Primary care is the cornerstone of the health system. The most successful health systems in the world rely on well-coordinated and accessible primary care. But in Quebec, primary care faces persistent challenges. More than 2 million Quebecers do not have a dedicated family doctor or specialized nurse practitioner (SNP). We are among the worst countries in the world in this aspect and among the worst provinces. It’s not acceptable.
A solid first line is the basis of an efficient healthcare system, that is, capable of improving the state of health of the entire population and the experience of users while optimizing the use of resources. It reduces neonatal mortality, hospitalizations, emergency room visits, and health costs. It also contributes to reducing the health gap between the richest and the poorest.
These benefits are explained by the crucial role that front-line professionals play: they not only treat you if you become ill, but offer preventive services, detect and manage chronic diseases, such as diabetes and asthma. They offer comprehensive and personalized care over time, facilitate and coordinate access to other services, and limit the use of costly specialized care.
Last fall, more than 9,000 Canadians, including 2,500 Quebecers, responded to a survey as part of the NosSoins research project.1. This pan-Canadian project aims to gather the opinions of citizens to improve our front-line care. Unsurprisingly, Quebec is at the top of the list of provinces with the highest proportion of adults declaring that they do not have a family doctor or an SNP (31% compared to 22% for Canada as a whole). But other comparisons are just as distressing: nearly 40% of Quebecers without a family doctor had to pay for care, double the Canadian average (21%).
Finding an appointment is hard enough when you don’t have a family doctor, being forced to pay out of pocket to make up for a lack of access is unacceptable.
These fees are an additional barrier for the most disadvantaged, when they are the ones who benefit the most from easy access to first-line care.
But the good news is that the results of the NosSoins survey also show that the vast majority of Quebecers are open to new models of practice to improve access to care.
A model based on place of residence
More than in any other province, Quebecers believe front-line teams should operate like the public education system and accept anyone who lives in the neighborhood. Three out of four respondents are even ready to have to change professional in the event of a move in exchange for such a model based on the place of residence. More than nine out of ten respondents would be open to consulting the same SNP for most of their needs, except when she considers that a medical opinion is necessary. However, only 3% of Quebecers surveyed have an IPS as their main health professional.
These results bear witness to the strong desire of Quebecers to have a more accessible and equitable health care system. They also testify to their openness to consulting various professionals.
Recently, 500,000 people were registered collectively with a GMF rather than with a single professional. Front-line access points (GAP) have been created for patients waiting for a family doctor to meet their needs and facilitate their navigation in the health care system. At the same time, the number of patients registered with a single family physician has decreased, in particular due to numerous retirements and the difficulty of attracting physicians from other provinces or from the private sector. The contribution requirements for hospital care or in other sectors (the “specific medical activities”, more important in Quebec than elsewhere in Canada), the fee-for-service model which does not encourage delegation to other professionals and the lack of administrative support also hinder care by family physicians in Quebec.
Collective registrations and GAPs can improve accessibility in the short term, but especially in the form of intermittent visits, to the detriment of continuity of care. This paradoxically contributes to an increase in emergency room visits, which are much more expensive. However, long-term, continuous and comprehensive care is essential to maximize the quality and efficiency of the first line.
Quebecers want accessible care close to home and are ready to adopt innovative models that promote interprofessional collaboration. It is imperative to rethink primary care in order to improve affiliation to a professional and an interprofessional team and to improve accessibility by modernizing the organization of health services. Several solutions exist to promote equitable access without threatening the continuity of care, both essential ingredients of a successful first line. In the implementation of these solutions, it will be necessary to take into account the capital contribution of the first line to the health of the population, to support it with substantial resources, and to value the professionals and family doctors who wear it.
* Co-signatories: Mylaine Breton, Associate Professor in the Department of Community Health Sciences at the Université de Sherbrooke and holder of the Canada Research Chair in Clinical Governance of Primary Care Services; Neb Kovacina, family physician at St. Mary’s Hospital in Montreal and Director of the Quality Improvement Program in the Department of Family Medicine at McGill University