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André Picard's Second Opinion

We need more primary care, not more physicians Add to ...

"B.C. commits to a family doctor for everyone by 2015."

That was the headline on an eye-catching press release from the B.C. Ministry of Health last week. Eye-catching because much is made of the fact that millions of Canadians do not have a regular family physician: This is purportedly one of the horrors of socialized medicine.

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If a provincial government can close that perceived care gap quickly and at relatively little expense, then this is certainly a newsworthy initiative.

So let's take a look behind the headline.

First and foremost, let's be clear on what B.C. Health Minister Kevin Falcon actually promised. He said that every resident who wants a family physician will have one. This is an important distinction because the data tell us that the majority of people without a doctor are not actually looking for one. The shortage is not nearly as bad as it is presented, and the solution is not necessarily hiring more doctors.

In fact, it's worth probing the data a little deeper. According to Statistics Canada, 85 per cent of Canadians have a regular family physician. Thanks to medicare, the publicly funded health insurance program, they do not pay for their doctors'services.

Still, it's concerning that 15 per cent of the population does not have a regular primary care provider. If nothing else, we are missing out on a tremendous opportunity to provide preventive healthcare. (Not that those with a regular doc are necessarily getting preventive care, but that's another issue.)

In real terms, there are 4.3-million Canadians whose health is not being monitored and who apparently do not have a clear place to reach out for health care if they need it. But, according to Statistics Canada, 54 per cent of them are not the least bit troubled by this fact. That leaves a pool of 1.9-million Canadians who want a doctor and can't find one. The reasons cited: no doctors are available where they live; doctors in their area are not taking new patients; a physician has recently moved or retired.

Yet 82 per cent of people in this "doctorless" group say they have a place they usually turn to for medical assistance: a walk-in clinic, a community health centre or the emergency department of a local hospital.

While walk-in clinics and ERs are not ideal ways of delivering care, the reality is that fewer than 350,000 Canadians actually have no place to turn for primary health care - pretty darn good in a vast country of 33 million. And it's a far cry from the alarming 4.3-million so often cited.

But let's get back to the B.C. promise. Beyond what Mr. Falcon, the health minister, said, it is important to examine what he did not say. He did not say the province plans to hire more doctors. He did not say that existing doctors will have to take more patients.

In fact, the B.C. Medical Association stressed this in a message to members: "This does not mean any doctor will have to simply increase his or her number of patients. Family physicians are not expected to work harder or longer hours to accommodate the 250,000+ British Columbians who do not have a strong attachment to a primary care provider."

So what is the magic formula? How do you ensure a doctor for every citizen without increasing the number of doctors or their workload?

Well, B.C. is going to create something called "divisions of family care" in which physicians will pool their resources to hire other health professionals to handle a lot of patient care. In other words, B.C. is going to ensure "everyone has a family doctor" by improving access to nurse practitioners, nurses, dieticians and other specialized health professionals.

Many jurisdictions are taking this approach - care delivered by multidisciplinary teams. It's a laudable, effective, cost-efficient approach, and it's long overdue.

The strategy is particularly useful for patients with chronic illnesses, or multiple chronic illnesses, who need regular monitoring and follow-up care. Their situations are ill-suited to the fee-for-service model of care delivery that is still all too prominent.

To his credit, Mr. Falcon underscored the need to target those with chronic illnesses; improving their access to care and continuity of care is essential.

The only problem with the B.C. initiative is how it was presented. What every Canadian needs is timely access to a primary care provider; what each of us needs is a care co-ordinator, both when we are well and when we are sick.

That is what B.C. and every other province should be aiming to provide. That primary-care provider does not have to be a doctor. It can be a nurse-practitioner. And the care co-ordinator need not be a doctor: It can be a nurse, a dietician, or a physiotherapist, depending on a patient's situation.

One of the most money-wasting institutions in Canadian healthcare is the walk-in clinic. The money poured into the provision of poor care in walk-in clinics would be far better spent hiring nurse-practitioners and opening community health clinics.

If we are going to improve primary care, we need to dispense with our lingering Marcus Welby fantasies and recognize that, while family physicians are important, they are not the be-all-and-end-all.

"B.C. commits to a primary care provider for everyone by 2015" would be a much more welcome headline.

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