A Prescription for Renewal
October, 2000
Table of content
Introduction
Background
Strategies and Recommendations
- Creating the Model : The Family Practice
Network (FPN)
- The Family Practice Network
- Interdisciplinary Teams and Collaborative Practice
- Patient Choice
- Health Information and Communications Technology
Summary of Benefits
Recommendations
- Sustaining the Model: The Resources
Needed
- Health Human Resources
- Training for Tomorrow
- Research
- Family Physician Remuneration
- Public/Private funding
- Ongoing Communication and Collaboration
Recommendations
Conclusion
Appendix 1
Appendix 2
INTRODUCTION
This Prescription for Renewal is presented as a ‘living document’.
It is part of an evolutionary process that has grown from years of policy work
in the area of primary care reform by the College of Family Physicians of Canada
(CFPC) and its Chapters.
In 1995, the CFPC’s green paper: Managing Change: The Family Medicine Group
Practice Model was the first response by any medical organization to the
Federal/Provincial/Territorial proposal for reforming primary care in Canada.
Subsequently, the CFPC was an active participant in the National Consultation
on Primary Care, which was part of the Prime Minister’s consultation with
Canadians on primary health care. Between 1996 and the present, the CFPC has
produced annually updated discussion papers on primary care renewal.
In May 2000, a major summit on the future of family medicine and primary care
in Canada was hosted by the CFPC. This conference was attended by more than
70 representatives of national and international health care and medical organizations,
family physicians and medical and surgical specialists, the public, nurses,
representatives of medical schools, students, residents, licensing authorities,
and the federal government. The consensus reached by summit participants contributed
substantially to this ‘Prescription for Renewal.’
In addition to involvement at the national level, the CFPC has also participated,
through the work of its Chapters, in primary care deliberations within the provinces.
Of particular note has been the work of the Ontario College of Family Physicians
(OCFP), which has taken a leadership role in primary care renewal discussions
in Ontario and has developed a series of important position papers on this subject
(see Appendix 1).
At their meeting in September 2000, the First Ministers agreed to collaborate
on several priorities for health system renewal. Their communiqué identified
many of the goals that the CFPC itself has long advocated and endorsed.
In this document, Primary Care and Family Medicine in Canada: A Prescription
for Renewal, the CFPC presents a model for delivery of primary care services
by family doctors, nurses, and other health care providers and offers strategies
and recommendations to both create and sustain this model. We hope that this
document will stimulate a response from governments and our health care partners
across Canada that will result in the realization of the vision we all share.
BACKGROUND
When governments and planners from around the world look for a health care
model to emulate, they are invariably drawn to what we have in Canada. Canadians,
too, value their health care system. Historically, Canadian medicare has enjoyed
one of the highest user satisfaction ratings of any nation.
One of the main reasons for this Canadian success has been the work of front-line
health care professionals, including family physicians. Primary care services
provided by family doctors and nurses contribute substantially to the quality
and cost-effectiveness of the system. Canada has long recognized this relationship,
and Canadians have benefited because family medicine has been nurtured and promoted
as a vital component of health care.
Today, almost every country with a successful public health system has a strong
primary care component led by family doctors. This is true of the United Kingdom,
France, the Netherlands, Finland, Australia, New Zealand, and other nations.
Even in the United States, where specialists have traditionally far outnumbered
primary care physicians, there is now great interest in recruiting family doctors,
particularly from Canada.
Why are family physicians playing an increasingly important role in the health
systems of these countries? Because, like Canada, other nations have recognized
that primary medical care is one of the best investments in health care that
can be made, and that the key to the success of a primary care system is having
a strong cadre of well trained family physicians.
Countless studies have shown that family physicians deliver the kind of health
care that planners and decision makers want and people need. Centred on patients
and committed to comprehensive continuing care, the discipline of family medicine
espouses the same principles so valued by health care systems around the world.
In Canada, family physicians provide diagnosis and medical treatment; health
protection, and promotion; coordination of care; advocacy on behalf of patients;
and office-based care, as well as care in hospitals, homes, nursing homes, and
community facilities. They provide not only first-line medical services, but
also a substantial amount of secondary and tertiary care in all communities,
particularly in rural and remote settings.
In spite of this, and even though the Canadian family medicine model is envied
throughout the world, governments here in recent years have lost sight of the
many benefits and strengths that family doctors bring to Canada’s health system.
Unfortunately, over the past decade, many public policies throughout Canada
have had the effect of undermining the important role of family physicians and
other primary care providers, demoralizing this vital health care workforce.
For example, the decision to downsize the hospital sector has, in many cases,
been implemented without a corresponding increase in support for the activities
of community-based family doctors and nurses. This has resulted in growing numbers
of patients in communities with more complex and higher acuity needs.
To meet this increasing demand, what we needed were more family doctors. .
