There’s a Better Way to Deliver Primary Health Care

Karen Lundgren says the community health centre where she works in downtown Victoria is the kind of place she’d want to receive medical care.

“It’s the best way to do health care,” Lundgren said. “I would love to go to my family doctor and have access to a physio there, counselling there, you know like a one-stop shop. It’s not the norm and it needs to be.”

Lundgren is the manager of the nursing team at Victoria Cool Aid Society’s community health centre and she runs the organization’s outreach sites and mobile health clinic. A non-profit that also provides housing and runs a dental clinic, Cool Aid targets its services to people who are impacted by poverty, colonization, stigma and homelessness.

The health clinic is one of 31 members of the BC Association of Community Health Centres. Other clinics in the association serve various populations, with some specializing in caring for Indigenous people, immigrants or seniors, or on a particular neighbourhood or region.

The provincial government has for years promised to increase the number of community health centres and better support them. But progress has been slow.

Following through on that commitment would be good for patients, health-care workers and the overall system, said Lundgren.

“There’s a real collaboration within the multidisciplinary team,” she said. “So we’re a team of doctors, nurses, medical office assistants, pharmacists, pharmacy assistants, acupuncturists, counsellors, help outreach workers, nurse practitioners, physio, and we collaborate very, very closely.”

The model works well for patients, but also for the providers, she said. While health-care worker stress and burnout has been one of the stories of the COVID-19 pandemic, the community health centre has not seen it to the same degree.

‘Created by and for community’

Despite working with a patient population that has complex health needs, said Lundgren, staff at the Cool Aid clinic enjoy a lot of autonomy and work to the full scope of their disciplines, making it much more satisfying than many other jobs in health care.

If nurses, and the physicians who work with them, know the full range of what nurses can take on, it also eases pressure on other providers and increases the capacity of the clinics where they work, Lundgren said. “Nurses can do all kinds of assessments independently and I think that would increase access for clients if nurses work at their full scope.”

Some of the other community health centres operating in the province include ones run by REACH and RISE in Vancouver, the Community First Health Co-op in Nelson and half a dozen across the Gulf Islands.

In Vancouver, REACH on Commercial Drive has “an increased focus on immigrants, reflecting the multicultural makeup of our community.” The Central Interior Native Health Society’s primary health-care clinic is dedicated to Indigenous health. A clinic at Luther Court in Victoria makes its services available to people in particular neighbourhoods. RISE gives priority to “Renfrew-Collingwood residents who do not have a regular health-care provider and experience barriers to accessing care.”

While the centres are diverse in who they care for and how they do it, they are all created by not-for-profit organizations or co-operatives to deliver integrated services and programs that reflect their communities’ needs and priorities, said BC Association of Community Health Centres’ executive director Valerie St. John.

They use a collaborative team approach to provide comprehensive, accessible, affordable and culturally appropriate services, she said. “They are all different because they serve different community needs,” but all of them are “created by community for community, and they’re governed that way.”

It’s a model that Health Minister Adrian Dix and the NDP have long said they want to expand.

Amidst doctor shortages, community health centres can help

In 2018 when Dix and then-premier John Horgan announced the government’s primary care strategy it included more support for non-profit community health centres to “bring together health and broader social services to improve access to health promotion, preventive care and ongoing services.”

And even before forming government, the NDP had promised to “fully capitalize” on community health centres to improve public health care and provide better access to primary care.

In a 2017 pre-election letter to the BC Association of Community Health Centres, it pledged to add 20 new community health centres and to provide the existing ones with more stable funding.

“Delivering primary health care through integrated, multi-disciplinary teams across urban and rural B.C. is a principal part of our plan for improving access to safe timely quality care, improving health and community outcomes, and reducing pressure on ERs, acute care hospital beds and residential care,” it said.

“Supporting and sustaining existing community health centres, and replicating their successes is integral to our platform commitment to make team based primary care the standard across B.C.”

But the association’s St. John said that while the promise of 20 new community health centres was achievable, just seven new ones have opened since the NDP formed government.

With roughly a million British Columbians lacking access to a family doctor or other primary care provider, the government has instead focused on attaching patients to primary care and opening urgent and primary care centres, which are also physician-centred, St. John said.

The direction has ignored how community health centres can help, she said, noting that some 80,000 patients are already attached to community health centres and make about 150,000 visits a year to the centres.

No global funding model

There’s no need to reinvent team-based care in doctor’s offices and there’s no question more communities want community health centres, St. John said. The association is working with 14 that would like to open community health centres and there are half a dozen proposals in front of government officials waiting for decisions.

Aside from the wait for new community health centres to win approval and support from the government, there’s a need to improve core funding for the existing centres, said St. John.

There’s a move towards funding community health centres through the government’s primary care networks “of providers and clinicians who come together to plan for and deliver all of the primary care needs of a community.”

But that doesn’t allow for services outside of primary care that many centres provide, such as addressing food security or housing.

As many as six ministries have programs that could run through community health centres, but delivering those services is done in an unco-ordinated way, she said. Funding needs to be integrated, she added, with different government ministries collaborating to support the variety of services the centres offer.

“They all struggle because there is no global funding model,” St. John said, adding that centres end up cobbling together funding from various sources, including community fundraising and contracts based on particular community needs.

The government has yet to deliver fully on its 2017 election promise, she said.

And yet St. John said she’s hopeful about what she’s been hearing from Dix and health officials recently. “We’re moving in a good direction,” she said. “We’ve been involved in a lot of good conversations with the ministry, which we appreciate.”

