The Generalist Manifesto: Reforming primary care in Ontario

A vision of health care in Ontario after the COVID-19 pandemic based on interprofessional, team-based primary care hubs providing care to geographically defined populations has been published in a white paper by a leading group of primary care physicians and nurse practitioners in the province.

The report comes in a global climate of ongoing concerns about the lack of physicians choosing to practice general family medicine.

Describing themselves as “an independent group of Ontario primary care clinicians, leaders and researchers” the authors of Primary Care 2025 include such prominent Ontario family physicians as Drs. Tara Kiran, David Kaplan, Meridith Vanstone and Sarah Newbery, prominent nurse practitioners and representatives from the Association of Family Health Teams of Ontario and the Ontario College of Family Physicians.

The group presents a series of recommendations which places generalist primary care at the centre of a reformed health care system. They note their model is based on the concept of the Patient Medical Home which is already widely endorsed by medical associations in Canada and advances the development of Ontario Health Teams which have already been established in the province.

The authors acknowledge the approach may be challenging to implement. It is likely to prompt many questions from fee-for-service primary care doctors (who make up 25% of primary care physicians in the province), specialists and those working in the acute-care sector. However the group’s authors state that addressing one of the province’s key priorities – the elimination of hallway medicine in hospitals “cannot happen without an investment in primary community care.”

The report discusses primary care in the province before, during and after the COVID-19 pandemic noting that “the disruption of the pandemic galvanized a cultural shift away from many embedded assumptions about how different elements of the healthcare system should work.”

The core recommendation of the report is the creation of primary care hubs “with responsibility for 100% enrollment of a geographically defined population. This goal would be facilitated through blended capitation payment models for family physicians “which will be matched with resources to establish and maintain a high-functioning team of interprofessional care providers.” This implies province-wide expansion of the type of family health team model which had been introduced into the province but is currently not accepting new teams. The report notes There is a 10-fold variation across Ontario in access to team-based care…the patients least likely to be enrolled in a primary care team are those who are poor, new immigrants, and medically complex.”

“Within 6 months, we recommend that patient-enrollment models are opened to new graduates, and team-based resources are expanded to those Ontario Health Teams s which are currently poorly resourced. … By 2025, all patients should have access to team-based care that is appropriate to their needs, no matter what setting they live in,” the report says. Referring to the estimated 1.5 million people in the province who don’t currently have a primary care provider, the report said the goal is for “all citizens in Ontario to be
assigned to a most responsible provider for their care delivery.”

In discussing the pandemic, the group notes that fee-for-service family physicians in the province “experienced significant challenges in being able to manage their practices and sustain care through the pandemic because of the directive to cease non-essential services. This left these practices with no income. In contrast, physicians remunerated through patient enrollment models continued to receive payment for their practice population and were not at risk of needing to close their clinics because of lack of funding.”

Specifically referencing the need for personal protective equipment (PPE), the report stated “many, and probably most, practices in Ontario found themselves without PPE supply sufficient to be able to see patients safely in person, even many weeks into the pandemic. Primary care was the lowest in the priority for receiving pandemic or emergency supplies from government stores.” The group goes on to say that this lack of PPE “is just one illustration of the need for networking and infrastructure support for primary care providers within geographical areas. Primary care practices should be networked, with each network recognized as an important partner within their Ontario Health team.”

The group specifically references calls for primary care practices to offer care on a 24/7 basis stating that “we encourage the use of multiple measures of access that are patient informed, as research has shown patients do not always prefer the “same day or next day” metric of access commonly used by news media and politicians.”

It also says that the pandemic “laid bare “the importance of the social determinants of health, and the vulnerabilities that many of our patients face related to employment, housing, transportation, race, and racism. Embedding primary care, social and health services in a medical neighbourhood will also encourage the delivery of trauma-informed culturally safe care and begin to address some of the structural determinants of health such as racism.” The report added that reforms will facilitate social prescribing by establishing partnerships with established agencies.

The report calls for better use of digital technologies to support the provision of connected care calling for the Creation of an integrated digital platform, “inclusive of home care, acute care, mental health and community support services to support a single, easy communication system for all primary care providers in the network integrated into primary care electronic medical records (EMR)s.

The group also calls direction attention to medical school training and would like to see “record numbers” of medical students choosing generalist primary care as a career by 2025. “Specifically, we are not targeting family medicine residency as a choice, but the choice to pursue comprehensive generalist care after graduation. Policy incentives will be needed to encourage family physicians to combine their area of focused practice with a generalist practice or with strong collaboration with generalists, rather than a retreat into a very small clinical area with limited community relevance and connection.”

The report also makes a strong commitment to involving patients and caregivers in care noting how “after significant improvements in patient and family-partnered care over the last decade, including strong shifts to co-designed care in many places, the perspectives of patients and families were largely excluded from COVID catalyzed changes to the healthcare system.” The report says there is an immediate need to acknowledge the importance of meaningful patient partnerships including the important role of caregivers.

The report’s authors acknowledge the proposed changes we propose in this report are likely to result in a loss of professional autonomy for family physicians because of a loss of choice in how they arrange and organize their practice. They also not that the group preparing the report did not include physicians working in a fee-for-service model, or patient or community stakeholders, “although we believe that as our recommendations move forward, their input about operationalization will be essential”.

“While the cost of change may be painful, it will be nothing compared to the cost of not changing,” the report concludes, with the group noting the white paper is intended to start a conversation on the issue.


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