Instead, since 1993, decreases in medical school enrolments and postgraduate
training positions have resulted in our producing 285 fewer family physicians
per year – a cumulative loss of more than 1900 family doctors for our system
(Thurber, Busing, Canadian Family Physician, September, 1999). .
Further compounding these resource problems have been the large number of family
physicians throughout the 1990s who chose to establish or move their practices
into the United States and the increasing numbers of family doctors who retired
from practice. The rate of retirements is actually expected to increase even
faster as the physicians who joined the work force in the 1960s enter the final
stages of their careers.
The cumulative result of all these trends, policies, and government decisions
has been steady erosion in the number of family doctors in this country.
Doctor shortages are now a reality being felt in communities in every part
of Canada, especially in rural areas. But shortages are not only a rural problem.
Today, many people living in the most populated areas are also experiencing
difficulty accessing a family doctor.
These shortages are putting enormous pressure on the existing workforce. According
to the CFPC’s 1997 National Family Physician Survey, family doctors are working
an average of more than 70 hours a week, including scheduled office visits,
hospital responsibilities, and after hours on-call services.
In spite of the hours they are working, many physicians find themselves at
the limit of their capacity to care for patients, causing them to either close
their practices to new patients or to limit the scope of services they offer-
e.g. no longer caring for hospitalised patients, not including palliative care
services, not delivering babies, etc.
Some family physicians, particularly in urban communities are confining their
practices to specific areas like sports medicine, occupational health or psychotherapy.
In rural or remote communities, family doctors facing similar pressures usually
cannot close or limit the scopes of their practices. Unfortunately, they often
see leaving the community as being their only option.
As noted above, many family doctors have moved to the United States or other
countries. Some have left medicine altogether. The 1997 CFPC National Family
Physician Survey reported 31% of family physicians planning to leave or substantially
alter their present practices within 2 years, and the Angus Reid/Alberta Medical
Association 1998 Survey identified 51% of physicians in Alberta as dissatisfied
with their medical careers and 29% considering leaving the province.
How have these changes affected patient care? Patients in one community after
another across Canada have been speaking out about the difficulty they are having
finding family doctors. More than half the family physicians in the 1997 CFPC
survey reported that patients were having difficulty accessing medical care.
With physician shortages already causing problems, many family doctors overworked,
and the supply of new family doctors insufficient to fill the growing gaps,
patients’ access to services could be even further compromised in the future.
There are simply not enough family doctors, and the numbers we do have are inadequate
to ensure equitable distribution around the country.
Patients today are more worried than ever that the system will fail them. They
are confronted with delays, waiting times, and crowded emergency departments.
In ever-increasing numbers, they are heading to United States centres for diagnosis
and treatment. They see more and more medical services being privatized.
"There is a perception among providers and the public that access to core
services is deteriorating." (National Forum on Health. Canada Health Action:
Building on the Legacy, Volume 2. Ottawa, 1997.)
To further complicate matters, recent medical school graduates concerned about
the lack of support for family doctors in our system are no longer choosing
careers in family medicine as they once did. Between 1995 and 2000 the percentage
of graduates selecting family medicine as their first choice careers fell from
40% to 29%. Our nation’s goal of having family doctors make up 50% of all practicing
physicians in the country could be seriously jeopardized if this trend continues.
In response to these many pressing problems and challenges, the CFPC has developed
this Prescription for Renewal. It is a new vision for primary
care and family medicine in Canada, and it offers innovative strategies and
recommendations for revitalizing our health care system. Our model proposes
roles and relationships for family doctors, nurses, and other health care professionals,
which would result in appropriate and improved access to primary care services
for all Canadians.
The CFPC urges ‘renewal’ rather than reform. Our current system, though in
need of repair, is still the envy of the world. We need to build on our strengths,
not tear down what has served Canadians so well for so long.
As providers and coordinators of care and patient and population health advocates,
family physicians are valuable assets to the Canadian medicare system. The success
of health system renewal in Canada will rest with a strengthened rather than
a diminished role for Canada's family doctors.
As stated by Dr. Carolyn Bennett in her book Kill or Cure – How Canadians
Can Remake their Health Care System (Harper Canada, 2000) – "At the
present time there are 15,000 members of the College of Family Physicians of
Canada… they are a firm foundation on which to build the reformed system. They
are part of the solution."
It is with this in mind that we have applied ourselves in formulating Primary
Care and Family Medicine in Canada: A Prescription for Renewal.
Strategies and Recommendations
The CFPC's Prescription for Renewal proposes strategies and makes
recommendations on two fronts: (A) Creating a Model for the Future Delivery
of Primary Care: The Family Practice Network (FPN); and (B) Sustaining
the Model: The Resources Needed.
(A) Creating the Model: The
Family Practice Network (FPN)
1. Family Practice Networks (FPNs)
One of the keys to the success of primary care renewal will be the ability
of family doctors to work together more effectively in providing services to
their patients.
