How UPCCs are trying—but failing—to solve Victoria's FP shortage and what locals are doing about it

The family doctor crisis has politically exploded in Victoria, capital of British Columbia, smack under the noses of the provincial cabinet. Since the beginning of this year, four busy walk-in clinics have closed due to doctor shortages and unsustainable funding. (At just over $30/visit, B.C.'s fee-for-service/Family Physician fee may be the lowest in Canada). There are regular reports of another family doctor quitting his or her practice—often young, not retirement age. Local journalists write about how the B.C. government's health funding and FP practice models are behind the times, not able to support longitudinal care. Public sympathies are with the doctors in this crisis, with letters to the editor pressing the government to make FPs’ jobs more desirable, so the void can begin to be filled. Read: Physician assistants say they could help ease pressure on Nova Scotia health system BC Health Care Matters' leader is a young Victoria woman called Camille Currie—a business owner and mother of two pre-teens. The children, along with her husband, have Leukodystrophy: an auto inflammatory disease caused by a rare genetic mutation. Their lives depend on carefully monitored medications and good care. Currie herself had heart surgeries at 31 and relies on her pacemaker 70%-to-90% of the time. The pacemaker has 10 months left in its battery. A detail like that is worrying because Currie lost her family doctor this winter and there was no doctor to take her place. Her response was to begin educating herself fully on what was driving FPs out of practice and closing clinics. She started BCHCM, took to social media and Victoria's family doctor shortage quickly became a runaway public issue. This city has had a serious doctor shortage for over a decade, without any hint of a public protest. One million of Canada's five million unattached patients reside in B.C. Yet the provincial government somehow managed to keep the problem under the radar, until now. The shortage was most recently camouflaged by the noisier COVID impact on health care resources. B.C. Doctors and nurses who work at hospitals and Health Authorities must sign restrictive clauses in their contract, preventing them from speaking out on issues that concern them. Read: Antibiotic use in young children may lower vaccine-induced antibody levels But B.C. doctors have become agile on social media. Amid clinic closures, FPs took to Twitter to describe why longitudinal family practice has become unsustainable in B.C. Not just the fees, which one FP pointed out compare poorly with the cost of calling in a competent appliance repair person. There’s also the paperwork burden. One Victoria FP, Dr. Jennifer Lush calculated that 40% of the hours she spends working is paid time. The other 60%—charting and forms in the evenings at home—that’s donation. As for other mind boggling inefficiencies in the B.C. system, such as a completely fragmented electronic health record, with multiple providers: the FP who described that on Twitter has given up entirely on practising in B.C. and gone elsewhere. In April, the CBC spent an entire week covering the family doctor shortage, with in-depth interviews on both the morning and afternoon shows that included conversations with doctors and doctor-less patients. People phoned in their questions, their stories of struggling with illness without a family doctor. Over 100,000 Victoria unattached patients have nowhere to go but overcrowded urgent care and emergency rooms. That number has grown with each new closure. This crescendo of doctor shortages has triggered a well-organized and deliberate grass roots campaign called BC Health Care Matters. BCHCM is circulating a petition ("Bring back our Family Doctors and our Walk-in Clinics) and has collected 33,000 signatures so far. It’s organizing a "No Care and Bad Care Do Not Equal Universal Healthcare" rally to take place at the B.C. legislature on May 19. Lawn signs are appearing all over Greater Victoria: "EVERYONE DESERVES A FAMILY DOCTOR." Read: What does an ER doctor/thriller novelist do all day? BCHCM’s goals, posted on its Facebook, include, "universal healthcare, the need for longitudinal care, the need for access to primary care, the need for transparency and accountability within the health ministry and health authorities and proper compensation for family physicians, to retain those we have left and to attract new ones." Not explicit on that official list, but featured prominently at the group's public meetings—like the one held at Victoria's Monterrey Centre on April 28 and now accessible on Facebook—was a warning to the BC Health Ministry: Building urgent and primary care centres may not be the solution to B.C.'s family doctor crisis, and it’s time for the UPCCs cost and efficacy to be publicly and independently evaluated. UPCCs are said to cost $2-to-$5 million apiece, and the government invested in them heavily as its solution to the unattached patient problem. This could be the biggest danger BCHCM poses to the government. FPs expressed disappointment when, instead of announcing a creative and urgent initiative to address the closure of so many doctors’ offices in Victoria and beyond, as they’d hoped, the government's 2022 B.C. Throne Speech said it would build more UPCCs. B.C.’s Ministry of Health announces and re-announces UPCCs. Communications manager, Krystal Thomson, in an email to the Medical Post in December of last year: "Today, 26 new urgent and primary care centres are open and providing care to British Columbians. Another four are opening in the next few months. And another ten will open in 2022/23." Read: Time to make time: Tentative deal with Quebec FPs to require them to allocate certain hours to urgent care UPCCs pay doctors good salaries, and some community-based FPs are closing their practices and moving to them. But there’s no evidence that UPCCs are increasing the pool of available family doctors by attracting new grads, or that family doctors currently working in hospital-based subspecialties are shifting careers to work in primary care at UPCCs. (The MOH may have that evidence but did not respond to our request for an interview). Asked about UPCCs, Doctors of BC president, Dr. Ramneek Dosanjh, a family physician by training. said: "I don't think family doctors on the ground think these are the solution to the problem. We can understand the intention of providing access to timely care, yes, but (the UPCCs) need to be evaluated in terms of effectiveness. We'll be interested in seeing what those evaluations show.” BC Health