Presentation to Select Standing Committee on Health

Presentation to Select Standing Committee on Health

Thursday, July 17, 2016

Vancouver BC

 

 

 

 

 

 

 

 

 

 

 

Executive Summary:

·      Primary care innovation is crucial if we want to have a sustainable, publicly funded and universally accessible health care system

·      Changes are happening that require a rethinking of the dominant primary care business model:

o   The way that a new generation of providers wants to work;

o   An evolution in the mental model of therapeutice relationship, and;

o   The promise of wellness-focused care for bending the healthcare cost curve.

·      A relatively small investment of resources in prototyping and testing “Primary Care Home” models that are co-developed by clinicians and citizens, would reduce the number of unattached patients, improve efficiency and satisfaction for family practice providers, and long term sustainability of healthcare in BC.

 

Introduction:

The Vancouver Citizens Health Initiative Society is an incorporated non-profit organization, dedicated to a sustainable health care system.   

Today, the question to which we are responding is:   How can we create a cost-effective system of primary and community care built around interdisciplinary teams.

We love this question!  It goes to the heart of how primary care is governed, funded, operated, evaluated and how income from the provision of healthcare is distributed.  More importantly, the issue speaks to the core of therapeutic relationships – inter-professional respect, scope of practice and the nature of the patient-provider relationship.  Our perspective is that there is a generational, technological and cultural shift that we can leverage to rethink how primary care is delivered, with significant sustainability benefits for healthcare in BC.

This presentation introduces our organization, explains our interdisciplinary business model of primary care and then shares our next steps and hopes for healthcare in BC.  My goal today is to share a new approach for co-designing models of primary care that address the needs of patients, providers and the public.  I’ll also share ways that you can catalyze innovation to solve the increasingly urgent problem of healthcare system sustainability.

Vancouver Citizens Health Initiative (Vancouver CHI) has two main purposes:

·      One is to involve citizens in understanding and influencing health care system improvement;

·      To co-design, build, operate and evaluate sustainable and universally accessible primary care clinics that some call a Patient’s Medical Home.

Board members include

·      Brett Sparks, Talent Specialist in the tech sector – expert on high performing collaborative teams, and experience with the millennial workforce;

·      Samiran Lakshman, Crown Counsel – critical perspective, focus on integration of technology to make healthcare fit our lives;

·      Trilby Smith, Evaluation Consultant in Health and Community Services Sector – formerly with Michael Smith Foundation for Health Research.

Kyle Pearce is co-founder and operational leader of Vancouver CHI.  He is a consultant in the health and social impact sector with a history of business innovations in oral and primary health care, including a dental clinic that has and continues to enable thousands of low income children to access dental care.

Kyle spent 5 years in the world of physician-led primary care innovation – incorporating the first divisions of family practice and leading the provincial prototype phase for A GP for Me.  He has also led primary care engagement and research for the Vancouver Division of Family Practice.  With his work provincially and in Vancouver, he has engaged over 600 family physicians and thousands of citizens around the question the Committee has posed.  Vancouver CHI’s approach comes from listening to both patients and providers as they declare the importance of strong primary care relationships and at the same time many lament how difficult it is to get one in a timely way.

Vancouver Citizens Health Initiative is an unaffiliated organization with set of non-negotiable values that are non-partisan.  We believe that:

·      A high-quality, universally accessible, and publicly funded Healthcare system is a treasured public good and everyone who participates has a stake in its sustained success;

·      Wellness begins with relationships and while we need to treat disease, as a collective enterprise we should be aiming at something higher that addresses what patrons really want;

·      Primary care is only one element of wellness.  Our frame of reference includes social supports, interpersonal connectedness, exercise, education, housing and food;

·      We believe that primary care can and should be transparently and appropriately accountable to patrons, providers and the public interest.

As board members, we are all parents, and want desperately to know that everyone, including our kids, will be able to enjoy the benefits of universally accessible healthcare.  Our motto is “Health care for everyone, now and in the future.”