Some have suggested that an expansion of Community Health Centres (CHCs)— staffed
by family doctors and other health professionals would accomplish this objective.
While the CFPC believes that CHCs will continue to be a model of choice for
some physicians and patients, there are too many variables from one community
to the next (e.g. geography, physician and nurse resources, patient/population
demographics, special needs) to presume that a single model will be appropriate
for all. We therefore oppose any attempt to force or conscript family doctors
into CHC practices. The reality is that in Canada, most family physicians still
favour some form of independent private practice and should be supported to
carry on in this way.
At their meeting in September 2000, the First Ministers stated that one of
their goals for the health system is to ensure that Canadians have timely access
to an appropriate, integrated, and effective range of health services. A particular
objective they highlighted is to decrease overuse of hospital emergency departments
to prevent overcrowding and to avoid the expensive and inappropriate use of
this limited resource.
The CFPC is proposing a model of primary care delivery that would meet the
goals and objectives described by the Ministers. It is calling for the establishment
of Family Practice Networks (FPNs) throughout Canada.
With this model, family doctors throughout Canada would be encouraged to form
real or virtual groups, practising either in the same office setting or in different
locations, but linked with one another to facilitate transfer of information
and to share clinical responsibilities. Wherever possible, this linkage should
be supported through the implementation of electronic information and communications
technology.
FPNs would facilitate provision of comprehensive and continuing care
by family physicians and other health care professionals. Some family physicians
would offer a broad range of services while others would provide expertise in
areas of special interest. Patients would benefit by having family doctors within
an FPN refer to one another when necessary to ensure access for them to the
entire range of services.
The number of physicians and other health care professionals to be included
in each FPN would be determined by factors such as its geographic location and
the demographics of the patient population to be served.
With family doctors and other health care professionals working together as
integrated teams, FPNs would be able to respond to the needs of patients with
respect to a defined scope of primary care services 24 hours a day, 7 days a
week, 365 days a year – with the after-hours on-call responsibilities shared
by the doctors and nurses of each FPN.
While more work needs to be done to define the scope of services to be included,
a good starting point might be the ‘set of mandatory functions for primary care’
preseoted in 1996 by the Ontario Provincial Coordinating Committee on Community
and Academic Health Science Centre Relations (PCCCAR) (see Appendix 2).
Family physicians working in FPNs would continue to be the entry point to the
medical care system, ensuring patients access to and coordination of all medical
services required, including care in office, hospital, home, and other community
settings. The role and responsibilities of nurses in FPNs would be substantial
and would recognize their knowledge and skills as defined by the scope of nursing
practice.
Patients should be encouraged to receive all their non-emergency primary medical
care from their FPN. If they access care elsewhere, no financial penalties for
patients, family doctors, or FPNs should be imposed. Freestanding walk-in clinics,
unaffiliated with comprehensive continuing care office practices, should not
be encouraged as part of our health care system.
It is important that there be a centralized record for each patient. This record
should be owned by the patient and maintained by his or her family physician
and FPN. It should follow the patient through the health care system.
FPNs should not be mandated, but should be introduced and allowed to expand
and grow as a result of patient and physician choice. With more than half of
all family physicians already practising in groups of three or more, we believe
that with the appropriate encouragement and support, FPNs could become the organizational
model of choice for all family physicians in Canada.
2. Interdisciplinary Teams and Collaborative Practice
Under the FPN model, family physicians, nurse practitioners, nurses, midwives
and other health care professionals would work in interdisciplinary, integrated
teams.
While this is already the case in a number of family practices across Canada,
the CFPC recommends that this approach be more strongly encouraged and supported
to help foster the kind of comprehensive, integrated care that our patients
will increasingly require in the future. Teamwork involving a broad spectrum
of health care professionals, with patients at the centre, is essential to the
provision of high-quality care.
The spectrum of care required by patients will be provided for them by their
family physicians working together with nurse practitioners, nurses and other
health care professional members of FPN teams. The number of family doctors,
nurse practitioners nurses, and others required to participate as part of an
FPN will vary from practice to practice depending on geographic location and
patient demographics. Besides nurse practitioners, nurses and midwives, other
professions, which could also be part of integrated teams, include dieticians,
social workers, psychologists, physiotherapists, occupational therapists, and
pharmacists.
While the specific roles of each provider may vary from one FPN to the next,
generally, family physicians would be responsible for taking the lead role in
providing and coordinating medical care, and nurses would provide and coordinate
a range of nursing services.
A collaborative practice approach based on mutually supportive roles for doctors
and nurses would facilitate the delivery of a comprehensive scope of primary
care services for patients within FPNs. As described by Way, Jones, and Busing
in their paper Collaboration in Primary Care – Family Doctors and Nurse Practitioners
Delivering Shared Care (May, 2000) "Collaborative practice involves
working relationships and ways of working that fully utilizes and respects the
contributions of all providers involved". Their article also states that
in a collaborative practice, "Nurses practice nursing, physicians practice
medicine."
