Our new Primary Care Patient Voices (PCPV) group in BC

[Colin O'Neill]

Hello all!

I'm a new PAN member from BC I've recently help start this provincial council connecting patient partners in primary care across our province. I'm on various leadership committees with Vancouver Coastal Health, and our members come from both urban and rural communities, coming with a wealth of experience.

We are for patients by patients, with strong contacts to the health authorities and the BC Ministry. Our meetings usually start with an education piece with a discussion from a Ministry exec on a relevant topic -- today's Zoom is on team-based care. We then hold a roundtable on new issues and try to open things up for Q/A.

It's been a learning experience on what is most useful for our members and how we can use this PCPV group for positive change. I definitely am looking forward to learning from you and the PAN community to help me with my own patient partner work, as well as to improve the efficacy of PCPV!

Thank you,

Colin

[Carolyn Canfield]

Welcome to PAN, Colin.

Congratulations on the Primary Care Patient Voices group. Say, do you think primary care has taken a back seat in....well, just about everything about patient partnership?

My experience is that the first interest came from the hospitals, then the provincial and federal agencies. After a while, it has been the professional associations for healthcare workers, possibly the regulators, the bargaining units and larger communities of practice, even interdisciplinary! Somewhere in here came the SPOR boost to research funding that instantly ramped up recruitment and team membership with patients and caregivers, big time.

Now primary care seems to have come to the table. Maybe it's been a slow realization because many family docs work alone. Asking patients for suggestions on practice improvement might seem to conflict with the value of being the trusted provider of vital health advice. If a patient criticizes, that might jeopardize trust.

Also, there has traditionally been little or no infrastructure for primary care quality improvement and patient safety. So those meso-level organizations that oftentimes lead patient engagement just don't existed. As Canadian health policy analyst Steven Lewis has said about the consequences of fee-for-service compensation:

Most physicians are independent contractors to the government and operate as cottage industry entrepreneurs with often only fleeting attachments to their place of work and its corporate objectives. Those with office-based community practices are neither formally part of, nor meaningfully accountable, to health regions or their equivalents. SOURCE

That was published in 2013, and today more doctors are affiliated with organizations that, at least obliquely, reference accountability. Not much has changed, however, in primary care. Wouldn't it be marvellous if all the talk about transforming primary care into team-based, relationship-based, Medical Home-based and other hyphenated connecting practice concepts also included improvement structures that embrace patient partnership?

Our current COVID-19 upheaval has suddenly implemented billing codes for virtual care, spreading scope of practice to others (think pharmacy for prescription renewals), and other longstanding streamlining to reduce what patients must do to connect up the pieces of care. Perhaps it is high time during a pandemic to learn from patients and family caregivers what works well in primary care, what needs improvement, and what's missing altogether?

I will be interested in how your group develops its priorities and then organizes around the structure of primary care practice in BC to frame improvement. I hope you are able to shift primary care culture towards partnering with patients to learn about "care as experienced", rather than "care as imagined".

Do post updates here. And to all PAN members, what do you know about primary care practice improvement? What's happening where you live?

Best wishes. Stay safe and be well.

Cheers, Carolyn

[Rachel Cooper]

Hi all,

Long time lurker, not a frequent poster.

For a time, I was a research assistant for a professor at the Factor-Inwentash Faculty of Social Work at the University of Toronto who was doing research into primary care (particular provision of mental health care in primary care) - to my knowledge there was little, if any talk about patient involvement in the research she was working in. I think some of it has to do with the various models that exist to provide care, at least here in Ontario (ie: solo practitioner fee for service docs only get paid when they're providing direct care, and so there's a lot of disincentive to collaborate, whereas Family Health team and other group models that use different funding formulas sometimes have more leeway).

If more comes to mind, I'll circle back and post again!

Cheers

[Carolyn Canfield]

Hi Rachel, Good to hear from you.

Exactly! I hear doctors asking how will they be paid if they join quality improvement discussions. As an unpaid volunteer working flat out over many years, this doesn't go down well with me or other patient partners. And yet... my annoyance doesn't create change.

It's time to implement blended salary+incentive models of pay for all doctors, don't you think? Surveys confirm this is what young doctors want, not the old entrepreneurial small business model.

Today's docs want to get involved in research and evaluation, training the next generation, spreading best practice and much more AS WELL AS seeing patients in longitudinal care (not drop-in clinics). Those will be much happier family docs, I'm sure, with a balanced work week of caring, meeting peers and giving back to the profession.

As you say, the current fee-for-service funding is a disincentive to collaborate with --anyone!

Cheers, Carolyn

[Colin O'Neill]

Thank you for your insights! I'll definitely become more active online here.. as PCPV gets its feet Compensation was one of the initial topics we discussed as a group.. we had the exec director for physician compensation (from the BC MoH) speak to our group. We had a lot of questions for her, and it was becoming a little heated. I think there is a big gap in incentives between providers and patients with fee for service in primary care. A couple key questions I have are:

1. Does culture and what is taught in medical school and residency programs create barriers to change from FFS?

2. Where do physician salaried models work best in healthcare? Have these been used successfully in other jurisdictions?

In BC, there is a large restructuring happening towards creating Primary Care Networks.. hopefully creating team-based care. They are trying to create salaried positions for physicians, but there is difficulty when these are in competition for FFS.

On the one hand the family doctors say they may be over worked (because they take on so many patients, FFS), and on the other, they say they wouldn't be paid enough in these salaried positions that limit their weekly hours.. Hm. And overall, the province has attachment challenges with many patients unable to get family docs.

Lots to think about.

Cheers,

Colin

[Alies Maybee]

Colin, these are great questions and I think pertain across the provinces and territories. We have a couple of models of compensation for doctors in ON as Rachel mentioned. The Family Health Team (FHT) model is a form of integrated care with various professions depending on the team. I think I am correct that the compensation is based on capitation plus something that helps even out the variables between types of patients. This bears more investigation. Then we have various versions of Fee for Service (FFS).

I do feel strongly that FFS is NOT patient-centred. It seems based on the factory model of pay per task. This hardly supports focusing on patient outcomes. I also think some of the younger generation are more open to other forms of compensation since they can often support a better work-life balance as Carolyn described above.

I am also dismayed that hospitals in ON don't compensate the doctors or surgeons. They operate as independent contractors. This means, as I discovered, if the hospital wants to have x policy, the doctors can thumb their noses at it and there is nothing the hospital can do to get compliance. How can change occur in that kind of environment?

I welcome more thoughts on this. Alies

[Annette McKinnon]

That issue you mention Alies, where the doctors are independent contractors to hospitals also created holes in our digital records.
The hospitals have portals, so we get some info from them, but not the doctors we see there, because they don't have to do it.

Annette