Has B.C.’s fledgling team-based care initiative been preempted by the urgent need to attach patients?

There are two populations in Canada right now, each with its own, distinct health outcomes: Those with family doctors, giving them proper access to health care. And the five-million or so Canadians without family doctors—people whose access is diminished with consequences yet to be fully measured. In family practice, everyone is talking about the “quadruple aim” of quality care, but the most politically pressing crisis facing health planners and politicians today is the urgent need to attach patients to doctors, so they can access that care. This is apparent in the way British Columbia configured its team-based primary care initiative, now about four years old. B.C. is home to 5.32 million people (and growing). Over a million B.C. residents do not have a family doctor. Team-based primary care models have taken root to one degree or another in several Canadian provinces. In Alberta, where the shift into team-based care was physician led and is now a particularly well-established and physician-centred system, they are called Primary Care Networks (PCNs). B.C. might have been emulating Alberta when the current provincial government launched B.C.’s PCNs in 2018. And that, right there, is the crux of the difference between the two systems: B.C.’s PCNs were initiated by bureaucrats, not primary care physicians, and they continue to be dominated by health authorities. B.C. PCNs are inseparable from the ministry of health’s (MOH)—understandable—preoccupation with “attaching” orphan patients to doctors ASAP. Read: Defending B.C.’s new FP billing model This is how a spokesperson from MOH put it, in a Jan. 19, 2023 email exchange with the Medical Post: “(BC’s) Primary Care Networks are intended to bring together the various partners and organizations providing longitudinal and episodic primary care services in a geographic area and support them to work together to meet the needs of people in their communities.… “The ministry provides local partners with funding and data to develop a service plan proposal to address local gaps in access and attachment.… “In terms of the resources allocated to PCNs, the ministry tracks recruitment progress by period across all primary care initiatives underway within the geography of each PCN. As of Period 8 (to Nov. 10 in fiscal 2022/23), funding for more than 2,112 FTEs has been approved and 1,292 have been recruited across all primary care initiatives. Specifically, for PCNs under implementation, 1,472 FTEs have been approved and 812 have been recruited.” If recruitment and patient attachment are central to B.C.’s PCNs, are the PCNs successfully achieving that goal? And can a system with its eggs in the recruitment basket also bring about high functioning team-based care, through support of established FPs? These are questions worth asking because other provinces can learn from the B.C. experience. B.C.’s PCNs have not been publicly evaluated. How many orphan patients have the PCNs attached? We don’t know. And of the “FTEs” MOH said it has recruited, how many are doctors entering the system, taking on unattached patients? And, by the way, why is there such a gap, after four years, between the number of funded FTE positions and the number of filled ones? Fact-gathering ‘engagement’ From a physician’s perspective, we know more. That’s because of a telling engagement organized last September by Doctors of BC’s General Practice Services Committee (now called the Family Practice Services Committee or FPSC). The engagement brought together physician leads from BC’s Divisions of Family Practice, the division PCN Steering Committee, division executive directors and Collaborative Services Committee (CSC) co-chairs. (Government and health authority representatives are members of CSC.) The engagement was convened to “provide divisions with the opportunity to share their experiences related to PCN governance with each other and with the (FPSC) caucus, in order to develop shared understanding of current pressures and areas for change that would enable PCN success.” The feedback generated by the session can be found as the attached file “PCN Governance – Divisions Engagement Session” at the bottom of this article. Importantly, participating physicians expressed a perceived “imbalance of power in PCN governance,” with health authorities and MOH exercising an upper hand over physician leaders. They pointed out the “difference in culture, approach and power dynamics” that exists as a result of the pairing of “relatively flat structures (divisions) with hierarchical structures (health authorities)” as a a barrier to collaboration. They called for “giving divisions more responsibility for PCNs (with additional resources, funding and supports),” with the goal of “ensuring primary care is being governed, planned and implemented by primary care providers within the community.” They also expressed a desire for PCN-funded nurses to be selected and employed directly by physicians. (Right now, with some atypical exceptions, the PCN nurses are unionized health authority employees—with the full package of benefits those employees automatically bring to a workplace.) Collaborative