THE RENEWAL OF PRIMARY CARE
Medicine Forum 2001
Ontario College of Family Medicine
Ian R. McWhinney
March , 2001
In 1978 the Institute of Medicine in the U.S.A. described the four cornerstones of primary care as accessibility, comprehensiveness, co-ordination, and continuity. They also added a feature that is shared with all sectors of healthcare: accountability. These are all general terms, as are the Colleges important four principles of family medicine. They require fleshing out in terms that have a personal meaning for doctors, nurses, and patients. What does it mean to be a family physician? To me it means that our relationship with patients is unconditional. All clinicians have relationships with patients. With most fields of medicine, the relationship is with a patient who has a certain disease: diabetes for the diabetologist, heart disease for the cardiologist, and so on. Other disciplines define themselves in terms of clinical content, not in terms of relationships. The relationship is conditional on the patient having a disease covered by the clinicians specialty.
In general practice, we form relationships with patients often before we know what illnesses the patient will have. The commitment, therefore, is to a person whatever may befall them. Our discipline depends on this unconditional commitment. If we allow it to break down, general practice could break into a hundred fragments. We must not say: I will care for you as long as you don't get too complicated, or as long as you dont get Aids, or become an alcoholic, or become housebound, or as long as you are not dying. If we refer the patient for specialized care, this does not end our relationship. Nor should we say I will care for you, but I only do psychotherapy, or palliative care, or addiction medicine. These are all splendid vocations, but they are not general practice. A patient we make a commitment to should feel assured that they will not be abandoned whatever may befall them. This commitment means that the relationship is open-ended: it is ended only by death, by geographical separation, or by mutual consent.
A number of things flow from this relationship. If successful, it allows intimacy and friendship to grow not a social friendship, but a friendship based on a mutual interest in the patients health and wellbeing. It will tend to be a long term relationship, since many of the ordeals our patients have to endure last for many years. At its best, the relationship will be one of trust; though trust has to be earned and it is fragile as well as precious. The relationship deepens our knowledge of our patients lives, though we must always be prepared for surprises. We may not know our patients as well as we think we do. Cumulative knowledge in a long term relationship gives us great advantages. It means that every new event can be understood in the context of a life story.
Of course, real life is not so neat as I have suggested. There never was a golden age when everything was perfect. In a mobile society, relationships end for geographic reasons. Relationships do not always work out. The rapport may not be there and it is then better for the relationship to end. Trust may fail - we all fail patients in this way at times. Sometimes we are forgiven, sometimes not. Some patients do not want a relationship let alone an intimate one. Others come to value the relationship only when they feel the need of one. Some relationships become distant when patients gravitate to secondary care with cancer or Aids or mental illness, and so may become strangers to us. Because of our own limitations, there are times when we have to transfer care to a specialist colleague, sometimes for a long period, but we never know when the patient may need us again.
The relationship with patients based on an unconditional commitment distinguishes us from physicians in other types of primary care, such as emergency medicine, and walk in clinics where treatment of episodes followed by discharge is built into the role and where there are boundaries that cannot be crossed.
There never was a golden age, but there was a time when this idea of the family physician was general across the province and across the country. Since then, the unconditional nature of the relationship has begun to unravel. Since there is no accountability for the comprehensiveness of care, it is possible to bite off the easier parts and to opt out of the more difficult ones: hospital care, home care, out of hours call, and so on. Doing so actually increases the material rewards so perverse are the incentives. The result is increasing fragmentation and lack of co-ordination with all their consequences. At the present rate of decline, I believe that in a few years we will not have a system: only a confusing jumble of disconnected pieces. This will have economic consequences: fragmented care is expensive care. It would be tempting to blame all this on the doctor shortage, but it would be wrong. I remember warning as long ago as the 1980s that a significant number of family physicians were abandoning their dying patients, or refusing home care, withdrawing from hospitals, and failing to make responsible deputizing arrangements. Of course, the doctor shortage has made things worse. It has greatly increased the pressures and the stressfulness of practice, so that the withdrawal that began as a diminishment of responsibility became for many a matter of survival.
All this began at a time when big changes in the system were predictable. The new technologies communication, investigative, monitoring and therapeutic favour dispersal rather than centralization of services. In the 1960s and 1970s, when machinery was cumbersome, surgery more invasive than it is now, and communication was by paper, it made sense to concentrate patients in hospitals and to centralize their paper records. Electronic communication, early hospital discharge, and portable technologies are shifting care more and more to the home, even for acute illness. For the elderly, this can be a boon because hospitals can be dangerous places for this age group. Intravenous chemotherapy, antibiotics, and rehydration is routine in the home. Pain control in the home is readily available for most patients. Pneumonia and relapses of congestive heart failure and COP-D can often be managed in the home.
The shift away from the hospital has been accentuated by the aging of the population. In the 1980s a CMA report concluded that even to maintain the existing hospitalization rate, the country would need a thousand additional 300 bed acute and chronic hospitals. This is clearly not going to happen. The writing is on the wall. As things stand now, our primary care system is ill prepared to meet this challenge even if there are no major unexpected catastrophes. I sometimes wonder, for example, how we would cope with an influenza epidemic on the scale of the one which swept the world in 1919.
