To describe the way he practises medicine, Baldev Sanghera gives the example of a teenager who comes into his Burnaby clinic seeking help with acne.
Sanghera would treat the skin problem. But he says he’d also be attentive to the patient’s anxiety that goes along with it. He would take the opportunity to talk with them about mental health, self-esteem and confidence.
If more is going on, he might talk about linking the teen with a school counsellor or teachers to help with educational supports or discuss sexual health.
The kinds of topics a doctor can raise when they have built a relationship with a patient over time.
“Each visit for me is a coaching visit,” Sanghera said. “I lay expectations out for the child, then as they become a young adult… the trust is already built for you to then talk about being careful with alcohol, being careful with drugs, how to maintain a good, healthy lifestyle so they don’t run into all the chronic diseases that they’re going to run into.”
It’s entirely different from the kind of care the patient would have gotten from a walk-in clinic or a virtual service focused on one-off appointments, he said. “You wouldn’t do that if you were just providing the single episodic care visit, which is, ‘Oh you’ve got acne, here’s your antibiotic. OK, thanks, bye.’”
That kind of cursory care has become increasingly common as the number of people without a regular doctor or other primary care provider has grown. Walk-in clinics, urgent primary care centres and now virtual care provided by corporations are filling a real vacuum.
Practices like Sanghera’s attempt to make sure patients can get timely care when they need it, but in a way that also offers an opportunity to build an attachment to a care provider who will know them over time.
Sanghera has his own family practice where he works as part of a group of 12 doctors. Together they also run a walk-in clinic that’s an extension of their own practices and a new urgent and primary care centre on the same site, where patients can get same-day non-emergency treatment for things like sprains, cuts or burns that may need urgent attention but don’t require a hospital visit.
“There’s no corporate bent on it. It’s all about patient-centred care, and that’s been our focus ever since I started practice,” said Sanghera, who is also the physician lead with the Burnaby Division of Family Practice, one of 35 such organizations across the province started as partnerships between the provincial government and the Doctors of BC to support family physicians.
“The one thing I’ve learnt in the last 25 years of practice is that if you focus your support for a person throughout their lifetime, right from the start as long as you’re looking after them, then it’s a consistent plan based on what the patient’s needs are, then the patient outcomes are great,” he said.
Walk-in clinics are needed to relieve pressures in the system, he said, but they should be closely co-ordinated with physicians who are providing long-term care for patients, he said. “Episodic care sometimes misses the big picture, and you’re focused on the immediate need of that person at that point.”
Burnaby has a population of 250,000. About 20 per cent of residents don’t have a family doctor, he said. He and his colleagues are working to change that.
“Our big push now is to help as many of those patients [as possible] get attached with our programs promoting longitudinal care, providing support to physicians to deliver that care, and also trying to be innovative in delivering other mechanisms for partnership and team-based care with the health authority,” he said.
The clinic is hiring more nurses, counsellors, dieticians and social workers and taking a group approach that allows them to attract more patients. In the last 18 months, they’ve added 10,000 patients and have a goal of reaching 30,000 within the next four years.
The idea is to build teams, led by a family physician, that take a long-term approach and have the skills to offer patients what they need at various stages of life.
Officially, it’s the kind of care the provincial government believes in and is trying to promote.
In June, Premier John Horgan participated in the opening of a similar clinic in Sooke, where he is also the local MLA. “I believe the model here at West Coast Family Medical Centre is the ideal model where you have [general practitioners], you have nurse practitioners, RNs, and other health-care providers that can provide that continuity of care.”
He acknowledged the challenge in recruiting and retaining doctors. The government is looking at adding post-secondary spaces to train more doctors, he said. “In the interim, putting in place primary care networks that can attach patients to the health-care providers they need is the appropriate way forward.”
A partnership between the health authorities and divisions of family practice, primary care networks are intended as a way different providers and organizations can work together to deliver needed primary care.
In May 2018, B.C. Health Minister Adrian Dix announced plans to boost primary care by funding doctors to work in team-based settings, adding more nurse practitioners, creating primary care networks in communities and opening urgent primary care centres.
The approach is also highlighted in the health ministry’s service plan released in February. The primary care strategy, it said, “is focused on providing improved access to care across the province by connecting patients to caregivers in an integrated team-based environment that includes a number of urgent primary care centres, primary care clinics, and community health centres.”
The strategy would “make it easier for people to access care, receive followup and connect to other services they may need, informed using research evidence in policy, planning and practice.” In particular it would strengthen health services for seniors, people with mental health and substance use issues and others with complex care needs.
Dix insists the change is under way. “All of the health authorities, as part of our primary care strategy, have brought forward unprecedented efforts to improve primary care across the province.”
In B.C. there are now 39 primary care networks, 17 urgent and primary care centres and new community health centres in several communities, he said. There are also primary care centres opening with First Nations leadership. The day Dix spoke to The Tyee, the province’s first clinic run by a nurse practitioner was opening in Nanaimo, and there were two more slated to open within a few weeks.
“This is a shift of primary care services away from the traditional model to a variety of team-based approaches,” Dix said. “In different ways these are all team-based approaches.”
The province is training more care aides, nurses, nurse practitioners and doctors, and there is a plan to open more clinics like the one in Sooke to serve rural communities, he said. “All of that represents a major shift towards a policy of team-based care. It’s just happening.”
Rita McCracken said she’s grateful that the current government is even asking questions about what’s needed to improve primary care. But it appears progress has been limited, she said.
McCracken is a family doctor who practises in East Vancouver, provides care in a nursing home and teaches at the University of British Columbia.
She said it’s unclear, for example, whether the new urgent primary care centres fill a need that wasn’t already well served in many communities by emergency departments and walk-in clinics. Nor does anyone seem to be tracking whether the centres help people move into longitudinal care with a family doctor.
