The double-edged sword of primary care reform in Quebec, redux

It has been over 15 years since the Medical Post published an article of mine titled: “The double-edged sword of primary care reform in Quebec.” My thesis was that primary care reform that started in 2004 had excellent potential but that the power given to the government to interfere in primary care delivery was a liability. Giving the government the control on where and how family doctors practice meant these become political and thus unenlightened decisions. I thought I would write again with an update. First the good news. The creation of family medicine groups has been a great success with the majority of family doctors practicing within these structures—and with good reason. Doctors are working with colleagues, nurses, and other health professionals such as dietitians, social workers and psychologists in family medicine groups—while maintaining the control of clinical functioning with the chief family doctor. Registration of vulnerable patients allows better funding to support their care. In return, the clinics cover the care of their patients six or seven days a week. Read: Dr. Brian Gore: Stop blaming FPs for the woes in primary care After lagging in technology, Quebec learned from the errors of other regions and adopted newer technologies, the most important of which was cloud computing. Now we have a central cloud database for the entire population of Quebec fed by all the databases in the province including medications, labs, vaccinations, and imaging clinics. Instead of imposing a single electronic medical record on physicians, a choice was given to physicians offering competition and a variety of data inputs. Each EMR must meet certain criteria such as being able to connect to the database or the consult system. It has worked very well. As other countries have been mired in their legacy systems, Quebec has leapfrogged ahead. However, in some areas of the province up to 40% of the population are unable to access this upgraded primary healthcare system. As I had warned, the powers given to government bureaucrats have led to significant errors in the organization of family doctor services. Since the ill-planned early retirement program of the late 1990s, the province has stumbled from mistake to mistake. The first was the introduction of regional human resource plans in 2005 with the intended purpose of ensuring equitable access for family doctor services. Based on flawed data which neglected the portability of health care, and based on political regional interests, equity of access has gone out the window. Rates of registration with a family doctor in Quebec’s 115 local regions vary from 94% to 61%. This has created a healthcare crisis in many areas of the province. Indeed, one area has close to 100,000 people without a family doctor and a restricted recruitment that barely allows replacement of departures. The situation is particularly difficult in urban centres such as Montreal which care for many patients from other regions. Extra provincial recruitment has been effectively blocked and the province has been a net exporter of doctors since the health human resource plans started in 2005. The second error was the imposition of prioritized medical acts set by the local regional department. Family doctors must spend 12 hours a week performing medical activities most of which occur outside of primary care causing a further drain on primary care. While refusing to address the inequity in access, and denying the portability of health care, the premier of the province has accused the physicians in hard-pressed areas of not working hard enough, resulting in the latest abreaction. The proposed Bill 11 will do two outrageous things. It will force family doctors to make their schedules available to regional bureaucrats who may fill those appointments and ensure work off hours. Secondly it proposes to restrict new patients to be taken only from the local patient waiting list in the area again controlled by local bureaucrats. You must live in the region to be on this wait list. The principles of portability of healthcare and the right of a citizen and a physician to agree on a therapeutic relationship offended in one proposed law. The inevitable result will be further chasing of family doctors out of the province or into private medicine. Perhaps the bean counters down the hall in the Quebec finance department would not mind this but the health consequences are severe. For every 100,000 people without a family doctor 49 people die annually. In my article 15 years ago, I mentioned the economist Friedrich Hayek and his comments on “the inevitability of planning.” Once you embark on attempting to control the activities of man you embark on an ever increasingly complex and inefficient process. That book is called The Road to Serfdom. I still recommend it. Quebec regions with low FP registration rates As of Dec. 31, 2020, 79% of the Quebec population is registered with a family doctor, resulting in 1,864,223 citizens without a family doctor. The target of the government is 85%. The 115 local regions of the province show significant inequality in registration rates with 22 regions below 75% and 22 subregions have attained a registration rate of 90% or more. (RLS stands for reseau locaux de service = local region.) Source: Quebec Ministry of Health 2021 Dr. Mark Roper is the director of the division of primary care in the department of family medicine at McGill University Health Centre. He created the Where are the family doctors? website with more information.

The double-edged sword of primary care reform in Quebec, redux

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