À LA RECHERCHE D�UN CONSENSUS POUR LARÉFORME DES SOINS DE SANTÉ AU CANADA

BUILDING CONSENSUS FOR HEALTH CARE RE-FORM IN CANADA

2002/02/14-16 MONTRÉAL, QUÉBEC, CANADA

Marie-Dominique BeaulieuAs requested by the organisers of the conference, I will first present what, in myview, primary care is - or should be- and raise some of the issues we are facingas we are to develop a strong primary care sector in Canada. I will then addresssome questions related to the primary care team: What significant changes toprofessional practices should occur as such an approach develops? Then, asrequested by the organisers of the Conference, and with much humility, I willmake some “prescriptions for changes”.

I bear particularly on Barbara Starfield’s work on primary care as well as onWHO definition of primary care; added to this, the richness of information we havefrom abroad. For, as you all know, some industrialised countries are trying to solvesimilar problems.

What is primary care ? What is the “plus value “ of primary care, from theperspective of citizens ? Primary care is “person-oriented care”. It is where 80% ofhealth care needs of individuals could be dealt with. Hence, it means that primarycare practices and services must effectively deal with the full spectrum of care :preventive, curative, readaptation and palliative care. Primary care is not “gatekeeping care”. It is not either “population care”.

Although accessibility is the corner stone of primary care, primary carecannot be reduced to accessibility. Continuity and coordination are the two otherkey functions of primary care, equally important if primary care is to play its rolefully. Coordination and continuity within primary care, but also between primarycare and referral and hospital care. Primary care can only play its role if it isadequately linked to the whole system - referral and public health care. Primarycare is not “revolving doors” care.

What is the plus value of having a developed and responsible primary caresystem ? I see two major gains for citizens. First, a system that functions better,more efficiently, for it is proven that the whole system works better where there isa strong and responsible primary care system. This means : easier access tospecialty care when needed, less crowded emergency rooms, more care close tohome. Second , it means more equity in health care. This has been shown par-ticularly by Starfield in her comparative international work. We must not forgetthat the health care system is one of the determinants of health.

Where are we at with our primary care system in Canada ? What are thestakes ? We still have a health care system driven by “secondary and tertiary”care. This is where the money is, this is where the power is. “They call the shots”,pardon the expression. There are no “Primary care system’s advocates” - exceptin Québec, to a certain extent, because of the CLSCs network. What are the risks

The Role and Valueof Primary CarePractice

Rôle et valuer dessoins de premièreligne

Chair/Président:Clermont RacineApproachescommunautaires etinégalites de santé,Université de Montréal

Participants

Dr. Marie-DominiqueBeaulieuCentre de RechercheCHUM et groupe derecherche interdis-ciplinaire en sante

Dr. Howard BergmanDivision of GeriatricMedicine, McGill Univer-sity and Jewish GeneralHospital

McGill Institute for the Study of CanadaL’Institut d’études canadiennes de McGill

Transcripts of the 7th annual conference ofActes de la 7ieme conférence annuelle du

3463, rue Peel, Montréal, Québec, Canada, H3A 1W7( 5 1 4 ) 3 9 8 - 8 3 4 6 f a x : ( 5 1 4 ) 3 9 8 - 7 3 3 6w w w . a r t s . m c g i l l . c a / p r o g r a m s / m i s c /

Conference principal partnerPartenaire principal de la conférence

of a primary care reform driven by the current existing forces within our system? The risks are that we willpropose “secondary care solutions” for primary care problems. Two examples : the attractiveness for “inte-grated health care networks” which bear on the disease management model and can, at one point, jeopardiselongitudinal, person oriented care. Also, the way information technologies are developed : I am yet to see agenuine commitment to develop information technology which will address the need of primary care practition-ers.

We are also mesmerised by “accessibility” problems. I dare to say that we do not have an accessibilityproblem. We have a problem of accessibility to personal, coordinated and longitudinal care. There are veryinteresting data from Québec, where a variety of financial incentives and constraints have been included in thephysicians’ payment scheme during the last 10 years. General practitioners do cover all the points of services(hospital, emergency, CLSCs) … in the same week, still citizens cannot find a family physician. We call this“pratique papillonante” (“butterfly practice”). Is this what we want ?