While it is recognized that in some parts of Canada, nurses with advanced training
i.e. nurse practitioners or extended-practice nurses, may now perform some acts
previously restricted to physicians, generally, nurses are not licensed to carry
out independent medical practice. The CFPC supports expanded roles for nurses
with advanced training but maintains that all licensed providers of medical
diagnosis and treatment in Canada should be required to meet the same high standards
of education and training.
It will be important for governments to provide appropriate funding to support
interdisciplinary teams. Currently, remuneration for office nurses is usually
provided by family physicians from their own earnings. This has resulted in
many private practices finding it difficult to include nurses as part of their
professional staffs. Continuation of this approach will likely rule out the
appropriate inclusion of nurses as key players in FPNs. The CFPC therefore supports
government funding being offered as an option for remuneration of nurses, nurse
practitioners, and other health care professionals working within FPNs.
To encourage maintenance of competence, governments should also support continuing
professional development for family physicians and other members of the FPN
team.
The CFPC also recommends that each provider on an FPN team be accountable for
his or her own professional practice and be responsible for securing his or
her own liability coverage.
3. Patient Choice
Every Canadian should be encouraged to have a family doctor of his or her choice,
preferably within an FPN. Patients should have the right to change family physicians,
FPNs. When patients transfer their care to other family physicians or FPNs,
their health records should follow them.
Programs should be developed to help patients understand their responsibility
to seek primary care services from only their own family physicians and FPNs
whenever possible. There should, however, be no financial penalties for patients,
family doctors, or FPNs if patients access care outside their own FPN.
The issue of patient registration or rostering has been the focus of debate
for some time. The CFPC recognizes that, while patient registration might provide
some organizational and health outcome benefits, it will only work if it is
strongly endorsed by both patients and physicians. We therefore believe that
formal patient registration or rostering should not be mandated but rather should
be left as an option which could be adopted by any practice.
4. Health Information and Communications Technology
The Canadian health care system has been slow to realize the potential benefits
and power of new information and communications technologies.
Hopefully the focus on e-health technologies emphasized in this fall’s meetings
of our First Ministers and Health Ministers will mark the beginning of greatly
increased support for the introduction and expansion of this important resource.
To stimulate the use of information technology in medical practice, the CFPC,
The Royal College of Physicians and Surgeons, Scotiabank, and WebMD Canada have
recently launched The Canadian Doctors Network
(CDN). This initiative will provide family doctors, medical and surgical specialists,
and patients with secure access to on-line medical and health information, including
the e-based tools needed to communicate, transfer data, carry out continuing
education, and share expertise with one another. Ultimately, we expect that
CDN will facilitate creation and management of electronic health records for
all Canadians.
One of the most advanced web-based portals in the health care field, CDN will
offer Canada the opportunity to accelerate the formation and support the functioning
of FPNs and would open the door for other patient and health care system benefits
in the future, including:
-
Enhanced physician-to-physician communications and
consultations including distance consultations.
-
Links between physicians and other health care
providers, pharmacies, hospitals, laboratories and other diagnostic services;
-
Immediate secure access to patients’ health records
(including information regarding medications) in clinical settings such as
emergency departments;
-
Patient access to information regarding their FP/FPNs
(i.e. through practice websites) as well as to other health information and
educational materials;
-
Shortened waiting times for appointments.
The CFPC recognizes much work still needs to be done to achieve this e-health
vision including development of standards to ensure compatibility of health
information networks and resolution of issues related to consent, privacy, security,
and confidentiality of personal health information.
We invite government and all health and medical care organizations in Canada
to join us and our partners in further development of the Canadian Doctors’
Network.
(A) Creating the Model: The Family Practice Network (FPN)
Summary of Benefits
I. Builds on Strengths
The FPN model expands on current practice structures, builds on existing patient-doctor
relationships, offers continuing comprehensive care to patients through a network
of family doctors and other health care professionals, avoids disruption for
patients and upheaval in the system, and, if introduced as part of a well-supported,
voluntary strategy, capitalizes on the power of motivation of those choosing
to participate.
II. Improves Patient Access
Teams of health care professionals working in FPNs will be better able to respond
to the needs of patients with respect to a defined scope of primary care services
24 hours a day, 7 days a week, 365 days a year.
III. Ensures Comprehensiveness and Continuity of Care
Drawing on the skills and knowledge of teams of family physicians and other
health care professionals, FPNs can offer comprehensive, continuing, primary
care services to patients throughout their lives.
IV. Provides Cost-Efficiencies
FPNs will help reduce health service duplication and inefficiencies, including
the costly overuse of hospital emergency departments.
FPNs will facilitate coordination of care.
V. Enhances Quality of Care and Facilitates Integration of Health Care Professionals
FPNs ensure delivery and coordination of a defined scope of needed services
for patients by highly skilled health care professionals working together as
integrated teams.
