When computer systems degrade, rebooting can help. It clears away mountains of operational crud that has accumulated over time, to the point it is now getting in the way of performing even basic tasks.
After a reboot, things are cleaner. You're left with the same resources you had before, but refreshed, unencumbered, and running at full capacity. With a few adjustments to the system, you can often keep it running smoothly and more efficiently without degrading over time as it did before.
Reboots are fast. They don't require throwing out large, expensive equipment, massive short-term capital expenditures, or throwing away everything to build something new from the ground up. They don't need years of meetings and planning.
Primary care in BC needs a reboot. It's already started. This is what it looks like.
Everyone involved needs to agree on some basic goals and principles. The most foundational are:
Ready access to effective longitudinal primary care for all British Columbians is critical.
This is the highest value intervention we can make.
The current situation is a disaster and must change now.
The following principles must guide our actions.
This is where we are now, and we're getting close to consensus as a result of recent efforts.
Incentives are effective tools to influence behaviour (more here). Current incentives are in conflict with the above foundations.
Incentives (or lack thereof) are the main reason that family physicians have been driven to deliver episodic care. COVID-19 showed that if you change the incentives (e.g., telehealth fees), doctors can respond very quickly.
Better incentivize what we most value.
Longitudinal care over episodic care, continuity over isolated encounters, time to provide proper and meaningful primary care.
Family physicians who can afford to work to their highest potential.
Family doctors have told us loud and clear what they need. Overall compensation (whether changes to FFS or alternative means like salaries) that covers overhead and equitably compensates them so they can spend adequate time with patients and effectively collaborate with other professionals. Pay more to doctors providing thorough care than a quick "churn and refer" that clogs the system further.
We're at the point where we understand what these incentives look like, but not at a point that we've committed to changing them. This can happen quickly.
Once solid incentives are in place, the key to a successful reboot is give physicians the autonomy and access to resources they need, and then get the hell out of their way.
Change will happen very quickly.
Trust the hundreds and thousands of family doctors, intimately familiar with what they need and properly incentivized to provide the valuable care they desperately want to.
The politicians and bureaucrats clamouring for top-down control of something they don't understand had their chance.
The current approach, top-down and driven by government and health authorities, is slow and ineffective. We need bottom-up decision making. Family physicians will do the right thing if you let them and show that you're committed to them. If we're incentivizing them better to provide longitudinal care than episodic care or other alternatives, a substantial portion of the nearly half of family physicians doing something other than longitudinal family practice will shift. And it will happen quickly.
Rather than government controlling how funding and resources are being used, they need to make them available to physicians to request and use as they require. We've seen this model used effectively by Alberta's physician-led PCN's. They know the resources their patients need, and the PCN framework there gives them the tools they need. They're not going to stand for money being spent on unimportant things when it could be better used elsewhere.
In the short-term, there will likely be some emergency funding needed to save existing clinics or bootstrap new ones, though redistributing the resources now devoted to UPCCs should take us a long way. But the key to behaviour change is a long-term commitment to effective and appropriate incentives.
This shift of control is the stumbling block. It's a big one. But if only requires changing the minds of a very small number of people. It's achievable and can happen fast if there's the will.
Information about system performance, globally and locally, needs to be collected and published. Success stories and lessons learned from practitioners need to be shared. Gag orders and intimidation need to stop. We need to work together and learn from each other. Let physicians on the ground adopt ideas they find valuable in their community. Stop telling them what's important and how to do their job. Trust them.
I expect we'll be hearing even more from the various grassroots organizations soon what those metrics are (e.g. attachment, wait time to see family practitioner, costs and performance for all areas including UPCCs). There's no excuse for poor performance and misuse of resources to continue unabated. Enough said for now.
We're not going to get it right the first time. Mistakes will be made and there will be unintended consequences. But we don't exactly have it right now, do we? Think about how pandemic benefits like CERB rolled out. Flawed but fast because it was urgent. Be prepared to acknowledge flaws and commit to fixing them.
Ending the gag orders can happen fast. Publishing existing internal data could happen fast with political will. Establishing effective and reliable longer-term measures, including regular report cards from external organizations, will happen over time. A time-limited, multi-party "cease fire" agreement, if not actual non-partisan cooperation, could facilitate rapid change.