Vancouver Citizens Health Initiative Perspective

•      Patrons – our primary focus is on the wellness of people who engage with the health care system in our community.  At an individual level, this includes everyone who has ever had contact with the health care system.  Right now, the biggest problems from this perspective include:

- too many people don’t have timely access to a family doctor.  VCH’s My Health My

Community survey estimates over 170,000 in Vancouver alone don’t have a GP

- if you’re lucky enough to have a family doctor, getting an appointment can take a lot of time. Almost 20% of daytime visits at VGH are for people who have a family doctor for issues that could be treated by primary care

·      Providers – patrons need consistent, productive, well-rested healthcare providers, so physician wellness is central to our vision.  Right now, most providers take the risk of starting up their own business using a model that is 100 years old, resulting in burnout and low satisfaction levels for physicians.  Younger doctors are less likely to be interested in that traditional model, which is why so many patients are being orphaned when their doctor retires.

•      Public – includes everyone who has a stake in the success of the collective enterprise of healthcare.  This means a system that functions well and is sustainable.   Right now, tax-based and out-of-pocket costs are rising for consumers, leaving less discretionary income and lower levels of available funding for other valuable investments in things that keep people well, like income security, housing, education, recreation and healthy food.

Vancouver Citizens Health Initiative Perspective

 

At the centre of everything we do is wellness – well patrons getting care from well providers in a well-connected and functioning system is our goal.

Changes in society that should drive primary care innovation

Our response to the question of creating a cost-effective system of primary and community care built around interdisciplinary teams is that we need to critically interrogate the assumptions that limit our ability to create new mental models that are more efficient and have better results.  Three examples of outmoded thinking include:

·      That interdisciplinary care is not financially feasible within FFS.  In fact, with the new GPSC incentives, our group – with the advice of 40 clinicians innovation leaders and knowledgeable patients - has developed a model that has nurses, doctors and other providers working in a non-hierarchical team to each’s optimal scope, and provides fair compensation to an extended team that includes a clinical pharmacist, navigation supports and social worker.

·      That primary care relationships are about how much time a doctor and patient spend together.  The nature of relationships is changing.  It’s true that patients want to spend some time with their doctor or NP when they have an appointment, but most would rather skip a second appointment and instead text their pharmacist when a prescription isn’t working or email a member of their interdisciplinary team when symptoms don’t subside.  If healthcare can adapt to this, then primary care relationships can strengthen its authoritative role in helping us get and stay as well as we are able.

·      That younger docs are lazy and it takes 2 of them to replace one experienced GP.  In fact, we have found that many in the new generation of GPs want to work in a qualitatively different way that is collaborative, integrates technology and focuses on prevention.  Contrary to this assumption, we believe that if we provide opportunities for younger docs to practice the way they want (and incidentally, the way they are trained), then the system will have enough capacity for everyone to have a family doctor.

In contrast to these pieces of conventional wisdom, Vancouver CHI has involved dozens of providers, experts, researchers and citizens to iterate a flexible platform for innovating in the developments, operation, governance and evaluation of primary care.

 

The Vancouver CHI Platform for Interdisciplinary Primary Care

The platform for the Vancouver CHI model has been developed through discussions with dozens of of people and organizations including:

-       GP residents, recent graduates, and physicians who have been practicing for decades; nurses and pharmacists;

-       Ministry of Health senior directors in primary care;

-       VCH and Providence primary care physicians;

-       Vancouver Division of Family Practice’s Continuity of Care Committee;

-       BC College of Family Physicians;

-       UBC’s primary care research team – CHSPR.  (Vancouver CHI participates on the BC Primary Health Care Research Network’s advisory committee)

-       Mid-Main and REACH community health Centres

-       Community Health Centres in Ontario

-       Pharmacy Leaders of Tomorrow

While we listen to everyone who has an opinion, the model is also the reflection of our values about universal access to a single-tier, publicly funded system.

Features of the model

·      Core of the model are teams of one physician working with 2 RNs (could potentially involve NPs if revenue generation is not through FFS);

·      Administration and business management is done by non-clinical staff;

·      Patient experience typical visit – exam room welcomed by a nurse, who discusses the patron’s wellness plan and any changes, does an assessment, identifies all the issues important to the patient. 