The primary care teamIn order to meet our goal, professionals must change the way they practice. Still, physicians are not the onlyones who will have to change. How will my work change ? I would work closely with a primary care nursepractitioner. She/he, will be a “Jack of all trades” like me. We will share the care of the same patients. We willbe able to increase the services to our patients. She will be able to manage common acute problems, such asotitis media. She will also have time to offer preventive care and education for chronic diseases. I would morea little bit more on the phone, like her. I will assume more complex responsibilities; will do more “curative”work. Somehow the patients will have figured out that we both care for them. They would know for what kind ofproblem she is in charge, and for which one I am. For sure : we would not have an hour-a-day team meeting.

We must beware of creating professional battle fields within the primary care teams, as we have oftenexperienced with the CLSCs when they were created. We should not but professionals in situations where theywill have to chose between allegiance to their professional autonomy, their team and their employer. What arethe arrangements which will permit the development of a strong feeling of belonging to a team responsible of a“clientèle” ? Can you work as an equal if you are kept in an employee-employer relationship ? What does“being followed by a team” mean to citizens ? Is it what they want ? How do they want this to unfold ? Buildingtrust will be the cornerstone of the success of the team approach. Between professions. But also, withinprofessions. Between specialists and family physicians. Between secondary care nurses and primary carenurses.

We were asked to consider two questions : What can be done immediately to improve the quality ofprimary care ? What organisational / funding incentive changes would you make immediately to improve betterintegration of care. I refuse to address those two questions separately, for I think, as Journalist Jean-ClaudeLeclerc from Le Devoir said this week, that the organisation of the system is as important as professionaldeontology when quality of care is concerned. I prescribe :1. The deployment of information systems developed to meet the needs of the practitioners : without goodinformation you are limited in your capacity to reflect on your practice, to identify your weakness and correctthem, to organise your services in response to your clientèle’s characteristics. I see simple things that can bedone now with the information we produce delivering services : I could receive feedback on the number of mypatients aged 50 to 69 who are reached by the breast screening program, for example. I think that PublicHealth can help us with this. There is the issue of confidentiality, but I think that it can be worked out.2. The consolidation of the “core primary care team”. An interesting study published in the BMJ last yearshowed that effectiveness of team functioning is a key determinant of quality in primary care.3. About financial incentives for physicians : we have to pay for “responsibility”, that is to pay not only forservices given or time spent on site, but for assuming the basic functions of primary care : longitudinality andcoordination. Capitation and inscription of clientèles can be means of doing this. But they can only be if theprimary care system is given the means of assuming its responsibilities.4. We need to create a primary care organisation which can relate efficiently to the rest of the system andmake it accountable to the primary care needs. I do not see how this would be possible without decentralisa-tion of the “bargaining power” to local authorities who will have not only the money to give primary care serv-ices but also to “sub-contract” for referral care services. I am in a “Groupe de médecine familiale”. We aretold that we have to develop “corridors of services” with referral care for our registered patients. Can anybodyin there right mind think that we will be able to do such a thing the way the system is organised and fundednow ? I often wonder if the worst think Michel Clair did was to say that “If there was only one recommendationto apply, it should be the one on the “Groupe de médecine familiale”

2 - The Role and Value of Primary Care Practice

I will conclude with one question : can we change primary care without changing the health care system as awhole ? If your answer is “No,” then it means that all the goodwill of the individuals and organisations involvedwill not be able to overcome the huge barriers on our way if the politicians do not have the courage to do theirpart in order to change some of the rules. And when we say the politicians, we mean the population. Indeed, ifpoliticians do not “feel” that the population want that kind of health care, they will not do it. When I see the pileof reports that have accumulated on shelves for the last 25 years, saying basically the same things, I must saythat my prognosis is reserved.