Its a great credit to the strength of our convictions that there are still many family physicians still trying, in the face of all the difficulties and in spite of all the disincentives, to hold the system together. And we are very fortunate in having the movement of self-renewal represented by those who have attended these forums.
Let me pick out some aspects of this process that I think are especially important. The proposal we are discussing has a number of great strengths:
Let me speak in more detail about aspects of implementation, and especially about the key issue of accountability.
Terms of Service
Defining province wide terms of service (Mandatory Functions) is crucial. The basket of services defined in the report is a first step, but the terms need to be much more specific. Some of them are so vague that they are open to many interpretations. For example, #8 requires "arrangements for 24 hour/7 day a week response". I could say that my response is a recorded message, telling patients to go to the nearest emergency room or walk-in clinic. Item #9 requires "support for in-home, long term care facility and hospital care." I could say "Yes, I support patients at home, in nursing homes, and hospitals: they can phone me any time, but I dont do home visits, attend nursing homes, or hospitals."
They need to be much more specific, always bearing in mind that we are talking here about a group responsibility with some potential for differentiation within the group. There are also geographic limits to a practices reach, but patients could be made aware of these limits when they join the practice.
The terms of service will be difficult to implement unless practices are accountable for them. To whom are they to be accountable? In every community I foresee the need for an organization on which family physicians are fully represented. In terms of organization, family practice in the community is the one sector that remains unstructured. Hospital departments of family medicine provide a structure through which family physicians are represented and accountable in the hospital; but fewer family physicians are now affiliated with urban hospitals. Family physicians in the community are not part of the community care structure, so in relating to the big institutions, there is nobody to speak for family practice, and no organization through which practices can be accountable for their services. In small communities, the hospital department might be able to take on this role by extending their reach into the community. In urban communities we need to think about forming such organizations and how they might relate to hospitals and community care access centres and to District Health councils. Two models would be worth looking at. The government funded Divisions of General Practice in Australia have provided communities with organizations of general practitioners that can fulfill this role; and the General Practice Co-operatives in Britain have brought together general practitioners for such purposes as providing after hours care for a whole community.
The Primary Care Team
What do we mean by the primary care team? We should distinguish here between the core team and the extended team. The extended team is a range of professionals who can be deployed according to individual patients needs: social workers, physiotherapists, psychologists, occupational therapists, and so on. The core team comprises those people who work together day in and day out with the same groups of patients. The key working relationship here is between nurse and physician and I would add the receptionist, even though this is not a clinical role. The core team of nurse and physician has hardly been realized in our system. It has great potential for enhancing both the efficiency and quality of care. I think the proposal is right in rejecting the notion of a nurse practitioner in our system as being a subordinate clinician, treating minor ailments according to pre-ordained algorithms. This is not a professional role. The literature does not support it (Starfield, 1998). The whole point of the nurse physician partnership is that it is a coming together of two disciplines, two sets of skills, and two perspectives. The result should be an increment of care. This has certainly been my experience in working with nurses in palliative care and home care. I think the role envisaged for nurse practitioners in primary care is an extension of the traditional one of office nurse. It could include, for example, follow-up visits with patients with diabetes and hypertension, health education, health assessments and screening procedures, home visits for homebound patients, and liaison with public health nurses, nurses in home care, and nurses in shared care programs.
Enrollment of Patients
Enrollment of patients in practices will be desirable in implementation of the proposal. This is not to enable payment by capitation, even though physicians may well choose this as part of a blended funding package. I think the proposal is right in separating the issue of enrollment from the issue of remuneration. Enrollment is desirable for several reasons. If the family physician is to be the co-ordinator of the patients record, this will require an agreement between patient and doctor. The doctor will have to know who his or her patients are and who he or she is responsible for. Confidentiality issues will have to be addressed. Registration of a practice population and computerization of practice records, with record linkage to other databases, is a major task and will require a big initial investment of funds. The process does not end when patients are enrolled. It is one thing to register a practice population and another to keep the register up to date, adding new patients and removing patients who move or die. There will need to be incentives for this. Moreover, the kind of record that is chosen will be a critical issue for us. The way information is coded can drive the way medicine is practiced. The code must support the methods that work in family practice. We must take this issue very seriously.
Enrollment and integration of records have great potential for communication, co-ordination of care, and preventive medicine. It will also enable community needs for health care workers to be based on accurate demographic data. It will provide us with feedback about our own performance, but we must be careful that this is not used by managers as a tool for increasing efficiency.
We are facing many difficult years as we try to meet increasing demands with limited resources. As the experience of other countries has shown, an increasing private sector will not solve this problem. It behooves us all as health care workers and as patients to use our limited resources wisely. Family physicians are highly efficient at conserving resources, without sacrificing quality. There is abundant evidence showing that this is so. There is also compelling evidence that countries with effective systems of primary care show lower health care costs and better outcomes than those who do not (Starfield, 1998). In spite of all that has been lost, we still have a good system of primary care. Lets save it before it is too late.