·      When the physician arrives, nurse inputs information into EMR, allowing unmediated contact between doctor and patron;

·      After doctor performs evaluation, diagnoses in collaboration with nurse and patient, and determines a course of treatment, they leave the nurse to complete the visit; 

·      Medication choices can be supported by clinical pharmacist;

·      If patient needs to see a specialist or has a visit to the ED or needs a community-based wellness support program, a navigator helps and ensures that information is incorporated into the patron’s file;

·      Patrons can make appointments online if they wish, and have control over their medical record, enabling others to see elements of it;

·      Scaled down versions are possible and sustainable within FFS – minimum 2 teams;

·      Scaled up versions are more attractive – enable sharing of 24/7 phone calls;

·      With a critical mass of teams, we can shift hours, schedule open times in each day, even have a mobile team on rotation to see patients at home, in the hospital, or other settings;

·      Evaluation of the model’s operation and impact is crucial:

o   to improve the timeliness, quality and experience of care,

o   ensure providers are satisfied and have a workplace and processes that are efficient and convenient for them

o   And ensure that the primary care clinic is having a positive impact on system costs such as ED visits and hospital readmissions

 

Overall impact of the model

The platform of the Vancouver CHI model can be adapted to a variety of situations, and will require a high-performing staff team that works using a highly efficient, collaborative and performing approach.  The rewards of succeeding and scaling up include:

·      Greatly increasing the panel capacity of a family physician and allowing for relationship continuity as clinicians have life events;

·      Providing a care team for every patient, and satisfaction for patients and providers;

·      Timely access, telephone, email and text connectivity and same-day visits will reduce Emergency Department usage;

·      Focusing on wellness and integration with community resources will slow advance of chronic conditions;

·      Providers have reasonable compensation, work-life balance, support for professional development and opportunities to influence improvements in systems and workplace culture;

·      Evaluation of the extent to which the model and its variations address the interests of patrons, providers and the sustainability of healthcare in BC.

 

Prototyping the Vancouver CHI model

Vancouver CHI has been in discussions with local recreation service agencies about the benefits of hosting a prototype within a facility that helps clients achieve and maintain wellness. 

We have developed a business case so we know what our startup and initial operating costs will be, and what our break-even point is.  We know that the model is actually profitable, with excess revenues that can provide incentives for providers, or fund additional clinics.

We have met with FP residents and newly-practicing physicians and experienced leaders in health care improvement to seek feedback, improve and assess the attractiveness of the model.  We know that the approach resonates for about 1/3 of younger physicians graduating each year.

With the scalable and adaptable model, we have started to think about how to properly govern and oversee the operation of clinics outside of Vancouver.   We think that scaling this – or any other like-minded model -  will have a significant impact on patient wellness, the provider workforce and overall healthcare costs.

Building a system of primary and community care built around interdisciplinary teams.

Vancouver Citizens Health Initiative might be one of the first to propose such a model but we hope we’re not the only one.   With health care consuming more of our public resource each year, we are certain that other diverse groups with an interest in healthcare access and sustainability will bring their non-clinician-focused approach to the public discussion about this treasured resource.

-       Our suggestion is that the Ministry, and its health authority partners should catalyze the creation of a plurality of models that are attractive to the next generation of primary care providers.  Public calls for local citizen-driven, led or supported models of primary care could result in the generation of new ideas that bend the cost curve. 

-       Promising approaches should explore innovative approaches to citizen involvement in co-design, to governance, business models (including staffing, technology, revenue generation, and making it easier for people to access care at the same time that we make it easier for providers to give.

-       Eligible respondents would include Divisions of Family Practice, other industry associations, non-profit organizations, and First Nations health organizations.  Requirements would be that the models would eventually be self-sustaining in either FFS, Blended or APP funding, and would be evaluated using an expanded triple aim.