Howard Bergman(French in beginning to come)

Primary care is the foundation of our healthcare system and I think that means that we need to bothstrengthen and transform primary care. I think also we need an evidence-based approach to health preventionand disease management and I think there again primary care is the key to an integrated system and a coher-ent system of care. I just want to give the example of diabetes, because it will come back and I can give theexample for congestive heart failure as well. We know that in diabetes, we know that if we invest in primarycare, in terms of population and patient education, in detection of diabetes, in treatment and ensuring compli-ance in diabetes, we know from many studies that we are going to have more positive health outcomes. Wealso know that there are going to be less complications as the result of diabetes and there are going to be lessutilization of secondary and even tertiary care at some point. We can say the same about congestive heartfailure, where by the way we have had a tremendous explosion of excellent medication in the past 15 years,but if you look at the statistics for readmission rates for people with congestive heart failure, over 65 years old,in the past 15 years, they haven’t changed. So for one reason or another, this medication is not getting to thepatients in an appropriate way. And again primary care is the key. We’ll come back to what this means to thehealth care system, because it means that you have to invest in one part of the health care system but you’renot going to get the returns right away, the returns might come back only in 5 or 10 or 15 years.

As I worked on the Clair Commission I was surprised that there’s actually quite a large consensus in themedical and non-medical community around what are the problems and the directions for change in the healthcare system. And what we put forward in the Clair commission wasn’t an invention, it was based on what wasbeing put forward by many organizations in Quebec and Canada, including organizations of primary carephysicians. And so, the problem of accessibility, meeting the needs, the problems of the vulnerable population,and I’ll just point out for my constituency that the frail or the elderly with disabilities comprise approximately 15-20% of all the elderly population, which means 3% of the total population. Well, that 3% of the total populationconsumes 30% of all the health and social services resources in our health care system. So, sure I’m worriedabout how we’re going to pay for dialysis for the well elderly, as senator Morin pointed out, but I am particularlyconcerned with how we are going to organize efficient care meeting the needs for this part of the population. Ithink here primary care again is essential.

The other thing is that we have to realize that nobody can do it alone anymore. The problems arecomplex, the treatments are complex and our system is terribly complex. So the old concept of the Dr. Welbygoing out in his car and visiting his patients is not possible, both from having doctors getting together anddifferent professionals getting together and different parts of the health care system getting together. Here iswhat I think are the key elements of primary care, based on what I have seen here and in other countries. Ithink that the issue of population and clinical responsibility is an essential issue. I think that a primary caregroup has to know what population it is dealing with. And that is where the issue of rostering comes into effect,because if you know what population you are dealing with then you can study the population, you can developprograms that are aimed at that particular population. And if you are working with a population, if your practiceis in downtown Montreal, or the Cote des Neiges district of Montreal, or the west Island of Montreal, you aregoing to have quite different populations that are going to be coming to see you, and you have to adjust yourintervention in a different way. The notion of clinical responsibility is also essential: what happens to yourpatient or your groups of patients beyond the moment when they leave the door of your practice or yourinstitution. Our system of care is based on taking good care of people when they are within the four walls ofyour institution and hoping for the best when they get out.

The second thing that we’ve talked about is an interdisciplinary, systemic approach. Marie-Dominiquementioned the question of information technology and I’d like to add general infrastructure as well. She said itvery well. You know that we are managing in Quebec a $17 billion enterprise not knowing what happens. Mostorganizations will not know their financial situation until three or four months later, will have no idea of theutilization of services that their population is using. We need infrastructure because we cannot do it alone. Imet a physician who said that he works alone and he doesn’t even have a secretary and it’s a terrific system.

Diagnostics & Solutions - 3

But it is very limited what he can do.We need accountability and incentives for excellence and performance. In other words, we can no

longer in the health care system distribute money for primary care, physicians, specialists, CLSCs or hospitals,without having some sort of indication of what the performance is, and having indicators in that performance,giving incentives for people doing an excellent job. And finally, we can’t do things in terms of the fee-for-servicefor primary care physicians or global budgets for CLSCs because I am including that in remuneration fundingmechanisms of primary care we need remuneration that will be able to support these different elements ofprimary care.

What we put forward in the Clair commission was that primary care is the basis of the health and socialservice system and we said that the two components of primary care are family medicine units and theCLSCs. But we also said that primary care needs to be supported by integrated service networks. There is awhole area of complex and vulnerable populations, the frail elderly, and mental health populations, very com-plex populations that even a well-organized family medicine unit will need to work with others in order to delivera complex combination of health and social services. We also have complex diseases like congestive heartfailure, pulmonary disease, alzheimer’s disease, that need the integrated support of secondary and eventertiary care. Integrated service networks supporting and working together with primary care: this is what thingsshould look like. It’s not rocket science. A lot of other people have been saying it, nursing groups, practitioners.Voluntary rostering makes sense. You want to be allowed to change physicians if you want to, but that can beworked into a voluntary rostering type of system. There is very interesting work in Britain around developmentof primary care trusts and also community trusts, bringing together primary medical care and community careinto trusts that are working together.

