paid for a minimum number of office hours per week and prorated for fewer hours of work. Also, an additional number of work units would be guaranteed within this time frame. Included in the calculation of the base would be payment for:
(iii) Pension contribution
(iv) Insurance - life, disability, medical/dental
|B. OVERHEAD COSTS
|Overhead costs would be separated to ensure that income and expense are readily transparent to both the public and the physician. This section includes all cost related to:
(iii) Legal and audit
|C. NON-VOLUME MODIFIERS
|Incentives would be paid to encourage the participation of physicians in needed areas of care:
(i) Isolation allowance
(iii) Maintenance of certification
(xii) Quality assurance programs
(vi) Nursing homes/residential care
(vii) Hospital practice
(viii) Administration and health care planning
(ix) Acquisition & maintenance of special skills
(x) Ambulatory care
(xii) Quality assurance programs
(xiii) Special community needs
|- A numerical value is placed on individual work units. As each physician accumulates a total number of work units, he/she would fit into a specific category, each having a dollar value. Work units could be equivalent to the resource-based relative-value fee units each province is evolving, i.e.,
0 - 1000 units =$A / 1000 - 2000 units =$B / 2000 - 3000 units=$C
- No increase would be given over an agreed number of work units, or
About the Author(s)
Walter W. Rosser, MD,MRCGP(UK), CCFP, FCFP
President, The Ontario College of Family Physicians
Jan Kasperski, RN, MHSC, CHE
Executive Director, The Ontario College of Family Physicians
College of Physicians and Surgeons of Ontario (CSPO). 1999. Annual Licensing Registration 1950-98.Toronto.
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Hay Group. 1997. A Vision of Ontario's Health Services System. Report to Health Services Restructuring Commission.
Kates, N.,M. Craven, J. Bishop, T. Clinton, et al. 1997. Shared Mental Health Care in Canada. A report from the joint committee of the Canadian Mental Health Association and the College of Family Physicians of Canada.
Leatt, P., G. Pink and D. Naylor. 1996. Integrated Delivery Systems: Has Their Time Come in Canada. Canadian Medical Association Journal 154(6):803-9.
Leopold, N., J. Cooper and C. Clancy. 1996. Sustained Partnerships in Primary Care. Journal of Family Practice 42(2): 129-37.
McCauley, R. G., U.M. Paul, G.H. Morrison, R.E. Boeuett and C.H. Goldsmith. 1990. Five Year Results of the Peer Assessment Program of The College of Physicians and Surgeons of Ontario. Canadian Medical Association Journal 143(11): 1193-99.
Ontario College of Family Physicians (OCFP). 1999a. Inaugural address from the president. Chapter 11:1.
- 1999b. Two Tier, Multilayered Health Care System. Toronto (available on OCFP website http://www.ctpc.ca/ocfp/).
- 1999c. Centres of Excellence in Family Medicine. Toronto (available on OCFP website http://www.cfpc.ca/ocfp/).
Rosser,W., and S. Shafir. 1998. Evidence-Based Family Medicine. BC Decker Hamilton.
Starfield, B. 1994. Is Primary Care Essential? Lancet 344:1129-33.
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PCCCAR - Subcommittee on Primary Health Care of the Provincial Coordinating Committee on Community and Academic Health Science Centre Relations. 1996. New Directions in Primary Health Care. Appendix 3.
White, K.L., T.F.Williams and B.G. Greenburg. 1961. The Ecology of Medical Care. New England Journal of Medicine 265
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