-       One a model passes a rigorous review, provide interest-free loans or a combination of grants and loans to incent sustainability, with clear cut-off criteria tied to clinic revenues over expenditures and meaningful evaluation measuring the interests of patients, providers and system sustainability;

-       As we collectively build expertise, create an oversight body to build capacity of less experienced developers and community groups;

-       Provide money outside of the Physician Master Agreement, to incent citizen/clinician co-design, and ensure accountability to the public interest;

-       Finally, embrace this as a business challenge and engage the public and providers in reimagining how primary care is delivered, governed, funded and evaluated.

The Vancouver Citizens Health Initiative thanks you for your attention, and looks forward to continuing shared efforts to achieve a sustainable, universally accessible and publicly funded healthcare system in BC.

 

 

Patients and providers design primary care in Vancouver

What would happen if we asked 500 family doctors, 1000 citizens and 50 health system experts to redesign primary care?

In 2013 and 2014, I was privileged to lead a team that did just that in Canada’s third-largest city, where almost 20% of residents do not have a family doctor.  Over 8 months, we brought 350 GPs and health authority staff together to answer a simple question:  “what can be done to improve primary care relationships, so that more people can have a family doctor?”   What started with a simple question is leading us to a new era in health care.

Using this question as our focus, we held several dialogue sessions that included over 300 family physicians and health authority staff.  Through these, we generated 250 pages of data, from which we extracted 22 ideas for making the family doctor’s office more efficient and better connected to the wider health care system in BC.  Then we circled back to all 800 local GPs to see which of these interventions were most practical, to create a shorter list of ideas with great promise.    

Once we knew what doctors thought would be possible, we asked patients – citizens – what they thought of those ideas.  Again using the theme of relationships, over 1000 citizens filled out an online survey to assess the physician-generated ideas.  We created a separate process for vulnerable groups (urban Aboriginal families, newcomers, seniors and others) to participate through a dozen in-person kitchen table events.

It would be unfair to promise patients the moon, so we asked them to assess the extent to which the ideas generated by health system experts – including family doctors – would address their needs, and what trade-offs people would make so that everyone could have a family doctor.  We found that people were easily able to make actionable recommendations for system change when we used the lens of therapeutic relationships.  For example, we found that patients place a high value on everyone having a family doctor, that they want both continuity and convenience, and would much prefer to see or talk with their own doctor’s office instead of going to a walk-in or emergency department.   These are all ideas that support health system sustainability.

Through the process, we uncovered clues that will form the foundation for the next era of primary care: 

·       how seniors and millenials share many preferences in the design of family practice,

·       how to best engage citizens and clinicians in co-designing primary care,

·       how a culture shift among primary care providers will form the foundation of a primary care system that can enable everyone to have a family doctor

From this work, a few of us have created a new organization to implement the vision of hundreds of family doctors and thousands of patients.   The Vancouver Citizens Health Initiative brings patients and providers together to co-create primary care settings through the lens of relationships, and an eye on convenience for citizens and work-life balance for clinicians. 

Our sights are set on developing a model of whole-person, collaborative care that is sustainable within fee for service, while doing everything we need primary care to do for patient, provider and community health.  Our preliminary business case shows that our primary care clinics can achieve twice the capacity, offer more convenient and timely access, and work upstream, supporting patients to address their social determinants of health.  You can check our progress at www.vanchi.ca, or follow us at @VancouverCHI. 

It turns out that it’s easier to reimagine primary care than we thought:  it starts with listening to what’s important to the people at the centre of the system!

Primary Care for People and Providers

For the past year, I’ve been writing, discussing and envisioning a new approach to sustainable and accessible primary care in BC.  Today, the Vancouver Citizens Health Initiative launches our non-profit organization, our website and shares our blueprint for a new model of primary care. 

As a group of citizens, we’ve been wrestling with how our children’s generation will have access to excellent, universally accessible healthcare.  Over five years of involvement in primary care innovation in BC, we’ve heard the best ideas for improving health care from over 500 Vancouver family physicians, system experts and 2000 citizens.  