Change is very difficult to accept and very difficult to understand, because we’ve been doing things thisway for many years and how could any other way be possible? I would like to finish by giving some elementsof what I consider the vision and strategy for change. Number one, the whole area of governance and man-agement. Unfortunately, our health care system is driven by very short-term objectives and we are plagued bythe fact that the chairman of the board of this industry changes about every two years, and the CEO, thedeputy minister changes about every year and a half or so. We calculated that Quebec has had 11 or 12 sous-ministres de sante in the past 15 years. So how can you develop a strategy for change and carry it out? Wesuggested that there may be ways to think of governance in a different way.

Number two, I think that we have to work very hard on consensus building. I strongly believe that we canget more done by confidence and incentives than by using the big stick. I think that we can build on leadershipas well. The third thing that Marie-Dominique brought as well as other people is that this change towardsstrengthening primary care as Walter Lutz brought out when he was talking about integrated care, saying itcosts before it pays. We have trouble understanding that in our health care system so we are always talkingabout the run-away costs but we never talk about investing in order to make the changes necessary to controlthese costs. Also, we need a change in the methods of allocating the resources. To allow for shift in resourcesfrom one level to another based on performance. So, in the case of diabetes, if we invest in primary care andthere is reduction in utilization of secondary and tertiary care, we need to have a mechanism for that money tocome back into the primary care. Otherwise, this investment in primary care is seen as just an additionalexpense. We are seeing that response to the SIPA project. In other words, something might make sense overoverall utilization and the costs of the health care system, but if there is no way of transferring the resources, itjust looks like an add-on and people say that it is too expensive. We see the same thing with informationtechnology.

My last point is that we need to open up two corridors in the way we govern our health care system. Oneis the corridor to look after the daily crises, the daily management of the health care system, the over-run ER,the accessability, the crises in a nursing home, etc. But we need another corridor which is separate from thatwhich is going to look at the strategic changes that need to be made in the health care system. And I amconcerned that, in terms of our efforts to get a family medicine group going, that if we don’t have those twocorridors, we are going to fail because it is going to be the immediate crises which are going to over-run any ofthe strategic changes.

Questions

Audience #1: With respect to the idea of performance of different aspects of the health care system, particu-larly hospitals and thinking about what Mr. Legault said recently. How do we look at performance of, for exam-ple a hospital , when so much of it depends on other aspects of the health care system, such as good

4 - The Role and Value of Primary Care Practice

primeary care system, home care, a place to discharge patients, because i think that’s really where the difficul-ties in the emergency arise, is that they can’t get their patients bed for acute care and long term care. Also,people arrive at the emergency for primary care which could be received elsewhere.

Howard Bergman: I completely agree. As the ER crisis emerged, there are more and more headlines and wesay we need to invest more in the ER room, so we pour more money into the Er and then lo and behold, wewonder why 6 months leter people go to the ER Rooms. You go there because that is where all the resourcesare, that’s where your needs will be responded to very quickly, and it’s an example of where we just look atperformance in a very isolated way. We need performance indicators for different types of institutions and wetalked a lot about performance indicators for hospitals but we don’t talk about performance indicators forCLSCs, for nursing homes, etc. But the idea of developing integrated performance indicators is fascinating.That comes back to the issue that we can do it if we do it from a patient-centered point of view, or a popula-tion-centered point of view.

Marie-Dominique Beaulieu: The question shows the importance of making silos, because you can really seeboth sides, primary care is not doing what should be done, that’s why there are problems with the hospitals. Tohave access to the hospital as a primary care practitioner for referral care is to send people to the hospitals.There is a problem there. Referral care has no incentive to collaborate with the primary care sector becausetheir budget is not looked at that way. We are in a vicious circle. Yes, the primary care sector could be moreefficient, but also part of it is that with better collaboration with referrals, we could have a better system. But thehospital has no incentive to do this. You question shows how important it is to change the way the moneyflows.

