The Family Physician's Role in a Continuum of Care Framework for Newfoundland and Labrador Report of the Primary Care Advisory Committee Kathy LeGrow, Chair EXECUTIVE SUMMARY In June 2001, medical directors and physicians from the each of the regional health boards in Newfoundland and Labrador called a meeting with the Department of Health and Community Services to voice their concerns the current crisis in primary care delivery, about including issues around recruitment and retention of physicians, and service gaps in hospitals. In response, Minister Julie Bettney appointed a committee to address their concerns. The Primary Care Advisory Committee (PCAC) first met on September 7th, 2001. The mandate of the PCAC was to advise the Department of Health and Community Services (DOHCS) on physician issues related to primary care renewal and to make recommendations to the Minister of Health and Community Services on a framework for primary care which facilitates the effective and timely implementation of primary health care renewal in Newfoundland and Labrador. Process The PCAC has met six times since its inception, working towards consensus on the issues surrounding primary care and the recommendations to address these issues. Full consensus was achieved, and by the committee's definition, this means that each member can "live with" the issues and recommendations that are presented in this report. The recommendations in this report define the family physician's role in a Continuum of Care framework. Parameters The World Health Organization defines Primary Health Care as "the first level of contact of individuals, the family and the community with the national health care system, bringing health care as close as possible to where people live and work and constitutes the first element of a continuing health care process". Primary care is defined as the first level of contact with medical care, that which is provided by a physician, be it via an emergency room visit, office appointment or house call. The terms "primary medical care" and "primary care" are interchangeable in the health care field. Primary health care is the larger context inside which primary medical care operates. A major theme that has emerged through earlier pilot projects in primary health care renewal is t hat physician endorsement is vital to the success of primary care reform. This committee focused on achieving physician endorsement of primary care renewal initiatives in the broader context of primary health care. Findings Physicians are generally not encouraged to participate in primary health care renewal initiatives due to systemic barriers to change. These barriers to change are exacerbated by a national physician shortage that particularly impacts Newfoundland. The committee identified three main barriers to change in the current system: Payment Models Deficiencies in the current fee-for-service arrangements and payment schedules may hamper primary health care renewal, particularly the interdisciplinary approach to service delivery. An important shortcoming of the present fee-for-service system is the absence of compensation for continuing medical education and professional development. One exclusive compensation system does not sufficiently allow the health care delivery system to adapt to the changing needs of the population. Physician Lifestyle Physician shortages result in increased workload for physicians. Both salaried and fee for service physicians are challenged to find a balance between providing optimal patient care and having a reasonable lifestyle. System disconnection The current service delivery structure does not foster coordinated approach to care. In particular, there is inadequate integration between family physicians and secondary/tertiary facilities. This is partly due to geographic constraints and chronic physician shortages. The lack of interdisciplinary contact to date, may be both the cause and the effect, of an absence of trust and confidence among various health professionals. Policy Implications The committee feels government should set and support standards of access to a Continuum of Care for all residents of the province. Within this continuum would be a basket of primary health care services to be provided to each region by its health authorities or board(s) based on the health needs of the population they serve. The health needs of the population should be determined by sound research evidence and/or stakeholder input where good data does not exist. These services should be provided by integrated primary health care teams, linked either by geographic, virtual or other means. To minimize redundancy of services, team members should function collaboratively within their scopes of practice, at the highest level of their skill set. This would also ensure that patients/clients would be able to manage their health concerns with the most appropriate supports. Where relationships between individuals and physicians or other health care providers already exist, these should be respected and every individual should have the option to participate or not participate in the primary health care team approach. Patient/client informed choice is paramount in the proposed primary care delivery framework. Patient/client education is required to enable enhanced self-care, recognizing the complex interrelationship of factors that contribute to self-reliance around personal health care choices. Within the proposed framework for primary care, the committee feels that family physicians should form relationships with regional governance structures (ie. Health boards). In this way, groups of physicians could provide the necessary medical services suggested in the basket of services provided by the board based on access standards for their population. In return, boards could provide the privileges associated with affiliation, including access to continuing medical education and collegiality. The physician parties and the board should sign an agreement determining the services to be provided and the remuneration, as well as monitoring and evaluation, standards. Government should provide access to enhanced training for physicians who wish to link their practices to community needs. In this way, service gaps could be minimized and family physicians could continue to advocate for their patients throughout the continuum of care. It was agreed that any new funding model for physicians should have standards that could be applied provincially. Also, it should not negatively impact the goals of the proposed framework, nor physician incomes or patient outcomes. The funding model should be flexible enough to accommodate regional diversity and could perhaps incorporate features of existing funding models in a blended way. For all of the above policy changes to occur, the committee recognizes that evolutionary implementation and access to information on the framework will be necessary to build trust among stakeholders. As well, training will be necessary for all health care providers at the student level and beyond to become familiar with the interdisciplinary approach to care suggested in the framework. Finally, as the GP/FP provides the link between primary health care and secondary health care in the Continuum of Care, it was recognized that existing referral patterns (from the GP/FP to the physician specialist) should be maintained, with consideration of exceptions as yet to be defined. This report is not intended to instruct policy makers on how to implement primary care renewal, rather it should serve as a foundation for future policy decisions. The PCAC believes that policy decisions surrounding implementation of these recommendations would be best informed by further committee discussions utilizing the transparent process developed for this purpose.