The challenges are significant:

·      Health care costs already consume 44% of the provincial budget.

·      Over twenty percent of Vancouverites do not have a family doctor. 

·      Even if people have a doctor, getting a same-day appointment with them is rare, pushing patients to walk-ins and emergency departments;

·      A culture shift is occurring among younger family physicians, moving us away from the “do it all myself” ethos of previous generations of doctors;

·      The dominant payment approach (fee for service) rewards piecework – the antithesis of whole-person care.

We have taken these and other elements apart, put them under a microscope to find positive potential, and put them back together in a way that responds to what’s needed from primary care now:  a focus on strong therapeutic relationships, a medical home that is designed to provide whole-person care and a culture that continuously creates collaboration.  For the past year, we’ve been testing our ideas with numerous clinicians and citizens in a spirit of continuous improvement.

Here’s what we’re designing primary care to do:

·      Double the capacity of family doctors to attach patients, while maintaining revenue and work-life balance for clinicians;

·      Enable and encourage patients to have same-day and evening appointments;

·      Expand the care team to support patients based on their life circumstances and income level;

·      Do all this within the fee for service payment approach.

We invite you to become part of the conversation and the work of building this new approach to primary care.  Please visit our site, let us know what you think, and stay connected.  We’re at the beginning of our journey and want you to participate! 

Optimize nurse’s role to improve healthcare

National Nursing Week is in full swing in Canada, and it’s crucial to recognize the tremendous contribution nurses make in all areas of health care.   I’m happy to see so many people singing their praises…and rightly so! But, despite their great commitment and healing impact, I think nurses can play a stronger role in health care.

Most health care professionals think that our system can be improved, and nurses know that the system would be better if they could do more for patients, alongside their clinical colleagues. In fact, if we want to provide quality health care to our children and their children, we will need nurses to play a stronger role, particularly in primary care settings like the family doctor’s office.

A new study from the Canadian Academy of Health Sciences explores the clinical division of labour that will support a health care system that serves all Canadians. The report is called “Optimizing Scopes of Practice: New Models of Care for a New Health Care System.” The upshot of their analysis is that the current, limited range of activities for nurses and other regulated health care professionals is more a result of past practices and politics than evidence or legal rulings of clinical responsibility.

The limits exist despite the broad training that we offer nurses. As one of the report authors, Ivy Lynn Bourgeault says, when it comes to nurses and other professionals, “we train and then constrain.” This means that nurses are capable of taking on a wide range of roles, but are then limited when they enter the workforce –by the expectations that have developed through decades of habit and practice.

The report calls for us to approach the concept of scope of practice from the dual perspective of flexibility and accountability.   Its authors argue that we need to develop scopes of practice that are based on patient and community need, rather than historical patterns. They also suggest we start using the term “optimal scope of practice,” so that team-based clinics can evolve the best division of labour based on clinicians’ relative competencies, and aimed at meeting the health needs of their panel and the community.

I witnessed this dynamic several years ago when BC was developing its initiative to increase the availability of Nurse Practitioners. A group of physicians and nurse practitioners spent over an hour demystifying their clinical roles, revenue sources and range of activities to each other so that we could lose our assumptions and approach the integration of nurse practitioners from a new perspective.

As the cost of health care systems rise, we will not have the luxury of limiting this dialogue to small group discussions. We need a critical mass of innovation to introduce interdisciplinary team-based care if we want to bend the cost curve in a meaningful way.

Such changes are possible if we reimagine clinical culture and workflow from a fresh perspective that creates optimal scopes of practice through the lens of patient health and safety, provider wellness and system sustainability. I think that enabling the full range of activities that nurses can do to keep us healthy should be a priority for all of us who appreciate what nurses already do!

In my next blog, I’ll describe governance and collaboration models that will help move these changes forward. In the meantime you can find the Executive Summary of Optimizing Scopes of Practice here:   http://www.cahs-acss.ca/wp-content/uploads/2014/05/Optimizing-Scopes-of-Practice_-Executive-Summary_E.pdf

Why Doctors Working Less Means Healthcare Can Deliver More, Part 2

In my previous blog, I described one perspective on how health care can do more with less…or more precisely, how inter-professional collaboration will improve access to family doctors, improve quality of care and create work places where many young doctors (and other clinicians) want to practice.