McCracken is the medical director of the large urban clinic where she practises. She doesn’t see how being part of a primary care network would change her experience as a doctor. “I’ve been asking these questions now for a couple years, and I’m not getting really any specific answers.”
And she said it’s hard to see how the approach can work with the current funded model, in which doctors are paid a fee for each service they provide to patients.
Even if a non-profit wanted to provide primary care services, under the current system it would need to rely on family doctors doing the billing to cover the costs, she said.
McCracken said there needs to be a much greater expansion of the community health centre model, with doctors, nurses and others working collaboratively.
And the government needs to allow much more flexibility in how physician-owned clinics can be run, she said. Many doctors would welcome an opportunity to be paid a salary to provide care to a broader population, rather than depend on fee-for-service billings.
McCracken describes a clinic that’s more like a typical public school, where there’s a physical location and a meaningful connection with the community. It would receive global funding instead of depending on fee-for-service and employ a broad-based team where each person would be an employee.
“Those models have been shown to be exceptionally helpful for the population that has trouble gaining access to health care otherwise,” McCracken said. “They’ve been found to be incredibly attractive to family physicians, and they also have shown some really interesting metrics about reduction of acute care services, like emergency department and hospital admissions.”
Governments have failed “to recognize that our current system has gaps and we’re seeing these private corporations come forward and offer an alternative,” she said.
Burnaby doctor Sanghera said the health ministry and the Doctors of BC need to look at the ways the current approach — and fee schedule — affects care. They need to avoid creating incentives for providers to care for patients with simple health issues and avoid people who need more complex care.
“If you just focus on corporate medicine, it’s delivering the care as fast as possible to the maximum number of people per day, and you have that treadmill that you’re running on, you’re really not worried about any of the big heavy stuff that’s going to need to be lifted as well,” he said. “You’re not going to focus as much on the mental health side of things, which really impacts people’s lives.”
Marcy Cohen, a community researcher who has worked on issues around primary care and community care for two decades, sees various ways for the government to get primary care onto a better path.
It could start with stronger regulations governing corporate primary care, she said. “And I really don’t think that’s being seriously considered by government, that they need a much stronger kind of regulatory system and that would require legislation.”
The threat of a corporate takeover of primary care is real and the implications are huge, Cohen said, but most Canadians are unaware. “I think Canadians would actually be quite shocked if they realized the jeopardy to one of our most precious institutions, our medicare system in Canada.”
Aside from stronger regulations, the government could be supporting primary care models that would fill the gap that corporations are pushing into. “The development of the alternatives to make Well Health and Telus not necessary have been slow to come,” she said.
“Part of the reason Well Health, at least, has come in is doctors who don’t want to work fee-for-service and just want to provide care for the patients don’t have easy alternatives that are not-for-profit alternatives.”
There’s a need to develop an alternative to the fee-for-service system, one that provides population-based funding or one where providers are paid a salary and supports team-based care, she said. “Increasingly what I’m hearing from the physician community is they really know they need those alternatives.”
Cohen has written in the past about earlier attempts to reorganize primary care that were thwarted by physicians unwilling to give up the fee-for-service model.
That’s shifting, she said.
“It’s very generational in my experience,” she said. “Older physicians who are used to fee-for-service and who are used to the long hours, and the younger physicians who have family responsibilities who are used to working in teams, who are educated more in teams. There’s a very big generational shift going on.”
Dix said some of the newer models are moving away from fee-for-service, acknowledging that’s thanks to doctors, especially younger ones, becoming more supportive of alternatives.
“In general, B.C. has really been, up to the present time, the most resistant to change with respect to fee for service. I think what you’re seeing is an evolution amongst the community of doctors.”
But he also argued that despite the challenges with the model, it incentivized doctors to take on more patients, which meant more people got care. “You have to balance these things off,” he said.
Dix acknowledged there’s more to do but said the government’s strategy is moving the province in the right direction.
“This is incremental change, but it’s powerful incremental change, because rather than just talking about policies we’re actually implementing them around the province with communities of doctors.”
Dix said companies like Telus and Well Health have a role to play in supporting the shift in primary care, particularly as providers of virtual care and keepers of electronic medical records.
Virtual health care and electronic medical records are supposed to provide better care for people in their communities, especially in rural and remote places, Dix said.
But it hasn’t always delivered, he said.
“I think the record is highly mixed,” he said. “But I do think what’s happened during the COVID pandemic will be an important shift, a permanent shift.”
Many people have tried virtual appointments for the first time and see it can be convenient and fill a need. “Virtual health, its role in the system, has been advanced years in months.”
It seems clear that virtual care provided by corporations will continue to grow, Dix said. There are advantages for patients who can get a doctor’s appointment without having to leave work for an office visit, he said.
“I’m not fearful about it. I think it can be positive, and it’s partly about improving primary care services.”
The government’s goal is to improve patients’ access to longitudinal care, Dix said. That means care based on their histories and personal situations, rather than a one-off visit to a doctor they’ve never met.
Corporations can help, he said.
“That includes electronic medical records and other things,” he said. “I don’t see any reason why the advance of virtual care can’t also promote longitudinal care, but we have to be prepared to do that and that’s part of the challenge and will be the challenge for Telus and everyone else who are involved in this area.”
Dix said the health system’s larger hurdles have to do with an aging population that brings both more demand for health services and more retiring doctors when “the number of people without a primary care doctor was already too high.”
“You just have to keep making progress, and that’s what we’re trying to do. Seventeen urgent primary care centres, 39 primary care networks, multiple new community health centres, multiple new First Nations run health centres, all of that is really positive, and there’s more to do.”
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