Audience #2: There is a question of money but also I feel, coming from the hospital setting, the question of lalourdeur du system. There are a lot of people who are very creative, who can do things, change things, butthere is and inertia in the system, there are so many levels of administration to get through, that people giveup. We need to develop a system that would foster creative solutions from the ground up. (FRENCH TOCOME) A lot of people feel they have no power in their own hospital to change things.

Audience #3: I have a question of curiosity about the funding mechanism that would be used for these inter-disciplinary teams under the Canada health act, since it does stipulate that its physician and hospital services.I am particularly intrigued, since the primary health care model abdicates the appropriate care by the appropri-ate provider, how this would work for a vulnerable population. I’ll take the example of the aboriginal population.Would a salary mechanism for doctors allow in the interdisciplinary tem, them to hire, for instance, a traditionalhealer, to work with the team. Do you think that this fits under the Canada Health provisions?

Marie-Dominique Beaulieu: I am a practitioner and not a politician so I am not a policy maker. But obviouslywhen we are talking about different levels of governments having to make some decisions, I think that you aregiving a good example. I think that one of the things that has to be rethought is what part can be paid and soon, so that you can really, at the level of the field, make that kind of decision. If you make the practionnerslocked in something they cannot do, like not being able to pay for nurses, under the Canadian Health Act, orthings like that, it’s like you are building people who want to change and placing them in situations that theycannot effect change. And I think that’s the same thing for some of the money flow. There needs some politicalcourage to change the money flow because the interest there won’t permit that. I wish that there would bechanges that permit us to redefine the services that we give.

Howard Bergman: One of our icons is the Canada Health Act. When you say that we have to relook at theCanada Health act, it does mean that the Canada Health Act, which was developed in the late 60s and early 70s, things have changed since then, the whole issue of chronic disease, vulnerablepopulation, the demography has changed. What you raise is an interesting point. Th Canada Health Act wasfocused on physicians and hospitals. Her is an example of how you could think of funding in a different way. Ifyou had a primary care structure that was funded on a per capita basis, and you said now you are responsiblefor organizing services, here are the types you have to organize, which leaves that community-based groupsome leeway as to whether they need 6 nurses, 4 or 10? How many doctors? Do they want traditional healers,etc., based on again a contractual agreement in terms of the services they have to give and the type of per-formance indicators. So one could think of that type of building in more flexibility, and perhaps linked to whatsomebody was saying of the lourdeur de la systeme, where all decisions have to come from the top.

Diagnostics & Solutions - 5

Audience #4: Now in Ontario, we are reinventing primary care reform or family health networks, which mysection feels is a redundancy and I find it kind of unwieldy, whilst the HSO has had some very innovative ones.The one which I think is the best in line with what you’ve just been talking about is in Sault St. Marie, which hasa third of the population and once you’ve got big population-based groups you can really do interesting things.It has a non-profit board so you can indeed bring in alternative practitioners. This model got frozen in the 90sby the ministry. I think that rostering should be universal; perhaps we should make it universal registration.Once you’ve registered the population, then rostering is the thing to do next. It is interesting to hear aboutDenmark where you have the option of derostering yourself. This fulfills everyone’s ideas about choice. I hopethat Romanow is going to listen to that. Denmark is a wonderful example. It’s cheaper and it throws in dentistryas well. In Toronto there are lots of people who don’t have insurance, the mentally-ill and the homeless, andunless you have some default mechanism to automatically get people into these settings, you are going tomiss many of the sickest, most problematic cases.

Dr. Beaulieu: I personally agree with rostering, it is something important, but you have to have the rightsystem. Obviously, the medical profession in Canada is not very agreeable. Rostering by itself is not a solution.It is agreeable when you have the rest to support it. And then we have to walk the Canadian populationthrough it. How will people react. Some people feel that it is an impingement on freedoms. You cannot haveengagement where you don’t deliver what you promise.

Audience #5 Paul Moreau, Sante Canada, premieres nations: (FRENCH TO COME)

Howard Bergman : (FRENCH TO COME)

Marie-Dominique Beaulieu: (FRENCH TO COME)

Audience #6 France Legare, medecin de famille: (FRENCH TO COME) How do you produce evidence,what are the questions that you are asking, which type of design? Most of the evidence that we are workingwith now has been done in tertiary care.

