Finding Primary Care

The difficulty in accessing primary care has dominated news and opinion pages for the last several months.

Some reports are highly anecdotal and often emotional. In contrast the Auditor General’s report provides a more analytic but dispassionate perspective. Between them all the opportunity for ruminating on the past has been exhausted. The important question is what to do now.

Premier McNeil has acknowledged the problem and identified improving access to primary care as a top priority for 2018.

The shortage of family physicians is not new. As of October 31, 2017, there were 1,050 in Nova Scotia, just 17 less than three years earlier, and still higher than the Canadian per capita average. Nevertheless, more than 40,000 Nova Scotians have identified themselves as wanting a family physician and unable to find one. The true number is likely much higher.

It is a complex problem, but one critical need is to address the issues surrounding family physician pay; how it is administered, how much, and what for.

1. Physicians are paid by MSI under direction from the Department of Health and Wellness (DHW). Those on Alternative Payment Plans negotiate, with the health authority (NSHA) and DHW, contracts which document the expected workload of the physician.

Absurdly, DHW does not modify payments if physicians fail to meet their obligations.

NSHA is, since last year, responsible for recruiting physicians. Nevertheless, DHW retains control of some of the recruitment incentives. This is a wrong-headed and inefficient division of labour. Let NSHA manage the financial terms and relationships with the family physicians.

2. Nova Scotia’s pay for family physicians is the lowest in Canada. That makes a difficult recruiting challenge even harder. We also have the highest income tax rates for high earners, and the tax advantages of sprinkling income to family members are being removed by the federal government. A substantial increase is needed.

The government should acknowledge, as it already has with hospitalists (family physicians who do inpatient care in hospitals), that this must be dealt with outside of its general framework of compensation for the public sector.

Work should begin immediately on new arrangements to be effective at the expiry of the current contract in March 2019.

Reaching and communicating a new agreement will send a strong positive message to both current and prospective physicians.

3. Some of the extra money should be used to encourage more efficient communications with patients, or between family physicians and specialists. At the moment faxes (remember them?) are the common instrument between clinicians.

Physicians are not paid for making phone calls to each other or to patients, nor for updating the website with patient information, which can include lab tests, diagnostic imaging results, and some specialist reports.

Use of email is not even permitted between clinicians, unlike many other jurisdictions.

For example, 35% of doctors email patients in the United States and United Kingdom, and in Switzerland, 68% communicate electronically with patients. Some countries, such as Denmark, even have national mandates that all individuals have the ability to email their primary care physician. Within Canada there is progress in Ontario and Alberta, but it is slow so far, perhaps in part because the pay issue has not been addressed.

It would be of great benefit to many patients, particularly in remote areas, to be able to do online or video consultations with a physician. This can be cost effective for taxpayers and convenient for patients. It would not be complicated to establish a system that mimics that provided by Maple, a private supplier.

The health authority sees collaborative family practice teams as a principal vehicle for delivery of primary care. There are already 50 in various stages of development across the province.

As well, there are collaborative emergency centres which add a modest emergency care element.

Walk-in clinics provide an important alternative access to care for patients after hours, and for those without a family physician. Yet no acknowledgement of their role is to be found on the NSHA website. And there are still many doctors operating as sole practitioners.

It is difficult for the average Nova Scotian to understand these distinctions. The NSHA’s website is too much about its own facilities and not enough about the full range of primary care options for patients.

The Auditor General’s report was highly critical of the messaging efforts:

“Communication is an important part of managing change. The department and the health authority need to inform Nova Scotians about how delivery and access to primary care, including family doctors, is expected to change in the future. Not doing so can result in public misunderstanding and a lack of trust due to perceived inaction.”

Achieving adequate access to primary care is a complex problem for Nova Scotia, and other provinces. Getting physician pay right, embracing today’s communications technologies, and much improved messaging are crucial.


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