Sunday, December 17, 2017

What Do We Want From Primary Care, Part III

What's a government to do, once it knows what it wants to do?

Primary care reform was never going to be easy. No matter what order the various priorities are placed in, each jurisdiction is still struggling with the shift, even where recruitment of family doctors and nurse practitioners isn't a problem. Sixty years ago, a country of independent, self-employed family doctors to deal with acute problems was good enough to meet most of the population's needs, and there was more than enough money floating around to pay the bills. However, now that we've (apparently) decided that the future of primary care lies in multidisciplinary teams, allocated (somehow) to meet the geographic and demographic needs of the population, there's a lot more planning and thinking and experimentation that needs to get done. So how's it all working out?

It's not.

But why aren't things going according to plan? It's not for a lack of planning, not (entirely) for a lack of money, and certainly not for a lack of people sitting around in committees talking over subs or wraps. The problem is a lack of scrutiny, of asking hard questions and refusing to accept deflection and spin.

An example is in order. While Ontario's Patients First is a stellar example of half-baked ideas, it's too easy to pick apart as a pointless endeavor on its face. Instead let's look at Nova Scotia, a place that remains forever near and dear to my heart.

The details of Nova Scotia's primary care crisis are best summed up in this "by the numbers" news report, the pointed op-ed in the Chronicle Herald and Medical Post by Dr. Ajantha "A.J." Jayabarathan, and a random glance at the list of current job openings for family doctors in Nova Scotia, a list that takes longer to scroll through than two or three chapters of the Iliad. Without getting too deeply into it, over 40,000 Nova Scotians are actively looking for a family doctor, 100,000 are without one, and the existing physician workforce is rapidly nearing retirement. In the case of Dartmouth, the "sister" of the capital city Halifax, 40% of the family doctors are set to retire imminently, delaying closure of their practices out of a sense of duty. Many, if not most, of the collaborative care clinics being ushered into the province are still in development. And the province is nowhere close to meeting its recruitment targets, despite the health authority's website with a charming catchphrase.

While I direct readers to Dr. A.J. for a description of the government's obfuscation and half-truths, it's the Public Accounts Committee proceedings (the video embedded in the story) that illustrates how a lack of scrutiny prevents meaningful reform from coming about. The first hour of the video is mostly made up of opposition party legislators (MLAs) asking general questions of senior bureaucrats, to get a sense of the magnitude of the problem. It's the second hour where the "action" happens, though the word is used in the loosest conceivable sense. The opposition MLAs do a solid job of holding senior bureaucrats' feet to the fire, calling out non-answers, relating complaints from constituents, and highlighting how little a grasp the health authority and Ministry seem to have on the problem.

It's when the governing MLAs get a turn to speak, however, that's telling, as the ones in power are simply derelict in their duties of governance. Just past the 1 hour mark, there is a solid 20 minutes of mutual congratulation on the part of the government and its bureaucrats. Later in the second hour, there are several exchanges that include softball questions ("how can we MLAs in the community help you better communicate your strategy?") and outright deference to the various plans and schemes. These plans and policies were developed by public servants with little-to-no input from front-line health care professionals.

When asked about the challenges recruiting to Dartmouth, the health authority's head of Family Medicine blamed local family doctors of dissuading prospective recruits. Nobody asked follow-up questions. Nobody explored what roles the medical association's lawsuit against the Nova Scotia government, or the government's heavy-handed "credentialing" process might have played. When asked about complex patients turned away by family doctors, the health authority and Ministry were "very concerned" and articulated a need for "innovative, creative strategies". Nobody asked what such buzzwords might translate to in the real world.

Nobody asked whether the any of these grand strategies is being reconsidered. Nobody pressed the issue of younger doctors working fewer hours, and how the government plans are being adapted. Nobody asked about the number of staff dedicated to all these committee meetings and recruitment drives and tours for young doctors, and the cost of hiring all these people. Nobody pushed back at the health authority's smug dismissal of orphaned patients' administrative needs, including application for disability benefits.

Public servants work with the best intentions, but they don't get hired or promoted for their creativity. Moreover, the higher up they are, the more insular and disconnected they get from the front lines and any sense of urgency. We rely on the media and elected politicians to perform the vital task of asking hard questions and challenging even basic assumptions. It should not be viewed as mere finger-wagging for the purpose of political points, but rather the best bet for getting public policy right. Failure to do so is not just dereliction of governance, it leads to bad public policy, throwing good money after bad, and fails to improve the day-to-day lives of citizens.

Primary care is facing severe unaddressed problems all across Canada. New doctors are increasingly running away from primary care, and aren't working the same style or hours when they do pursue it. The population is aging, amassing chronic health problems that modern medicine can treat but not readily reverse. The country is massive, with sparse populations outside of a few dozen cities. The infrastructure is lousy -  health care and otherwise - for many of the sickest and neediest Canadians. The costs of medical care, technology, and multidisciplinary teams continue to grow apace, but governments are increasingly disinterested in paying.

These problems can be overcome, some of them probably for less money than we fear. But that can't happen until our leaders - elected or appointed - set firm priorities, and embrace rather than avoid hard questions.

Note: Barring something truly newsworthy, this is my last post for 2017. Hope everyone has a terrific Christmas/Holiday season, and we'll see you back in 2018!

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