Dr. Kristy Williams is another BC-based family physician resident who sees a future in team-based care for a different reason: she envisions new models that enable her to provide the kind of care that prevents people from having to visit their doctor in the first place!

Kristy realizes that there are limits to what a doctor can do – especially if we look at our health care system as means to balance both patient health and clinician self-care. By working as part of a team with nurses, pharmacists and patient advocates, she feels we’ll have a better system for everyone: “We should be looking at models where patients feel better supported and have the tools to follow through on treatment plans. Research shows that up to 50% of patients don’t fill their prescription. Do we know why this is the case? We need get more patient involvement and feedback to help identify how care can be more appropriately delivered and I think that means breaking down the idea that working solo is best. ”

Kristy feels that if we are able to do this, we’ll be better able to assist patients to achieve health, and more importantly, to maintain health: “If we address discrimination between types of clinicians with different training we will be able to focus on what we all bring to the care of the patient. I’m personally inspired how we could mobilize upstream interventions, like using community gardens, art and social programs to prevent illness.”

Like many younger doctors, Kristy sees the fee for service payment model as a barrier to providing this kind of care: “Fee for service takes away from the focus on the patient, and it’s not sustainable because it’s not fulfilling for many physicians entering the profession.” By encouraging limits like “1 problem per visit” it moves us away from providing truly comprehensive care and solutions that fit the life circumstances of people outside of the clinical setting.

From my conversation with Kristy and other younger doctors, we have an opportunity to shift our primary care system towards more and better care, with doctors working as part of a team and sharing responsibilities. This reduces the burden of care solely on physicians…in other words enabling more to be done with less. In my next article, I’ll be speaking with a young pharmacist who sees his future as part of a team with doctors and nurses.   I will also describe a new initiative that will develop models of care to increase physician and practice capacity by involving citizens in their design and operation.

What do you think about a future where health care delivers more with less?

Why Doctors Working Less Will Mean Healthcare Delivers More, Part 1

It sounds like a contradiction to say that someone working “less” will do more, but in primary care that may be the case.   Currently there is a culture shift happening among family doctors – many younger doctors don’t want what the previous generation had: responsibility for opening and operating their own family practice clinics where the doctors are supported by a receptionist, but otherwise do everything from soup to nuts.

I sat down with Dr. Daniel Heffner, a pharmacist and now family practice resident in Vancouver. Dr. Heffner is currently working in one of VCH’s Community Health Clinics, and looking forward to his career as a family doctor. Beyond his talents as a clinician, Daniel is also a virtuoso flamenco-fusion guitarist.

Daniel identifies himself as part of a new breed of family physician who loves being a generalist but doesn’t feel like it’s possible to do everything perfectly for every patient on his own.  Daniel says: “providing care is so complex now. For example, prescribing used to include detailed knowledge of only a few categories of drugs, but now the number of new medications, complex indications and the circumstances of every patient make it challenging even for specialists to make the best decision within their area of expertise.”

Another issue we discussed is a culture change among many young doctors. Younger doctors want to have a healthy work-life balance and time to raise their children, something that is difficult when doctors have responsibility for operating a health care business business and providing comprehensive care for their patients, with little or no support.  

So how will it be possible for family doctors to provide the best care as a generalist in an age of great and increasing complexity?   And how can we have a system that provides more care to more people with more complex conditions, when many in the next generation of GPs wants to do less of what we have come to expect of family doctors?

A new way of providing care can help us achieve more with less, according to Daniel. Working as part of a team that includes physicians, nurses, pharmacists and other care providers will bring a range of expertise to the diagnosis and treatment of illness, so fewer errors will be made. We discussed primary care settings where nurses will be a core part of continuous care, by being an initial contact and supporting the patient’s treatment plan. Pharmacists will use their specialized expertise to determine the right medicine for each person’s personal and health circumstances.