FPNs ensure access for patients to services provided by their family doctors
and other health care professionals in offices, homes, hospitals, and other
community settings.
FPNs support and facilitate integrating the care of physicians, nurses, and
other health professionals, recognizing and respecting each for the knowledge
and skills related to their disciplines.
VI. Enables Optimal use of Health Information and Communications Technology
The FPN model facilitates rapid adoption and ongoing evaluation of new technology.
VII. Supports Rural and Remote Communities
The availability of teams of health care professionals who share primary care
responsibilities will enhance recruitment and retention of family physicians
and other health care providers in underserviced areas.
The introduction of health information and communications technology will greatly
enhance patient care and help meet the continuing professional development needs
of rural family doctors and other health care professionals.
VIII. Meets both the Professional and Personal Needs of Family Physicians
and Other Health Care Providers
FPNs offer more flexible working arrangements, which could lead to improved
personal and family health for family physicians and other members of the team.
FPNs can accommodate family doctors with more specialized scopes of practice,
allowing them to pursue their areas of interest while still being part of a
team that provides patients with comprehensive, continuing care.
(A) Creating the Model: The Family Practice Network (FPN)
Recommendations
A1 Every Canadian should have a family physician
of his or her choice, preferably one who is part of an FPN.
A2 Family physicians, nurses, and other health
care professionals in Canada should be encouraged and supported to join FPNs.
A3 Interdisciplinary integrated care teams should
be established within each FPN.
A4 FPNs should serve all Canadians as the point
of entry for primary care family practice services.
A5 FPNs should provide comprehensive continuing
care for patients throughout their lives.
A6 FPNs should be prepared to respond to the
needs of patients with respect to a defined scope of primary care services 24
hours a day, 7 days a week, 365 days a year. After hours, the family physicians
and nurses who are part of the FPN team should share on-call responsibilities.
A7 There should be no financial penalties for
patients, family doctors, or FPNs if patients access care outside their own
FPNs.
A8 Freestanding walk-in clinics, unaffiliated
with comprehensive continuing care office practices, should be discouraged.
A9 Direct funding from government should be
available as an option for remunerating nurses, nurse practitioners, midwives,
and other health care professionals working in FPNs.
A10 Government funding should support FPNs in
the acquisition and maintenance of computerized information and communications
systems.
A11 Patients should own their health records;
family doctors should be custodians of the records. If patients move from one
family doctor or FPN to another, their health records must move with them.
A12 Formal patient registration or rostering
should not be mandated but rather should be left as an option which could be
adopted by any practice.
(B) Sustaining the Model: The Resources
Needed
As a society, Canadians must be assured of access to high quality primary care
both today and in the future.
To sustain the model will require a commitment to:
- The human resources needed to provide the services;
- The training of future providers;
- The research required to evaluate outcomes;
- The remuneration and funding strategies needed to
support all parts of the system and,
- The collaboration and communications amongst all key players which will
be required.
1. Health Human Resources
There is an urgent need for a substantial increase in the number of trained
family physicians in Canada. As described earlier, doctor shortages are now
a pressing problem in many communities. Yet Canada is presently producing approximately
285 fewer family doctors a year than it was in the early 1990s.
While the CFPC is pleased that some provinces have introduced modest increases
in medical school enrolment, we believe more must be done. In keeping with the
recommendations of the Canadian Medical Forum (CMF), we support an immediate
expansion of medical school entry positions to at least 2000 per year (up from
1500 as of September 1999).
As well, we propose that family medicine residency positions be increased to
50% of the total of all first year postgraduate residency positions available
across Canada (from the present 38%).
While increasing opportunities for young Canadians to enter and complete their
medical training in Canada must be a priority, we recognize that the benefits
of this strategy will not be felt for at least 6 to 10 years.
The CFPC therefore also supports implementation of programs to identify and
help train physicians from other countries in order to help them to become Certified
(CCFP) and fully licensed family physicians in Canada able to help us meet the
immediate problems patients are experiencing accessing family doctors.
While we welcome those who have been educated and trained in other countries
as valuable colleagues in the Canadian health care system, we believe that all
physicians must be expected to meet the same high standards before they are
awarded Certification or granted licenses to practice.
We will also continue to encourage provincial and territorial governments and
licensing authorities to work toward standardizing their policies and protocols
for the awarding of licenses to new physicians and locum tenens physicians in
order to diminish the complicated process and the confusion that presently exists
from one jurisdiction to another across Canada.
The CFPC is also concerned about the serious shortages of other health care
professionals, especially nurses. Of note, in 1999, the Canadian Nurses Association
projected a shortage of more than 50 000 registered nurses by 2010. We encourage
and support an immediate increase in nursing school entry positions as an essential
component of the renewal of primary care in Canada.
