Shirley Schipper is the president of the College of Family Physicians of Canada. Vishal Bhella is the president of the Alberta College of Family Physicians.
The Alberta government’s proposals contained in Bill 21, the Ensuring Fiscal Sustainability Act, ostensibly aim to improve access to health care in underserved regions of the province. Yet experiences from across Canada have shown that attempts to control where doctors can practise, or where they can’t practise without being penalized, are unlikely to produce the intended results. An innovative, collaborative approach is needed for Albertans to have equitable access to health care – one that includes the input of family physicians who are directly affected by these proposals.
British Columbia, New Brunswick and Nova Scotia have tried limiting where family doctors can obtain billing numbers for their practices (which is how the government generally pays them for their services). In each case, the goal was to get physicians to work in locations in need and where they might not be drawn naturally. The results were not successful for physicians and, in turn, adversely affected patients. In Quebec, restricting billing numbers was just one part of a larger strategy.
In British Columbia, this practice, plus fee restrictions applied to new doctors working in overserved areas, led to a legal challenge in the mid-1990s. Many family doctors left the province. Physicians successfully argued that new doctors had the same right to make practice decisions as those already working in the field. The province failed in its appeal of the court’s decision.
Research conducted by the College of Family Physicians of Canada shows that using billing number restrictions to force doctors to practise in rural areas might increase supply in the short term, but they don’t usually stay for the long term. Providing financial incentives may be one part of the solution, but money alone is not enough.
Forcing doctors to work in particular regions when they don’t have the appropriate experience and support does a disservice to both the physicians and the local communities.
In 2017, the CFPC and the Society of Rural Physicians of Canada released the Rural Road Map for Action. It aims to improve the health of rural Canadians by producing more family physicians who are equipped to practise in under-resourced rural and remote communities and sustaining them in their roles.
Its recommendations include dedicating funding and resources to support medical education and clinical teaching sites in rural and remote areas, as we know that those who train in these communities tend to choose generalist practice and are prepared to work in smaller communities. They also recommend investing in infrastructure such as telemedicine/telehealth and fostering collaboration among communities, governments, educators and physicians to provide a supportive practice environment and to retain doctors in those communities.
Efforts to generate more rural physicians need to start before medical school. We need to educate students about health care in rural and high-need areas, and we need to select medical-school candidates who have an interest in serving these communities. Also, for any family physician to move to a rural community usually means relocating with a partner and family. Recruitment and retention efforts are typically more successful when the needs of the whole family are part of the offer.
More can and should be done to increase the number of family physicians practising in underserved areas of Alberta, including rural and Indigenous communities outside urban centres. The CFPC and the Alberta College of Family Physicians urge the Alberta government to reconsider Bill 21 and seek a multipronged, long-term solution.
The Alberta government must also look at physician resource planning from a broader perspective, as this is a health work force issue. Medical schools train new graduates based on the CFPC’s educational standards, and these individuals are prepared to work in Patient’s Medical Home (PMH)-aligned practices, which means team-based and patient-focused environments. The PMH is referenced in the Primary Health Care Strategy, which the Alberta government released in 2014 and still serves as the foundational vision for health care for Albertans.
Family doctors base medical decisions affecting their patients on high-quality evidence. The same should apply to decisions being made about the physician work force in Canada. We hope to continue to collaborate with policy makers and other stakeholders to provide equitable access to high-quality health care close to home for patients in Alberta as well as the rest of Canada.
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