In this situation, doctors can focus on what’s important – the continuous care of the patient, the diagnosis of disease, and the best course of action to treat the patient and their illness.     With a team of providers available, patients can get easier access to the care of their family doctor, avoiding trips to a walk-in clinic or emergency department.

It’s not just about adding more clinicians to the mix – doctors will always be the lead in diagnosing and prescribing treatment. The change requires working in a different way so that doctors can be freed up to focus what’s important. Daniel thinks that’s good for him, that it’s the way that many clinicians want to work, and it will ensure quality of care and access for patients.

Daniel points out that “the new generation of doctors are still Type A: we want to be all things to all people.  But now we realize that better care for patients results from involving the patient and other care providers.” Working in this way strengthens the doctor-patient relationship because “the doctor is able to focus on what’s most important to the patient.”

Daniel also wants you to help figure out the solution. He says: “Society needs to decide what kind of care they want, and then help make it happen. Do people want access, shared care, community health centres? Do they want a situation where doctors operate as a business? There is an opening for citizens to get involved in shaping the health care system.”

The time is right for new primary care models that will improve access and be functional for the younger generation of clinicians. In my next article, I’ll discuss how new models can expand the range of preventive services provided by a new generation of team-based clinics to improve wellness.

Incidentally, Daniel is also a virtuoso flamenco guitar player – you can check out his videos at www.danielheffner.com or catch him live in Vancouver or Calgary.

Why Social Enterprise Will Help Save Healthcare in BC

A woman in my neighbourhood was diagnosed with late stage colon cancer by a doctor a walk-in clinic. She was given two years to live, and recently passed away after three years. The reason she was diagnosed too late for medical intervention? She couldn’t find a family doctor.

In Vancouver where I live, over 120,000 people don’t have a family doctor, and another 25,000 arrivals are expected each year. That means the problem will get compounded, as new arrivals to Vancouver are the least likely to have a doctor – even after being here for 10 years. 

Who will solve the problem? Getting family doctors to take up the slack is unrealistic for two reasons. First, they are already working at or over capacity. Second, even if each doctor in Vancouver took on another 150 people as patients, their patients would have to wait longer for an appointment. We could recruit and retain more doctors, but those efforts would only solve the problem for a short time, or create the same problem elsewhere.

What we need is innovation in the way that primary care is provided, to multiply the impact of the doctors we have now. Most system experts believe that involving nurses and pharmacists as part of a team of care, is the best way to increase access to family doctors without increasing costs to the system. After all, it is comparatively expensive and time-consuming to train doctors, so increasing their efficiency through team-based care is a good long-term investment.

However, consider that changing to team-based care requires a different business model, and we can’t expect family doctors – who are at the same time business owners – to absorb the risk of changing their model of care in BC…If a family doctor hires a nurse to help provide care, they have to pay their salary and risk reducing their main source of income. Some are ready to take on this challenge, but many are not.

Enter the social enterprise: non-profits that embody a hybrid of business and community values that have the ability to change the game. Social enterprises can take on the risk of exploring new models of care. Good ones can imagine, build and operate family practice clinics in new ways, so that family doctors can focus on doctoring and more people can have one. If done well, we could find models that ensures that our children will have as strong a health care system as we do now.

Examples are already out there. REACH and Mid-Main are non-profits that have operated interdisciplinary care models for decades. There are community dental clinics that have found a way to remove the barrier of cost for low-income individuals and families using a business model that reinvests any profits into free treatment. In White Rock / South Surrey, a non-profit clinic operated by a group of family doctors and Fraser Health, has helped to make a primary care provider available for everyone…without family doctors having to shoulder the entire burden themselves. 

BC’s healthcare system is being pressed from all sides. We need enterprising non-profits to help us find new ways of making a continuous relationship with a primary care provider accessible for everyone.

In my next blog, I’ll describe how the next generation of primary care providers have the right stuff for saving universal healthcare in Canada, partly because they will work shorter hours than previous generations of family doctors.