In September 2000, the First Ministers promised to "coordinate efforts
on the supply of doctors, nurses, and other health care personnel so that Canadians,
wherever they live, enjoy reasonably timely access to appropriate health care
services." We applaud their words and hope they will be translated into
action.
2. Training for Tomorrow
Core training
To ensure a sustainable supply of practising family physicians, nurses, and
other health care professionals, Canada must provide opportunities to educate
and train adequate numbers of young Canadians to meet the present and future
health care needs of our society. This will require not only an increase in
the number of training positions but also an ongoing commitment to ensure
that the training provided is meeting these needs.
The 16 Canadian University Departments of Family Medicine and the CFPC have
long been committed to this goal and will continue to work together to help
further clarify and define the core knowledge and skills that should be included
as mandatory components of all family medicine residency-training programs.
The PCCCAR set of mandatory primary care services can serve as one of the
models for the further development of the core curriculum objectives for family
medicine residency training (see appendix 2).
The CFPC’s accreditation standards for family medicine residency training
programs should include the requirement for programs to have provided residents
with the opportunity to develop their competence in a defined set of core
knowledge and skills.
As well, the CFPC must remain committed to ensuring that the awarding of
Certification in Family Medicine (CCFP) includes the requirement for physicians
to have demonstrated their competence in a defined set of core family practice
knowledge and skills.
Following completion of residency training, family physicians usually decide
which services they will provide (or not provide) based on their own competencies,
interests and needs as well as the needs of the patient population they are
serving. While each family doctor should be encouraged and supported to provide
as broad a scope of services as possible, gaps may exist in an individual
physician’s practice. To fill these gaps and to ensure patients have access
to the most comprehensive scope of primary care services possible, family
doctors should practice in collaboration with others, i.e., in FPNs.
Added skills training
While core family practice competencies must be included in all 2-year family
medicine residency programs, each trainee should also have the opportunity
to acquire extra skills to meet the needs of specific communities or populations
(e.g., rural, inner city, aboriginal). These extra skills could be acquired
as elective experiences during the 2 years of family medicine training or
during optional third year (R3) programs.
At present, while at least 40% of those in two-year family medicine programs
indicate their interest in acquiring further training, R3 positions are available
for only 10% of them. The CFPC is therefore calling for an immediate fourfold
increase in the total number of R3 positions to meet the needs of both the
graduating physicians and the populations they will be serving.
There should also be an increased number of added skills training positions
to accommodate both international medical graduates and family physicians
in practice seeking to return for further training. These positions could
be offered for varying lengths of time based on the past experience and competency
of each individual.
The positions for family medicine residents moving directly from R-2 to R-3
slots should be protected (separate from those for international medical graduates
[IMGs] and re-entry candidates).
Training for rural practice
Over the past several years, the CFPC has clearly stated its position supporting
the need for more exposure to rural and remote community practices for all
undergraduate medical students and family practice residents. Medical school
admission criteria need to be modified to encourage and welcome more applicants
from rural, remote, and other special-needs communities. Family physicians,
including rural physicians, should have larger roles as lecturers, supervisors,
and mentors for undergraduate medical students.
Better role modelling and positive messages about family practice, including
rural practice, at both undergraduate and postgraduate levels, must be encouraged.
All programs should offer rural-based training experiences following the recommendations
in the May 1999 CFPC position paper, Postgraduate Education for Rural Family
Practice: Vision and Recommendations for the New Millennium.
Integrated training
The CFPC supports integrated models of education and training for all health
care professionals (family physicians, specialists, registered nurses, etc).
We believe providing shared experiences during both undergraduate and postgraduate
training will enable those preparing for different health care professions
to learn to work together and enhance their understanding of one another's
roles.
Funding and support
Enhanced training of increased numbers of medical and nursing students, postgraduate
residents, IMGs, re-entry physicians, and others will only be possible if
adequate funding and other support resources are provided for university departments,
hospitals, and physician and nurse teachers and researchers.
Overlooking or denying this support will severely compromise the likelihood
that Canada will resolve its present and future health human resource problems.
3. Research
Primary care and family practice research is one of the most important components
of the discipline of family medicine.
Ensuring sustainability of a high-quality primary health care system will require
a commitment to ongoing research. Studies should be carried out to measure the
impact of FPNs and physicians’ different patterns of practice on patient care
and health system outcomes.
Family medicine as an academic discipline and as a community-based resource
with family doctors practising across the country is ideally placed to lead
these research initiatives. Establishment of information and communications
technology systems in FPNs would facilitate research activities.
The CFPC and the 16 University Departments of Family Medicine are committed
to playing a leadership role in the future of primary care and family medicine
research in Canada.
4. Family Physician Remuneration
One of the effects of the changes taking place in the health care system (hospital
downsizing, regionalization, health human resource shortages, aging population,
increasing complexities of care, etc) has been that family physicians are increasingly
being called upon to ‘fill the gaps’ and provide a growing number of services,
including some with greatly increased complexity.