relationships were found to be better in some health authorities than in others. (Island Health, in a recent Doctors of BC survey, was deemed the most difficult health authority in the province). But the call for a more physician-centred governance structure—closer to Alberta’s—was resounding. What physicians have to say Dr. Janet Evans, a FP from Kelowna (and member of both the Central Okanagan Division of Family Practice and the FPSC) participated in the September engagement. Her division was an early adopter of PCNs and has been one of the most successful at collaborating with its local health authority (Interior Health). Dr. Evans has had a positive experience with PCNs. She appreciates having been allowed to keep the nurse she had already trained, and continues to employ her, with PCN funding. But Dr. Evans also worked for several years as an FP in Alberta’s PCNs. She is able to compare the two systems, at their core. “In Alberta, the doctors thought, this is a good idea (creating the PCNs), and what happened in B.C. is that the health ministry said, look what they’re doing (in Alberta)—You shall do this,” Dr. Evans recalled in an interview. The Medical Post spoke with a number of FPs, in different parts of the province, to get a range of feedback on PCNs: We could start with Burnaby/New Westminster FP, Dr. Carllin Man. He sits on the board of the Fraser Northwest Division of Family Practice. A young FP, he currently has a 900-panel longitudinal practice, sharing his office in a loose arrangement with one other FP. Having trained in Alberta and done his residency there, Dr. Man absolutely loved Alberta’s physician-led PCNs. When, seven years ago, he started working in B.C., he was disappointed there were no PCNs. “When they finally came, I was like, wow, this is nowhere close to what I imagined, based on my experience in Alberta,” he said. “So it was a really, really big failing.” Dr. Man finds that, compared to Alberta’s, B.C. PCNs are very under-resourced. “The PCN has helped me with my practice,” he said, “but not to the extent that I would have wanted.” He appreciates the counselling services the PCN provides—“they really help my patients”—but he only gets .5 FTE of support and could use a lot more. “Mental health is, like, probably the number one visit reason in my practice.” Dr. Man also gets limited access to a PCN nurse, but—with only two doctors on site—he was not eligible to have an FTE nurse based in his office. He was OK with that though, seeing there were all kinds of HR complexities involved in taking on a health authority employee. “When the nurses were first moving into family doctors’ offices, there was a bit of contention because, you know, we had to follow health authority rules in our private clinics,” said Dr. Man. “So things like doing liquid nitrogen treatment for skin warts apparently became an issue, or having a plant in the room—because I guess a patient could throw it at you.” He still has a hard time wrapping his head around the fact that, “compared to Alberta, B.C. is like, 10 years behind in terms of the way (information technology) works, especially from a primary care aspect.” “You know, originally I was feeling like, OK, I have all these great ideas, let’s make things better. And then I realized, everything works so slowly here that it’s a waste of my time to even try to make things better.” Dr. Vanessa Young is a Victoria FP who is a member of the clinical faculty at the University of Victoria’s Island Medical Program. Through previous leadership roles in the South Island Division of Family Practice, she helped to design her division’s PCN service plan. “I think it is really important for people to understand that the health ministry’s goal for PCNs was to increase attachment and access. The Division of Family Practice’s goals were to improve and actually reform primary care. So the very small piece of alignment we had was team-based care,” Dr. Young said in an interview. Like Dr. Man, Dr. Young and her (three) clinic partners declined the FTE nurse option.They were short on office space, and health authority nurses “all come from acute care,” Dr. Young said. The MOH expectation that comes with a FTE nurse—to take on 500 unattached patients—was also problematic. “That’s better for patients, it’s better for the system. But for me personally? I already have 400 patients more than I should,” Dr. Young said. The idea is that taking on a nurse enables doctors to work more efficiently and see more patients, but the math does not work in practices that are short on physical space and over-capacity in their patient panels. Dr. Christopher Dowler is another Vancouver Island FP. He practices at Shoreline Medical in Sidney, B.C. Dr. Dowler’s partners had no problem attaching 500 patients. They have attached more like 10,000 and recruited 16 new doctors because their clinic model is so distinct and successful, they had to expand to a second site. He has many concerns about how B.C.’s PCNs are configured. “I have to say though, I’m reticent about being too harsh because of Bill 36,” he said, referring to B.C.’s new Health Professions and Occupations Act. “Bill 36 is a gag order,” Dr. Dowler said, and even though the legislation has not come into effect yet, he is afraid of repercussions. “I think something that I’m comfortable being quoted on is that there are very good individuals working within the PCN.