In 2000, the Clair Commission affirmed that the first line was the foundation of a sustainable health system. She therefore proposed the creation of family medicine groups (GMF), which, from 2001, were quick to establish themselves.
FMGs constitute a major and necessary change not only on an organizational level, but also – what is even more important – on the level of interdisciplinary frontline practice.
Successive governments have promoted GMFs, which have been well received by the population. They even made them key election promises. Today, more than 70% of Quebec family physicians practice in 370 FMGs, which meets the needs of more than 65% of the population of Quebec.
Despite this, accessibility to primary care has become, with good reason, a great source of dissatisfaction among the population and frustration among clinicians.
Successive governments and ministers of health and social services have supported the growth and proliferation of FMGs by increasing the number of professionals and professions involved (nurses, nurse practitioners, social workers, pharmacists) and by focusing on foot the electronic medical record. They also attempted to increase the number of family physicians by setting a goal of increasing the proportion of places in family medicine residency programs by 55%. Nevertheless, the problem persists and the COVID-19 pandemic only exacerbates the weaknesses of the system.
The issue of accessibility to primary care is a complex problem closely linked to multiple issues such as organization, resources and their distribution, interprofessional and intersectoral collaboration, productivity, etc.
Unfortunately, successive governments and ministers, often pressed for an upcoming election, have failed to find workable solutions. They will continue to fail as long as their attempts are tainted with accusations and simplistic changes that focus only on productivity and technological aspects like appointment scheduling systems. Once again, the denigration and threats are followed by negotiations and agreements that take place behind closed doors between the Ministry of Health and Social Services (MSSS) and the Fédération des médecins omnipraticiens du Québec (FMOQ). It follows an implementation of changes marked by an even more excessive centralization and micromanagement on the part of the Ministry.
To persist in using the same approach will inevitably lead to failure once again, not to mention the growing frustration which will have negative effects on the health of the population as well as on the sustainability of our health system.
It’s time to take a new approach. It’s time to stop and make the changes.
Therefore, the government should set up a small and independent working committee made up of credible people and supported by adequate resources. This committee would have three months to carry out its mandate. The committee should work transparently and have respectful and open discussions with key ministry decision-makers, union representatives, network managers, family medicine professors, clinicians and patients.
Mandate of the working committee
Examine, determine all of the accessibility factors and make recommendations for each of them, in particular:
- the organization of medical practice in FMGs;
- the balance between productivity and quality of care;
- optimal use of all FMG health professionals;
- access to specialists and imaging techniques;
- access to community services and collaboration with these services as well as with community partners;
- the training, number and distribution (PREM system) of family physicians;
- the method of remuneration and financial and professional incentives;
- and the revaluation of family medicine among medical students.
Rely on emerging solutions and best practices:
- study a sample of FMGs that have succeeded in providing optimal accessibility and those that have tried unsuccessfully to understand the success factors and obstacles;
- and examine best practices in the area of communication and collaboration with community services, specialists and hospitals.
Propose an implementation plan accompanied by an elaborate change management system to stimulate and support transformations:
- bring together the MSSS and its GMF partners within a governance structure based on collaboration;
- engage, mobilize, support and train clinicians and managers of FMGs in a quality improvement process;
- adopt a step-by-step approach for the implementation of innovative projects in several FMGs in different settings (urban, rural, suburban and remote region) which is accompanied by a rigorous and continuous assessment leading to gradual generalization;
- and aim for diversity in the implementation and avoid the prescriptive “one-size-fits-all” approach, because what works in a GMF in Val-d’Or does not necessarily work in a GMF in Montreal or Sherbrooke.
I already see several people rolling their eyes: “Another committee! “Of course, the project is ambitious. But, unfortunately, changing too quickly does not work. This is why, if a major and lasting transformation of the first line, the foundation of our health system, becomes the goal to be achieved, it is important to allocate the time necessary for such an approach. The public, patients, all physicians and health professionals deserve it.
* Howard Bergman was a member of the Clair Commission (2000) and is the author of Quebec Alzheimer Plan (2009)
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