At the same time, however, there have been no incentives for family doctors
to take up this additional workload. In fact, many governments over the past
decade have provided disincentives, such as caps or ‘claw backs’ on physician
incomes.
We hope that the September 2000 federal/provincial/territorial agreement will
mark an end to these approaches and the beginning of an era that will identify
more appropriate recognition of the needs of patients and the role of family
doctors. This must include appropriate remuneration for their services as well
as programs that address the need for them to have a balance between practice
commitments and their personal lives.
If we are to ensure Canadians of an adequate supply of family physicians in
the future, it is imperative that family doctors be appropriately compensated
for the many roles they play and services they deliver. This must include incentives
for providing care in hospitals, homes, and community-based facilities; obstetrical
care; palliative care; anaesthesia; emergency room work; and other more demanding
services. In addition, family physicians must be supported in their critical
role in health promotion and prevention, in teaching, and in research.
With respect to the model of remuneration, the CFPC urges flexibility and choice.
In February 2000, this point was made in an open letter to the Federal Minister
of Health, the Honourable Allan Rock, in which we strongly opposed the suggestion
that all family physicians in Canada might be placed on salaries and emphasized
our support for each physician and community retaining the right to choose the
payment strategy best suited to them.
Patients and their needs vary widely, and this diversity must be reflected
in how doctors are compensated. Several years ago, the CFPC put forward a blended
funding formula that supports this flexibility. This mechanism offers a range
of remuneration options (e.g., fee-for-service, salaries, sessional fees, and/or
capitation) that can be implemented either alone or in combination.
Whatever the payment mechanism, the goal is to ensure that patients receive
the highest-quality health care possible. This will require a motivated workforce
of health care professionals. We must ensure that family doctors, nurses, and
other members of the primary care team are well remunerated with appropriate
incentives to support the broad range of services they offer.
5. Public / Private Funding
The CFPC supports a single-payer, publicly funded system for all medically
necessary services. We also support medically necessary home care services and
essential medications being publicly funded as part of our nation’s medicare
program.
We recognize, however, that public funding must be maintained at appropriate
levels if Canadians are to be protected from the need to pay privately for such
services.
Patients must also be assured that they will not have to pay directly for medically
necessary services even if such services are delivered by the private sector.
When the private sector is involved in delivering services, providers and facilities
should be required to meet the same standards as are expected of those in the
public sector. Governments working with professional colleges and associations
have a responsibility to establish a monitoring and disciplinary process applicable
to the private sector.
The roles and relationships of the private and public sectors in the delivery
of health and medical care services require ongoing study. The effects of private-sector
delivery of services on patients, providers, governments, and other players
must be part of this research.
As a society, we have important challenges ahead of us. One challenge is to
try to agree on which services are to be defined as ‘medically necessary.’
6. Ongoing Communication and Collaboration:
Many of the concepts forwarded in the FPN model will require further deliberation,
communication, and study as they are being addressed and implemented, including:
- The supports needed to establish and sustain the
model;
- The roles and relationships of nurses and other health
care professionals within FPNs;
- Studies to be carried out to measure the pros and cons
of formal patient registration;
- Studies to measure the impact of FPNs on patient care
and health system outcomes;
- Strategies to ensure accountability of providers, patients, and governments;
Collaboration, which includes all key players – physicians, nurses, patients,
other health care providers, and governments – will be critical to the ultimate
success of this vision.
(B) Sustaining the Model: The Resources Needed
Recommendations
B1 There should be immediate expansion of medical school enrolment across
Canada to address the critical shortage of practising physicians.
B2 There should be immediate increases in family medicine residency
positions to address critical shortages of practising family physicians.
B3 There should be immediate increases in other appropriate training
programs across Canada to address critical shortages of medical and surgical
specialists, nurses, and other health care professionals.
B4 The CFPC and the University Departments of Family Medicine should
maintain their commitment to ensuring that a clearly defined set of core knowledge
and skills are a mandatory part of the curriculum of the two-year family medicine
residency-training program for all residents.
B5 The CFPC’s accreditation standards for family medicine residency
training programs should include the requirement for programs to have provided
residents with the opportunity to develop their competence in a defined set
of core knowledge and skills.
B6 The CFPC must remain committed to ensuring that the awarding of Certification
in Family Medicine (CCFP) includes the requirement for physicians to have demonstrated
their competence in a defined set of core knowledge and skills.
B7 There should be expanded training opportunities for ‘added skills’
in family practice for family medicine residents, IMGs, and physicians in practice
seeking further training.
B8 All university undergraduate and residency programs should offer
rural-based training experiences consistent with the CFPC’s May 1999 position
paper: Postgraduate Education for Rural Family Practice: Vision and Recommendations
for the New Millennium.
B9 Integrated education and training programs for health and medical
professionals should be introduced and supported to provide shared experiences
among various disciplines.
