Progress on Primary Care Access is Impeded by Bureaucracy

Access to primary care is a crucial issue for Nova Scotians. It can be improved by increasing the number of family physicians, and by helping them to become more productive. The track record on both is discouraging.

The responsibility for recruiting family physicians was transferred from the Department of Health and Wellness to the Nova Scotia Health Authority (NSHA) last year.

Bizarrely, the department has retained authority for administering some of the recruitment incentive programs. The Auditor General advises that “department management felt the incentive programs they administer align with the department roles and responsibilities.” Translation: It’s ours because it’s ours.

The NSHA has a plan to grow the role of collaborative care centres in primary care, and it has a strategy for filling family physician vacancies, of which there are currently 55. Neither strategy is well communicated, nor has the authority defined what success would look like.

The NSHA maintains an online registry of people looking for a doctor but is often unaware when someone finds a doctor or moves away, and should be removed from the list. Physicians are not required to refer to the wait list when deciding to add patients. A lack of health information on the site means that seriously ill patients are not prioritized.

The department has retained responsibility for paying physicians but does not monitor the working hours of those who are in salaried positions, which is common for those working in collaborative care centres.

All of this points to a system focused more on bureaucratic convenience than maximizing patient access to care. This is even more true when it comes to communications and information technology.

An out-of-province organization called Maple is offering Nova Scotians “Online consultations providing you with more healthcare choice and control,” for a price.

Maple has five Nova Scotian physicians among the more than a hundred providing the service in seven provinces. The physicians typically have full time jobs as emergency room or family practitioners, and do this work in their off hours.

Video-chats can be a viable way of accessing primary care in many instances that are neither complex nor severe, especially for those who live far from a doctor’s office, or those who don’t have a primary care physician.

There will be those who argue that this somehow violates the Canada Health Act. It does not, since care by video is, like cosmetic surgery, not an insured service. Unlike cosmetic surgery, it should be.

Why don’t doctors within the public system use the same vehicle? It is not difficult to create the necessary technology. Rather, the problem is that doctors don’t get paid for it. If they did, the bureaucratic requirements would be firmly rooted in the documentation protocols of the last century.

For example, it was only this year that it became possible for family physicians to be paid for using a telephone, either with certain patients, or with a specialist to discuss a patient.

To access a specialist, the patient’s doctor must submit a written referral. It “and the formal consultation report must be available in the patient’s medical record; both the referring physician and the specialist must maintain copies of both documents.” These are typically transmitted by fax. The department advises that email is not permitted.

The province has launched which promises to give you “secure access to your health information anytime, anywhere, using a computer, smartphone, or tablet. Those who sign up will have access to secure, easy-to-use technology to view test results electronically… and may no longer need to see their health care provider to go over routine test results.”

The problem is that the physician does not get paid for taking the time to update the website, which actually costs her money because doing so eliminates the need for an office visit.

On Thursday, president-elect of Doctors Nova Scotia Tim Holland was quoted as saying that reform of pay for primary care physicians “will probably be something that’s in the process for three or four years and will probably need, realistically, another year before it can be rolled out across the province.”

Taking that long would be a terrible outcome. The family physicians are underpaid, and are not paid for doing the right things, or using the best available information technology. No wonder we don’t have enough of them.

It is in the interest of both doctors and patients that the reform be in place not later than the expiry of the current contract in March, 2019. The province should make it a top priority.


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