Care Matters' Currie has had to test out the UPCCs herself, with her immunocompromised children, carrying her thick binder of medical data. "The government would probably say, 'Oh we're great, because we've created all these wonderful UPCCs,’” she said. “But, you know, we've had to take that route several times, when we've shown up and they're at capacity already. I've had another time where I've shown up and just because I suggested that it might have to do with my heart rhythm condition, they refuse to see me and told me I had to go to the hospital. We've had other times when we've gone in and they simply don't have the time to be able to listen to the complexity of my children's conditions." "The biggest problem with UPCCs is you are asking these senior individuals to go stand in lineups for hours to wait and hope that they get seen,” Currie adds. “It's just not reasonable. And it's not universal health care, that's for sure." She heads to the ER now, when she needs medical help. But what she really needs is a family doctor to navigate and manage her family's medical conditions—and to help her address the impending issue of her pacemaker battery. Currie did not start a community organization to address her personal needs. BCHCM has become a huge commitment, one that grows every day because of the people who come forward. She’s heard heartbreaking stories that illustrate the medical and personal consequences of not having a family doctor. One of her co-organizers is a young woman whose breast cancer progressed to stage 4 before it was diagnosed in the ER. Currie has also been entrusted with concerning inside information, particularly with respect to the UPCCs that are soaking up such a large portion of the healthcare budget. "It's not as though I would be opposed to UPCCs if I was hearing that they are an environment that works well for those in the medical field, and if it seemed like a fiscally prudent choice,” Currie said. “But none of that is coming out. And I feel that the government is not providing facts that should be available, even though we have put through a couple of freedom of information requests." Most of the insiders who talk to Currie about UPCCs must remain anonymous because of their contract, but there was one who was prepared to be named. Dr. Steven Keeler is a Victoria family physician and member of the Clinical Faculty at the University of British Columbia. As well as working in an independent family practice with three other doctors, Dr. Keeler does shifts one or two days a week at a Victoria UPCC. "The taxpayers of BC deserve to know the cost of these clinics," he told the Medical Post. “There must be financial accountability, transparency and efficiency data made available to allow an open discussion on how these clinics might work within our failing primary care system.” Dr. Keeler feels strongly that, “the emphasis should be on enhancing supports for family physicians, not creating more inefficient, expensive UPCCs." He said that “based on Island Health Authority numbers, the Westshore UPCC, in Premier Horgan's riding will see approximately 17,000 patients per year, at an annual operating budget of close to $4 million: working out at well over $200 per patient visit.” By comparison, he said, his own family practice, with three physician FTEs and three MOAs will see more patients in a year and cost quarter of that per patient visit. “We provide relationship-based, comprehensive, longitudinal care whereas the UPCCs are providing episodic care.” Read: No room! B.C. doc says stop building big residential housing where there are no FPs to care for newcomers “If that one UPCC budget was spent on physician contracts, it could fund 12 family doctors, which would eliminate approximately half of the orphaned patients on the Victoria Westshore.” If UPCCs were to be useful in tackling the problem of unattached patients, they should be revamped, Dr. Keeler suggested. They should be staffed on a team-based care model with new to practice family physicians who would assume care of unattached patients. “As things stand now, shifts at UPCCs, hospital-based medicine and some telehealth services are drawing family practitioners away from longitudinal care. Many established family physicians have closed their practices to work in these alternative options. A move that would not have been necessary if their private practices had been better supported by the government through funding incentives to offset the cost of overhead, boost to FFS amounts and financial support to hire allied health professionals.” Dr. Keeler stressed that the quality of patient care in the UPCCs is not the issue. "The doctors, nurses, allied health staff provide patients with excellent care—if the patient is fortunate enough to get in the door. Which, unfortunately, many do not.” The original intent of the clinics was to provide access to care improvements and attachment for patients, he said. “Unfortunately they have not achieved these two primary goals and currently the UPCCs are essentially providing walk-in care at ER visit time and cost.” Read: Empowering Canadians to improve our healthcare system Doctors of BC is in contract negotiations with the government right now and Dr Dosanjh remains hopeful that a solution will emerge, and in a timely enough manner to stabilize existing family practices and draw younger FPs into longitudinal care. “We know that there’s many physicians that would rather be in a contract or salaried position. So they don’t have to think about the management or the overhead or the rising cost of business. But the fee-for-service system works for some physicians.There are many different models that are available. There needs to be a menu of options and nothing should be dictated, it should be up to the physician that’s doing the practice to determine the type of care and practice they’re going to provide.” “We’re pressing government for timely action on a number of fronts, and one of them is new contract models that address the rising cost of doing business, and to provide fair compensation for longitudinal care. Another thing is expansion of team-based care . . . meaning doctors can get back to doctoring, Dr. Dosanjh said. “We are in a crisis. We need to understand that. But in order to prevent this from going any further we need to be able to support the physicians on the ground that are doing longitudinal work.” Read: Filling the gaps: Why Canada still needs a public dental health plan despite decades of medicare

How UPCCs are trying—but failing—to solve Victoria's FP shortage and what locals are doing about it

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