Primary care is the heart of healthcare
Dr. Trevor Hancock
20 February 2017
I spent the first 4 years of my career working as a family physician, both in rural New Brunswick and in a community health centre in Toronto. It was very satisfying work and I enjoyed it greatly, but my wish to move further upstream and prevent rather than treat and manage illness took me into public health. While I have never regretted that choice, I have a soft spot for primary health care, which I see as the heart of health care, and the key to an effective health care system.
Primary care is the point of first contact for most health care, handles most of the patient load and is the gatekeeper for access to specialty care. Good primary care systems can and should coordinate care at home and in the community, and should be able to follow their patients into and back out from the hospital and specialty care.
The late Dr. Barbara Starfield, one of the world’s leading researchers on primary care, noted in 2008 that countries with strong primary care systems have better health outcomes, lower costs and greater equity in health. She also noted that “within countries, areas with higher primary care physician availability (but NOT specialist availability) have healthier populations” and that “more primary care physician availability reduces the adverse effects of social inequality”.
So it is distressing to see that family practice is not in good shape here in BC, or for that matter across Canada. A 2012 report from the Canadian Foundation for Healthcare Improvement noted “Despite significant progress since 2000, the performance of Canadian primary care trails that of many other high-income countries”. This is bad for patients, bad for the health of the population and bad for society as a whole. It’s also bad for doctors, who want to practice in a better way.
Last year, two experienced family physicians here in Victoria were so concerned about the state of primary care that they were moved to write opinion pieces in the Times Colonist. In June, Dr. James Stockdill, a family doctor here for 37 years, identified a number of problems including, above all the need to “very quickly to establish nurse practitioners in a community-care role”. But he concluded “The institutions that could favourably deal with this crisis have failed to implement effective policies that would alter the course of this downward spiral in primary care”.
And then in September a clearly frustrated Dr. Robert Brown, a family physician in a clinic in Sidney, wrote that primary care in BC is not working because it “operates in a foundational and structural vacuum”. He memorably described the present system as operating “much like a tent city — disorganized and not meeting anyone’s needs”. He called for the creation of ‘medical homes’ – what I would call community health centres. These would be facilities designed for teams of family physicians and other primary care providers (he suggested nurse midwives, nurse practitioners, licensed practical nurses and social workers), serving a patient population registered with the practice, and able to “adequately provide for all the needs of their patients at all times”.
But while the province claims that primary care is a priority, it has not been getting anywhere near enough attention. The Ministry of Health’s 2015 Discussion Paper on a strategic policy framework for primary and community care in BC begins by admitting that “This is the first time that the Ministry of Health has attempted to capture the significant and sometimes loosely connected initiatives and policy that make up efforts to improve primary care and home and community care”. But there is no mention of either ‘medical homes’ or community health centres – only ‘team-based family practices’. And it does not sound as if there is any sense of urgency; the recurring theme is about being opportunistic and incremental.
So in the coming election campaign, we need our political parties to take a clear and strong position in support of primary care, and to commit to strong and urgent action on primary care reform. They must recognize primary care as the heart of the health care system, and its practitioners as the key to an effective and well-functioning system, and treat it and them accordingly.
© Trevor Hancock, 2017