B10 There must be a commitment to ongoing research in primary care and
family practice in order to sustain the system.
B11 There must be adequate funding and other support resources for university
departments, hospitals, and physician and nurse teachers involved in the training
of family physicians, nurses and other health care professionals.
B12 Family physicians must be appropriately compensated for the increasing
numbers and complexity of services they provide, including incentives for carrying
out specific services needed by patients across the country. Such services include
emergency care, in-hospital care, palliative care, obstetric deliveries, services
for rural and remote communities and other special-needs populations, house
calls, and achieving preventive health goals.
B13 Family physicians should be remunerated by the payment mechanism
that best responds to their professional, practice, and patient needs.
B14 Nurses and other members of the health care team must be appropriately
remunerated.
B15 As a nation, we must try to define ‘medically necessary services’
and ensure that public funding is always able to support provision of these
services to all Canadians.
B16 Where private-sector providers exist, governments must ensure that
all medically necessary services are publicly funded and that governments, professional
Colleges, and Associations establish monitoring and disciplinary processes to
guarantee that private providers and facilities will meet quality and standards
of care.
B17 Studies should be carried out to measure the impact of the FPNs
and physicians’ patterns of practice on patient care and health system outcomes.
B18 Strategies must be developed to ensure accountability of providers,
patients and governments.
B19 Ongoing collaboration, including representatives of family medicine,
medical and surgical specialties, nursing, other health care professions, patients
and governments, must be carried out regarding the FPN model: (a) to address
questions still to be answered related to its creation and sustainability, and
(b) to evaluate its ongoing impact.
Conclusion
As the voice of family medicine in Canada, the CFPC, its 10 provincial Chapters,
and its 15 000 practising family doctor members across the country are dedicated
to enhancing the health and health care of all Canadians. This commitment is
brought to life by what family doctors do every day—in medical schools, through
research, and on the front lines in their practices.
Canada’s family doctors are proud of our nation’s health care system and believe
we should build on its strengths. While there are challenges to improve and
renew it, we are ready to work with governments and all other stakeholders in
this renewal process.
We believe that Primary Care and Family Medicine in Canada: A Prescription
for Renewal presents strategies and recommendations for creating and
sustaining a model of care that will meet the needs of all Canadians.
Contacts:
Dr. Peter Newbery, President
Dr. Don Gelhorn, President Elect
Dr. Calvin Gutkin, Executive Director and CEO
Dr. Claude Renaud, Director of Professional Affairs
Ms. Leslie Challis, Communications and Media Relations Officer
1-800-387-6197
fax: 905-629-0893
info@cfpc.ca
Appendix 1
The following is a list of some of the papers on primary care reform/renewal
produced by the Ontario College of Family Physicians (OCFP)
Bringing the Pieces Together: Planning for the Future - March, 1995
Bringing the Pieces Together: Beginning the Process -March, 1995
Family Medicine in the 21st Century – A Prescription for Excellence
in Health Care – Visioning the Future, Listening to Reality -November,
1999
Family Medicine in the 21st Century – A Prescription for Excellence
in Health Care -June, 1999
Where Have Our Family Doctors Gone: #1 A Brief History of the Family Physicians
Shortage in Ontario - 1999
Where Have Our Family Doctors Gone: #2 Reversing the Trend -1999
Where Have Our Family Doctors Gone: #3 Hospitals without Family Physicians
-1999
Where Have Our Family Doctors Gone: #4 The Future is Now! -September, 1999
Family Medicine in the 21st Century – Implementation Strategies
-March, 2000
Mental Health Reform Initiatives – Implementation Strategies for the New Millennium-March,
2000
Implementation Strategies: "Collaboration in Primary Care – Family Doctors
& Nurse Practitioners Delivering Shared Care" -May, 2000
Implementation Strategies: Protecting Trust in the Patient-Physician Relationship-June,
2000
Implementation Strategies: "Too Many Hours, Too Much Stress, Too Little
Respect"-July, 2000
Appendix 2
Provincial Coordinating committee on Community and Academic Health Science
Centre Relations (PCCCAR), 1996
Common Set of Mandatory Functions
-
Health Assessment
-
Clinical evidence-based illness prevention and health
promotion
-
Appropriate interventions for episodic illness and
injury
-
Primary Reproductive Care
-
Early Detection, Initial and Ongoing Treatment of
Chronic Illnesses
-
Care for the majority of illnesses (in conjunction
with specialists as needed)
-
Education and Support for self-care
-
Support for In-Home Long Term Care Facility and
Hospital Care
-
Arrangements for 24-hour/7-day a week response
-
Service Coordination and Referral
-
Maintenance of a comprehensive client health record
for each rostered consumer in the primary health care agency
-
Advocacy
-
Primary Mental Health Care including psycho-social
Counseling
-
Coordination and Access to Rehabilitation
-
Support for People with a Terminal Illnes
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