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.

1. Introduction

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).

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.

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.

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.

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).

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.

4. Conclusion

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.

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