Dix says he’s still a fan of the model. A significant number of community health centres have been created since the government came to office, including some that are Indigenous-led and the foundation is in place to quickly create more.

“My view is we’re going to have numbers such as 20 well in the rear view very soon,” Dix said in a late March interview. “That number will grow significantly in the next period. The reason I think it will grow significantly is that the profound change that I was talking about for at least a decade prior to the 2017 election in [the] fee-for-service model that we’ve now undertaken.”

Last October the government reached an agreement with the Doctors of BC that included payment for the number of hours a physician works and for how many patients they are caring for, including amounts that vary depending on how complex the patients’ needs are.

Previously about 80 per cent of primary care in B.C. was paid for through a fee-for-service model where doctors are paid a flat rate for each service they provide, regardless of how long it takes.

“The new model to pay doctors supports community health centres,” Dix said. “I expect that model to become more and more the prevalent model in B.C. health care and the system will be the better for it.”

The government has also been providing consistent financial support for community health centres since 2017 along with support for the BCACHC umbrella group, he said. It has introduced primary care networks and is building out team-based care in a way that benefits community health centres, he added.

“All of this is transformational for the primary care system and it’s going to lead to more and more community health centres,” Dix said. “That’s an intended consequence of the strategy.”

At the same time, he said, there’s only so much he and the government can do. “Community health centres have to come from the community,” he said. “When I hear about them, I support them.”

Dix gave a similar answer at a March 16 event, stressing that he and the ministry need to listen to what communities want. “A community health centre is developed in the community,” he said. “Why is there one in Renfrew-Collingwood? Because the community made a proposal approved by the Ministry of Health, and it's going ahead. Why did Lu'ma start? For the same reason.”

When Mary Chudley was told about Dix’s comment that he can’t create the proposals for community health centres himself, she had a ready answer.

“I’ll do it,” she said. “Tell him that.”

A model that works for everyone

Chudley is the director of health services at Cool Aid. She also sits on the BC Association of Community Health Centres board and worked at a similar organization in Ontario in 2005 when that province doubled its number of community health centres to 120.

“A community will take health-care services,” she said, adding that introducing a community health centre might require taking time to educate people about the model. “A community’s not going to say no.”

B.C. has been comparatively directionless on community health centres, said Chudley. “It’s so haphazard here,” she said, before adding that recent talk of a more permanent funding model is encouraging. “The haphazardness is, I think, decreasing.”

Along with financial support, it would be better to have one point of contact for community health centres at the ministry, she said, at least as the model is expanded, instead of managing them through five different health authorities.

Chudley also cautioned that the new model for paying doctors may not be a good fit for every community health centre, noting that basing payment on “attachment” or return visits by particular patients will present a challenge for clinics like Cool Aid’s that provide care to people when they see them but may not be able to count on the same individual returning for further care.

“My life goal is everyone will have access to a community health centre,” Chudley said. “This is a model that works for every single person. It works for our health-care system, it’s going to save us money. It works for our health-care providers because they get to do the job that they have been trained to do, and now more than ever... we have to have them doing the job they’re trained to do.”

One of the first things a new patient to a community health centre like Cool Aid would notice is how quickly they were connected to the right provider for what they need, said Chudley.

It might be a referral to a nurse for wound care, a walk down the hallway to see a counsellor or meeting with a medical office assistant who can arrange a referral to a specialist, she said. “It’s literally sometimes taking the person to the provider so that they can see them,” she said. “They’re not just triaged into the system and you wait for a call from some specialist. You’re accompanied throughout.”

Community health centres also tailor the care to the needs of the population they are serving, she said, giving Cool Aid as the example. “It’s so important that they will experience health care that is trauma-informed and that understands there’s an assumption that if you’re a patient here you’ve most likely experienced trauma of some sort in your life or because of what has been placed on your body through substance use disorder, living under-housed or on the street.”

For many of the people the clinic serves it’s a very vulnerable moment to be talking to someone about their health, she said. “If you’re having that vulnerable moment and you’re also living a vulnerable life, and you do not feel safe because in the past you’ve experienced the health-care system judgment, stigmatization... you can’t express that pain and what’s wrong with you.”

Cool Aid applies a social determinants of health perspective to the care provided and can make sure people feel seen and don’t get lost in the system, she said. “I’m not saying we get it perfect all the time, but we have to actually get it pretty perfect, otherwise we can’t do the kind of care we’re doing.”

Green Party Leader and Cowichan Valley MLA Sonia Furstenau recently visited Cool Aid’s clinic. “You walk in and you already get a sense of the energy and vibrancy at this health centre,” she said. “Everybody in there is working as a team. You’re not just walking into a doctor’s office where you have one doctor who’s the point person for every patient that comes in.”

While there’s a lot of talk about moving to team-based care, community health centres are actually doing it, and that’s good for both the patients and the people providing the care, Furstenau said.

“You see a much lower rate of burnout,” she said. “You see more stability in the health-care delivery, more connection with the community and with the patients, and that is essentially a part of a health-care system that works not just for patients and communities, it works for the health-care providers.”

Compared to urgent and primary care centres, which don’t seem to be delivering the results the government promised, community health centres have demonstrated real success, she said, adding that she’s delighted to know more are coming.

"The government has often actually been a barrier to the doctors and health-care teams that come together that want to bring a community health centre to their communities,” Furstenau said. “I’ve heard this over and over again the barriers have largely been at the ministry of health level, but also at the health authority levels.”

The government needs to do more to actually support the model instead of getting in the way, she said.