… But the design of it is vulnerable and flawed. And it’s an experiment, fusing small businesses (i.e. physicians) with government employees.” Most of the time, unless it’s a health-authority-driven priority, there is “a bit of a push-pull,” he said. “The health authority (Island Health) wants to do things a certain way with their employees (the nurses)—and they can kind of unilaterally just force that on us.” “And, you know, it’s difficult when we’re talking to people within the health authority, who —you know, they’re middle managers, and they can’t make decisions. They’ll say, ‘Oh, let me just talk to my superior.’” Back on the B.C. mainland in New Westminster., B.C., Dr. Paras Mehta has been PCN physician lead in the Fraser Northwest Division of Family Practice since the early days of PCNs. The Northwest Division was an early adopter. As an active collaborator, he’s generally proud of how the PCNs are evolving. His clinic (six physicians) has an FTE health authority nurse who knows the patients well and eases the physicians’ workload in a multitude of ways, especially with pediatric patients. They have elbow room in their practice and have taken on nearly 400 unattached patients over the past three years. Dr. Mehta and his clinic partners have figured out ways to use the PCN resources to increase capacity. The principle of freeing doctors to do the doctors’ work is working exactly as it’s supposed to work. He just wishes he could amplify that success, and have the nursing support extend into chronic disease management and geriatrics. If there could be more FTE nurses and allied health professionals—and a way to affordably accommodate them. If they could physically accommodate another doctor or two. His clinic could provide more care and further increases in attachment would happen. “The challenge is in terms of physical space,” he told the Medical Post. “In our community the actual physical space that is affordable is very limited. You’re seeing older buildings being torn down, the newer buildings provide commercial space at a much higher cost. And you still have to do your tenant improvements, you still have to buy equipment. That initial cost is not funded (by the PCN). I think we could do more to create capacity. But, you know, that’s the next sort of limiting step.” The ‘refresh’ on the horizon Dr. Evans is optimistic about the future of B.C.’s PCNs. Her own experience has been positive. The division manager is from Alberta and, right from the get go, she effectively communicated to Interior Health the importance of enabling physicians to select their staff. They developed an onboarding process, requiring prospective health authority nurses to make a presentation and go through an interview process. That eliminates candidates who lack genuine interest in primary care. Her practice had no difficulty agreeing to gradually take on 500 unattached patients. There was a partner whose practice had growing room. Now, as a member of the FPSC, Dr.Evans is involved in the “Refresh” that emerged from the September 2022 engagement, The Refresh is acting on the engagement’s recommendations for changes in governance. The FPSC’s initial Refresh document was prepared in December 2022. (A copy of “Primary Care Network Governance Refresh Summary” is attached at the bottom of this article.) “What would I like to see come out of the Refresh? I would like to see the further development of team-based care,” Dr. Evans said. “As far as the governance is concerned, kind of what they’re talking about is empowering the PCN steering committees—I think to work more with the community and figure out what the community needs, and then letting that be part of the PCN as opposed to the health authorities getting their fingers in primary care,” she said. “I mean, they are not in primary care, they don’t understand primary care. And so it’s a little bit of a shift of the balance, while still recognizing they are a valuable, valuable partner and we need to work together.” The health ministry, so far, has been supportive of the Refresh. It is aware the PCNs need tweaking if they are to become more successful in drawing new doctors and attaching more patients. “I think what they’re looking at right now is a ministry or health authority/physician co-chair relationship, which should be an equal, collaborative relationship. I think it often has been a little bit lopsided, because the person who controls the money somehow feels that they have the power,” Dr. Evans said. “If we don’t agree, let’s not just make arbitrary decisions, let’s actually figure out how to problem solve and get to what actually we’re after, which is the quadruple aim—team-based care and, better patient care.” “This is an amazing opportunity to create something that’s a little bit closer to what’s happened in Alberta, where the doctors’ decisions carry more weight.” The FPSC’s Refresh document is expected to be completed by the end of March.

Has B.C.’s fledgling team-based care initiative been preempted by the urgent need to attach patients?

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