What parent hasn't experienced the anguish of a child waking up ill and inconsolable in the middle of the night? Your family doctor or pediatrician is long in bed. So what to do but take your child to the emergency ward? By and large, that's the only option once Marcus Welby has gone home for the day.

Many parents wonder at the phenomenon of young children apparently always taking sick after hours. But the more perplexing question for our health-care system is why the concept of "after hours" still exists.

For years, policy-makers have promoted a new approach to family medical services with the ungainly name of primary health reform. It is the holy grail of fixing medicare. Every report, regardless of ideological bent -- Mazankowski, Fyke, Kirby, Romanow -- begins from this same premise.

"Modernizing and transforming the health-care system," Mr. Romanow said at Harvard University last month, "involves the evolution of primary care -- people's first point of contact with the health-care system. We need, for instance, to shift the focus away from hospitals and medical treatments and to break down traditional barriers among health-care providers."

So what is this primary health-care reform? Why is it so important? Why has it proven so difficult to achieve?

To start, it is about reconceiving the traditional lone-doctor, fee-for-service family medical practice. You know the place. The one with the inconvenient hours, waiting room backlogs and dated copies of Reader's Digest.

The idea is to move family doctors into larger-scale group clinics where they can work alongside other medical professionals: physiotherapists, mental health specialists, pharmacists and the like. The most appropriate provider would dispense the most appropriate care. These clinics could operate on a 7/24 schedule, eliminating the need to take your child to a far more costly hospital emergency room in the middle of the night.

Family clinics might also employ nurse-practitioners, highly trained nurses who would serve as the first point of contact for patients. They would take care of routine matters, freeing up physicians for the more complex tasks. So the first goal of primary health reform would be greater economic efficiency and consumer convenience.

Just as important, family doctors could be compensated in ways other than the fee-for-service model, with its inbred bias to administer as many services as possible. Some doctors might prefer the certainty of working for a salary; some might find it easier to work part-time. Clinics could be financed on a capitation model, with funds allocated based on the number of patients under care rather than the amount of care given.

Indeed, herein lies the secret ingredient of primary health reform. Experts say it would alter the incentive from treatment of illness to promotion of wellness. It is a lot cheaper to prevent a heart attack than to treat one, not to mention more beneficial to the individual.

Unfortunately, family doctors tend to be highly protective of their anachronistic ways. Garbed in white coats, they refuse to accept that they, like everyone else in society, must live with change. It sometimes recalls the old joke about the difference between doctors and God: at least God doesn't think he's a doctor.

All this explains why primary health reform has been such a disappointment. There has been some movement, but it is minimal and halting -- and, where attempted, often underfunded.

In Quebec, community clinics have been set up, but starved of the funds necessary to operate "after hours." Elsewhere in Canada, family doctors have simply refused to pool resources. Their fee-for-service, solo-practice model predates medicare and they aren't about to surrender their independence now.

In September of 2000, when the federal and provincial governments signed a $21.5-billion health accord, they set aside a special $800-million fund to grease the wheels of primary health reform. You would think, given the interest of policy-makers and the logic of the argument, that it would be oversubscribed. In fact, more than two years later, only $460-million has been drawn down.

Given all this, we are tempted to say governments must be more aggressive. They must force family doctors to do the right thing for the good of the health-care system. No more kowtowing to this powerful special interest.

Tempted, but not persuaded.

Coercion rarely makes for good public policy. Confrontation comes with a high price. We have no reason to think the forced collectivization of family practices would be any more successful than Stalin's forced collectivization of farms, or the recent coercive behaviour of the Quebec government toward emergency-room doctors.

Instead, we recommend allowing nature to take its course -- with active encouragement from policy-makers. In agriculture, unproductive family farms are giving way over time to more innovative, consolidated operations. The same will prove true in the medical field.

We live in a free society. Doctors are entitled to practise as they see fit. Older doctors, having operated in a certain style for decades, cannot be expected to change their stripes overnight.

But younger doctors have different priorities. Spurred in part by the feminization of medicine, newer entrants to the field appear far more receptive to the teamwork and flexibility that integrated clinics afford. They don't mind sharing responsibilities with other health-care professionals and would rather lead the normal lives (i.e. being able to sneak off to a school concert) that a team approach allows. To get from here to there, however, involves three factors beyond determined patience.

First, we must make sure the system is churning out adequate numbers of doctors, nurses and technicians, reversing the rollbacks of the 1990s. Currently, an unacceptable 15 per cent of Canadians are without a family physician; the situation is even worse in rural areas.

Second, patients must maintain the right to choose their own family doctor.

Third, new public investment must be put into electronic record-keeping, a necessary aspect of health reform in any case. An integrated approach to care cannot occur without a common informational platform.

Beyond that, let's get on with the task of devising the financial inducements necessary to bring doctors and other health-care professionals together. What's needed here is not a revolution that fails but an evolution that succeeds.