This story is part of an ongoing look at the challenges facing the health-care system in Greater Victoria and B.C. Future stories will look at possible solutions, things that are working well, and the B.C. government's ongoing efforts to reform primary health care.
The B.C. government is working on multiple fronts to improve people’s access to family doctors and fix what patients and physicians in Greater Victoria are calling a “crisis,” Health Minister Adrian Dix says.
Dix said he inherited a significant challenge when the NDP took power two years ago.
At the time, there were about 750,000 people in the province without a family doctor, despite the former Liberal government’s promise to find a doctor for everyone who wanted one through its GP for Me program.
“The previous plan by the previous government had been abandoned the year before I got here,” Dix said.
The program made significant gains, but with ongoing physician retirements, it failed to meet its promise.
“The number of people needing a primary care provider increased in that time and it’s not because the people doing that didn’t care or didn’t know what they were doing,” Dix said. “It’s difficult.”
The problems are particularly acute in Greater Victoria, where 18 per cent of the population or nearly 60,000 people had no regular health-care provider in 2015-2016, the most recent period for which numbers are available from Statistics Canada.
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During the 2017 election campaign, the NDP promised to deal with the issue. It has embraced a team-based approach to primary care in which physicians share the workload with nurse practitioners, licensed practical nurses, registered nurses, mental health and addictions specialists, pharmacists, dietitians and other health-care professionals.
The goal is to make more efficient use of doctors and nurse practitioners by allowing them to focus on more serious matters, while directing some cases to other professionals.
To do this, the government is using a three-pronged strategy: establishing primary care networks, opening urgent primary care centres, and expanding the number of non-profit community health centres. (See our explainer for more detail.)
“Younger doctors will not now or in the future practise the way more traditional doctors have,” said Stephen Brown, assistant deputy health minister. “That’s the shift, the changing reality the province is trying to address.”
As part of the plan, the government has pledged about $225 million over three years to hire 200 new GPs and 200 nurse practitioners. The hope is they will work on contract rather than under the fee-for-service model, which pays doctors a fee for each service provided. Additional money is available for primary care networks to add other health-care professionals and create team-based practices.
“This is significant reform,” Dix said.
However, recruitment of these new practitioners by communities has gone slower than the government expected, with no official number of how many have been hired under the new funding to date, and physicians, patients and other observers are largely taking a wait-and-see approach.
“I think the government’s actually going in the right direction with team-based care and networks,” said Dr. Martin Dawes, professor of family practice at the University of B.C. “There’s no question that they are part of the solution.”
But that doesn’t mean there aren’t problems.
For one thing, it’s hard to build a network of clinics when some are closing their doors as older doctors retire or scale back their hours, and younger doctors are showing little interest in setting up a classic family practice.
“The idea of having networks is great, but at this point, I’m not sure what they’re going to network,” said Dr. Rita McCracken, a family physician and researcher at the University of B.C.
McCracken favours increased investment in community health centres. She questions the government’s push to open urgent primary care centres when the main problem is getting access to a family doctor.
She’s not alone.
“There has never been an urgent care crisis in B.C.,” said Dr. Vanessa Young, who teaches at University of Victoria’s Island Medical Program and serves as board chair of the South Island Division of Family Practice. “It’s a primary care crisis.”
Repeated government unveilings of new urgent care centres are of concern to some family practitioners.
“If primary care was robust, many patients would never end up in ERs or urgent care centres for things like bladder infections or rashes or prescription refills, which is the vast majority of the type of patients who are presenting to both urgent care and ERs,” Young said, noting that this is her personal opinion.
For some, the real problem is the way physicians are compensated.
Most family doctors still get paid using the fee-for-service model. But many say the system is archaic, time-consuming and fails to cover their high overhead costs or compensate them for long hours of paperwork.
“Most family doctors really feel that they’re not adequately reimbursed financially for what they do — for the amount of training that they’ve had to go through and for the responsibility that they have,” said Dr. Robert Brown, a family physician and medical director of the Ocean Pier Medical Centre in Sidney.
“So that’s why a lot of people have abandoned going into community practice.”
Dr. Eric Cadesky, past-president of Doctors of B.C., says some of those issues are addressed in the new physician master agreement, including efforts to help doctors cover rising overhead costs.
“It does not cover the rising overheads, but it’s a recognition and it’s a step in the right direction,” he said.
The new agreement, which was approved this spring, also commits the government and doctors to working with other health-care professionals to form teams.
Negotiations with doctors in some regions have gotten stuck on how much to pay new doctors and allied health workers who elect to be paid by salary by health authorities.
More discussions between the government and family doctors and the Doctors of B.C. are expected to take place in the fall on a contract for doctors who have built up practices and want to switch from the fee-for-service model. If successful, the changes could be implemented over the winter.
Dr. Jason Wale said family practice is “one of the most challenging yet rewarding areas of medicine.” But, “unable to emotionally detach from patients who needed help 24-7,” he moved to emergency medicine.
Wale said it’s come to a point where it is not uncommon for a doctor to diagnose metastatic cancer in the ER and make arrangements for the patient’s biopsy results to go to a walk-in clinic.
“Nobody should be hearing about a diagnosis of cancer in an ER or walk-in clinic from a stranger who has no more than a few minutes of time to spare, after waiting hours to be seen.”
Wale applauds the efforts by the province and health authorities to build out team-based care, but, given the gravity of the “crisis,” he said further solutions need to come from “society at large.” Otherwise, he fears, “change will not come quickly enough.”
Dix has indicated that he remains open to a number of different approaches, noting that there’s no one way to increase access to family doctors.
“I’m trying not to get stuck on models,” he said. “I want these to be as efficient as possible. We want to see how they work and we’ll make changes if we need to make changes.”
“There are things we need to try that may or may not be successful the first time,” he said. “It takes courage to work together.
“I’m optimistic that within this framework, we can come together and find the solutions because we don’t have any other choice. Our health-care system cannot continue the way it’s been going.”
— Lindsay Kines and Cindy E. Harnett, Times Colonist