At war with family physicians for the month of June, the Legault government comes to declare a cease-fire. No question, for the moment, of “punishing” general practitioners who do too little. Before negotiating with them, Quebec wants to arm itself with solid figures. Corn what really needs to be done to improve access to primary care? Experts offer possible solutions.
The observation is relentless. The number of Quebeckers registered with the Access to a Family Doctor Service has doubled since 2018: from 430,000, it rose to nearly 870,000 in 1er October 2021.
Meanwhile, the average salary of family physicians has continued to climb. It increased by 20% between 2018 and 2020, according to the Régie de l’assurance maladie du Québec.
A shocking reality for Quebecers without a family doctor who end up in the emergency room after trying, in vain, to obtain a consultation in clinics without an appointment.
Unfortunately for them, Bill 11, tabled Thursday in the National Assembly by the Minister of Health and Social Services, Christian Dubé, will not change anything in the short term, Judge Régis Blais, full professor in the Department of Management, d evaluation and health policy of the University of Montreal.
“It’s an attempt to do something in the short term, to show that the government is taking it seriously,” he thinks. It’s micromanagement. “
By the Minister of Health’s own admission, Bill 11 is one of “management”. To come to an agreement with general practitioners, Christian Dubé requires detailed data on the management of patients by family physicians, data he wishes to share with the managers who each year determine the number of physicians in the various regions.
If adopted in its current form, the bill will oblige any general practitioner to “send the minister their available time slots” and to take care only of orphan patients registered at the Access Desk.
François Béland, professor at the School of Public Health at the University of Montreal, does not think that having data on the time slots not filled by doctors will solve the crying problem of the more than 800,000 patients registered with the Access desk.
“It may help to rationalize the current offer a little, with a better managed appointment system,” he says, “but from there to create places for 800,000 people?” It remains a management tool, it will not be magic if we do not touch the organization of the entire first line and links with medical specialists or with the hospital. “
Use other professionals
Régis Blais is categorical and has been repeating the same message for years: “Give more space to other professionals! “
Yes, Quebec has made progress, in particular by allowing pharmacists to adjust or extend an expired prescription for a maximum of 12 months. But these professionals could do more to free doctors, he believes. Specialized nurse practitioners (IPS) too.
Since last January, IPS have the right to diagnose diseases such as diabetes, hypertension, asthma and chronic obstructive pulmonary disease. “But Quebec is lagging behind the other provinces, especially Ontario,” says Régis Blais.
Paul G. Brunet, President of the Council for the Protection of the Sick, also deplores it. “Omnis will not be able to solve the problems of primary care on their own,” he believes. Why don’t we have more nurses who can take care of minor health problems? It has been happening all over Ontario for over 20 years and in British Columbia. “
Rearranging the first line is complex, but “passageways” are possible, believes Dr.r Jean Mireault, associate professor at HEC Montréal and consultant in healthcare establishments. How? ‘Or’ What ? Enroll patients not only with a physician, but with a clinic, and review the method of payment. Doctors could receive a lump sum for a certain number of patients (capitation), whether or not combined with a fee-for-service payment.
“I saw these models in clinics in Ontario, where we have a capitation logic that allows us to have staff [infirmières, psychologues, etc.] and an expanded expertise base ”, indicates this expert.
The clinic then adapts to its clientele. If she has a lot of patients with lung problems, she can, for example, call on a respiratory therapist three half-days a week for follow-up.
“It’s not just a notion of registration,” says the Dr Mireault. Are we following patients well? Do we prevent them from coming to the emergency room? Is the patient with diabetes, heart disease, anxiety or lung problems well controlled and does not need to go to the hospital? “
Echoes from elsewhere
Around the world, this multidisciplinary approach is emerging, notes Dr.r Jean-Frédéric Lévesque, President and CEO of the New South Wales Clinical Innovation Agency, Australia. “Several countries, with very different backgrounds, are all trying to improve the first line by setting up patient registration. [à un Guichet], remuneration according to mixed models [à forfait et à l’acte] and the practice of multidisciplinary groups ”, indicates this former deputy of the Commissioner for health and well-being.
In this regard, Quebec is ahead of Australia, says Dr Levesque. The province has made “giant strides” since its reform of the front line 20 years ago after the Clair commission, he assures. “It is certain that the registration of patients [à un médecin], the multidisciplinary group practice established following the creation of FMGs [groupe de médecine familiale], these are important foundations for continuing to build the reform of the first line [au Québec] He says.
At the Quebec Ministry of Health and Social Services (MSSS), they say they want to “go further” in this approach. The Swedish model inspires the government. There, around 1,200 frontline clinics, each with four or five doctors, receive patients. “In addition to general practitioners and nurses, there are social workers, psychologists, midwives, physiotherapists, etc. », Writes the MSSS.
Access to the first line is not just about better use of professionals, according to the experts consulted. During their first 15 years of practice, family physicians must devote 12 hours each week to specific medical activities (AMP in the jargon) in hospitals or CHSLDs.
“General practitioners, do we just want them in the office or do we want them versatile in their practice? asks the Dr Jean Mireault. Do we want them to continue doing emergency, intensive care, hospital? We are the province where the medical practice of omnis is the most extensive. It is a choice of society. “
This aspect is “important”, according to Dr Levesque. “The reality of a shortage or not always depends on what family physicians are asked to do,” he notes. In Australia, for example, omnis do very little work in hospitals, with specialists taking care of patients there, he says.
In Ontario, family physicians are also working more in offices, allowing them to follow an average of about 1,400 patients, according to Dr.r William Hogg, professor at the University of Ottawa, associate vice-president for research and scientific director of the Institut du Savoir Montfort associated with the hospital of the same name. “No one is forcing Ontario doctors to close their clinics to go to work in hospitals,” he says.
New desire for balance
If the Legault government wants general practitioners to spend more time in the office, it could ask specialist doctors to take more care of hospitalized patients, submits Régis Blais.
One thing is certain, increasing the remuneration of family physicians is not the solution for them to follow more patients, according to him. “This is the principle of target income,” explains Régis Blais. A doctor who earns $ 300,000 a year, if we increase his salary by 10%, he will perhaps say: “At $ 300,000, I have enough, I will reduce my working time by 10% and I will earn the same salary ”. “
The new generation of family physicians “tend to value work-family balance in a reasonable way,” he adds. Young people no longer want to work 70 hours a week like their predecessors did. “It is commendable and completely justified”, says Régis Blais.
The profession is also becoming more feminine. The proportion of female family physicians rose from 40% in 2011 to 50% in 2020, according to the Collège des médecins du Québec. These general practitioners “may be forced to reduce their working time” to take care of their children, recalls Régis Blais. A phenomenon that will not disappear in the future. “We have even more female students than men [en médecine], he said. We will have to find solutions. “
It remains to be seen whether the Legault government will be able to measure the scope of all these issues thanks to the data it is asking for.
With Isabelle Paré and Sandrine Vieira