Marie-Dominique Beaulieu: (FRENCH TO COME)

Howard Bergman : (FRENCH TO COME)

Clermont Racine: (FRENCH TO COME)

Audience #7 Isabelle Arsenault, CLSC, du région de Sherbrooke: (FRENCH TO COME)Howard Bergman: (FRENCH TO COME)

Marie-Dominique Beaulieu: (FRENCH TO COME)

Audience #8 Sonia Samonic, PhD student in nursing at McGill University: I would like to thank Mme.Beaulieu for recognizing the absence of nursing at this table. I am interested in hearing more about the pro-posed role of nurses in the family medicine group. I think there is a lot of concern in nursing that nurses are notused as physician replacements, and that nurses are actually used in recognition of their role in families copewith transitions and health education. I am also interested in how we see family medicine groups interfacingwith the CLSC, particularly in my area of expertise, perinatal health, where a large percentage of the primarycare is provided by nurses at the CLSCs.

Howard Bergman: Just in terms of numbers, what we proposed was 2-3 nurse clinicians or practionners to 6attendants. I agree with you. We have to carve out s specific role for nurses, which is distinctive but collabora-tive with the physicians. This is going to take time. The same principal from the standpoint of perinatal careapplies to the frail and elderly. A nurse practitioner in a family medicine group is probably going to be ageneralist, depending on the group. Linked up with the family medicine group are the CLSCs, with their homecare program, their professional program and with their nurse practitioner clinicians. This is an example of anintegrated group working with the generalists of the family medicine unit.

6 - The Role and Value of Primary Care Practice

Dr. Beaulieu: I realize that the word group de médecins de famille carries a message which removes it fromnursing. There is a lot of work to do and we don’t have a model in Canada. To create a primary care team,people need to feel that they belong to a team. We as professionals are accountable to our profession, we areaccountable to the people who pay for us, and we are accountable to our team. If there is still a division, wherenurses are in one organization and doctors in another, we won’t accomplish the team building.

Audience #9: I am a family physician and am fortunate to work in a very positive team environment, at St.Michaela’s hospital in downtown Toronto. I am part of a group where about half of our patient population is HIVpositive, and this is a practise that has evloved over the recent past. We were formerly of the Welsley hospital,got swallowed by St. Michael’s hospital and so on. The team itself is composed of not only physicians andnurses, but we have pharmacists, physiotherapists, and nutritionists and social workers. And on that team weactually have some of those that are specifically dedicated to a HIV population, and then we have a wholeother contingent that are for the rest of our patients. That team meets every week with the residents and thestudents and we discuss problematic cases and we go through some efforts to try to address not just medicalproblems but also psyco-social issues and nutritional issues, and so on. There is on-going negotiation in termsof what each member of the team does. It does work. I trained in Ottawa, in an environment where one of mymain teachers was a nurse. If I have to think back to the things that made this work is, first, the leadership inthe hospital and in the family medicine department. Philip Burger, who is now our chief of family medicine, hasbeen very proactive in making that happen. The other big component has been the community itself. It is notby chance that a lot of that came about because we were dealing with HIV positive patients who are verycomplicated patients. We need to listen to the communities and let them tell us what they need and from therewe’ll be able to develop the system we need.

Audience #10: Carl Guttman, Family Medicine College of Canada: Integration amongst all of the playersproviding primary care and all parts of the system is essential. We are facing major challenges in the renewalof primary care because the rest of the system is not coordinated with this. The role of the family physician inhospitals remains a critical piece of this. Across Canada, the role of the family doctor has been diminishing inhospitals, whether it is active provision of care at the bedside or supportive care, it has dropped to nothing inmany instances, particularly in urban and academic hospital settings. This is the link between the hospital andthe community at large. The other aspect of integration is the role-modeling and philosophy that has to hap-pen in terms of educating our future health care providers. We are always going to be fighting an uphill battlein terms of trying to change those who have been in practise for years and years.Audience #11: Fernand Montchenie . J (FRENCH TO COME)

Howard Bergman (FRENCH TO COME)

Marie-Dominique Beaulieu: (FRENCH TO COME)

Clermont Racine: (FRENCH TO COME)

Audience #12: (FRENCH TO COME)

Audience #13: (FRENCH TO COME)

Clermont Racine: (FRENCH TO COME)

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8 - The Potentials and Problems of Home Care

Diagnostics & Solutions - 7